Exam 2 Material Flashcards
Where is the visual center located in the brain?
Occipital lobe
Half of the neocortex is involved with processing visual information
What protects the eye?
Protected by the bony orbital cavity and cushioned by fat 3/4 protected by bone, 1/4 protected by eyelids
Palpebral fissure
Where eyelids touch
Limbus
White goes into color; cornea and sclera
Pupil
Absence of tissue; aperture of the eye
Medial and lateral canthus
Corners of the eye
Conjunctiva (palpebral and bulbar)
Always clear unless pathology is present
Lacrimal apparatus
Tear glands
Palpated in exam to determine if there is lacrimal reguritation
Extraocular muscles
Multiple muscles that are attached to the eyeball that twists and turn the eyeball to where it needs to go.
Innervated by cranial nerves III, IV, and VI
CN IV allows eyes to look toward the nose
CN VI lets the eyes look laterally
CN III does all other movements
If eye is not moving correctly, what is the likely cause?
Innervation problem. Muscles normally are fine unless there is trauma.
What cranial nerve innervates the extraocular muscles that moves the eyes laterally?
CN VI
What cranial nerve innervates the extraocular muscles that moves the eyes toward the nose
CN IV
Layers of the eye
The eye is a sphere of three concentric coats
- Outer layer -sclera
- Middle layer - choroid: ciliary body, iris, pupil, lens, anterior chamber
- Inner layer - retina: optic disc, retinal vessels, macula
What is the center of vision in the eye
Macula
Does not coincide with where the optic nerve innervates
Dense cones and rods
Fovea: center of the macula - highest density of cones, no rods
What is in the retina
Macula (center of vision) and optic disc (where the optic nerve is attached to the eye)
Visual reflexes
- Pupillary light reflex (direct light reflex vs consensual light reflex)
- Light causes pupils to constrict
- Both eyes should constrict evenly with light shown only in one eye
- Accomodation
Vision pathway
Light to cornea to lens to retina to nerve impulses to optic nerve to visual cortex
What happens to depth perception when blind in one eye?
Do not have depth preception
Health history questions for eyes
- Vision difficulty? acuity, blurring, blind spots
- Pain
- Strabismus, diplopia
- Redness, swelling
- Watering, discharge
- Past history of eye problem
- Glaucoma
- Use of glasses or contact lenses
- Self-care behaviors - make up?
Equipment needed for Eye Exam
- Snellen or Rosenbaum
- Opaque card
- Penlight
- Ophthalmoscope
Snellen/Rosenbaum
Tests visual acuity (CN II)
Myopia
- Near sighted
- Flatter eyeball; more oblong
- Light focuses in front of the retina
- Develops in childhood
Hypermyopia
- Far-sighted
- Retina is too high
- Light focuses behind the retina
- Develops in childhood
How do glasses help with vision acuity?
Change the way the light foces so that it is cetnered on the macule
Hyperopia uses convex lenses
Myopia uses concave lenses
What is an astigmatism?
- Cornea or lens are curved irregularly/enevenly (not round)
- Causes a fuzzy or distorted vision
- Refraction of light does not focus the right way
- Often causes halos and glare at night
- Sometimes can be corrected
- Brain learn to compensate
Corneal Light Reflex (Hirschberg Test)
- Shine a light in the middle of the nose and see where the light reflects
- If pupils are not in the same position, the light will reflect in different places
- Not about being symmetric, it is about being in the same spot
- May look cross eyed, but not
Cover Test
- Detects small degrees of stabismus (lazy eye) by interrupting fusion reflex that normally keeps eyes parallel
- Ask the person to stare straight ahead to your nose even though gaze may be interrupted
- With a card, cover one eye
- Not uncovered eye normal response: steady fixed gaze
- If muscle weakness exists, covered eye will drift into a relaxed position
- Uncover the eye and observe it for movement - it should be straight ahead; if it jumps to reestablish fixation, eye muscle weaness exists
Causes of strabismus
Lazy eye
Eyeball is not turned in the right direction (typically a nerve issue, can be muscular)
Eye patches are used to cover the good eye to try to strengthen the bad one
6 Cardinal Fields of Gaze
Tests muscles and their innervations
Can tel if someone has a beat - neurological impairment
PERRLA
- Pupils
- Equal
- Round
- Ractive
- Light
- Accomodation: pupils dilate at a distant and constrict and converge when object is closer
Blepheritis
Inflammation of the eylash follicles
Hordeolum
Stye
