May 30, | nursing, med, NURS, Paper
How to Write a Persuasive Speech: Complete Guide 2022
Have you ever tried proving a point so bad that it escalates into a physical fight or verbal abuse? A Persuasive speech involves everything from arguing about football, politics, and fashion. You must meet the audience halfway; hence you must agree to disagree.
What is a persuasive speech?
A persuasive speech is a vocalization whose aim is to convince your audience to believe or do something. When writing a persuasive speech, you should have the ability to convince the audience into viewing your opinion from your standpoint. A good persuasive speech should be informative, compelling, and entertaining.
You can only convince the audience if you come across as genuine and well-versed with your topic. How exactly do you convince a group of strangers to share your opinions? You wonder. How do you connect with critics hanging on to your every word?
Do you want to have the audience eating at your fingertips? Well, success in persuasive speech requires attention to what motivates listeners. You must know your audience regarding their age, gender, and beliefs. Knowledge of the audience helps you determine the content and message to deliver. If you are stuck stating a persuasive speech ? seek help from the best persuasive speech writers.
Types of persuasive speech
The subject at hand and the content of a speech determine the type of persuasive speech. We have three main types of persuasive speeches if you want to learn how to write a persuasive speech. They are
1. Factual persuasive speech
This type of speech persuades the listeners on whether a topic is valid or not. Using evidence is especially critical in a persuasive speech when your target audience is unpersuaded. For instance, banning beauty pageants for children is an example of factual persuasive speech.
There have been so many documented overwhelming cases of rape, murder, and suicide among kids who must grow up early. The children are vulnerable to psychotic sexual predators and naively end up as their victims.
2. Value persuasive speech
This kind of speech questions the moral or ethical aspect of an issue. For instance, is graffiti an act of vandalism or art? Is the death punishment moral or immoral?
Life is sacred and should be preserved as such. So, is it right to punish a wrongdoer by death? They are accused of capital offences like treason or espionage, but is it worth taking a life?
3. Policy persuasive speech
A policy persuasive speech is meant to move the audience into supporting or rejecting a policy, rule, or candidate. When choosing topics for persuasive speeches, you need to identify the problem, describe it, and persuade the audience into seeking a solution.
For instance, if the Senate agrees with the girl child campaign, they can write a speech to their ruler to convince them to agree to their viewpoint. Through the conviction, the feminists get government support and protection.
How do you introduce a persuasive speech?
You might be at a loss on how to start a persuasive speech, right? You need to hook in the audience; hence your introduction is crucial. The most effective ways of creating a speech include:
Using a relevant quote
Using an imagined scenario
Using a rhetorical question
Using proven statistics
Using a powerful statement or phrase
What is a persuasive paragraph?
A persuasive paragraph starts with a topic sentence stating your opinion about the chosen topic. To learn how to write a persuasive speech, try to convince the reader that your idea is worthy of consideration. You must consider both sides of an issue but reveal a bias favouring one side over the other.
Do you know how to write a persuasive speech example? If not, bear in mind that you must:
State your claim clearly
Understand your audience
Engage through emotions focus on your side of the argument
Use concrete evidence to amplify your opinion
Be organized
Use active language
What are the five persuasive techniques?
If you are looking to gain website traffic or the accolade of your coworkers and supervisors, persuasion is an important skill to hone in writing a persuasive speech. Being persuasive makes it easier for you to get things done, for you can influence others to your way of thinking.
Some of the effective persuasive techniques include:
1. Establishing reliance and developing believably
To persuade people, you must connect with them by being authentic. The audience will see you as an authority on a subject once they trust you, and that’s the essentials’ for establishing credibility.
Your persuasive speech topic outline should prioritize;
The target audience
Ways to appeal to the target audience
Purpose of the persuasive speech
How to make your opinion heard
Once you have outlined your persuasive speech, consider these techniques for connecting with your audience and establishing credibility
Appealing to emotion
Making an emotional appeal in your speech is a guaranteed way of getting people’s attention and connecting with them at a visceral level. Have you ever seen commercials for nonprofits calling upon individuals to donate and save a life or feed a starving child? Yeah, the advert is meant to move you to tears and action, which is the crucial point in how to write a persuasive speech.
Appealing to authority
Speaking entirely from personal experience is bound to fail because people believe it more when you point to an expert’s opinion. In the quest to receive donations for the less fortunate, a non-governmental organization can be involved to make the call to action more credible.
2. Understanding the reader’s purpose and aligning your own
As a persuasive speechwriter, you should think like a search engine. Why exactly are people accessing your content? This helps you in how to write a persuasive speech, meaning you have to be informative and persuasive.
3. Pay heed to language
The language you use in your writing can be persuasive to impact your readers in a meaningful way, thus forging a connection. Persuasion is fully gained by
Using flattery
Writing hyperbolically
Speaking directly to the reader
Using active language
Quoting actual statistics
4. Tone consideration
It should go without saying your tone should be favourable to your reader. Conveying tone through persuasive speech requires a careful selection of techniques and language. Your tone can be authoritative, logical, passionate, witty, intelligent, or neutral.
Some tonal qualities to avoid in how to write a persuasive speech include brevity, abrasiveness, and casualness. They are used when you know that your readers are expecting them. These defining qualities help you determine which literary devices to use and the most appropriate language for your audience.
5. Use of rhetoric and redundancy
This might sound queer, but rhetorical questions and repetition are important when connecting with your audience. Repetition, especially keywords, is an emphatic persuasive speech technique that helps illustrate a point.
