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Bloom PA I NYCC

NYCC Patient Assessment I fall 2010 Dr. Bloom first exam

QuestionAnswer
___________is 99% of an accurate diagnosis History
an accurate diagnosis is essential for an appropriate treatment. an accurate diagnosis is essential for an appropriate treatment.
Patient's _______ is found in the history treatment
Identifying Data • Name • Age • Gender • Body type/habitus (ecto-, meso-, endomorph) • Occupation • Other (marital status, etc…)
Source of the history • Patient consultation • Medical records • Family member or friend
Reliability • Results from FROMAJE or MSE…or mini MSE which is what we mostly do“Patient oriented x3” •Person (name), Place, Time
“Patient oriented x3”
Identifying Data
Source of the history • Patient consultation • Medical records • Family member or friend
Reliability • Results from FROMAJE or MSE…or mini MSE which is what we mostly do
Patient oriented x3
Chief Complaint • Note in patient’s own words in “quotation marks” • CONSIDER ALL DIFFERENTIALS !!!!!!!!!!!! • Visceral, Musculoskeletal, Systemic
Present Illness (OPQRST) Onst, Palliative/Provocative, Quality, Radiation, Site, Temporal, Work/social/home, Goals of patient for recovery
Past History • General state of health perceived by the patient • Childhood illness • Adult illnesses • Psychiatric history • Accidents, injuries, surgeries • Other hospitalizations
Current Health Status • Allergies • Immunizations • Screening tests • Environmental exposures • Use of safety measures (seat belts, etc.)
Exercise and Leisurely Activities • Sleep patterns • Diet • Current medications (OTC and Rx) • Tobacco • Alcohol consumption • Substance abuse
Family history should include Spouse! Parents, siblings, children. Grandparents for maternal and paternal.
Family history should include the age, health status and cause of ______ for each noted death
Family history inquiry should specifically ask about what conditions? Diabetes, heart disease, hypertension, stroke, renal disease, arthritic conditons, cancer, mental illness
Psychosocial history home situation and significant others, daily life, important experiences, personal/religious/spiritual beliefs relevant to illness or injury, General outlook
Review of Systems General (weight change, fever, fatigue), Skin, Head, Eyes, Ears, Nose and sinuses, Mouth and throat
Exercise and Leisurely Activities • Sleep patterns • Diet • Current medications (OTC and Rx) • Tobacco • Alcohol consumption • Substance abuse
Family history should include Spouse! Parents, siblings, children. Grandparents for maternal and paternal.
Family history should include the age, health status and cause of ______ for each noted death
Family history inquiry should specifically ask about what conditions? Diabetes, heart disease, hypertension, stroke, renal disease, arthritic conditons, cancer, mental illness
Psychosocial history home situation and significant others, daily life, important experiences, personal/religious/spiritual beliefs relevant to illness or injury, General outlook
Review of Systems General (weight change, fever, fatigue), Skin, Head, Eyes, Ears, Nose and sinuses, Mouth and throat
Review of Systems Mouth & throat Neck Breasts (male & female) Respiratory Cardiac Gastrointestinal urinary Genitoreproductive
Review of Systems Peripheral vascular Musculoskeletal Neurologic Hematologic Endocrine Psychiatric
Ways the patient's mental status affects intake: Peripheral vascular Musculoskeletal Neurologic Hematologic Endocrine Psychiatric
F-R-O-M-A-J-E Test – provides a numerical representation of a patient’s mental status Function -Reasoning -Orientation Memory- Arithmetic- Judgment Emotion
F-R-O-M-A-J-E test Function Reasoning Orientation Memory Arithmetic Judgment Emotion
Scoring on FROMJAE test (Function, Reasoning, Orientation, Memory, Arithmetic, Judgment, Emotion) 1 = Normal 2 = Some difficulty 3 = Significant difficulty 7–8 = Pt does NOT display significant abnormal behavior 9-10 = Mild dementia 11-12 = Moderate dementia, depression or altered mental status 13 or more = Severely altered mental status
Other mental health states which may affect patient's ability to report: Eating disorders OCD (Obsessive Compulsive Disorder) Bipolar disorder Primary Depression Phobias…
Some causes of altered mental states: Pain, fatigue, depression, bipolar, hyperadrenalism, thyroid disease, chronic disease, stress, OTC rx/interx, Rx meds/interx, dementias, alterered serum glucose, nutritional def., cortical destruction, Mitral valve prolapse
symptom of hyperthyroidsim in geriatric patient dementia
absence of anything assoc. w heart or chest but could be symptom of anxiety attacks - may be treated by MD's with valium but is actually mitral valve prolapse
greatest factors affecting correct diagnosis and positive outcomes: (2) patient's history and mental status
what must you use when taking a chief complaint? blue or black ink, baby
Components of CNS for evaluation: cerebellum, VBAI, Dorsal Columns, Pyramidal system (corticospinal and corticobulbar), Extrapyramidal system (basal ganglia)
pyramidal systems corticospinal, corticobulbar for face
corticospinal and corticobulbar are pyramidal systems
extrapyramidal system basal ganglia
the basal ganlia is extra (outside of) pyramidal system because not in corticospinal or corticobulbar. Test tone across elbow for cog wheel and lead pipe rigidity basal gang.
