PD Exam III Flashcards
Mini-Mental State Exam
30 pt questionnaire
cognitive impairment - dementia
cognitive and higher cognitive
What are the categories of Mental Status Exam
appearance and behavior speech and language mood thought processes thought content judgment insight abstract thinking cognitive higher cognitive
speech and language
quantity: talkative, silent
rate: fast or slow
volume: loud or soft
fluency: rate, flow, melody
thought process
flight of ideas, incoherence, confabulation, etc,
thought content
compulsions, obsessions, phobias, anxieties, delusions, unreality
circumstantiality
speech with unnecessary detail, indirection, and delay in reaching the point
derailment
shift topics that are loosely connected or unrelated
flight of ideas
continuous flow of speech but abrupt changes from one topic to next
neologisms
invented or distorted words
incoherence
incomprehensible and illogical speech w/o meaningful connections
blocking
interruption of speech mid-sentence (losing thought)
confabulation
fabrication of facts or events in response to questions; to fill in gaps from impaired memory
preservation
persistent repetition of words or ideas
echolalia
repetition of words and phrases of others
clanging
choosing words based on rhyming rather than meaning
judgment
affected by anxiety, mood, edu, income, intelligence, culture
also delirium, dementia, psychosis
insight
can have denial of impairment (memory loss/confusion)
cognitive function
orientation attention remote memory recent memory new learning ability
higher cognitive function
information and vocab
calculating ability
abstract thinking
constructional ability
high cognitive functions
calculating
abstract thinking: concrete v abstract
information and vocabulary
constructional ability
concrete v abstract thinking
concrete: both mouse and rat have tails, sew rip before it gets bigger
abstract: both are animals, prompt attention to problem prevents trouble
information and vocabulary
name object
word comprehension
reading comprehension
writing
constructional ability
draw clock with hands pointing to specific time
where do the cranial nerves emerge from?
1, 2: cerebrum
3-12: brain stem
which cranial nerve relates BEYOND head and neck?
vagus CN10
Which CNs are Sensory, Motor, Both?*
Some say marry money but my brother says big brains matter more
What two muscles does CN11 (accessory) control?
SCM
Trap
What muscles do CN12 control?
strap muscles - infrahyoid ones
hyposmia v hyperosmia
hyposmia: partial loss of smell
hyperosmia: exaggerated sensitivity
dyosmia
distorted smell
anosmia
total loss of smell
phantosmia
olfactory hallucination
cacosmia
smelling something burned, foul, or rotten
what CN do irritating smells stimulate?
trigeminal (peppermint, NH3 –> dont use to test)
common olfactory disorders
post traumatic
post infection
olfactory hallucinations in epilepsy
what to do to examine olfaction?
inspect for obstruction sniff test (occlude one)
unilateral olfactory disturbance can be from what?
sub-frontal meningioma
rods v cones
rods: low light, low spatial acuity
cones: high light level, color, high spatial acuity
L/R VISUAL FIELDS of BOTH eyes go to which side of brain?*
L visual field of BOTH eyes: right brain
R: left brain
The image on the retina is…?
inverted
outside areas of both L/R visual fields lost, damage is at..?
chiasm`
Isihara’s testing
color vision
optic nerve testing
snellen chart
color vision
visual fields by confrontation
fundoscopic exam
testing CN II, CN III: PERRLA
pupils equal, round, react to light, accomodation
direct and consensual response to light
direct: shine light, pupil constrict
consensual: other pupil also constricts w/o direct light
anisocoria
different of 0.4mm in pupil diameter
testing CN3,4,6
Eyelid for symmetry (ptosis)
extraocular mvmts (6 cardinal directions)
convergence: look towards nose
nystagmus
medial/lateral canthus
corners of the eyes
sclera
whites of eye, covered by conjunctiva
limbus
outer edge between iris and sclera
two types of conjunctiva
bulbar: over sclera
palpebral: under eyelid
meibomian gland
produce mebium: oily substance to prevent tear evaporation
dysfunction: dry eyes
adie’s syndrome
neurological: usually unilateral mydriasis, no reaction to light, loss of deep tendon reflex, abnormal sweating
who can get Adie’s (tonic) pupil?
diabetic neuropathy
alcoholism
what is sustained in Adie’s pupil?
