PD Neuro Part 2 Flashcards
Primary sensations
Light (superficial) touch Pressure (deep touch) Vibration Position of joints Pain Temperature Touch
Which sensory functions are spinothalamic tract?
Pain
Temperature
Crude touch
Which sensory functions are dorsal column?
Light touch
Pressure
Vibration, position of joints
For a completel neurologic evaluation, which peripheral nerves are tested?
Each major peripheral nerve
Routine exam
Hands Lower arms Abdomen Feet Lower legs Face (while testing CNs)
General considerations of exam
Pts eyes are closed
Minimal stimulation initially, gradually until pt becomes aware
Always test contralateral side of body, asking pt to compare
Where is strong stimulus needed?
Back
Buttocks
With each type of sensory stimulus, there should be:
Minimal differences side to side
Correct interpretation of stimulus
Discrimination of side of body tested
Relative location to last stimuli
What to do if sensory impairment is found
Map boundaries by the distribution of major peripheral nerves or dermatomes
Cortical sensory functions
Stereognosis Two point discrimination Extinction phenomenon Graphesthesia Point location
Abnormality of previous functions
Lesion in cerebral cortex or posterior columns of spinal cord
Superficial touch
Light strokes with cotton wisp
Avoid hair areas
Don’t depress skin
Ask for where stimulus was
Superfcial pain
Sharp/dull
Allow time between stimuli
Unpredictable pattern
Ask patient: sharp or dull, location?
When to test temp and deep pressure?
When superficial pain is not intact
Temperature testing
Test tubes of hot and cold water
Ask pt where and whether it is hot or cold
Side to side comparison
Deep pressure
Firmly squeeze muscle body
Expect discomfort
Vibration
Place stem of vibrating tuning fork against several bony prominences/joints
Begin at most distal joint
Should feel buzzing/tingling sensation
Ask where felt and for how long
Sites tested for vibration
Sternum Shoulder Elbow wrist Finger joints Shin Ankle Toes
Position of joints
Proprioception Hold joint by lateral aspects Begin with joint in neutral position Move up or down and ask patient for position of movement Great toes and a finger on each hand
Stereognosis
Ability to identify an object by touch and manipulation
Use familiar object for patient to identify
Tactile agnosia suggests…
Parietal lesion
Two point discrimination
Use 2 needles and alternate touching pts skin with 1 or 2 points
Find shortest distance the patient cannot identify two points
Depends on area of body tested
Why is two point discrimination different depending on area of body?
Fingers have more sensation than palm
Extinction
Simultaneously touch two separate parts of the body with a sharp stimuli
Ask patient how many stimuli they felt, and where
Both sensations should be felt
Graphesthesia
Using blunt object, trace letter or number on palm
Ask pt to identify figure
Repeat with different figure on other hand
Point location
Touch an area of pts skin and withdraw stimulus
Ask pt to point to area touched
Often performed simultaneously when testing superficial touch
Assessing motor function
Body position
Involuntary movements
Muscles
Coordination
Body position
Observe during movement and at rest
Involuntary movements
Tics
Tremors
Fasciculations
Muscles
Bulk - normal or atrophy
Tone - normal vs hypotonic or flaccid, vs spasticity or rigidity
Strength - normal vs weakness
Coordination
Determines throughout (testing cerebellar function, proprioception, strength)
Paresis
Impaired strength
Weakness
Plegia
Absence of strength
Paralysis
Hemiparesis
Weakness of half of body
Hemiplegia
Paralysis of half of body
Paraplegia
Paralysis of legs
Quadraplegia
Paralysis of all four limbs
Assessing motor strength
Assess all major muscle groups for strength, comparing side to side
Graded on scale 0-5
Motor strength scale
0 - no muscle contraction
1 - trace of contraction, but no mvmt
2 - Active mvmt of body part with gravity eliminated
3 - Active mvmt against gravity
4 - Active mvmt against gravity and some resistance
5 - Active mvmt against gravity and full resistance
Shoulder abduction
C5 + C6 Deltoid main muscle Innervated by axillary nerve Pt flexes elbow with arm at 45 degrees Pt attempts to abduct further against resistance
Shoulder adduction
C5 - T1
Pectoralis major main muscle, latissimus dorsi and others also contribute
Pt flex elbow at 45 degrees, have pt adduct against resistance
Elbow flexion
C5 + C6
Have pt pull at your hand against resistance
Elbow extension
C6 - C8
Have pt push at your hand against resistance
Wrist extension
Radial nerve test
C6-C8
Have pt make a fist and resist you pulling it down
Grip
C7 - T1
Have pt squeeze your fingers
Test both hands at same time
Finger abduction
Ulnar nerve test
C8, T1
Position pts hand with palm down and fingers spread
Try to force fingers together
Thumb opposition
When is weakness common?