the cerebellum has a ____________ organization somatotopic (layered)
Dogs Eat Good Food From outside cerebellum to vermis: Dentate, Eboliform, Globose, Fastigial
Dentate, Eboliform, Globose, & Fastigial nuclei are arranged somatotopically in the cerbellum from outside to inside/vermis (Dogs Eat Good Food)
nucleus that deals with antigravity muscle groups and other synergies involved with standing and walking. fastigial
Nucleus for most peripheral structures Dogs/DENTATE
Nucleus for middle extremity Eat/EBOLIFORM
Nucleus for proximal extremtiy Good/GLOBOSE
Nucleus for midline structures Food/FASTIGIAL for reflexive spinal control muscles so won't hold adjustment. Flocculus and Vermis and Vestibulocochlear n.
3 major arteries of cerebellum Posterior inferior cerebellar artery (PICA), Anterior inferior cerebellar artery (AICA), Superior cerebellar artery (SCA)
PICA, AICA, and SCA are all part of the vertebral artery system (they are all branches)
Posterior Circulation is COBS: Cerebellum, Occipital lobe, Brainstem, Spinal cord
what are the components of the Posterior circulation? COBS: Cerebellum Occipital Brainstem Spinal cord
Positive findings in cerebellar exam may suggest arterial compromise!
arterial compromise may be suggested by positive findings during a cerebellar exam
If it isn't COBS, it's the ___________________artery which causes spastic paralysis Internal carotid
Why would the anterior circulation/Internal carotid artery cause spastic paralysis? because the motor nerves live in the anterior lobe
cerebellum has _______ memory, also called engrams, of how you like to and learned to do things. MOTOR
The cerebellum is a checkpoint for the _______ lobe in _________ movement. frontal, planning
The cerebellum controls ______-motor movement of all __________ muscles. fine-motor, skeletal
the cerebellum, as it controls fine-motor movement of all skeletal muscles, controls the balance between _______ & _________ muscles. agonist & antagonist
The cerebellum has reflexive control of ____ movement. eye (nystagmus test)
The cerebellum has reflexive control of ________ spinal muscles. intrinsic/INTERSEGMENTAL
What controls intrinsic spinal muscles? cerebellum (ataxia, cerebellum rights you when walking)
Controls reflexive eye movements? cerebellum
Has fine-motor control of all skeletal muscle? cerebellum
Is the check point for frontal lobe in planning movement? cerebellum
Has all the MOTOR memory (engrams)? cerebellum
resting tremors go with basal ganglia
intention tremors go with cerebellum
Cerebellar reflexive control of the intrinsic spine muscles means control of the ____________ Motion of the spine Intersegmental
Anterior spinal artery feeds the anterior 2/3 of spinal cord, which includes the lateral funiculus - which thus includes the lateral corticospinal tract. This ischemia causes ___________paralysis spastic
The cerebellum is Ipsilateral, Specific, _______. Time
Ipsilateral, Specific, Time Cerebellum
Engram, Intrinsic, Ipsilateral Cerebellum
Symptoms of the cerebellum will present ________ to lesion ipsilateral
Symptoms of the cerebellum will be ipsilateral and be specific to the _________ area affected. somatotopic
Early symptoms of the cerebellar lesion may take _____, and create soft neurological findings. time
History questions reflect the function/dysfunction of the _________ involved tissues
Dizziness can be a problem with cerebellum or dorsal columns. What is the difference in findings? positive for dorsal columns is eyes shut
positive dizzy for dorsal columns is a test with the ______ shut. eyes
cerebellar possible dysfunction presentations dizzy, loss of balance, tremors when moving, slurred speech, knocking things over when reaching for them, shaking eyes
Cerebellar testing is performed with the patient _________ if possible! standing!!!!!
stand up! cerebellar test
why should patient be standing during cerebellar test (3)? The anterior lobe controls torso in relation to extremities, the posterior lobe is in control of head relative to torso, sitting allows the anterior lobe to work less so standing forces both lobes to fire!
