Exam 2 Week 5 Seale Content Flashcards
what is the purpose of doing a neuro exam
it is a systemic investigation to see what systems are working well, what systems have impairments and limitations, or limit activity. we use the neuro exam to screen and investigate.
when do we use a screening exam
not when we suspect neurological involvement, but to confirm that the NS in intact.
now, a neuro exam is used…
to dive a little deeper. we know there is an issue, the screen uncovered an abnormality but we don’t know where it is.
the neuro exam provides the basis for
the evaluation
what is the evaluation
cerebral process and resulting clinical judgement
what is our end goal
to ID the patients functional limitations and impairments, activity restrictions
how do we use the deductive process with all of this
identify what their limitations are (observation or self report)
hypothesize possible impairments, that you want to examine in more detail
examine the impairments with good tests and measures.
how does neuroanatomy come in
we want to look at the limitations, and hypothesize the location of the lesion, and confirm the extend of the lesion.
what is the difference between a primary and secondary impairment
primary: signs and symptoms that are direct result of disease or pathology (stroke)
secondary: abnormal changes in the structure and function as a consequence of the pathology (since the stroke, they have this deviation)
which impairments, primary or secondary, do we try to intervene in more
secondary, we don’t want them happening. its really hard to intervene in the first.
talk through the example of primary and secondary impairments, after a SCI (Fell table 3.1)
primary: paralysis of muscles, spasticity, sensory deficits below the lesion of the SC. also, bowel, bladder and sexual dysfunction.
secondary: range of motion deficits, muscle wasting, impaired endure, aerobic conditioning.
functional limitation: needs assistance, limited locomotion
why is the correct identification and categorization of impairments crucial
to select the correct intervention. we do not want to give them the whole kitchen sink treatment
describe how the neuro exam is an ongoing process, and what should be at its center
the patient should be at the center. We are continually observing, determining if our hypothesis are correct, confirming impairments, and ID limitation and then doing interventions.
what four things comprise the neuro exam
we want to observe the patient, get their history, review relevant systems (ROS), and do appropriate tests and measures.
TF: observation is key throughout. why
yes. we need to be able to key in on big things. watch how they move. we always want to watch their every move, from car, to waiting room. you often pick up on more when they do not think you are watching.
when does patient observation begin
the moment we see the patient, as soon as they walk into the clinic, or get out of the car.
what are we looking for when we observe the patient
quality and quantity of movement.
what is the foundation of the exam, and what happens here
history. where we establish rapport.
can we 100% rely on the referral diagnosis
no we cannot, want to see that what we find lines up with it
what must we ID in the history
health risk factors, health restoration and prevention (preventing a second stroke) needs, medications and co morbidities
who gives us the patient history information
sometimes its the patient, other times it is a family member, or care taker.
what are some components of the patient centered history
demographics, CC, HX or current condition, current and past medical history, social habits and history, functional status and diagnostic tests.
describe the kinds of questions we can ask to get detailed in our history
understand the nature of the problem, time since onset, what happened right before, have them fill out health lists, assess them as they speak.
what happens in the review of systems
ID symptoms that might have been minimized in the history, want to know about cardio, pulm, MSK, neuro, GI, reproductive, hematologic, psychological, nervous and endocrine.
we determine which T/M (tests and measures) to use based on…
observation
history
ROS
what are the 6 areas to consider when selecting tests and measures
- current functional status (ambulatory, AD, work at home?)
- cognitive status
- in what clinical setting with they be tested (inpatient, home…)
- patients chief concerns
- patients goals and expectations
- living situation (alone, home…?)
TF: exam and eval is an ongoing process
true
what is key during your exam
observation
TF: we do not have to be patient centered
false.
what is the benefit of having an appropriate T/M
guides to a more targeted, efficient and effective treatment.
where might a neuro screen be appropriate
in the absence of a known or suspected neurological lesion.
the purpose of the screen is to rule in or out the need for
a more depth examination
what are the components of the neuro screen
mental status, cranial nerves, motor sensory and reflexes, coordination and stance and gait.
what are we looking for in the mental status screen
- alertness,
- orientation (person, place, time, situation A/O x4) (time day, why here)
- current events (who is the president)
- general cognition (FOGS, visual acuity and communication)
FOGS
Family story of memory loss, orientation of the patient (person place and time), general information (president or VP) and spelling (spell world backwards, or count backwards from 100 by 3s)
what happens in the cranial nerve screen
use clinical reasoning to drive what you test.
