Module 4

Question 1

Amplitude scale

Answer 1

4: Bounding, aneurysmal
3: Full, increased
2: Expected
1: Diminished, barely palpable
0: Absent, not palpable

Question 2

Claudication pain

Answer 2

Dull ache
Muscle fatigue and cramps
Usually appears during sustained exercise
Few minutes of rest will ordinarily relieve it
It recurs again with the same amount of activity
Continued activity causes worsening pain

Question 3

Hepatojugular reflux

Answer 3

Sign of right heart failure

Question 4

Temporal arteritis (giant cell arteritis)

Answer 4

An inflammatory disease of the branches of the aortic arch, including the temporal arteries

Question 5

Arterial aneurysm

Answer 5

Localized dilation, generally defined as 1.5 times the diameter of the normal artery, caused by a weakness in the arterial wall
Arteriovenous fistula
Pathologic communication between an artery and vein

Question 6

Arteriovenous fistula

Answer 6

Pathologic communication between an artery and vein

Question 7

Peripheral arterial disease

Answer 7

Stenosis of the blood supply to the extremities by atherosclerotic plaques

Question 8

Raynaud phenomenon

Answer 8

Exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually in response to cold exposure

Question 9

Arterial embolic disease

Answer 9

Emboli that are dispersed throughout the arterial system

Question 10

Venous thrombosis

Answer 10

Sudden or gradual with varying severity of symptoms; can be the result of trauma or prolonged immobilization

Question 11

Tricuspid regurgitation

Answer 11

Backflow of blood into the right atrium during systole; a mild degree of tricuspid regurgitation can be seen in up to 75% of the normal adult population

Question 12

Coarctation of the aorta

Answer 12

Stenosis is seen most commonly in the descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum.

Question 13

Kawasaki disease

Answer 13

Acute small vessel vasculitic illness that may result in the development of coronary artery aneurysms
Cause unknown

Question 14

Preeclampsia-eclampsia

Answer 14

Syndrome specific to pregnancy with hypertension that occurs after the 20th week of pregnancy and the presence of proteinuria; eclampsia is preeclampsia with seizures when no other cause for the seizures can be found

Question 15

Venous ulcers

Answer 15

Results from chronic venous insufficiency in which lack of venous flow leads to lower extremity venous hypertension

Question 16

Atherosclerotic plaque formation begins in the

Answer 16

intima

Question 17

The peripheral veins contain unidirectional valves that

Answer 17

promote venous return to the heart.

Question 18

Veins from the arms, upper trunk, and head and neck drain into

Answer 18

the superior vena cava, which empties into the right atrium

Question 19

Veins from the abdominal wall, liver, lower trunk, and legs drain into

Answer 19

the inferior vena cava

Question 20

Veins from the abdominal viscera drain into

Answer 20

the portal vein, which drains through the liver

Question 21

the leg veins are susceptible to irregular dilatation, compression, ulceration, and invasion by tumors

Answer 21

Because of their weaker wall structure,

Question 22

pitting edema.

Answer 22

Edema that is compressible, or lessens when external pressure is applied, is known as

Question 23

Lymphedema,

Answer 23

from obstructed lymphatic drainage, is usually not compressible.

Question 24

Lymphadenopathy

Answer 24

refers to enlarged lymph nodes, with or without tenderness.

Question 25

Symptomatic limb ischemia with exertion is usually

Answer 25

atherosclerotic PAD

Question 26

Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet, is .

Answer 26

neurogenic claudication

Question 27

Pulsus parvus

Answer 27

refers to weak pulses, usually seen with atherosclerotic PVD,

Question 28

pulsus tardus

Answer 28

refers to sluggish pulses, usually occurring in the setting of aortic stenosis or low cardiac output.

Question 29

Poikilothermia is

Answer 29

the relative hypothermia of one extremity as compared with another. It is usually seen in peripheral vascular disease.

Question 30

Pitting edema scale:

Answer 30

1+: Barely detectable impression when finger is pressed into skin

2+: Slight indentation; 15 seconds to rebound

3+: Deeper indentation; 30 seconds to rebound

4+: >30 seconds to rebound

Question 31

ABI

Answer 31

. Normal ABI ranges from 0.90 to 1.40 because the pressure is normally higher in the ankle than the arm.

Question 32

The strongest risk factors for AAA are

Answer 32

older age, male sex, smoking, and family history;

Question 33

Chronic Venous Insufficiency

Answer 33

Edema is soft, with pitting on pressure, and occasionally bilateral. Look for brawny changes and skin thickening, especially near the ankle. Ulceration, brownish pigmentation, and edema in the feet are common. It arises from chronic obstruction and incompetent valves in the deep venous system.

