Phys DIE Flashcards
5 assessments of the nervous system
- cerebral function: mental status
- brainstem function: cranial nerves
- spinal cord function: motor and sensory dermatome testing
- Integration: corticosensory function
- Cerebellar function, tests of movement
Tools for nervous system assessment
- penlight
- ophthalmoscope
- visual acuity card
- disposable sharp object
- 128hz tuning fork
- tuning hammer
Mental status assessment includes (4)
- appearance and behavior
- emotional stability
- cognitive abilities
- Speech and language
3 components of orientation
person
place
time
AAOX3
Cognitive ability testing
- assess cognition: the execution of complex mental processes
- learning, perceiving, decision-making, memory
How to test memory
- recent: 3 item recall
- remote: historical or verifiable information
Mini-mental state exam
- 11 items that test orientation, registration, attention nd calculation, recall, and language
- positive test is 24-26 of 30
- doesn’t work on pt with severe depression, they “don’t give a shit”
Mini-mental state exam
- language
- naming (hand, finger, nail)
- comprehension/commands - repetition of a phrase
- reading: word, phrase, passage
- writing: name or sentence
How to test CN I
Olfaction
- test each nostril separately with a non-volatile substance such as coffee beans or cloves
- usually only test if there is a loss of taste or behavior issues (frontal lobe has a lot to do with behavior)
How test CN II
- visual acuity (Rosenbaum, Snellen, Maxwell charts)
- peripheral vision (the best test ever)
How test CN III
- extraocular eye movement (SLOW)
- direct and consensual pupillary response to light
- accommodation and convergence
How test CN IV
(superior oblique)
- extraocular eye movements
How test CN V
- Blink reflex (testing sensation of V1)
- Facial sensation: light touch in all three distributions (V1 - V3) bilaterally (6 touches)
- Pain in all 6 areas only if trigeminal lesion
- Motor: when patient bites down, feel for symmetry in the masseter and temporal muscles symmetry
How test CN VII
- facial muscle strength: smile, raise eyebrows, puff cheeks
- taste (anterior 2/3): place salt water on tongue
- blink reflex (along with CN V)
How test CN VIII
- finger rub test
- Weber
- Rinne
How to truly test hearing
audiologist :) the CN tests are just testing gross function
How test CN IX
- Palatal and uvula elevation
- sensation portion of gag reflex
- speech
*if talking and swallowing, nerve should be intact
How test CN X
- Palatal and uvula elevation
- motor portion of gag reflex
- speech
*if talking and swallowing, nerve should be intact
How test CN XI
- shoulder shrug (trapezius) against pressure
- head turn (SCM) against pressure
How test CN XII
- inspection for atrophy and fasciculations
- tongue protrusion (lick wound)
- lateral movement of tongue (press against hand on outside of cheek)
What does the fundoscopic exam test?
