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311 Cards in this Set
- Front
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What are the common mental disorders seen in primary care pts?
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Anxiety
Depression Bipolar disorder Somatoform disorders Alcohol and substance abuse |
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What dual diagnosis should you be looking for in pt with unexplained symptoms
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depression and anxiety
in 50% of pt with mental disorder |
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What are common functional syndromes?
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irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder, and multiple chemical sensitivity
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What are types of symptom overlap that occur in common functional syndromes?
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fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems
functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy. |
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What are some identifiers for mental health screening?
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Medically unexplained physical symptoms—more than half have a depressive or anxiety disorder
Multiple physical or somatic symptoms or “high symptom count” High severity of the presenting somatic symptom Chronic pain Symptoms for more than 6 weeks Provider rating as a “difficult encounter” Recent stress Low self-rating of health High use of healthcare services Substance abuse |
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What to look for in a mental status history/exam?
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patient’s level of alertness, mood, orientation, attention, and memory
his insight, judgment, and any thought disorder or disorder of perception |
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What is Level of consciousness
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how aware the person is of his environment
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What is attention?
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the ability to focus or concentrate
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how do you describe a pt that is awake and aware?
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alert?
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how do you describe a pt that needs to be spoken to in a loud, forceful manner?
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lethargic
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how do you describe a pt that you must shake a patient to get a response
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Obtunded
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the patient is unarousable except by painful stimuli (sternal rub)
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Stuporous
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What is the term for a pt that is completely unarousable?
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coma
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What is the process of recording and retrieving information
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memory
Short-term memory- events that occurred minutes to days before Long-term memory- events that occurred months to years before |
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What should a pt know if they are oriented?
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aware of person (who they are)
place (where they are) time (when is it) this requires memory and attention |
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awareness of the objects in the environment to the five senses and their interrelationships
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perceptions
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the logic, coherence, and relevance of a patient’s thoughts as they lead to thoughts and goals; HOW people think
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thought processes
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awareness that thought, symptoms, or behaviors are normal or abnormal; e.g., distinguishing that a daydream or hallucination is not real
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insight
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process of comparing and evaluating different possible courses of action
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judgement
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the observable mood of a person expressed through facial expression, body movements, and voice
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affect
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the complex symbolic system for expressing written and verbal thoughts, emotion, attention, and memory
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language
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level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking
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higher cognitive fx
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what is the definition of mood and what are the three types?
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the sustained emotion of the patient
Euthymic: normal Dysthymic: depressed Manic: elated |
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what components make up the mental status exam?
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Appearance and behavior
Speech and language Mood Thoughts and perceptions Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability |
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how do you Assess the level of consciousness
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Is the patient awake and alert?
Does the patient understand your questions? Does the patient respond appropriately and reasonably quickly or lose track of the topic and fall silent or even asleep? |
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What do you do if the patient does not respond to questions determining consciousness?
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Speak to the patient by name and in a loud voice
Gently shake the patient |
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how do you assess a pt posture or motion?
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Does the patient lie in bed or prefer to walk around?
Is the patient sitting or lying comfortably? Is the patient agitated with repetitive movements |
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What should you be looking for when assessing a pt facial expressions in a mental status exam?
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A flat affect (lack of facial movement) can be seen due to a physical reason such as Parkinson’s disease or a psychological reason such as profound depression
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what should you be asking when Assessing the patient’s manner, affect, and relationship to people and things
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Does the affect reflect the mood?
Is the affect stable or labile (mood changing from happiness to tears and back quickly)? Does the patient seem to see or hear things you do not? |
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What 5 things should you observe when looking at a persons speech and language in a mental status exam?
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Quality
Rate Loudness articulation of words fluency |
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What are some examples of fluency problems in speech?
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Hesitancies in speech (as seen in patients with aphasia from strokes)
Monotone inflections (schizophrenia or severe depression) Circumlocutions: words or phrases are substituted for the word a person cannot remember; e.g., “the thing you block out your writing with” for an eraser Paraphasias: words are malformed (“I write with a den”), wrong (“I write with a branch”), or invented (“I write with a dar”) |
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What to do when assessing mood?
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Use open-ended questions
“How do you feel about that?” “How are you feeling?” How long has the patient’s mood been this way How good or bad has the patient felt Sometimes you have to ask friends or family of the patient to help you assess the patient’s mood Do not be afraid to ask the patient about thoughts of self-harm or suicide |
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what is the 11th leading cause of death in the US?