Median nerve
C8, T1
Have pt touch tips of little finger and thumb together
Try to pry apart
Weak opposition common in carpal tunnel syndrome
Hip flexion
Iliopsoas
L2 - L4
Pt supine, place hand on thigh and ask pt to raise the leg against resistance
Hip adduction
Adductors
L2-L4
Pt supine, place your hands on bed between pts knees and have them try to bring knees together
Hip abduction
Gluteus medius and minimus
L4-S1
Place hands on outside of knees and have pt try to spread legs apart
Hip extension
Gluteus maximus
S1
With pt prone, have pt push posterior thigh up against your hand
May be more easily tested with pt standing
Knee extension
Quadriceps
L2-L4
Support knee in flexion and ask pt to straighten leg against your hand
Knee flexion
Hamstrings
L4-S2
With knee flexed and foot on bed, ask pt to keep foot on bed as your try to straighten leg
Dorsiflexion
Toes towards head
L4-L5
Plantar flexion
Tip toe
S1
Extensor hallucis longus
L5 strength test
Superficial reflexes
Upper abdominal
Lower abdominal
Cremasteric
Plantar
Deep reflexes
Biceps Brachioradial Triceps Patellar Achilles
Upper abdominal
T7-T9
Lower abdominal SL
T10-T11
Cremasteric SL
T12 - L2
Plantar SL
L4-S2
Biceps SL
C5-C6
Brachioradial
C5-C6
Triceps
C6-C7 (C8)
Patellar
L2-L4
Achilles
S1-S2
Upper and lower abdominal reflexes
Pt supine, lightly stroke each quadrant with end of a reflex hammer, or tongue blade
Slight mvmt of umbilicus towards the stimulus should occur
Should be equal bilaterally
Cremasteric reflex
Stroke inner tight
Proximal to distal
Testicle and scrotum should rise on same side
Babinski sign
Plantar reflex
Use pointed object to stroke lateral side of foot from heel to ball, then across foot to medial side
Some pts withdraw leg, hold ankle
Normal response is plantar flexion of all toes
Babinski sign is present when there is extension of great toe, with or without fanning of other toes
When is babinski normal?
Response in children younger than 2
Babinski reflex suggests…
CNS lesion in the pyramidal tract
DTR
Deep tendon reflexes
Pt relaxed, sitting or lying down
Distract pt with alternate action to relax area to be tested (have pt pull clenched hands apart)
Position limb with only slight tension on tendon to be tapped
Palpate tendon to locate
Use flick of wrist to briskly tap tendon
Compare side to side
Scale for DTR
0 - no response
1+ - sluggish or diminished, minimal contraction
2+ - active/expected contraction of muscle
3+ - more brisk than expected, slightly hyperactive
4+ - hyperactive with intermittent or transient clonus
Absent DTR indicate…
Neuropathy or lower motor neuron disorder
Hyperactive DTR indicate…
Upper motor neuron DO
Biceps reflex
Flex pt arm at 45 degrees at elbow
Palpate biceps tendon in antecubital fossa
Place tumb on tendon and fingers under elbow
Strike thumb, not tendon!
Brachioradialis reflex
Flew arm at 45 degrees and rest pts forearm on your arm with hand slightly pronated
Strike tendon directly and couple inches above wrist
Elbow will slightly flex, wrist will slightly supinate and fingers will slightly flex
Triceps
Sitting, standing, or supine
Hold elbow at 45 degrees
Patellar reflex
Flex knee at 90 degrees
allow leg to hand loosely
Strike tendon just below patella
Alternative to patellar reflex
Supine with legs bent and feet on table
Supine with one leg bent, one leg extended
Achilles reflex
Pt sitting, flex knee to 90 degrees
Keep ankle neutral position by slightly dorsiflexing the foot
Strike achilles tendon at level of ankle malleoli
Contraction of gastrocnemius causes plantar flexion
Reinforcement
Jendrassik maneuver
Patient locks fingers together and pulls hard as you tap the quadriceps tendon
Voluntary UMN innervation of arm overflows to increase excitability of LMN pool of the lower extremities (easier to elicit reflex)
Clonus
Commonly tested on ankles
Specifically when reflexes are hyperactive
Support pts knee in partially flexed position
Briskly dorsiflex foot
Look and feel for rhythmic oscillations between dorsiflexion and plantar flexion
Clonus indicates…
Upper motor neuron disease
