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Neuromusculoskeletal Diagnosis > NEURO FINAL OSCE > Flashcards

NEURO FINAL OSCE Flashcards

1
Q

List the elements of the Mental Status Evaluation

A 
Arousal/Alertness
Memory
Attention and Orientation
Language
Gerstmann’s Syndrome
Apraxia
Neglect and Construct
Sequencing and Frontal Release
Logic and Abstract
Abnormal Thought Process
Mood
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2
Q

Evaluate ALERTNESS and AROUSAL (with the GLASCOW COMA SCALE)

A

Glascow coma scale:

  • EYES: score 4-1, open before stimulus-to sound-to stimulus-none
  • VERBAL: 5-1, Correct answers-confused-words-sounds-none
  • MOTOR: 6-1, obey 2part task-hand above clavicle-elbow flexion-decorticate flexion-decerebrate-none
  • adaptable to kids for no speak, baby crying

THEORY:

  • Decorticate: corticospinals cut + rubrospinals ok (cortex, int. capsule, thalamus) = dystonia; flex upper limb, ext. lower limb
  • Decerebrate: brainstem damage, serious, head and neck arched
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3
Q

Evaluate AROUSAL and ALERTNESS (with level of consciousness test)

A

Level of consciousness:

  • Speak request ->Loud ->Shake ->Pain ->Repeat pain
  • Alert ->Lethargic ->Obtunded ->Stupor ->Coma

THEORY:

  • brainstem, cortex, thalamus
  • toxic/metabolic, focal lesion, dementia, encephalitis
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4
Q

Evaluate ATTENTION and ORIENTATION

A 
ATTENTION
-Spell WORLD backward
-Months backward
-Repeat 6 numbers (1/s)
-Repeat 4 numbers backward (1/s)
—Count backward by 7 from 100 (5 jumps)
*Get 2 tests correct is enough

ORIENTATION

  • name, address, date, time
  • person, place, time

THEORY:
-focal lesion, dementia, encephalitis

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5
Q

Evaluate MEMORY

A

RECENT: Repeat 3 words: apple, penny, table now
-Again in 5min

REMOTE: School, hometown, occupation, breakfast
*must know answers

EXPLICIT: facts and experiences
IMPLICIT: unconscious skill, habit (ride a bike)

THEORY:

  • false (+) if deficit ATTENTION
  • lymbic system
  • frontal association cortex = working memory
  • temporal lobes and diencephalon = consolidation
  • cortex = long term memory
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6
Q

Evaluate for Gerstmann’s Syndrome

A

ACALCULIA: simple addition/subtraction (1-9)

R-L CONFUSION: touch R elbow

FINGER AGNOSIA: touch R ear with L thumb

AGRAPHIA: write name or short sentence

THEORY:

  • if all 4 impaired = Gerstmann’s
  • Left Parietal Angular Gyrus
  • maybe also aphasia or language, praxis, construction, logic, abstract issues
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7
Q

Evaluate for APRAXIA

A

MIMING TASK:
-pretend to brush your teeth

Apraxia: can’t follow motor commands but primary motor area ok

THEORY: higher order planning and conception of task -> language areas lesion

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8
Q

Evaluate for NEGLECT

A

VISUAL:
-hold 2 fingers each hand in upper visual quadrants
-alternate wiggling R, L, both and ask to say what
-Repeat with lower quadrant
(+) notice less often the neglected side or always

TACTILE:

  • Eyes closed, ask to point where I poke
  • Alternate L, R, both

SENSORIMOTOR:
-Neglect drawing: face of clock with all numbers, split a horizontal line down the middle, turn lines to Xs
-Copy drawing: Copy square, circle triangle
(+): all smooshed on one side or blank side

THEORY:

  • left neglect = R lobe lesion
  • L lobe lesion does nothing
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9
Q

Evaluate SEQUENCING and FRONTAL RELEASE

A

MANUAL ALTERNATING SEQUENCE:
-Draw square and triangles in a continuous line
-Luria Task: fist, palm, chop
(+) perseveration or abulia (slow)

GRASP REFLEX: touch palm = grab

SUCKING REFLEX: poke palate = suck

SNOUT REFLEX: touch upper lip = purse lips

PALMOMENTAL REFLEX: stroke thenar eminence = I/L orbicularis oris and mentalis contraction

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10
Q

Evaluate LOGIC and ABSTRACT

A

PROVERBS: Explain the meaning of Actions speak louder than words

ANALOGIES: How are apples and oranges alike? Door and window?

