DTRs Flashcards

1
Q

Reflexes are an__________________ response ( predictable response is what we are looking for )

A

involuntary, stereotyped

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Reflexes are a unit of ____________ and _____________ function.

A

sensory (afferent)

motor (efferent)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Reflexes depend on ?

A

Intact sensory nerve fibers

Functional synapses in spinal cord

Intact motor nerve fibers

Functional neuromuscular junctions

Competent muscle fibers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

DTRs helpful in ?

A

Can help to localize a lesion

Correlate with motor and sensory findings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

DTR: Ankle (Achilles) ?

A

S1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

DTR: Knee (Patellar) ?

A

L 2, 3, 4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

DTR: Supinator (Brachioradialis) ?

A

C 5, 6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

DTR: Biceps ?

A

C 5, 6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

DTR: Triceps ?

A

C 6, 7

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Cutaneous Reflexes: Abdominal – upper ?

A

T 8, 9, 10

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Cutaneous Reflexes: Abdominal – Lower ?

A

T 10, 11, 12

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Cutaneous Reflexes: Plantar (Babinski) ?

A

L5, S1

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Cutaneous Reflexes: Anal ?

A

S 2, 3, 4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

DTR: To elicit a reflex ?

A

Patient must be relaxed!

Strike briskly with wrist movement

Patient can be supine or sitting for all

**the patient need to be completely relaxed

hit hard enough to get a response ( same strength on each side to elect a reflex)

pointed end for smaller areas and bigger end for bigger area **

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

DTR: Response is affected by your force ?

A

Use as little force as needed to elicit a response

Compare bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Rate DTR’s on ______ scale

A

0-4/4

**pulse 0-3
strength 0-5 ( 5/5 is NL)
reflex 0-4

some people just have really bad reflexes and it can be normal **

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

DTR: 0/4 ?

A

absent, areflexia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

DTR: 1/4 ?

A

low normal, hyporeflexia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

DTR: 2/4 ?

A

average, NORMAL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

DTR: 3/4 ?

A

above average, +/- assoc. with disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

DTR: 4/4 ?

A

very brisk, hyperactive, with clonus

(rhythmic oscillations) hyperreflexia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

DTR: Use _________ for barely detectable response

A

reinforcement

**distracted to improve results **

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

DTR: Isometric contraction of other muscles: UE ?

A

clench teeth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

DTR: Isometric contraction of other muscles: LE ?