A rhetorical question is meant to be emphatic. Its incorporation in persuasive writing allows you to move your paper towards a particular theme or conclusion. Repetition can be monotonous, but not when you use a rhetorical question.
Examples of persuasive speech topics
If you think writing a persuasive speech is challenging, selecting the right topic is a nightmare! The chosen topic must be suitable if you want to impact the audience. When it comes down to how to write a persuasive speech, you must be wise and cautious during the topic selection process.
You cannot convince the audience to believe in your opinions unless you believe in the topic you chose to write about. The topic you have chosen should be close to your heart. Here is a variety of persuasive speech topics whose mention ignites an uproar
Is graffiti art or vandalism
Significance of art and culture
Are Museums the dying reservoir of arts and culture?
To pay or not to pay the entrance fee to museums
Is there authenticity in modern arts?
Political unrest retards economic growth
Reality shows are fraudulent
Education is the only source of wealth
Reality shows diminish IQ
Extracurriculars are a waste of time
Media sways political decisions
Virtual reality is the future of education
How to write an informative speech
Bullying shapes personality
Legalization of Euthanasia
Banishment of pageants for kids
Environmental degradation is a global concern
Body hawking should be legal
Men shouldn’t dress in pink
Punishment by death for serial killers
Garbs define a person
Jewellery defines one’s value
Actualizing a dream is hard
Social media is the death of face-to-face communication
Dating sites are a haven for sex predators
Humans have become cyber addicts
What are the elements of a persuasive speech?
An effective persuasive speech should strike a balance between logical and emotional appeal. As a student learning how to write a persuasive speech, you must demonstrate an understanding of elements of a persuasive speech. Traditionally, persuasion enlists
1. Ethos or credibility
If you want to be persuasive, you must balance logic and emotions. Your compelling speech’s lack of statistics or anecdotes might not yield the desired results. Who wants half-baked statistics and fictional tales in an issue affecting the masses?
2. Logos or logic
If you want the audience to believe in your point of view entirely, you must use proven statistics when writing your speech outline. Tested and proven hypothesis triggers the audience’s minds that such data-driven speech is trustworthy.
3. Pathos or emotions
The bridge between statistics and a powerful connection with your audience is the emotional appeal as a persuasion technique. The best way to emotionally appeal to your audience is by using real anecdotes to wrap up your statistics beautifully.
You can affirm that most commercials have fueled you into purchasing an unnecessary product, right? You are born with the basic human need of emotions, and so does your audience. Therefore, an emotional appeal is bound to be informative and more persuasive.
A persuasive speech format
A persuasive speech is at times structured like an informative speech, but the most used persuasive speech format is Monroe’s motivated sequence and the subsequent reaction you desire from your audience
A persuasive speech format has
An introduction
-The introduction has a hook or an attention-getter.
The hook when learning how to write a persuasive speech is said to catch your audience’s attention. It can vary from a shocking statistic to a dramatic anecdote. In an attempt to have the audience psyched, don’t ask a question that elicits a verbal response or ask the audience if they agree or disagree with you; of course, someone will always be on the opposing side.
-It has a clear thesis statement
The thesis statement is derived from your topic and communicates your stand. If, for instance, your topic is ‘Body hawking legalization’, your thesis statement should be ‘My speech today is on the legalization of body hawking, and I am against it. ’
A body
The body contains the information. The information includes a simplified explanation of your topic, for there are people who might be ignorant of it.
When stating your main points, you should try using the
Deductive approach – This means you go from a general idea to a specific idea
E.g., All men are immortal
Socrates was a man
Socrates was mortal
The above deductive approach is meant to engage the audience. Your audience agrees with the first general statement, then the second general statement. Finally, they must agree with the last statement, which is your opinion on the topic at hand.
Inductive approach – This is the reverse of the deductive method, meaning you go from the specific idea to the general idea using the laws of probability. The final statement should always be your stand on the topic at hand.
Carrot-stick approach – This approach presents both sides of the issue but depicts your side as weightier than the other hence should be adopted. You are required to list both the pros and cons of the topic.
Primacy or recency approach
Primacy means that you should start your persuasive essay’s body with the strongest points and end with the weakest points. Starting strong demonstrates your knowledge and understanding of the topic at hand.
Recency is the opposite of primacy, meaning you start the body of the persuasive speech with the weakest points and build to the strongest point hence creating a climatic approach
When writing down your points in the body, it’s wise to include the following
i.statistics
Using proven statistics helps strengthen your argument, thus making your persuasive speech more credible.
Testimony
A testimony is a direct quote from an authority or person and a recommended addition to a persuasive speech. A personal testimony makes the idea more relatable to your audience.
De anchoring beliefs
The de anchor beliefs is a highly recommended persuasive speech technique. To de anchor other people’s views, you can appeal to their emotions and thus change their mindset. The different feelings you can appeal to include fear in adults.
Psychiatrists have proven overtime that adults experience fear of the loss of basic needs, freedom, and the fear of the unknown. The fear of the unknown includes death. Appealing to these emotions is very effective.
You don’t get emotionally involved by involving the audience and not your ego. In a way, you manipulate your audience’s emotions and steer them to action.
Summary
The conclusion reiterates the thematic statement. You also must use concluding remarks to make the audience aware that the speech is over.
How to write a five-minute persuasive speech
Have you ever motivated a person? How about trying to change a person’s conviction through persuasion? Well, persuading an individual is almost downright impossible. Learn how to write a persuasive speech here in an instant.
You might think that a five-minute persuasive speech has an organizational pattern, but it isn’t so. A persuasive speech is about convincing your audience of a different possibility for their lives.
