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Spring 2014 OMS I – Exam 3 H & P Exam 3. Neurology Exam General appearance Vital signs CV – carotids, heart, peripheral Mental status – attention, orientation,

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Presentation on theme: "Spring 2014 OMS I – Exam 3 H & P Exam 3. Neurology Exam General appearance Vital signs CV – carotids, heart, peripheral Mental status – attention, orientation,"— Presentation transcript:

1 Spring 2014 OMS I – Exam 3 H & P Exam 3

2 Neurology Exam General appearance Vital signs CV – carotids, heart, peripheral Mental status – attention, orientation, language, fund of knowledge, memory Visual-Spatial function: draw things – fill in clock & a time Abnormality  neglect drawing #s all on 1 side Aphasia: cortical dysfunction in speech Be able to recognize & categorize them Can people say things you understand, do they understand you, have them say uncommon words, repetition, word substitutions

3 Neurology Exam Cranial Nerves I: optional – anosmia (loss of smell – HTN meds, trauma) II: visual acuity, fields & fundi 3ft apart, 4 quadrants Optic radiations loop into temporal lobe Papilledema – increased pressure, acute problems Venous pulsations w. occular veins  normal CSF pressure III, IV, VI: pupils, eye movements Aniscoria – asymm. Pupil size Horner’s syndrome – IL symp NS loss, normal light reflex, loss of sweating, ptosis, anhydrosis Nystagmus – rhythmic ossicilations (slow & fast phases) Phenytoin – causes it when looking L or R (not abnormal) 1* gaze – abnormal Congenital – normal for them, they see normal

4 Neurology Exam Cranial Nerves V: facial sensation, corneal reflex V1 (to tip of nose), V2, V3 sensation areas Jaw strength VII: facial symmetry & strength LMN – Bell’s palsy: entire ½ of face, no sensory loss – perceive numbness b/c muscles aren’t working VIII: hearing, balance Vestibular neuropathy (vertigo) Whispered hearing test, tuning forks IX: palate movement X: autonomic function XI: SCM & Trapezius XII: tongue protrusion (points to side of lesion)

5 Neurology Exam Muscle Strength Weakness: a muscle cannot exert normal force UMN (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 contraction Tone Cog wheel: passive movement, increased tension/tone causing catching (PD) Any atrophy or abnormal movements Fasciculations – muscle twitches, have to watch for a while

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10 Neurology Exam Muscle Coordination (cerebellar function – IL dysfunctions) Rapid alternating movements (flipping hands back n forth, touching each fingertip to thumb in rapid succession) Heel-shin test Check 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 dermatomes Vibration – use tuning fork on distal joints first (working proximal) & your finger underneath the joint Proprioception – hold onto lateral aspect of phalange, patient’s eyes are closed & you tell them what is up, down & neutral 2 point discrimination

11 Neurology Exam Muscle Reflexes Grading: (4) – greatly increased, clonus (3) – somewhat increased (2) – normal (1) – diminished response (0) – no response Reinforcement: UE – clench teeth, LE – hands together & pull Levels: 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 – Patellar S1 – Achilles (foot in dorsiflexsion, hit achilles tendon) Checking for clonus – support knee while supine, flex & point food then rapidly dorsiflex Pathologic: Grasp – when they grab your hand after stroking it Babinski – UMN, loss of cortical inhibition Globellar – tap on patient’s forehead, no accommodation = abnormal Jaw jerk – brisk (UMN), normal + hyperflexia elsehwere (LMN)

12 Musculoskeletal Exam Pain is a SYMPTOM not a diagnosis Diagnosis based on structure Hx – alleviating & aggravating factors & reproducing the pain Localized pain – MSK almost always localized, can radiate elsewhere Neck & arm, back & legs = units Primary pain generator = being able to reproduce pain via touch Gait Analysis Single sequence of functions of one limb consisting of two steps Step length: distance between both heels Stride length: distance between heel of same foot after two steps Stance: 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 time Speed: length per time Most energy efficient & comfortable – 3mph Decrease speed by decreasing cadence or increasing step length