Question 34

Lymphedema

Answer 34

Edema is initially soft and pitting, then becomes indurated, hard, and nonpitting. Skin is markedly thickened; ulceration is rare. There is no pigmentation. Edema often occurs bilaterally in the feet and toes. Lymphedema arises from interstitial accumulation of protein-rich fluid when lymph channels are infiltrated or obstructed by tumor, fibrosis, or inflammation, or disrupted by axillary node dissection and/or radiation.

Question 35

Chronic Arterial Insufficiency

Answer 35

claudication, progresses to pain at rest
decreased/absent pulse
pale on elevation, dusky red on dependence
cool temp
no edema
shiny, atrophic skin, loss of hair
This condition occurs in the toes, feet, or possibly areas of trauma (e.g., the shins). Surrounding skin shows no callus or excess pigment, although it may be atrophic. Pain often is severe unless masked by neuropathy. May be accompanied by gangrene, along with decreased pulses, trophic changes, foot pallor on elevation, and dusky rubor on dependency.

Question 36

chronic venous insufficiency

Answer 36

painful
normal pulse
edema
brown pigmentation around ankle, thickening of skin
This condition usually appears over the medial and sometimes the lateral malleolus. The ulcer contains small, painful granulation tissue and fibrin; necrosis or exposed tendons are rare. Borders are irregular, flat, or slightly steep.

Question 37

3 types of joints

Answer 37

synovial, carilaginous, fibrous

Question 38

synovial joint

Answer 38

freely moveable
bones of joints do not touch each other
ex- knee, shoulder

Question 39

who has increased soft tissue laxity

Answer 39

younger people, women

Question 40

Types of Synovial joint

Answer 40

1. spheroidal (ball and socket)
2. hinge
3. condylar

Question 41

spheroidal joint

Answer 41

Convex surface in concave cavity

Wide-ranging–flexion, extension, abduction, adduction, rotation, circumduction

Shoulder, hip

Question 42

Hinge joint

Answer 42

Flat, planar

Motion in one plane; flexion, extension

Interphalangeal joints of hand and foot; elbow

Question 43

Condylar joint

Answer 43

Convex or concave

Movement of two articulating surfaces not dissociable

Knee; temporomandibular joint

Question 44

Cartilaginous Joints

Answer 44

Fibrocartilaginous discs separate the bony surfaces of these joints, which allow for a small amount of movement

Question 45

Fibrous Joints

Answer 45

. Fibrous joints, such as the sutures of the skull, have intervening layers of fibrous tissue or cartilage that hold the bones together The bones are almost in direct contact, which allows no appreciable movement.

Question 46

Bursae

Answer 46

oughly disc-shaped synovial sacs that facilitate joint action and allow adjacent muscles or muscles and tendons to glide over each other during movement with reduced friction

Question 47

myalgias

Answer 47

Generalized muscle “aches and pains

Question 48

Arthralgia

Answer 48

is a joint pain without evidence of arthritis.

Question 49

monoarticular

Answer 49

If pain is localized to only one joint,

Question 50

oligoarticular or pauciarticular)

Answer 50

joint pain involving two to four joints

Question 51

polyarticular

Answer 51

joint pain involving more than 4 joints

Question 52

four cardinal features of inflammation

Answer 52

swelling, warmth, and redness, in addition to pain

Question 53

gel phenomenon

Answer 53

brief periods of daytime stiffness following inactivity that usually last from 30 to 60 minutes then get worse again with movement

Question 54

Consider cauda equina syndrome if

Answer 54

bowel or bladder dysfunction (usually urinary retention with overflow incontinence), especially with saddle anesthesia or perineal numbness

Question 55

crepitus

Answer 55

an audible or palpable crunching during movement of tendons or ligaments over bone or areas of cartilage loss

Question 56

most active joint in the body

Answer 56

temporomandibular joint (TMJ)

Question 57

fasciculations

Answer 57

fine tremors of the muscles

Question 58

Crossover or crossed body adduction test

Answer 58

Adduct the patient’s arm across the chest.
Test shoulder joint

Question 59

Apley scratch test

Answer 59

touch opposite scapula in two ways

Question 60

Painful arc test

Answer 60

Fully abduct the patient’s arm from 0° to 180°.

Question 61

Neer impingement sign

Answer 61

Press on the scapula to prevent scapular motion with one hand and raise the patient’s arm with the other. This compresses the greater tuberosity of the humerus against the acromion

Question 62

Hawkins impingement sign

Answer 62

Flex the patient’s shoulder and elbow to 90° with the palm facing down. Then, with one hand on the forearm and one on the arm, rotate the arm internally. This compresses the greater tuberosity against the supraspinatus tendon and coracoacromial ligament.

Question 63

External rotation lag test

Answer 63

. With the patient’s arm flexed to 90° with palm up, rotate the arm into full external rotation and ask the patient to keep the arm in this position.

Question 64

Internal rotation lag test (lift-off test).

Answer 64

With you standing to the patient’s rear, bring the dorsum of the hand behind the low back with the elbow flexed to 90°. Then grip the wrist and lift the hand off the back, which further internally rotates the shoulder. Ask the patient to keep the hand in this position as you release the wrist.