A

lock fingers and pull hands

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
DTR: Biceps and location ?
C5, C6 Partial elbow flexion, press on tendon, strike own finger, watch and feel for response **thumb on tendon and then u hit yours thumb ( easier to find the tendon with you thumb) - looking for bicep to control = hand will move or the tendon will tighten up and it will push against your finger ( tighten is most common) **
26
DTR: Triceps and location ?
C6, C7 Partial elbow flexion, strike above olecranon - OR – arm abducted, elbow flexed
27
DTR: Brachioradialis and location ?
C5, C6 Use flat edge of hammer, 1-2” above wrist Hand on lap, partially pronated – watch for forearm supination and flexion
28
DTR: Patellar and location ?
L2, L3, L4 Flex knee, strike below patella
29
DTR: Achilles and location ?
S1 Support foot in neutral position **keep foot in little dorsiflexion because reflex makes foot plantar flex and if it is already in flexion then it has not were to move **
30
DTR: Clonus ?
hythmic oscillation response Eg: Dorisflex and plantar flex foot a few times, then sharply dorsiflex foot, hold it there and feel for “beats” **keep beating after the reflex should be over **
31
Clonus NL ?
A few beats of clonus can be normal if tense or after exercise Sustained clonus can indicate CNS disease
32
Cutaneous Stimulation Reflexes: Plantar (Babinski) and location ?
L5, S1 Use a key or wooden end of cotton applicator Stroke foot, curving medially over ball of foot Normal – plantar flexion Abnormal - fanning of toes
33
Plantar (Babinski) NL ?
plantar flexion
34
Plantar (Babinski) abnormal ?
fanning of toes
35
Cutaneous Stimulation Reflexes: Abdominal Reflexes ?
4 quadrants – upper and lower Stroke toward umbilicus Note umbilical deviation toward stimulus Obesity can mask
36
Cutaneous Stimulation Reflexes: Anal and location ?
S 2, 3, 4 Dull object (cotton swab) Stroke outward from anus in 4 quadrants Watch for reflex contraction of the anal musculature
37
Recording DTR’s NL ?
All reflexes 2+/4 throughout
38
Recording DTR’s abnormal ?
All reflexes 2+/4 except_______ Or diagram
39
Special Maneuvers: Meningeal signs ?
if meningitis is suspected. Don’t do on trauma patients! Neck mobility (nuchal rigidity) – supple flexion Brudzinski’s sign Kernig’s sign * *Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves (neck flexion), the femoral nerve(Brudzinski) or the sciatic nerve (Kernig). * *
40
Brudzinski’s sign positive ?
Positive = flexion of hips and knees in response to neck flexion **flexion of neck stretches femoral nerve **
41
Kernig’s sign | Positive?
Positive = pain b/l behind knee when flexed knee is extended **stretch on the sciatic nerve - sign of meningitis pain behind the knee not just discomfort **
42
Asterixis: Helps identify metabolic _______________ when mental functions are impaired
encephalopathy Liver disease, uremia, hypercapnia
43
Asterixis procedure ?
Ask patient to “stop traffic” – both arms extended, hands cocked up and fingers spread Watch for 1-2 minutes
44
Asterixis positive ?
Positive if sudden, brief nonrhythmic flexion of hands and fingers
45
Stuporous or Comatose Patient: facts ?
Typically evaluation sequence is H&P, Labs These patients require a different sequence of evaluation
46
Stuporous or Comatose Patient sequence of evaluation ?
ABC’s - first Level of consciousness Neuro exam Info from relatives, friends, witnesses
47
Stuporous or Comatose Patient sequence of evaluation: DO NOT DO THESE?
DO NOT Dilate the pupils - can mask signs Flex the neck - make C-spine trauma worse
48
Comatose Patient: ABC's ?
Skin color and breathing pattern Check posterior pharynx, listen for stridor Consider intubation Pulse, BP and RECTAL temp ( more reflective or core temp.) IV access/fluids
49
Comatose Patient: level of consciousness ?
Alert Lethargic – drowsy but arousable. Answers questions, then back to sleep Obtunded – opens eyes, responds but slow and confused Stuporous – require painful stimulus to arouse Comatose - unarousable
50
Comatose Patient : Posture and Tone- In response to painful stimulus NL ?
avoidant
51
Comatose Patient : Posture and Tone- In response to painful stimulus - stereotypical ?
Decorticate - flexion abnormal Decerebrate - extension abnormal
52
Comatose Patient : Posture and Tone- In response to painful stimulus - flaccid ?
no response, no tone Vertical forearm, wrist at 90 Raise arm 12” off bed and drop it
53
Stereotypic response – painful stimulus evokes a postural response : Decorticate rigidity ?
flexor response
54
Stereotypic response – painful stimulus evokes a postural response: Decerebrate rigidity ?
extensor response
55
Decerebrate rigidity lesion location ?
Lesion in diencephalon, midbrain or pons
56
Decerebrate rigidity severe what can cause this ?
Or severe metabolic disorder – hypoxia, hypoglycemia
57
Decorticate rigidity location of lesion ?
Lesion of corticospinal tracts in or near cerebral hemispheres
58
Comatose Patient: 
Oculocephalic Reflex (Doll’s eyes) procedure ?
Hold eyelids open Turn head side to side
59
Oculocephalic Reflex (Doll’s eyes): If brainstem is intact ?
– eyes turn to keep looking at the same spot ** good - the eyes staying pointed forward **
60
Oculocephalic Reflex (Doll’s eyes): If brainstem lesion ?