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suicide
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What population has the highest suicide rate?
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white men over 65 (14.3 deaths per 100,000)
white men over 85 (17.8 deaths per 100,000) |
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FActs about suicide
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More than half of patients completing suicide have visited their physician/provider in the prior month, and 10% to 40% in the prior week.
Two-thirds of suicides occur on the first attempt. Pursue any clinical suspicion of suicide by asking patients directly about suicidal ideation and plans. Refer at-risk patients immediately for psychiatric care. |
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What are the risk factors for suicide?
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More than 90% of people who die by suicide have depression or other mental disorders
Substance abusers. Prior suicide attempts Delusional or psychotic thinking FHx of suicide, mental disorders, or substance abuse Family violence, including physical or sexual abuse Firearms in the home Incarceration |
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What are some abnormalities in thought process?
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Circumstantiality: speech characterized by indirection and delay due to the patient’s excessive use of details that have no connection to the point
Derailment: speech in which a person shifts topics with no apparent relation between the topics Flight of ideas: accelerated change of topics in a very fast but generally coherent manner Neologisms: invented or distorted words |
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What is incoherence?
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speech that is incomprehensible because it is illogical
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What is blocking?
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sudden interruption of speech, before the completion of an idea, occurs in normal people
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What is confabulation?
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fabrication of facts to hide memory impairment
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What is perseveration?
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persistent repetition of words or ideas
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What echolalia?
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repetition of the words or phrases of others
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What is clanging?
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choosing a word on the basis of sound rather than meaning
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What are compulsions?
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repetitive behaviors that a person feels driven to perform to prevent or produce some future state of affairs
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What are obsessions?
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recurrent, uncontrollable thoughts, images, or impulses that a patient considers unacceptable
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What are phobias?
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persistent fear of a stimuli the patient feels is irrational (spiders, snakes, the dark)
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What is anxiety?
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apprehension or fear that may be focused (phobia) or free floating (general sense of dread)
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What are delusions and what are some examples?
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false, fixed beliefs that are not shared by other members of the person’s culture
Delusion of persecution, grandeur, or jealousy Delusion of reference: a person believes an outside event or object has an unusual personal reference to them; i.e., a comet passing earth means the patient should buy a car Delusion of being controlled by outside forces Somatic delusion: believing one has a disease or defect that he does not Systematized delusion: a single delusion with many elaborations around a single theme all systematized into a complex network; i.e., the KGB is after the patient |
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What should you ask to inquire about false perceptions?
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Do you hear voices other people don’t hear?
Do you see things other people don’t see? Do you know things other people don’t know? |
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What are illusions?
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misinterpretations of real stimuli; e.g., the postman leaves mail, therefore there is a plot to poison the patient
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What are hallucinations?
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a subjective external stimuli the patient hears or sees that others do not hear or see and that the patient may not recognize as false; these can be auditory, visual, olfactory, gustatory, or tactile
does not include false perceptions during dreaming/sleeping |
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Distrust and suspiciousness
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Paranoid
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Detachment from social relationships, with a restricted range of emotional expression
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Schizoid
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Eccentricities in behavior and cognitive distortions; acute discomfort in close relationships
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Schizotypal
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Disregard for rights of others; a defect in the experience of compunction or remorse for harming others
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Antisocial
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Instability in interpersonal relationships, self-image, and affective regulation
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Borderline
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Emotional overreactivity, theatrical behavior, and seductiveness
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Histrionic
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Persisting grandiosity, need for admiration, and lack of empathy for others
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Narcissistic
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Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
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Avoidant
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Submission and clinging behavior
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dependent
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Rigid, detail-oriented behavior, often associated with compulsions to perform tasks repetitively and unnecessarily
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Obsessivecompulsive
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What three things should you do to assess attention?
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Digital span: give the patient a string of numbers to recite back to you
Serial 7s: ask the patient to subtract serial “7s” from 100 Spelling backward: ask the patient to spell W-O-R-L-D backwards |
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how do you assess remote memory?
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ask about past historical events
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how do you assess recent memory?
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ask about something recent like the weather and national events
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how do you assess new learning ability?
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give the patient 3 or 4 words to remember then ask them to repeat it after several minutes
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how do you assess calculating ability?
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ask the patient to perform more difficult calculations such as making change (e.g., if you had a dollar’s worth of nickels and someone needed 65 cents how many nickels would you have left?)