Question 65

Drop-arm test

Answer 65

. Ask the patient to fully abduct the arm to shoulder level, up to 90°, and lower it slowly. Note that abduction above shoulder level, from 90° to 120°, reflects action of the deltoid muscle.

Question 66

External rotation resistance test.

Answer 66

Ask the patient to adduct and flex the arm to 90°, with the thumbs turned up. Stabilize the elbow with one hand and apply pressure proximal to the patient’s wrist as the patient presses the wrist outward in external rotation.

Question 67

Empty can test

Answer 67

. Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place downward pressure on the arms.

Question 68

Hand Grip Strength

Answer 68

. Ask the patient to grasp your second and third fingers as tightly as possible (Fig. 23-47). This tests function of wrist joints, the finger flexors, and the intrinsic muscles and joints of the hand. It is always important to determine if weakness is related to pain or true inability to perform the desired action

Question 69

Finkelstein test

Answer 69

Ask the patient to grasp the thumb against the palm and then move the wrist toward the midline in ulnar deviation

Question 70

Tinel sign

Answer 70

by repeatedly tapping over the course of the median nerve in the carpal tunnel

Question 71

Phalen sign

Answer 71

, ask the patient to hold the wrists in full flexion and juxtaposing the dorsum of each hand against each other for 60 seconds with the elbows fully extended

Question 72

Spurling test

Answer 72

have the patient look over the shoulder and then up at the ceiling. Next, position yourself behind the patient and carefully apply downward pressure on the patient’s head and check if the maneuver reproduces the neck pain with radiation to the same on the same side of the turned head

Question 73

Stance phases of gait

Answer 73

Heelstrike
foot flat
midstance
push off

Question 74

Swing gait

Answer 74

when the foot moves forward and does not bear weight (40% of the normal gait cycle)

Question 75

Stance gait

Answer 75

when the foot is on the ground and bears weight (60% of the normal gait cycle)

Question 76

McMurray Test.

Answer 76

With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers and thumb along the medial joint line. From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, slowly extend the lower leg in external rotation.

The same maneuver with internal rotation of the foot stresses the lateral meniscus.

If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a tear.

Question 77

Adduction (or Varus) Stress Test.

Answer 77

With the thigh and knee in the same position, change your position so that you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side (varus stress). Feel for excessive widening of the joint and lack of endpoint that may signal the ligament is no longer intact.

Question 78

Anterior Drawer Sign

Answer 78

. With the patient supine, hips flexed, and knees flexed to 90° and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings. Sit on the patient’s foot to ensure it does not move during the maneuver. Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur. Compare the degree of forward movement with that of the opposite knee. The knee should have a firm endpoint with minimal movement. Lack of a firm endpoint with excessive movement may indicate the ACL is no longer intact.

Question 79

Lachman Test.

Answer 79

Place the knee in 15° of flexion and mild external rotation. Grasp the distal femur on the lateral side with one hand and the proximal tibia on the medial side with the other. With the thumb of the tibial hand on the joint line, forcefully and simultaneously pull the tibia forward and the femur back. Estimate the degree of forward excursion. There should be a firm endpoint to any forward movement. Lack of a firm endpoint with excessive movement may indicate the ACL is no longer intact.

Question 80

Posterior Drawer Sign.

Answer 80

Position the patient and place your hands in the positions described for the anterior drawer test. Sit on the patient’s foot to minimize foot movement. Push the tibia posteriorly and observe the degree of backward movement in the femur. There should be minimal posterior movement and excursion of the tibia relative to the femur. Excessive movement suggests an insufficient or torn PCL.

Question 81

Osteoporosis

Answer 81

: T score < −2.5 (>2.5 SDs below the young adult mean)

Question 82

Osteopenia

Answer 82

: T score between −1.0 and −2.5 (1.0 to 2.5 SDs below the young adult mean)

Question 83

Antiresorptive agents

Answer 83

inhibit osteoclast activity and slow bone remodeling, allowing better mineralization of bone matrix and stabilization of the trabecular microarchitecture.59,75 Currently used agents include bisphosphonates and selective estrogen-receptor modulators (SERMs). Bisphosphonates are considered the first-line therapy for osteoporosis

Question 84

Rotator Cuff Tendinitis (Impingement Syndrome)

Answer 84

Repeated shoulder motion, for example, from throwing or swimming, can cause edema and hemorrhage followed by inflammation, most commonly involving the supraspinatus tendon. Acute, recurrent, or chronic pain may result, often aggravated by activity. Patients report sharp catches of pain, grating, and weakness when lifting the arm overhead. When the supraspinatus tendon is involved, tenderness is maximal just below the tip of the acromion. In older adults, bone spurs on the undersurface of the acromion may contribute to symptoms.