Focal acute infection of the eyelash follicle or less commonly the meibomian gland
Chalazion
Eyelid cyst
Obstruction of the meibomian gland; may become chronic
Not necessarily injected, just blocked
Conjunctivitis
Pink eye
Hemotoma of the conjunctiva
Superficial; does not go into the iris; between the conjunctiva and sclera
Can breakthrough the sclera and “bleed”
Can’t do anything about this
Can happen when sneezing or on blood thinners
Bruise on eye
Senile plaque
Found on the sclera
Normal
Icterus
Jaundice of the eye
Lacrimal examination
Pressing on the lacrimal duct to see if there is regurgitation
Use of the ophtalmoscope
Diopters
Lens opening
The red refelx
Red Reflex
Reflection of the light on your retina
A tumor or cataracts: light goes right through
CANT do with a penlight
Can be seen with cameras
Eyesight and infants/children
- Macula is absent at bith, it is fully developed by 8 months
- Why babies have no focused vision
- Infants are born farshighted (80%) but decreases after 7-8 y
- Some kids will grow out of their glasses
- Eyeballs reach adult size by 8 years
Arcus senilis
Fat deposits on the cornea; gray or white visible arc
Normal varian; does not really do anything to them
Occurs in older adults
Ectropion
Eyelid flips open and dries out the eye
Occurs in older adults
Entropion
Eyelashes in the eye (mostly lower eyelid)
Many infections
Needs to be surgically corrected
Occurs in older adults
Adults and eyes
- Pupil size decreases
- Lenses loses elasticity, becomes hard and glasslike, which decreases its ability to change shape to accomodate for near vision (Presbyopia)
- By age 70, normally transparent fibers of lens begin to thicken and yellow, the beginning of cataracts
- Visual acuity may diminish graduallly after age 50, and more so after age 70
Ears
Sensory organs for hearing and maintaining equilibrium and have three parts:
External ear
Middle ear
Inner ear
Parts of the middle ear
Malleus, incus, and stapes
Eustachian tube
Parts of inner ear
Vestibule and semicircular canals
Cochlea
Eardrum/tympanic membrane
- Far into the skull
- Nor really going to damage it with an otoscope
- Have to pull ear in certain directions to angle the otoscope to see through
- Can still hear if it is broken
- Ear infections often have fluid that is backed up behind the membrne
- Membrane should be pearly gray, intact, and translucent
Middle ear bones
- Malleus, incus, and stapes
- Bones create waves tha transmit the sounds to the nerves
- Can be out of place after trauma
- Can’t hear when the bones are out of place - nothing is transmitting the pulsations
Cristae
Part of the inner ear
They move to give a sense of position in space (proprioception)
3 levels of the auditory system
Peripheral
Brainstem
Cerebral cortex
Conductive hearing loss
Problem with the impulse
Trauma can cause this
Sensorineural (perception) hearing loss
Problem with the nerve conducting the impulse to the brain
Could be problems with the brain
Equilibrium problems in the ear
Inner ear problems
Not really a hearing problem - can cause tenatis (ringing)
Pathway of hearing
Sound waves travel to the ear and produce vibrations on the typanic membrane.
Vibrations are carried by the middle ear ossicles to the oval window.
From the oval window, it travels through the cochlea to the round window.
Basilar membrane vibrates as well that has receptor hair cells of the organ of Corti.
As the hair cells bend, it sends electrical impulses to the brainstem by CN VIII.
Brainstem determines the direction of the sound and identification of the sound.
Cortex interprets the sound and the appropriate response.
How can a hearing aid attached to the skull amplify sounds?
Sound waves can go through the skull
Exostosis
Bone spur or malformation that prevents the sound waves from reaching the tymanic membrane
Otitis media with effusion
Can cause hearing loss
Serum in middle ear that transudes to relieve negative pressure from the blocked eustachian tube.
May see air bubbles or fluid level.
Hearing loss due to cochlea damage
Sensorineuro - can’t normally fix sensorineural, can normally fix conductive hearing loss
What frequency is typically lost first?
High frequency
Equipment needed for an ear exam
Otoscope with a bright light
Tuning fork in 512 Hz (cut of normal hearing - hearing acuity test)
Inspection/palpation of the external ear
Palpate for tenderness, not really trying to feel for something
Observe the size and shape, skin condition, external auditory meatus (canal)
Ears and brain formation
Ears form when the brain forms.
