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Physical Dx > L12: Neuro & Sports Physical > Flashcards

L12: Neuro & Sports Physical Flashcards

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1
Q

Gait: Inspection

What are you looking for?

What is an abnormal gait?

What does an abnormal gait indicate (generally?)

A
  • Observe posture and gait
    • Patient walks toward and away from you
    • Toe walk, heel walkTandem gait
  • Abnormal = gait that lacks coordination and stability
    • CNS or PNS abnormality
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2
Q

Steppage Gait

What is it?

Description of gait?

If unilateral?

If bilateral?

A
  • Steppage Gait AKA Neuropathic gait
  • Foot drop:
    • Patient drags foot/feet or lifts them high, then foot slaps floor
  • Unilateral → peroneal nerve injury, spinal nerve compression
  • Bilateral → amyotrophic lateral sclerosis (ALS), Charcot-Marie-Tooth disease and other peripheral neuropathies
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3
Q

Spastic Hemiparesis

What is it?

Description of gait?

Cause?

Example?

A

Spastic Hemiparesis

  • Drag toe, circle leg stiffly outward and forward (circumduction), or lean trunk to contralateral side to clear affected leg during walking.
  • Affected arm is flexed, immobile, and heldclose to the side, with elbow, wrists, and interphalangeal joints flexed.
  • Affected leg extensors are spastic; ankles are plantar-flexed and inverted.
  • Seen in corticospinal tract lesions
    • Stroke
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4
Q

Scissors Gait

What is it?

Description of gait?

Cause?

Example?

A

Scissors Gait

  • Patients advance each leg slowly and thighs tend to cross
  • Stiff gait and short steps
  • Seen in spasticity disorders
    • Cerebral palsy
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5
Q

Sensory Ataxia

What is it?

Description of gait?

Cause?

Example?

A

Sensory Gait

  • Unsteady gait and wide based stance
  • Throw feet forward and outward, first bring down heel then toes with double tap
  • Watch ground
  • Due to loss of proprioception
    • Peripheral neuropathy
    • Posterior column damage
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6
Q

Parkinsonian Gait

What is it?

Description of gait?

Cause?

Example?

A

Parkinsonian Gait

  • Stooped posture with head, arm, hip and knee flexion
  • Shuffling, short steps; slow to start
  • Decreased arm swing and stiff turns
  • Due to basal ganglia abnormalities
    • Parkinson disease
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7
Q

Trendelenburg Gait

What is it?

Description of gait?

Unilateral?

Bilateral?

A

Trendelenburg Gait AKA Myopathic gait

  • Pelvic drop leading to waddling gait
  • Due to hip abductor weakness
  • Unilateral → spinal nerve compression, superior gluteal nerve injury
  • Bilateral → muscular dystrophy
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8
Q

Coordionation

What does it require?

Ataxia: define

Dysmetria: define

A
  • Requires integration of the nervous system:
    • Motor
    • Cerebellar
    • Vestibular
    • Sensory
  • Neurologic Terms:
    • Ataxia: Impaired coordination of muscle (out of proportion to weakness)
    • Dysmetria: Improper measure of distance
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9
Q

Romberg Test

What does it test?

How to test?

Abnormal test? Indication?

A
  • Position sense
  • Ask patient to stand with feet together, watch for swaying, then ask patient to close eyes
  • Abnormal –> unable to maintain upright posture
    • Posterior column disease
    • Cerebellar abnormality
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10
Q

Pronator Drift

What does it test?

How to test?

Abnormal test? Indication?

A
  • Ask patient to elevate arms to shoulder level w/ palms up. Should hold position w/ eyes closed ~20 sec.
    • Variation – Firmly tap one arm; Patient should bring arm back up
  • Abnormal –> unable to keep arm at shoulder height and/or arm pronates/drifts downward
    • UMN lesion (stroke)
    • Oscillating – cerebellar
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11
Q

Heel to Shin Test

What does it test?

How to test?

Abnormal test? Indication?

A
  • Place heel at opposite knee, slide down leg then back up
  • Should be able to keep contact with opposite leg
  • Abnormal
    • Cerebellar disease: Heel overshoot’s the knee, foot oscillates side to side
    • Post. column damage: Heel lifts too high
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12
Q

Finger-to-Nose Test

What does it test?

How to test?

Abnormal test? Indication?