Question 85

Rotator Cuff Tears

Answer 85

The rotator cuff muscles and tendons compress the humeral head into the concave glenoid fossa and strengthen arm movement—the subscapularis in internal rotation, the supraspinatus in elevation, and the infraspinatus and teres minor in external rotation. Injury from a fall, trauma, or repeated impingement against the acromion and the coracoacromial ligament may cause a partial- or full-thickness tear of tendons in the rotator cuff, especially in older patients. Patients complain of chronic shoulder pain, night pain, or catching and grating when raising the arm overhead. Weakness or tears of the tendons usually start in the supraspinatus tendon and progress posteriorly and anteriorly. Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles related to disuse from pain or retraction in the setting of a complete tear. Palpate anteriorly over the anterior greater tuberosity of the humerus to check for a defect in muscle attachment and below the acromion for crepitus during arm rotation. In a complete tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrug of the shoulder when trying to raise the arm and a positive “drop arm” test when trying to lower the arm

Question 86

Calcific Tendinitis

Answer 86

Calcific tendinitis is a degenerative process in the tendon associated chronic tendon injury with improper healing that leads to the deposition of calcium salts. The supraspinatus tendon is usually involved. Acute disabling attacks of shoulder pain may occur, usually in patients ages ≥30 yrs, especially in women. The arm is held close to the side, and all motions are severely limited by pain. Tenderness is maximal below the tip of the acromion when the supraspinatus is involved. The subacromial/subdeltoid bursa, which overlies the supraspinatus tendon, may also be inflamed. Chronic less severe pain may also occur.

Question 87

Bicipital Tendinitis

Answer 87

Inflammation of the long head of the biceps tendon and tendon sheath causes anterior shoulder pain resembling and often coexisting with rotator cuff tendinitis. Both conditions may involve impingement injury. Tenderness is maximal in the bicipital groove. Externally rotate and abduct the arm to separate this area from the subacromial tenderness of supraspinatus tendinitis. With the patient’s arm at the side, elbow flexed to 90°, ask the patient to supinate the forearm against your resistance. Increased pain in the bicipital groove confirms this condition. Pain during resisted forward flexion of the shoulder with the elbow extended (“Speed’s test”) is also characteristic.

Question 88

Adhesive Capsulitis (Frozen Shoulder)

Answer 88

Adhesive capsulitis refers to fibrosis of the glenohumeral joint capsule, manifested by diffuse, dull, aching pain in the shoulder and progressive restriction of active and passive range of motion, especially in external rotation, with localized tenderness. The condition is usually unilateral and occurs in people ages 40–60 yrs. There is often an antecedent disorder of the shoulder or another condition (such as myocardial infarction) that has decreased shoulder movements. The disorder may take 6 mo to 2 yrs to resolve. Stretching exercises and steroid injection may help.

Question 89

Acromioclavicular Arthritis

Answer 89

Acromioclavicular arthritis is relatively common, usually arising from prior direct injury to the shoulder girdle with resulting degenerative changes. Tenderness is localized over the acromioclavicular joint. Patients report pain with movements of the scapula and arm abduction. The cross-arm test may be positive.

Question 90

Osteoarthritis (Degenerative Joint Disease)

Answer 90

Heberden nodes on the dorsolateral aspects of the distal interphalangeal (DIP) joints from bony overgrowth of osteoarthritis (OA). Usually hard and painless, they affect middle-aged or older adults and are often associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Bouchard nodes on the proximal interphalangeal (PIP) joints are less common. The metacarpophalangeal (MCP) joints are generally spared.

Question 91

Acute Rheumatoid Arthritis

Answer 91

Tender, painful, stiff joints in RA, usually with symmetric involvement on both sides of the body. The DIP, MCP, and wrist joints are the most frequently affected. Note the fusiform or spindle-shaped swelling of the PIP joints in acute disease.

Question 92

Chronic Rheumatoid Arthritis

Answer 92

In chronic disease, note the swelling and thickening of the MCP and PIP joints. Range of motion becomes limited, and fingers may deviate toward the ulnar side. The interosseous muscles atrophy. The fingers may show “swan neck” deformities (hyperextension of the PIP joints with fixed flexion of the DIP joints) related to inflammatory destruction of the joints and supporting ligaments. Less common is a boutonnière deformity (persistent flexion of the PIP joint with hyperextension of the DIP joint). Rheumatoid nodules are seen in the acute or the chronic stage.

Question 93

Chronic Tophaceous Gout

Answer 93

Urate crystal deposits, often with surrounding inflammation, cause deformities in subcutaneous tissues, bursae, cartilage, and subchondral bone that mimic rheumatoid arthritis (RA) and OA. Joint involvement is usually less symmetric than in RA. Acute inflammation may be present. Knobby swellings around the joints ulcerate and discharge white chalk-like urates.