Can often twll if there is a brain concern by observing the ears.
Low set of ears can be a sign of Down’s.
Darwin’s tubercle
The same as the tip of an ear of a dog/cat.
Present in 10% of people
External Otitis
Ear infection of the outer ear.
Swimmer’s ear
Swelling can be so bad it can shut.
Hearing acuity test
Can assess during conversational speech - turn away to see if they respond and are not just reading your lips.
Voice test: 3 numbers/letters standing behind them they can repeat back.
Weber Test
Tuning fork test
- Hold the tuning fork at the stick
- Squeeze prongs together
- Measure sbone conduction
- Should be able to hear sound bilaterally
- If they do not, it is a sound processing issue (sensoineural)
Renne Test
Measures air and bone conduction
- Set off tuning fork
- Put tuning fork behind the ear with the tuning fork angled down (pointing away from the ear)
- Then tak ethe fork of when they can’t hear it any more and put it next to the ear to see if they can still hear
- Air conduction should be greater than bone conduction - they can still hear after the fork is removed
Otoscopic examination
- Position the head and ear
- Down and out for adults
- Up and out for infant (up to 3)
- Method of holding the otoscope (whatever is comfortable)
- External canal (color, swlling, lesions, dishcarge)
- Cerumen usually present - normal mechanism of the ear to lubricate and clean
- Dry cerumen: gray and flaky
- Wet cerumen: honey brown to dark brown and mist
Normal tympanic membrane (TM)
- Color: see-through, white/gray
- Characteristics: flat
- Should be intact
- Cone of light - always pointing toward the jaw
- 5 o’clock: right ear
- 7 o’clock right ear
Retracted Tympanic membrane
- Tympanic membrane is pulled backward
- Dehydrated
- Makes the bone stick out - like cellophane wrap over the bones
- Cone of light is not distinct and not in correct location
Bulging tympanic membrane
- May see air bubbles
- Fluid is behind the membrane
- Erythematous
- Fluid is a sign of infection - may be a sinus infection
Tympanostomy
Tubes in tympanic membrane to equalize the pressure
Should fall out on their own
If they do not fall out, they may be overgrown but still left unless there is a problem
Ears of older adults
- Cilia become coarse and stiff
- Cerumen is dryer - why there is cerumen impaction
- Result is ofter impacted cerumen and hence conductive hearing loss
Presbycusis
- Hearing loss that occurs with aging
- Sensorineural loss caused by nerve degeneration
- Starts to occur around 50 and slowly progresses
- High-frequency tone loss
- Ability to localize sound is also impaired
- Not much you can do about it
Process of Swallowing
- Tongue elevates to soft palate when bolus is placed in the oral cavity
- Positive pressure is applied to the bolus tail
- Epiglottis comes down and closes the entrance of the trachea - prevents aspiration
- Many different things can go wrong - makes it difficult to diagnose what the dysfunction is
Nasal cavity
- Surrounded by bony structures with sinuses behind
- Lined by mucosa
- Polyps can grow and form an obstruction (occurs often with allergies and infections)
- Openings into the cavity:
- Eustachian tube
- Tear ducts - why we blow our nose when we cry
- Frontal sinus
- Most of the nose is cartilage, only top third is bone
Function of the nose:
Warms, moistens, and filters inhaled air
Is a sensory organ of smell
Air is turbulent in the cavity
Septum of the nose
Anterior part of the septum hold a rich vascular network, Kisselbach’s plexus (most common site of nosebleeds - why we put pressure on the nose).
Separates nostrils (naris)
Turbinates and meatus
- Lateral walls of each nasal cavity contain three parallel bony projections: superior, middle, and inferior turbinates
- Underlying each turbinate is a cleft, the meatus, which is named for the turbinate above
- Sinuses drain into the middle meatus
- Tears from the nasolacrimal duct drain into the inferior meatus
Paranasal sinuses
- Two are accessible to examination
- Frontal sinuses: in frontal bone above and medial to orbits
- Maxillary sinuses: in maxilla along side walls of nasal cavity
- Non-accessible, smaller and deeper:
- Ethmoid sinuses: between the orbits
- Sphenoid sinuses: deep within skull in the sphenoid bone
What sinuses are present at birth?