A
  • Hold your finger out in front of patient, then ask them to touch their nose then touch your finger with theirarmfullyextended. Moveyourfingerin different planes.
  • Patient should be steady and accurate
  • Abnormal = dysmetria (past pointing)
    • Cerebellar disease
    • Intention tremor – multiple sclerosis
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13
Q

Rapid Alternating Movements

What does it test?

How to test?

Abnormal test? Indication?

A
  • Patient places hands on thighs with palms down then palms up, perform as quickly as possible
  • Rapid finger tap – tap the distal joint of thumb with index finger
  • Abnormal = dysdiadokinesia (slow, clumsy, irregular movement)
    • Cerebellar disease
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14
Q

Aphasia

Define

Cause

A

Aphasia: inability to express or understand language

Often secondary lesion in dominant/left hemisphere

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15
Q

Dysarthria

Define

Cause

A
  • Dysarthria: abnormal pronunciation of speech
    • Many poss. causes.
    • Lesion involving muscles of articulation (CN V, VII, IX, X, XII) vs. central process
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16
Q

Neglect

Define

Cause

A
  • Neglect: abnormality in attention to one side
    • Most often secondary lesion in the nondominant/right hemisphere (seen on the left)
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17
Q

Mental Status

How to assess for:

Appropriate behavior

Orientation

Ability to concentrate & focus attention

A
  • Appropriate behavior:
    • Observation of speech, dress, hygiene, personal interaction, etc.
  • Orientation: A and O x 3 (or x 4)
    • Level of alertness/consciousness
    • Degree of orientation
      1. Person
      2. Place
      3. Time
      4. Situation
  • Ability to concentrate and focus attention:
    • Serial 7s, spell WORLD backwards, etc.
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18
Q

Mental Status: Memory

Define:

Immediate recall

Recent memory

Remote memory

A

Immediate recall: give patient 3 words to repeat

Recent memory: repeat the 3 words after 5 minutes

Remote memory: well known events/people, dates, or locations

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19
Q

Cranial Nerves

CN I

Name

Sensory/Motor/Both

Function

Test

Abnormal

A
  • CN I: Olfactory (S)
  • Function:
    • Sense of smell
  • Test:
    • Could have patient smell familiar scent
  • Abnormal:
    • Anosmia
    • Head trauma, Parkinson disease
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20
Q

Cranial Nerves

CN II

Name

Sensory/Motor/Both

Function

Test

Abnormal

A
  • CN II: Optic (S)
  • Function:
    • Vision
  • Test:
    • Visual fields
    • Acuity
    • Funduscopic
    • Pupillary light reflex
  • Abnormal:
    • Visual field defect 2° retinal emboli, optic neuritis, pituitary tumor, stroke
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21
Q

Cranial Nerves

CN III

Name

Sensory/Motor/Both

Function

Test

Abnormal

A
  • CN III: Oculomotor (M)
  • Function:
    • Eye movement
    • Raises upper eyelid
  • Test:
    • EOMs
    • Pupillary light reflex
  • Abnormal:
    • Vertical and horizontal diplopia
    • Ptosis
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22
Q

Cranial Nerves

CN IV

Name

Sensory/Motor/Both

Function

Test

Abnormal

A
  • CN IV: Trochlear (M)
  • Function:
    • Downward, internal rotation of the eye
  • Test:
    • EOMs
  • Abnormal:
    • Vertical diplopia
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23
Q

Cranial Nerves

CN V

Name

Sensory/Motor/Both

Function

Test

Abnormal

A
  • CN V: Trigeminal (B)
  • Function:
    • Motor – temporal, masseter and lateral pterygoids
    • Sensory – 3 divisions
  • Test:
    • Clench jaw and lateral jaw movement
    • Check facial sensation
  • Abnormal:
    • Trigeminal neuralgia
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24
Q

