NEURO/Musculoskeletal Flashcards
How can you assess the TMJ?
- Place tips of index finger just in front of the tragus of ear- ask pt to open mouth
- Fingertips should drop into joint spaces as mouth opens
- Check for smooth range of motion, swelling/tenderness
- Snapping and clicking normal
- Ask patient to open and close mouth, protrude & retract (jutting the jaw forward) & perform side to side motion.
- Assess for pain, tenderness, full ROM from side to side.
How to do you assess SHOULDER GIRDLE? Why is a shoulder assessment important?
(adduction, abduction, flexion, extension, internal & external rotation)
- Abduct arms to shoulder level
- Raise arms vertical position above head palms facing each other
- Place both hands behind back of neck with elbows out to the side
- Place both hand behind small of back
The Shoulder
- Thoracic outlet syndrome: compression of brachial plexus adn subclavian vessels near 1st rib
- Ask pt if they can sleep with arms above head without numbness or tingling for a prolonged period of time?
Walk me through a cranial nerve assessment.
- I- olfactory
- Small- chapstick, coffee beans
- II- Optic
- Sight- confrontation test, pupillary reaction to light
- Confrontation test- face person and both cover the same eye, bring arm in from side, both should see the arm in the periphery at the same time
- III= Oculomotor
- Pupillary reaction to light; extraocular movement
- Take pen and allow eyes to follow you from side/side, up/down
- IV= Trochlear→ superior oblique muscle
- Extraocular movement- up/down
- V= trigeminal nerve (muscles of mastication/sensation)
- Ask patient to clench his/her teeth as you palpate temporal and masseter muscles
- Check sensation in areas on face
- Corneal reflex
- VI= Abducents→ lateral rectus
- Extraocular movement→ side/side
- VII= Facial nerve
- Ask patient to :
- Raise both eyebrows
- Frown
- Close eyes tightly so you can’t open them
- Show teeth
- Smile
- Puff out both cheeks
- Ask patient to :
- VIII= Acoustic
- Hearing- usually done by audiology
- IX= Glossopharyngeal
-
X= Vagus
-
IX and X assessed by:
- Voice hoarseness
- Gag reflex- tongue depressor
- AHH- palate should rise symmetrically
-
IX and X assessed by:
- XI- spinal accessory
- Ask patient to turn head to each side against your hand
- Ask pt to shrug both shoulders upward against your hand (trapezii strenght)
- XII Hypoglossal
- Tongue movement, ask them to move tongue side to side
How do you assess MUSCLE STRENGTH?
Grade on 0-5 scale: Active movement
- 0: no muscular contraction detected
- 1: barely detectable
- 2: active movement with gravity eliminated
- 3: active movement against gravity
- 4: active movement against gravity with some resistance
- 5: active movement against gravity with full resistance
How do you assess the nerve integrity of the cervical spine?
Elbow flexion: C5, C6
Elbow Extension: C6, C7, C8
Hand grip: C7, C8, T1
Finger abduction: C8, T1, ulnar nerve
Opposition of thumb: C8, T1, median nerve
How do you assess the nerve integrity of the lumbar spine?
- Hip flexion & adduction: L2, L3, L4
- Hip abduction: L4, L5, S1
- Hip Extension: S1
- Knee extension: L2, L3, L4
- Knee flexion: L4, L5, S1, S2
- Dorsiflexion: L4, L5
- Plantar Flexion: S1
What are some periop considerations for patients on steroids?
- Suppression or disease of pituitary adrenal axis will prevent the patient from responding to stress of sx appropriately
- Any patient who has received corticosteroid therapy (suppression of pituitary-adrenal axis) for at least a month in the past 6-12 months needs supplementation
- 2 possible regimens (many named in various classes)
- 100 mg hydrocortisone preop, intraop, post op
- 25 mg hydrocortisone preop, 100 mg IV gtt over 12-24 hours
What are some MAO inhibitors and anesthesia implication?
Monoamine Oxidase Inhibitors (TIPS BBIM)
- Watch for the following drugs:
- Tranylcypromine
- Isocaboxazid
- Phenelzine
- Selegiline
- Befloxatone
- Brofaromine
- Iproniazid
- Moclobemide
- LIFE THREATENING interaction can occur with consumption of foods containing tyramine and with Ephedrine and Meperidine
What specific questions would you ask a patient with Multiple Sclerosis preoperatively?
MS- autoimmune demyelinating disorder affecting the CNS
- Any recent history of illness or infection?
- Which medications are they taking and how often?
- *Interferon → flu like → typically on NSAIDs
- Steriods?
- Remission and exacerbation intervals- frequent? - make pt aware that they may have exacerbation around sx.
- Optical changes?
- CN involvement?
- Severity and nature of symptoms
- Respiratory status
- Previous triggers
What are important pre-existing deficits that should be documented prior to surgery for a patient with Multiple Sclerosis?
- Paralysis (assess motor strength)
- Sensory disturbances (dermatomes)
- Autonomic disturbances (resting HR, ortho hypotension)
- Visual impairment (cranial nerve usually impacted first)
- Seizures (medications)
- Emotional disturbances
What health history questions would be important to ask a patient with Parkinson’s Disease and why are these questions relevant to the disease process?
- Age of diagnosis, recent exacerbations and hospitalizations? Is levodopa still working?
- Current and past symptoms (oculogyric crisis, when? How long did it last? What helped?)–> eyes locked, acute loss of levodopa
- ANS symptoms (orthostatic BP)
- Hx of pergolide therapy
- Severe aortic/mitral regurg
- Temp regulation issues
- Pulmonary status optimized
- Potential for aspiration, atelectasis, PNA
- Dysphagia and or dyspnea
- Pulmonary infection
- Current med regimen and note s/e
- Levodopa- what happens if pt misses a dose
- Short half life- take it right before going back
- Anticholinergics and MAOIs
- Anticholinergics- diff urinating and tachycardia
- MAOI B- DA selective (still avoid ephedrine and meperidine)
- Levodopa- what happens if pt misses a dose
- Note the natural ROM for positioning→ typically need GA d/t tremor
- Deactivate deep brain stimulators before electrocautery
- Check with the manufacturer if it needs to be turned off.
What are the symptoms should you document for a pt with Guillain-Barre?
- Facial paralysis
- Difficulty swallowing
- Impaired ventilation
- Decreased deep tendon reflexes
- Extremity paresthesia
- Pain
What are some preoperative considerations for anklyosing spondylitis patients?
- Evaluate for co-existing vasculitis, aortitis, aortic insufficiency, pulmonary fibrosis
- Will airway be managed in standard way? Awake fiberoptic? Restrictive pattern?
- Evaluate for severity of kyphosis (difficult airway)
- SPO2, EKG, ECHO, CXR, PFT
- CBC, BUN, Cr
- Discontinue NSAIDS 2 days preop
- May have positioning challenges.
What are some questions you would ask a patient with a brain tumor?
- N/V?
- Headache
- Muscle strength
- Sensation assessment
- Visual deficits
- Current medications → Steroids? Anticonvulsants?
- Cranial nerve assessment
What pre-op questions would you ask a pt with Systemic Lupus Erythematosus (SLE)?
- Neuropathies
- Exercise tolerance
- ROM
- Valvular disease
- Myocarditis
- Pleural effusions
- What labs would you order?
- CBC, BMP, LFTs, PFT, CXR, low threshold for cardiac testing, pre-op N/V plan