– eyes move with head * *if eyes go with head = bad! * *
61
Oculovestibular reflex (caloric test)
 procedure ?
Head at 30° Cold water into EAC Eyes deviate toward water if brainstem is intact (initial nystagmus away)
62
Comatose Patient: pupils inspection ?
size, equality, response to light
63
Comatose Patient: pupils - structural cause of coma ?
no response
64
Comatose Patient: pupils - Metabolic cause of coma ?
positive response
65
Comatose Patient: ocular movements ?
eyes should be straight ahead at rest
66
Comatose Patient – Signs of Poor Outcome or Death ?
Absent corneal reflex - wisp of cotton on cornea Absent pupillary response Absent withdrawal response from pain No motor response At 72 hours, no motor response
67
Involuntary Movements types ?
Tremors Orofacial dyskinesias Tics Chorea Athetosis (athetoid movement)
68
Tremors 3 types ?
Resting (Static) Postural Intention
69
Tremor: Resting (Static) ?
↑ at rest, ↓ or gone with voluntary movement ex: Parkinsonism
70
Tremor: Postural ?
↑ with maintaining a posture ex: anxiety, fatigue, hyperthyroidism
71
Tremor: Intention ?
absent at rest, appears with activity, worse as closer to target ex: MLS, cerebellar dz
72
Orofacial dyskinesias ?
Repetitive bizarre movements of face, mouth, jaw, tongue
73
Orofacial dyskinesias are seen with ?
longstanding psychoses elderly edentulous long term complication of certain psychotropic drugs (tardive dyskinesia) **sometimes it is drug induced **
74
Tics ?
brief, repetitive, coordinated movements at irregular intervals
75
Tics examples ?
Wink Grimace Shoulder shrug
76
Tics seen with ?
Seen with Tourette’s, certain meds, etc.
77
Chorea – (choreiform movement) description ?
Unpredictable, non-repetitive brief, rapid, jerky, irregular
78
Chorea can involve what ?
can involve face, head, forearms, hands
79
Chorea can occur at ?
can occur at rest or interrupt activity
80
Chorea examples disease ?
Huntington’s disease
81
Athetosis (athetoid movement) description ?
Slow, twisting, writhing movement of face or distal extremity **twisting movement of hand**
82
Athetosis associated with ?
Often associated with spasticity
83
Athetosis example disorder ?
cerebral palsy
84
Abnormalities of Gait and Posture types ?
Spastic Hemiparesis Steppage Gait Scissors Gait Parkinsonian Gait Cerebellar Ataxia Sensory Ataxia
85
Spastic Hemiparesis lesion ?
Corticospinal tract lesion from stroke
86
Spastic Hemiparesis description ?
Poor control of flexor muscles during swing phase
87
Spastic Hemiparesis affected arm is ?
flexed and immobile
88
Spastic Hemiparesis affected ankle is ?
plantar-flexed and inverted Toe drags, may circle leg stiffly outward or lean leg is not bending **“swing around cause flexors are not really good “ **
89
Steppage Gait seen in ?
Seen in foot drop, secondary to peripheral motor unit disease
90
Steppage Gait | patients either ?
Patients either drag their feet or lift them high with knees flexed and bring foot down with a slap Unilateral or bilateral
91
Steppage Gait cannot ?
heel walk **foot drop so toes dont pick up unless they pick there knee up no heel walking and it can be B/I **
92
Scissors Gait seen in ?
Spinal cord disease ex: CP
93
Scissors Gait description ?
Bilateral lower extremity spasticity Legs are advanced slowly and thighs tend to cross
94
Scissors Gait: gait is ?
stiff
95
Parkinsonian Gait seen in ?
Basal ganglia defects of Parkinson’s
96
Parkinsonian Gait | has _________ posture ?
stooped
97
Parkinsonian Gait: ______ of head, arms, hips and knees
Flexion
98
Parkinsonian Gait | extra facts ?
Slow to start Shuffling gait with short steps Decreased arm swing Patients turn slowly “all in one piece” **once they get going they move faster but they have hard time stopping and run into stuff difficulty initiated gait masked facies **
99
Cerebellar Ataxia | disease of ?
cerebellum
100
Cerebellar Ataxia description ?
Staggering, wide base, unsteady
101
Cerebellar Ataxia have exaggerated difficulty with ?
turns
102
Cerebellar Ataxia: Can’t stand steadily with ?
feet together
103
Sensory Ataxia description ?
Loss of position sense in the legs Wide base, unsteady
104
Sensory Ataxia patients throw ?
Pts throw feet forward, bring them down on heels with a double tap. They watch the ground for guidance Can’t stand steadily with feet together (+Romberg)
105
Sensory Ataxia versus Cerebellar Ataxia ?
two types of ataxia but the gait is similar wide gait cause they dont have balance
106
Screening Neuro Exam -AAN: Mental status ?
Level of alertness, appropriateness of responses, orientation to date and place
107
Screening Neuro Exam -AAN: Cranial nerves ?
Visual acuity, pupillary light reflex, EOM’s Hearing Facial strength – smile, eye closure
108
Screening Neuro Exam -AAN: motor system ?
Strength – shoulder, elbow, wrist, finger, hip, knee, ankle Gait – casual and tandem Coordination – fine finger movements, finger-to-nose
109
Screening Neuro Exam -AAN: sensory system ?
One modality at toes (light touch, pain/temp or proprioception)
110
Screening Neuro Exam -AAN: reflexes ?
DTR’s – biceps, patellar, Achilles Plantar response (Babinski) If anything is suspicious, then more complete exam is required
111
Neurologic Exam: last slide ?
Use your equipment for visual cues Sample write up p.739 Bates