Neurology Exam General appearance Vital signs CV carotids,
heart, peripheral Mental status attention, orientation, language,
fund of knowledge, memory Visual-Spatial function: draw things fill
in clock & a time Abnormality neglect drawing #s all on 1 side
Aphasia: cortical dysfunction in speech Be able to recognize &
categorize them Can people say things you understand, do they
understand you, have them say uncommon words, repetition, word
substitutions
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Neurology Exam Cranial Nerves I: optional anosmia (loss of
smell HTN meds, trauma) II: visual acuity, fields & fundi 3ft
apart, 4 quadrants Optic radiations loop into temporal lobe
Papilledema increased pressure, acute problems Venous pulsations w.
occular veins normal CSF pressure III, IV, VI: pupils, eye
movements Aniscoria asymm. Pupil size Horners syndrome IL symp NS
loss, normal light reflex, loss of sweating, ptosis, anhydrosis
Nystagmus rhythmic ossicilations (slow & fast phases) Phenytoin
causes it when looking L or R (not abnormal) 1* gaze abnormal
Congenital normal for them, they see normal
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Neurology Exam Cranial Nerves V: facial sensation, corneal
reflex V1 (to tip of nose), V2, V3 sensation areas Jaw strength
VII: facial symmetry & strength LMN Bells palsy: entire of
face, no sensory loss perceive numbness b/c muscles arent working
VIII: hearing, balance Vestibular neuropathy (vertigo) Whispered
hearing test, tuning forks IX: palate movement X: autonomic
function XI: SCM & Trapezius XII: tongue protrusion (points to
side of lesion)
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Neurology Exam Muscle Strength Weakness: a muscle cannot exert
normal force UMN (increased tone & reflexes, Babinski sign),
LMN (decreased tone & reflexes, fasciculations) Grading: (5)
Normal power (4) Active movement against gravity & resistance
(3) Active movement against gravity (2) Active movement only with
gravity eliminated (1) Trace contraction (flicker) (0) No
contraction Tone Cog wheel: passive movement, increased
tension/tone causing catching (PD) Any atrophy or abnormal
movements Fasciculations muscle twitches, have to watch for a
while
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Neurology Exam Muscle Coordination (cerebellar function IL
dysfunctions) Rapid alternating movements (flipping hands back n
forth, touching each fingertip to thumb in rapid succession)
Heel-shin test Check test (hands in supination, and any drifting to
pronation; push down on extended arms abnormal if cant bring back
up or overcompensate) Sensation (always compare symmetric areas)
Touch (sharp & dull) scatter yourself appropriately so patients
dont follow your pattern, cover many dermatomes Vibration use
tuning fork on distal joints first (working proximal) & your
finger underneath the joint Proprioception hold onto lateral aspect
of phalange, patients eyes are closed & you tell them what is
up, down & neutral 2 point discrimination
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Neurology Exam Muscle Reflexes Grading: (4) greatly increased,
clonus (3) somewhat increased (2) normal (1) diminished response
(0) no response Reinforcement: UE clench teeth, LE hands together
& pull Levels: C5 - Biceps (antecubital fossa, press on it
& hit your thumb) C6 - Brachioradialis (1/3 prox. Wrist, slight
pronation, hit your thumb) C7 Triceps (flex arm & shoulder,
holding arm up with yours) L4 Patellar S1 Achilles (foot in
dorsiflexsion, hit achilles tendon) Checking for clonus support
knee while supine, flex & point food then rapidly dorsiflex
Pathologic: Grasp when they grab your hand after stroking it
Babinski UMN, loss of cortical inhibition Globellar tap on patients
forehead, no accommodation = abnormal Jaw jerk brisk (UMN), normal
+ hyperflexia elsehwere (LMN)
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Musculoskeletal Exam Pain is a SYMPTOM not a diagnosis
Diagnosis based on structure Hx alleviating & aggravating
factors & reproducing the pain Localized pain MSK almost always
localized, can radiate elsewhere Neck & arm, back & legs =
units Primary pain generator = being able to reproduce pain via
touch Gait Analysis Single sequence of functions of one limb
consisting of two steps Step length: distance between both heels
Stride length: distance between heel of same foot after two steps
Stance: time which limb is in contact with ground (60%) Swing: time
which foot is in the air for limb advancement (40%) Cadence: number
of steps per unit time Speed: length per time Most energy efficient
& comfortable walking @ 3mph Decrease speed by decreasing
cadence or increasing step length
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Musculoskeletal Exam Center of Gravity Typically 5 cm anterior
to S2 vertebra Displaced 5 cm horizontally and 5 cm vertically
during an average adult male step Base of Support Space outlined by
feet and any assistive device in contact with ground Normally, 5
cm-10 cm between heels
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Musculoskeletal Exam Stance Phase Initial contact: time
following initial contact of foot with ground Loading response: IC
until contralateral foot lifted off ground. Weight shift occurs.