Fire at will! Why should a cerebellar test patient stand if possible? Anterior lobe controls torso in relation to extremities, while posterior lobe controls head in relation to torso. Standing makes both lobes fire, whereas sitting would let ANTERIOR lobe off the hook.
name the 5 locations for ascultation: supraclavicular, anterior SCM, posterior SCM (at occiput), temporal = all with bell. Then orbital with diaphragm if patient not wearing contacts.
why do we ascultate the 5 locations? for bruits
Why take bilateral blood pressure? Intermediolateral cell column: cerebellum sides each control parasympathetic nuclei activity in the brainstem. If L cerebellum raises parasymp on L, the L sympathetic activity is lowered at the Intermediolateral cell columns (sympathetic origin).
how does the cerebellum control the sympathetic activity at the IML? via the parasympathetic nuclei of the brainstem - remember there are 2 cerebelli (R/L)
What is first thing when taking bp Palpatory method for systolic
the mmHg reading when you hear the first pulse sound systolic pressure
mmHg reading when the pulse sound is no longer audible diastolic
Why should you continue to listen and allow the cuff to fully deflate after the diastolic has been determined? ascultory gap
normal blood pressure high? normal blood pressure low? prehypertensive? 120/80 normal, 90/60 normal low, 126/85 prehypertensive
why take bilateral blood pressure? because it not only assesses bp but also the cerebellum b/c cerebelli fire up parasymps in brain stem and put brakes on INL sympathetics (pregangs to sympathetic efferents).
all stuff innervated by the same nerve root can react to each other, i.e., visceral problem has common innervation to muscle so that muscle responds Hylton's Law
If NSAID does not work, then it's a vascular problem. (this is why they don't work for migraines)
Cerebellar is ______-side presentation!!!!!!!!!!!!! same
when taking blood pressure, stand to the patient's _______. Place steth around your neck. right
Why should you do neurological tests in your office? because findings are likely to present in a chiro office so look for subtle (mild +) findings.
A + finding will steadily get worse
People with early onset pathology will compensate beautifully so we want the test to be as __________ as possible, for instance, requiring the patient to stand so the anterior lobe is not resting. provocative
All cerebellar tests are done standing except seated marching test
difference between intention and resting tremor origin intention is cerebellar
describe decreased muscle tone for cerebellum Hypotonia, Rag doll posture, ataxic gait, pendular deep tendon reflexes (count the beats and compare right to left)
How to test ataxia? Rhomberg's position, Tandem gait (heel to toe), Babinski Weil (walk forward, walk backward)
What is Rhomberg's position? Stand still, feet together so narrow base, arms out, eyes OPEN for cerebellar. Fall out= hard +, waver = soft +, small waver = soft + for CEREBELLAR lesion
What is tandem gait? Patient walks heel to toe for 10 steps. Can't balance, then soft or hard + for CEREBELLAR lesion
What is Babinski Weil?
iatrogenic secondary condition caused by a drug
Why perform the nystagmus test for cerebellum? What the hell do the eyes have to do with the cerebellum? Cerebello-vestibulo Ocular Reflex! Cerebellum goes down spine or up decussate, CN VIII (vestibular nuclei), CN VI nucleus, CN II nucelus, split to both eyes Lateral Rectus and Medial Rectus.
History of dizziness and slurred speech Test cerebellar vermis for reflexive effect on eye movement. NYSTAGMUS lateral gaze 10 sec. Positive finding is nystagmus or difficulty doing the movement on one side or other.
inability to perform rapidly alternating movements dysdiadochokinesia
With dysdiadochokinesia, you must always test both sides and both upper and lower limbs. Test the integrity of the sys by increasing the duration of the test to at least 10 sec. or more.