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how do you assess abstract thinking?
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Interpreting proverbs: “A stitch in time saves nine”
Similarity exercises: What do a ball and an orange have in common? |
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how do you assess constructional ability?
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Ask a patient to copy a geometric figure onto a sheet of paper
Ask a patient to draw a clock face indicating 5:00 |
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What is the folstein test?
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Brief 30-point questionnaire test
Used to screen for cognitive impairment. It is also used to estimate the severity of cognitive impairment at a given point in time and to follow the course of cognitive changes in an individual over time, thus making it an effective way to document an individual's response to treatment. In the time span of about 10 minutes it samples various functions including arithmetic, memory and orientation. |
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What are the 9 aspects to the MMSE?
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Orientation to time – year, season, month, day, time
Orientation to place – country, state, city, type of building, floor Registration – name 3 objects (no visual clue) Attention and calculation –serial 7’s. spell world backwards Recall – 3 objects named above Language – “pencil, watch” point to them for pt to name Repetition – “no ifs, ands or buts” Complex commands – “fold this piece of paper in half and put it on the floor” Copy this picture |
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How do you score the MMSE?
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>25 points (out of 30) is normal (intact).
severe (≤9 points) moderate (10-20 points) mild (21-24 points |
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What makes up the peripheral nervous system?
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12 pairs of cranial nerves and the spinal and peripheral nerves
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What do the cranial nerves control?
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motor, sensory, and specialized functions like smell, vision, and hearing
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What does CN1 do/how do you test it?
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Olfactory
occlude each nostril and test different smells |
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What does CN2 do/how do you test it?
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Optic
test visual acuity with snellen inspect fundi screen visual fields by confrontation |
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What does CN3,4,6 do/how do you test it?
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Oculomotor, trochlear, abducens
extraocular movements in 6 cardinal directions lid elevation convergence |
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What does CN5 do/how do you test it?
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Trigeminal
palpate temoral and masseter mm while pt clenches teeth test forehead, cheeks, and jaw on each side for sharp of dull sensation test corneal reflex |
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What does CN7 do/how do you test it?
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Facial
assess face for asymmetry, ticks, abnormal movements ask pt to raise eyebrows, frown, and close eyes tightly ask pt to smile, show teeth, and puff both cheeks |
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What does CN8 do/how do you test it?
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Acoustic
test hearing, lateralization, and air and bone conduction |
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What does CN9 and 10 do/how do you test it?
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glossopharyngeal and vagus
assess if voice is hoarse assess swallowing say AH test gag reflex |
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What does CN11 do/how do you test it?
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spinal accessory
assess strength as pt shrugs shoulders against your hands Note contraction of opposite sternocleidomastoid, and force as patient turns head against your hands |
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What does CN 12 do/how do you test it?
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Hypoglossal
Ask patient to protrude tongue and move it side to side. Assess for symmetry, atrophy |
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What are the common sites for injection of steroid and anesthesia?
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knee and shoulder
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What are common sites for aspirations of fluid, blood, or inflammatory fluid?
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knee and elbow
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What are contraindication for doing an aspiration or injection?
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if there is a chance for bacteria entering the joint/bursa
burns or infections in a hemophiliac |
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What are the most common complications of joint aspiration?
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bleeding, infection, pain, intra-articular injury, re-accumulation of fluid
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What are less common complications of joint aspiration?
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vascular or neural injury, scoring injury to intra-articular surface
allergic rxn to iodine or anesthesia |
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What are the most common bursal aspiration complications?
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infection, pain, chronic recurrence, chronic drainage via sinus tracts, acute recurrent swelling (some bursae communicate directly into the joint space)
recurrence is high and may need to be referred to orthopedics |
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How do you set up for joint aspiration?
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Informed consent-including risks and benefits
Patient can sign the form or practitioner can documentation conversation regarding the risk and benefits Procedure takes about 5-10 minutes after about a 10 minutes scrub Inform the patient this is a sterile procedure Patient needs to be supine with knee extended as far as possible |
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What equipment is used in a joint aspiration?
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Tray table
Sterile drapes or sterile towels Sterile gloves Providone-iodine solution or surgical prep 1% lidocaine Sterile 1-inch 25 gauge needle (lidocaine) Sterile 18-19 gauge needle (aspiration) Three 20 or 30 ml syringes |
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how do you perform a joint aspiration?