THEORY: look for logic, coherence, compression
-damage to higher-order areas (association cortices)

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11
Q

Evaluate for ABNORMAL THOUGHT PROCESSES

A 
Compulsions
Obsessions
Phobias
Anxiety
Delusions

THEORY:
-toxic/metabolic, psychiatric disorders, focal lesions, seizures

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12
Q

Evaluate MOOD

A

Facial expression
Body language
Voice

Euthymic (normal), Dysthymic (depressed), Manic (elated)

Psychiatric, toxic, metabolic (thyroid)

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13
Q

Evaluate LANGUAGE

A

SPONTANEOUS SPEECH:
-listen for fluency, rate, errors, invented words, abundance

COMPREHENSION:

  • I point, they name (pencil, door, nose)
  • I name, they point (where is the door)
  • Repeat: No ifs, ands or buts

ABNORMAL SPEECHES:
-Hesitancy, monotone, circumlocutions, paraphasias, aphasia, incoherence, blocking, confabulation, perseveration, echolalia, clanging, circumstantiality, derailment, flight of ideas, neologisms

THEORY:

  • frontal, temporal, parietal lobes
  • Wernicke’s, Broca’s, thalamus, caudate nucleus
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14
Q

Hesitant vs Blocking speech

A

Hesitant:

  • difficulty initiating speech
  • stroke -> Broca’s aphasia

Blocking: sudden stop in middle of idea

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15
Q

Circumlocutions vs confabulations in speech

A

Circumlocution: Substitute forgotten word with its definition

Confabulation: fabrication of facts to hide memory blank

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16
Q

Paraphasias vs neologisms speech

A

Paraphasias: Words malformed, wrong or invented

Neologisms: invented or distorted words

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17
Q

Broca’s ahasia vs Wernicke’s aphasia

A

Broca: can’t express but can understand

Wernicke: easily talks but wrong sense of words

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18
Q

Perseveration vs echoalia vs clanging speech

A

Perseveration: persistent repetition or words or phrases (stuck in a loop)

Echolalia: repetition of words or phrases (like a catchphrase)

Clanging: choose word for sound instead of meaning (similar sounds)

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19
Q

Circumstantiality vs derailment vs flight of ideas speeches

A

Circumstantiality: tangent of extreme detail of no connection BUT return to OG subject

Derailment: shifts topics of no relation

Flight of ideas: fats change of topics but still coherent (manic)

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20
Q

List how we evaluate the Olfactory CN

A

OBJECT SMELLING:

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21
Q

List the ways to evaluate the Optic CN

A 
Ophthalmoscopy
Pupillary light reflex
Convergence/Accommodation
Visual acuity
Colour vision
Visual fields
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22
Q

List the tests for the Oculomotor CN

A 
Eye movements
Smooth pursuit
Saccades
Optokinetic nystagmus
Oculocephalic testing

INDIRECTLY:
+ Pupillary light reflex
+ Convergence and Accommodation

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23
Q

List the tests for the Trigeminal CN

A

Facial sensation
Corneal reflex
Mastication muscles
Jaw jerk reflex

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24
Q

List the tests for the Facial CN

A

Facial muscles
Taste

INDIRECTLY:
-corneal reflex

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25
Q

List the tests for the Cochlear nerve (Vestibulocochlea CN)

A

General hearing
Otoscopy
Weber
Rinne

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26
Q

List the tests for Vestibular nerve (Vestibulocochlear CN)

A

Dix-Hall Pike

Fukuda Step Test

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27
Q

List the tests for the Glossopharyngeal CN

A

Palatal movement
Gag reflex
Dysphagia

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28
Q

List the tests for the Glossopharyngeal CN

A

Palatal movement
Gag reflex
Dysphagia

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29
Q

List the tests for Vagus CN

A

Voice and cough
Dysarthria
Aphasia

INDIRECTLY:
-Gag reflex

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30
Q

List the tests for Accessory CN

A

Observe SCM and traps

Test SCM and traps

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31
Q

List the tests for Hypoglossal CN

A

Observe tongue
Protrude tongue
Poke check

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32
Q

Object Smelling test

A

OLFACTORY CN 1

  • Eyes closed
  • Known classic smells (coffee, mint, vanilla)

CLINICAL: impaired taste

CAUSES:

  • Obstruction
  • Bulb -cribiform fracture
  • Nerve -tumour

THEORY:

  • limbic system: hypothalamus, amygdala
  • bypasses the thalamus
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33
Q

Opthalmoscopy

A

OPTIC CN 2

  • dark room
  • R hand R eye R pt eye
  • thumb on their brow
  • scope to my orbit, large light scope, 0 lens
  • pt focus on single spot ahead, if pain ill stop

STEPS:

  • 30cm away, 15o from midline
  • find red light reflex, follow it in
  • find disc and adjust focus
  • Report on disc
  • Find arteries and veins and report
  • Refocus to 10 to observe anterior eye for opacities in vitreous humour or lens
  • Pt look into the light - check macula and fovea - Report

DISC report:

  • sharpness of outline
  • white center, yellow disk
  • cup-disk ratio 0.3

ARTERIES: light, bright, smaller
VEINS: dark red, larger

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34
Q

Pupillary light reflex

A

OPTIC CN 2 and OCULOMOTOR CN 3 (parasymp. GVE)