Which fingers should the patient use for finger to nose test for dysmetria? 4th or 5th
Who is associated with the Rebound Phenomenon test? Holmes and Thomas
Holmes and Thomas were rebound lovers Holmes and Thomas are assoc. with rebound test for cerebellar lesion. Rebound test is from Romberg's position. Push arms down with some force.
what should happen during the rebound test is patient is normal? arms should return to normal position
diseases of the cerebellum include: vascular infarct (VBAI), tumors, cerebellar atrophy, HIV, MS, alcoholism, Chiari malformation, Lyme disease
Nausea, Vertigo, Vomiting, Gait abnormalities, Sensor/Motor changes, Loss of consciousness, Blurred/double vision, Tinnitus, Speech difficulties all things that say... do not adjust!!!!
Cervical joint and vestibular dysfunction, suboccipital muscle spasm, primary cerebellar lesion, or any lesion along the cerebellovestibulo-ocular pathway (nystagmus) syndromes with similar presentations to VBAI
reason you should get informed consent from a patient: No screen for arterial dissection odds post adjustment (no material risk, although small, but should inform patient of everything appropriate to their treatment)
4 risk factors for general stroke personal history, age, family history, medications
Most common symptoms of vertebral artery dissection? neck pain or stiffness and headache
The headache associated with VBA dissection is the worst headache of the patient's life
Is cervical stiffness assoc. with trauma? no
Stroke symptoms may take up to _______ to present following a dissection 2 weeks (no cervical adjustments!)
Since we all know there is no one test to determine VBA compromise potential, what should you do? increasing number of items on list of risk factors will help you
loss of cortical inhibition causing ESCAPE of motor neuron activity UMNL (upper motor neuron lesion)
motor is in the _______ lobe so the artery is the anterior, anterior cerebral artery and middle cerebral artery
anterior cerebral artery stroke will show spasticity of lower extremity due to blood occlusion of posterior parietal/motor
middle cerebral artery stroke will show upper extremity spasticity due to arterial flow stopped to post central gyrus/motor
What does the UMN system include? Corticospinal/pyramidal tract and Corticobulbar tract (face)
another term for corticospinal tract pyramidal (run in the 'pyramids' of anterior spinal column)
characteristics of UMN lesions Spastic paresis (increased muscle tone), hyperreflexia, pathological reflexes, NO CHANGE IN SENSATION
why is hyperreflexia characteristic of upper motor neuron lesion? UMN's are loss of cortical inhibition causing escape of motor neuron activity. In other words, overkill because no brakes.
why is spastic paresis indicative of UMN lesion? UMN's are loss of cortical inhibition, causing escape of motor neuron activity. In other words, overkill with no brakes on the motion.
Why would pathologic reflexes indicate UMN lesion? Because UMN lesions mean cortical loss of motor control, an escape of control, so reflex will be overkill or none at all
which disease has both UMN and LMN lesions ALS (proteins accum. in anterior lobe and descend to ventral horn cells, hence both)
Hyper and hyporeflexia may be normal but ________ is not. clonus
What controls the myelinated areas outside of the cortex? thalamus
what controls the thalamus? basal ganglia
If basal gang sends info to thalamus and thalamus doesn't control (stop or start) motion, what is affected? Corticospinal tract (pyramids), hence motor, hence resting tremor or getting stuck mid-stride (no stop, no start)
The corticospinal/pyramdial has fibers branching off, forming the corticobulbar tract, which is, therefore, controlled by basal gang to thalamus, and has motor nuclei going to brainstem
Hyperreflexia is okay but with ______ = UMNL clonus
atrophy LMN
areflexia LMN
flaccid LMN
weakness LMN (and UMN)
fasiculations! LMN
Pressure on the _________ of the cord may cause hyperreflexia or other UMNL signs in the lower extremity anterior
Pathological reflexes only happen when there is an _____ lesion (ie, Babinski's upgoing toe sign) Upper motor
No _______ loss in either UMN or LMN because it's MOTOR!!!!! sensory - there is no sensory in motor
spondylosis lipping or spurring
why would longterm biomechanical stress cause pressure on the ventral corticospinal tracts? ossification of sharpey's fibers leads to spondylosis to pushing in canal to anterior spinal so ventral corticospinal
why doesn't a disc "slip"? because Sharpey's fibers attach to them
The spinal cord is laminated so all outer tracts belong to the _______ extremity lower
where are the lower extremity tracts found in the spinal cord? to the outside.