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Position pt that will be the most comfortable for the pt and give you the easiest access to the effusion
Prepare a sterile field to work in Sterilize the joint Put on sterile gloves and drape the knee Find the superior pole of the patella identify landmarks anesthesia |
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What landmarks should you look for on a knee aspiration?
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lateral and medial suface of patella and superior pole of patella
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What procedures should be done after landmarks have been identified for a joint aspiration?
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Draw up 5-10 ml of 1% lidocaine and using the 25 gauge needle anesthesia the knee by advancing the needle as deep as anesthesia is required and aspirate for blood (resistance will be felt at the joint capsule)
While withdrawing the needle inject Remove the 25 gauge needle and assemble the 18 gauge needle Hold the syringe like a pencil When one is about to enter the joint space or just in it, it can be very painful for a moment |
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What does it mean to milk the knee?
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applying pressure above patella
to ensure all the fluid is removed |
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What should the fluid from an aspiration be tested for when being sent to the lab?
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gram stain, cell count, and cultures
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How do you perform a bursal aspiration?
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Position pt that will be the most comfortable for the pt and give you the easiest access to the effusion
Prepare a sterile field to work in Sterilize the joint Put on sterile gloves and drape the area With elbow flexed at 90 enter the olecranon bursa from the side at 90 degrees Aspirate the bursa until flat |
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What is included in follow up care after injection or aspiration?
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Advise the pt to limit use of the joint for 24 hours
If trauma was the cause of the effusion then immobilization or non-weight bearing may be indicated If aspiration revealed an unstable joint then immobilization and further evaluation is indicated If infection is suspected then prompt referral to orthopedic is necessary |
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Where does the spinal cord extend from?
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brainstem (medulla) to L1 or L2
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What are the 5 segments of the spinal cord?
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cervical (C1-8)
thoracic (T1-12) lumbar (L1-5) sacral (S1-5) coccygeal |
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What three important question should you ask to check neuro motor function?
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Is the mental status intact?
Are right-sided and left-sided examination findings symmetric? If the findings are asymmetric or otherwise abnormal, does the lesion lie in the? |
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What is the central NS?
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the brain and spinal cord
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What is the peripheral NS?
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consisting of the 12 pairs of cranial nerves and the spinal and peripheral nerves
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How many pairs of peripheral NN are there and what are they?
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31 pairs of nerves that attach to the spinal cord: 8 cervical, 2 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
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each peripheral N has two parts. What are they and what are their functions?
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anterior (ventral) root containing motor fibers
posterior (dorsal) root containing sensory fibers the anterior and posterior roots merge to form a short (<5 mm) spinal nerve |
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what should you focus on when assessing the motor system?
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body position
involuntary movements characteristics of the muscles (bulk, tone, and strength) coordination. |
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How do you assess body position for motor nerve function?
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Observe the body position during movement and rest.
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How do you assess involuntary movements for motor nerve function?
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Watch for tremors, tics, or fasciculations.
Note their location, quality, rate, rhythm, and amplitude, and their relation to posture, activity, fatigue, emotion, and other factors. |
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How do you assess muscle bulk when checking motor nerve function?
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Inspect the size and contours of muscles.
Do the muscles look flat or concave, suggesting atrophy? unilateral or bilateral? proximal or distal? When looking for atrophy, pay particular attention to the hands, shoulders, and thighs. Be alert for fasciculations in atrophic muscles. If absent, tap on the muscle with a reflex hammer to try to stimulate them |
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Where are most common places for mm atrophy?
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hands, shoulder, thigh
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What are some causes of muscle atrophy?
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diabetic neuropathy, motor neuron diseases, any disease that affects the peripheral motor system, rheumatoid arthritis, and protein-calorie malnutrition
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What is pseufohypertrophy?
Where do you see it? |
increased bulk with diminished strength
Duchene muscular dystrophy |
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What do Fasciculations with atrophy and muscle weakness suggest?
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peripheral motor disase
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What is muscle tone?
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When a normal muscle with an intact nerve supply is relaxed voluntarily, it maintains a slight residual tension known as muscle tone.
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how do you assess muscle tone?
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by feeling the muscle's resistance to passive stretch.
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what does decreased resistance in muscle tone suggest?
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disease of peripheral NS
cerebellar disease acute stage of spinal cord injury |
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What does marked floppiness of hand and wrist indicate?