  • if hurt I stop
  • dark room
  • hand on nose

1) Direct response
2) Consensual response
3) Swinging flashlight
- 3s interval
- Marcus Gun pupil: afferent defect makes dilate during consensual reponse = Optic neuritis

Efferent defect = never constricts

REFLEX PATHWAY: Optic n. ->chiasm ->tract ->Brachium superior colliculus ->pretectal area ->Edinger Westphal Nuclei ->Parasymp pregang. ->Oculomotor n. -> Ciliary gang. ->postgang. ->pupil constrictor muscles

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35
Q

Convergence and accomodation

A

-hand on nose

Convergence: Oculomotor CN 3 GSE

Accommodation: CN 3 GVE

  • lens thickens (contraction of muscles) for closer vision
  • Optic CN 2 -> chiasm ->tract -> Thalamus LGB ->optic radiations -> occipital lobe -> EWN ->CN 3 parasympathetic ->ciliary muscle
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36
Q

Visual Acuity

A

OPTIC CN 3

  • Snellen eye chart
  • good eye first, cover other eye
  • 20 feet / 6m from chart
  • try to read the smallest line you see
  • Pt distance from chart / last line can read assigned number (means distance normal person can read that line from)
  • Ex: 20/40 -> can read at 20f what healthy person can at 40f
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37
Q

Colour Vision

A

OPTIC CN 2

1) Ishihara charts
- colour blindness

2) Red desaturation:
- optic neuritis (red will be dull)
- compare R and L

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38
Q

Visual Fields

A

OPTIC CN 2

  • Gaze into each other’s eye (one eye blocked)
  • come from 4 directions
  • finger equidistant from pt and me

-method B: from side of pt

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39
Q

Eye Movements

A

OCULOMOTOR, ABDUCENS, TROCHLEAR (CN 3, 4, 6)

  • Trace H
  • start in middle, end in middle
  • one eye, other eye, both at once

Abducens: lateral rectus - abducts eye
Trochlear: superior oblique - down and in

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40
Q

Smooth Pursuit

A

OCULOMOTOR, ABDUCENS, TROCHLEAR (CN 3, 4, 6)

  • TRACE X
  • start middle, end middle

-one eye, other eye, both together

THEORY:
-?…

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41
Q

Saccades

A

OCULOMOTOR, ABDUCENS, TROCHLEAR (CN 3, 4, 6)

  • Hold 2 separate fingers about 20cm appart
  • head still, pt alternates gaze

1) Horizontal
2) Vertical

Theory???

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42
Q

Optokinetic Nystagmus

A

OCULOMOTOR, ABDUCENS, TROCHLEAR (CN 3, 4, 6)

  • Ask patient to count red squares
  • Move strip at medium-fast speed
    1) Horizontal
    2) Vertical
  • nystagmus is normal
  • backtracking is abnormal

THEORY:

  • Optokinetic Reflex
  • Afferent: Optic CN
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43
Q

Oculocephalic Testing

A

OCULOMOTOR, ABDUCENS, TROCHLEAR (CN 3, 4, 6)
VESTIBULAR n. CN 8

  • Comatose pt.
  • Headpiece level
  • Thumbs keep lids open
  • Brisk head rotation to one side, then other
  • Normal VESTIBULOCULAR reflex: gaze deviates C/L

(+) doll’s eyes = brainstem injury

THEORY:
-Semicircular canals ->vestibular nucleus ->CN3,6 nucleus ->muscles

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44
Q

Facial Sensation

A

TRIGEMINAL CN 5 GSA

  • Baseline: eyes open, clavicle - ask how it feel
  • Eyes closed, cotton bud
  • R then L - ask if same
  • Ophthalmic, Maxillary, Mandibular zones
45
Q

Corneal Reflex

A

TRIGEMINAL CN 5 (afferent)
FACIAL CN 7 (efferent)

  • explain to pt., they look up
  • approach from side, touch cornea with cotton bud
  • note absence or asymmetry

THEORY:
-cornea ->ophthalmic n. ->trigem sensory nucleus ->facial motor nucleus ->facial n. ->orbicularis oculi m.

46
Q

Mastication Muscles

A

TRIGEMINAL CN 5 SVE

1) Clench jaw (I palp masseter and temporalis)
2) Close jaw and resist opening
3) Open jaw and resist closing

Jaw deviates to weak side

47
Q

Jaw Jerk Reflex

A

TRIGEMINAL CN 5

  • Thumb under bottom lip
  • Mouth half open
  • Hammer thumb and observe

(+) Jerk close mouth (hyperreflexia_

THEORY:

  • masseter muscle spindle ->mesenteric nucleus ->CN 5 motor nucleus ->motor CN 5 ->Masseter m.
  • Causes: UMN lesion
  • rare bc B/L corticobulbar innervation of CN 5 motor nucleus
48
Q