Maxillary and ethmoid
- Maxillary sinuses full size after all the permanent teeth have erupted
- Ethmoid snuses grow rapidly between 6-8 years and after puberty
- Frontal sunses (absent at birth) are fairly well developed bytween ages 7 and 8, reach full size after puberty
- Sphenoid sunses are minute at birth and develop after puberty
What age can you assess sinuses?
8
Function of the mouth
Functions in the digestive and respiratory systems
Parts of the mouth
- Hard and soft palates
- Tongue
- Uvula (should be straight)
- Salivary glands: parotid, submandibular, sublingual
- Lingual frenulum
- Teeth
Salivary glands
Parotid, submandibular, sublingual
Can get blocked, have a stone, get inflamed, get an infection
What gets snipped in a tongue tie?
Lingual frenulum
Why are teeth important?
Can get systemic infections from a tooth infection because they grow from bone
Can show how the body is functioning
Parts of the throat
Tonils
Nasopharynx
Equipment needed for nose, mouth/throat exam
Otoscope or penlight
Gloves
Tongue blade
Alcohol swab and coffee or other intense smelling substances
External nose exam
- Is it striaght? Has light bend or extensive?
- Test patency of nostrils - with smells
- Olfactory sense CN I
Nasal cavity exam
- Look for color, polyps, exudate
- Nasal septum - straight?
- Turbinates
Why is it important to look under the tongue?
Common site for mouth cancers because it is the site of salivary glands
Mouth exam
- Lips
- Teeth
- Gums
- Tongue
- Under the tongue
- Buccal mucosa
- Hard and soft palate
- Uvula
- Tonsils
- Pharynx
What cranial nerve causes tongue movment?
CN XII
Tonsil grading
+4 = kissing tonsils
+3 = touching uvula
+2 = prominent tonsils
+1 = have to look to see them
Cranial neves in swallowing/gaging
CN IX and X
Mucocele
- Little blister in the mucosa
- From trauma
- Usually benign
Mumps
- Infection of the salivary glands
- Usually unilateral
- Can cause infertility, especially in males
Torus Palatinus
Tumor - can be malignant or benign
Needs to be excised
Normal variation in the hard palate
More common in American Indians, Inuits, Asians and females
Cleft Palate/Lip
- When it is split all of the way, it needs to be fixed
- Effects nutrition, risk of infection, failure to thrive
- Fixed with bone grafts
- Bone is missine
- Sometimes needs multiple surgeries
- Surgery is often done around age 3
- Often those with cleft palates have ear infections
Vagal reflex
Pressure on the vagus nerve causes the heart rate to drop and can cause syncope
Can put pressure on the vagal nerve to help with tachycardia
CN X
Glossopharyngeal Nerve (CN IX)
Specific to the tongue and throat
Coodinates most of the movement with swallowing
Issues with swallowing after stroke due to this nerve
Hypoglossal nerve (CN XII)
Innervates the botton of the tonuge
Movement of the tongue (lower 2/3)
Should innervate equally bilaterally - why it should stick out straight
Stroke can cause it to go TO THE SIDE THE STROKE OCCURRED on
Allergic salute
Permanent crease in the nose due to wiping nose from allergies
Pediatric mouth teaching
- Saliva and drooling at 3 months
- Does not mean they should have teeth
- No bottle to bed
- Fluoride - stabilizes enamel
Pediatric Throat Assessment
- Tonsils: many variations in size
- Some children normally have “kissing” tonsils
- Important to compare over time and assess other symotoms
- Always remember to consider the ear, nose, mouth, and throat for a foreign body
- Symptoms: foul ordor, purulent drainage, and wheezing if aspirated
Changes in older adult nose and mouth
- Nose appears more prominent
- Subcutaneous tissue in the face becomes diminished
- Nasal hairs grow coarser
- Diminished sense of smell
- Decreased number of taste buds
- Why older people use more salt
- Affects flavor of food
- Changes in teeth
- Loss in gingiva, discoloration, loss of bone density
Non-synovial joints
Bones united by fibrous tissue or cartilage
Synovial joints
Freely moveable
Have synovial membranes and/or bursa
Number of bones in the body
206
Types of bone
- Trabecular
- Spongy
