Physical Examination Flashcards
NAI:
Demeanour of carer
–> Unkempt, intoxicated, aggressive
Carer/child interaction
–> Detached, hostile
General state of care
–> Hygeine, nutrition status, rashes/ infection, clothing.
General signs NAI
–> Bruising (4FACESP)-
–> eyelids, neck, ears, fleshy cheeks
–> Frenulum
–> Fundoscopy for retinal haemorrhage
Burns
Fractures incl rib deformities
HINTS
Indicated when persistent acute vestibular syndrome indicate ?central cause:
Accurate ++….. if trained ++. Subtle.
Check: neck safety.
HEAD IMPULSE
- Normal or central: track the whole time
- Peripheral: Corrective saccades
NYSTAGMUS
- Normal: none
none*
- Peripheral: Horizontal, unidirectional (beats TOWARDS pathology acutely)
- Central: Vertical, bidirectional or pure torsional
TEST of SKEW
- Peripheral: stays focused
- Central: vertical correction
Hallpike/ Epley:
Diagnose BPPV, when movement-related symptoms.
Check neck safety. Warn of symptoms.
- Sit up at distance where head will overhang
- Turn 45deg
- Rapid lay back, overhang head 30deg
- Watch for 30secs
—> *Expect: latent, unidirectional, +- torsional nystagmus on same side as pathology - Repeat other side.
EPLEY:
- At end of Hallpike
- Turn head 90deg other way
- Roll onto shoulder
- Face down to floor
- Sit up
- Face to centre
- Chin to chest
^all for 30secs
Meningitis exam:
Fever/SIRS
GCS/ mental state
Photophobia
Nuchal Rigidity: low GCS, lift shoulder off bed- head will come
Kernig: Lift leg and straighten knee. Look for resistance
Brudinski: Flex neck, look for knee flexion
Peripheral stigmata: purpura of Neisseria, endocarditis.
Facial droop:
UMN (lower 2/3 only) or LMN (whole side)
If LMN
- ? Ramsay-Hunt (HZV of facial nerve)
—> Shingles to forehead, ears, oral
—> Can also affect V (numb face), VII (vertigo/ tinnitus), X/XI/XII (swallow, voice)
- ? Parotid lesion
- ? OM
- ? Sensorineural hearing (acoustic neuroma)
- ? BOS (temporal bone) #
?other LMN-opathy (MS, bulbar for miller fisher GBS)
Hearing Test:
Note hearing or mobility aids
Ask about pain/ hearing change
GROSS
- Stand behind. Rub tragus of one ear.
- In other, whisper a word 60cm from ear
- Ask them to repeat.
- x 3 words.
- If can’t get 2/3, repeat in normal voice, then loud voice.
WEBER
- Activate tuning fork on your knee
- Hold to forehead
- Ask ”where do you hear the sound?”
—> Normal: equal. SN: louder on UNaffected. Conductive: louder on AFFected
RINNE
- Activate tuning fork on knee
- Apply firmly to mastoid
- When patient can no longer hear it, move it to the auditory canal
—> Normal if they can hear it again, implies air > bone conduction. SN: normal (equally reduced). Conductive: won’t hear at canal
___________________________
CONDUCTIVE (air to middle ear): Earwax, OE, OM, perforation, otosclerosis.
SENSORINEURAL (cochlea to brainstem): age, noise exposure, viral (CMV), ototoxins.
GENERAL NEURO:
GENERAL
UMN:
- Decorticate/ decerebrate posture (brainstem. Local, or coning)
- Hemiplegic posture
- Extrapyramidal Sx (dystonias)
LMN (/NMJ/ muscle):
- Wasting
- Weakness/ foot drop etc.
- Fasciculations
_______________________
TONE
UMN = increased
- Spasticity: changes with velocity (worse when faster), range (often gives after a bit) and direction (eg. worse flex than ext)
- Hypertonia/rigidity: unaffected by speed
Lead-pipe: NMS
Cogwheel: Parkinson’s
- CLONUS (LL)
LMN (/NMJ/ muscle) = decreased
__________________________
POWER
- Isolate and test all muscle groups
- Grade:
0 = Nil
1 = Flicker
2 = No gravity
3 = Against gravity, not resisted
4 = Weak resisted
5 = Normal
UMN =
- Upper limb extensors/ lower limb flexors the weakest (ie. pyramidal posture)
LMN =
- Proximal weakness = myopathy
- Single nerve territory
______________________________
REFLEXES
UMN
- HyPER
- Upgoing Babinski
LMN/ NMJ/ muscle
- HyPO
________________________________
SENSATION
Demonstrate each on sternum first.
