2Neurology Exam General appearance Vital signs CV – carotids, heart, peripheralMental status – attention, orientation, language, fund of knowledge, memoryVisual-Spatial function: draw things – fill in clock & a timeAbnormality neglect drawing #s all on 1 sideAphasia: cortical dysfunction in speechBe able to recognize & categorize themCan people say things you understand, do they understand you, have them say uncommon words, repetition, word substitutions
3Neurology Exam Cranial Nerves I: optional – anosmia (loss of smell – HTN meds, trauma)II: visual acuity, fields & fundi3ft apart, 4 quadrantsOptic radiations loop into temporal lobePapilledema – increased pressure, acute problemsVenous pulsations w. occular veins normal CSF pressureIII, IV, VI: pupils, eye movementsAniscoria – asymm. Pupil sizeHorner’s syndrome – IL symp NS loss, normal light reflex, loss of sweating, ptosis, anhydrosisNystagmus – rhythmic ossicilations (slow & fast phases)Phenytoin – causes it when looking L or R (not abnormal)1* gaze – abnormalCongenital – normal for them, they see normal
4Neurology Exam Cranial Nerves V: facial sensation, corneal reflex V1 (to tip of nose), V2, V3 sensation areasJaw strengthVII: facial symmetry & strengthLMN – Bell’s palsy: entire ½ of face, no sensory loss – perceive numbness b/c muscles aren’t workingVIII: hearing, balanceVestibular neuropathy (vertigo)Whispered hearing test, tuning forksIX: palate movementX: autonomic functionXI: SCM & TrapeziusXII: tongue protrusion (points to side of lesion)
5Neurology Exam Muscle Strength Weakness: a muscle cannot exert normal forceUMN (increased tone & reflexes, Babinski sign) , LMN (decreased tone & reflexes, fasciculations)Grading:(5) Normal power(4) Active movement against gravity & resistance(3) Active movement against gravity(2) Active movement only with gravity eliminated(1) Trace contraction (flicker)(0) No contractionToneCog wheel: passive movement, increased tension/tone causing catching (PD)Any atrophy or abnormal movementsFasciculations – muscle twitches, have to watch for a while
10Neurology ExamMuscle Coordination (cerebellar function – IL dysfunctions)Rapid alternating movements (flipping hands back n forth, touching each fingertip to thumb in rapid succession)Heel-shin testCheck test (hands in supination, and any drifting to pronation; push down on extended arms – abnormal if can’t bring back up or overcompensate)Sensation (always compare symmetric areas)Touch (sharp & dull)– scatter yourself appropriately so patients don’t follow your pattern, cover many dermatomesVibration – use tuning fork on distal joints first (working proximal) & your finger underneath the jointProprioception – hold onto lateral aspect of phalange, patient’s eyes are closed & you tell them what is up, down & neutral2 point discrimination
11Neurology Exam Muscle Reflexes Grading: (4) – greatly increased, clonus(3) – somewhat increased(2) – normal(1) – diminished response(0) – no responseReinforcement: UE – clench teeth, LE – hands together & pullLevels:C5 - Biceps (antecubital fossa, press on it & hit your thumb)C6 - Brachioradialis (1/3 prox. Wrist, slight pronation, hit your thumb)C7 – Triceps (flex arm & shoulder, holding arm up with yours)L4 – PatellarS1 – Achilles (foot in dorsiflexsion, hit achilles tendon)Checking for clonus – support knee while supine, flex & point food then rapidly dorsiflexPathologic:Grasp – when they grab your hand after stroking itBabinski – UMN, loss of cortical inhibitionGlobellar – tap on patient’s forehead, no accommodation = abnormalJaw jerk – brisk (UMN), normal + hyperflexia elsehwere (LMN)
12Musculoskeletal Exam Pain is a SYMPTOM not a diagnosis Diagnosis based on structureHx – alleviating & aggravating factors & reproducing the painLocalized pain – MSK almost always localized, can radiate elsewhereNeck & arm, back & legs = unitsPrimary pain generator = being able to reproduce pain via touchGait AnalysisSingle sequence of functions of one limb consisting of two stepsStep length: distance between both heelsStride length: distance between heel of same foot after two stepsStance: time which limb is in contact with ground (60%)Swing: time which foot is in the air for limb advancement (40%)Cadence: number of steps per unit timeSpeed: length per timeMost energy efficient & comfortable – 3mphDecrease speed by decreasing cadence or increasing step length
13Musculoskeletal Exam Center of Gravity Base of Support Typically 5 cm anterior to S2 vertebraDisplaced 5 cm horizontally and 5 cm vertically during an average adult male stepBase of SupportSpace outlined by feet and any assistive device in contact with groundNormally, 5 cm-10 cm between heels