Facial Muscles

A

FACIAL CN 7 SVE

1) Smile (zygomatics, levator anguli ori)
2) Wrinkle forehead (frontalis)
3) Squeeze eyes and resist opening (orbicularis oculi)
4) Whistle (buccinator, orbic oris)
5) Blow cheeks (buccinators)
6) Show teeth (orbic oris)
7) Platysma upside down smile

UMNL: C/L facial weakness LOWER only

LMNL: I/L whole face weakness

B/L bulbar innervation of forehead only

49
Q

Taste

A

FACIAL CN 7 SVA

  • Ant 2/3 tongue
  • use lemon
  • Post 1/3 is glossopharyngeal
50
Q

General hearing

A

COCHLEAR CN 8

  • Eyes closed
  • Randomly one ear, other ear, both
    1) Whisper numbers in ear and ask to repeat
    2) Rub fingers by ear

Causes of decreased hearing:

  • conductive -tympanum damage
  • sensorineural -age, noise induced
51
Q

Otoscopy

A
  • hold like pen w. scope down
  • R ear R hand
  • pinky on temple, not IN canal
  • warn of tickling, cough

STEPS:

  • pt on couch corner, C/L lat. flex. and extension
  • pull pinna up and back
  • Report external canal: inflam., exccess wax/hair
  • Report eardrum: shiny, pearl grey, translucent, no bulge/retraction, no bubbles, perforations
  • Report malleus handle: narrow opaque band at 10h (R) or 2h (L)
  • Report light reflex: 8h (R) or 4h (L)
  • Report annulus smooth
52
Q

Weber and Rinne tests

A

512 fork

WEBER:

  • Centre forehead
  • ask about even loudness
  • (+ conductive loss) louder
  • (+ sensorineural loss) less loud
  • Conductive: air, canal, tympanum, ossicles; object, drum damage, otitis media
  • Sensorineural: neural impulse cochlea, cochlear n., temporal lobe; noise induced, age, neuritis, trauma, vestibular schwanoma

RINNE: after Weber’s

  • On mastoid, say when sound stops
  • Quick to meatus -ask if can hear again
  • Test both ears and compare
  • (+) - can’t hear sound again = conductive loss
  • (+) -hearing decreased in one ear relative to other ear = Sensorineural loss

THEORY: sound travels better in air than bone
-if conductive loss, bone will transmit better

53
Q

Dix-Hall Pike

A

Vestibular system

  • explain test and ask to report vertigo, nausea, tell me if need stop
  • clear neck issue Hx
  • Pt sit legs straight, rotate neck 45o to me
  • Eye contact whole time
  • Count 3-2-1 -quick down to neck extension, hold 20s
  • Once symptom clear, rapid sitting -note symptoms
  • Repeat 2-3x -note if fading
  • (+) nystagmus or vertigo = BPPV
  • (+) delayed vertigo, horz nystag <30s, adaptation = Peripheral lesion
  • (+) immediate vertigo, changing nystagmus >30s, consistent intensity = Central lesion

THEORY:

  • max stim. post. Semicircular canal of down ear and ant. canal of up ear
  • BPPV: otolith debris degenerated in utricle and migrated in canal to stimulate cupula with head movement
  • idiopathic, or head trauma
54
Q

Fukuda Step Test

A

VESTIBULAR CN 8

  • eyes closed, arms extended, palms down
  • step fast, high knees for 60 seconds

(+) rotation > 45o = I/L vestibular dysfunction

Poor specificity
recent cold may give false (+)

55
Q

Palatal Movement and Gag Reflex

A 
PALATAL MOVEMENT:
-push out tongue, hold with depressor
-say « Ahhh», note palate and uvula
(+) uvula deviates away from weak side
-fale (+) if scarring
-only tests efferent

GAG REFLEX:

  • Long cotton bud
  • Touch soft palate/pharynx
  • Note presence or absence of reflex
  • No reflex but palatal movement (earlier) = afferent issue only

THEORY:

  • Afferent: GLOSSOPHARYNGEAL CN 9
  • Efferent: VAGUS CN 10
  • stimulus ->CN 9 ->Spinal trigem nucleus ->nucleus ambiguus ->CN 10 ->pharyngeal connstriction
  • vary btw people, but consistent in same person
56
Q

Dysphagia

A

TRIGEM., FACIAL, HYPOG., VAGUS, GLOSSOPH.
CN 5, 7, 9, 10, 12

  • ask about Hx
  • give water then have speak

CAUSES:

  • CN lesion
  • ccorticobulbar tract
  • NMJ
  • local ST
57
Q

Voice and Cough

A

TRIGEM., FACIAL, HYPOG., VAGUS, GLOSSOPH.
CN 5, 7, 9, 10, 12

  • ask to deep cough
  • speak (note hoarseness)
  • Hx of recent voice change

(+) Bovine cough (slow shallow whispy)
(+) Hoarse voice = recurent laryngeal

Lesion: muscles, vocal cords, NMJ, CN 5, 7, 9, 10, 12

58
Q

Dysarthria test

A

TRIGEM., FACIAL, HYPOG., VAGUS, GLOSSOPH.
CN 5, 7, 9, 10, 12

-Repeat «pa x4, ta x4, ga x4»
(+) slow, slurred speach

THEORY:
-NMJ, muscle, motor cortex, cerebellum, basal ganglia, corticobubar tract

59
Q

Aphasia test

A

HIGHER ORDER OR COGNITIVE ISSUE

  • Conversation
  • can also test comprehension (I point you name)

(+) easily talks but nonsensical = Wernicke’s
(+) can’t express, can understand = Broca’s

60
Q

SCM and Trapezius strength evaluation

A

ACCESSORY CN 11

  • Observe for volume and contour of SCM and Traps (winging, hollowing)
  • against gravity then resist 1 sec
    1) C/L head rotation
    2) I/L lateral flexion
    3) Neck flexion
    4) Shoulder elevation
    5) Neck extension

(+) moderate, transient, impaired SCM n traps = supranuclear lesion CN 11

THEORY: SCM corticobulbar is I/L, Traps is C/L

61
Q

Tongue muscles evaluation

A

HYPOGLOSSAL CN 12

1) observe for atrophy or fasciculations
2) ask to protrude tongue
3) poke tongue in cheek

(+) atrophy or fasciculations = LMNL
(+) tongue deviates toward weak side

Causes: stroke, polio, ALS, SOL

62
Q

What constitutes a POSITIVE nerve tension test result?

A

1) Pain
2) Neurological symptoms: paraesthesia, numbness, burning
3) Increased sensitivity compared to other side
4) Abnormal ROM or resistance compared to my experience

63
Q

Passive Neck Flexion

A
  • Pt supine, head neural, arms side, legs together
  • I flex their head to chest, hold <20s
  • note symptoms, ROM, resistance
  • SENSITIZE: ASLR

-Indicated if spinal cause suspected

THEORY:

  • Brudzinski sign (meningitis; flex head = hip/knee flexion)
  • Lhermitte’s sign (quick neck flexion sitting = electric shock sensation)
  • tensions all spine
  • normal is pulling sensation at C-T junction
64
Q

Straight Leg Raise (plain)

A
  • supine, neutral head, arms by side
  • Contact achilles and knee
  • slight adduction, internal rotation, lift leg slowly
  • note symptoms, ROM, resistance
  • compare L-R (ok side first)
  • SENSITIZE: active neck flexion

THEORY:

  • <30o : straightening of neural slack
  • 30-70 : dural sleeves and L4-S2 roots loaded
  • > 70 : further loading and hamstrings, Gmax, hip/L/SI joints
  • normal is 0-90o
  • normal is posterior thigh, knee, calf
  • Kernig’s sign: supine + hip/knee flexed, then knee extension provokes spasm
65
Q

SLR -tibial bias

A
  • adduct and internaly rotate hip
  • dorsiflex and evert foot
  • note symptoms, ROM, resistance

THEORY:

  • branch off sciatic nerve at popliteal fossa
  • splits into sural nerve
  • wraps around medial malleolus
  • roots L4-S3
66
Q

SLR -sural bias

A
  • adduction, internal rotation of hip
  • dorsiflex and invert foot
  • note symptoms, ROM, resistance

THEORY:
-branch off tibial and common peroneal nerve

67
Q

SLR -peroneal bias

A
  • adduct and internaly rotate hip
  • plantarflex and invert foot
  • note symptoms, ROM, resistance
68
Q

Well Leg Raise

A
  • Passive straight leg raise of leg without symptoms
  • note symptoms, ROM, resistance

THEORY:
(+) pain increases in symptomatic (not raised) leg = Medial disc protrution
(+) pain decreases in symptomatic (not raised) leg = Lateral disc protrusion

69
Q

Prone Knee Bend (plain)

A
  • Pt prone with neck FLEXED
  • plantar flex + flex knee to butt
  • grab thigh and lift while stabilizing I/L SIJ
  • hold for 15s
  • note symptoms, ROM, resistance
  • DESENSITIZE: extend neck

THEORY:
-anterior thigh symptoms
-normal: pulling, pain in quads
-indications: knee, ant thigh, hip, lumbar symptoms, trouble kneeling
(+) I/L lumbar pain, buttock, post thigh = L2-3 root
(+) ant thigh pain = femora nerve L2-4

70
Q

Prone Knee Bend -femoral bias

A
  • side lying in a slump with neck flexion, knee to chest
  • extend the hip with straight leg
  • flex knee
  • note symptoms, ROM, resistance
  • DESENSITIZE: Extend neck

THEORY:
-pain radiating down anterior thigh

71
Q

Prone Knee Bend -lateral femoral cutaneous bias

A
  • side lying, slump, neck flexion, knee to chest
  • extend hip, extend knee
  • hip adduction
  • note symptoms, ROM, resistance

