NEURO FINAL OSCE Flashcards
List the elements of the Mental Status Evaluation
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
Evaluate ALERTNESS and AROUSAL (with the GLASCOW COMA SCALE)
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
Evaluate AROUSAL and ALERTNESS (with level of consciousness test)
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
Evaluate ATTENTION and ORIENTATION
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
Evaluate MEMORY
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
Evaluate for Gerstmann’s Syndrome
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
Evaluate for APRAXIA
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
Evaluate for NEGLECT
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
Evaluate SEQUENCING and FRONTAL RELEASE
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
Evaluate LOGIC and ABSTRACT
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)
Evaluate for ABNORMAL THOUGHT PROCESSES
Compulsions Obsessions Phobias Anxiety Delusions
THEORY:
-toxic/metabolic, psychiatric disorders, focal lesions, seizures
Evaluate MOOD
Facial expression
Body language
Voice
Euthymic (normal), Dysthymic (depressed), Manic (elated)
Psychiatric, toxic, metabolic (thyroid)
Evaluate LANGUAGE
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
Hesitant vs Blocking speech
Hesitant:
- difficulty initiating speech
- stroke -> Broca’s aphasia
Blocking: sudden stop in middle of idea
Circumlocutions vs confabulations in speech
Circumlocution: Substitute forgotten word with its definition
Confabulation: fabrication of facts to hide memory blank
Paraphasias vs neologisms speech
Paraphasias: Words malformed, wrong or invented
Neologisms: invented or distorted words
Broca’s ahasia vs Wernicke’s aphasia
Broca: can’t express but can understand
Wernicke: easily talks but wrong sense of words
Perseveration vs echoalia vs clanging speech
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)
Circumstantiality vs derailment vs flight of ideas speeches
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)
List how we evaluate the Olfactory CN
OBJECT SMELLING:
List the ways to evaluate the Optic CN
Ophthalmoscopy Pupillary light reflex Convergence/Accommodation Visual acuity Colour vision Visual fields
List the tests for the Oculomotor CN
Eye movements Smooth pursuit Saccades Optokinetic nystagmus Oculocephalic testing
INDIRECTLY:
+ Pupillary light reflex
+ Convergence and Accommodation
List the tests for the Trigeminal CN
Facial sensation
Corneal reflex
Mastication muscles
Jaw jerk reflex
List the tests for the Facial CN
Facial muscles
Taste
INDIRECTLY:
-corneal reflex
List the tests for the Cochlear nerve (Vestibulocochlea CN)
General hearing
Otoscopy
Weber
Rinne
List the tests for Vestibular nerve (Vestibulocochlear CN)
Dix-Hall Pike
Fukuda Step Test
List the tests for the Glossopharyngeal CN
Palatal movement
Gag reflex
Dysphagia
List the tests for the Glossopharyngeal CN
Palatal movement
Gag reflex
Dysphagia
List the tests for Vagus CN
Voice and cough
Dysarthria
Aphasia
INDIRECTLY:
-Gag reflex
List the tests for Accessory CN
Observe SCM and traps
Test SCM and traps
List the tests for Hypoglossal CN
Observe tongue
Protrude tongue
Poke check
Object Smelling test
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
Opthalmoscopy
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
Pupillary light reflex
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
Convergence and accomodation
-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
Visual Acuity
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
Colour Vision
OPTIC CN 2
1) Ishihara charts
- colour blindness
2) Red desaturation:
- optic neuritis (red will be dull)
- compare R and L
Visual Fields
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
Eye Movements
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
Smooth Pursuit
OCULOMOTOR, ABDUCENS, TROCHLEAR (CN 3, 4, 6)
- TRACE X
- start middle, end middle
-one eye, other eye, both together
THEORY:
-?…
Saccades
OCULOMOTOR, ABDUCENS, TROCHLEAR (CN 3, 4, 6)
- Hold 2 separate fingers about 20cm appart
- head still, pt alternates gaze
1) Horizontal
2) Vertical
Theory???