Cranial Nerves

CN VI

Name

Sensory/Motor/Both

Function

Test

Abnormal

A
  • CN VI: Abducens (M)
  • Function: Motor
    • Lateral deviation of the eye
  • Test:
    • EOMs
  • Abnormal:
    • Horizontal diplopia, esotropia
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25
*Cranial Nerves* **_CN VII_** Name Sensory/Motor/Both Function Test Abnormal
* **CN VII: Facial (B)** * _Function:_ * Motor – facial movements * Sensory – taste, ant. tongue * _Test:_ * Raise eyebrows, smile, frown, puff out cheeks * _Abnormal:_ * Central – Cerebral infarct (that spares the forehead) * Peripheral –Bell’s palsy (ipsilateral weakness of entire face)
26
*Cranial Nerves* **_CN VIII_** Name Sensory/Motor/Both Function Test Abnormal
* **CN VIII: Acoustic (S)** * _Function:_ * Hearing and balance * _Test:_ * Gross hearing, gait * _Abnormal:_ * Unilateral hearing loss, disequilibrium, vertigo, nystagmus
27
*Cranial Nerves* **_CN IX_** Name Sensory/Motor/Both Function Test Abnormal
* **CN IX: Glossopharyngeal (B)** * _Function:_ * Motor – pharynx * Sensory – posterior tongue * _Test:_ * Palate elevation, gag reflex * _Abnormal:_ * No gag reflex, loss of taste posterior 1/3 of tongue
28
*Cranial Nerves* **_CN X_** Name Sensory/Motor/Both Function Test Abnormal
* **CN X: Vagus (B)** * _Function:_ * Motor - Palate, pharynx, larynx * Sensory – Pharynx, larynx * Cardiac, thorax and abdomen * _Test:_ * Palate elevation, quality of “ah” and uvula midline * _Abnormal:_ * Hoarseness, dyspnea, dysarthria, loss of gag reflex
29
*Cranial Nerves* **_CN XI_** Name Sensory/Motor/Both Function Test Abnormal
* **CN XI: Spinal Accessory (M)** * _Function:_ * Sternocleidomastoid and upper trapezius motor function * _Test:_ * Shoulder shrug and head rotation * _Abnormal:_ * Trapezius weakness, atrophy and fasciculation's = scapular winging
30
*Cranial Nerves* **_CN XII_** Name Sensory/Motor/Both Function Test Abnormal
* **CN XII: Hypoglossal (M)** * _Function:_ * Tongue movement * _Test:_ * Wag tongue, push tongue into cheek * _Abnormal:_ * Central lesion = contra. weakness/tongue deviates away * Peripheral lesion = ips. weakness/tongue deviates to weak side
31
**Name that CN** * What are 3 CN’s involved in articulation? * An abnormality in what CN would cause shoulder to droop? * Damage to which CN results in anosmia? * Patient w/ vertigo and nystagmus could be due to damage to which CN? * In patient with asymmetric smile and loss of nasolabial fold, what CN is affected?
* What are 3 CN’s involved in articulation? * CN V, VII, IX, X, XII * An abnormality in what CN would cause shoulder to droop? * CN IX (Glossopharyngeal) * Damage to which CN results in anosmia? * CN I (Olfactory) * Patient w/ vertigo and nystagmus could be due to damage to which CN? * CN VIII (Acoustic) * In patient with asymmetric smile and loss of nasolabial fold, what CN is affected? * CN VII (Facial)
32
**Sensory Terms: Touch** _Define:_ Anesthesia Hypoesthesia Hyperesthesia
**Anesthesia:** absence of touch sensation **Hypoesthesia:** decreased sensation to touch **Hyperesthesia:** increased sensitivity to touch
33
**Sensory Terms: Pain** _Define:_ Analgesia Hypoalgesia Hyperalgesia Allodynia
**Analgesia:** absence of pain sensation **Hypoalgesia:** decrease in pain awareness **Hyperalgesia:** increased sensitivity to pain **Allodynia:** pain elicited from non-painful stimulus
34
**Sensory Exam Components** _How to test for:_ Light touch Pain Temperature Position Vibration
* **Compare bilaterally, evaluate distal to proximal** * **_Light touch:_** * Cotton swab/ball, pad of finger * Don’t apply too much pressure * **_Pain:_** * Sharp end of cotton swab, do not pierce skin * **_Temperature:_** * Compare hot/cold (if unable to feel pain sensation) * **_Position:_** * Hold sides of digit, demonstrate position * **_Vibration:_** * Place vibrating tuning fork on DIP joint, ask what patient feels
35
**Dermatomes: Upper Extremity** _What are the dermatome levels for:_ * Lateral upper arms * Radial forearm and thumb * Middle finger * Ring and little finger * Ulnar Forearm
Dermatomes are helpful when patient has complaint of sensory loss in a specific distribution * Lateral upper arms (C5) * Radial forearm and thumb (C6) * Middle finger (C7) * Ring and little finger (C8) * Ulnar Forearm (T1)