THEORY:
-meralgia paresthetica: compression under inguinal ligament
-anterolateral thigh pain
Obesoty, pregnancy, tight beld, scar tissue

72
Q

Prone Knee Bend -saphenous bias

A
  • prone + neck flexed
  • extend + abduct hip + externaly rotate hip
  • dorsiflex + evert foot
  • note symptoms, ROM, resistance

THEORY:

  • L3-4
  • entrapment at aduductor/Hunter canal (middle 1/3 of thigh)
  • medial knee and leg pain
  • prolonged walking/standing
73
Q

Slump test (plain)

A

-Sit knees together at edge of couch, hands linked behind back
-I hold neck, you slump
-flex neck then I overpressure
-extend knee then dorsiflex, down then the other
-stop as soon as positive result
-note symptoms, ROM, resistance
DESENSITIZE: neck back to neutral

Indications: getting into car, kicking a ball, spine symptoms

THEORY:

  • tensions nerve roots and dural sheath
  • not if unstable disc
  • normal: T8/9 pain, post knee pain, tight hamstrings, restricted dorsiflexion
74
Q

Slump test -obturator bias

A
  • Pt sitting on corner of couch
  • hands behind back, i hold neck they slump, flex neck, overpressure
  • abduct thigh until symptoms
  • note symptoms, ROM, resistance

THEORY:

  • obturator is branch off lumbar plexus
  • supplies adductors
  • not if unstable disc
  • T8/9 pain is normal
75
Q

Median Nerve

A
  • depress shoulder
  • pistol grip thumb + lateral 3.5 fingers
  • abduct to 90-110
  • supinate
  • extend wrist and fingers
  • extend elbow
  • note symptoms, ROM, resistance
  • SENSITIZE: C/L lateral flexion

THEORY:

  • runs midline, anterior to elbow, carpal tunnel, anterior lateral 3.5 fingers and posterior tips
  • pronation, lateral wrist flexors
  • normal: deep ache in cubital fossa down anterior lateral arm, finger tingling
  • all brachial plexus is loaded
76
Q

Radial Nerve

A
  • scapula off couch, I face caudad,
  • depress shoulder with thigh
  • extend elbow
  • abduct
  • pronate
  • flex wrist and fingers and ulnar deviate
  • abduct more
  • note symptoms, ROM, resistance
  • SENSITIZE: C/L lateral neck flexion

THEORY:

  • runs posterior in radial groove of humerus, medial to lateral
  • enters forearm anterior to lateral epicondyle, cubital fossa, splits into deep motor and supperficial sensory lateral dorsum of hand and 3.5 fingers but not tips
77
Q

Ulnar Nerve

A
  • scap ON table, palm to palm contact wrap 4th and 5th finger
  • depress shoulder
  • extend wrist and finger
  • pronate
  • flex elbow
  • abduct
  • externally rotate shoulder
  • note symptoms, ROM, resistance
  • SENSITIZE: C/L lateral flex neck

THEORY:

  • runs posteromediql in arm, posterior to medial epicondyle
  • into anterior compartment on medial side
  • through Guyon’s tunnel
  • medial forearm and medial palm and 1.5 fingers anterior and posterior
78
Q

List the elements of the motor exam

A
  • Observation
  • Inspection
  • Palpation
  • Muscle tone testing
  • Functional testing
79
Q

Motor exam: Observation, Inspection and Palpation

A

OBSERVATION:

  • twitches, tremors, fasciculations, involuntary movements
  • posture (decorticate)
  • flacidity

INSPECTION:

  • muscle wasting, hypertrophy
  • intrinsic hand muscles (hypothenar, thenar, finger adductors)
  • subclavicular fossa
  • compare L to R
  • Measure (biceps, forearm, calf, thigh)
  • think BMI, age

PALPATION:
-firm, B/L
-biceps, forearm, thigh, calf
(+) tenderness, nodules, inflammation

80
Q

List the parts of Muscle Tone Testing

A

UPPER LIMB:

  • Tone
  • Fast elbow
  • Clonus

LOWER LIMB:

  • Fast knee
  • Tone
  • Clonus

ASHWORTH SPASTIC SCALE:
-any simple joint

81
Q

Execute Muscle Tone Testing of the upper limb

A

TONE:

  • grab hand and elbow
  • pronate/supinate, roll wrist, elbow in/out
  • compare L/R
  • NOTE: clasp knife, resistance throughout, rebound contraction

FAST ELBOW:

  • hold hand n elbow in flexion
  • rapid elbow extension
  • NOTE resistance

CLONUS:

  • relaxed in slight flexion
  • palm-palm contact, mild wrist extension
  • fast short thrust to max extension
  • NOTE jerking (continuous or fading)

ASHWORTH SPASTIC SCALE:

  • place muscle in max action position
  • move to min action over 1 sec
  • score
82
Q

Execute Muscle Tone Testing of the lower limb

A

FAST KNEE:

  • supine, fast knee lift
  • note stiffness, heel drag

TONE:

  • Simulaneous hip, knee, ankle full ROM and NOTE resistance
  • Roll thigh and watch foot lag
  • NOTE clasp knife, resistance throughout, rebound contraction

CLONUS:

  • supine, knee extended
  • support ankle in mild dorsiflexion
  • fast short thrust into mx dorsiflexion
  • NOTE clonus

ASHWORTH SPACTIC SCALE

83
Q

Explain the Ashworth Spastic Scale Scoring system

A

0 - no resistance (normal tone)
1 - Catch n release + min resistance at en ROM (slight + tone)
1+ -Catch at >half ROM + min resistance (slight + tone)
2 - Increase tone in most ROM but easily moved
3 - Movement difficult (considerable + tone)
4 - Rigid

THEORY:

  • Hypertonic: spastic or rigid (cog-wheel is type of rigid)
  • Spastic: UMNL, clasp knife, stiff and quick release
  • Rigid: basal ganglia, not dependent on rate or force, constant in ROM, lead pipe
  • Cog-wheel: rigid-give-rigid-give
  • Causes of hypertonicity: MS, huntington, parkinsons, stroke, brain trauma
84
Q

List the tests done in Functional Testing

A

1) Drift
2) Fine movements
3) Myotomal Muscle Strength

85
Q

Drift test

A

FUNCTIONAL TESTING
-done at start of exam to detect subtle abnormalities

  • Eyes closed, arms horizontal, palms up, feet appart
  • shake head NO for 60 sec
  • note drift

(+) Upward n pronation = cerebellar disease (golgi n spindles)
(+) Searching fingers only = lost proprioception (somatosensory activation)
(+) Downward, pronation, fingers/wrist/elbow flexion = UMNL/pyramidal weaknes, muscle weakness, subtle spasticity (cortical damage spares flexors n pronators)

86
Q

Fine Movements

A

FUNCTIONAL TESTING

  • at start of exam, subtle abnormalities
  • L n R simultaneously
  • slight dominance normal

1) Tap thumb to index
2) Pronation-supination (light bulb change)
3) Tap hands on thighs
4) Tap toes on ground (heel stays on floor)

(+) difficulty = weakness, tone, tremor, coordination

THEORY:

  • UMNL: clonus, primitive reflexes, hyperreflex, hypertonia
  • LMNL: atrophy, fasciculations, hyporeflex, hypotonia
  • Both: weakness
87
Q

Explain the Rating scale for Myotomal Muscle Strength

A
  • active 1st, hold 4 sec
  • stabilize always somewhere
  • resist my force
SCORE:
0 - no contraction
1 - muscle flicker
2 - movement
3 - resists gravity
4 - resists some examiner force
5 - normal strength (resists my force)
88
Q

Execute Myotomal Muscle Strength of the Upper limb

A 
(Standing behind)
C1-2 : neck flexion
C3 : lateral flexion
C4 : shoulder elevation
C5 : arm abduction
(Standing in front)
C6 : elbow flexion full supination (at 45o elbow flex)
      : wrist extension (at 90o elbow flex)
C7 : elbow extension (at 90o)
      : wrist flexion
      : finger extension
C8 : finger flexion
T1 : finger abduction
89
Q

Execute Myotomal Muscle Testing of the Lower Limb

A 
L1-2: hip flexion
L2-3 : hip adduction
L3 : knee extension
L4 : foot inversion
L4-5 : dorsiflexion
         : hip abduction
L5 : big toe extension
L5-S1 : hip extension
           : knee flexion
S1 : plantar flexion
     : eversio
S2 : toe flexion
90
Q

What movements can test myotome L1

A

Hip flexion

91
Q

What movements can test myotome L2

A

Hip adduction

92
Q

What movements can test myotome L3

A

Hip adduction

Knee extension

93
Q

What movements can test myotome L4

A

Inversion

Dorsiflexion

94
Q

What movements can test myotome L5

A 
Dorsiflexion
Big toe extension
Hip abduction
Hip extension
Knee flexion
95
Q

What movements can test myotome S1

A

Hip extension
Knee flexion
Plantarflexion
Eversion

96
Q

What movements can test myotome S2

A

Toe flexion

97
Q

List the elements of the Sensory Exam

A

1) Primary sensation -exteroreceptors
- pin prick
- light touch

2) Cortical -sensory cortex interpretation
- stereognosis
- graphaesthesia
- 2point discrimination
- point localisation

3) Proprioceptive sensation
- joint position sense
- passive movement
- vibration sense

98
Q

Execute the Pin Prick Sensation testing

A

-explain will not break skin

  • Baseline: eyes open, clavicle, ask to describe
  • Close eye, do R then L, ask for: «Yep… Same…»
  • If (-) sensation, map out borders w. pencil

