Tests detail Flashcards
General observation - what to look for - 6 items.
Posture. Assymetry. Gait. Involuntary movements. Atrophy. Skin condition/lesions.
Vital signs - Height and weight
Ask patient as part of history taking. Note build. If necessary check tables to determine over or underweight. BMI over 30 is obese.
Vital signs - Aural temperature
Thermometer in ear and hold for 2-3 s. Normal is 37. 7. Higher in evening.
Vital signs - Radial pulse rate
Compress radial artery at wrist with index and middle fingers. Count for 15s x 4. If very irregular, count for 60s. Normal is 60 to 100. >100 Tachycardia. <60 Braycardia. T is normal with stress or exercise. B is normal at rest for athletes.
Vital signs - Radial pulse regularity and amplitude
Compress radial artery at wrist with index and middle fingers. Regular - may vary with respiration. Regularly irregular - pattern with skipped beats. Irregularly regular - no pattern. Strong or weak?
Vital signs - Respiration rate
Observe patient’s brathing without announcing it. Notice any difficulty or irregularity. Count for 15s x 4. Normal is 14 to 20 with the occasional sigh.
Vital signs - Blood pressure - before procedure
Patient ot sit quietly for 5 mins before. Room quiet and warm. No alchohol or smoking 15 mins before. Check neither arm is contraindicated - lymphoedema. Check arm is free of clothing.
Vital signs - Blood pressure - Procedure
Palpate brachial pulse. Position arm with elbow crease at heart level - e.g on table. Fit cuff 2.5cm above crease centred on brachial artery. Arm slightly flexed. Measured in mmHg. Bilateral on first visit. Pump up cuff while palpating radial pulse till it annot be felt - systolic. Defleat and wait 15s. Place bell of stethascope on brachial artery and inflate about 30 above. Decrease slowly until 2 consecutive beats are heard - systolic. Decrease further till sound muffles and disappears - diastolic. Record to nearest 2mmHg. Check both sides if first visit. Twice on each arm and take higher reading.
Vital signs - Blood pressure - Interpretation of readings.
Use worst classification if s and d differ. Optimal under 120/80. Normal under 130/85. High-normal under 140/90. Hypertension: grade 1 under 160/100, grade 2 under 180/110. Grade 3 over. Difference of > 10 - 15 each side indicates compression or obstruction. Initial reading may be high due to white coat syndrome.
Extra vital signs - Oral temperature
Glass thermometer - shake down and place under tongue for 3-5 mins. Electronic - use disposable cover, insert under tongue, takes 10 s. Normal varies during day 35.8 morning, 37.3 evening. Over 38.5 is fever.
Extra vital signs - Axilliary temperature
Normal 36.3 - least accurate.
Extra vital signs - Orthostatic hypotension
Take blood pressure in 3 positions: supine after resting for 3 to 10 mins, sitting and standing within 3 mins. A difference of > 20 is positive.
Extra vital signs - Leg blood pressure
Normal for systolic to be 5 to 10 mmhg lower in legs. Large cuff around thigh, prone patient or flexed leg for popliteal. Can also measure dorsalis pedis.
Cerebral function tests - procedure
Assess while taking case history
Cerebral function tests - interpretation
Doesnt know time, day, date, place. Cannot name everyday objects. Cannot follow verbal instructions. Difficulty writing. Possible dementia. Sifficulty speaking, articualtion, fluency, vocabulary. Possible dementia or dysphasia.
Standing and walking freely - procedure
Observe patient standing and ask then to walk.
Heel and toe walking - procedure
Ask patient to walk away with on toes and back towards you on heels.
Tandem walk - procedure
Ask patient to walk in a straight line with heel touching the toe of the previous foot.
Rhomberg’s - procedure
Ask patient to stand with feet close together. Ask patient to close eyes.
Rebound test - procedure
Ask patient to stand with eyes closed and arms outstretched. Strike firmly down on one arm .
Finger to nose - procedure
Patient seated. Ask patient to point at own nose and your finger, several times with finger moved each time
Rapid alternating hand - procedure
Ask patient to alternately tap dorsal and palmer side of hand quickly on thigh - one hand then other. Demonstrate.
Heel down shin - procedure
Patient sitting. Ask patient to place one heel on opposite knee and run it down the shin and off at ankle. Demonstrate.
Standing and walking freely - interpretation
Check for sway when standing (vestibular problem); sways but corrects (hysteria). Check gait for veering, balance, intention tremor, ataxia (cerebellum, MS); shuffling, resting tremor (parkinsons); antalgic (pain avoidance), spastic paralysis gait (possible spinal cord lesion).