what are you looking for in the motor screen test
visual inspection of how they move, the profanatory drift test, gross strength of the UE and LE, fasciculations
when testing reflexes, what are we looking for
absent, diminished, and excessive reflexes, or asymmetry.
what do you do during the sensory screen
touch lightly, bilaterally, on the face shoulder, forearm, hand thigh foot, etc. for diminished feeling on one side, differences, or no feeling at all.
how can we test sensation if language is impaired
have them point or nod their head.
what is stereognosis
ability to feel a tiny object in your palm, move it around, and ID it.
what does stereognosis testing tell us
if sensory pathways are intact.
how can we do a coordination screen in the UE and LE
UE: abduct arms to 90 degrees, close eyes, and alternate and rapidly touch R and L finger to nose.
LE: heel to shins.
when doing a coordination screen, what also is being tested
if the performance degrades with repetition, they may have impaired joint position sense, or poor endurance.
how can we test diadochokinesia. in UE and LE
controlling rapidly alternating movements. tap thumb and index together, same time, both hands, and watch movement. also, tap foot on floor (with heal planted)
how can we observe stance and gait
watch them walk into the clinic, walk back, sit to stand and heel raises, perturbation, tandem walk, Romberg test.
what are we confirming with the neuro exam
that the information we got lines up with the medical diagnosis.
what can the neuro exam tell us in terms of impairments
what was expected and what was unexpected.
what is the big picture of what the neuro exam tells us
what neuro disorders may be, or where they may be.
how are HX and ROS drivers
HX tells us the time, onset progression and pattern, and the ROS determines non neuro factors,
what is a problem list
what they are limited/restricted in. helps us to figure out what to treat first.
what is the strength list, and its importance
helps us figure out what they can do, and where we can start with our treatments. This allows us to give them something positive to focus on, and make sure our treatments match their abilities, and we get them off to a good start. want to show them that they have strengths, and can lead to early positive outcomes.
how do we take all this data, and translate it into patient care
- ID most important results, and compare them to the impairments and activity limitations
- you want to prioritize the functional problems that must be addressed first. You need to come up with a list, like fall risk.
- this data can also give a prognosis
what are the vital signs we want to test
HR, BP, RR, Temp,
when do we take the vital sign measures
take measures at rest, right after activity and recovery
are vital signs taken enough
not! never really taken after the ICU stage.
what si normal HR
60-100 BPM
how should the HR feel
regular, consistent and strong
what is bradycardia
low HR, below 60 BPM
what is tachycardia
high HR, above 100 BPM
what is BP
pressure in arterial vessels
when should you measure BP
at rest, with positional changes, during exercise and with recovery
how should you initially take BP
in both arms, then continue to take it in the arm with the highest pressure.
what is the goal BP
younger then 60, below 140/90
above 60: below 150/90
what is orthostatic hypotension
drop in SBP of 20mmHg that accompanies change to a more upright position, or getting dizzy or lightheaded.
how do we measure respiration rate
while you take the pulse, just continue to watch their respiration rate, because people will breath differently when they know you are watching them.
what is the normal RR in adults
14-22
what is paradoxical breathing
upper chest collapses, and abdomen rises excessively during inspiration
we usually combine RR with what measure
pulse ox.
what are we watching for as people breathe
asymmetrical chest motions, and impaired expansion.
why do we use perceived exertion scales
to see how hard the exercise is. we may have abnormal HR responses to exercise, like because of meds, so we want to make sure that we aren’t pushing them too hard.
what does the modified Borg dyspnea scale measure
SOB from 1-10, 10 being so short you had to stop
why might we need to know a persons temperature
to see about infection, HR elevated, fatigue
how often should assess vitals
every visit, at least twice a visit
why must we be familiar with diagnostic imaging
to help us understand what the patients has going on,
what are the three categories of diagnostic testing
clinical lab test, diagnostic imaging and electrophysiologic testing.
what is critical care monitoring
in an inpatient setting, lots of lines and tubes that monitor HR, RR, BP and temperature. also, central vascular pressure, intracranial pressure, blood gases and pulmonary pressure.