accommodation sustained –> complain blur vision from distant to near
Argyll Robertson Pupil
moisis
iris atrophy
cant dilate in dark
What causes argyl robertson pupil?
neurosyphilis
abducens palsy
eye mvmt disorder: lesion of CN6 –> gaze paresis
cant eye abduct
unilateral or bi- increase intracranial pressure
complete abducens palsy causes…?
convergent strabismus (looking straight, one goes in )
trochlear palsy
CN4: SO weakness
diplopia on downward gaze
oculomotor palsy
CN3 compression from tumor or post communicating a. aneurysm –> dilation (blown pupil)
complete v incomplete
30% pupil sparing
causes of trochlear palsy
myasthenia
dysthyroid eye disease: grave ophthalmology
cause of oculomotor palsy
diabetes
strabismus
eyes don’t align bilaterally: exotropia
complete oculomotor palsy
ptosis
lateral deviation, slightly downward
types of nystagmus (oscillation mvmt)
pendular: slow waveform, congenital ,MS
vestibular: peripheral (suppressed by visual fixation), central (unaffected by fixation)
gaze evoked: certain direction (Tav)
down beat: chiari malformation
convergence: dorsal midbrain
endpoint: physiological
CN5 Trigeminal
pons
facial sensations
mastication: muscles
damage to trigeminal during mastication
jaw deviate to affected side
4 muscles of mastication
masseter
temporalis
medial, lateral pterygoids
3 divisions of trigeminal nerve
ophthalmic n.
maxillary n.
mandibular n.
sensations of trigeminal
sharp-dull
hot-cold
light touch
compare side to side
how to test corneal reflex (trigeminal n.)
cotton to one eye –> blinking of both eyes
Facial nerve CN7
pons
ant 2/3 taste
facial muscle expression
parasymp: submandibular, sublingual, lacrimal glands
Motor function branches of facial n.*
two zebras bit my clavicle: temporal zygomatic buccal mandibular cervical
Bell’s palsy
one sided facial droop
LOWER motor neuron
facial nerve
difference between stroke and bell’s palsy
stroke: UMN, paralysis of lower face
Bell’s: LMN, paralysis of entire side
Types of hearing loss (vestibulocochlear n.) and how to test for it
conductive
sensorineural
Weber: lateralization
Rinne: conduction
Weber Test*
tuning fork midline
conductive hearing loss: heard best affected ear
nerve: heard best by intact ear
Rinne Test
conduction test
Normal: AC > BC
conductive loss: BC > AC
nerve: AC > BC, sound stops much earlier
How to straighten ear canal?
pull ear up
Glossopharyngeal CN9
medulla
swallowing throat muscles
post 1/3 taste
gag reflex
jugular foramen syndrome
nasopharyngeal carcinoma compress CN9
glossopharyngeal neuralgia
tumor or vascular
pain swallowing
Vagus n. damage*
deviation of uvula AWAY from affected side* dysphagia dysphasia dysarthria flattening palatal arch
dysphagia
difficult swallowing
dysphasia
difficult use/understand language
Aphasia
cant use/comprehend words
dysarthria
difficult articulating words
assess vagus nerve by…?
listen tot quality of voice
ask pt to say “ahh” and observe uvula, soft palate rising
roots of accessory n.
spinal root
bulbar root
Test accessory n.
turn head against resistance
shoulder shrug against hand
what nerve do surgeons nick a lot?
accessory n.
hypoglossal n.
tongue mvmt
test for hypoglossal n.
voice
tongue midline, side to side
push tongue against cheek
hypoglossal damage: which side tongue and uvula deviates to?*
tongue TOWARD*
uvula: AWAY*
Your patient tells you they have a prickly sensation on their lower left anterior thigh. What is a word to describe this?
Paresthesia
What is the definition of Fasciculations?
Random involuntary muscle twitches
Normal Muscle Strength would be graded as what number?
5/5
Define Ataxia
A gait that lacks coordination and is unstable
Considering what you know about Anatomy, Besides Balance, what else does walking on your toes and Heels test for (respectively)?
Plantar flexion/ dorsiflexion of ankles
Afferent Nerve fibers travel toward the spinal cord and away from the stimulus in a deep tendon reflex
True
A normal exam finding would be which of the following?