Heel and toe walking - interpretation
Difficulty could indicate balance, co-ordination problems or muscle weakness. Toe drop - L4 myotome, tib anterior. Heel drop - S1 myotome, Gastroc, soleus.
Tandem walk - interpretation
Patient veers to the side. Possible CN VIII (vestibular), eyes and feet, proprioception, cerebellum.
Rhomberg’s - interpretation
Positive if sway is significantly greater with eyes closed. Indicates proprioception problem, peripheral neuropathy or dorsal column.
Rebound test - interpretation
Excessive rebound swinging indicates problem with cerebellar function.
Finger to nose - interpretation
Action, intention, endpoint tremor or dysmetra indicates cerebellar lesion. May also have nystagmus & hypotonia (cerebellar dytaxia).
Rapid alternating hand - interpretation
Lack of co-ordiantion and unevenness of rhythm and force indicates dysdiadochokinesia (Cerebellar function).
Heel down shin - interpretation
Leg dystaxia/ lack of coordination indicates problem with cerebellar function.
Motor function - Passive ankle and wrist flexion/extension - procedure
Patient supine and relaxed. Manipulate resting joint to feel muscle tone and elasticity. Use different speeds and anatomical movements on ankle, elbow and wrist.
Clonus - procedure
Patient supine and relaxed. Flex knee slightly. Place hand on sole of foot and briskly dorsiflex. Maintain pressure.
Babinski sign - procedure
Patient supine and relaxed. Hold ankle and stroke end of reflex hammer slowly from heel up lateral foot and sweep across ball of foot, avoiding base of toes.
Motor function - Passive ankle and wrist flexion/extension - interpretation
Normal is slight resistance through whole range. Spacticity - pyramidal lesion. Cogwheel Rigidity - extra pyramidal e.g. parkinsons. Hypotonia - Peripheral neuropathy, myopathy, central lesion or congenital e.g cerebral palsy or downs syndrome.
Clonus - interpretation
A few clonic jerks is normal. Oscillating flexion/extention as long as pressure maintained indicates UMN lesion.
Babinski sign - interpretation
Normal (No babinski sign) - toes curl, foot withraws, jump, no movement. Poitive - Big toe extends. Babinki sign is normal in infants. In adults it can indicate UMN lesion.
Vibration sense - procedure
Patient supine. Eyes closed. Hold large tuning fork to DIP joint of toe and finger and ask patient if they can feel it.
Proprioception - procedure
Patient supine, Support arm, grasp sides of finger and show up and down. Ask patient to close eyes and move finger to up or down position and ask which. Repeat for other side and toes.
Limb repositioning - procedure
Sitting. Ask patient to close eyes. Move limb into position. Say to patient to remember it and move arm back to it.
Touch localisation - procedure
Ask patient to point where you touch. Touch arms and legs
Sensory inattention - procedure
Ask patient to point where you touch.Touch both arms or both legs
Stereognosis - procedure
Ask patient to close eyes and place and object in their hand. Ask what it is.
Graphaesthesia - procedure
Ask patient to close eyes and draw a number or letter on their hand.
Vibration sense - interpretation
Lack of feeling in glove and stocking ditribution - peripheral neuropathy, possibly diabetes. Other lack of vibration sense indicates dorsal column problem. With Rhomberg, areflexia & hypotonia - sensory dytaxia.
Proprioception - interpretation
Failure to indicate whether finger/toe is up or down correctly could indicate malingering, hysteria, neurodisease (Dorsal column) or unclear communicaiton to patient.
Limb repositioning - interpretation
Failure to reproduce the limb position - Proprioception problem (Dorsal column).
Touch localisation - interpretation
Failure to tell where touch is - dorsal column problem.
Sensory inattention - interpretation
Patient only recognising one side when both are touched - Brain lesion
Stereognosis - interpretation
Failure to recognise objects by touch - Parietal lobe lesion
Graphaesthesia - interpretation
Failure to recognise a number or letter drawn on the hand - Parietal lobe or dorsal column
History of anosmia - procedure
Ask patient if they have any difficulty with sense of smell.
Visual fields - procedure
Patient covers one eye. “Tell me when you see my fingers.” Wiggle fingers from 4 corners.
Neglect - procedure
Hold fingers to left and right of patients head. “Point to any finger that moves.” Wiggle one then other, then both. Repeat in inferior and superior quadrants.
Pupillary light reactions - procedure
Dim lighting. Ask patient to look into the distance. Shine pentorch into one eye from side. Observe reflex in each eye. Repeat for other eye.
