Module 4 Flashcards
(185 cards)
1
Q
Amplitude scale
A
4: Bounding, aneurysmal
3: Full, increased
2: Expected
1: Diminished, barely palpable
0: Absent, not palpable
2
Q
Claudication pain
A
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
3
Q
Hepatojugular reflux
A
Sign of right heart failure
4
Q
Temporal arteritis (giant cell arteritis)
A
An inflammatory disease of the branches of the aortic arch, including the temporal arteries
5
Q
Arterial aneurysm
A
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
6
Q
Arteriovenous fistula
A
Pathologic communication between an artery and vein
7
Q
Peripheral arterial disease
A
Stenosis of the blood supply to the extremities by atherosclerotic plaques
8
Q
Raynaud phenomenon
A
Exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually in response to cold exposure
9
Q
Arterial embolic disease
A
Emboli that are dispersed throughout the arterial system
10
Q
Venous thrombosis
A
Sudden or gradual with varying severity of symptoms; can be the result of trauma or prolonged immobilization
11
Q
Tricuspid regurgitation
A
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
12
Q
Coarctation of the aorta
A
Stenosis is seen most commonly in the descending aortic arch near the origin of the left subclavian artery and ligamentum arteriosum.
13
Q
Kawasaki disease
A
Acute small vessel vasculitic illness that may result in the development of coronary artery aneurysms
Cause unknown
14
Q
Preeclampsia-eclampsia
A
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
15
Q
Venous ulcers
A
Results from chronic venous insufficiency in which lack of venous flow leads to lower extremity venous hypertension
16
Q
Atherosclerotic plaque formation begins in the
A
intima
17
Q
The peripheral veins contain unidirectional valves that
A
promote venous return to the heart.
18
Q
Veins from the arms, upper trunk, and head and neck drain into
A
the superior vena cava, which empties into the right atrium
19
Q
Veins from the abdominal wall, liver, lower trunk, and legs drain into
A
the inferior vena cava
20
Q
Veins from the abdominal viscera drain into
A
the portal vein, which drains through the liver
21
Q
the leg veins are susceptible to irregular dilatation, compression, ulceration, and invasion by tumors
A
Because of their weaker wall structure,
22
Q
pitting edema.
A
Edema that is compressible, or lessens when external pressure is applied, is known as
23
Q
Lymphedema,
A
from obstructed lymphatic drainage, is usually not compressible.
24
Q
Lymphadenopathy
A
refers to enlarged lymph nodes, with or without tenderness.
25
Symptomatic limb ischemia with exertion is usually
atherosclerotic PAD
26
Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet, is .
neurogenic claudication
27
Pulsus parvus
refers to weak pulses, usually seen with atherosclerotic PVD,
28
pulsus tardus
refers to sluggish pulses, usually occurring in the setting of aortic stenosis or low cardiac output.
29
Poikilothermia is
the relative hypothermia of one extremity as compared with another. It is usually seen in peripheral vascular disease.
30
Pitting edema scale:
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
31
ABI
. Normal ABI ranges from 0.90 to 1.40 because the pressure is normally higher in the ankle than the arm.
32
The strongest risk factors for AAA are
older age, male sex, smoking, and family history;
33
Chronic Venous Insufficiency
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.
34
Lymphedema
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.
35
Chronic Arterial Insufficiency
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.
36
chronic venous insufficiency
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.
37
3 types of joints
synovial, carilaginous, fibrous
38
synovial joint
freely moveable
bones of joints do not touch each other
ex- knee, shoulder
39
who has increased soft tissue laxity
younger people, women
40
Types of Synovial joint
1. spheroidal (ball and socket)
2. hinge
3. condylar
41
spheroidal joint
Convex surface in concave cavity
Wide-ranging–flexion, extension, abduction, adduction, rotation, circumduction
Shoulder, hip
42
Hinge joint
Flat, planar
Motion in one plane; flexion, extension
Interphalangeal joints of hand and foot; elbow
43
Condylar joint
Convex or concave
Movement of two articulating surfaces not dissociable
Knee; temporomandibular joint
44
Cartilaginous Joints
Fibrocartilaginous discs separate the bony surfaces of these joints, which allow for a small amount of movement
45
Fibrous Joints
. 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.
46
Bursae
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
47
myalgias
Generalized muscle “aches and pains
48
Arthralgia
is a joint pain without evidence of arthritis.