Optokinetic Nystagmus
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
Oculocephalic Testing
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
Facial Sensation
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
Corneal Reflex
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.
Mastication Muscles
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
Jaw Jerk Reflex
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
Facial Muscles
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
Taste
FACIAL CN 7 SVA
- Ant 2/3 tongue
- use lemon
- Post 1/3 is glossopharyngeal
General hearing
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
Otoscopy
- 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
Weber and Rinne tests
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
Dix-Hall Pike
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
Fukuda Step Test
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 (+)
Palatal Movement and Gag Reflex
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
Dysphagia
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
Voice and Cough
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
Dysarthria test
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
Aphasia test
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
SCM and Trapezius strength evaluation
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
Tongue muscles evaluation
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
What constitutes a POSITIVE nerve tension test result?
1) Pain
2) Neurological symptoms: paraesthesia, numbness, burning
3) Increased sensitivity compared to other side
4) Abnormal ROM or resistance compared to my experience
Passive Neck Flexion
- 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
Straight Leg Raise (plain)
- 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
SLR -tibial bias
- 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
SLR -sural bias
- adduction, internal rotation of hip
- dorsiflex and invert foot
- note symptoms, ROM, resistance
THEORY:
-branch off tibial and common peroneal nerve
SLR -peroneal bias
- adduct and internaly rotate hip
- plantarflex and invert foot
- note symptoms, ROM, resistance
Well Leg Raise
- 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
Prone Knee Bend (plain)
- 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
Prone Knee Bend -femoral bias
- 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
Prone Knee Bend -lateral femoral cutaneous bias
- 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
Prone Knee Bend -saphenous bias
- 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
Slump test (plain)
-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
Slump test -obturator bias
- 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
Median Nerve
- 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
Radial Nerve
- 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
Ulnar Nerve
- 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
List the elements of the motor exam
- Observation
- Inspection
- Palpation
- Muscle tone testing
- Functional testing
Motor exam: Observation, Inspection and Palpation
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
List the parts of Muscle Tone Testing
UPPER LIMB:
- Tone
- Fast elbow
- Clonus
LOWER LIMB:
- Fast knee
- Tone
- Clonus
ASHWORTH SPASTIC SCALE:
-any simple joint
Execute Muscle Tone Testing of the upper limb
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
Execute Muscle Tone Testing of the lower limb
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
Explain the Ashworth Spastic Scale Scoring system
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
List the tests done in Functional Testing
1) Drift
2) Fine movements
3) Myotomal Muscle Strength
Drift test
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)
Fine Movements
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
Explain the Rating scale for Myotomal Muscle Strength
- 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)
Execute Myotomal Muscle Strength of the Upper limb
(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
Execute Myotomal Muscle Testing of the Lower Limb
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 flexionWhat movements can test myotome L1
Hip flexion
What movements can test myotome L2
Hip adduction
What movements can test myotome L3
Hip adduction
Knee extension
What movements can test myotome L4
Inversion
Dorsiflexion
What movements can test myotome L5
Dorsiflexion Big toe extension Hip abduction Hip extension Knee flexion
What movements can test myotome S1
Hip extension
Knee flexion
Plantarflexion
Eversion
What movements can test myotome S2
Toe flexion
List the elements of the Sensory Exam
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
Execute the Pin Prick Sensation testing
-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
Execute the Light Touch Sensation testing
- 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
Stereognosis test
SENSORY TESTING
- Eyes closed, Place item (spring, stapler, eraser, pencil) in hand, ask to identify
- Tests sensation, cortex memory
Graphaesthesia test
SENSORY TESTING
- Eyes closed, trace large nuber (0-9) on palm (in their POV)
- 6 consecutive correct answers
Two-Point Discrimination test
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
Point localization test
SENSORY TESTING
- lightly touch shin
- ask pt to point to that spot
Joint position sense testing
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
Passice Movement
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
Vibration Sense test
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
List the elements of the Trunk Examination
Sensory
- light touch
- pain
Motor:
-Beevor’s sign
Trunk sensory examination: Light touch and pain
- 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
Beevor’s Sign
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