Pursuit - procedure
Hold finger 50 cm in front of patient. Draw H slowly. Ask patient to follow it without moving the head and say if they see double.
Vergence - procedure
Ask patient to look into the distance then at your finger 50 cm away.Ask patient to follow as you move finger towards their nose. Look for nystagmus. Also check for ptosis.
Temporalis, masseter and pterygoid strength - procedure
Notice whether the jaw is deviated to one side or cannot close. Palpate temporlis while patient clenches jaw. Palpate temporalis while patient bites. Ask patient to deviate jaw to sideagainst resistance.
Light touch and pain on V1, V2 and V3 - procedure
Use cotton wool and medipin. Test each side and ask patient if they feel it. Compare with neck. If impaired test temperature also. V1 - opthalmic - forehead. Above eye. V2 - maxilliary - upper cheek. V3 - mandibular - lower cheek near chin.
Function of facial muscles - procedure
Ask patient to raise eyebrows (frontalis), Close eyes tightly (obicularis oculi), purse lips (buccinator, orbicualris oris), grimace (platysma)
Screen hearing - procedure
Ask patient to cover one ear and repeat a phrase whispered in the other ear.
Weber’s - procedure
Strike tuning fork and place on top of patients head. Ask if they can hear it equally in both ears.
Rinnes - procedure
Strike tuning fork and place on mastoid process. Ask patient to say when it disappears. Place fork by ear and ask if they can hear it.
Swallowing - procedure
Ask patient if they have any problems swallowing.
Uvula - procedure
Ask patient to open mouth wide and shine pentorch in. Use tongue depresor to observe uvula. Ask patient to say “Ahh”.
Trapezius, and sternocleidomastoid strength - procedure
Observe back and shoulders. Ask patient to raise shoulders against resistance for 5 secs. Observe and palpate SCM. One hand on shoulder, other on side of forehead. Ask patient to turn head towards hand and upwards. Ask patient to deviate jaw against resistance.
Observe tongue - procedure
Observe tongue. Ask patient to protude tongue.
Tongue strength - procedure
Ask patient to push tongue against cheek.
History of anosmia - interpretation
CN 1 lesion. Upper respiratory tract infection. Head injury. Degenerative disease. Tumour. Aneurism in circle of willis. Raised ICP.
Visual fields - interpretation
Pattern defects. Bitemporal hemianopia (lateral blindness in each eye) - optic chiasm lesion. Homonomous hemianopia - Optic tract (contralateral), radiation or occipital cortex (macula spared). Quadrantanopia - radiations (Upper = temporal. Lower = parietal. Contralateral.) Monocular blindness - optic nerve lesion (ipsilateral).
Neglect - interpretation
Patient only sees hand one when both sides are wiggled - Parietal cortex or parieto-occipital cortex lesion.
Pupillary light reactions - interpretation
Pupil should constrict for normal reflex. Direct and consensual impaired when testing same eye - Optic nerve lesion (afferent). No reflex in one eye regardless of which is tested - oculomotor lesion (efferent).
Pursuit - interpretation
Normal movement is full, smooth & co-ordinated. No double vision or nystagmus (uncontrolled movements) Double vision indicates eyes are not co-ordinated. Problem when looking down and L or R may be CN IV on opposite side (possible cerebellar tumour). Problem when looking L or R may be CN VI on same side (VI is long so could indicate raised ICP). Others CN III (CIII passes circle of willis). Nystagmus may indicate CN VIII (vestibular). All with V & possible proptosis indicates cavernous sinus and orbital fissure.
Vergence - interpretation
Normal movement is full, smooth & co-ordinated. Possible CN III. Nystagmus may indicate CN VIII (vestibular) or cerebellar lesion. Ptosis indicates CN III lesion, Horners syndrome or myesthenia gravis.
Temporalis, masseter and pterygoid strength - interpretation
Lack of muscle tone, inability to clench jaw, jaw deviation - CN V lesion (motor)
Light touch and pain on V1, V2 and V3 - interpretation
Map any area of sensory deficit. One division sensory deficit - peripheral nerve or nucleus. All divisions - ganglion or nucleus. If dissociated - pons, medulla or spinal cord. Sharp deficit may result from trigeminal neuralgia.
Function of facial muscles - interpretation
Lack of muscle strength or asymmetry in upper and lower face indicates CN VII motor lesion. Lower face only - UMN contralateral (tumour or vascular). Upper and lower face - LMN ipsilateral (Bells Palsy). Bilateral - LMN (Pontine lesion, Guillan Barre, lyme disease or muscle disease).
Screen hearing - interpretation
Patient cannot hear a whispered phrase well enough to repeat it - conductive (e.g. earwax) or sensoryneural deafness.
