CCF II Exam I Flashcards
_______ describes a range of sensations such as feeling faint, woozy, weak or unsteady.
Dizziness
*vertigo, pre-syncope/syncope
______ describes a false sense that your or your surroundings are spinning or moving
Vertigo
_____ describes the feeling that one will faint/collapse or actually briefly fainting or collapsing with loss of consciousness
Syncope
More than 4/10 people will have an episode of dizziness that takes them to a healthcare provider. 40% of people over the age of 40 years old tend to be the most common.
What are the MC causes of Dizziness?
inner ear disease, migraine, Meniere disease
Dizziness: The following are common examples of?
- Benign Paroxysmal Positional Vertigo
- Vestibular neuronitis
- Meniere disease
- Immune-mediated inner ear disease.
Peripheral vertigo
The most common causes of dizziness are inner ear disease, migraines and Meniere disease (often causing vertigo, and/or orthostatic hypotension).
What are the MC causes of Central Vertigo?
a. Vestibular migraine
b. Acoustic neuroma
c. Orthostatic hypotension
d. Vascular lesions of the brainstem/Cerebellum
All of the above
*demyelination
The most common causes of dizziness are inner ear disease, migraines and Meniere disease.
What are Factors associated with serious etiology:
> 60 years old, focal abnormalities, and imbalance.
A 24 year old patient presents with complaints of episodic vertigo, tinnitus and hearing loss. You suspect?
Meniere disease
- avg. age = onset 20-40 years old
- endolymphatic hydrops that distort and distend the membranous, and endolymph-containing portions of the labyrinthine system.
A female patient (MC women) presents to the clinic complaining of headache. She states it began with dizziness but progressed to migraine. Aura confirmed. She states episodes last up to 2 hours. Patient states she feels like the room is spinning during these episodes.
You suspect
Vestibular migraine
- internal or external motion (patient spins vs. room spins)
- minutes to hours
- fewer to several episodes/year
- triggers common to other migraine types (chocolate, OH, stress, lack of sleep)
NOTE: It may present as a typical migraine aura (i.e. start with dizziness, develop into migraine), or it may present with photophobia, phonophobia or aura without headache.
A 63 year old woman present with complaints of sudden onset of “rocks in her head” (otoconia). She states she has nausea and vomiting episodes. You note on PE involuntary eye movements (nystagmus).
The former describes what dizziness disorder?
Benign Paroxysmal Positional Vertigo
- MC in women (>60 y/o inc. incidence)
- “Rocks in your head” otoconia
- Nystagmus (involuntary eye movements)
- Nausea/Vomiting
- Sudden onset
*Nystagmus: slow pursuit movement followed by fast resetting phase (named by direction of reset phase)
How do you Dx bening paroxysmal positional vertigo? How do you treat it?
Dix-Hallpike test
Tx:
- -1st line: canalith repositioning procedure (epley maneuver)
- -2nd line - surgery
Orthostatic Hypotension is an ANS dysfunction that is associated with abnormal vagus responses. It may be due to:
- Acute/Chronic volume depletion (heat illness, post-dialysis)
- Medication (B-blockers) adverse effects
How is it tested? What are complications?
Complications:
- -dizziness when standing
- -syncope, cerebrovascular accident, angina
Dx:
- -Tilt table test
- -Orthostatic Hypotension test (check b.p. standing, sitting)
Acoustic neuroma (a.k.a. vestibular Schwannoma) is commonly derived from _________ in the vestibular portion of CN 8. The MC symptom is unilateral hearing loss.
It constitutes 80% of the tumors found within the cerebellopontine angle.
Schwann cells
(a.k.a. vestibular Schwannoma)
- uncommon in kids (except Neurofibromatosis type 2)
- higher in Taiwanese, Asian Pacific islanders
- low in Hispanic/AA’s
How would you Dx and Tx Acoustic Neuroma?