Therefore, a five-minute persuasive speech has the following framework
1. Establishing a problem your audience cares about and finding a solution.
Your audience has their perspective on things because they have had a lifetime of experiences. Therefore, it would be very wrong to convince them to delve right into your solution. Your priority in how to write a persuasive speech should be the audience’s problems.
For instance, individuals suffering from obesity have plenty of evidence bluntly telling him or them that they can’t lose weight. The most significant thing is that they still care about being healthy. Your persuasive speech should meet the audience where they are, not where you want them to be.
2. Identifying typical solutions
Why is it so hard for people to embrace new solutions? They have tried them in the past, and there was no observable change to their predicament. Their reluctance should be an opportunity for you to set up a solution.
You wonder how you will set up a solution that has already been tried and yielded negative results, right? First, you must identify the errors that occur as the people try to solve the problem in question.
Try explaining that they aren’t the cause of the negative results. Instead, the problem is in the solution. This eases their tension and gives them a sense of relief and hope to try again.
3. Explaining your solution
Most people will start with the solution when writing a persuasive essay. You have spent so much time developing the steps, components, and other information related to the solution; hence should keenly explain it.
After explaining the solution to the audience, you might provide a call to action to prompt them into taking the next steps with you. The call to action in how to write a persuasive speech should not be void of emotions.
Critical mistakes to avoid when writing a five-minute persuasive speech
Your audience will often mention the qualities that you must embrace and add to your personality, but none will guide you on how to write a persuasive speech. Below is a list of things you need to avoid when writing an effective persuasive speech in five minutes
1. Avoid using big words and complex sentence structures.
Words are the greatest strength when it comes to how to write a persuasive speech; hence you should use them wisely. Big words and complex sentences that the audience can’t easily understand discourages them from reading your speech.
2. Dont use styles that don’t come naturally to you
Every author has a unique personal style of writing. Deviating from your comfort zone can be disastrous and not earn you the applause you want from your audience.
3. Never overgeneralize
When you generalize, you make your speech less persuasive; therefore, you should be specific about your writing information. Over generalization may preach to too many people instead of the target audience.
4. Don’t use any slang
The use of slang is awkward and reflects poorly on your professionalism. Keeping language as basic as possible should be your priority. Connecting to the audience isn’t achieved by using slang but rhetorical questions.
5. Don’t tailor the message to yourself
As Benjamin once said, ‘talk to a man about himself, and he will listen for hours ‘. If you don’t speak to the audience about themselves in your persuasive speech, they most likely won’t listen. You should make sure you address their needs in your persuasive speech outline.
When you haven’t done your homework on how to write a persuasive speech, your content will be shallow, and your audience will know you lack the skills. The audience’s response will be disappointment, anger, frustration, and disengagement. Who are you without your fan base?
6. Data dumping
When you rely too much on logos as a persuasive speech technique, you are too wordy in your writing. Your audience disengages and undermines your innate ability to inspire, connect, and persuade them.
7. Failure to inspire
When writing a five-minute persuasive speech, you decide based on emotions first. You then embark on the journey of finding facts and figures to justify that emotion. Ironically your audience also does the same.
Seek your words, actions, and visuals to inspire emotion. Then, deliver the analysis to justify that emotion. A good persuasive speech should communicate facts and feelings to the head and heart.
8. Not crafting a powerful opening hook
The beginning of your persuasive speech is the most critical part. It determines whether your audience is hooked or disappointed. Don’t waste the opportunity to catch their interest by rambling pointlessly, apologizing needlessly, or stating half-baked statistics.
You and your audience deserve better. Bag them in by telling an engaging or relevant story, stating a startling statistic, or asking a thought-provoking question. If you can get their attention at the beginning of a persuasive speech, you get them to the end.
9. Using too much humour
Do you want your persuasive speech to be dry and monotonous? The answer to this question should be a big no but remember not to try too hard to be funny. In how to write a persuasive speech, it’s advisable to be yourself and infuse a bit of humour when necessary or appropriate.
10. Summarizing your speech with a question and answer
Your conclusion is your grand finale to emphasize your key points more. Emphasis on the key points ensures memorability of your message and motivates the audience to action. Don’t start strong and end weak; keep the strength until the curtains close.
Do you know how to write a persuasive speech example?
If you want to know how to write a persuasive speech example, follow the following guidelines
Select a topic
The topic should be controversial enough to spawn a heated debate regardless of your standpoint. The issue could be about anything and passionate to you. If the subject is too broad, choose a specific angle to focus on. Ensure you research extensively while focusing on the key facts and arguments.
Define your persuasive goal
After choosing the topic in preparation for how to write a persuasive speech, decide precisely why you want to persuade the audience. Knowing your compelling goal helps you make wise decisions about how to approach writing your persuasive essay.
Analyze your audience
When writing a persuasive speech, knowledge of your audience’s perspective is critical. Remember, you are not only writing to get their attention but also to move them to action.
Ensure you are aware of your audience’s
Age
Gender
Education level
Culture
Beliefs
Interests
Attitudes
Size
Egocentrism
Build an effective persuasive argument
If you want a compelling, persuasive argument, develop persuasive techniques to help you attain your goal. Persuading the audience is easy once you build on a good idea.
Outline your speech
You must have a speech outline example to organize your main points and structure your speech for maximum impact. When creating a speech outline, remember
Be strong by letting your audience know your theme, why it matters to you and your hope to have them persuaded towards change.
List your main points in an orderly sequence and build on each argument for your position, thus overcoming opposing perspectives.