Patellar DTR, 2/4 bilaterally
If you found the previous answer number 4 “Patellar DTR, 2 on the left and 4 on the right” in your patient, What might this suggest?
CNS lesion on the left
You all received the “Meningitis vaccine”, what organism does that vaccine protect you from (several serogroups of this bacteria Anyway-but not all)
Neisseria meningitidis
fasciculation
muscle twitch
When upper motor neurons are damaged above the crossover of its tracts in the medulla, motor impairment is on?
opposite side of the body
When upper motor neurons are damaged below the crossover of its tracts in the medulla, motor impairment is on?
same side of the body
When do you check temperature sensation?
only if pain sensation (sharp or dull test) is abnormal
Analgesia v. Hypoalgesia v. Hyperalgesia
Analgesia – absence of pain sensation
Hypoalgesia - DECREASED sensitivity to pain
Hyperalgesia - INCREASED sensitivity to pain
Anesthesia v. Hypesthesia v. Hyperesthesia
Anesthesia – absence of touch sensation
Hypesthesia – DECREASED sensitivity to touch
Hyperesthesia - INCREASED sensitivity to touch
Paresthesia – peculiar sensation without an obvious stimulation
Dysesthesia – distorted sensation in response to stimulus
What can loss of proprioception and vibration be causes by?
multiple sclerosis, B12 deficiency, posterior column disease, peripheral neuropathy
how to test proprioception (position)
- hold sides of big toe and move it up and down (tell them which is which)
- pt close eyes and tell you up or down
how to test vibration
- place tuning fork on DIP big toe
2. ask pt when vibration stops
what if vibration test abnormal?
move distally, eg medial malleolus, tibial tuberosity
How to check light touch?
cotton ball
pt tell you when they feel it (eyes closed)
test side to side (does it feel the same)
looking for anesthesia
tests for discriminative sensation
stereognosis graphesthesia two point discrimination: 1 or 2 pts point localization extinction: touch at same place on each side (eyes close), they to where
What to INSPECT in motor sensory test
muscle bulk: side to side
muscle tone
body position
body stance
muscle tone
residual tension in relaxed muscle
test through passive mvmt
muscle bulk
active mvmt: I and palp for atrophy
paratonia
increased resistance that decreases when pt distracted
rigidity
increased resistance through mvmt
what to watch out for in motor exam?
fasciculations
atrophy
abnormal movements
involuntary movements
Myoclonus*
Rapid shock-like muscle jerks
Chorea*
rapid, jerky twitches, similar to myoclonus but more random in location and more likely to blend into one another
Tics*
abrupt, stereotyped, coordinated movements or vocalizations
Dystonia*
maintenance of abnormal posture or repetitive twisting movements
paresis v plegia
paresis: weakness
plegia: paralysis
How to test Grip Strength
pt squeeze 2 fingers as hard as they can
test bilaterally
Rapid alternating mvmt
palm up and down, one by one tap toes to your hand thumb to fingers tongue wiggle "lalala" "papapa"
how to test coordination and equilibrium (taxia)
rapid alternating mvmt
point to point mvmt: finger to nose and to finger
how to test for gait
walk heel to toe (tandem walking)
walk on toes, heels
hop one foot
shallow knee bend
Romberg Test
push pt side to side and have them maintain balance
whats a positive romberg test?
pt can stand well w/eyes open but lose balance when they’re closed
pronator drift
- pt close eyes
- have pt flex and supinate and HOLD 20-30sec
POS: if cant hold and starts supinate - tap arm downward
what is pyramidal drift?
arm tapping of pronator drift
pronator drift is positive in what condition?
stroke
corticospinal tract lesion contralaterally
Normal rating in DTR
2/4
What muscles does the patellar reflex stimulate?
quadriceps
What is 5/4 for a DTR rating?
sustained clonus
what type of lesion in a hyper reactive DTR?*
central (CNS/upper motor neuron) lesion
What spinal tract is responsible for DTR and where does it cross over?
Corticospinal
medulla
corticospinal tract lesion above medulla result
contralateral hyper reflexia
below: ipsilateral
Where are DTRs?