13 Musculoskeletal Exam Center of Gravity Typically 5 cm anterior to S2 vertebra Displaced 5 cm horizontally and 5 cm vertically during an average adult male step Base of Support Space outlined by feet and any assistive device in contact with ground Normally, 5 cm-10 cm between heels

14 Musculoskeletal Exam Stance Phase Initial contact: time following initial contact of foot with ground Loading 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 plane Terminal stance: MS until just prior to initial contact of contralateral heel Preswing: TS until just prior to ipsilateral unloading toe from ground Swing Phase Initial swing : Lift of extremity from ground to maximum knee flexion Mid swing : KF to vertical tibia position Terminal swing: Vertical tibia position to just prior to initial contact

15 Musculoskeletal Exam Gait Dysfunctions Antalgic gait: Stance phase is abnormally shortened relative to the swing phase, a good indication of pain with weight-bearing Trendelenburg gait: Uncompensated: During stance phase, the weakened gluteus medius allows the pelvis to tilt down on the opposite side. Bilateral = “Waddling” or “Myopathic” Gait Compensated: 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 nerve Foot 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

16 Musculoskeletal Exam Gait Dysfunctions Vaulting: Stance leg excessively plantar flexes to allow toes of swing leg to clear the ground Circumduction: Swing leg excessively hip abducts so that the toes of swing leg can clear the ground Genu recurvatum: Backbending of knee causing excessive extension at the tibiofemoral joint due to weak quads or limited ankle dorsiflexion / excessive plantar flexion Ataxic 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

17 Musculoskeletal Exam Muscle Testing 5/5 Complete ROM against gravity with full resistance 4/5 Complete ROM against gravity with some resistance 3/5 Complete ROM against gravity 2/5 Complete ROM with gravity eliminated (rare) 1/5 Evidence of slight contractility with no joint movement 0/5 No evidence of contractility (visual or tactile) Upper Limb C5: Biceps (EF) C6: Extensor carpi radialis (WE) C7: Triceps (EE) C8: FDP D3 (FF) T1: ADM (D5 Abduction) Lower Limb L2: Iliopsoas (HF) L3: Quads (KE) L4: Tibialis anterior (DF) L5: Extensor hallucis longus (Great toe extension) S1: Gastrocnemius-Soleus (PF)

18 Musculoskeletal Exam Deep Tendon Reflexes 0 - Absent (even with reinforcement) 1+ - Hypoactive 2+ - Normal 3+ - Hyperactive without clonus* 4+ - Hyperactive with clonus Clonus: 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 inhibition Locations: C5 - Biceps tendon C6- Brachioradialis tendon C7- Triceps tendon L4 - Patellar tendon L5 - Medial hamstring (unreliable)* S1 - Achilles tendon Sensation Normal Increased (hyperesthetic) Decreased (hypoesthetic) Unpleasantly altered (dysesthetic) Not unpleasantly altered (paresthetic) Absent (anesthetic)

19 Root LevelMuscle WeaknessReflex AbnormalitySensory Deficit C5Biceps Lateral Arm (Lateral Anticubital Fossa) C6Extensor Carpi RadialisBrachioradialisLateral Forearm (Dorsal Proximal D1) C7Triceps Middle Finger (Dorsal Proximal D3) C8Flexor Digitorum Profundus (D3)NoneMedial Forearm (Dorsal Proximal D5) T1Abductor Digiti Minimi (D5)NoneMedial Arm (Medial Antecubutal Fossa) L2IliopsoasNoneMedial Anterior Thigh L3QuadricepsPatellarMedial Anterior Knee L4Tibialis AnteriorPatellarAnterior Thigh / Medial Calf / Medial Malleolus L5Extensor Hallucis LongusMedial Hamstring (unreliable) Lateral Calf / Dorsal base of 3 rd MT) S1Gastronemius-SoleusAchillesPost. Calf / Lateral Heel