Spinal cord compression is usually visible in flexion
Pressure on the _________ of the cord may cause hyperreflexia or other UMNL signs in the lower extremity anterior
Pathological reflexes only happen when there is an _____ lesion (ie, Babinski's upgoing toe sign) Upper motor
No _______ loss in either UMN or LMN because it's MOTOR!!!!! sensory - there is no sensory in motor
spondylosis lipping or spurring
why would longterm biomechanical stress cause pressure on the ventral corticospinal tracts? ossification of sharpey's fibers leads to spondylosis to pushing in canal to anterior spinal so ventral corticospinal
why doesn't a disc "slip"? because Sharpey's fibers attach to them
The spinal cord is laminated so all outer tracts belong to the _______ extremity lower
where are the lower extremity tracts found in the spinal cord? to the outside.
Spinal cord compression is usually visible in flexion
Flexion of the head will compress the anterior/ventral corticospinal tracts
Percentage of crossed vs uncrossed in ventral corticospinal tracts 20% uncrossed, 80% crossed
Hyperreflexia to ventral corticospinal tract only presents in cervical flexion
Causes of UMN lesions cerebrovascular accident (CVA), Intramedullary SOL interrupting tract fibers, Extramedullary SOL (disc!) compressing brain or spinal cord
UMN questions sudden headache? chronic and slow headache? any headache made worse by coughing or sneezing? fainting? head or spine trauma? confusion? vomiting? change in sensation or movement to face? unusual tightness in muscles?
Why would coughing or sneezing exacerbate an UMN lesion? thecal sac because intracranial/vascular lesion made worse by sneezing (CSF or air space affected)
are intermedullary tumors worsened by coughing or sneezing? no
what kind of paresis with UMN? spastic! (no motor control)
Muscular hyper-tonia: how to perform check for clonus for UMN lesion? briskly extend wrist and briskly bring ankle into dorsiflexion. + finding is CLONUS
Deep tendon reflexes findings: hyperreflexia +3, hyperreflexia with transient clonus +4, hyperreflexia with sustained clonus +5
Deep tendon reflex tests for UMN lesions biciptial tendon, patellar tendon, Achilles tendon, triceps tendon
What is the most reliable kind of test for UMN lesion? Pathological reflex testing
Pathological reflexes are present in the ____________ corticospinal tract between cortex and medulla contralateral
pathological reflexes are present in the ipsilateral corticospinal tract from medulla downward
How are pathological reflexes for UMN lesions recorded in findings? Present or absent or Pathological
"absent" pathological reflex testing for UMNL means no response
"present in pathological reflex testing for UMNL means normal response
"pathological" in pathological reflex testing for UMNL means pathological response, like Upgoing toe sign for Babinski's
3 responses for the very reliable pathological reflex testing for UMNL absent, present (normal), pathological (ie, upgoing toe sign)
responses for clonus testing of UMN lesion clonus
responses for DTR testing for UMN lesion hyperreflexia +3, hyperreflexia with transient clonus +4, hyperreflexia with sustained clonus +5
Hypertonia test for UMN lesion for clasp knife spasticity? Tone across the elbow
Tone across the elbow for UMN Lesion specifically will render a + finding of clasp-knife spasticity
What is the plantar test for lower extremity and what does it look for? the pathological reflex test of briskly stroking from lateral heel to great toe. + finding would be UTS (up going toe sign)
Gordon's lower extremity Grab the gam (squeeze the calf)! UTS is + finding for UMNL
Chaddock's lower extremity write your name in the sand. Draw a "C" around lateral malleolus. UTS is + finding for UMNL
Oppenheim's lower extremity Oop! Whacked my shin! Drag knuckles on lateral side of tibial crest, knee to foot. Pathological + finding is UTS for UMNL
Schaefer's lower extremity Briskly squeeze the Achilles handle. UTS is + finding for UMNL
Rossolimo's lower extremity is the only pathological sign for UMNL that doesn't exhibit upgoing toe. 3-4 quick taps on distal end of 3rd metatarsal (ball of 3rd toes) is +finding if FLEXION OF THE TOES
which lower extremity test for pathological reflex (UMNL) is different and why? Rossolimo's lower extremity is only one that is not UTS but if + finding, there is FLEXION OF THE TOES
Gordon's upper extremity Grab the gin! Press pisiform of patient, if extension, then + finding for UMN lesion
Chaddock's upper extremity Grab the haddock! Press wrist with both thumbs; if extension of fingers, then + finding for uMNL
Rossolimo's upper extremity bang the hammer against the middle finger; if extends fingers, + finding for UMNL
Tromner's upper extremity hold/support and briskly strike ends of 3,4th digits. If fingers curl in, then pathological reflex sign for uMN lesion
Hoffman's upper extremity OK! Hoffman's is OK! Support at hypothenar eminence and briskly strike middle finger. IF index and thumb make OK sign, then + finding for UMNL
snout for face (corticobulbar tract) tap on one side of the nostril, then the other. If patient looks like Elvis, then +finding for UMNL
glabellar for face (corticobulbar tract) tap 3rd eye - if hurts (wincing and closing of eyes) then + finding for uMNL
absent superficial reflexes can suggest ACUTE upper motor neuron lesion - generally returns when CNS shock resolves. Mediated at cord.