Question 94

Dupuytren Contracture

Answer 94

The first sign of a Dupuytren contracture is a thickened band overlying the flexor tendon of the fourth finger and possibly the little finger near the distal palmar crease. Subsequently, the skin in this area puckers, and a thickened fibrotic cord develops between the palm and finger. Finger extension is limited, but flexion is usually normal. Flexion contracture of the fingers may gradually develop.

Question 95

Trigger Finger

Answer 95

Trigger finger is caused by a painless nodule in a flexor tendon in the palm, near the metacarpal head. The nodule is too big to enter easily into the tendon sheath during extension of the fingers from a flexed position. With extra effort or assistance, the finger extends and flexes with a palpable and audible snap as the nodule pops into the tendon sheath. Watch, listen, and palpate the nodule as the patient flexes and extends the fingers.

Question 96

Ganglion

Answer 96

Ganglia are cystic, round, usually nontender swellings along tendon sheaths or joint capsules, frequently at the dorsum of the wrist. The cyst contains synovial fluid arising from erosion or tearing of the joint capsule or tendon sheath and trapped in the cystic cavity. Flexion of the wrist makes ganglia more prominent if present on the dorsum of the wrist with extension tending to obscure them. Ganglia may also develop on the hands, ankles and feet. They can disappear spontaneously.

Question 97

Acute Tenosynovitis

Answer 97

Inflammation of the flexor tendon sheaths, acute tenosynovitis, may follow local injury, overuse, or infection. Unlike arthritis, tenderness and swelling develop not in the joint but along the course of the tendon sheath. In the fingers, this often occurs from the distal phalanx to the level of the metacarpophalangeal joint. The finger is held in slight flexion since finger extension is very painful. Tenosynovitis can result from inflammation related to injury or irritation of the sheath or from infection. Causative infectious agents include Staphylococcus and Streptococcus species, disseminated gonorrhea, and Candida albicans.

Question 98

Felon

Answer 98

Injury to the fingertip may result in infection of the enclosed fascial spaces of the distal pulp or phalanx pad of the fingertip, usually from Staphylococcus aureus. Severe pain, localized tenderness, swelling, and dusky redness are characteristics. Early diagnosis and treatment, usually incision and drainage, are important for preventing abscess formation. If vesicles are present, consider herpetic whitlow instead, usually seen in health care workers exposed to herpes simplex virus in human saliva (rare when universal precautions are used).

Question 99

Morton Neuroma

Answer 99

Look for tenderness over the plantar surface between the third and fourth metatarsal heads, from perineural fibrosis of the common digital nerve due to repetitive nerve irritation (not a true neuroma). Check for pain radiating to the toes when you press on the plantar interspace and squeeze the metatarsals with your other hand. Symptoms include hyperesthesia, numbness, aching, and burning from the metatarsal heads into the third and fourth toes

Question 100

Neuropathic Ulcer

Answer 100

When pain sensation is diminished or absent, as in diabetic neuropathy, neuropathic ulcers may develop at pressure points on the feet. Although often deep, infected, and indolent, they are painless because of the sensory disruption that often leads to their formation. Underlying osteomyelitis and amputation may ensue. Early detection of loss of sensation using a nylon filament is the standard of care in diabetes.

Question 101

Each cerebral hemisphere is subdivided

Answer 101

into frontal, parietal, temporal, and occipital lobes.

Question 102

basal ganglia

Answer 102

, which affect movement,

Question 103

The thalamus

Answer 103

processes sensory impulses and relays them to the cerebral cortex

Question 104

The hypothalamus

Answer 104

maintains homeostasis and regulates temperature, heart rate, and blood pressure. It also affects the endocrine system and governs emotional behaviors such as anger and sexual drive

Question 105

Brainstem 3 sections

Answer 105

midbrain, pons, medulla

Question 106

31 pairs of spinal nerves

Answer 106

attach to the spinal cord: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal

Question 107

Cranial Nerve I

Answer 107

Olfactory- sense of smell

Question 108

Cranial Nerve II

Answer 108

Optic- Vision

Question 109

Cranial Nerve III

Answer 109

Oculomotor

Pupillary constriction, opening the eye (lid elevation), and most extraocular movements

Question 110

Cranial Nerve IV

Answer 110

Trochlear

Downward, internal rotation of the eye

Question 111

Cranial Nerve V

Answer 111

Trigeminal

Motor—temporal and masseter muscles (jaw clenching), lateral pterygoids (lateral jaw movement)
Sensory—facial. The nerve has three divisions: (1) ophthalmic, (2) maxillary, and (3) mandibular.