14Musculoskeletal Exam Stance Phase Initial contact: time following initial contact of foot with groundLoading response: IC until contralateral foot lifted off ground. Weight shift occurs. Body has lowest center of gravity.Midstance: LR until both ankles are aligned in frontal planeTerminal stance: MS until just prior to initial contact of contralateral heelPreswing: TS until just prior to ipsilateral unloading toe from groundSwing PhaseInitial swing: Lift of extremity from ground to maximum knee flexionMid swing: KF to vertical tibia positionTerminal swing: Vertical tibia position to just prior to initial contact
15Musculoskeletal Exam Gait Dysfunctions Antalgic gait: Stance phase is abnormally shortened relative to the swing phase, a good indication of pain with weight-bearingTrendelenburg gait:Uncompensated: During stance phase, the weakened gluteus medius allows the pelvis to tilt down on the opposite side. Bilateral = “Waddling” or “Myopathic” GaitCompensated: During stance phase, the trunk lurches to weak side to maintain a level pelvis throughout the gait cycle.Foot drop: Dropping of the forefoot into plantarflexion due to significant tibialis anterior weakness (1/5-2/5 strength) or damage to peroneal nerveFoot slap: Milder form of foot drop resulting in a “slapping” sound at initial contact (3/5-4/5 strength)Steppage (Hip Hiking) gait: Swing leg excessively hip flexes so that the toes of swing leg can clear the ground
16Musculoskeletal Exam Gait Dysfunctions Vaulting: Stance leg excessively plantar flexes to allow toes of swing leg to clear the groundCircumduction: Swing leg excessively hip abducts so that the toes of swing leg can clear the groundGenu recurvatum: Backbending of knee causing excessive extension at the tibiofemoral joint due to weak quads or limited ankle dorsiflexion / excessive plantar flexionAtaxic gait: unsteady, uncoordinated walk, employing a wide base and the feet thrown out. Commonly seen with cerebellar pathology, classic drunken appearance.Festinating gait: Involuntary advancement of legs with short, accelerating steps, often on tiptoes (shuffling). Seen with Parkinson’s Disease
17Musculoskeletal Exam Muscle Testing Upper Limb Lower Limb 5/5 Complete ROM against gravity with full resistance4/5 Complete ROM against gravity with some resistance3/5 Complete ROM against gravity2/5 Complete ROM with gravity eliminated (rare)1/5 Evidence of slight contractility with no joint movement0/5 No evidence of contractility (visual or tactile)Upper LimbC5: Biceps (EF)C6: Extensor carpi radialis (WE)C7: Triceps (EE)C8: FDP D3 (FF)T1: ADM (D5 Abduction)Lower LimbL2: Iliopsoas (HF)L3: Quads (KE)L4: Tibialis anterior (DF)L5: Extensor hallucis longus (Great toe extension)S1: Gastrocnemius-Soleus (PF)
18Musculoskeletal Exam Deep Tendon Reflexes Sensation 0 - Absent (even with reinforcement)1+ - Hypoactive2+ - Normal3+ - Hyperactive without clonus*4+ - Hyperactive with clonusClonus: Rapid alternating contractions and relaxations of muscle after forced stretch.Reinforcement requires maximal isometric contraction of muscles at a remote part of the body (clench jaw, lock fingers “Jendrassik Maneuver”) in order to distract the patient for voluntary suppression and by decreasing the amount of descending inhibitionLocations:C5 - Biceps tendonC6 - Brachioradialis tendonC7 - Triceps tendonL4 - Patellar tendonL5 - Medial hamstring (unreliable)*S1 - Achilles tendonSensationNormalIncreased (hyperesthetic)Decreased (hypoesthetic)Unpleasantly altered (dysesthetic)Not unpleasantly altered (paresthetic)Absent (anesthetic)
20Musculoskeletal ExamTMJ dysfunction: deviation, popping or clicking of the TMJ with range of motionHerberden’s nodes: bony enlargements of DIP joint found in osteoarthritisBouchard’s nodes: bony enlargements of the PIP joint assoc. w. osteo & rheumatoid arthritisRotoscoliosis: lateral curvature of the spinePes planus: loss of foot archBallottement: technique used to identify fluid w/in the joint space where the provider rapidly taps the patella posteriorly & assesses for its bobbing up if excessive fluid is presentValgus stress test: MCL assessment, provider holds the supine patients straightened ankle & places other hand along lateral aspect of the kneeAnkle pushed laterally as medial pressure applied at the kneeVarus stress: LCL assessment, provider holds the supine patients straightened leg @ ankle & places other hand along medial aspect of the kneeAnkle pushed medically as lateral pressure applied at the knee
21Musculoskeletal ExamAnterior Drawer Test: ACL assessment, patient is supine with knee 60* & foot anchored, provider grasps lower leg behind the knee & applies anterior displacement, noting shift of tibia from under femurPosterior Drawer Test: PCL assessment, patient is supine with knee bent @ 60* & foot anchored, provider grasps lower leg behind the knee & applies posterior displacement, noting shift of tibia backward under femurMeniscal tear: tear of the medial or lateral menisciMcMurray’s sign: clicking or pain in the knee suggesting a meniscal tear elicited as provider places the supine patient’s lower leg in first internal rotation w. varus pressure on the knee while taking the knee & hip thru flexion & extension to asses the LM then reversing the forces to ext. rotate w., valgus pressure to assess the MMApley Grind: meniscal tear test, patient prone, knee flexed at 90*, apply downward pressure with internal & external rotation, feeling for grinding or popping