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muscle hypotonia or flaccidity, usually from a disorder of the peripheral motor system.
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What is spasticity?
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Increased muscle tone (hypertonia) that is rate dependent
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What is clasp knife and when might this occur?
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During rapid passive movement, initial hypertonia may give way suddenly as the limb relaxes
after stroke |
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What is rigidity?
when do you see this? |
increased resistance
parkinsons |
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What is the term for Increased resistance that persists throughout the movement arc, independent of rate of movement
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lead-pipe rigidity
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What is the term for when flexion and extension of the wrist or forearm, a superimposed rachetlike jerkiness
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cogwheel rigidity
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What is flaccidity?
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Loss of muscle tone (hypotonia), causing the limb to be loose or floppy.
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When might you see flaccidity?
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Guillain-Barré syndrome
initial phase of spinal cord injury (spinal shock) or stroke |
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What is paratonia?
When might you see this? |
Sudden changes in tone with passive range of motion
dementia |
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What is the term for Sudden loss of tone that increases the ease of motion
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mitgehen
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What is the term for Sudden increase in tone making motion more difficult
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gegenhalten (holding against)
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when is a muscle strongest and weakest?
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a muscle is strongest when shortest, and weakest when longest
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Describe the 6 grades of muscle strength.
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0—No muscular contraction detected
1—A barely detectable flicker or trace of contraction 2—Active movement of the body part with gravity eliminated 3—Active movement against gravity 4—Active movement against gravity and some resistance 5—Active movement against full resistance without evident fatigue. This is normal muscle strength. |
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How do you test flexion of biceps and extension of triceps?
What spinal nerves does this test? |
Have the patient pull and push against your hand
C5, C6, C7, C8 |
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How do you test extension of the wrist and what muscles and nerves is it testing?
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ask the patient to make a fist and resist your pulling it down
extensor carpi radialis longus and brevis radial nerve made of C6, C7, C8 |
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How do you test grip and what spinal nerves does it test?
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Ask the patient to squeeze two of your fingers as hard as possible and not let them go. Testing both grips simultaneously with arms extended or in the lap facilitates comparison.
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How do you test finger abduction and what nerve does that test?
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Position the patient's hand with palm down and fingers spread. Instructing the patient not to let you move the fingers, try to force them together.
C8, T1 making the ulnar n |
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how do you test opposition of thumb and what nerve does this test?
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The patient should try to touch the tip of the little finger with the thumb, against your resistance.
median nerve from C8, T1 |
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how do you test flexion of hip and what nerves and muscle does it test?
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placing your hand on the patient's thigh and asking the patient to raise the leg against your hand.
L2, L3, L4 iliopsoas mm |
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How do you test adduction of hips and what nerves does it test?
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Place your hands firmly on the bed between the patient's knees. Ask the patient to bring both legs together
L2,L3,L4 |
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how do you test abduction of hip
What nerves and mm does it test? |
Place your hands firmly on the bed outside the patient's knees. Ask the patient to spread both legs against your hands.
L4,L5,S1 gluteus med and min |
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how do you test hip extension and what nerves and mm does it test?
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Have the patient push the posterior thigh down against your hand
S1 gluteus max |
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how do you test extension at the knee and what nerves does it test?
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Support the knee in flexion and ask the patient to straighten the leg against your hand. The quadriceps is the strongest muscle in the body, so expect a forceful response
L2,L3, L4 |
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How do you test flexion of the knee?
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Place the patient's leg so that the knee is flexed with the foot resting on the bed. Tell the patient to keep the foot down as you try to straighten the leg.
L4, L5, S1, S2 |
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How do you test dorsiflexion and plantar flexion?
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Ask the patient to pull up and push down against your hand
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What nerves are tested in dorsiflexion?
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L4,L5
tibialis anterior |
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What nerves are tested in plantar flexion?
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S1
gastroc and soleus |
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what is the term for absence of strength?
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paralysis, or plegia.
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What is hemiparesis?
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weakness of one half of the body
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What is hemiplegia?
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paralysis of one half of the body.
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What type of nervous system disease is seen with weakness/hemiparesis of a motor action typically?
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peripheral nervous system
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What type of nervous system disease is seen with paralysis/hemiplegia of motor function?
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central nervous system disease
stroke or MS |
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In what diseases might you see a weak grip?
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cervical radiculopathy, de Quervain's tenosynovitis, carpal tunnel syndrome, arthritis, epicondylitis
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When might you see weak opposition of thumb?