Question 112

Cranial Nerve VI

Answer 112

Abducens

Lateral deviation of the eye

Question 113

Cranial Nerve VII

Answer 113

Facial

Motor—facial movements, including those of facial expression, closing the eye, and closing the mouth
Sensory—taste for salty, sweet, sour, and bitter substances on the anterior two-thirds of the tongue and sensation from the ear

Question 114

Cranial Nerve VIII

Answer 114

Vestibulocochlear

Hearing (cochlear division) and balance (vestibular division)

Question 115

Cranial Nerve IX

Answer 115

Glossopharyngeal

Motor—pharynx sensory—posterior portions of the eardrum and ear canal, the pharynx, and the posterior tongue, including taste (salty, sweet, sour, bitter)

Question 116

Cranial Nerve X

Answer 116

Vagus

Motor—palate, pharynx, and larynx

Sensory—pharynx and larynx

Question 117

Cranial Nerve XI

Answer 117

Spinal accessory

Motor—the sternocleidomastoid and trapezius

Question 118

Cranial Nerve XII

Answer 118

Hypoglossal

Motor—tongue

Question 119

upper motor neuron or corticospinal tract damage leads to

Answer 119

increased muscle tone and hyperreflexia because the lower motor neurons are disinhibited

Question 120

lower motor neuron damage causes

Answer 120

decreased muscle tone and hyporeflexia; atrophy and fasciculations can also be seen

Question 121

dermatome

Answer 121

is the band of skin innervated by the sensory root of a single spinal nerve.

Question 122

Subarachnoid hemorrhage classically presents

Answer 122

as “the worst headache of my life” with instantaneous onset

Question 123

meningitis

Answer 123

Severe headache and stiff neck

Question 124

Dull headache increased by coughing and sneezing, especially when recurring in the same location, occurs in

Answer 124

mass lesions from brain tumors or abscess

Question 125

Headache Warning Signs

Answer 125

Progressively frequent or severe over a 3-month period
Sudden onset like a “thunderclap” or “the worst headache of my life”
New onset after age 50 years
Aggravated or relieved by change in position
Precipitated by Valsalva maneuver or exertion
Associated symptoms of fever, night sweats, or weight loss
Presence of cancer, HIV infection, or pregnancy
Recent head trauma
Change in pattern from past headaches
Lack of a similar headache in the past
Associated papilledema, neck stiffness, or focal neurologic deficits

Question 126

dysarthria

Answer 126

difficulty forming words

Question 127

dysesthesias

Answer 127

distorted sensations

Question 128

Tremor,

Answer 128

“a rhythmic oscillatory movement of a body part resulting from the contraction of opposing muscle groups,” is the most common movement disorder

Question 129

Test Cranial Nerve I

Answer 129

presenting the patient with familiar nonirritating odors.

Question 130

Test Cranial Nerve II

Answer 130

Test visual acuity in each eye.
Inspect the optic fundi with your ophthalmoscope, paying special attention to the optic discs.
Test the visual fields by confrontation

Question 131

Test Cranial Nerve II and III

Answer 131

Inspect the size and shape of the pupils and compare one side with the other

Question 132

Anisocoria

Answer 132

, or a difference of >0.4 mm in the diameter of one pupil compared to the other,

Question 133

Test Cranial Nerves III, IV, and VI

Answer 133

Test the extraocular movements in the six cardinal directions of gaze and look for loss of conjugate movements in any of the six directions. Check convergence of the eyes.

Question 134

nystagmus

Answer 134

, an involuntary jerking movement of the eyes with quick and slow component

Question 135

Planes of nystagmus

Answer 135

horizontal, vertical, rotary, or mixed

Question 136

ptosis

Answer 136

(drooping of the upper eyelids)

Question 137

Test Cranial Nerve V

Answer 137

ask the patient to firmly clench the teeth
Test light touch, pain sensation, temp sensation

Question 138

Test Cranial Nerve VII—Facial.

Answer 138

Ask the patient to:

Raise both eyebrows
Frown
Close both eyes tightly so that you cannot open them.
Show both upper and lower teeth
Smile
Puff out both cheeks

Question 139

Test Cranial Nerve VIII

Answer 139

Assess gross hearing with the whispered voice test.

Question 140

Test Cranial Nerves IX and X

Answer 140

Listen to patient’s voice
Ask the patient to say “ah” or to yawn as you watch the movements of the soft palate and the pharynx.

Question 141

Test Cranial Nerve XI

Answer 141

Ask the patient to shrug both shoulders upward against your hands
Ask the patient to turn the head to each side against your hand

Question 142

Test Cranial Nerve XII

Answer 142

Listen to the articulation of the patient’s words.

Question 143

Spasticity

Answer 143

is increased tone that is velocity-dependent and worsens at the extremes of range of motion. Resistance increases with more rapid movement. Spasticity is seen in central diseases affecting the corticospinal tract.

Question 144

Rigidity

Answer 144

is increased tone that remains the same throughout the range of motion; it is not velocity dependent. Rigidity is seen in central disorders affecting the basal ganglia, such as Parkinson disease.

Question 145

Scale for Grading Muscle Strength

Answer 145

Muscle strength is graded on a 0 to 5 scale:

5—Active movement against full resistance without evident fatigue. This is normal muscle strength.

