What is the recommended physical assessment for a patient with Tourette's syndrome and mild intermittent motor tics, but otherwise normal health?

Physical Assessment Documentation for Tourette Syndrome with Mild Intermittent Motor Tics

For a patient with Tourette syndrome and mild intermittent motor tics who is otherwise healthy, document a focused neurological examination that characterizes the tics, screens for comorbidities, and excludes complications, while avoiding excessive testing that can cause iatrogenic harm.

Essential Components of the Physical Assessment

General Appearance and Vital Signs

• Document baseline vital signs and general appearance, noting any visible tics during the encounter 1
• Observe and describe the specific motor tics present (e.g., eye blinking, facial grimacing, head jerking, shoulder shrugging) 1
• Note the frequency, intensity, and any suppressibility of the tics during the examination 2

Neurological Examination

Motor and Tic Characterization

• Describe the type and distribution of motor tics observed: simple motor tics typically include eye blinking, facial grimacing, head jerking, and shoulder shrugging 1
• Document whether tics are simple or complex, and note any patterns or triggers observed during the visit 2
• Assess for premonitory urges by asking if the patient experiences sensations before tics occur 2
• Evaluate muscle strength, tone, and coordination to establish baseline motor function 3

Cervical and Musculoskeletal Assessment

• Perform careful cervical spine examination, particularly if neck-involving tics are present, as violent neck tics can rarely cause cervical myelopathy 4
• Assess neck range of motion and palpate for tenderness in cervical musculature 4
• Document any pain, paresthesias, or neurological deficits in the extremities that could suggest spinal cord compression 4

Cranial Nerves

• Complete cranial nerve examination to exclude other neurological pathology 1
• Pay particular attention to extraocular movements and facial symmetry, as these may be affected by tics 1

Sensory and Reflex Examination

• Test sensation in all extremities to establish baseline and exclude myelopathy 4
• Document deep tendon reflexes and plantar responses 4
• Assess gait and coordination 3

Screening for Comorbidities

ADHD Assessment

• Screen for attention deficit hyperactivity disorder, which is present in 50-75% of children with Tourette syndrome 1, 5
• Document observations of attention, impulsivity, and hyperactivity during the encounter 2

OCD/Anxiety Screening

• Screen for obsessive-compulsive behaviors, present in 30-60% of patients with Tourette syndrome 1, 5
• Note any repetitive behaviors, anxiety, or emotional symptoms observed or reported 2

Documentation Pitfalls to Avoid

• Avoid ordering excessive diagnostic testing (neuroimaging, EEG, laboratory studies) as diagnosis is primarily clinical and unnecessary testing causes iatrogenic harm 1
• Do not misdiagnose tics as habit behaviors or psychogenic symptoms, which leads to inappropriate interventions 1, 5
• Recognize that stress, anxiety, and fatigue exacerbate tics, while relaxation and focused activities alleviate symptoms 2

Key Documentation Elements

Document the following in your assessment:

• Specific description of observed motor tics (type, frequency, body regions involved) 1, 2
• Presence or absence of vocal tics 1
• Duration of symptoms (must be >1 year for Tourette syndrome diagnosis) 1
• Impact on function and quality of life 6
• Screening results for ADHD and OCD comorbidities 1, 5
• Musculoskeletal examination findings, particularly cervical spine 4, 3
• Normal findings in other neurological domains 1