36
**Dermatomes: Landmarks** _What are the dermatome levels for:_ * Nipple line * Umbilicus * Inguinal region
Dermatomes are helpful when patient has complaint of sensory loss in a specific distribution * Nipple line (T4) * Umbilicus (T10) * Inguinal region (L1)
37
**Dermatomes: Lower Extremities** _What are the dermatome levels for:_ * Anterior/proximal thigh * Knee/medial shin * Lateral shin, dorsal foot to great toe * Lateral and plantar foot
Dermatomes are helpful when patient has complaint of sensory loss in a specific distribution * Anterior/proximal thigh (L3) * Knee/medial shin (L4) * Lateral shin, dorsal foot to great toe (L5) * Lateral and plantar foot (S1)
38
**Specialized: Discriminative Sensations** * What are these/how to test for? * Stereognosis * Graphesthesia * Two-point discrimination * What is normal? * Extinction * Indication if abnormal?
* **Will depend on touch and position sense** * **Stereognosis** – ask patient to recognize familiar objects * **Graphesthesia** – number identification * **Two-point discrimination** – alternate double and single stimulus. * Normal \<5mm on finger pads * **Extinction** – touch patient in same place on both sides of body * Test for neglect * **Abnormal** – sensory cortex pathology
39
**Motor Exam Componnets** What are you evaluating for?
1. Body Position 2. Involuntary Movements 3. Muscle Bulk 4. Muscle Tone 5. Muscle Strength
40
**Involuntary Movements: Tremors** _Define & eaxmples:_ Static Postural Intention
* **Static tremor:** seen at rest * Parkinson disease (pill-rolling tremor) * **Postural tremor:** seen when affected area maintains posture * Hyperthyroid, anxiety, fatigue, essential tremor * **Intention tremor:** absent at rest, appear with movement * Multiple sclerosis
41
_Involuntary Movements:_ **_Tics_** Define Eaxample
* **Tics:** brief, habitual motion of particular muscles * Tourette syndrome, medications
42
_Involuntary Movements: **Dystonia**_ Define Example
* **[Dystonia](https://youtu.be/gfj97YcGtxo):** twisted posture of large body parts * Medications, spasmodic torticolli**s**
43
_Involuntary Movements:_ **_Dyskinesias_** _Define_ _Example_
* **Dyskinesias:** bizarre, rhythmic, repetitive movements * Parkinson disease, psychoses, medications
44
_Involuntary Movements: **Akathisia**_ Define Example
* **[Akathisia](https://youtu.be/DKNtv1LPSEM):** inability to sit still * Medications (antipsychotics, Compazine)
45
_Involuntary Movements: **Chorea**_ Define Example
* **[Chorea](https://youtu.be/BnBpTsWiIhg):** brief, jerky, rapid unpredictable movements * Huntington disease, rheumatic fever
46
_Involuntary Movements: **Athetosis**_ Define Example
* **[Athetosis](https://youtu.be/G-kVmaMMNmE):** slow, twisting, writhing movements * Cerebral palsy
47
**Muscle Bulk**
48
**Muscle Tone** _Define:_ Hypertonia vs hypotonia Spasticity Rigidity
* **Hypertonia vs. hypotonia?** * Central vs. peripheral causes * **Spasticity:** increased muscle tone, velocity dependent * UMN pathology * **Rigidity:** increased resistance throughout range of motion * Basal ganglia lesion * Cog-wheel rigidity --\> Parkinsonism
49
**Muscle Strength** What are the grades of muscle function?
50
**_UE_**_: what are the nerve root & peripheral nerve for:_ Shoulder abduction Wrist Extension Finger abduction Thumb opposition
* Shoulder Abduction * C5, C6 * Axillary n. * Wrist Extension * C6, C7 * Radial n. * Finger Abduction * C8, T1 * Ulnar n. * Thumb opposition * C8, T1 * Median n.
51
**LE: What are the nerve root(s) for:** Hip Flexion Hip Adduction Knee Extension Hip Abduction Knee Flexion Ankle Dorsiflexion Ankle Plantarflexion
* Hip Flexion, Hip Adduction, Knee Extension * L2, L3, L4 * Hip Abduction * L4, L5, S1 * Knee Flexion * L5, S1 * Ankle Dorsiflexion * L4, L5 * Ankle Plantarflexion * S1
52
**Deep Tendon Reflexes (DTRs)** How to rate response?
* How to rate response: * 0 = No response * 1+ = Diminished/Hypoactive * 2+ = Normal * 3+ = Increased/Hyperactive * 4+ = Hyperactive, associated with clonus
53
