TOPIC 5-6 Flashcards
CN 1- olfactory test
o With person’s eyes closed, occlude one nostril and present familiar aromatic substance
-e.g., coffee, orange, vanilla, soap, or peppermint
CN II- optic test
o Test visual acuity (eye exam chart) and visual fields by confrontation (peripheral vision)
CN III, IV, and VI- oculomotor, trochlear, and abducens nerves
eye lid blink
pupils (size, regularity, equality, direct and consensual light reaction, and accommodation)
eye up, down, side to side movement, cross eyed
nystagmus
involuntary rapid eye movements - back-and-forth oscillation of eyes
pendular movement
oscillations move equally left to right
jerk movement
a quick phase in one direction, then a slow phase in other
assessment of nystagmus: amplitude
degree of movement: fine, medium, or coarse
assessment of nystagmus: frequency
constant, or fades after a few beats
assessment of nystagmus: plane of movement
horizontal, vertical, rotary, or combination
CN V- Trigeminal
-palpating temporal and masseter muscles as person clenches teeth
-with person’s eyes closed, test light touch sensation by touching a cotton wisp to designated areas on person’s face: forehead, cheeks, and chin
corneal reflex
blinking in response to corneal stimulation by a cotton wisp, Þ Tests sensory afferent in cranial nerve V and motor efferent in cranial nerve VII (muscles that close eye)
CN VII- facial test
-request to smile, frown, close eyes tightly (against your attempt to open them), lift eyebrows, show teeth
-puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sides
(taste on anterior 2/3 is not routinely tested)
CN VIII- Vestibulocochlear test
o Test hearing acuity by ability to hear normal conversation and by whispered voice test
CN IX and X- glossopharyngeal and vagus test
-Depress tongue with tongue blade, and note pharyngeal movement as person says “ahhh” or yawns;
-Gag reflex-Touching posterior pharyngeal will induce; voice should sound smooth, not strained
CN XI- accessory test
o Ask person to shrug shoulders against resistance
CN XII- hypoglossal test
o Inspect tongue; no wasting or tremors should be present
o Note forward thrust in midline as person protrudes tongue
o Ask person to say “light, tight, dynamite,” and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct
anosmia
decrease or loss of smell bilaterally
hemianopia
Visual defect that affects half of visual field
what are the developmental changes in the neuro system of the agin adult
Atrophy with steady loss of neuron structure in brain and spinal cord
o loss of weight /volume with thinning of cerebral cortex,
o reduced subcortical brain structures, and
o expansion of the ventricles
Decreased Velocity of nerve conduction in older adults leads to
reaction time slower
Delay at synapse in older adult leads to
diminished sensation of touch, pain, taste, and smell
Motor system is older adults
general slowing down of movement; muscle strength and agility decrease
Progressive decrease in cerebral blood flow and oxygen consumption in older adults
may cause dizziness and loss of balance (increasing fall risk)
if an older adult has any problems with diziness what are they more at risk for
orthostatic hypotension
micturition syncope
feeling like fainting while urinating at night
Screening neurologic examination is used for
o well persons with no significant findings from history
Complete neurologic examination is used for
o persons with neurologic concerns, e.g., headache, weakness, loss of coordination
o shown signs of neurologic dysfunction
Neurologic recheck examination is used for
persons with demonstrated neurologic deficits who require periodic assessments
what is the sequence for a complete neurologic exam
-Mental status
-Cranial nerves
-Motor system
-Sensory system
-Reflexes
nero assessment equiptment
Penlight, Tongue blade, Cotton swab, Cotton ball, Tuning fork: 128 Hz or 256 Hz, Percussion hammer
what do you assess for in the muscles?
size
strength
tone
involuntary movement
balance test
-Gait: observe as person walks 10 to 20 feet, turns, and returns to starting point;
o walk straight line in heel-to-toe fashion;
o Also, walk on toes, then on heels for a few steps
Romberg test
o stand up with feet together and arms at sides; when in stable position, ask person to close eyes and to hold position for about 20 seconds
o shallow knee bend or hop in place, first on one leg, then other
Rapid Alternating Movements (RAM)
ask the person to pat the knees with both hands, life tup, turn hands over, and pat knees with the backs of the hands, then faster, usually with equal turning and quick rhythmic pace
Finger-to-finger test
with eyes open, ask person to use index finger to touch your finger, then their own nose; then move your finger to continue test
Finger-to-nose test
with eyes closed and stretch out arms and touch tip of their nose with each index finger, alternating hands and increasing speed
Heel-to-shin test
ask person in supine position to place heel on opposite knee and run it down shin to ankle
faccidity
Decreased muscle tone or hypotonia;muscle feels limp, soft, and flabby; muscle is weak and easily fatigued
Spasiticity
Increased tone or hypertonia;increased resistance to passive lengthening
Rigidity
Constant state of resistance; resists passive movement in any direction; dystonia
Cogwheel rigidity
Type of rigidity in which the increased tone is released by degrees during passive range of motion so it feels like small, regular jerks
Paralysis
Decreased or loss of motor power caused by problem with motor nerve or muscle fibers
hemiplegia
spastic or flaccid paralysis of one side (right or left) of body and extremities
paraplegia
symmetric paralysis of both lower extremities
quadriplegia
paralysis in all four extremities
Paresis
weakness of muscles rather than paralysis
Tic
Involuntary, compulsive, repetitive twitching of a muscle group
Myoclonus
Rapid, sudden jerk or a short series of jerks at fairly regular intervals.
