Advanced Physical Assessment
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| Stroke: is a sudden neurologic deficit caused by | Hemorrhage: (13%) which may be intracerebral (10%) or subarachnoid (3%) also Cerebrovascular Ischemia: (87%) ↓ vascular perfusion results in sudden focal but transient brain dysfunction in TIA
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| Address disease-specific risk factors for stroke | atrial fibrillation, carotid artery disease, and sleep apnea
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| Delirium | is an ACUTE confessional state marked by sudden onset, fluctuating course, inattention and changes in the level of consciousness; it is often undetected. Can be assessed by CAM algorithm, hyperattention, lethargic, rambling, stuperous…
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| Dementia | is best assessed by the Mini-Mental State Examination and the Mini-Cog (DD: benign forgetfulness)
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| Depression | is common in individuals with significant medical conditions. Ask well-validated screening questions: “Have you been feeling down, depressed, or hopeless?” and “Have you felt little interest or pleasure in doing things?”
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| Warning signs of headache | sudden onset, like thunderclap, new onset after 50, worst HA ever, progressively frequent, aggravated by position (tumor) or precipitated by vasalva→ sinusitis, head trauma
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| An older person greater than 50 with progressive headache, changes with position | may be a tumor
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| Vertigo | false sense of rotational motion; it points to an inner ear lesion, CN VIII lesion, or a brain lesion
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| Weakness vs fatigue | Weakness: means actual loss of strength from central, peripheral NS, or muscles- abrupt can be TIA OR STROKE- lower extremity can be guillan barre (flu shot)- chronic can be spinal cord tumor
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| Proximal weakness | -bilateral- think MYOPATHY thigh is more proximal than the leg, the arm is more proximal than forearm
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| Distal weakness | think neuropathy (diabetes)- leg/hand
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| Myasthenia gravis | asymmetric- diplopia, ptosis, dysarthria, and dysphagia
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| Numbness | In patient who reports numbness, ask if there is tingling, altered sensation (paresthesias), distorted sensation (dysesthesias)
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| Syncope | think seizures- neurogenic or vascular or arrythmias (ventricular tachy or brady)
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| Tonic-clonic motor activity | Incontinence, and post-ictal state in generalized seizures. Unlike in syncope, tongue biting or bruising of limbs may occur
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| Low-frequency unilateral resting tremor | rigidity, and bradykinesia in Parkinson disease
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| Essential tremors | if high frequency, bilateral, upper extremity tremors that occur with both limb movement and sustained posture and subside when the limb is relaxed
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| cerebellar tremors | happen when the pt moves- kinetic/intention tremors
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| cranial nerve 1 | olfactory- smell
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| cranial nerve 2 | optic- vision, visual fields, eye fundus, pupillary rx
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| cranial nerve 3 | occulomotor- Pupillary constriction, lid elevation- ALL Extraocular muscles (EXCEPT: LR6SO4)- pupillary rx, extraocular movements
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| cranial nerve 4 | trochlear- Downward& internal rotation of eye- SO4, extraocular movements
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| cranial nerve 5 | trigeminal- Motor: Jaw clenching, and lateral jaw movement Sensory: Facial: ophthalmic, maxillary, mandibular, Corneal reflex, facial sensation, and jaw movements, Voice and speech
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| cranial nerve 6 | abducens- Lateral deviation of the eye- LR6, extraocular movements
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| cranial nerve 7 | facial- Motor: facial movements including expressions, closing the eye, closing the mouth- Sensory: Ear& taste on the anterior 2/3 of tongue- facial movements, Voice and speech
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| cranial nerve 8 | acoustic- Hearing (cochlear div.) and balance (vestibular div.)- hearing and balance
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| cranial nerve 9 | glosso-pharyngeal- Motor: pharynx- Sensory: posterior ear canal and ear drum, posterior tongue & pharynx, Swallowing, palate rise, gag reflex
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| cranial nerve 10 | vagus- Motor: palate, pharynx, and larynx- Sensory: pharynx and larynx, Swallowing, palate rise, gag reflex, Voice and speech
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| cranial nerve 11 | accessory-- motor: SCM; upper portion of trapezius, Shoulder and neck movements
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| cranial nerve 12 | hypoglossal- motor- tongue- Voice and speech, Tongue symmetry, position & movement
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| Prechiasmal (anterior) defects | glaucoma, optic neuritis
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| Chiasmal | Bitemporal hemianopia in pituitary tumors
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| Postchiasmal | homonymous hemianopia in occipital lesions (stroke)
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| the nasal retina sees the | temporal field
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| the temporal retina looks at the | nasal field
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| Test- Light reaction cranial nerves | (CN II optic afferent & III oculomotor efferent)- light shines in one eye and CN II lets the midbrain know on both sides- impulses to constrict the pupils- oculomotor is efferent nerve
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| RAPD or Marcus Gunn | medical sign observed during the swinging-flashlight test- pt pupils constrict less in affected eye (therefore appearing to dilate) when a bright light is swung from the unaffected eye to the affected eye.
