Patient Assessment- Lungs, Neuro
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| Dyspnea | difficult/labored breathing
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| Tachypnea | increased RR…persistently about 25 respiration/min---can be from pain, fluid in abdominal cavity, enlarged liver
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| Bradypnea | slow rate….12/rr/min---can be electrolyte imbalance, infection
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| Hyperpnea | breathing forcefully and deeply as in hyperventilation
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| Hypopnea | abnormally shallow respirations
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| Kussmal breathing | rapid, deep, labored
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| Cheyne-stokes | regular breathing, followed by apnea and then varying depths of respiration. This type of breathing is observed in children during sleep and older adults. Otherwise is seen in serious illness where there is increased ICP, renal failure, HF.
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| Sighing | not significant unless in excess
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| Air trapping | inspiration is normal, but unable to get the air out…in COPD patients. Air cannot be expelled, lungs inflate, can lead to respiratory distress
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| Apnea | spontaneous respiration stops. Can be due to abnormalities in respiratory system as well as cardiac and CNS. Apnea of premature infants; sleep apnea
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| Pectus excavatum | funnel chest, concavity in chest; Marfans
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| Barrel chest | more rounded; Increased AP diameter
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| Pectus carinatum | Pigeon chest, protrusion of chest
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| Kyphosis | Prominent back hump, Dowager's hump. More prone to resp. infx.
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| Costocondritus | inflammation in the intercostal margins
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| Crackles | Abnormalities of lungs or airways. most often heard during inspiration. Are discontinuous sounds through small airways in the respiratory tree. Can be fine, medium or coarse. Pneumonia, fibrosis, congestive heart failure, bronchitis
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| Rhonchi | deeper than crackles, most often heard in expiration. Often difficult to determine if crackles or rhonchi but rhonchi tend to disappear after coughing and crackles do not (caused by passage of air through thick secretions of spasms of muscle)
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| Wheeze | more high pitched, considered musical. Can be heard during inspiration or expiration. High velocity air flow through narrowed airway. Can be heard in asthma, COPD, bronchitis
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| Friction rub | occurs outside the respiratory tree; dry, crackly sound (over the pericardium can suggest pericarditis; over lungs suggest pleurisy
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| Whispered pectoriloquy | Ask patient to whisper “1,2,3”
Should be muffled in normal lung
Distinct sounds signify consolidation
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| Egophony | Ask patient to say ”eee”
If the “ee” changes to “ay” it signifies consolidation or compression (E to A changes)
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| Bronchophony | Ask patient to repeat “99”
Should be soft and muffled in normal lung
Words become distinct with increased lung density
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| Acute disorder of attention, memory, perception; treatable | Delirium
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| Causes of delirium | D rugs
E nvironment change (consider ears/eyes as well)
L ow O2 (MI,ARDS, PE, CHF, COPD)
I nfection
R etention (urine or stool), restraints
I ctal state
U nderhydration/undernutrition
M etabolism (DM, Post-operative, sodium abnormalities)
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| rare, degenerative brain disease causes progressive dementia. Related to changes in a protein called prion. Can be hereditary, acquired (by exposure to infected brain, nervous system tissue) Mad cow: spongeform encephalopathy | Creutzfeld-Jacob
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| Progressive decline in memory and at least 1 other cognitive area in an alert person (attention, orientation, judgment, abstract thinking) Rare under age 50 Results from brain damage | Dementia
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| genetic disorder causing degeneration of neurons in basal ganglia and cerebral cortex. Uncontrollable movements, changes in mood, memory loss. | Huntington's Disease
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| Odor identification; asnosmia | CN-I Olfactory
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| Visual acuity, visual fields, fundoscopy; blindness, hemianopsia, papilledema, optic atrophy | CN-II Optic
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| raise eyelids, EOM’s, pupil constriction; paralysis, tonic pupils, blindness | CN- III Oculomotor
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| downward and inward movement of eye; nystagmus, intra-nuclear opthalmoplegia | CN- IV Trochlear
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| lateral deviation of eye; observe lids for lag, PERRLA, nystagmus, convergence; nystagmus, intra-nuclear opthalmoplegia | CN- VI Abducens
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| Motor: muscles of mastication; Ophthalmic, maxillary, mandibular sensory; cornea with cotton wisp; motor/sensory loss | CN- V Trigeminal
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| Motor: facial movement; mediates taste sensation in anterior 2/3 of tongue (sweet/salt); 6 facial tests; weakness of PNS/CNS (Bell's Palsy, Stroke) | CN- VII Facial
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| Mediates hearing/vestibular function; Sensorineural loss causes lateralization to affected ear where AC>BC Conduction loss causes lateralization to affected ear where BC>AC | CN- VIII Acoustic