Body has lowest center of gravity. Midstance: LR until both ankles
are aligned in frontal plane Terminal stance: MS until just prior
to initial contact of contralateral heel Preswing: TS until just
prior to ipsilateral unloading toe from ground Swing Phase Initial
swing : Lift of extremity from ground to maximum knee flexion Mid
swing : KF to vertical tibia position Terminal swing: Vertical
tibia position to just prior to initial contact
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Musculoskeletal Exam Gait Dysfunctions Antalgic gait: Stance
phase is abnormally shortened relative to the swing phase, a good
indication of pain with weight-bearing Trendelenburg gait:
Uncompensated: During stance phase, the weakened gluteus medius
allows the pelvis to tilt down on the opposite side. Bilateral =
Waddling or Myopathic Gait Compensated: During stance phase, the
trunk lurches to weak side to maintain a level pelvis throughout
the gait cycle. Foot drop: Dropping of the forefoot into
plantarflexion due to significant tibialis anterior weakness
(1/5-2/5 strength) or damage to peroneal nerve Foot slap: Milder
form of foot drop resulting in a slapping sound at initial contact
(3/5-4/5 strength) Steppage (Hip Hiking) gait: Swing leg
excessively hip flexes so that the toes of swing leg can clear the
ground
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Musculoskeletal Exam Gait Dysfunctions Vaulting: Stance leg
excessively plantar flexes to allow toes of swing leg to clear the
ground Circumduction: Swing leg excessively hip abducts so that the
toes of swing leg can clear the ground Genu recurvatum: Backbending
of knee causing excessive extension at the tibiofemoral joint due
to weak quads or limited ankle dorsiflexion / excessive plantar
flexion Ataxic gait: unsteady, uncoordinated walk, employing a wide
base and the feet thrown out. Commonly seen with cerebellar
pathology, classic drunken appearance. Festinating gait:
Involuntary advancement of legs with short, accelerating steps,
often on tiptoes (shuffling). Seen with Parkinsons Disease
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Musculoskeletal Exam Muscle Testing 5/5 Complete ROM against
gravity with full resistance 4/5 Complete ROM against gravity with
some resistance 3/5 Complete ROM against gravity 2/5 Complete ROM
with gravity eliminated (rare) 1/5 Evidence of slight contractility
with no joint movement 0/5 No evidence of contractility (visual or
tactile) Upper Limb C5: Biceps (EF) C6: Extensor carpi radialis
(WE) C7: Triceps (EE) C8: FDP D3 (FF) T1: ADM (D5 Abduction) Lower
Limb L2: Iliopsoas (HF) L3: Quads (KE) L4: Tibialis anterior (DF)
L5: Extensor hallucis longus (Great toe extension) S1:
Gastrocnemius-Soleus (PF)
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Musculoskeletal Exam Deep Tendon Reflexes 0 - Absent (even with
reinforcement) 1+ - Hypoactive 2+ - Normal 3+ - Hyperactive without
clonus* 4+ - Hyperactive with clonus Clonus: Rapid alternating
contractions and relaxations of muscle after forced stretch.
Reinforcement requires maximal isometric contraction of muscles at
a remote part of the body (clench jaw, lock fingers Jendrassik
Maneuver) in order to distract the patient for voluntary
suppression and by decreasing the amount of descending inhibition
Locations: C5 - Biceps tendon C6- Brachioradialis tendon C7-
Triceps tendon L4 - Patellar tendon L5 - Medial hamstring
(unreliable)* S1 - Achilles tendon Sensation Normal Increased
(hyperesthetic) Decreased (hypoesthetic) Unpleasantly altered
(dysesthetic) Not unpleasantly altered (paresthetic) Absent
(anesthetic)
Musculoskeletal Exam TMJ dysfunction: deviation, popping or
clicking of the TMJ with range of motion Herberdens nodes: bony
enlargements of DIP joint found in osteoarthritis Bouchards nodes:
bony enlargements of the PIP joint assoc. w. osteo & rheumatoid
arthritis Rotoscoliosis: lateral curvature of the spine Pes planus:
loss of foot arch Ballottement: technique used to identify fluid
w/in the joint space where the provider rapidly taps the patella
posteriorly & assesses for its bobbing up if excessive fluid is
present Valgus stress test: MCL assessment, provider holds the
supine patients straightened leg @ ankle & places other hand
along lateral aspect of the knee Ankle pushed laterally as medial
pressure applied at the knee Varus stress: LCL assessment, provider
holds the supine patients straightened leg @ ankle & places
other hand along medial aspect of the knee Ankle pushed medically
as lateral pressure applied at the knee
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Musculoskeletal Exam Anterior Drawer Test: ACL assessment,
patient is supine with knee bent @ 60* & foot anchored,
provider grasps lower leg behind the knee & applies anterior
displacement, noting shift of tibia from under femur Posterior
Drawer Test: PCL assessment, patient is supine with knee bent @ 60*
& foot anchored, provider grasps lower leg behind the knee
& applies posterior displacement, noting shift of tibia
backward under femur Meniscal tear: tear of the medial or lateral
menisci McMurrays sign: clicking or pain in the knee suggesting a
meniscal tear elicited as provider places the supine patients lower
leg in first internal rotation w. varus pressure on the knee while
taking the knee & hip thru flexion & extension to asses the
LM then reversing the forces to ext. rotate w., valgus pressure to