20 Musculoskeletal Exam TMJ dysfunction: deviation, popping or clicking of the TMJ with range of motion Herberden’s nodes: bony enlargements of DIP joint found in osteoarthritis Bouchard’s nodes: bony enlargements of the PIP joint assoc. w. osteo & rheumatoid arthritis Rotoscoliosis: lateral curvature of the spine Pes planus: loss of foot arch Ballottement: 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 present Valgus stress test: MCL assessment, provider holds the supine patients straightened ankle & places other hand along lateral aspect of the knee Ankle pushed laterally as medial pressure applied at the knee Varus stress: LCL assessment, provider holds the supine patients straightened ankle & places other hand along medial aspect of the knee Ankle pushed medically as lateral pressure applied at the knee

21 Musculoskeletal Exam Anterior 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 femur Posterior Drawer Test: PCL assessment, patient is supine with knee 60* & foot anchored, provider grasps lower leg behind the knee & applies posterior displacement, noting shift of tibia backward under femur Meniscal tear: tear of the medial or lateral menisci McMurray’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 MM Apley Grind: meniscal tear test, patient prone, knee flexed at 90*, apply downward pressure with internal & external rotation, feeling for grinding or popping

22 Musculoskeletal Exam Straight leg raise: assess for a herniated lumbar disc Carpal tunnel syndrome: compression of the median nerve as it passes through the carpal tunnel, causing numbness, paresthesia & hand weakness Phalen’s sign: undsidedown prayer motion – CTS test Tinel’s sign: CTS, percuss over extended wrist Rotator cuff: complex of tendinous insertions of supraspinatus, infraspinatus, teres minor, subscapularis muscles Arm 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 resistance Push-off test – subscapularis integrity, arm behind patient’s back and they push off with the hand from the back Passive painful arc test – provider passively moves patient’s arm while stabilizing the shoulder Sulcus sign – pull patient’s arm downward while stabilizing the shoulder, assessing for laxity of the joint (abnormal = >2cm movement) Apprehension test

23 Psych Exam 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 state Unstructured observation and focused questions about current symptoms Theoretical foundations: Empathic descriptive phenomenology Empirical clinical observation. **most important** Objective descriptions of a patient signs and symptoms, and patient's subjective experience.

24 Psych Exam Recording (receiving isn’t necessarily in this order) Appearance Attitude (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

25 Psych Exam Recording Affect (the external and dynamic manifestations of a person's internal emotional state) the apparent emotion conveyed by the person's nonverbal behavior Intensity, range, reactivity and mobility. Appropriate or inappropriate Congruent or incongruent with their thought content Constricted or labile. Speech (Production of speech rather than the content of speech) Thought Process Quantity, tempo and logical coherence Cannot be directly observed but can only be described by the patient, or inferred from a patient's speech.

26 Psych 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 mind suicide, homicidal thoughts, suspicious or fearful beliefs Overvalued ideas – hypochondriasis, dysmorphophobia, anorexia nervosa Obsessions - Undesired, unpleasant, intrusive thought that cannot be suppressed through volition Phobias - dread of an object or situation that does not in reality pose any threat, and the patient is aware that the fear is irrational.

27 Psych Exam Recording Perceptions (any sensory experience) Hallucination - a sensory perception in the absence of any external stimulus, and is experienced as external Can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinationsauditoryvisualtactileolfactorygustatory Illusion is defined as a false sensory perception in the presence of an external stimulus, and may be recognized. Cognition Patient'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.

28 Psych Exam Recording Insight Recognition that one has an illness Compliance with treatment The ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. Insight is on a continuum Capacity to consent to treatment Judgement Capacity 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 diagnosis Has implications for the person's safety or the safety of others


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