49
monoarticular
If pain is localized to only one joint,
50
oligoarticular or pauciarticular)
joint pain involving two to four joints
51
polyarticular
joint pain involving more than 4 joints
52
four cardinal features of inflammation
swelling, warmth, and redness, in addition to pain
53
gel phenomenon
brief periods of daytime stiffness following inactivity that usually last from 30 to 60 minutes then get worse again with movement
54
Consider cauda equina syndrome if
bowel or bladder dysfunction (usually urinary retention with overflow incontinence), especially with saddle anesthesia or perineal numbness
55
crepitus
an audible or palpable crunching during movement of tendons or ligaments over bone or areas of cartilage loss
56
most active joint in the body
temporomandibular joint (TMJ)
57
fasciculations
fine tremors of the muscles
58
Crossover or crossed body adduction test
Adduct the patient’s arm across the chest.
Test shoulder joint
59
Apley scratch test
touch opposite scapula in two ways
60
Painful arc test
Fully abduct the patient’s arm from 0° to 180°.
61
Neer impingement sign
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
62
Hawkins impingement sign
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.
63
External rotation lag test
. 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.
64
Internal rotation lag test (lift-off test).
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.
65
Drop-arm test
. 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.
66
External rotation resistance test.
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.
67
Empty can test
. 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.
68
Hand Grip Strength
. 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
69
Finkelstein test
Ask the patient to grasp the thumb against the palm and then move the wrist toward the midline in ulnar deviation
70
Tinel sign
by repeatedly tapping over the course of the median nerve in the carpal tunnel
71
Phalen sign
, 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
72
Spurling test
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
73
Stance phases of gait
Heelstrike
foot flat
midstance
push off
74
Swing gait
when the foot moves forward and does not bear weight (40% of the normal gait cycle)
75
Stance gait
when the foot is on the ground and bears weight (60% of the normal gait cycle)
76
McMurray Test.
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.
77
Adduction (or Varus) Stress Test.
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.
78
Anterior Drawer Sign
. 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.
79
Lachman Test.
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.
80
Posterior Drawer Sign.
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.
81
Osteoporosis
: T score < −2.5 (>2.5 SDs below the young adult mean)
82
Osteopenia
: T score between −1.0 and −2.5 (1.0 to 2.5 SDs below the young adult mean)
83
Antiresorptive agents
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
84
Rotator Cuff Tendinitis (Impingement Syndrome)
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.
85
Rotator Cuff Tears
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
86
Calcific Tendinitis
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.
87
Bicipital Tendinitis
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.
88
Adhesive Capsulitis (Frozen Shoulder)
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.
89
Acromioclavicular Arthritis
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.
90
Osteoarthritis (Degenerative Joint Disease)
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.
91
Acute Rheumatoid Arthritis
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.
92
Chronic Rheumatoid Arthritis
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.
93
Chronic Tophaceous Gout
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.
94
Dupuytren Contracture
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.
95
Trigger Finger
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.
96
Ganglion
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.
97
Acute Tenosynovitis
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.
98
Felon
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).
99
Morton Neuroma
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
100
Neuropathic Ulcer
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.
101
Each cerebral hemisphere is subdivided
into frontal, parietal, temporal, and occipital lobes.
102
basal ganglia
, which affect movement,
103
The thalamus
processes sensory impulses and relays them to the cerebral cortex
104
The hypothalamus
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
105
Brainstem 3 sections
midbrain, pons, medulla
106
31 pairs of spinal nerves
attach to the spinal cord: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal
107
Cranial Nerve I
Olfactory- sense of smell
108
Cranial Nerve II
Optic- Vision
109
Cranial Nerve III
Oculomotor
Pupillary constriction, opening the eye (lid elevation), and most extraocular movements
110
Cranial Nerve IV
Trochlear
Downward, internal rotation of the eye
111
Cranial Nerve V
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.
112
Cranial Nerve VI
Abducens
Lateral deviation of the eye
113
Cranial Nerve VII
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
114
Cranial Nerve VIII
Vestibulocochlear
Hearing (cochlear division) and balance (vestibular division)
115
Cranial Nerve IX
Glossopharyngeal
Motor—pharynx sensory—posterior portions of the eardrum and ear canal, the pharynx, and the posterior tongue, including taste (salty, sweet, sour, bitter)
116
Cranial Nerve X
Vagus
Motor—palate, pharynx, and larynx
Sensory—pharynx and larynx
117
Cranial Nerve XI
Spinal accessory
Motor—the sternocleidomastoid and trapezius
118
Cranial Nerve XII
Hypoglossal
Motor—tongue
119
upper motor neuron or corticospinal tract damage leads to
increased muscle tone and hyperreflexia because the lower motor neurons are disinhibited
120
lower motor neuron damage causes
decreased muscle tone and hyporeflexia; atrophy and fasciculations can also be seen
121
dermatome
is the band of skin innervated by the sensory root of a single spinal nerve.