Dx: Gadolinium contrast MRI is gold standard Tx: --surgical excision --sterotactic radiation therapy --serial observation
*view image in notes
Diagnosis of Dizziness depends on assessment. Indicate what tests should be performed if you suspect the following:
- Head trauma or concern for CNS etiology
- Pharyngitis
- Neck
- Cardiac
- Pulmonary
*also be sure to perform Fingerstick blood sugar and Hb and hematocrit tests
- Head trauma
- -CT, MRI - Pharyngitis
- -rapid strep - Neck
- -Cervical X-ray - Cardiac
- -ECG, Echo, Holtor monitor, US carotids - Pulmonary
- -Chest X-ray
Treatment of dizziness depends on the lead differential. What situations are considered emergent?
a. head trauma
b. sudden and severe onset
c. staggering or ataxic gait
d. severe hypoglycemia
All of the above
- head trauma (anti-coag meds) **CT immediately
- sudden/severe onset
- -staggering, vomiting, double vision, slurred speech, numbness of face/body,
- hypoglycemia (FSBS <30)
There are 7 characteristics that were independently associated with dizziness on a multi-variate analysis. Which of the following is not one?
a. anxiety trait
b. depressive symptoms
c. past MI
d. Recovery from flu
Answer: D
also:
- polypharmacy (>5 meds)
- impaired hearing
- postural hypotension (mean dec. in blood pressure >20%)
- impaired balance (path deviation and time to turn circle > 4 sec)
True/False: Medical communication can be cost effective, help increase patient safety/decrease medical errors and enables all stakeholders to share the same frame of reference.
True
_____ describes the practice of alternating between two or more languages or varieties of language in conversation. It is also referred to as “language contact phenomena”, or as boundary levelling/maintaining and verbal strategy.
The ultimate goal is shared frame of reference.
Codeswitching
*differentiates roles - student/attending formal setting vs. non-formal settings
A distinguishing feature of codeswitching that is characterized by the idea that the more you talk to someone in your vernacular and the closer your relationship, the more likely they are to accept your language and vice versa.
Language transfer
For the History and Physical, full reimbursement from Medicare/Medicaid requires complete ROS and PE. How many ROS’s are required? How many organ systems need to be assessed?
ROS - 10 systems
*9 organ systems with at least 2 parts noted: eyes pupillary reflex and sclera
True/False: SOAP notes and consult notes should be concise and tailored to the complaint or consultation.
For example, for surgery, incision site and drains with fluid collected may be included. For cardiac, full cardio exam (auscultate, pulses, capillary refill, PMI).
True
The 5 basic qualities of effective oral presentations are based on SOAPS:
- ___: ID’s : ID’s and describes the complaint concisely (OPQRSTA)
- ____ facts located where the listener expects (subjective vs. objective)
- ____: makes case for assessment plan
- _____: only relevant info to assessment plan
- _____: fluent, volume, professional language, and avoids judgement
- Story
- Organization
- Argument
- Pertinence
- Speech
A summary statement should be included in the Assessment of your SOAP note along with ___ differentials associated to chief complain. You must explain the reasoning for your top choice
3 differentials
True/False: The Plan portion of the SOAP note should include Diagnostic/Therapeutic/Education as well as disposition (admit, outpatient) and follow up
True
Your role as a physician includes that of educator. It is important to remember that the baseline is 3rd grade level, and thus, medical jargon should be used minimally.
Which of the following must be used/considered when interacting with patients?
a. use example (heart is a pump…)
b. utilize teach back (patient explains what you’ve said)
c. empathy
d. admit when there are unknown variables/diagnosis (will work to find out the answer
All of the above
*refer to specialists if needed
Meningitis: Which of the following populations are burden most with meningitis in N. meningitidis?
Newborns (6-8 months)
*Tx: all who have direct contact with CSF
Meningitis: N. meningitis is most often seen in children, adults and elderly.
What are high risk populations? Who have higher risks of disseminated disease?
High risk: college, military, close quarters
Dissemination: Complement deficiencies
*meningococcemia = may occur alone/conjunction with this meningitis
Meningitis: Which of the following virulence factors distinguishes Listeria from Strep agalactiaie the likely cause of meningitis
- *causative organism has a capsule; L monocytogenes does not.
- grows well on blood and chocolate agars after 24 hrs.