22Musculoskeletal ExamStraight leg raise: assess for a herniated lumbar discCarpal tunnel syndrome: compression of the median nerve as it passes through the carpal tunnel, causing numbness, paresthesia & hand weaknessPhalen’s sign: undsidedown prayer motion – CTS testTinel’s sign: CTS, percuss over extended wristRotator cuff: complex of tendinous insertions of supraspinatus, infraspinatus, teres minor, subscapularis musclesArm drop test – supraspinatus tendon assessment (hold at 120* then slowly drop looking for fluidity)Empty Can test – supraspinatus integrity, abduct arm to 90* then internally rotate arm as if emptying the can then externally rotate arm against provider’s resistancePush-off test – subscapularis integrity, arm behind patient’s back and they push off with the hand from the backPassive painful arc test – provider passively moves patient’s arm while stabilizing the shoulderSulcus sign – pull patient’s arm downward while stabilizing the shoulder, assessing for laxity of the joint (abnormal = >2cm movement)Apprehension test
23Psych Exam Theoretical foundations: A structured observation of patient’s current appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment.A comprehensive cross-sectional description of the patient's mental stateUnstructured observation and focused questions about current symptomsTheoretical foundations:Empathic descriptive phenomenologyEmpirical clinical observation. **most important**Objective descriptions of a patient signs and symptoms, and patient's subjective experience.
24Psych Exam Recording (receiving isn’t necessarily in this order) AppearanceAttitude (patient’s approach to the interview)Behavior (level of activity & arousal, body movements)Abnormal movements: choreoathetoid (involuntary, rapid complex jerky movements), anti-emetic can cause achethesia (intense restlessness)Mood (a person's predominant internal feeling state at any one time)Described using the patient's own words,Euthymic, Dysphoric, Euphoric, Angry, Anxious or Apathetic.Alexithymic - unable to describe their subjective mood state.Anhedonic - An individual who is unable to experience any pleasure
25Psych ExamRecordingAffect (the external and dynamic manifestations of a person's internal emotional state)the apparent emotion conveyed by the person's nonverbal behaviorIntensity, range, reactivity and mobility.Appropriate or inappropriateCongruent or incongruent with their thought contentConstricted or labile.Speech (Production of speech rather than the content of speech)Thought ProcessQuantity, tempo and logical coherenceCannot be directly observed but can only be described by the patient, or inferred from a patient's speech.
26Psych Exam Recording Thought Content Delusion - a false, unshakeable idea or belief out of keeping with the patient's educational, cultural and social background and held with extraordinary conviction and subjective certainty [ + mood congruent vs incongruent]Preoccupations - thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mindsuicide, homicidal thoughts, suspicious or fearful beliefsOvervalued ideas – hypochondriasis, dysmorphophobia, anorexia nervosaObsessions - Undesired, unpleasant, intrusive thought that cannot be suppressed through volitionPhobias - dread of an object or situation that does not in reality pose any threat, and the patient is aware that the fear is irrational.
27Psych Exam Recording Perceptions (any sensory experience) Cognition Hallucination - a sensory perception in the absence of any external stimulus, and is experienced as externalCan occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinationsIllusion is defined as a false sensory perception in the presence of an external stimulus, and may be recognized.CognitionPatient's level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions.The mini–mental state examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment.
28Psych Exam Recording Insight Judgement Recognition that one has an illnessCompliance with treatmentThe ability to re-label unusual mental events (such as delusions and hallucinations) as pathological.Insight is on a continuumCapacity to consent to treatmentJudgementCapacity to make sound, reasoned and responsible decisions.How the patient has responded or would respond to real-life challenges and contingencies.Executive system capacity in terms of impulsiveness, Social cognition, self-awareness and planning ability.Impaired judgment is not specific to any diagnosisHas implications for the person's safety or the safety of others