- not any CN
- the fundus can give some neuro information
- papilledema
Motor function
- inspection/palpation
- posture
- tremors
- fasciculations
- bulk
- atrophy
- joint malalignment
- asymmetry
Two types of tremor
- intention (cerebellar tremor)
2. Resting tremor
Intention tremor
- ataxia
- goes away when movement stops
Resting tremor
- describe
- Parkinson’s disease, basal ganglia
- best observed when there is no movement
Resting tremor examples
- pill rolling
- cogwheel rigidity: jerky muscle flexion
- flattened affect
- shuffling gait
- arrested gait
- not present during sleep
Muscle tone testing
- overview
- pt contracts muscle against resistance
- quickly release muscle and watch for jerking response (clonus, cogwheel)
- check each UE and LE separately, compare
- check for symmetry and appropriateness for development and age
Fine motor movement tests (2)
- precision finger tap
- toe tap
Strength grading
0: no movement or contraction
1: flicker but no movement
2: horizontal plane, voluntary movement but not enough to overcome gravity
3: movement overcomes gravity but not resistance
4: voluntary movement capable of overcoming resistance
5: normal strength
Individual muscle groups to test UE
- arm abduction: deltoids/axillary nerve
- Elbow flexors: biceps/ musculocutaneous nerve
3: Elbow extensors: triceps/radial nerve
4: wrist flexors: flexor carpi ulnaris and radialis/median nerve - Wrist extensors: extensor carpi/radial nerve
Additional UE strength tests
- grip strength (squeeze fingers)
- abduction/adduction of fingers: ulnar nerve
- touch thumb to 5th finger and don’t let me pull through: median and ulnar
Individual muscle groups to test LE
- Hip flexors: iliopsoas/LS plexus
- Knee extensors: quadriceps/femoral nerve
- Knee flexors: hamstrings/sciatic nerve
- Ankle dorsiflexors: anterior tibialis/deep peroneal nerve
- Ankle plantar flexors: gastrocnemius/tibial nerve
Additional LE strength tests
- move great toe up and down
- inversion/eversion of foot against resistance
5 things to test when testing sensation
- light touch
- pain (sharp and dull)/temperature
- Proprioception
- two point discrimination
- vibration
How to test sensation
- test pain sharp pain and light touch first
- if can’t feel touch, then test proprioception and vibration
- if can’t feel pain, then test temperature
How to test sensation if in a rush
- test lowest dermatomes: fingers and big toe
How to test proprioception
- pt closes eyes
- move finger (or other joint) up and down, stop
- ask patient which direction it is pointed
- hold joint on sides, not on top and bottom
What is the first sensation to go in DM
- vibration
What is light touch testing?
dorsal column
what is pain and temperature testing?
spinothalamic tract
What is proprioception testing?
dorsal column
What is two point discrimination testing
dorsal column
What is vibration testing
dorsal column
Cortical sensation
- 3 tests list
- Graphesthesia
- Stereognosis
- Tactile extinction
Graphesthesia
ID letter/number drawn on palm
Stereognosis
ID objects based on touch
Tactile extinction
ID touch simultaneously on both sides of body
- if have a loss, will only be able to identify touch on one side
What do abnormalities of cortical sensation tests indicate?
- lesion in contralateral somatosensory cortex
- seen in Alzheimers
- get an MRI!
Reflexes
- how to grade
0 absent 1+ trace 2+ normal 3+ brisk 4+ non-sustained clonus 5+ sustained clonus
what to look for when testing reflexes
- symmetry!!
What are signs of upper motoneuron issue
- hyperreflexia
- fasciculations
- disuse atrophy
What are signs of lower motoneuron issue
- hyporeflexia
- atrophy
What are the five places to test reflexes and associated nerve
- Achilles (S1-S2)
- Patellar (L3-L4)
- Brachioradialis (C5-C6)
- Biceps (C5-C6)
- Triceps (C7-C8)
Additional reflex test
Plantar response/Babinksi
- run back side of hammer up outside of foot and across pad of foot
- NL: downward contraction of toes
- Babinski (positive test): upward great toe with fanning of other (UMN issue)
5 ways to test cerebellar function
- finger to nose to finger
- heel to shin
- rapid alternative movements
- tap each finger with thumb
- tap the floor
How to test gait and station
- Observation of stance, posture, leg swing
- toe-walking gait
- heel-walking gait
- stand on one foot and hop up and down
- tandem (heal to toe) gait
- Romberg: stand on one leg with arms out and close eyes
What sensations used to stand in place?
- when remove vision, what is tested?
- vision, proprioception, vestibular sense
- exposes upper motoneuron lesions if drift to side or fall sideways
Meningitis
- triad presentation
fever
HA
neck stiffness
Meningitis
- two signs
- Kernig’s sign: unwilling to extend leg at knee d/t pain
2. rudzinski’s sign: passive flexion of head induces flexion of lower limbs (into fetal position?)
Cauda equina syndrome
- what nerves
- name of presentation
- common sx
- Nerve roots below L1-L2
- saddle numbness S2-S5
- urinary dysfunction (atonic bladder and constipation)
- decreased rectal tone