- no growth on McConkey
Meningitis: Distinguish b/t the virulence of:
- Strep Agalactiae
- E. coli
- L. monocytogenes
- Strep
- -capsule - E. coli
- -capsule - L. monocytogenes
- -facultative intracellular pathogen
- -LLO (phagolysosome escape)
- -ActA (cell to cell spread)
Abdomen: Which of the following is a common pathology indicated by symptoms in the umbilical region?
a. pancreatitis
b. early appendicitis
c. stomach ulcer
d. inflammatory bowel
all of the above
*small bowel, umbilical hernia
Abdomen: Courvoiser’s sign and yellow tone of the skin is most likely indicative of
distended gallbladder
*pancreatic head cancer obstructing duct (see slide)
Abdomen: You perform a shifting dullness test. You expect to hear tympani to percussion until you reach the level of water. When the patient lies on their side, there is a shift in dullness to percussion towards the umbilicus.
This is a confirmatory percussive test for
abdominal ascites
Abdomen: Grading for splenomegaly occurs from 1-5 with 5 being an enlarged spleen. The following describes the grades:
- _____: spleen palpable ONLY on deep inspiration
- ____: spleen palpable on mid-clavicular line
- _____: spleen expands towards umbilicus
- _____: spleen goes past umbilicus
- ______: the spleen expands toward the pubic symphisis
Grade 1-5 respectively
Abdomen: Which of the following is an indication for an NG tube?
a. when you need to know the contents of the stomach
b. when you need to decompress (suck out the stomach)
c. when you need to put something into the stomach
All of the above
*suck out - intractable vomiting due to retained gastric material or pyloric obstruction; backflow of bile
Abdomen: What are absolute contraindications to NG tube?
a. maxillofacial skull trauma
b. actively seizing patient
c. blood transfusion
d. poisoning with corrosive agent (acid, alkali, hydrocarbons, petroleum)
A, B, D
Abdomen: How can you confirm NG tube is placed in the correct area?
- patient can talk normally after placement
- CXR (tip in stomach below diaphragm
- auscultation and inject air into tube
- aspiration of gastric contents from the tube (acid pH)
**perform at least two
Abdomen: The following are indications for what procedure?
- determine the cause of ascites
- detect the presence of pathologic cells (cancer, infection, bacteria)
- therapeutic removal of fluid (pronounced distension or respiratory distress associated with distension)
- To determine if intra-abdominal bleeding is present, or a viscus has ruptured
- Diagnose acute hemorrhagic pancreatitis
Paracentesis
- ***detect presence of pathologic cells
- also as an alternative to diuretic therapy
Abdomen: Contraindications for paracentesis primarily are if you are unsure of the cause (i.e. abdominal distension is due to peritoneal fluid, intestinal distension or presence of a cystic structure). What is important to consider before performing paracentesis?
Don’t tap it until you map it!
*US 1st – look for big black space (fluid)
Abdomen: True/False - Coagulopathy and Thrombocytopenia are NOT absolute contraindications to diagnostic paracentesis, but should be considered if performing large volume paracentesis
True
*concern for bleeding risk (INR > 2.5, platelets <40,000) = fresh frozen plasma and platelets may be needed
Abdomen: A patient presents with sudden severe pain in the abdomen with history of slow worsening. Nothing relieves the pain except farting. Moving makes it worse. Pain is a cramp-like ache with sharp bursts. On PE you note pain upon the release of pressure from the abdomen. Abdomen is rigid/hard and not fully palpable. Patient guards (contract muscles during palpation).
On auscultation you note quiet bowel. You suspect
Acute abdomen
Abdomen: A patient presents with sudden severe pain in the abdomen with history of slow worsening. Nothing relieves the pain except farting. Moving makes it worse. Pain is a cramp-like ache with sharp bursts. Patient states it is “The worst pain he has ever had.”
On PE you note pain upon the release of pressure from the abdomen. Abdomen is rigid/hard and not fully palpable. Patient guards (contract muscles during palpation). On auscultation you note quiet bowel in all 4 quadrants. You suspect
Acute abdomen
- admission and send directly to surgery
- urgent surgical laparotomy
Abdomen: What are 4 indications to proceed with high volume paracentesis?
