Clin Assess Flashcards
Reflects patient’s capacity for arousal or wakefulness, determined by level of activity that patient’s can be aroused to perform in response to stimuli from examiner
Level of consciousness
What should you not do if patient in stupor or coma?
Do not dilate pupils and do not flex neck if any question of trauma to head or neck
What can you do to evaluate for head or neck trauma?
X-ray!
Using normal tone of voice, patient’s arousal intact; responds fully & appropriately
Alert
Using loud tone of voice, patient appears drowsy but opens eyes and responds then falls asleep
Lethargic
Shake patient gently; patient opens eyes, but responds slowly, somewhat confused
Obtunded
Apply painful stimulus to arouse patient from sleep, cereal responses slow/absent, unresponsive when stimulus ceases
Stuporous
Unarousable with eyes closed after repeated painful stimuli, no response to environment
Comatose
Patients with a Glasgow coma scale score of 3-8
Coma
3 components of Glasgow coma scale?
Eye opening, motor response, verbal response
Small or pinpoint pupils, large pupils, mid position fixed pupils, one large pupil
Pupils in comatose patients
No pupillary reaction to light
Problem in midbrain (structural lesion or compression)
Constricted or dilated pupils
Metabolic/toxic exposure
Two meningeal signs
Brudzinski’s sign and Kerning’s sign
Positive if flexion of both hips & knees is noted when neck is flexed
Brudzinski’s sign
Positive if pain & increased resistance is noted to straightening the knee after hip and knee are flexed
Kernig’s sign
Patient extends both arms with hands cocked up. Positive if sudden, brief, nonrhymic flexion of hands and fingers
Asterixis
What does Asterixis test for?
If mental function is impaired and may indicate metabolic encephalopathy
Smell
CN I
Visual acuity, visual fields, and fundoycopic exam
CN II
Pupillary reactions (direct and consensual)
CN II, III
Extraocular movements (including convergence)
CN III, IV, VI
Corneal reflexes, facial sensation (3), clench teeth
CN V
Facial movements
CN VII
Hearing (whispered voice)
CN VIII
Swallow, say “ah”, and gag reflex
CN IX, X
Voice and speech
CN V, VII, X, XII
Shoulder and neck movements
CN XI
Tongue symmetry and position
CN XII
Tests for lateralization
Weber test
Lateralizes to impaired ear
Positive Weber for conductive hearing loss
Lateralizes to good ear
Positive Weber test for sensorineural hearing loss
Tests for air and bone conduction
Rinne test
AC>BC
Positive Rinne for sensorineural hearing loss
BC=AC or BC>AC
Positive Rinne if conductive hearing loss
Increased tone; rate-dependent, increasing with rapid movement (e.g. stroke)
Spasticity
Increased resistance throughout ROM, not rate-dependent; “lead pipe rigidity.” Rachetlike jerkiness with flexion/extension of wrist or forearm “cogwheel rigidity” (e.g. parkinsonism)
Rigidity
Marked floppiness (eg Guillain-Barre & spinal shock)
Flaccidity
Sudden change in tone with passive ROM (e.g. dementia)
Paratonia
Deltoid and biceps (shoulder abduction and elbow flexion)
C5
Bicep flexion and wrist extensors
C6
Triceps, wrist flexors and finger extensors
C7
Finger flexors and interossei muscles (aB and aD duction of fingers)
C8
Interossei muscles ONLY
T1
Head
C1-C2
Diaphragm, breathing
C3-C4
Hip flexion
L2
Knee extension
L3
Ankle dorsiflexion
L4
Great toe extension
L5
Ankle plantar flexion, ankle eversion, hip extension
S1
Knee flexion
S2
Patient extends both arms and pushes against a wall
Winging of Scapula
Do this test if shoulder muscles seem weak or atrophic
Winging of scapula
If medial border of scapula juts backwards
Positive winging of scapula
What can a winging of the scapula suggest?
Weakness of serratus anterior muscle, seen in muscular dystrophy or injury to long thoracic nerve
When do you test straight-leg raise?
If patient has low back pain with lumbosacral radiculopathy
Pain radiates into ipsilateral leg (foot dorsiflexion can further increase leg pain)
Positive SLR
What is noted in rapid alternating movements in cerebellar disease?
dysdiadochokinesis
What is noted in gait in cerebellar disease?
ataxia
Stand with feet together and eyes open, then close eyes for 30-60 secs, only minimal sway should occur
Romberg test
Stand for 30 seconds with arms straight forward, palm up and eyes closed. Then tap arms briskly downward
Test for Pronator drift
What does Pronator drift test?
Proprioception
If touch and position sense are intact, what type of testing should you proceed to?
Discriminative sensations to test the sensory cortex
stereognosis, graphesthesia, two-point discrimination, point localization, and extinction
Discriminative sensations for sensory cortex
Ankle reflex
primary S1
Knee reflex
L2, L3, L4
Brachioradialis reflex
C5, C6
Biceps reflex
C5, C6
Triceps reflex
C6, C7
At what DTR level would you test for clonus?
4+
Dorsiflex and plantar flex foot a few times then sharply dorsiflex food and hold - look and feel for rhythmic oscillations between dorsiflexion and plantar flexion
Clonus
What can positive clonus indicate?
Central nervous system disease
Lesion in lower motor neuron
hypofunction
Lesion in upper motor neuron
hyperfunction
What nerves innervate above umbilicus?
T8, T9, T10
What nerves innervate below umbilicus?
T10, T11, T12
What can an absent abdominal reflex indicate?
central or peripheral nerve disorder
Stroke lateral aspect of sole from heel to ball of foot, curving medially across the ball and note the movement of the great toe
Babinski response
What nerves does Babinski test?
L5, S1
Positive if dorsiflexion of great toe
Babinkski
What does positive Babinski indicate?
CNS lesion in corticospinal tact, unconscious states from drugs/alcohol intoxication, postictal period after seizure
Loss of reflex contraction of the anal reflex may indicate what?
Cauda equina lesins (S2, S3, S4)