Anterolateral tracts: crude touch pain temp
-dorsal root ganglion ->decussate at level of spinal cord ->spinothalamic tract -> ventral post. lat. nucleus thalamus ->primary somatosensory cortex

SPOTS:
-C2 jaw angle, C3 side sternal notch, C4 shoulder tip, C5 lat. arm, C6 thumb pad, C7 3rd finger pad, C8 pinky pad, T1 medial forearm, T2 arm armpit, T4 lat. to nipple, T10 lat. to umbilicus, L1 ASIS, L2 ant. thigh, L3 med. knee, L4 med. shin, L5 dorsal foot, S1 pinky toe, S2 post. thigh, S3 buttock

99
Q

Execute the Light Touch Sensation testing

A
  • Baseline: eyes open, clavicle, ask to describe
  • Close eye, do R then L, ask for: «Yep… Same…»
  • Blunt end

Posterior columns medial lemniscus: fine discriminatory, vibration, conscious position
-dorsal root gangion ->cuneatus then decussate ->medial lemniscus ->thalamus ->primary somatosenory cortex

SPOTS:
-C2 jaw angle, C3 side sternal notch, C4 shoulder tip, C5 lat. arm, C6 thumb pad, C7 3rd finger pad, C8 pinky pad, T1 medial forearm, T2 arm armpit, T4 lat. to nipple, T10 lat. to umbilicus, L1 ASIS, L2 ant. thigh, L3 med. knee, L4 med. shin, L5 dorsal foot, S1 pinky toe, S2 post. thigh, S3 buttock

100
Q

Stereognosis test

A

SENSORY TESTING

  • Eyes closed, Place item (spring, stapler, eraser, pencil) in hand, ask to identify
  • Tests sensation, cortex memory
101
Q

Graphaesthesia test

A

SENSORY TESTING

  • Eyes closed, trace large nuber (0-9) on palm (in their POV)
  • 6 consecutive correct answers
102
Q

Two-Point Discrimination test

A

SENSORY TESTING

  • Bent paperclip
  • randomly alternate single or double poke, ask to identify
  • keep narrowing until Pt incorrect
  • Compare L-R and to Normal values for that spot

THEORY:

  • areas w many touch receptors have large humunculus in primary sensory cortex
  • at east one receptor must remain unstimulated btw the 2 points
  • High density: Hands, lips, face
  • Lips, finger pads = 3mm
  • Palm = 12mm
  • Shins, back = 35mm
  • Cortical dysfunction or local issue
103
Q

Point localization test

A

SENSORY TESTING

  • lightly touch shin
  • ask pt to point to that spot
104
Q

Joint position sense testing

A

SENSORY TESTING

1) Eyes closed, place arm in position, then to neutral
- ask to mimic with same limb and then opposite

2) Eyes closed, place arm in position
- ask to touch index w other index (only moving one limb)

3) Eyes closed, tough nose w index

105
Q

Passice Movement

A

SENSORY TESTING

  • Eyes closed, hold medial and lateral sides of joint
  • Move limb up or down (back to neutral quicky)
  • Ask to say «Up… down…»
  • Continue until 6 successive correct
  • if fail, move to proximal joint
  • phalanx, wrist, elbow

-big toe, ankle

106
Q

Vibration Sense test

A

SENSORY TESTING

  • ???? Hz fork (the big one)
  • Baseline: eyes open, clavicle, ask what feels n when stops
  • Do L-R in one tap
  • Setup Pt so all points available at once
  • Ask to say «Yep… Same…»

UPPER LIMB: shoulder tip, radial head, scaphoid base, index fat pad (sitting)
LOWER LIMB: ASIS, medial knee, medial malleolus, big toe fat pad (supine)

Pathway: dorsal column–medial lemniscus
dorsal root ganglia ->dorsal columns ->medulla ->decussates at medial lemniscus ->thalamus ->internal capsule ->primary somatosensory cortex (postcentral gyrus)

Gracile = lower limb
Cuneate = upper limb
107
Q

List the elements of the Trunk Examination

A

Sensory

  • light touch
  • pain

Motor:
-Beevor’s sign

108
Q

Trunk sensory examination: Light touch and pain

A
  • Baseline: eyes open, clavicle, ask what they feel
  • L-R, eyes closed
  • Say « Yep… Same…»

????? Go from where to where?
nipples = T5
Umbilicus = T10
ASIS = T12

PIN PRICK: explain does not break skin

109
Q

Beevor’s Sign

A

TRUNK MOTOR EXAMINATION

  • Neck flexion and mini crunch
  • hold pen in line with umbilicus and watch for superior shift

THEORY:

  • healthy: all rectus abd. contracts at once = umbilicus still
  • upper abd pulls umbilicus bc no resistance from lower abd.
  • lesion T9 or lower

Neuromusculoskeletal Diagnosis (4 decks)

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