superficial reflexes can be 2 kinds of deficits: sensory (receptor) deficit and motor (effector) deficit: lower motor neuron lesion
superficial deficit at the motor effector is a Lower motor neuron lesion
a superficial deficit of sensory is not a upper or lower motor neuron lesion because there is no sensory in motor tract
superficial reflex for CN V Trigeminal(sensory)to face and CN VII Facial (motor) to face Superficial corneal reflex - wash hands, strand out cotton, have patient look up and away, touch cornea where iris meets with cotton, PRESENT: bilateral blink, ABSENT: unilateral blink or no response
Corneal reflex test is for superficial reflex test of Trigeminal V sensory and Facial VII motor so bilateral blink present is normal. Absent is unilateral or no blink after cotton touches cornea. Indicates lesion to V, VII (CNS) but UMNL in acute stage
Superficial reflex for CN IX Glossopharyngeal (sensory) and CN X (motor) Gag reflex: stimulates Glossopharyngeal and Vagus. Touch lateral wall of patients palatoglossal fold on both sides. PRESENT: bilateral raise of soft palate ABSENT: cannot raise one side Indicates lesion to IX, X (CNS)but UMNL in acute
Superficial reflex test for T7-10 and T10-12 Abdominal Reflex: Have patient lie down, knees slightly bent to enhance reflex. Brisk draw with object towards umbilicus in 4 directions. PRESENT: umbilicus points towards stimulus. ABSENT: no abdominal reflex. Indicates CNS lesion but UMNL if acute.
Superficial reflex for UMNL using Babinski's plantar reflex Plantar reflex: stroke lateral side patient foot through ball of great toe. PRESENT: normal flex/withdraw, ABSENT: no response, PATHOLOGICAL: UTS indicates UMNL
the superficial reflex responses are CNS but can be _______ in acute stage, with the latter restored as time passes. Upper motor neuron lesion
In any superficial reflex (corneal for V sensory & VII motor, gag for IX sensory & X motor, abdominal for T7-10 above & T10-12 below, and plantar reflex/Babinski, the most significant findings are ______________ ASYMMETRICAL.
Superficial reflex for Glossopharyngeal IX & Vagus X: Gag reflex- must be performed bilaterally for sensory arc (IX). Must observe soft palate rise bilaterally for motor arc (X). PRESENT: bilateral raising of the soft palate ABSENT: unilateral or bilateral failure of palate to rise indicates UMNL acute
3 superficial reflexes you won't, God bless you, be testing in your practice. Cremasteric/Geigel, Anal, Gluteal
What makes up the dorsal columns? Gracile fasiculus and Cuneate fasciulus, with nucleus gracilis and cuneate nucleus at the tops. For VDPP (vibration, discrimination, proprioreception-upper only, pressure)
Name 3 conditions that affect the dorsal columns M.S., B12 deficiency, B1 deficiency
MS + dorsal columns Hx of intermittent numbness, weakness, visual disturbance, L'Hermitte's sign
sometimes called the Barber Chair phenomenon, is an electrical sensation that runs down the back and into the limbs from involvement of the posterior columns, and is produced by bending the neck forward or backward. L'Hermitte's sign of MS damage to dorsal columns
Brain malformation that consists of a downward displacement of the cerebellar tonsils through the foramen magnum (the opening at the base of the skull), sometimes causing hydrocephalus as a result of obstruction of cerebrospinal fluid (CSF) outflow. Arnold Chiari malformation
When would L'Hermitte's sign, intermittent weakness, numbness and visual disturbance be tested? Dorsal columns. Suspect MS (or any # of things on Wikipedia pg for this symptom)
Weak, NUMB, visual disturbance, L'Hermitte's sign MS - test dorsal columns for VDPP
ASA use, elderly, poor diet, chronic gastric condition with systemic/bilateral presentation B12 deficiency - dorsal columns for VDPP
ASA use, gastric upset B12 deficiency - dorsal column test
B1 deficiency requires a ________________ test dorsal columns
ETOH (drinking), "BURNING ON SOLES OF FEET" B1 deficiency - check dorsal columns. History of patient is best indicator.