- Produces red blood cells
- Ends of long bones, pelvis, ribs, vertebrae, and skull
- Cortical
- Dense and strong
- 80% of skeletal mass
- Less bioactive
- Carrying part of the bone
- Hollow with bone marrow
Cartilage
Avascular
Receives nourishment from synovial fluid
Stable connective tissue with a slow cell turnover
Tough, firm consistency, yet flexible
Cushions bones and gives a smooth surface to facilitate movement
Ligament
Fibrous bands that go from bone to bone
Help prevent undesirable movements
Tendon
Strong, fibrous cord that connects muscle to bone
Bursa
Sac full of synovial fluid
Bone
- A dynamic tissue that is in constant turnover
- Basic multicellular unit (BMU)
- Calcium deposits are the bone structure
Osteoclast
Remove bone
Osteoblasts
Replace bone
Osteocyte
The actual bone cell
Bone remodeling
- Activation: pre-osteoclasts are stimulated and differentiate under the unfluence of cytokines and growth factors into mature active osteoclasts
- Resorption: osteoclasts digest bone mineral matrix (old bone)
- Reversal: end of resorption
- Formation: osteoblasts synthesize new bone matrix
- Quiescence: osteoblasts become resting bone lining cells on the newly formed bone surface
Muscles
- Account for 40-50% of the body’s weight
- Muscle mass declines by 8% a year after 40 and 15% a year after age 70
- Important to determine if muscle loss is sudden or over time
- Three types: skeletal, smooth, and cariac
Skeletal muscle
- Voluntary muscles under conscious cotnrol
- If there are involuntary movements, there is something wrong
- Each skeletal muscle is composed of bundles of muscle fibers, or fasciculi
- Skeletal muscles are attached to bone by tendons, a strong fibrous cord
Tempromandibular joint
Temporal bone and condyle of mandible
Connected to a muscle in a joint capsule
Structure of the spine
- 7 Cerival
- 12 Thoracic
- 5 Lumbar
- 5 Sacral
- 3-4 cocygeal
Spine and Age
- With age, intervertebral disks shrink - why people shring
- With age, kypohsis often develops
Shoulder
- Glenohumeral joint: articulation of the humerus with glenoid fossa of scapula
- Ball-and-socket action allows mobility of arm on many axis
- Rotator cuff: group of four muscles and tendons support and stabilize shoulder
- Palpable landmarks to guide your examination
- Scapula and clavile form the shoulder girdle
- Can feel the bumb of the scapula acromion process at the very top of the shoulder
Elbow
- 3 bony articulations: humerus, radius, ulna
- Hinge action moves forearm (radius and ulna) on one plane, allowing flexion and extension
- Palpable landmarks:
- Medial and lateral epicondyles of humerus
- Olecranon process of ulna
- Radius and ulna articulate with each other at two radioulnar joints, one at the elbow and one at wrist
- Permit pronation and supination of hand and forearm
Wrist and Capals
- Radiocarpal joint
- Midcarpal joint
- Metacarpophalangeal joints
- Interphalangeal joints
- Carpal tunnel is the tendons that come into the hand in a sheath and then after the carpal tunnel (wrist), they separate
Osteoarthritis
Typically weight bearing
Rheumatoid arthritis
Typically not weight bearing
Hip
- Articulation between acetabulum and head of the femur
- Ball-and-socket action
- Range of motion (ROM) on many axes, less than shoulder, but more stability for weight-bearing function
- Three bursae facilitate movement
- Can’t do a full range of motion assessment while laying down/sitting
- Most weight bearing joint of our body
Knee
- Femur, tibia, and patella
- Suprapatellar pouch
- Medial and lateral menisci
- Prepatellar bursa
- Quadriceps muscle
- 2 sets of ligaments:
- Cruciate gives anterior and posterior stability and help control rotation
- Collateral ligaments give medial and lateral stability and prevent dislocation
- Patella increases in the number of ligaments (compared to elbow)
- Should have limited movements
- Menisci typiclaly will not fix themselves (they are avascular)
Baker’s Cyst
Synovial syst on the back of the knee from overuse
Typically not painful
Can get irritated
Not in itself harmful
Ankle and Foot