Summarize by appealing to your audience to respond in a way that shows you have successfully persuaded them.
Write a winning speech
Your opinions are essential, but writing them when it comes down to how to write a persuasive speech is more important. A winning speech has standard and easy grammar, a good flow of ideas, a simple sentence structure, and is self-explanatory.
How to build on your persuasion skills
It’s pretty difficult to convince an individual without an altercation. If you have seen men argue over football and politics while women argue over fashion, you know how ugly it can get. Building on your persuasive speaking and writing skills is vital for peaceful coexistence.
Effective persuasion skills include
Excellent communication
Communication can be verbal or non-verbal, but it should impact your audience. When the audience engages with you, they are open to hearing you speak.
Active listening
Attentiveness shows that you respect the other person’s opinions. Listening to them talk makes them feel valued, hence establishing trust. It’s easier to build effective arguments to win their support if you understand their viewpoints on a particular subject.
Emotional intelligence
You can pick up on your audience’s emotions by watching their body language and mood, thus responding appropriately. Emotional intelligence helps you adjust your persuasion tactics, thus achieving your set goal.
Logic and reasoning
Do you need your audience to commit fully to your idea? First, help them understand why they should pursue that idea. Use logic, reasoning, and evidence to back that idea.
Establish credibility
The ability to maintain positive interactions and maintain meaningful relationships with your audience is the basis of better credibility. Work towards that and have your audience eating at the palm of your hands.
Summary
Writing a persuasive speech can be challenging because you need to hone your persuasion skills, writing skills, and diction. It’s tough teaching an old dog new tricks unless you can navigate its mind and conquer the old habits and beliefs. This article is meant to inspire you on how to write a persuasive speech and impact people.
May 30, | nursing, med, NURS, Paper
Family Medicine 22: 70-year-old male with new-onset unilateral weakness
Family Medicine 22: 70-year-old male with new-onset unilateral weakness
Author: George Nixon, MD; Associate Editor: John B. Waits, MD, FAAFP; Case Editor: Lacy Smith, MD
INTRODUCTION
HISTORY
You review the patient schedule with Dr. Wilson.
It is late autumn and you are working at Dr. Wilson’s office.
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Dr. Wilson looks over his patient schedule and asks you to see Mr. Glenn Wright, a 70-year-old man who has been a patient in Dr. Wilson’s practice for six years. Today, he is listed as a “walk-in” visit.
You knock, and then enter to begin this patient encounter. It is 3:15 p.m.
HISTORY OF PRESENT ILLNESS
HISTORY
You interview Mr. Wright.
You introduce yourself and begin the interview while also reviewing the EMR which displays the following chief concern: “Fell down and couldn’t get up.” Family Medicine 22: 70-year-old male with new-onset unilateral weakness.
“I understand that you are here for evaluation after falling yesterday. Can you tell me what happened?”
“Did you lose consciousness or blackout?”
“What happened next?”
MEDICAL, FAMILY AND SOCIAL HISTORY
HISTORY
You ask,
“At what time or how long has it been since this happened, Mr. Wright?”
You are concerned Mr Wright may need urgent evaluation so you proceed rapidly with focused questions.
You learn the following: Mr. Wright has some right knee soreness, but denies weakness, headache, current vision or speech problems, chest discomfort, palpitations, shortness of breath, nausea, abdominal pain, and incontinence of urine or stool.
You scan his chart in the EMR.
Summary of most recent progress note:
Date: Four months prior.
Chief Concern: Follow-up hypertension & hyperlipidemia
Subjective: Persistent stiffness in knees, but pain relieved with acetaminophen. Urine flow improved. Denies exertional chest discomfort, decreased stamina, headaches, dizziness and weakness. Occasionally omits diuretic and statin. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.
ROS: Occasional dizziness and decreased energy for 2 to 3 months. Decreased night vision. Occasional heartburn, stiff back and knees. Denies fever, syncope, headache, weight loss, abdominal discomfort or change in bowel habits or stool.
Past Medical History: Essential hypertension, osteoarthritis, peptic ulcer disease, benign prostatic hyperplasia, hyperlipidemia, cataracts, shingles. No surgery.
Family History: Type 2 diabetes mellitus, hypertension, glaucoma.
Social History: Widowed for four years, retired railroad worker. Children: two daughters out-of-state and a son who lives nearby. Smoking – 1/2 pack per day resumed four years ago after ten-year abstinence. Alcohol – single shot whiskey most nights. Hobbies – quail hunting and fishing.
Medications: Hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, doxazosin 2 mg every evening, simvastatin 20 mg every evening, over the counter ranitidine, acetaminophen.
Allergies: No known allergies.
Immunizations: H zoster, pneumococcal, Tdap, and influenza vaccines current.
Objective: Blood pressure 166/80 mmHg. No carotid bruits. Lungs: Clear. Heart: Regular rhythm. Rate 70’s beats/minute, point of maximal impulse (PMI) laterally displaced. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.
Labs: Fasting lipid profile: total cholesterol 190 mg/dl, HDL 31 mg/dl, LDL 129 mg/dl, triglycerides 150 mg/dl.
Assessment: Hypertension – poorly controlled, hyperlipidemia – poorly controlled, osteoarthritis of the knees, benign prostate hyperplasia. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.
Plan: Follow-up 6 to 8 weeks.
Discussed importance of medication compliance, smoking cessation, and lifestyle changes on personal health risks for stroke, heart, and kidney disease. Given DASH Diet brochure and prescription coupons.
You confirm this past medical history, family history, and social history with Mr. Wright.