- suspect infection
- difficulty breathing
- abdominal pain
- umbilical herniation
- rapid accumulation
*avoid inserting needle into vein
Abdomen: A patient with (+) Rovsing’s sign most likely has
Appendicitis
Abdomen: What physical diagnostic test would you perform to determine if abdominal distension is secondary to fat accumulation or ascites
Fluid wave/shifting dullness
Ultrasound
Abdomen: Stair stepping fluid levels on X-ray indicates
Small bowel obstruction
Abdomen: A patient presents with a palpably enlarged gallbladder which is non-tender and accompanied with mild painless jaundice. This is what sign?
Courvesier sign
- often jaundiced
- see slide 50
Abdomen: Palpatory exam reveals distension while percussive exam reveals tympanic notes. (See X-ray slide 51)
You suspect
Volvulus
*surgical emergency
Abdomen: When might you see blood effusion?
Malignancy (tumor, pancreatic mass)
Abdomen: When might you see cloudy/reddish effusion?
bacterial infection
*see slide 56
What does VINDICATE stand for?
- Vascular (stroke, subarach. hemorrhage)
- Infections (meningitis, encephalitis)
- Neoplasm (primary brain tumor)
- Degenerative (alzheimer’s, huntington)
- Intoxication/Iatrogenic (narcotics, OH)
- Congenital (epilepsy)
- Autoimmune (CNS lupus)
- Traumatic (brain injury, epidural hematoma)
- Endocrine/Metabolic (hypoglycemia, thyroidism)
Clinical Reasoning: True/False: Semantic qualifiers are often abstract descriptors that are paired or opposing. Examples include:
- Acute - Chronic
- Sudden - Gradual
- Immediate - Delayed
- Unilateral - Bilateral
- Exudative - Non-exudative
- Tender - non-tender
True
Clinical Reasoning: True/False: It is important to use the best diagnostic test when performing imaging/labs. Thngs to consider are “key labs” or imaging that can help nail down the diagnosis.
For example, elevated troponin for ST segment elevation
True
Clinical Reasoning: When preparing an illness script, it is best to prepare a vertical preparation, that lists the conditions followed by the epidemiologies of each condition, and then time course etc.
True
Lumbar puncture: What are indications of secondary headaches? (SNOOP5)
- Systemic symptoms
- -fever, malaise, meningitis - Neurologic signs
- -mental status change, hemiparesis, diplopia - Older age onset of headache
- -onset after age 50 - Onset of headache attack (peak within 30-60 seconds)
* thunderclap
*Need lumbar spinal tap
Lumbar puncture: Who needs a spinal tap?
a. pain with neck flexion
b. fever w/ altered mental status
c. petechial rash
d. new seizures
e. migraine
A - D
*previous surgery
Lumbar puncture: Which of the following is an indication for a lumbar puncture?
a. Analysis of CSF
b. Staging work-up for lymphoma
c. Measurement of CSF pressure
d. Therapeutic drainiage
e. Injection of agents
All of the above
- Analysis
- -infection, SAH - Staging
- -lymphoma (cell types) - Measurement of pressure
- -pseudomotor cerebri - Therapeutic drainage
- -normal pressure hydrocephalus - Injection
- -contrast, chemotherapy, analgesics, antibiotics and/or antifungals
Lumbar puncture: Which of the following is a contraindication of lumbar puncture?
a. Increased intracranial pressure
b. Infections near the puncture site
c. Planned myelography or pneumoencephalography
d. Coagulation disorders
all of the above
Pressure: mass lesions, blood/fluid
Planned myelography: unless emergent
Infections: shingles, cellulitis
Coagulation: bleeding, epistaxis, coumadin, transfusions, Tx of a-fib
*slides 15, 16, 17
Lumbar puncture: Where are the safe sites to perform a lumbar puncture?
- L3/L4 *CSF/anesthesia
- L4/L5 *epidural
*spinal cord terminates at L1-L2
Lumbar puncture: What steps must be taken before performing a lumbar puncture?
- H and P
- -look for complications/contraindications
- -CT/MRI: lesions/herniation
- -Meds: anti-coags inc. bleeds
- -cellulitis: iatrogenic infection - Discuss procedure
- –indications, alternatives - Obtain consent (conscious)
Lumbar puncture: What should be done during the procedure?
a. find and mark appropriate landmarks for the procedure (L3/L4 or L4/L5)
b. use appropriate PPE (CSF is infectious)
c. Sterility to avoid iatrogenic infection (meningitis)
All of the above
Lumbar puncture: Manometer pressure is evaluated prior to collecting CSF. One there is a CSF return, the manometer can be attached and the pressure measured.