Weber’s - interpretation
Normal is equal sound in both ears. Louder in one ear indicates conductive deafness in the louder ear (less background noise) or sensoryneural deafness in the quieter ear (less hearing).
Rinnes - interpretation
Positive test if patient hears sound louder through air when it has faded through bone. Positive test is normal unless Webers is also positive. Bothe positive indicates sensorineural deafness (lesion in cochlear apparatus, cerebellopontine angle or brain stem). Negative (bone conduction longer than air) indicates conductive deafness (wax).
Swallowing - interpretation
Problems swallowing. Speech impairment. CN IX and X. If CN XI is also affected - jugular foramen syndrome.
Uvula - interpretation
Normal for uvula to move symmetrically. If asymetrical or arch of soft palate dropped - LMN lesion (uvula moves towards unaffected side).
Trapezius, and sternocleidomastoid strength - interpretation
Dropped shoulder. Weakness of trapezius. SCM atrophy or . weakness (when turning to opposite side). Traps and SCM on same side - LMN lesion (peripheral accessory nerve palsy). Possible jugular foramen syndrome with X and IX. Ips SCM and contra traps - UMN CN XI
Observe tongue - interpretation
Unilateral deviation. Atrophy. Flaccid. Fascicualtions - LMN lesion ips side. Small fascicualtions - Bilat LMN. Unilateral deviation, no atrophy - Unilateral UMN lesion contra side. Reduced range of movements - Bilat UMN. CNXII
Tongue strength - interpretation
Weak tongue to one side indicates CN XII lesion. Use observation to determine lesion type
Dermatomes general
Ask patient to close eyes and say when touched with cotton wool. Repeat with medipin. Sharp = Spinothalamic tract. Soft - dorsal column.
Dermatome C5
Upper arm - lateral (top)
Dermatome C6
Lateral forearm, thumb and forefinger.
Dermatome C7
Middle finger
Dermatome C8
Ring and little fingers. Medial forearm.
Dermatome T1
Distal part of medial upper arm.
Dermatome L2
Upper thigh
Dermatome L3
Middle thigh to medial knee
Dermatome L4
Medial lower leg
Dermatome L5
Top of foot and front of lower leg
Dermatome S1
Lateral side of lower leg and foot
Deltoid
Ask patient to raise both arms and maintain position resisting pressure. Apply pressure steadily. C5 myotome. Only do for axillary nerve.
Biceps
Arm bent. Steady under elbow and put pressure on forearm away from
body. C5 or C6 myotome. Musculocutaneous nerve. Use for C5 myotome.
Triceps
Arm bent. Steady under elbow and put pressure on forearm towards body. C7 myotome. Radial nerve. Use for C7 myotome.
Wrist flexors, finger flexors
Hold out hand palm up and bend middle finger. Resist straightening it. Hold forearm palm up and put pressure on hand downwards. C8 myotome. Flexor carpi radialis/ulnaris. Median and ulnar nerve. Use only the finger for myotome C8 and wrist only for peripheral nerves.
Wrist extensors
Hold forearm palm down with wrist extended and put pressure on hand. C6 or C7 myotome. Extensor carpi ulnaris. Posterior interosseus nerve. Use for C6 myotome.
Finger adductors/abductors.
Ask patient to spread fingers and put pressure to close each pair. Put your fingers between theirs and ask them to squeeze. T1 myotome. Palmar interossei. Ulnar nerve. Use for T1 myotome, but only little finger.
Hip flexion
Ask patient to raise knee against resistance. Myotomes L1/L2. Femoral nerve. Do supine using both hands to resist. Use for L2.
Knee extension
Foot hanging. Steady knee and hold ankle. Ask patient to resist while foot is pushed back. Myotomes L3/L4. Femoral nerve. Use for L3.
Knee flexion
Foot hanging. Steady knee and hold ankle. Ask patient to resist while foot is pushed forward. Myotome L5. Use only for sciatic nerve.
Hallux extension
Foot on ground. Patient raise toe against resistance. Myotome L5. Deep peroneal nerve. Use for L5.
Ankle dorsiflexion
Walking on heels test completed earlier for balance. Myotome L4 or L5. Deep peroneal nerve. Tibialis anterior. Use for L4.
Ankle plantarflexion
Walking on toes test completed earlier for balance. Myotome S1. Tibial nerve. Gastroc or soleus. Use for S1.
Biceps reflex
Ensure patient relaxes. Support arm. Find tendon with thumb, just proximal to anterior elbow. Strike own thumb with hammer. C5. Musculocutaneous nerve.