assess the MM Apley Grind: meniscal tear test, patient prone, knee
flexed at 90*, apply downward pressure with internal & external
rotation, feeling for grinding or popping
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Musculoskeletal Exam Straight leg raise: assess for a herniated
lumbar disc Carpal tunnel syndrome: compression of the median nerve
as it passes through the carpal tunnel, causing numbness,
paresthesia & hand weakness Phalens sign: undsidedown prayer
motion CTS test Tinels sign: CTS, percuss over extended wrist
Rotator cuff: complex of tendinous insertions of supraspinatus,
infraspinatus, teres minor, subscapularis muscles Arm drop test
supraspinatus tendon assessment (hold at 120* then slowly drop
looking for fluidity) Empty Can test supraspinatus integrity,
abduct arm to 90* then internally rotate arm as if emptying the can
then externally rotate arm against providers resistance Push-off
test subscapularis integrity, arm behind patients back and they
push off with the hand from the back Passive painful arc test
provider passively moves patients arm while stabilizing the
shoulder Sulcus sign pull patients arm downward while stabilizing
the shoulder, assessing for laxity of the joint (abnormal = >2cm
movement) Apprehension test
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Psych Exam A structured observation of patients current
appearance, attitude, behavior, mood and affect, speech, thought
process, thought content, perception, cognition, insight and
judgment. A comprehensive cross-sectional description of the
patient's mental state Unstructured observation and focused
questions about current symptoms Theoretical foundations: Empathic
descriptive phenomenology Empirical clinical observation. **most
important** Objective descriptions of a patient signs and symptoms,
and patient's subjective experience.
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Psych Exam Recording (receiving isnt necessarily in this order)
Appearance Attitude (patients approach to the interview) Behavior
(level of activity & arousal, body movements) Abnormal
movements: choreoathetoid (involuntary, rapid complex jerky
movements), anti-emetic can cause achethesia (intense restlessness)
Mood (a person's predominant internal feeling state at any one
time) Described using the patient's own words, Euthymic, Dysphoric,
Euphoric, Angry, Anxious or Apathetic. Alexithymic - unable to
describe their subjective mood state. Anhedonic - An individual who
is unable to experience any pleasure
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Psych Exam Recording Affect (the external and dynamic
manifestations of a person's internal emotional state) the apparent
emotion conveyed by the person's nonverbal behavior Intensity,
range, reactivity and mobility. Appropriate or inappropriate
Congruent or incongruent with their thought content Constricted or
labile. Speech (Production of speech rather than the content of
speech) Thought Process Quantity, tempo and logical coherence
Cannot be directly observed but can only be described by the
patient, or inferred from a patient's speech.
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Psych Exam Recording Thought Content Delusion - a false,
unshakeable idea or belief out of keeping with the patient's
educational, cultural and social background and held with
extraordinary conviction and subjective certainty [ + mood
congruent vs incongruent] Preoccupations - thoughts which are not
fixed, false or intrusive, but have an undue prominence in the
person's mind suicide, homicidal thoughts, suspicious or fearful
beliefs Overvalued ideas hypochondriasis, dysmorphophobia, anorexia
nervosa Obsessions - Undesired, unpleasant, intrusive thought that
cannot be suppressed through volition Phobias - dread of an object
or situation that does not in reality pose any threat, and the
patient is aware that the fear is irrational.
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Psych Exam Recording Perceptions (any sensory experience)
Hallucination - a sensory perception in the absence of any external
stimulus, and is experienced as external Can occur in any of the
five senses, although auditory and visual hallucinations are
encountered more frequently than tactile (touch), olfactory (smell)
or gustatory (taste)
hallucinationsauditoryvisualtactileolfactorygustatory Illusion is
defined as a false sensory perception in the presence of an
external stimulus, and may be recognized. Cognition Patient's level
of alertness, orientation, attention, memory, visuospatial
functioning, language functions and executive functions. The
minimental state examination (MMSE) or Folstein test is a brief
30-point questionnaire test that is used to screen for cognitive
impairment.
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Psych Exam Recording Insight Recognition that one has an
illness Compliance with treatment The ability to re-label unusual
mental events (such as delusions and hallucinations) as
pathological. Insight is on a continuum Capacity to consent to
treatment Judgement Capacity to make sound, reasoned and
responsible decisions. How the patient has responded or would
respond to real-life challenges and contingencies. Executive system
capacity in terms of impulsiveness, Social cognition,
self-awareness and planning ability. Impaired judgment is not
specific to any diagnosis Has implications for the person's safety
or the safety of others