In what position must the patient be in to obtain a proper pressure eval?
Lateral decubitus
- straighten patients legs for accurate reading (falsely elevated with knees flexed)
- fungal meningitis/TB: high opening pressure
Lumbar puncture: CSF fluid (10cc) should be collected in 4 plastic tubes. Tubes should be filled in numeric order. If possible, the CSF that is in the manometer should be used for Tube 1.
What is the exception to this rule?
When trying to remove a large volume of CSF to evaluate NPH
Lumbar puncture: What happens if the CSF is slow to flow?
- ask the patient to bear down or cough (valsalva)
2. reposition bevel (rotate 90 cephalad)
Lumbar puncture: Once CSF has been collected, what are the next steps in the procedure?
- replace stylet and remove needle
- place a band aid over the site
- place patient on back for 45 minutes
*Physician takes speciment to the lab
Lumbar puncture: What are potential complications of lumbar puncture?
a. post-spinal LP headache
b. bloody tap
c. dry tap
d. infection
e. hemorrhage
all of the above
- dysesthesia (bumped nerve fibers)
- post-puncture cerebral herniation
Lumbar puncture: The following are normal numbers for which age group?
- Opening pressure: 7-25 cmH2O
- Protein: 20-120 ml/dl
- Glucose: 2/3 serum glucose
- Cells:
- -Leukocytes 0-10mm
- -RBC’s: 0-675 mm3
Newborns
Lumbar puncture: Typical lab results:
- An elevated WBC count suggests ___
- _____ infections are traditionally associated with a preponderance of PMN’s (leukocytes)
- Traumatic taps will introduce WBC’s and RBC’s into the CSF. Tube 1 will be bloody, but the fluid should clear by tube 4. You can still evaluate bloody fluid (1 wbc/1000 RBC is normal).
- elevated WBC
- Bacterial infection
- all tubes contain blood: SAH
- images slide 31
Cirrhosis: What has been proved in prospective studies to categorize ascites better than total protein based exudate/transudate and better than modified pleural fluid exudate/transudate?
serum-ascites albumin gradient
- <1.1 = no portal HTN; no salt restriction
- > 1.1 = portal HTN; salt restriction
- oral diuretics
Cirrhosis: If there is a high pre-test probability of occurrence of the disease under consideration, what could be performed?
cytology and smear for mycobacteria
Cirrhosis: Initial lab investigation should include an ascitic fluid cell count, total protein and SAAG.
True/False: If ascitic fluid infection is suspected, it should be cultured at bedside in aerobic and anerobic blood culture bottles prior to initiating antibotics.
True
Neurologic exam: Identify the 5 components of the neurologic exam
- Assess mental status, cognition, memory
- Cranial nerve exam
- Reflexes
- Motor
- Sensory
*determine location of abnormality
Neurologic exam: What are symptoms that would indicate the need for a neurologic exam?
A. dizziness/vertigo
b. headaches
c. weakness-generalized/localized
d. numbness/tingling
All of the above
*syncope, seizures, tremors, abnormal movements, stroke-like symptoms, head injury, behavioral changes
Neurologic: Reflex testing allows for assessment of function and coordination of sensory and motor pathways. Stretch receptors in the tendon generate impulses through sensory nerves that travel to the spinal cord and then to LMN’s that produce muscular reflex when struck with a hammer.
Deep tendon reflexes are monosynaptic. What does a normal reflex indicate? Abnormal?
Normal: all components of reflex arc intact
Abnormal: locate pathologic lesion
Neurologic: Examination of the deep tendon reflexes should involve which of the following?
a. perform the exam with the muscle in a neutral position
b. position the extremity so the tendon can be easily struck
c. utilize a gentle, brisk stroke
d. use distracting maneuvers
all of the above
distractors:
- -Jendrassik maneuver (pull fingers apart)
- -Clench another muscle
*grade based on level of muscle contraction
Neurologic: True/False: The grading scale for the deep tendon reflex is scaled from 0 to 4, with 0 meaning no response and 4 meaning very brisk, hyperactive clonus present.