- Tibiotalar joint
- Medial and lateral malleolus
- Subtalar joint
- Permits inversion and eversion of foot
- Metatarsals
Inversion Sprain
- Ankle joint is connected with a lot of different tendons and ligaments that become sprained
- Pulled, overextended will cause microtears that cause bruising
- Tissue around it that is tender, NOT THE BONE
Inspection of musculoskeletal
- Size and contour of the joint
- Skin and tissues over the joint
Palpation of skeletomuscular
- Skin temperature
- Muscles, bony articulations, area of joint capsule
Grading Muscle Strength
- If a person can’t follow commands, this can’t be tested
- Apply opposing force
- 5 = Full ROM against gravity, full resistance
- 4 = Full ROM againse gravity, some resistance
- 3 = Full ROM with gravity
- 2 = Full ROM with gravity eliminated (passive motion)
- 1 = Slight contraction
- 0 = No contraction
Exam of TMJ
- Inspect joint area
- Palpate as person opens mouth
- Motion and expected range
- Open mouth maximally
- Protrude lower jaw and move side to side
- Stick out lower jaw
- Palpate muscles of mastication
Cervical Spine Exam
- Inpext alignment of head/neck
- Palpate spinous processes/muscles
- ROM:
- Chin to chest
- Lift chin
- Each ear to shoulder
- Turn chin to each shoulder
Shoulder Exam
- Inspect joint
- Palpate shoulders and axilla
- Motion and expected range:
- Arms forward and up
- Arms behing back and hands up
- Arms to side and up over head
- Touch hands behind head
Elbow Exam
- Inspect joint in flexed and extended positions
- Palpate joint and bony prominences
- Motion and expected range:
- Bend and straighten elbow
- Pronate and supinate hand
Wrist and Hand Exam
- Inspect joints on dorsal and palmar sides
- Palpate each joint
- Motion and expected range:
- Bend hand up
- Bend hand down
- Bend fingers up, down
- Turn hands out, in
- Spread fingers, make fist
- Touch thumb to each finger
Physical Exam of the Hip
- Inspect as person stands
- Palpate with person supine
- Motion and expected range:
- Riase leg
- Knee to chest
- Flex knee and hip, swing foot out, in
- Swing laterally, medially
- Stand and swing leg back
- Want to inspect when standing (want to see how hip manages weight-bearing), palpate when sitting/laying (want to get into spaces)
Physical Exam of the Knee
- Inspect joint and muscle
- Palpate
- Motion and expected range
- Bend knee
- Extend knee
- Check knee while ambulating
The Physical Exam of the Ankle and Foot
- Inspect with person sitting, standing, and walking
- Palpate joints
- Motion and expected range:
- Point toes up, down
- Turn soles out, in
- Flex and straighten toes
Physical Exam of the Spine
- Inspect while person stands
- Palpate spinous processes
- Motion and expected range:
- Bend sideways, backward
- Twist shoulders to each side
Parts of the Nervous System
- Central nervous system (CNS)
- Brain
- Spinal cord
- Peripheral Nervous System (PNS)
- Includes all nerve fibers outside of the brain and spinal cord
- CN I-XII
- 31 pairs of spinal nerves and all of their branches
- Sensory (afferent) messages to CNS from sensory receptors
- Afferent: leading to something
- Motot (efferent) messages from CNS to msucles and glands, as well as autonomic messages that govern internal organs and blood vessels
- Efferent: away from something
Cerebral Cortex
Center of functions governing thought, memory, reasoning, sensation, and voluntary movement
Parts of the CNS
- 2 halves of brain, each divided into 4 lobes
- Frontal lobe
- Broca’s area (expressive aphasia, nonfluent aphasia)
- Parietal lobe
- Temporal lobe
- Wernicke’s area (receptive aphasia, fluent aphasia)
- Occipital
- Basal ganglia
- Thalamus
- Hypothalamus
- Cerebellum (balance center)
- Brainstem
- Midbrain: regulates everything (breathing, heart, etc)
- Pons
- Medulla
- Spinal cord: skeletal muscles are innervated
- Sensory pathways: afferent
- Motor pathways: efferent
When Broca’s area is damaged, what happens?
People have trouble naming words; disconnection between thought and words
What happens when there is damage to Wernicke’s area?