Question
Given Mr. Wright’s history of dizziness, visual symptoms, left arm numbness, and imbalance,
TIA (transient ischemic attack)
is on your differential along with several cardiovascular disorders. What risk factors does Mr. Wright have for cerebrovascular and cardiovascular disease (ASCVD)?
The suggested answer is shown below.
Letter Count: 965/1000
SUBMIT
Answer Comment
Age over 45 years
Smoking history
Hypertension
Hyperlipidemia
TEACHING POINT
Risk Factors for Cerebrovascular Disease
The risk factors for cerebrovascular disease are very similar to those for coronary artery disease.
For more REQUIRED information on ASCVD risk factors and for lifestyle modifications for ASCVD prevention, see the Aquifer Cholesterol Guidelines module.
Due to this risk, the United States Preventive Services Task Force recommends:
ALL adults >18 yrs be screened for hypertension
Adults > 20 yrs should be screened for hyperlipidemia if at increased risk for CAD (i.e., diabetic, hypertensive, premature personal history of atherosclerosis or family history of CAD in males < 50 yrs or females < 60 yrs)
All adults be asked about tobacco use, and all smokers be given tobacco cessation interventions.
Clinicians should discuss aspirin chemoprevention with all men over 50 for primary prevention of myocardial infarction. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.
References
Bibbins-Domingo K, et al. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(12):836-845.
Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40(6):2276-2293.
ORTHOSTATIC VITALS
PHYSICAL EXAM
You perform the TUG test on Mr. Wright.
While washing your hands, you tell Mr. Wright that you will be performing a physical and neurologic exam.
You begin the exam testing for orthostatic changes.
Orthostatic Vital Signs
Position – Supine:
Heart rate: 110 beats/minutes
Blood pressure: 166/82 mmHg
Position – Standing:
Heart rate: 120 beats/minute
Blood pressure: 162/80 mmHg
TEACHING POINT
Orthostasis
A reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who has accommodated to the supine position assumes a standing or sitting position.
Some experts also consider the test to be positive when the pulse rate remains increased by 20 beats per minute or more (16 beats per minute in the elderly). Family Medicine 22: 70-year-old male with new-onset unilateral weakness
References
Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Orthostatic changes. J Neurol Sci. 1996;144:218-219.
TIMED UP AND GO TEST
PHYSICAL EXAM
You perform the TUG test on Mr. Wright.
You then proceed to assess Mr. Wright’s general balance, mobility, and risk for fall by having him perform the (TUG test) “Timed Up and Go” test.
You know that it is important to screen rapidly patients who present with neurologic symptoms. Clinical findings can change quickly, and the establishment of a baseline provides a comparative benchmark.
TEACHING POINT
Timed Up and Go Test
Measures mobility and fall risk in people who are able to walk on their own. The person may wear their usual footwear and can use any assistive device they normally use. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.
Instructions to the patient:
Sit in the chair with your back to the chair and your arms resting in your lap.
Without using your arms, stand up from the chair and walk 10 ft. (3m).
Turn around, walk back to the chair, and sit down again.
Timing begins when the person starts to rise from the chair, and ends when he or she returns to the chair and sits down. The person should be given one practice trial and then three actual trials. The times from the three actual trials are averaged.
Prediction of Mobility
Average Number of Seconds for TUG
Mobility Prediction
<10
Freely mobile
< 20
Mostly independent
20-29
Variable mobility
> 30
Impaired mobility
Note: This test is more discriminative in patients who are more debilitated.
TEACHING POINT
Initial Physical Exam of Neurologic Symptoms
Exam of cranial nerve VII
Facial asymmetry is not specific for stroke as it can also be caused by Bell’s Palsy or Horner’s syndrome. Weakness or asymmetry of the muscles of facial expression (CN VII) is a common presenting sign of stroke.
Auscultation of carotids
Listen for carotid bruits as emboli from carotid arteries are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.
Romberg
Ischemic blood flow in the vertebrobasilar system is associated with ataxic gait and instability of balance that may be revealed with Romberg testing.
Cardiopulmonary
The presence of murmurs or irregular rhythms on thecardiovascular exam may signal valvular disease and intra-cardiac mural thrombi as sources for cardiac emboli.
Gross visual fields
Emboli from carotid bruits are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.
Proprioception
Proprioceptive and spatial deficits are present in patients who have suffered brain ischemia affecting the sensory areas.
Mental status exam & assessment of motor strength
Documentation of mental status to include the level of alertness, orientation, comprehension (both receptive and expressive) and memory are essential, as are tests of gross motor strength and coordination.
12 lead electrocardiogram
An electrocardiogram can detect abnormalities of QT interval, conduction abnormalities, and ST changes suggestive of paroxysmal arrhythmia or myocardial ischemia producing transient central nervous system hypoperfusion.
References
Podsiadlo D, Richardson S. The timed ‘Up and Go’ Test: a test of basic functional mobility for frail elderly persons. J of Am Geriatr Soc 1991;39:142-148
Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc. 2013 Feb;61(2):202-8. doi: 10.1111/jgs.12106. Epub 2013 Jan 25.
COMPLETING THE PHYSICAL EXAM
PHYSICAL EXAM
You check Mr. Wright’s carotids.
You perform a complete examination and record the following in the EMR:
Vital signs:
Temperature: 37 Celcius
Heart rate: 100 beats/minute
Respiratory rate: 16 breaths/minute
Blood pressure: No orthostatic changes
Weight: 80 kgs
Height: 5′ 10″
Pain: 0
Physical exam:
General: 70-year-old well-nourished man in no distress, alert, cooperative, fully oriented
TUG test: Normal
Head/Neck: Atraumatic, symmetric facies, no carotid bruit or neck vein distension.