True
Neurologic: Examination of the deep tendon reflexes should involve which of the following?
a. perform the exam with the muscle in a neutral position
b. position the extremity so the tendon can be easily struck
c. utilize a gentle, brisk stroke
d. use distracting maneuvers
all of the above
distractors:
- -Jendrassik maneuver (pull fingers apart; patellar reflex)
- -Clench another muscle
*grade based on level of muscle contraction
Neurologic: List the dermatomes associated with the following:
- Biceps reflex:
- Brachioradialis
- Tricpes
- Knee (patellar)
- Ankle (Achilles)
- C5, C6
- C5, C6
- C6, C7
- L2-L4
- S1
Neurologic: You observe a patient’s gait to try to determine a clinical diagnosis. You note circumduction of the foot on the affected side and flexion or swinging of the hand on the same side.
Cause is most likely due to hypertonicity in flexion and extension with distal weakness in the lower limbs.
Hemiplegia
Neurologic: You observe a patient’s gait to try to determine a clinical diagnosis.
You note universal flexion with festinating gait. Little steps are taken. You suspect
Parkinson’s
Neurologic: You note your patient has a broad stance with wide staggering quality. Patient fall toward the side of illness. Trunk sways when standing still (titubation).
This best describes what kind of gait?
Cerebellar/ataxic gait
Neurologic: Abnormal reflexes include:
- Areflexia/Hyporeflexia
- Hyperreflexia
- Reflex asymmetry
True/False: Areflexia/Hyporeflexia may be a sign of lesions in the spinal nerves or peripheral nerves. However, you must always check your technique to avoid mis-diagnosis
True
Your patient comes to you complaining of difficulty seeing at night. You observe his gait in a dark space and note stomping/stamping. This best describes
Stomping/Stamping gait
*worse in the dark
You observe your patient as she walks to the exam room. You note she walks on her tiptoes with adduction or “scissor-like” gait. You also note flexion of her arms. You suspect
Cerebral palsy
You observe your patient waddling as she walks. When you ask her to lift her leg, the other hip falls to the side due to weak pelvic muscles. This is what kind of gait?
Myopathic/Waddling gait
You observe your patient as he walks. You note high steps and loss of dorsiflexion (foot drop). This describes what kind of gait?
Neuropathic gait (equine/steppage gait)
Your patient displays involuntary writhing movements while seated as well as while walking. This describes what kind of gait?
Choreiform
Neurologic: Abnormal reflexes include:
- Areflexia/Hyporeflexia
- Hyperreflexia
- Reflex asymmetry
_____ sign of upper motor neuron lesions. Clonus (beating, rhythmic contraction)
Hyperreflexia
Neurologic: Abnormal reflexes include:
- Areflexia/Hyporeflexia
- Hyperreflexia
- Reflex asymmetry
____ is associated with focal deficits in nerve roots of peripheral nerve lesions. Loss of bilateral distal tendon reflexes may indicate polyneuropathies
Reflex asymmetry
*patients normally should be symmetric w/ regard to reflex responses
Neurologic: Abnormal reflexes may result from pathologies including
- hypothyroidism
- cortical stroke, spinal cord compression
- Parkinsonism, cerebellar stroke/tumor
- Polio, ALS, peripheral neuropathy
What abnormalities would be seen in these conditions?
- slowed relaxation
- hyperreflexia
- normal to hyporeflexia
- Hyporeflexia
Neurologic: Evaluation of the motor system includes assessment of:
- Body position
- Involuntary movements
- Muscle bulk
- Muscle tone
- Muscle strength
- Coordination
- Gait
Abnormalities may identify a specific site of injury/illness vs. cluster of findings may indicate an underlying disease process. What should be assessed with regard to body position, buscle bulk and muscle tone?
- Body position
- -slumping/leaning to one side - Involuntary movements
- -resting tremors, tics, muscle fasciculations, chorea in the context of the situation/affect - Muscle bulk
- -inspect size, shape, symmetry and signs of atrophy - Muscle tone
- -normal muscles have some tension when relaxed
- -assess for spasticity, rigidity, hypotonia
Neurologic: Evaluation of the motor system includes assessment of:
- Body position
- Involuntary movements
- Muscle bulk
- Muscle tone
- Muscle strength
- Coordination
- Gait
Abnormalities may identify a specific site of injury/illness vs. cluster of findings may indicate an underlying disease process. What should be assessed with regard to strength?