how is inter cranial pressure measured
a catheter is inserted into the lateral ventricle.
what are the 4 areas of clinical lab
chemistry
hematology
microbiology
immunohematology
how might a glyacsted hemoglobin (Hgb A1C) test be useful to us
tells us the long term average of blood glucose levels, and how well they are being controlled. a regular glucose measure just tells us what it is at that given period of time.
what is the implication of sodium
changes in sodium can lead to changes in BP and tachycardia. must monitor BP and hydration levels.
implications of potassium
hypokalemia in people on diuretics, so cardiac arrhythmia may be present. careful with PT
implications of calcium
in active form, watch for arrhythmia, cardiac arrest, tetanus. must monitor BP, RR, HR, and rhythm
implications of magnesium
active form, same as with calcium
what is hematology
the cellular composition of blood
what is hemostasis
information on the clotting function of blood
what is a CBC
complete blood count.
what is an erythrocyte count
the about of red blood, hematocrit and hemoglobin. red blood cell health.
too little: anemia
too much: polycythemia. (thrombosis, MI, stroke)
when do we see increased white blood count
with infection, inflammation and tissue damage, necrosis and leukemia.
thrombocytes initiate what
clotting
thrombocytopenia
low platelet count, no clotting
thrombocytosis
high platelet count, too much clotting, stoke, DVT things like that
immunology
lots of neuro diseases from pathology with an abnormal immune response.
what does the production of immunoglobulins lead to
auto-antibodies that target and damage parts of the CNS, neurons, nerve, muscles and organs.
what are some neuromuscular myopathies
Myasthenia gravis (MG): and labert eaton myasthenia syndrome.
what are some neuromuscular neuropathies
amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS)
what is polyneuropathy
rheumatoid arthritis (RA) and lupus (SLE)
why must we know microbiology
super bugs, need to be safe when going patient to patient, make sure to wash hands.
why is it important to know if they are immune-compromised
we don’t want to expose them to a disease.
what is the quickest, best way to rule out hemorrhage in case of stroke
CT
what is electrophysiologic testing
direct or indirect measure of physiological activity of the NS, nerves, motor units or muscles. electroneuromyography or ENMG
what is electrophysiologic testing used to evaluate
neuromuscular disorders, like PNS (anterior horn cells, DRG, nerve root, plexus, peripheral nerves, NM junction and muscles)
what are the two main components of ENMG
- nerve conduction study (record the response to stimuli)
2. EMG electromyography: asses electrical activity of a muscle.
why do we screen attention, cognition, perception and communication
determine the patient ability to participate in the exam, provide context, plan for the patients, early detection of disease, neurological things, plan strategies and see if we need to refer to a neurologist.
what is cognition, and what components make it up
the act of knowing, made up by awareness reasoning, judgement, intuition and memory.
what is executive functions
cognition skills involving planning, manipulating information, self monitoring and abstract thinking.
what part of the brain controls executive functioning
frontal
what is alertness
degree to which a person is awake, aroused, and attentive
what is awareness,
having knowledge of something, the ability to perceive or be aware of a fact, occurrence or an event
what is arousal
the redness for action, ranges from fully awake to comatose.
what is attention
the ability to focus ones consciousness on specific information
what is the critical first step in creating memories
attention
where is attention controlled, what hemisphere
the non dominant (R)
attention is affected by,.
consciousness, arousal, awareness and motivation
what is selective attention
ability to select important and relative information and ignoring other sources. not getting distracted by other conversations
what is divided attention
ability to process more then one source of information or perform more then one test at a time. talk and walk, money out of a wallet
what is attention switching, alternated attention
switch between two tasks. talking, must stop to do the complex thing, then continues talking
what is sustained attention
ability to pay attention for a long period of time without losing you attention. right hemisphere. doing a task, 3x15 and not losing focus on it.
what is included in mental status testing
level of consciousness, attention, orientation, language, memory, sequencing, alternating, logic and abstractions, calculation, R/L discrimination, writing, neglect, construction of figures.
what is explicit memory
declarative: acquisition, retention and retrieval of information that can be consciously and intentionally recollected. knowing trivia or facts, or knowing the information we study
what is implicit memory
procedural or nondecalarative: can’t be accessed by conscious recall, and occurs through unconscious systems, like movement and perception. so we can ride a bike, but can we explain to someone how to do it?