122
Subarachnoid hemorrhage classically presents
as “the worst headache of my life” with instantaneous onset
123
meningitis
Severe headache and stiff neck
124
Dull headache increased by coughing and sneezing, especially when recurring in the same location, occurs in
mass lesions from brain tumors or abscess
125
Headache Warning Signs
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
126
dysarthria
difficulty forming words
127
dysesthesias
distorted sensations
128
Tremor,
“a rhythmic oscillatory movement of a body part resulting from the contraction of opposing muscle groups,” is the most common movement disorder
129
Test Cranial Nerve I
presenting the patient with familiar nonirritating odors.
130
Test Cranial Nerve II
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
131
Test Cranial Nerve II and III
Inspect the size and shape of the pupils and compare one side with the other
132
Anisocoria
, or a difference of >0.4 mm in the diameter of one pupil compared to the other,
133
Test Cranial Nerves III, IV, and VI
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.
134
nystagmus
, an involuntary jerking movement of the eyes with quick and slow component
135
Planes of nystagmus
horizontal, vertical, rotary, or mixed
136
ptosis
(drooping of the upper eyelids)
137
Test Cranial Nerve V
ask the patient to firmly clench the teeth
Test light touch, pain sensation, temp sensation
138
Test Cranial Nerve VII—Facial.
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
139
Test Cranial Nerve VIII
Assess gross hearing with the whispered voice test.
140
Test Cranial Nerves IX and X
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.
141
Test Cranial Nerve XI
Ask the patient to shrug both shoulders upward against your hands
Ask the patient to turn the head to each side against your hand
142
Test Cranial Nerve XII
Listen to the articulation of the patient’s words.
143
Spasticity
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.
144
Rigidity
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.
145
Scale for Grading Muscle Strength
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
146
Ataxia
refers to a loss of control of coordinated voluntary movements.
147
an abnormality called dysdiadochokinesis
these movements are slow, irregular, and clumsy, in cerebellar disease
148
Romberg Test
. 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.
149
Stereognosis
. Stereognosis refers to the ability to identify an object by feeling it.
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
151
Wernicke aphasia
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
152
Broca Aphasia
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
153
Spastic Hemiparesis
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.
154
Scissors Gait
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.
155
Steppage Gait
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.
156
Parkinsonian Gait
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).
157
Cerebellar Ataxia
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.
158
Sensory Ataxia
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.
159
Tension headache
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
160
Migraine
Unilateral
Throbbing or aching, pain, moderate to severe in intensity; preceded by aura in up to 30%
Rapid onset, peak in 2 hours
161
Cluster headche
Unilateral, usually behind or around the eye or temple
Sharp, continuous, intense; severe in intensity
Clustered in time
162
Tonic–Clonic (Grand Mal) seizure
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.
163
Absence seizure
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
164
Myoclonic seizure
Sudden, brief, rapid jerks, involving the trunk or limbs. Myoclonus has many potential causes, however, and is not always caused by seizure
165
Myoclonic atonic (drop attack)
Sudden loss of consciousness with falling but no movements. Injury may occur
166
Resting (Static) Tremors
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.
167
Postural Tremors
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.
168
Intention Tremors
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.
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Oral–Facial Dyskinesias
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.
170
Tics
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.
171
Dystonia
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.
172
Athetosis
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.
173
Chorea
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.
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Decorticate Rigidity
(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.
175
Decerebrate Rigidity
(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.
176
6 Ps of acute ischemia
pulseless
pain
pallor
paresthesia
paralysis
poikilothermia (cold)
177
cap refill
normal- less than 1 sec
178
pulse scale
3- bounding
2- expected
1- diminished
0-absent
179
triceps reflex
c5,6
180
brachioradialis reflex
c5,6
181
biceps reflex
c5,6
182
knee reflex
l 2,3,4
183
ankle reflex
s1
184
peripheral venous disease
dull pain, edema (especially lower extremity), pulse present
elevated legs helps
affects deoxygenated blood flowing back to the heart
185
peripheral arterial disease
painful, sharp, no pulse, no edema
elevated legs worsens