People can speak just fine, but can’t process what others are saying
Can’t process information
Afferent sensory pathways
- Spinothalamic tract
- Anterior = pressure
- Lateral = pain
- Posterior = fine touch
Sensory pathway
Spinal cord to medulla to pons to midbrain to cortex
Motor pathways (efferent)
- Corticospinal or pyramidal tract = higher function
- 10% do not cross over
- Extrapyramidal tracts = gross motor function
- More primitive function gross motor
- Cerebullar system = movement, equilibrium, posture
- Upper motor nerves in CNS are affected during a stroke (CVA)
- MS and ALS influences the lower motor nerves
Cortical Homunculus
“Little man” of the primary motor cortex in precentral gyrus
Can have very localized deficits with stroke
Pathway of Corticospinal Tracts
- Upper motor neurons
- Can be affected by CVA and MS
- Lower motor neurons
- Can be affected by ALS
Cranial Nerves
- Enter and exit the brain rather than the spinal cord
- CN I and II extend from the cerebellum
- CN II - XII exctend from the lower diencephalon and brainstem
CN X
Vagus nerve
Travels to heart, respiratory muscles, stomach, and gallbladder
Spinal nerves
- 31 pairs of spinal nerves
- Named for the region of spine from which they exit:
- 8 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral
- 1 coccygeal
Somatic Nervous System
Voluntary muscles (skeletal muscles)
Autonomic Nervous System
Involuntary (smooth muscle, cardiac muscle)
Innervates the bowels
Types of reflexes
- Deep tendon
- Superficial
- Visceral PRL
- Pathologic Babinski
Reflex Arc
- Steps
- Intact sensory, afferent nerve
- Functional synapse
- Intact motor, efferent nerve
- Competent muscle
- Voluntary muscles but an involuntary response
- Information makes its way to the brain after the movement already occurred
- Hitting the tendon stretches the muscle
- Sensory nerves send the information to the spinal cord which sends information to the motor nerve
- Motor nerve in spinal cord causes movement without signal from the brain
- All chemical based - no higher function occurs
- Issues with electrolyte imbalances can cause reflexes to change
- Refelxes tells us how excitable the nervous system is
Dermatomes
Dermal segmentation in cutaneous distribution of various spinal nerves
Can test spinal nerves by touching their skin
CN I
Olfactory: smell
CN II
Optic: sight
CN III
Oculomotor: eye movement
CN IV
Trochlear
CN V
Trigeminal
Motor and sensory function
CN VI
Abducens
CN VII
Facial
Motor and sensory function
CN VIII
Acoustic
CN IX
Glossopharyngeal
Sensory and motor
Taste on the posterior 1/3 of the tongue
Parotid gland, carotid reflex
CN X
Vagus
Motor and sensory function
Sensory sensation from carotid body, carotid sinus, pharynx, viscera
CN XI
Spinal accessory
Motor
CN XII
Motor
Hypoglossal
Balance Tests
Cerebellar function
- Gait
- Tandem walking
- Romberg test
- Knee bend
Coordination and skilled movments
Cerebellar function
- Rapid alternating movements
- Finger-to-finger test
- Finger-to-nose test
- Heel-to-shine test
Exam of the spinothalamic tract
- Pain (sharp-dull) - lateral STT
- Temperature - lateral STT
- Crude or light touch - anterior STT
Exam of posterior (dorsal) column tract
- Vibration
- Position (kinesthesia, proprioception)
Tactile Discrimination
- Higher cortical function (fine touch)
- Stereognosis: know what something is just from touch
- Graphesthesia: know the number/letter from writing it on the skin
- Two-point discrimination
- Extinction (inability to perceive multiple stimuli at the same time)
- Point location
Grading reflexes
- 4+ very brisk, hyperactive with clonus, indicative of disease
- 3+ brisker than average, may indicate disease
- 2+ average, normal
- 1+ diminished, low normal
- 0 no response
- Reinforcement: concentration on other muscle groups
- 4+ in preeclampsia can indicate a seizure is going to happen soon
- Reflexes are named after the tendon that is hit and compared from side to side
Plantar reflex
Should cause toes to curl in an adult
In a newborn, Babinski sign is normal (toe spreading)
Tested when expecting a brain trauma or demyelinating disease
Neurological Recheck
- Level of consciousness
- Motor function
- Pupillary response
- Vital signs
Mental Status Exam
- Appearance - posture, dress, hygiene
- Cognition - orientation, memory, attention span
- Psycholgicla and psychiatris disorders - depression, anxiety
- Judgment/though process - reason, logic, hallucinations, obsessions
- Behavior - affect, speech, LOC
- Substance use - prescriptions, OTC, street drugs
- Developmental considerations - Peds: Denver II
Level of Consciousness
- Person - own name, occupation, names of workers, their occupation
- Place - where the person is, name of the building, city, state
- Time - day of the week, month, year, season, holiday
- Glasgow coma scale