where does cognitive screening begin
with observation and conversation
can we fire off questions to a patient
no, we must give them time to process and give an adequate response.
what doe this mean: use tact with screening
do not use questions that can cause anxiety, defensiveness or uncomfortableness. we give this questionaries to everyone,
how do we document
what test was done, what it was scored, assessment, implication, referrals.
what is the screening order…
arousal/alertness
attention
condition and executive function
depression
how do we screen for arousal
by level of consciousness and observation
describe a coma
complete loss of arousal, no sleep or wake cycles, and no purposeful responses. no awareness
vegetative state:
low awareness, sleep was cycle are present, responds only to a noxious stimuli
what is a minimally conscious state
partial preservation of conscious awareness. inconsistent localized responses, purposeful behavior
what is the Glashow Coma scale
records responses to eye opening, verbal and motor responses. the higher you score, the less of a brain injury you have
with the Rancho los amigos cognitive scale, what is the level of a coma
levels 1-3
what is the coma recovery scale, revised. scoring?
0-23
sub-scales: auditory, visual, motor, verbal, communication and arousal
lower scores= reflex activity
higher scores= cognitively mediated activity.
how can we test attention
spell a word backwards, count back by 7s, say months in reverse order
how do we test for sustained attention
digit response test: repeat progressively longer series of digits beginning with a 3-digit number
test vigilance: ask pt to listen and respond when they hear the letter A in a long series of letters
watch for motor impersistence: have them do something for 30 seconds, and make sure they do not stop.
what is divided attention
ask to perform a dual test, like talk and talk, or times up and go test.
the addenbrooke cognitive exam is more focused on
dementia
Montreal Cognitive Assessment asses
a broad range of cognitive function, and takes 10 minutes. Its free and broad and shortest.
what is post traumatic amnesia
PTA is a loss of memory regarding pre and post brain injury events. also a loss in the ability to process information after the injury.
difference between retrograde and anterograde amnesia
retro: loss of memory before
anterograde: loss of memory after event
Galveston Orientation and Amnesia Test (GOAT). what scores are impaired and normal
monitor and tracks recovery of cognitive function after PTA>
impair: less then 66
normal: 76-100
how do we test for agitation
agitated behavior scale
self awareness
ability to recognize, perceive and reflect on aspects of ones own self
anosognosia
patient without any sense or self awareness of deficits. they don’t understand that after the stroke R side weak, they cannot walk to the bathroom
why must we screen for depression
important, also want to use tact
what 6 screening tools should we be aware of
Ranchos levels of cognition JFK Coma Recovery Montreal Cognitie Assessment agitated behavior Beck Depression Screening for unilateral spatial neglect.
what is superficial sensation
tactile, receptors on the surface of the body, skin, appendages, discriminative,
what is deep sensation
proprioception, conscious or unconscious. position or movement of joints. aware of muscle length
what are some superficial sensations
pain, temp., light touch, pressure touch (skin deformation)
what are some discriminative sensations
vibration, tactile localization (where the location of the stimulus is), two point discrimination, graphethesia (recognize symbols traced on the palm) stereognosis (recognize an object by tactile manipulation only)
what are some deep sensations
joint position sense, proprioception, and joint movement sense (kinesthesia- degree, velocity and direction of movement)
general guidelines for sensory testing
start with questions, demonstrate tests, explain as you demonstrate, apply stimulus to an area with intact feeling, define terms and option, eliminate vision, maintain stimuli for several seconds, determine non-verbal responses, BILATERAL
what should the sequence of sensory testing be (both superficial and deep)
in dermatomes. in order
deep, in an order, of joints
what parameters are we testing with sensory testing
quantity: extend, size, dimension, dermatomes, peripheral nerve, or region
quality: degree of dysfunction, intact, impaired absent.
anesthesia
all sensory modalities lost
hypesthesia
decreased sensibility or awareness
hyperesthesia
excessive or increased sensitivity to stimuli
dysesthesia
ordinary stimuli results in disagreeable sensation
allodynia
exaggerated or painful response to a not painful stimuli
paresthesia
abnormal sensation of burning, pricking, tingling, tickling and numb