Muscle strength
- -wide variation in normal
- -dominant vs. non-dominant
- -paresis (impaired strength)
- -paralasys/plegia (absent)
- subjective
- effort depends on part of patient-pain/limited understanding of instructions
Neurologic: Muscle strength is graded on a scale of 1-5.
0 =
1 =
2 = active movement WITHOUT gravity
3 = active movement against gravity
4 = active movement against gravity with ____
5 = against gravity with ______ and ______
0 = no muscle contraction 1 = trace 2 = movement without 3 = against 4 = against w/ some resistance 5 = against w/ resistance but NO fatigue
Neurologic: Hoover’s sign is a method to assess whether or not the weakness is real. A healthy patient will flex the right hip and automatically extend the left hip. Hemiparetic patients will have preserved hip extension.
True/False: No movement of the opposite leg may suggest functional weakness.
True
Neurologic: Which of the following is associated with tremors?
a. Parkinson’s
b. postural hyperthyroidism
c. Intention-cerebellar disease (stroke/tumor)
d. multiple sclerosis
All of the above
*anxiety, fatigue
Neurologic: Which of the following is associated with involuntary movements?
a. oral-facial dyskinesias
b. Tics-Tourette’s
c. Dystonia medication side effects, torticollis
d. Athetosis-cerebral palsy
e. Chorea-Sydenham’s chorea with rheumatic fever
All of the above
- Huntington
- Oral facial-dyskensia: late complication of psychotropic drugs and anti-emetics
Neurologic:
- Spasticity is associated with _______ lesions
- Rigidity is associated with _____ lesions
- Flaccidity is associated with ____ lesions
- UMN lesion stroke (chronic)
- Basal ganglia (lead-pipe and cog-wheel Parkinsonism)
- LMN (Guillan barre, spinal shock)
Neurologic: Coordination is evalutaed to assess the integration of nervous system function. It involves assessing:
- Muscle strength (motor)
- Rhythmic movement and posture (cerebellar)
- Balance and coordinating movements (vestibular)
- Position sense (sensory)
What are common tests performed?
- Rapid alternating movements
- Point to point movements
- Gait and standing
Neurologic: Coordination is evaluated to assess the integration of nervous system function. It involves assessing:
- Muscle strength (motor)
- Rhythmic movement and posture (cerebellar)
- Balance and coordinating movements (vestibular)
- Position sense (sensory)
What are common tests performed?
- Rapid alternating movements
- Point to point movements
- Gait and standing
Neurologic: A patient presents for a neurologic exam. While she is seated, you ask her to demonstrate hitting her thigh with one hand, then raising it up, turnning it over and striking the thigh again with the back of her hand.
You then ask her to tap the distal joint of her thumb with the tip of her index finger. These are examples of
Rapid alternating movements
- encourage repeating as quickly as possible
- observe smoothness, rhythm, speed
Neurologic: A patient presents for a neurologic exam. While she is seated, you ask her to demonstrate hitting her thigh with one hand, then raising it up, turnning it over and striking the thigh again with the back of her hand.
You then ask her to tap the distal joint of her thumb with the tip of her index finger.
Finally, you observe as she taps as she taps your hands with the balls of her feet. These are examples of
Rapid alternating movements
- encourage repeating as quickly as possible
- observe smoothness, rhythm, speed
- feet not usually as coordinated as hands
Neurologic: A patient presents for a neurologic exam. You ask her to touch her index finger to yours and then to her nose. You perform this multiple times changing the location of your finger each time.
In addition, you perform the heel to shin test. You ask her to do it with her eyes open and then closed (position sense). These are tests for
Point to point movements
Neurologic: True/False - Coordination abnormalities may be an indication of cerebellar disease. Patients with cerebellar disease cannot rapidly perform one movement following the opposite movement. Alternate movements may be slow and clumsy. Furthermore, movements may be unsteady and patient has little control over the direction, force or speed.