**DTRs: Hypoactive vs. Hyperactive** Define Cause Additional findings in LMN/UMN disease
* **_Hypoactive_** * Diminished or absent * Diseases of spinal nerve roots or peripheral nerves * Additional findings in **_LMN_** disease: * Weakness * Atrophy * Fasciculations * **_Hyperactive_** * Brisk and can be associated with clonus * CNS lesions along descending corticospinal tract * Additional findings in **UMN** disease: * Weakness * Spasticity * Positive Babinski
54
**DTRs: What is the nerve root for:** * UE * Biceps * Brachioradialis * Triceps * LE * Patella * Achilles
* UE * Biceps: C5, C6 * Brachioradialis: C5, C6 * Triceps: C6, C7 * LE * Patella: L4 * Achilles: S1
55
**Clonus** What does it test? How to test? Abnormal test? Indication?
* Alternate dorsi- and plantar flexing patient's ankle, then brisklydorsi-flexankle. Evaluateforrhythmicoscillations. * Compare bilaterally, can be normal * If abnormal, check at wrist * Abnormal: * UMN pathology
56
**Babinski** What does it test? How to test? Abnormal test? Indication?
* L5, S1 * Stroke lateral aspect of plantar foot from heel to ball * Normal for toes to flex * Abnormal: * Great toe extends and other toes fan out * UMN pathology
57
**Superficial Abdominal Reflex** What does it test? How to test? Abnormal test? Indication?
* Stroke abdomen toward umbilicus * Muscle contracts toward stimulus * Rated as present or absent * Should get a muscle contraction * Abnormal: no muscle contraction * Central (UMN) and peripheral (LMN) pathologies
58
**Cremateric Reflex** What does it test? How to test? Abnormal test? Indication?
* Stroke proximal medial thigh * Normal for ipsilateral testicle to rise * Rated as present or absent * Abnormal: * UMN, LMN * L1, L2 nerve injury * Ilioinguinal injury s/p hernia repair
59
**Brudzinski Sign** What does it test? How to test? Abnormal test? Indication?
* Minengeal Signs * Patient is supine, then flex patient’s neck * **Normal**→patient remains relaxed * **Abnormal**→hip and knee flexion; meningeal inflammation
60
**Nuchal Rigidity** What does it test? How to test? Abnormal test? Indication?
* Meningeal Signs * Place hands behind patient’s head and flex head toward chest * Normal→easy motion * Abnormal → pain and resistance indicating potential meningeal inflammation
61
**Kernig Sign** What does it test? How to test? Abnormal test? Indication?
* Meningeal Signs * Flex patient’s hip and knee, then straighten knee * Normal→may have tightness in hamstring * Abnormal→neck pain and resistance indicating meningeal irritation
62
_Name that test:_ **Abnormal gait due to loss in proprioception?** How to test? Abnormal test? Indication?
**Sensory ataxia** * Unsteady gait and wide based stance * Throw feet forward and outward, first bring down heel then toes with double tap * Watch ground * Due to loss of proprioception * Peripheral neuropathy * Posterior column damage
63
_Name that test:_ **What test(s) do you perform to evaluate a patients position sense?** How to test? Abnormal test? Indication?
* **Romberg** * Position sense * Ask patient to stand with feet together, watch for swaying, then ask patient to close eyes * Abnormal –\> unable to maintain upright posture * Posterior column disease * Cerebellar abnormality * **Joint position**
64
_Name that test:_ **What test is performed by placing a familiar object in patient’s hand?** How to test? Abnormal test? Indication?
**Stereognosis**: ask patient to recognize familiar objects
65
_Name that test:_ **What test(s) help evaluate cerebellar function?** How to test? Abnormal test? Indication?
* **Heel to shin** * Place heel at opposite knee, slide down leg then back up * Should be able to keep contact with opposite leg * Abnormal * Cerebellar disease: Heel overshoot’s the knee, foot oscillates side to side * Post. column damage: Heel lifts too high * **Fnger-to-nose** * Hold your finger out in front of patient, then ask them to touch their nose then touch your finger with theirarmfullyextended. Moveyourfingerin different planes. * Patient should be steady and accurate * Abnormal = dysmetria (past pointing) * Cerebellar disease * Intention tremor – multiple sclerosis * **and/or RAMs** * Patient places hands on thighs with palms down then palms up, perform as quickly as possible * Rapid finger tap – tap the distal joint of thumb with index finger * Abnormal = dysdiadokinesia (slow, clumsy, irregular movement) * Cerebellar disease
66

Physical Dx (11 decks)

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