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| Taste is over posterior 1/3 of tongue; difficulty swallowing | CN- IX Glossoparyngeal
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| Taste: bitter/sour; posterior 1/3 of tongue Mediates sensory and motor functions of palate, pharynx and larynx; difficulty swallowing, hoarse voice/aphonia | CN- X Vagus
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| Innervates sternoclidomastoid muscle and upper trapezius; weakness trying to turn head, uses muscles | CN- XI Spinal accessory
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| Mediates motor function of tongue affecting articulation of words; "tongue feels thick or clumsy", slurring of speach, Protrusion will favor weak side (unaffected side will "overpower" weak side) | CN- XII Hypoglossal
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| Dysarthria | defective articulation
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| Diplopia | double vision
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| Ataxia | gait lacking coordination; reeling, unstable
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| Agnosia | inability to recognize common objects, sounds, persons in absence of perceptual disability
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| Atrophy | loss in muscle bulk; wasting
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| Fasiculation | involuntary muscle twitching
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| Flaccid | lacking muscle tone
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| Vertebra prominens | C7; highest point when neck if flexed forward
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| 3 Lobes, shorter due to liver | Right lung
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| 2 Lobes, narrower due to heart | Left lung
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| A&P changes of lungs in older adults | Barrel chest from loss of strength in thorax and loss of lung resiliency. Dorsal curve of thoracic spine. Alveoli less elastic. Decrease in vital capacity in residual volume. Mucous membranes drier. “stooped shouldered” with hunched back.
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| Decrease fremitus | occurs with emphysema, pleural effusion, pneumothorax…..obstructs transmission of the vibration (excess air in lungs)
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| Increased fremitus | occurs with compression or consolidation of lung issue as in pneumonia; small areas of pneumonia will not significantly affect fremitus (fluid or solid mass in lungs)
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| Thoracic and abdominal respiration | seen in healthy individuals
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| Abdominal breathing | contraction of diaphragm and use of abdominal muscles as well…seen in young infants
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| Paradoxic breathing | seen in severe COPD or other diseases that weaken the diaphragm.
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| Costocondritus | inflammation of intercostal margins
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| Percussion that predominates in healthy lung tissue in adults. Have to take into account the muscular chest wall of an athlete or in an obese person where subcutaneous fat produces scattered dullness | Resonance
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| Percussion sound that is found where too much air is present; pneumothorax or emphysema | Hyperresonance
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| Abnormal density in lungs; pneumonia, PE, tumor | Dullness
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| What do you always have patients do when auscultating their lungs? | Breath in and out through mouth
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| Vesicular breath sounds | over most of lung fields; Soft, low sound; inspiration longer than expiration
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| Bronchovesicular breath sounds | 1st, 2nd interspaces and over scapula; Medium sound; duration: inspiration = expiration
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| Bronchial breath sounds | over manubrium (front of neck); Loud/high; expiration longer than inspiration
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| Tracheal breath sounds | over trachea; Very loud/high; inspiration = expiration
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| Decreased/absent breath sounds | foreign body, mucous plug, secretions, emphysema (sounds far away), pneumothorax, PE, pleurisy
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| Increased breath sounds | Pneumonia (consolidation), fluid in intrapleural space
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| altered sensation | pins and needles, formication, burning
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| alteration in the sense of touch. Light touch may cause burning or irritating sense. | Dysesthesias
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| 6 Neuro changes in older adults | 1) Stumbling/increased falls 2) decreased agility, strength, interfering w/ADLs), 3) Hearing/vision loss, anosmia 4) development of tremor 5) Fecal/urinary incontinence 6) transient neuro deficits
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| Expressive aphasia | know what you want to say, but have trouble saying/writing what you mean
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| Receptive aphasia | Wernicke; hear voice or see print but can't make sense of words
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| Anomic aphasia | have trouble using correct word for objects, places, events (can't find the word)
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| Global aphasia | can't speak, understand speech, read or write
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| Cerebellum | receive both sensory & motor input; Coordinates movements & maintains upright position (ataxia)
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| Corticospinal (pyramidal) tract | Voluntary movements & integrates skilled or delicate movements
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| Basal ganglia | Includes motor pathways between cerebral cortex, basal ganglia, brainstem & spinal cord. Maintains muscle tone & controls body movements-especially gross movements.