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| CN III lesion | out and down + ptosis + mydriasis
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| CN IV lesion | SO4 nasal upshoot
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| CN VI lesion | LR6 crossing eyes
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| Nystagmus | Involuntary jerking movement of the eye with quick and slow components
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| Trigeminal- CN7 | Difficulty clenching the jaw -masseter problem- or moving it to the opposite side, lateral pterygoid weakness- acoustic neuroma with absent blinking- sensory-ophthalmic-maxillary and mandibular
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| TEST Facial- CN7 | raise brows, frown… bells palsy has flattening of nasolabial fold- peripheral damage-CANNOT RAISE EYEBROW-(central lesion- stroke can raise eyebrows- starts eyebrow down)
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| Pt has conductive hearing loss on the left side | BC>AC for the rinne and webers will go to the left ear B for Bad side and BC with conductive
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| Pt has sensorineural hearing loss on the right side | Rinne test AC>BC on the right side and for the webers it will lateralize to the left/normal- Sensorineural stays on the good side and AC for good/normal side
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| Vertigo and nystagmus signifies what | Meniere’s dz
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| Listen to the voice: Hoarseness occurs in | vocal cord paralysis; nasal voice in paralysis of the palate- CN 9 and 10
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| Say ah | CN 10
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| Gag reflex | CN 9 and 10
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| Listen to the word articulation, Dysarthria, poor articulation from damage to | CN X or CN XII
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| Test Inspect the protruded tongue (CN XII)- lesion on right hypoglossal nerve- tried to protrude, where is it going to point? | To the side of the lesion, so to the right same with the eye is stroke the eyes look to the side of the lesion
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| Muscle tone- Spasticity | is velocity-dependent increased tone that worsens at extremes of range.
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| Muscle tone- Rigidity | is increased resistance throughout the range of movement and in both directions; it is NOT rate-dependent
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| Muscle tone- hypotonia or flaccidity | Marked floppiness indicates muscle hypotonia or flaccidity, usually from a peripheral motor system disorder
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| Elbow Flexion | (C5& 6) biceps and brachioradialis
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| Elbow Extension | (C6, 7& 8) triceps
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| Wrist Extension | (C6, 7& 8)
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| Hand Grip | (C7& 8, T1)
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| Finger abduction | (C8, T1) ulnar nerve
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| Thumb opposition | (C8, T1) median nerve
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| Hip flexion | L2, 3 and 4- iliopsoas
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| Hip extension | S1- gluteus maximus
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| Hip adduction | L2, 3, and 4- adductors
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| Hip abduction | L4, 5, S1- gluteus medius and minimus
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| Knee extension | l2, 3, and 4- quadriceps
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| Knee flexion | L4, L5, s1 and S2 – hamstrings
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| Ankle dorsiflesxion | L5-5 tibialis anterior
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| Ankle plantar flexion | S1- gastrocnemius, soleus
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| Coordination of muscle movements requires FOUR areas of the nervous system to function in an integrated way | motor system: for muscle strength, cerebellum: normal rhythmic movement & steady posture, vestibular system:balance/ coordinating eye, head/body movements, The sensory system: for position sense
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| To assess coordination, observe the patient for FOUR things | rapid alternating movements (Dysdiadochokinesis), Point-to-point movements, Gait: and other related body movements, Standing in specified ways
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| Dysmetria | is the inability/ reduced ability to accurately control the range of movement in muscular acts- point to point movements
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| Cerebellar disease | is the most common cause of abnormal finger-to-nose testing (d/t stroke)
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| Test- The most accurate test of the cerebellum is | MRI
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| Test- What is the first test to do for a pt with a stroke? | CT
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| Walk on toes then on heels is what kind of damage? | corticospinal tract
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| Test- Posterior column lesion | ataxia upon closing eyes- B 12 deficiency
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| Test- Cerebellar lesion and ataxia | it doesn’t matter if eyes are open or closed- the center itself is damaged