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median nerve disorders such as carpal tunnel syndrome
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What is suggestive of myopathy or a muscle disorder?
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symmetric weakness of proximal mm
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What is suggestive of polyneuropathy or peripheral N disorder?
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symmetric weakness of distal mm
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What 4 parts of nervous system must function to have coordinated mm movements?
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1 The motor system, for muscle strength
2 The cerebellar system (also part of the motor system), for rhythmic movement and steady posture 3 The vestibular system, for balance and for coordinating eye, head, and body movements 4 The sensory system, for position sense |
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What 4 things should be performed when *****sing coordination in a motor nerve exam?
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Rapid alternating movements
Point-to-point movements Gait and other related body movements Standing in specified ways |
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What is dysdiadochokinesis?
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In cerebellar disease, one movement cannot be followed quickly by its opposite, movements are slow, irregular, and clumsy.
problem with rapid alternating movements. |
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What do point to point movements test?
(moving finger to finger to nose, leg heel to shin, finger to finger with eyes closed |
These maneuvers test position sense and the functions of both the labyrinth and the cerebellum
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What can you expect to see with point to point movements in cerebellar disease?
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clumsy, unsteady, and inappropriately varying in their speed, force, and direction
An intention tremor overshoot incoordination that worsens with eyes closed. |
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What is dysmetria?
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in point to point movements when finger initially overshoots but then reaches it
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What does consistent deviation to one side in point to point movements suggest and what is it called?
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cerebellar or vestibular disease
past pointing |
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What is tandem walking?
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walking heel to toe in a straight line
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What is a gait that lacks coordination with reeling instability called?
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ataxic
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Why make pt walking on heels and toes?
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to identify distal muscle weakness in legs
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Inabilty to heel walk is a sensitive test for what?
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cortocospinal damage
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difficulty hopping could indicate what?
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weakness
lack of position sense cerebellar dysfunction |
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describe spastic hemiparesis?
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poor control of flexor muscles during swing phase
affected arm, elbow, wrist, is flexed, immobile, and held close to side leg extensors spastic ankle plantar flexed and inverted toe drag lean to contralateral side |
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When does spastic hemiparesis appear?
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corticospinal tract lesion in stroke
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describe scissor gait?
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gait is stiff
thighs cross forward on each other leg moves slowly steps are short "walking through water" |
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When do you see scissor gait?
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spinal cord disease
causes bilateral lower extremity spasm |
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describe steppage gait?
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foot drop
drag feet or lift them high "walking on stairs" tibialis anterior and toe extensors are weak |
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When do you see steppage gait?
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secondary to peripheral motor unit disease
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What is parkinsons gait?
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posture stooped
flexion of head, arms, hips, knees slow short shuffling steps "all in one piece" turn around postural control poor (retropulsion) |
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When do yoy see parkinsons gait?
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basal ganglia disease of parkinsons
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describe cerebellar ataxia?
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gait is staggering, unsteady and wide based
cannot stand with feet together dysmetris, nystagmus, intention tremor (all indicate cerebellar disorder) |
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describe sensory ataxia?
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unsteady wide based gait
feet out and around and heels down first watch ground for guidance walking positive rhomberg sign |
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When do you see sensory ataxia?
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loss of position sense in legs
polynueropathy or posterior column damage |
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What is romberg sign and what does it test for?
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tests position sense
stand feet together and maintain normal posture then close eyes and pt cant remain steady indicative of dorsal column disease, loss of position sense, cerebellar ataxia positive= cant stay balanced |
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What is pronator drift test?
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stand feet together and push down on flexed arms and pt hold position
sensitive and specific for corticospinal tract lesion in contralateral hemisphere |
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what does sideward movement with writing motions of hands in pronator drift suggest?
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loss of position sense
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What does arms returning to normal postion but overshoots or bouncing in pronator dift indicate?
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cerebellar incoordination
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What do sensory impulses do?
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participate in reflex activity
give rise to conscious sensation calibrate body position in space regulate internal autonomic functions like blood pressure, heart rate, and respiration |
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What things should be assessed when evaluating the sensory system?
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pain and temperature(spinothalmic tracts)
position and vibration (posterior columns) light touch (both pathways) discriminative senstations (cortex) |
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What is a suggested pattern for dermatome testing?