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| Where are upper motor neurons and what happens when they are damaged? | Begin on cerebral cortex and project onto lower motor neurons; Damage produces weakness, hypertonia, hyperactive tendon reflexes, positive babinski signs
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| Where are lower motor neurons and what happens when they are damaged? | Brainstem and spinal cord to skeletal muscles; Damage produces weakness, hypotonia, hypoactive reflexes, muscle atrophy, fasciuclation (random firing of nervous system)
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| C3 dermatome innervation | front and back of neck
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| T4 dermatome innervation | nipples and nipple area
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| C6 dermatome innervation | thumb and forearm
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| C8 dermatome innervation | ring, little fingers, and hindarm
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| L1 dermatome innervation | inguinal
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| L4 dermatome innervation | Knee
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| L5 dermatome innervation | Anterior ankle and foot
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| Sensory innervation of radial nerve | thumb, thenar
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| sensory innervation of ulnar nerve | digits 4/5, ulnar hand
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| sensory innervation of median nerve | underside of digits 1-3.5
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| sensory innervation of lateral cutaneous nerve | lateral thigh
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| sensory innervation of anterior femoral cutaneous nerve | anterior thigh
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| sensory innervation of cutaneous branches of saphenous nerve | interior thigh and leg
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| Dyssynergy | accessory muscles used to achieve voluntary movements. Wide arc movement and past pointing; cerebellar sign
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| Dysmetria | The loss of ability to gauge distance & speed, and strength & velocity of voluntary movement; cerebellar sign
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| Dysdiadochokinesis | difficulty with rapid alternating movements; cerebellar sign
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| Dysarthria | difficulties with speech; cerebellar sign
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| Ataxia | swaying, have trouble staying upright. Fall toward lesion side; cerebellar sign
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| Intention tremor | more fine the movement, worse tremor gets; cerebellar sign
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| Clasp knife spasticity | very stiff and rigid with giveaway; like MS
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| Muscle strength grading: 0 | no muscular contraction detected
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| Muscle strength grading: 1 | barely detectable flicker or trace of contraction
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| Muscle strength grading: 2 | active movement of body part with gravity eliminated
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| Muscle strength grading: 3 | active movement against gravity
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| Muscle strength grading: 4 | active movement against gravity and some resistance
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| Muscle strength grading: 5 | active movement against full resistance without fatigue. This is normal muscle strength
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| Hip flexion | L2, L3, L4
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| Hip extension | S1
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| Hip adduction | L2, L3, L4
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| Hip abduction | L4, L5, S1
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| Knee extension | L2, L3, L4
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| Knee flexion | L4, L5, S1, S2
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| Ankle dorsiflexion | L4, L5
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| Ankle plantar flexion | S1
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| Biceps flexion/Brachioradialis | C5, C6
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| Triceps extension | C6, C7, C8
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| Wrist extension | C6, C7, C8
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| Grip strength | C7, C8, T1
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| Finger abduction | C8, T1
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| Thumb opposition | C8, T1
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| Antalgic | injury of knee or foot. Limp is adopted to decrease pain on weight-bearing structure
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| Cerebellar Ataxic gait | Unsteady, uncoordinated walk; legs spread apart to widen base for balance; like a drunk person
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| Steppage gait | Lifts foot high to avoid dragging foot; as foot comes down it “slaps” floor
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| Spastic hemiparesis | Leg swings outward from hip, may drag floor; arm flexed at side with minimal swing(circumduction); stroke/brain trauma
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| Parkinsonian gait | Posture stooped; flexion of head, arms, hips, knees; steps short and shuffling; arm swing decreased
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| Spastic diplegia | stiff, each leg advances slowly and thighs tend to cross forward on each other at each step. Steps are short; Cerebral palsy
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| Romberg test | Proprioception; Patient stands with feet together and eyes open, then with eyes closed for 20-30 sec without support. Loss of balance when eyes closed is a positive test. Have trouble feeling where you are (not a cerebellar problem).