ex: A hiccup is a myoclonus of diaphragm. Single myoclonic arm or leg jerk is normal when the person is falling asleep
Fasciculation
Rapid, continuous twitching of resting muscle or part of muscle without movement of limb, which can be seen by clinicians or felt by patients
chorea
Sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face. Occurs at irregular intervals, not rhythmic or repetitive, more convulsive than a tic. Some are spontaneous, and some are initiated; all are accentuated by voluntary acts. Disappears with sleep.
Athetosis
Slow, twisting, writhing, continuous movement, resembling a snake or worm. Involves the distal more than the proximal part of the limb.
tremor
Involuntary contraction of opposing muscle groups. Results in rhythmic, back-and-forth movement of one or more joints. May occur at rest or with voluntary movement. All tremors disappear while sleeping.
rest tremor
It occurs when muscles are quiet and supported against gravity (hand in lap); partly or completely disappears with voluntary movement (e.g., “pill rolling” )
intention tremor
Rate varies; worse with voluntary movement as in reaching toward a visually guided target.
seizure disorder
a time-limited event caused by excessive, hypersynchronous discharge of neurons in the brain
spastic hemiparesis
Arm is immobile against the body, with flexion of the shoulder, elbow, wrist, and fingers and adduction of shoulder; does not swing freely. Leg is stiff and extended and circumducts with each step (drags toe in a semicircle).
cerebellar ataxia
staggering, wide-based gait; difficulty with turns; uncoordinated movement with positive Romberg sign
parkinsonian (festinating)
Posture is stooped; trunk is pitched forward; elbows, hips, and knees are flexed. Steps are short and shuffling. Hesitation to begin walking, and difficult to stop suddenly. The person holds the body rigid. Walks and turns body as one fixed unit. Difficulty with any change in direction.
scissors
Knees cross or are in contact, like holding an orange between the thighs. The person uses short steps, and walking requires effort.
steppage or footdrop
slapping quality-looks as if walking up stairs and finds no stair there. lifts knee and foot high and slaps it down hard and flat to compensate for footdrop.
waddling
weak hip muscles- when the person takes a step, the opposite hip drops, which allows compensatory lateral movement of pelvis. often the person also has marked lumbar lordosis and a protruding abdomen
short leg
Leg length discrepancy >2.5 cm (1 inch). Vertical telescoping of affected side, which dips as person walks. Appearance of gait varies, depending on amount of accompanying muscle dysfunction.
cerebral palsy
paralysis due to damage to cerebral cortex from a developmental defect
muscular dystrophy
Chronic, progressive wasting of skeletal musculature, which produces weakness, contractures, and in severe cases respiratory dysfunction and death.
parkinsonism
Loss of dopamine-producing neurons in the substantia nigra and through the basal ganglia, causing motor tract disorder. Cardinal symptoms are resting tremor, bradykinesia, cogwheel rigidity, loss of balance; also anxiety, depression, and urinary incontinence. Cognitive impairment is widespread, including loss of executive function, visual-spatial impairment, and memory loss.7Body tends to stay immobile; facial expression is flat, staring, expressionless; excessive salivation occurs; eye blinking is reduced. Posture is stooped; equilibrium is impaired; balance is easily lost;
cerebellar
lesion in one hemisphere produces motor abnormalities on the ipsilateral side. Characterized by ataxia, lurching forward of affected side while walking; rapid alternating movements are slow and arrhythmic
multiple sclerosis
Chronic, progressive, immune-mediated disease in which axons experience inflammation, demyelination, degeneration and, finally, sclerosis. Structures most frequently involved are the optic nerve, oculomotor nerve, corticospinal tract, posterior column tract, and cerebellum. Thus symptoms include nystagmus, diplopia, extreme fatigue, weakness, spasticity, loss of balance, hyperreflexia, Babinski sign (upgoing toes). MS affects young adults in their productive years, with onset between 20 and 40 years
decorticate rigidity upper extremities
-Flexion of arm, wrist, and fingers
-Adduction of arm: tight against thorax
decorticate rigidity lower extremities
-Extension, internal rotation, plantar flexion; indicates hemispheric lesion of cerebral cortex
Decerebrate rigidity upper extremities
stiffly extended, adducted, internal rotation, palms pronated
Decerebrate rigidity lower extremities
stiffly extended, plantar flexion; teeth clenched; hyperextended back
flaccid quadriplegia
complete loss of muscle tone and paralysis of all four extremities, indicating completely nonfunctional brainstem
Opisthotonos
prolonged arching of back, with head and heels bent backward, and meningeal irritation
what are the routine screening procedures for the sensory system
o testing superficial pain, light touch, and vibration in few distal locations, and testing stereognosis
pain is tested by
person’s ability to perceive a pinprick.