4—Active movement against gravity and some resistance

3—Active movement against gravity

2—Active movement of the body part with gravity eliminated (planar motion)

1—A barely detectable flicker or trace of contraction

0—No muscular contraction detected

Question 146

Ataxia

Answer 146

refers to a loss of control of coordinated voluntary movements.

Question 147

an abnormality called dysdiadochokinesis

Answer 147

these movements are slow, irregular, and clumsy, in cerebellar disease

Question 148

Romberg Test

Answer 148

. This is mainly a test of position sense. The patient should first stand with feet together and eyes open and then close both eyes for about 30 seconds without support. Note the patient’s ability to maintain an upright posture. Normally any swaying is minimal.

Question 149

Stereognosis

Answer 149

. Stereognosis refers to the ability to identify an object by feeling it.

Answer 150

4-Very brisk, with clonus (rhythmic oscillations between flexion and extension)

3Brisker than average; possibly but not necessarily indicative of disease

2Average; normal

1Somewhat diminished, or requires reinforcement

0Reflex absent

Question 151

Wernicke aphasia

Answer 151

Fluent; often rapid, voluble, and effortless. Inflection and articulation are good, but sentences lack meaning, and words are malformed (paraphasias) or invented (neologisms). The meaning of speech may be totally incomprehensible

impaired comprehension

Question 152

Broca Aphasia

Answer 152

Nonfluent; slow and broken, with few words and laborious effort. Inflection and articulation are impaired, but words are meaningful, with nouns, transitive verbs, and important adjectives. Small grammatical words are often dropped
Comprehension okay

Question 153

Spastic Hemiparesis

Answer 153

Seen in corticospinal tract lesions that cause poor control of flexor muscles during swing phase (for example, from stroke).

Affected arm is flexed, immobile, and held close to the side, with elbow, wrists, and interphalangeal joints flexed.
Affected leg extensors are spastic; ankles are plantar-flexed and inverted.
Patients may drag toe, circle leg stiffly outward and forward (circumduction), or lean trunk to contralateral side to clear affected leg during walking.

Question 154

Scissors Gait

Answer 154

Seen in spinal cord disease, causing bilateral lower extremity spasticity, including adductor spasm.

Gait is stiff. Patients advance each leg slowly, and the thighs tend to cross forward on each other at each step.
Steps are short.
Patients appear to be walking through water, and there may be compensating sway of the trunk away from the side of the advancing leg.
Scissoring is seen in all spasticity disorders, most commonly cerebral palsy.

Question 155

Steppage Gait

Answer 155

Seen in foot drop, usually secondary to peripheral nervous system disease.

Patients either drag the feet or lift them high, with knees flexed, and bring them down with a slap onto the floor, appearing to be walking up stairs.
Patients cannot walk on their heels.
Gait may involve one or both legs.
Tibialis anterior and toe extensors are weak.

Question 156

Parkinsonian Gait

Answer 156

Seen in the basal ganglia defects of Parkinson disease.

Posture is stooped, with flexion of head, arms, hips, and knees.
Patients are slow getting started.
Steps are short and shuffling, with involuntary hastening (festination).
Arm swings are decreased, and patients turn around stiffly—“all in one piece.”
Postural control is poor (anteropulsion or retropulsion).

Question 157

Cerebellar Ataxia

Answer 157

Seen in disease of the cerebellum or associated tracts.

Gait is staggering and unsteady, with feet wide apart and exaggerated difficulty on turns.
Patients cannot stand steadily with feet together, whether eyes are open or closed.
Other cerebellar signs are present such as dysmetria, nystagmus, and intention tremor.

Question 158

Sensory Ataxia

Answer 158

Seen in loss of position sense in the legs from polyneuropathy or posterior column damage.

Gait is unsteady and wide based (with feet wide apart).
Patients throw their feet forward and outward and bring them down, first on the heels and then on the toes, with a double tapping sound.
Patients watch the ground for guidance when walking.
With eyes closed, patients cannot stand steadily with feet together (positive Romberg sign), and the staggering gait worsens.

Question 159

Tension headache

Answer 159

Most common headache
Usually bilateral; may be generalized or localized to the back of the head and upper neck or to the frontotemporal area

Gradual onset

Question 160

Migraine

Answer 160

Unilateral
Throbbing or aching, pain, moderate to severe in intensity; preceded by aura in up to 30%
Rapid onset, peak in 2 hours

Question 161

Cluster headche

Answer 161

Unilateral, usually behind or around the eye or temple
Sharp, continuous, intense; severe in intensity
Clustered in time

Question 162

Tonic–Clonic (Grand Mal) seizure

Answer 162

The patient loses consciousness suddenly, sometimes with a cry, and the body stiffens into tonic extensor rigidity. Breathing stops, and the patient becomes cyanotic. A clonic phase of rhythmic muscular contraction follows. Breathing resumes and is often noisy, with excessive salivation. Injury, tongue biting, and urinary incontinence may occur.