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| Romberg test is caused by | B12 deficiency or neurosyphilis
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| A hemisensory loss pattern suggests a lesion in the | contralateral cerebral hemisphere
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| A sensory level- when one or more sensory modalities are reduced below a dermatome, on one or both sides, suggests a | spinal cord lesion
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| For pain, temperature, and touch sensation: compare | distal to proximal areas of extremities; try to sample most of the dermatomes and major peripheral nerves. One suggested pattern is to include
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| both shoulders | (C4)
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| the inner and outer aspects of forearms | (C6 and T1)
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| the thumbs and little fingers | (C6 and C8)
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| the fronts of both thighs | (L2)
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| the medial and lateral aspects of both legs | (L4 and L5)
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| test the little toes | (S1)- plantar flexion of the ankle, sensation of little toe
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| the medial aspect of each buttock | (S3)
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| Point localization- touch skin briefly, and ask patient to open both eyes and identify the place touched, which lesions are impaired and lose the ability to localize points accurately? | Lesions of the sensory cortex
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| Two-point discrimination: Use the 2 ends of paper clip to find minimal distance on patient’s finger pad at which two points can be distinguished- Lesions of __________ increase the distance between two recog. points (Normally <5 mm on the finger pads) | sensory cortex
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| Stereognosis: | Place a familiar object in the patient’s hand and ask the patient to tell you what it is - + in sensory cortical lesions- in STROKE
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| Number identification | graphesthesia- lesion in sensory cortex- STROKE
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| Point localization: | touch skin briefly, and ask patient to open both eyes and identify the place touched- r/t sensory cortex and stroke
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| Extinction: Simultaneously touch opposite, corresponding areas of the body; ask whether the patient feels one touch or two (Normally TWO points are felt) | With lesions of the sensory cortex, only one stimulus is recognized. The stimulus on the side opposite to damaged cortex is gone
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| Reflex grading | focus on muscle contraction/twitches- absent is 0, average is 2+, hyperactive is 4+
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| Hyperactive reflexes, hyperreflexia | +Babinski, Are seen in CNS lesions of the descending corticospinal tract. Look for associated upper motor neuron findings of weakness, spasticity
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| TEST- Slowed relaxation phase (hung reflex) | seen in hypothyroidism, best detected at the ankle
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| The Biceps Reflex | (C5, C6)
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| The Triceps Reflex | (C6, C7)
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| The Brachioradialis Reflex | (C5, C6)
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| The Patellar (Quadriceps) Reflex | (L2, L3, L4)
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| The Ankle (Achilles) Reflex | (S1)
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| If the reflexes seem hyperactive | test for ankle clonus- upper motor neuron lesions- grade 4 (no clonus is 3)
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| The Biceps Reflex | (C5, C6)
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| The Triceps Reflex | (C6, C7)
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| The Brachioradialis Reflex | (C5, C6)
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| The Patellar (Quadriceps) Reflex | (L2, L3, L4)
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| The Ankle (Achilles) Reflex | (S1)
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| Plantar response | L5, S1
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| + Babinski sign in adult | abnormal- + upper motor neuron lesion- Dorsiflexion of the big toe (and fanning of the other toes) is a positive Babinski response- drug and etoh intoxication and following sz postictal
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| If you suspect meningitis/SAH, check for | Brudzinskis sign- bend/flex head forward, Flexion of both the hips and knees is a positive sign.
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| kernigs sign for meningitis/SAH | Flex the patient’s leg at both the hip and the knee, then slowly extend- should not produce pain- Pain and increased resistance to knee extension are a positive sign
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| Test- An ipsilateral positive straight leg test is a | sensitive test for the presence of radiculopathy (80% sensitive, 40% specific)
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| Test- A contralateral (crossed) positive straight leg test | is a more specific test for the presence of radiculopathy (90% specific).