Biceps Triceps Brachioradialis Abdominal Patellar tendon (knee) Achilles (ankle)
abdominal reflex
stimulate ab wall –> see contraction
Plantar (Babinski) reflex
stroke foot, curve medially over ball of foot –> flexion
Babinski reflex in infants
fanning of toes bc incomplete myelination
clonus
rhythmic oscillation response (hands, feet)
how to check for clonus?
sharply dorsiflex foot and hold (passive)
feel for oscillations
anal reflex
stroke outward in 4 quadrants from anus –> contraction
meningeal signs
neck mobility
brudzinski’s sign
Kernig’s sign
Kernig’s sign
for meningitis
pos: pain bilateral behind knee when flexed knee is extended
Brudzinski’s sign
for meningitis
pos: flexion of hips and knee in response to flexing neck
priapism
prolonged erection usually w/o sexual arousal
CVA tenderness
pain w/percussion of costovertebral angle (over kidneys)
What should you inspect in genitourinary exam?
perineal skin tanner staging position of urethral meatus compress glans for discharge lice and eggs
What to evaluate with inguinal canal?
hernia by having patient bear down
What’s in inguinal canal?
spermatid cord
genital branch of genitofemoral n.
ilioinguinal n.
What is inguinal ligament between
ASIS
pubic tubercle
Sequence of inspection and palpation
inspect penis
palpate testes and epididymis
palpate each spermatid cord
evaluate for hernias
What to palpate for hernias in the groin?
observe
pt standing and valsalva maneuver
palpate inguinal rings and femoral canal
Which is medial: external or internal inguinal ring?
external
How to tell there’s a scrotal hernia?
fingers cannot get above mass
Indirect Hernia frequency, course, and origin
most common, often children
all sex, age
origin: above inguinal lig, midline (internal ring)
course: down into scrotum through canal
where does your finger touch an indirect hernia?*
fingertip
Direct Hernia frequency, course, and origin
less common
usually men >40, rare in women
origin: above inguinal lig, close to pubic tubercle (ext ring)
course: bulge ant, rare in scrotum
where does your finger touch a direct hernia?*
side of finger forward
Femoral Hernia frequency, course, and origin
least common
more women than men
origin: BELOW inguinal lig, more LATERAL (hard diff from nodes)
course: never into scrotum, inguinal canal empty
condyloma accuminata
HPV warts
rare symptomatic, sometimes painful
HIV serology 6/11 (not same as cancer)
Genital Herpes Simplex
found: penis shaft, vagina/vulva/cervix, around anus
HSV, painless; painful if blisters rupture
chancre
primary syphilis, painless
hypospadius
urethral opening on underside of penis
surgical correction 1st 18months life
Peyronie’s Disease
fibrous plaques top above cavernosum (beneath buck’s fascia) –> painful CURVATURE
connective tissue disorder
Carcinoma of penis
squamous cell
localized lesion,
may be painful, drainage can start to bleed and enlarge
risks of carcinoma of penis
HIV
HPV
Warts
Differential diagnosis of testicular mass
tumor epididymitis hydrocele: cystic, asymp, around testis spermatocele: cystic swelling, top of testis varicocele: cystic, asymp
epididymitis v. tumor
tumor: painless, swelling, attach to penis, solid
epididymitis: acute, painful, swelling, no fever, around testi
epidermoid cysts
benign cysts
surgical removal if painful
causes of scrotal edema
many: cancer, heart liver failure, lymph, vein, bladder
risks of cryptorchidism
testicular cancer
reduced fertility
most common testicular tumor
germ cell tumor: seminoma or nonseminoma
cause of acute epididymitis
STD, UTI
Spermatocele
cyst with sperm on epididymis, painless usually
tuberculous epididymitis
inflam, swelling of epididymis from mycobacterium tuberculosis
testicular torsion onset
rapid and severe pain
blood supply compromised
What to look at in rectal exam
perianal skin: hemorrhoids, warts, lesions
digital exam: sphincter tone, prostate, rectal vault, hemoccult card
anal fissure
tear in anal lining
valve of houston
transverse fold into rectum
Patient positions for genitourinary exam
standing
left lateral decubitus
Ext v int hemorrhoids
ext: painful
int: painless
Most common rectal cancer
squamous cell, linked to HPV