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| Pronator drift | Patient stands for 30 sec with both arms straight forward, eyes closed, palms up; feet regular width apart. Tap each arm briskly downward ask patient to keep arm up (arms should return to where they were). Downward drift and pronation is a positive test.
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| Spinothalmic tract sensory pathway | free nerve endings in skin; pain temperature and crude touch (thalamus)
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| Posterior column sensory pathway | Peripheral large fiber projections found in skin and joints; vibration, proprioception, kinesthesia, pressure and fine touch (sensory cortex)
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| Shoulders | C4
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| Inner/outer Forearms | C6 & T1
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| Thumbs & little fingers | C6 & C8
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| Fronts of thighs | L2
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| Medial/lateral calves | L4&L5
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| Little toes | S1
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| Medial aspect of buttocks | S3
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| Point localization | lightly touch a point on patient’s skin (eyes closed). Ask them to open eyes and point to that spot.
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| Tactile Extinction | Touch areas on body bilaterally at same time. (patient’s eyes closed). Asked where they feel your touch.
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| Graphesthesia | Outline a number in patient’s palm. Ask patient to identify it. Repeat with different number, opposite hand
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| Stereognosis | Place a familiar object in patient’s hand. Ask them to identify it. Repeat with different object, opposite hand
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| Grading scale for DTRs 4+ | very brisk, hyperactive, with clonus
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| Grading scale for DTRs 3+ | brisker than average; possibly but not necessarily indicative of disease (upper neuron lesions)
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| Grading scale for DTRs 2+ | normal, average
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| Grading scale for DTRs 1+ | somewhat diminished; low normal
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| Grading scale for DTRs 0 | no response
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| Grading scale for DTRs 5 | this means sustained clonus)
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| Babinski sign | Using a pointed object, stroke lateral side of foot from heel to ball of foot; curve across ball of foot to medial aspect. Dorsiflexion of great toe with or without fanning of other toes is considered a positive Babinski sign.
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| Abdominal superficial reflexes | abs will move upon stimulation; Upper: T7, 8, 9, Lower: T10, 11
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| Cremasteric superficial reflex | testicles rise; T12, L1, L2
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| Anal superficial reflex | Anal; cuada equina syndrome; S4, S5
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| Nuchal rigidity | stiff neck. With patient supine, slip your hand under their head and raise it, flexing the neck (checks neck mobility)
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| Brudzinski sign | flex neck as above. Involuntary flexion of hips and knees is a positive Brudzinski sign, indicating meningeal irritation
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| Kernig’s sign | Patient supine, flex leg at the knee and hip; attempt to straighten leg; pain and resistance to straightening leg at the knee is a positive Kernig’s sign, indicating meningeal irritation.
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| Straight Leg Raise | test for lumbosacral radiculopathy/sciatic neuropathy; positive test w/pain that radiates into ipsilateral leg or contralateral leg. L5/S1 shooting pain down the back of leg.
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| Monofilament | Used to test for sensation on bottom of feet in patient’s with diabetes, peripheral neuropathy. Patient should feel the sensation at all sites tested.
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| Myasthenia Gravis | autoimmune neuromuscular disease. Weakness of voluntary muscles with repetitive activity because muscles do not receive enough acetylcholine for effective contraction. Receptor sites are blocked. Affects chewing, swallowing, respiration.
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| Guillian-Barre | often follows nonspecific infection. Inflammation or demyelination of nerves leading to impaired nerve conduction. Causes ascending symmetric muscle weakness that increases in severity over time. Paralysis results. Majority of patient fully recover.
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| Peripheral neuropathy | motor or sensory loss in nerve distrubution. Patient can have numbness, tingling, burning, cramping in extremity. Common in diabetics. Can be caused by exposure to toxins also.
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| Parkinsons | a deficiency of dopamine causes movement and balance disorder. Progressive and degenerative disease. Tremors at rest and with fatigue and disappear with intentional movement. Initially is unilateral. Pill-rolling of fingers .
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| Post polio | reappearance of neurologic signs in patients who had polio past. Although cause unknown, thought to be caused by inability of neurons to develop axon sprouts. Results in muscle weakness and profound fatigue.
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