Question 163

Absence seizure

Answer 163

A sudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. Two subtypes are: typical absence—lasts <10 sec and stops abruptly; atypical absence—may last >10 se

Question 164

Myoclonic seizure

Answer 164

Sudden, brief, rapid jerks, involving the trunk or limbs. Myoclonus has many potential causes, however, and is not always caused by seizure

Question 165

Myoclonic atonic (drop attack)

Answer 165

Sudden loss of consciousness with falling but no movements. Injury may occur

Question 166

Resting (Static) Tremors

Answer 166

These tremors are most prominent at rest and may decrease or disappear with voluntary movement. Illustrated is the common relatively slow, fine pill-rolling tremor of parkinsonism, about 5/sec.

Question 167

Postural Tremors

Answer 167

These tremors appear when the affected part is actively maintaining a posture. Examples include the fine rapid tremor of hyperthyroidism, the tremors of anxiety and fatigue, and benign essential (and often familial) tremor.

Question 168

Intention Tremors

Answer 168

Intention tremors, absent at rest, appear with movement and get worse as the limb approaches the target. Seen in disorders affecting the cerebellum or its related tracts, such as multiple sclerosis or stroke.

Question 169

Oral–Facial Dyskinesias

Answer 169

Oral–facial dyskinesias are arrhythmic, repetitive, bizarre movements that chiefly involve the face, mouth, jaw, and tongue: grimacing, pursing of the lips, protrusions of the tongue, opening and closing of the mouth, and deviations of the jaw. The limbs and trunk are involved less often. These movements may be a late complication of antipsychotic or antiemetic drugs such as phenothiazines, termed tardive (late) dyskinesias. They also occur in long-standing psychoses, in some older adults, and in some edentulous persons.

Question 170

Tics

Answer 170

Tics are brief, repetitive, stereotyped, coordinated movements occurring at irregular intervals. Examples include repetitive winking, grimacing, and shoulder shrugging. Causes include Tourette syndrome and late effects of drugs such as phenothiazines.

Question 171

Dystonia

Answer 171

Dystonia causes irregular movements resembling athetosis or tremor. These are often accompanied by abnormal postures that limit voluntary movement and can at times be painful. Examples include writer’s cramp, blephorospasm, and as illustrated, spasmodic torticollis.

Question 172

Athetosis

Answer 172

Athetoid movements are slower and more twisting and writhing than choreiform movements and have a larger amplitude. They most commonly involve the face and the distal extremities. Athetosis is often associated with spasticity. Causes include cerebral palsy.

Question 173

Chorea

Answer 173

Choreiform movements are brief, rapid, jerky, irregular, and unpredictable. They occur at rest or interrupt normal coordinated movements. Unlike tics, they seldom repeat themselves. The face, head, lower arms, and hands are often involved. Causes include Sydenham chorea (with rheumatic fever) and Huntington disease.

Question 174

Decorticate Rigidity

Answer 174

(Abnormal Flexor Response)

In decorticate rigidity, the upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed. The legs are extended and internally rotated. The feet are plantar flexed. When seen bilaterally in a comatose patient, this implies a destructive lesion affecting the corticospinal tracts within or very near the cerebral hemispheres. This posture can also be seen unilaterally in a patient in the chronic recovery phase after a lesion of the corticospinal tract (chronic spastic hemiplegia), for example after stroke.

Question 175

Decerebrate Rigidity

Answer 175

(Abnormal Extensor Response)

In decerebrate rigidity, the jaws are clenched, and the neck is extended. The arms are adducted and stiffly extended at the elbows, with forearms pronated, wrists and fingers flexed. The legs are stiffly extended at the knees, with the feet plantar flexed. This posture may occur spontaneously or only in response to external stimuli such as light, noise, or pain. It is caused by a lesion in the diencephalon, midbrain, or pons, although may also arise from severe metabolic disorders such as hypoxia or hypoglycemia.

Question 176

6 Ps of acute ischemia

Answer 176

pulseless
pain
pallor
paresthesia
paralysis
poikilothermia (cold)

Question 177

cap refill

Answer 177

normal- less than 1 sec

Question 178

pulse scale

Answer 178

3- bounding
2- expected
1- diminished
0-absent

Question 179

triceps reflex

Answer 179

c5,6

Question 180

brachioradialis reflex

Answer 180

c5,6

Question 181

biceps reflex

Answer 181

c5,6

Question 182

knee reflex

Answer 182

l 2,3,4

Question 183

ankle reflex

Answer 183

s1

Question 184

peripheral venous disease

Answer 184

dull pain, edema (especially lower extremity), pulse present
elevated legs helps
affects deoxygenated blood flowing back to the heart

Question 185

peripheral arterial disease

Answer 185

painful, sharp, no pulse, no edema
elevated legs worsens