True
ex: finger to nose - patient overshoots the mark and then have to correct
Neurologic: Gait abnormalities can identify patients at risk for fall and may also be part of a constellation of findings to help arrive at a diagnosis. Gait can be tested in many ways such as: Physician observation while guiding patient to evaluation room.
True/False: To avoid falls, Gait testing may be deferred in hospitalized patients unless additional help is present.
True
Neurologic: Which of the following is a test for gait?
a. ask patient to walk across the room, turn around and walk back
b. tandem walking - heel toe in a straight line
c. walk. on the toes and then on the heels
d. hop in place on each foot
all of the above
- shallow knee bend
- rise from sitting position without support (use when hopping/knee bend not appropriate)
Neurologic: Gait that lacks coordination and may lead to instability. It may be a result of cerebellar disease, loss of position sense or intoxication. Tandem walking may reveal presence that was not obvious with regular walking.
Ataxia
- walking on toes and heals - distal muscle weakness
- knee bending issues/seated to standing: proximal weakness
Neurologic: Gait abnormalities include:
- Spastic Hemiparesis stroke
- Scissors Gait cerebral palsy
- Steppage gait foot drop
- Parkinsonian Gait
- Cerebellar ataxia
_____ describes the affected arm flexed/immobile and leg extensors are spastic-drag toe. Legs circumducted
Spastic hemiparesis
Neurologic: Neurologic: Gait abnormalities include:
- Spastic Hemiparesis stroke
- Scissors Gait cerebral palsy
- Steppage gait foot drop
- Parkinsonian Gait
- Cerebellar ataxia
____ stiff gait/short steps/thighs cross forward on each other with each step (walking through water)
Scissors gait
Neurologic: Gait abnormalities include:
- Spastic Hemiparesis stroke
- Scissors Gait cerebral palsy
- Steppage gait foot drop
- Parkinsonian Gait
- Cerebellar ataxia
__ lift the leg high off the floor and slap the foot down
Steppage gait
Neurologic: Gait abnormalities include:
- Spastic Hemiparesis stroke
- Scissors Gait cerebral palsy
- Steppage gait foot drop
- Parkinsonian Gait
- Cerebellar ataxia
___ stooped posture, short and shuffling steps with hastening (festination), turn en bloc
Parkinsonian
Neurologic: The Romberg and Pronator drigt can be performed for gait-stance testing.
- _____ tests for position sense. Patient stands with feet together and eyes open. Ask them to close their eyes for 30-60 seconds. Observe their ability to maintain upright with minimal or no swaying.
- ____ patient stand or sits for 20-30 seconds with both arms straight in from of them and palms up with eyes closed. Assess for pronation. Also, tap the arms downward (they should return to horizontal position)
- Romberg
2. Pronator drift
Neurologic: Abnormal ROmberg can indicate
- Dorsal column disease
- Cerebellar disease
_____ Vision can compensate for sensory loss so the patient does well with eyes open, but loses balance when eyes are closed.
Dorsal column
Neurologic: Abnormal ROmberg can indicate
- Dorsal column disease
- Cerebellar disease
_______ patient has difficulty standing whether eyes are open or closed
Cerebellar
Neurologic: Sensory system assessment includes:
- pain and temp spinothalamic tracts
- position and vibration posterior columns
- light touch spinothalamic and post. columns
- discriminative sensations (tracts and cortex)
True/False - Vibration and position can be assessed in the fingers and toes first
True
Pain: tool safety pin/needle/sharp vs. dull
Temperature: not tested if pain intact; hot or cold tool
Light touch: cotton
Vibration: tuning fork (distal interphalangeal joint
Proprioception: Hold big toe - up and down movements
Discriminative: stereognosis - object by feel; graphesthesia
Neurologic: Special techniques include
- Babinski
- Meningeal (nuchal rigidity; Brudzinki/Kernig)
- Lumbosacral radiculopathy (straight leg raise)
- Asterixis (metabolic encephalopathy)
_____ is when you stroke the patients lateral aspect of the sole of the foot from heel to the ball curving medially. It should cause plantar flexion in the great toe. If it is positive, dorsiflexion occurs.
Babinskin
*CNS lesion,