Eyes: Normal visual acuity, pupils equal, round, reactive to light and accommodation (PERRLA), extraocular movements intact (EOMI), no nystagmus, normal visual fields, sub-optimal fundoscopic exam secondary to cataracts, but no evidence of papilledema.
Ear/Nose/Throat: Unremarkable.
Chest: Normal respirations and lung fields.
Cardiovascular: Rate 118, irregularly irregular rhythm (not previously noted), no murmur, point of maximal impulse (PMI) 5th intercostal space laterally displaced 3cm.
Abdomen: Unremarkable.
Genitourinary: Deferred.
Musculoskeletal: Strength 5/5 and equal in right upper and bilateral lower extremities, strength 4/5 in left upper extremity, osteoarthritic knee changes.
Neurological: No dysphonia or dysphagia, gag intact. No sensory or proprioceptive deficit. No Babinski, normal Romberg. FAST test: Symmetric smile. No pronator drift. Able to repeat, ‘No ifs ands or buts’ without slurring or difficulty.
TEACHING POINT
Pronator Drift
The pronator drift is one of the most sensitive tests for upper extremity weakness.
The patient is asked to flex their arms 90 degrees at the shoulders, supinate their forearms, close their eyes, and hold the position. If a forearm pronates, then the patient is said to have pronator drift on that side.
Pronator drift
TEACHING POINT
The National Institutes of Health Stroke Scale (NIHSS)
A standardized comprehensive tool with proven utility for efficiently ensuring systematic documentation of key components of the neurologic exam in a patient with suspected stroke. Its application enables performance of a standardized exam for TIA and stroke patients which then can be subsequently used by examiners to more precisely evaluate neurologic improvement and deterioration.
Use this scale to score components of the preceding examination which have been performed and to familiarize yourself with the components which ideally should have been included.
You may also view a video on the performance of the NIHSS exam.
TEACHING POINT
Face Arm Speech (FAST) Test
Face Arm Speech (FAST) test used by ambulance paramedics and physicians for the rapid clinical assessment of patients with suspected transient ischemic or stroke symptoms.
Developed in 1998 as a stroke identification instrument, to be used outside the hospital. Studies have demonstrated variable diagnostic accuracy of stroke by paramedics and emergency medical technicians with positive predictive values between 64% and 77%.
Instructions
References
Nor AM, McAllister C, Louw SJ, et al. Agreement between ambulance paramedic – and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients. Stroke.2004;35:1355-1359. http://stroke.ahajournals.org/cgi/reprint/35/6/1355
Josephson SA, Hills NK, Johnston SC. NIH Stroke Scale reliability in ratings from a large sample of clinicians. Cerebrovasc Dis. 2006;22:389-395.
Lyden P, Raman R, Liu L, Emr M, Warren M, Marler J. NationalInstitutes of Health Stroke Scale certification is reliable across multiple venues. Stroke. 2009;40:2507-2511
University of Nebraska Medical Center. Pronator Drift (Video). Movies from the NeuroLogic Exam and PediNeuroLogic Examwebsites are used by permission of Paul D. Larsen, M.D., University of Nebraska Medical Center and Suzanne S. Stensaas, Ph.D., University of Utah School of Medicine. Additional materials were drawn from resources provided by Alejandro Stern, Stern Foundation, Buenos Aires, Argentina; Kathleen Digre, M.D., University of Utah; and Daniel Jacobson, M.D., Marshfield Clinic, Wisconsin. The movies are licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 2.5 License.
SUMMARY STATEMENT
CLINICAL REASONING
At 3:25 p.m., Dr. Wilson knocks, enters the exam room and greets Mr. Wright just as you are concluding your exam. Aware that Mr. Wright is here for an acute care visit, Dr. Wilson has come to assess whether Mr. Wright’s visit might require his immediate attention.
Question
Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.
Guidelines for summary statements.
Your response is recorded in your student case report.
Letter Count: 513/1000
SUBMIT
Answer Comment
Mr. Wright is a 70-year-old man with poorly controlled hypertension and hyperlipidemia who presents after an episode of lightheadedness that resulted in a fall. There was associated left hand numbness and visual disturbance but no loss of consciousness and all symptoms resolved after 15 minutes. Physical exam is remarkable for elevated blood pressure, irregularly irregular heart rhythm, and tachycardia.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: 70-year-old man with poorly controlled hypertension and hyperlipidemia.
Key clinical findings about the present illness using qualifying adjectives and transformative language:
associated left hand numbness
associated visual disturbance
symptoms resolved after 15 minutes
elevated blood pressure on exam
irregularly irregular heart rhythm
tachycardia
DIFFERENTIAL DIAGNOSIS
CLINICAL REASONING
ELECTROCARDIOGRAM
TESTING
Mr. Wright’s electrocardiograph
Question
After you have finished discussing your current differential diagnosis with Dr. Wilson, the nurse returns to the hallway and gives you Mr. Wright’s electrocardiograph. Dr. Wilson asks you, “What is your interpretation of this?” Your interpretation statement should include descriptions of rate, rhythm, axis (normal or abnormal), hypertrophy, and ST segment.
The suggested answer is shown below.
Letter Count: 0/1000
SUBMIT
Answer Comment
Irregularly irregular rate of 168 beats/minute. Rhythm of supraventricular origin with normal but leftward axis, left ventricular hypertrophy (LVH), Inferior and lateral ST depression. Dx: Atrial fibrillation with LVH, inferior & lateral ST depression.
