Clinical assessment quiz 2 Flashcards
Why neurological testing?
test coordination of afferent/efferent impulses (to/away from CNS)
regions of body supplied by spinal nerves
8 cervical spinal nerves
12 thoracic spinal nerves
5 lumbar spinal nerves
5 sacral spinal nerves
myotomes and dermatomes
spinal nerves have
motor fibres
sensory fibres
motor fibres of spinal nerves
innervate certain muscles
sensory fibres of spinal nerves
innervate certain areas of skin
dermatome/myotome pattern – is it consistent between different people?
despite slight variations, pattern distribution is relatively consistent b/w people.
Dermatome =
skin area innervated by sensory fibres of a single nerve root
Dorsal vs Ventral roots of spinal nerves
Dorsal root = Afferent fibres enter CNS via “
Ventral root = Efferent fibres exit CNS via “
dermatome vs dorsal roots
bilateral area of skin associated with pair of Dorsal Roots from spine
why is dermatome region important?
pain following dermatome region may indicate spinal damage or neurological stenosis
E.g. Compressed spinal nerve may show as pain elsewhere (E.g. @ Dermatome region)
other clinical significances of DERMATOMES
finding site of damage to spine
E.g.
Viruses that affect spinal nerves – E.g. Herpes Zoster
“MIGRATES ALONG SPINAL NERVE TO AFFECT ONLY AREA OF SKIN SERVED BY THAT NERVE”
“Symptoms are usually unilateral but in the immune suppressed, they are more likely to become bilateral and symmetrical, meaning that the virus is present in both ganglia of a dorsal root ganglion pair.”
MYOTOMES
group of muscles innervated by the Motor fibres of a single nerve root (VIA VENTRAL ROOT OF SPINAL NERVE)
DEEP TENDON REFLEXES
assess the functioning of nerve or nerve roots supplying the reflex
how is DTR caused?
stretching of muscle spindle
” synapses via sensory neurons to spinal cord then back via motor neurons
What happens when DTR is absent?
spinal cord, nerve root, peripheral nerve or muscle has been damaged
when response is weak/abnormal – indicates disruption of sensory and/or motor neurons
CLONUS
“When reflexes are very brisk, clonus is sometimes seen. This is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch.”
clonus = “muscular spasm involving repeated, often rhythmic, contractions.”
DTR ratings/scale
0: absent reflex
1+: trace, or seen only with reinforcement
2+: normal
3+: brisk
4+: nonsustained clonus (i.e., repetitive vibratory movements)
5+: sustained clonus
normal vs. abnormal DTR reflex
Deep tendon reflexes are normal if they are 1+, 2+, or 3+
Reflexes rated as 0, 4+, or 5+ are usually considered abnormal.
clonus, hyperreflexia
In addition to clonus, other signs of hyperreflexia include spreading of reflexes to other muscles not directly being tested and crossed adduction of the opposite leg when the medial aspect of the knee is tapped.
hyperreflexia
Hyperreflexia happens when your muscles have an increased or overactive reflex response.
What is being tested during DTR test?
DTR reflex diminished during problems in
A) muscles
b) sensory neurons
c) lower motor neurons
d) NMJ
e) upper motor neurons (acute lesions)
f) joints (joint disease = mechanical factors)
abnormally increased reflexes =
upper motor neuron nerve lesions
DTR reflexes variables of influence
age
metabolism
thyroid dysfunction
electrolyte imbalances
mental state (e.g. anxiety)
why it is important to repeat the test multiple times (5-6 times)
to ensure consistent response
(inconsistent response can indicate pathology – E.g. fading response due to nerve root lesion)
two point test (pin prick assessment)
ability to discern two distinct points touching skin
often as two sharp points touching a part of skin
E.g.
two points @ 2-4 mm apart should be felt on lips and finger pads
two points @ 8-15 mm on palms
two points @ 30-40mm on the shins or back
(points are at same dermatome)
BP
force of blood pushing against walls of arteries
units for BP
mm HG – mm of mercury
why two readings?
pressure changes when heart contracts/relaxes – therefore two readings
SYSTOLIC and DIASTOLIC
systolic
heart contracts and forces blood into vessels
diastolic
heart is relaxed
blood filling up inside heart
BP varies – variables
lower when at rest
higher when active
lying down vs standing up
emotions
pregnancy
smoker or not
medication
environment
acceptable BP?
less than 140 / 90
140 systolic
90 diastolic
120/80 = optimal
BP chart
<130, <85 = Normal
130-140, 85-90 = high normal
140-160, 90-100 = stage 1 hypertension (mild)
160-180, 100-110 = stage 2 hypertension (moderate)
180-210, 110-120 = stage 3 hypertension (severe)
210 or more, 120 or more = stage 4 (very severe)
how many BP reading per year?
once when healthy
> 1 if heart condition
danger of high BP
too high = blood vessel can burst
burst in brain = stroke
burst in vessel leading to heart = heart attack
other danger of high BP
damage BV wall
lead to fatty plaque build up (ATHEROSCLEROSIS)
atherosclerosis and stroke/heart attack
piece of plaque breaks
blood clot forms
blocks blood flow to brain or heart
= stroke or heart attack
BP for patients with diabetes or kidney disease
<130 mmHg systolic
<80 mmHg diastolic
note about reliability of single BP reading
single high reading does not necessarily indicate high BP
should be tested at another time to confirm
high BP diagnosis not based on single reading
BP assessment environment
create calm environment
keep patient relaxed
minimize disturbance
pulse?
usually accurate measure of heart rate
when is pulse not measuring heart rate correctly?
pathologies
some heart beats not strong enough to stretch aorta –> create palpable pressure wave
i.e.
Pulse is irregular and heart rate can be higher than pulse rate
E.g.
Some arrhythmias
what to do if pulse is not a reliable measure of heart rate?
when pulse is not accurate, stethoscope should be used
“auscultation of heart apex”
normal heart rate / pulse
60-100 BPM
exception
“well-conditioned” athletes can have resting heart rate lower than 60BPM
bradycardia
lower than 60BPM heartrate at rest
tachycardia
greater than 100BPM heartrate at rest
heart rate during sleep
as low as 40BPM
heart rate during exercise
150-200BPM for intense physical activity
heart rate / pulse in young children and infants
higher
resting heart rate of infant
average 110BPM
close to adult’s pulse rate during exercise
how to check pulse
count beats in period of time
E.g. 15 seconds
multiply by 4
when faster when slower
slower at rest
E.g.
faster during stress, exercise, or fever
which fingers to feel pulse
usually fingertip pads of 2nd and 3rd digits
common pulses that can be felt
Temporal Artery
Facial Artery
Common Carotid Artery
Brachial Artery
Radial Artery
Ulnar Artery
Femoral Artery
Popliteal Artery
Posterior Tibial Artery
Dorsalis Pedis Artery
the dermatomes
C1-8
T1-2
L1-5
S1-2
the myotomes (lower extremity)
L1/L2 = hip flexion
L3 = knee extension
L4 = ankle dorsiflexion
L5 = big toe extension
S1 = plantar flexion
= hip extension
= ankle eversion
S2 = knee flexion
the myotomes (upper extremity & head)
C1/C2 = neck flexion
C3 = neck side flexion
C4 = shoulder elevation
C5 = shoulder abduction
C6 = elbow flexion & wrist extension
C7 = elbow extension & wrist flexion
C8 = thumb extension, ulnar deviation
T1 = digit abduction/adduction
the DTRs
C5/C6 = biceps
C6 = brachioradialis
C7 = triceps
L4 = patellar
L5 = medial hamstrings
S1 = achilles tendon (gastrocnemius/soleus?)