- Light touch -cotton wool (ST/DC)
–> All dermatomes - Pinprick (ST)
–> All dermatomes - Vibration (DC)
–> Thumb/Toe IPJ only (progress up proximal joints only if impaired) - Proprioception (DC)
–> Thumb/Toe IPJ only (progress up proximal joints only if impaired)
Mononeuropathy
Glove+ stocking = peripheral neuropathy (diab, ETOH)
Proximal weakness = myopathy (thyroid, infect, steroid)
Radiculopathy (dermatomal)= nerve root
Cord syndromes
________________________________
COORDINATION
- Finger-nose / heel-shin
- Look for intention tremor, dysmetria, DDK (ipsilateral cerebellar)
What is Pyramidal vs Extrapyramidal?
Pyramidal
= voluntary motor movement (corticospinal and corticoculbar)
ie. facial droop and hemiplegic posturing in stroke
Extrapyramidal
= INvoluntary movement, coordinationand reflexes
ie. EPS: acute dystonic reaction, tarditive dyskinesia
Upper Limb Myotomes
C2- Look at your shoe (neck flex)
C3- Fallen tree (lat flex)
C4- I’m not sure (shoulder elev)
C5- Arms out wide (shoulder abd)
C6- Smell your wrist (wrist ext, elbow flex)
C7- No zombies in heaven (wrist flex, elbow ext)
C8- Doing great (thumb abd, radial dev)
T1- I am done (finger spread, ulnar dev)
Lower Limb Myotomes
L2- Lifts the shoe (hip flex)
L3- Extends the knee
L4- Stops the door (dorsiflex)
L5- The toes divide (great toe ext)
S1- Can lift a tonne (plantarflex)
S2- Knee back to you (knee flex)
GCS
Gait Examination
- Walk 10m away and back (stand back from the patient)
- Stand on toes (calf weakness- S1)
- Stand on heels (foot drop- L4/L5)
- Romberg
If looks like Parkinsonsim: Righting reflex (pull sharply back on shoulders)
__________
Antalgic
Waddling
- Proximal myopathy- hip ABd weakness
–> Pelvic drop
Hemiplegic:
- Unilateral UMN
–> Arm flex, leg ext, circumduct leg
Scissoring
- Bilateral UMN as above
Broad based
- Ataxia- cerebellar or vestibular
Foot slap
- Foot drop OR peripheral neuropathy with sensory loss
High stepping
- Foot drop- L4/L5
Shuffling
- Parkinsonism
Cerebellar exam
Nystagmus
—> Vertical, bidirectional, pure torsional
Staccato speech
–> “Say Baby Hippopotamus”
Gait
–> Broad-based
–> Heel-toe to accentuate
Romberg
–> NEG in cerebellar
–> + means ataxia is sensory or proprioceptive (dorsal columns)
-Upper limb:
—> Overshoot
–> Intention tremor
–> Dysmetria
–> DDK
… cerebellar signs are IPSILATERAL
Cranial Nerve exam
I- Ask about changes to smell. Coffee.
II- Acuity. Pupils incl. RAPD. Colour vision (if optic neuritis suspected). Fundoscopy.
III, IV, V, and VI - H test.
–> III: ptosis, mydriasis, down-and-out
–> IV: tilted head, up-and-in
–> VI: inward eye, can’t look out
V- v1,v2,v3 sensation. Muscles of mastication. Corneal reflex.
VII - Ask about taste. Facial movements.
VIII - Hearing: gross, Rinne, Weber. Ask about balance. VO reflex (should stay fixed. If corrects- abnormal)
IX and X- Voice. Swallow. Cough. Gag reflex.
XI- Shrug (trapezius), head turn (SCM)
XII- Tongue wasting, fasciculations, deviation.
UPPER LIMB DERMATOMES:
C5- Badge
C6- Thumb
C7- middle
C8- Pinky
T1- inner forearm
T2- axilla
UPPER LIMB: rapid neuro screen
ROCK, PAPER, SCISSORS, OKAY
ROCK (with tucked thumb)
- Median
- Finger flexion (1-3)
- Thumb opposition
PAPER (with wrist back)
- Radial
- Wrist extension
- MCP extension
SCISSORS
- Ulnar
- Finger abduction/ adduction
OKAY (with paper grip)
- Anterior interosseus (median)
- Flexion at distal finger and thumb
SHOULDER Exam:
General inspection
Shoulder inspection (include deltoid wasting of axillary nerve)
Landmarks + special tests:
- Clavicle
- AC joint + scarf test
- Humeral head (ensure not infracoracoid)
- Greater tuberosity + proximal humerus
- Supraspinatus + empty can test (just beyond 30deg) (RC)
- Scapular spine
- Infraspinatus/ teres minor + resisted external rotation (RC)
- Test subscapularis with lift-off (RC)
- Axillary nerve: regimental badge, abduction
- Rotator cuff: Empty can + external rot + lift off tests… PLUS arc test (bring arm fully up- ask to slowly lower. Will get pain halfway down)… PLUS int and ext rot impingement
- FULL ROM