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| Rooting reflex | CN V- touch on corner of the infant’s mouth; the infant should open its mouth and turn its head in the direction of stimulation. (minimal or absent if the infant was recently fed)
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| Sucking reflex | CN V- place your finger in the infant’s mouth, feeling the sucking action; the tongue should push up against your finger with good strength; note the pressure, strength, and pattern of sucking
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| Doll’s eye maneuver | can be CN 8, 2,3, 4,6 hold the infant under the axilla in an upright position, head held steadily; rotate the infant first in one direction and then in the other; the infant’s eyes should turn in the direction of rotation
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| To differentiate between ischemic and hemorrhagic stroke? | CT – 1st test
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| To tell if a stroke is ischemic? | MRI- if hemorrhage is excluded within 3.5 hours, thrombolytics can be given- TPA- best test is MRA (angiogram) – in the 1st hour- posterior artery detection
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| 3 main questions r/t stroke | what area r/t brain, ischemic (TIA) or hemorrhagic (not reversible)
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| If at 230 pt was okay and at 231 pt was not | its emboli, if it’s between 230-3pm, it’s thrombotic
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| Anterior circulation – Anterior cerebral artery (ACA) | Contralateral leg weakness- artery for stroke
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| Anterior circulation – Middle cerebral artery (MCA) | most common artery for stroke- Contralateral face, arm > leg weakness, sensory loss, visual field loss, apraxia, aphasia (left MCA), or neglect (right MCA)
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| Resting (Static) Tremors | parkinsons- Most prominent at rest, and may decrease or disappear with voluntary movements- the common, relatively slow (5/sec), fine, pill-rolling tremor
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| Intention (Kinetic) Tremors | ataxic- Absent at rest, appear with movement and often get worse as the target gets close- Causes include cerebellar disorders and multiple sclerosis
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| Postural Tremors | Appear when affected part is actively maintaining a posture- hyperthyroidism, anxiety, and benign essential tremor- improves with etoh
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| Fasciculations | Fine, rapid flickering of muscle bundles in lower motor neuron disorders
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| Test- aphonia/dysphonia | Defect in phonation usually due to a lesion in larynx/ or its nerve supply- speaker is off
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| Test- dysarthria | Defect in the articulation of words due to CNS, PNS, or cerebellar dis.
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| Test- aphasia | Defect in the production and comprehension due to cortical lesion
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| It presents with fluent speech without effort or labor but is devoid of content.Speech has normal word count but is filled with neologisms and empty phrases. | wernickes- Hearing is intact, but the patient is unaware of the problem that comprehension is defective.
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| Brocas expressive aphasia | non-fluent speech-hesitant and labored. The pt is aware & frustrated- pronouns, prepositions, and conjunctions are omitted Comprehension is intact. Handwriting is intact, but word content is not. They cannot say “No ifs, ands, or buts.” d/t Stroke- MRI
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| Test- Wernicke’s location | Left (Dominant) Posterior superior temporal lobe- if you are right handed
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| Test- Broca’s location | Left (Dominant) posterior inferior frontal lobe- if you are right handed
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| Causes of nystagmus | lesions of CN VIII, the labyrinth (hearing and tinnitus), the cerebellum, or midbrain- Central nystagmus: from stroke or MS-
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| Test- Vertical nystagmus | a rare condition associated with Phencyclidine (PCP) or severe phenytoin toxicity
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| In stroke, can you move your eyebrows? | yes
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| The lower portion of the face | CNVII- is normally controlled by upper motor neurons located only on one side of the cortex- the opposite side- contralateral damage- Left hemispheric damage to these weakens the right-stroke
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| The upper face and stroke | however, is controlled by pathways from both sides of the cortex. Even though the UMN on the left are destroyed, others on the right remain, and the right upper face continues to function fairly well
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| Test- Peripheral nerve damage to CN VII | paralyzes the entire right side of the face, including the forehead- Bell’s Palsy
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| Test- Central nerve damage to CN VII | paralyzes the lower face but cortical innervation to the forehead is preserved- stroke
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| Bells Palsy | facial paresis associated w/herpes simplex I virus- abrupt onset, face stiff, pulled to side; unable to move forehead. ipsilateral restriction of eye closure, disturbance anterior 2/3 tongue and eye closure
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| Lower motor nerve lesion | peripheral
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| Central Nervous System Disorder | upper motor lesion
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| Muscle tone | we get spasticity in UMNL and we get rigidity in parkinsons, and we get flaccidity in LMNL (gullan barre, stroke) and we get paratonia in textbooks
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| Spastic Hemiparesis (Hemiplegic gait) | Circumduction of the affected leg: the affected leg swings outward in a semicircular motion with the foot dragging and scraping the floor- arm flexed in- indicates stroke- do CT/MRI
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| Ataxic Gait (Cerebellar gait/ataxia*) | Cerebellar lesions: MRI- staggering, unsteady: feet wide apart,exaggerated difficulty on turns- worsened by trying to have the patient do tandem or heel-to-toe walking.Cannot stand feet together: eyes open or closed
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| Sensory ataxia | posterior column- caused by loss of position sense- worse with eyes closed- in the legs from polyneuropathy or posterior column damage- + Romberg
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| Neuropathic gait/step gait | This gait gives the appearance of walking upstairs; inability to walk on their heels- foot hits floor with a slap- unilateral is L5 radiculopathy/ or sciatic or bilateral
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| Parkinson’s gait | Seen in: basal ganglia defects, stooped, with flexion of head, arms, hips, and knees, shuffling, involuntary hastening (festination), gradual acceleration is called a festinating gait- stiffly “all in one piece”-tremor and postural instability
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| Classic migraine | comes with aura
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| Common migraine | no aura
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