TEACHING POINT
Atrial Fibrillation – Definition, Epidemiology, & Characterization
Definition
Atrial fibrillation is rapid, irregular, and chaotic atrial activity without definable p waves on electrocardiogram. Its presence should be suspected in individuals presenting with dizziness, syncope, dyspnea, or palpitations. While palpation of an irregular pulse or auscultation of an irregular heart rate may raise suspicion of atrial fibrillation, the diagnosis requires confirmation with electrocardiogram.
Epidemiology
Atrial fibrillation (AF) is the most common arrhythmia physicians face in clinical practice, accounting for about one-third of hospitalizations for arrhythmia. The prevalence of AF increases with age and the severity of congestive heart failure or valvular heart disease. Furthermore, in most cases, AF is associated with the cardiovascular diseases of hypertension, coronary artery disease, cardiomyopathy, and mitral valve disease. Pulmonary disorders of COPD, obstructive sleep apnea, and pulmonary embolism are associated and predisposing factors. Other associated conditions include surgery, excess alcohol intake, hyperthyroidism, and febrile illnesses.
Distinguishing persistent vs. paroxysmal
Atrial fibrillation less than 72 hours total duration would be classified as new onset. Chronic atrial fibrillation may be either persistent or paroxysmal. In the paroxysmal form, atrial fibrillation may recur and then revert back to normal rhythm spontaneously, with variable periods of normal sinus rhythm between episodes. The presence of normal rhythm does not rule out the existence of paroxysmal atrial fibrillation. This arrhythmia can occur episodically without clinical detection or significant symptoms for several months.
In this case example, atrial fibrillation may have contributed to the fall, and spontaneously reverted to sinus rhythm before the ambulance arrived, later recurring prior to your examination of the patient.
DEEP DIVE
References
January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et. al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1–76.
Page RL. Newly diagnosed atrial fibrillation. N Engl J Med. 2004;351:2408-2416.
Rathore S, Berger A, Weinfurt K, et al. Acute myocardial infarction complicated by atrial fibrillation in the elderly: Prevalence and outcomes. Circulation. 2000;101;969-974.
MECHANISMS OF TIAS OR POSSIBLE STROKE
TEACHING
“So, let’s see if we can fit our findings together into something that makes sense. Mr. Wright presented with numbness, vision changes, transient weakness, and incoordination that occurred yesterday but has since resolved. What are the four cardiovascular or cerebrovascular mechanisms of TIA or stroke that we have to consider in the evaluation of these symptoms?” prompts Dr. Wilson.
Question
List the four cardiovascular or cerebrovascular mechanisms of TIAs or possible stroke which should be considered in Mr. Wright.
The suggested answer is shown below.
Letter Count: 148/1000
SUBMIT
Answer Comment
Embolic
Thrombotic
Cardiogenic
Hemorrhagic
TEACHING POINT
Mechanisms of TIAs or Possible Stroke
Cardiovascular or Cerebrovascular Mechanisms:
1.Embolic
Most commonly from the heart or carotid artery– arrhythmias may produce emboli from mural thrombi, atrial appendages, or from diseased heart valves
2.Thrombotic
Native clot within the intracranial vasculature — 85% of strokes are caused by vascular occlusion (thrombotic)
3.Cardiogenic
Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation
4.Hemorrhagic
Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.
Hematologic and Vascular Mechanisms:
Hematologic
Hyperviscosity or myleoproliferative syndromes (polycythemia, leukemias, or thrombocytosis), vascular obstruction (sickle cell anemia), severe anemia and conditions associated with hypercoagulable states (lupus anticoagulant or antiphospholipid antibody; presence of Factor V Leiden; or deficiencies of protein C, protein S, or antithrombin III).
Vascular mechanisms
Hypertension leading to thrombosis or bleeding, atherosclerotic emboli from carotid or vertebral plaques, extrinsic compression of cranial vessels (cervical osteophytes, or rotational kinking, tumor), vasospasm (migraine, cocaine) and vasculitis.
“Let’s go tell Mr. Wright what we are thinking,” urges Dr. Wilson. “And, you know… we probably need to mention to him that we’re recommending transport to the hospital…”
DISCUSSION OF DISPOSITION
CARE DISCUSSION
Dr. Wilson explains the results of the ECG.
You and Dr. Wilson return to Mr. Wright’s room. Dr. Wilson sits down and says, “Mr. Wright, I am concerned that you may have had a TIA. Also, your electrocardiogram shows atrial fibrillation, which is an irregular heart beat or rhythm. Your fall may have been caused by a brief loss of blood flow to the brain due to your irregular heart rhythm, or it may have been related to a TIA. I am therefore recommending admission to the hospital for additional diagnostic testing and monitoring.”
Mr. Wright responds:
“I feel fine, I don’t understand why I have to be admitted into the hospital?”
“How long do you figure I’ve had this irregular heart beat? You said my heart was ok at my last exam.”
Dr. Wilson asks Mr. Wright if he has any other questions to which Mr. Wright answers “No.” You then exit to make arrangements for Mr. Wright’s transfer to the hospital.
TEACHING POINT
TIA Symptoms Preceding Stroke
Individuals experiencing TIA symptoms have been shown to have an 8% to 12% chance of having a stroke within one week and an 11% to 15% chance of having a stroke within one month.
DEEP DIVE
References
AHA. American Heart Association 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care- Part 9: Adult Stroke, Circulation. 2005;112:IV-111-IV-120.
Edward C. Jauch, Jeffrey L. Saver, Harold P. Adams et.al. “Guidelines for the Early Management of Patients with Acute Ischemic Stroke.” Stroke 2013, published online January 31, 2013.