B1 burning my feet, B12 making me sick to my stomach, MS making me numb - what test am I gonna do? dorsal columns
History of anemia, ASA use, poor diet and chronic gastric B12 deficiency - anemia! test dorsal columns
besides MS, B12 and B1 (burning), what else can affect the dorsal columns? Extramedullary lesion, HIV/syphilis, Lyme disease
Dorsal column questions Do you have any BALANCE problems and do you bump into things at night (ie, IN THE DARK)?
What is difference between balance problem of dorsal column and one of cerebellum? Dorsal column is EYES SHUT because worse without light
Dorsal column balance problems are evened out when patient can see or there is sufficient light
All dorsal column tests (VDPP) are performed with the patient's eyes _________, SHUT!!! eyes wide shut, dammit
ASA use associated with B12 deficiency that warrants dorsal column testing... what's ASA? acetylsalicyic acid. It's aspirin, you pretentious boob. Aspirin.
What are the 4 types of tests for dorsal column (MS for numbness, B12 for ASA and gastric, B1 for burning, HIV, Lymes, extramedullary lesion): Pallesthesia (vibration), Proprioreception (kinesthesia), Deep pressure, Multimodal like stereognosis and graphesthesia
All dorsal column testing is performed with patient's eyes ______!!!! closed!
Describe dorsal column test for vibration/pallesthesia CLOSES EYES!!!! patient lying down, arms up, naked feet. Apply 128 tuning fork to longest finger, then longest toe, both sides. Ask them to tell you what they feel (vibration) then when it stops. +finding: inability to detect vibration indicates DC lesion
If +finding for apallesthesia/inability to detect vibration, what would be order of testing on lower extremity? If didn't feel on longest toe tip, then lateral malleolus, tibial tuberosity, ASIS, etc.)
If patient has +finding of apallesthesia/inability to detect vibration on upper extremity, what is order of the rest of the test? If cannot feel on tip of middle finger, then pisiform, radial styloid, olecranon, clavicle)
Who cares if the patient can't feel the 128 tuning fork vibrating on their middle finger or toe; if they didn't ______________, then you didn't test the dorsal columns! shut their eyes
shut their eyes for dorsal column testing (pallesthesia, proprioception, pressure, multimodal)
What is the dorsal column test for proprioception? shut their eyes the RHOMBERG'S TEST. Hold position for @ least 10 sec. MILD+ finding: swaying. STRONG+ finding: complete loss of balance Indicates Dorsal Column lesion
Even if you touch their fingers with the 128 tuning fork or they fall on their butts during Rhomberg's for proprioreception, if they didn't __________, then you didn't test squat. shut their eyes! dorsal column test is shut their eyes.
Dorsal column test for proprioreception besides Rhomberg's test. Positional change in digits: lie down, eyes shut, hands up, feet naked. Doc moves digit slightly towards head or foot. Patient must distinguish. +finding is can't tell which way is up;-) indicates Dorsal column lesion
Describe dorsal column test for deep pressure Abaides- tell me which is less pressure/abates! Patient SHUTS EYES, lying down. Doc asks patient to tell which squeeze is greater, 1st or 2nd. Achilles and Biernacke's (ulnar). +finding is they can't distinguish indicates Dorsal Column lesion
What is another test for deep pressure of the dorsal columns that we won't be doing (I won't be doing it for certain!)? Pitre's test of the testicles. Forget it.
What is the problem with the Abaide's and Biernacke's tests? Dorsal column tests for deep pressure (Abaides Achilles, Biernacke el'Bow) is all test pain which is carried in spinothalamic tract.