temperature is tested
only when pain sensation is abnormal; otherwise, you may omit it because the fiber tracts are much the same.
light touch is tested by
apply wisp of cotton to skin in random order of sites and at irregular intervals; include arms, forearms, hands, chest, thighs, and legs; ask person to say “now” or “yes” when touch is felt
vibration is tested by
tuning fork over bony prominences
position (kinesthesia)
test person’s ability to perceive passive movements of extremities
Tactile discrimination (fine touch):
tests also measure discrimination ability of sensory cortex
Stereognosis:
test person’s ability to recognize objects by feeling their forms, sizes, and weights
Graphesthesia:
ability to “read” a number by having it traced on skin
Two-point discrimination:
test ability to distinguish separation of two simultaneous pin points on skin
Extinction:
simultaneously touch both sides of body at same point; normally both sensations are felt
Point location
touch skin and withdraw stimulus promptly; ask person to put finger where you touched
Peripheral neuropathy (abnormal)
Loss of sensation involves all modalities; loss most severe distally at feet and hands
Individual nerves or roots (abnormal)
o Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve
Spinal cord hemisection (Brown-Séquard syndrome) (abnormal)
o Loss of pain and temperature, contralateral side, loss of vibration and position discrimination on ipsilateral side
Complete transection of spinal cord (abnormal)
o Complete loss of all sensory modalities below level of lesion; associated with motor paralysis and loss of sphincter control
thalamus (abnormal)
o Loss of all sensory modalities on face, arm, and leg; contralateral to lesion
cortex (abnormal)
o Loss of discrimination on contralateral side; loss of graphesthesia, stereognosis, recognition of shapes and weights, finger finding
deep tendon reflexes (DTR)
muscle contraction; Measurement of stretch reflexes reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels
Reflex response graded on 4-point scale
4 = very brisk, hyperactive with clonus, indicative of disease
3 = brisker than average, may indicate disease
2 = Average, normal
1 = diminished, low normal, or occurs with reinforcement
0 = no response
Biceps reflex, C5 to C6
Support the person’s forearm on yours; place your thumb on biceps tendon and strike a blow on your thumb
-Normal response is contraction of biceps muscle and flexion of forearm
Triceps reflex, C7 to C8
o Tell person to let arm “just go dead” as you strike triceps tendon directly just above the elbow
-Normal response is extension of forearm
Brachioradialis reflex, C5 to C6
o Hold person’s thumbs to suspend forearms in relaxation and strike forearm directly, about 2 to 3 cm above radial styloid process
-Normal response is flexion and supination of forearm
Quadriceps reflex, L2 to L4 (“knee jerk”)
o Let lower legs dangle freely to flex knee and stretch tendons; strike tendon directly just below patella
-Normal response is extension of lower leg
Achilles reflex, L5 to S2 (“ankle jerk”)
o Position person with knee flexed; hold foot in dorsiflexion and strike Achilles tendon directly
-Normal response is foot plantar flexes against your hand
Þ Abdominal reflexes: upper: T8 to T10; lower: T10 to T12
o Person in supine position, knees slightly bent; use handle end of reflex hammer to stroke skin
o Move from each corner toward midline at both upper and lower abdominal levels
o Normal response is ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward stroke
Cremasteric reflex, L1 to L2 (not routinely done)
o On male, lightly stroke inner aspect of thigh with reflex hammer or tongue blade
-Note elevation of ipsilateral testicle
Plantar reflex, L4 to S2
o Position thigh with slight external rotation
o With reflex hammer, draw a light stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down “J”
-Normal response is plantar flexion of toes and inversion and flexion of forefoot
use the ____ examin ation fro older adults as younger adults
same
senile tremors
benign and include head nodding and tongue protrusion
dyskinesias
repetitive stereotyped movements in jaw, lips, or tongue may accompany senile tremors; no associated rigidity present
gait in a an older adult
may be slower and more deliberate than in younger person; may deviate from midline path
in older adults, senstion of vibration, tactile sensation, light touch, and DTR
tend to lose sensation, may need stonger stimuli
clonus
test when reflexes hyperactive
clonus test
o Support lower leg in one hand and with other hand, move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing foot; hold the stretch
-Normal response: you feel no further movement
-When clonus present, you will note rapid rhythmic contractions of calf muscle and movement of foot