TRANSPORT TO THE EMERGENCY DEPARTMENT
MANAGEMENT
Pending hospital transfer, you help the nurse place Mr. Wright on nasal oxygen and a continuous heart monitor. Dr. Wilson observes as you place a catheter in an antecubital fossa for IV access. You are successful on your first attempt, and your technique demonstrates familiarity with the precepts of universal precautions.
Before the EMTs arrive to transport Mr. Wright to the hospital, you discuss with Dr. Wilson that you would like to follow and to observe how the emergency room physician will evaluate and manage Mr. Wright. Dr. Wilson thinks this an excellent idea, and you agree to meet at the hospital in the morning to make rounds and follow up on Mr. Wright.
When you arrive at the emergency room, the staff physician Dr. Powell has already been filled in about Mr. Wright. His initial evaluation includes: repeating vital signs, a neurologic exam using the NIH stroke scale, and exam of the carotids, lungs, and heart. His exam is unchanged from what you found at Dr. Wilson’s office
TEACHING POINT
Stroke Systematic Assessment and Outcomes
The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome.
Patients with symptoms highly suggestive of stroke are preferentially routed to a hospital that has been certified as a stroke center, as patients with symptoms of stroke who receive treatment at hospitals with this certification have been shown to have improved outcomes among patients treated for stroke.
TEACHING POINT
Universal Precautions
Universal precautions are safety procedures designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other blood borne pathogens. Implementation involves the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials. Proper disposal and precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices are also a part of this medical safety practice.
DEEP DIVE
References
Brott T, Adams HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864-70.
CDC. Universal Precautions for Prevention of Transmission of HIV and Other Bloodborne Infections. 1987. Updated 1996.
Edward C. Jauch, Jeffrey L. Saver, Harold P. Adams et.al. “Guidelines for the Early Management of Patients with Acute Ischemic Stroke.” Stroke 2013, published online January 31, 2013.
LABORATORY EVALUATION
THERAPEUTICS
Dr. Powell discusses stroke testing with you.
Dr. Powell finishes his exam, then the two of you briefly discuss the evaluation protocol.
TEACHING POINT
Evaluation of a Patient with Suspected Ischemic Stroke
Time is crucial in evaluation of a patient with suspected ischemic stroke because if given within four-and-a-half hours, intravenous t-PA has proven benefit in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given within six hours.
Since time is so critical, there is an organized protocol for the emergency evaluation of patients with suspected stroke. The goal is to complete an evaluation and to decide treatment within 60 minutes of the patient’s arrival in the emergency department. A designated acute stroke team includes physicians, nurses, and laboratory/radiology personnel. All patients with suspected acute stroke are triaged with the same priority as patients with acute myocardial infarction or serious trauma, regardless of the severity of the deficits.
As for all critically ill patients, the initial evaluation follows the path evaluation and stabilization of the patient’s CABs (circulation, airway, breathing). This is quickly followed by a secondary assessment of neurological deficits and possible comorbidities with the National Institutes of Health Stroke Scale (NIHSS).
The overall goal is not only to identify people with possible stroke, but also to exclude stroke mimics, identify other conditions requiring immediate intervention, and determine potential causes of the stroke for early secondary prevention.
A limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation of a patient with suspected acute ischemic stroke.
Although it is desirable to know the results of these tests before giving recombinant tissue Plasminogen Activator (rtPA), thrombolytic therapy should not be delayed while awaiting the results unless:
there is clinical suspicion of a bleeding abnormality or thrombocytopenia
the patient has received heparin or warfarin
use of anticoagulants is not known
Question
Several tests are recommended to be performed routinely in patients with suspected ischemic stroke to identify systemic conditions that may mimic or cause stroke or that may influence therapeutic options. If you were to imagine that Mr. Wright were presenting with symptoms of an acute stroke, which studies would you order now for Mr. Wright? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
A. Toxicology screen
B. Blood alcohol level
C. Noncontrast brain CT or brain MRI
D. Blood glucose
E. Serum electrolytes/renal function tests
F. ECG
G. Markers of cardiac ischemia
H. Complete blood count, including platelet count
I. Prothrombin time/international normalized ratio (INR)
J. Activated partial thromboplastin time
K. Oxygen saturation
L. Chest radiography
M. Lumbar puncture
SUBMIT
Answer Comment
The correct answers are C, E, F, G, H, I, J, K, L.
TEACHING POINT
Recommended Tests for the Initial Emergency Evaluation of a Patient with Suspected Acute Ischemic Stroke
The American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups have all come together to create guidelines for the early management of adults with ischemic stroke. The following tests are recommended.
CT and MRI
Imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke. Multimodal CT and MRI may provide additional information that will improve diagnosis of ischemic stroke.
Class I, Level of Evidence A
Renal function / electrolytes
Abnormalities of renal function or electrolyte disturbances are prevalent in patients who have risk factors for stroke and should be assessed.
Class I, Level of Evidence B
Electrocardiogram (ECG)
An electrocardiogram (ECG) is recommended because of the high incidence of heart disease in patients with stroke.
General agreement supports the use of cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. It is generally agreed that cardiac monitoring should be performed during the first 24 hours after onset of ischemic stroke.
Class I, Level of Evidence B
Markers for cardiac ischemia
Markers for cardiac ischemia are important for all patients with suspected ischemic stroke, as myocardial ischemia is a potential complication of acute cerebrovascular disease.
CBC and PT/PTT
Abnormalities o