Even if you use the 128 tuning fork, flick their digits up or down, get'em to stand still for 10sec, squeeze their Abaides Achilles or press on their Biernacke el'Bows, if the don't ____________, you haven't tested squat. shut their eyes!!!! dorsal column is shut their eyes
If you test stereognosis in the upper extremity for a dorsal column lesion, what are you going to test in the lower extremity? graphesthesia/graphognosis (unless your patient has no arms and is used to holding objects with his feet, then use graphesthesia on the lower ex)
Test the dorsal columns for multimodal sensation that can only be tested via the upper extremity: stereognosis on upper extremity: patient lying down, eyes shut. Place object in hand and ask them to id it. If can only describe, then parietal lobe problem. +finding is cannot name. Indicates dorsal column lesion. Can also perform graphesthesia test.
Dorsal column test for multimodal sense that can be tested on both upper and lower extremity? Graphesthesia: patient lies down, eyes shut. Socks off. Draw simple # or letter on palm, then sole of foot, both sides. Ask them to id. +finding is cannot id. Indicates dorsal column lesion. Make sure you draw the #/letter upright to patient!
You can vibrate their toes, flick their fingers, make'em stand with their arms out, squeeze their ankle and press on their elbows, draw on their feet and put a paperclip in their hands, but if they don't have ___________, you didn't test squat for D.col. eyes shut!!!!
Involvement of the basal ganglia means _____________ evaluation is necessary. extrapyramidal
symptoms of extrapyramidal/basal ganglia involvement thalamic escape (motor fires simultaneously), hard to initiate or stop movement, involuntary movements, increased movements, decreased movements, altered muscle tone and posture
dyskinesia Dyskinesia is a movement disorder which consists of effects including diminished voluntary movements[1] and the presence of involuntary movements, similar to tics or chorea. (wiki)
involuntary, repetitive body movements dyskinesia
history of Parkinson's, resting tremor (pill-rolling), chorea, can't move... test basal ganglia! with tone across the elbow for cog-wheel rigidity and lead pipe rigidity
a neural network located in the brain that is part of the motor system involved in the coordination of movement.
Dyskinesias associated with Basal ganglia dysfunction Athetoid movements (flowing), Choreas (tics), Hemiballism (ballistic), Dystonia
Causes of extrapyramdial involvement of the Basal Ganglia: long term psychotropic drugs (ending in "-ine"), Head trauma, Congenital, Unknown
Questions for extrapyramidal/basal ganglia involvement: Any tremors when not moving? Handwriting changes? Difficult making yourself move (dyskinesia of Parkinson's), Unusual motions? Medications for psychological conditions (antipsychotics cause dyskinesia), Any family history of Parkinson's, Wilson's?
What's the number one sign of basal ganglia dysfunction/ increased or rigid muscle tone
Increased or rigid muscle tone, difficulty initiating and/or ceasing movement, the absence of muscular atrophy all in the presence of normal voluntary muscle strength and stretch reflexes indicates: basal ganglia
Assessing movement via the _____________ system partially bypasses the basal ganglia. limbic system
Soque's test seated patient is askied to lean back while doc supports their full weight. Doc removes support briefly and suddenly. Patient should have reflexive extension of limbs to counterbalance falling. POSITIVE SOQUE's is failure to extend extremities
Dizziness can be either cerebellum or dorsal columns
CN I Olfactory questions Any head or neck trauma/ Has food lost its taste/ Do things smell funny or bad/ Have you noticed a loss in your sense of smell?
Why would things smell funny or bad to a person with an Olfactory nerve lesion? firing of uncinate gyrus ruins perception (food smells like petrol, etc.)
Damage to what bone causes Olfactory nerve damage? Terminal end bone
CN I Olfactory is considered special sensory, exits through skull and is tested with non-noxious, common substances.
What is the main thing to note when testing both CN I Olfactory nerves? Symmetry!
A deviated septum can cause extreme fatigue, require surgery, require a sleep study and the packing they use these days can stay and dissolve.
CN I requires testing for nasal patency _________ bilaterally
Describe CN I test Explain procedure to patient, Have them close eyes and cover one nostril, Ask patient to note WHEN they detect odor and IDENTIFY the odor. Variation in +finding: ANOSMIA complete loss due to terminal end bones,not brain, PAROSMIA distorted smell, brain
what is a subcategory of Parosmia (CN I test)? Cachosmia: (central)where everything smells like shit
anosmia is ________ problem, while Parosmia is a _______ problem as is cachosmia. peripheral, central
CN II Optic questions Hve you noticed any change in the CLARITY of your vision/ Any LOSS of vision/ Any BLIND spots?
Visual CLARITY for CN II testing is due to the ANS workings of the _________________ nucleus. Edinger-Westphal nucleus
Created by: hecutler