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shoulders (C4)
inner and outer aspects of the forearms (C6 and T1) thumbs and little fingers (C6 and C8) fronts of both thighs (L2) medial and lateral aspects of both calves (L4 and L5) little toes (S1) medial aspect of each buttock (S3). |
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should eyes be open or closed when testing for sensation?
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closed
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how do you test pain sensation?
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using a pin or cotton swab to test sharp and dull pain and symmetry
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What is the absence of pain?
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analgesia
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What is decreased sensitivity to pain
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hypalgesia
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What is increased sensitivity to pain?
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hyerpalgesia
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When do you do temperature testing?
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if pain sensation is abnormal
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how do you assess light touch?
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ask pt to let you know when they feel the cotton wisp on you
(not on calloused skin) |
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how do you test vibration sense?
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tuning fork vibrating on DIP of finger and toe
testing on trunk may be useful in finding spinal cord lesion if cant feel on DIP |
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What is the first sense to be lost in peripheral neuropathy?
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vibration sense
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What sense is lost in posterior column disease like tertiary syphillis or vitamin B12 deficiency
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vibration sense
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how do you test proprioception?
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move big toe up and down
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When would you see loss of proprioception/position sense?
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tabes dorsalis
MS b12 deficiency posterior column disease peripheral neuropathy |
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what it the ability to identify an object by feeling it?
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stereognosis
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what is the inability to recognize objects placed in the hand?
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astereognosis
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What is the ability to recognize a number drawn on your palm?
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graphesthesia
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What is the normal distance for two point discrimination?
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less than 5mm
if not normal could be lesion in sensory cortex |
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What do point localization and extinction indicate?
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lesions in sensory cortex
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What is a dermatome?
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A dermatome is the band of skin innervated by the sensory root of a single spinal nerve.
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list the dermatomes for matching
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C2 - posterior half of the skull cap
C3 - high turtle neck shirt C4 - low-collar shirt C6 - (radial n.) 1st digit (thumb) C7 - (median n.) 2nd & 3rd digit C8 - (ulnar n.) 4th & 5th digit T4 - nipples T5 - Inframammary fold T6/T7 - xiphoid process T10 - umbilicus T12 - pubic bone L1 - inguinal ligament L4 - includes the knee caps S2/S3 - genitalia |
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What is the scale for grading reflexes?
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4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)
3+ Brisker than average; possibly but not necessarily indicative of disease 2+ Average; normal 1+ Somewhat diminished; low normal 0 No response |
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What should you use if symmetrically diminshed reflexes or absent?
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reinforcement (involving isometric contraction of other muscles for up to 10 seconds)
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What do hyperactive reflexes indicate?
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CNS lesion along descending corticospinal tract
(look for associated babinski sign) |
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What do hypoactive reflexes indicate?
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disease of spinal N roots, spinal NN, plexuses or peripheral N
(associated weakness, atrophy, fasciculations) |
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What spinal n is biceps reflex test?
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C5, C6
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What spinal N is triceps reflex test?
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C6, C7
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What does brachioradialis reflex test?
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C5, C6
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What does patellar reflex test?
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L2,L3,L4
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What does ankle reflex test?
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S1
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What is clonus and what does it test for?
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rhythmic oscillations b/w dorsiflexion and plantarflexion
indicated CNS disease |
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What do abdominal reflexes test and what do they indicate if absent?
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T8, T9, T10 above umbilicus
T10, T11, T12 below umbilicus CNS and PNS disorders if absent |
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What is babinski sign and what does it test for?
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dorsiflexion of big toe when stimulating plantar foot
CNS lesion in corticospinal tract, unconscious states or postictal |
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What does los of anal reflex indicate?
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lesion in S2-S4 reflex arc
cauda equina |
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What is a meningeal sign?
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neck stiffness when passively flexing neck
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What is brudzinskis sign?
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tests for meningitis by flexing the neck and watching for abnormal flexion of the hip and knees in response to neck flexion
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What is kernig sign?
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test for meningitis by flexing knee and hip and then straightening the knee while looking for abnormal pain and resistance
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What does the straight leg raise test for?
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lumbosacral radiculopathy- L5-S1 (sciatica)
tightness or discomfort in butt or hamstrings |
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what is a positive crossed SLR?
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pain when contralateral healthy leg is raise
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What is a positive SLR?
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pain into ipsilateral leg and increased pain with dorsiflexion
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What is asterixis?
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identifies metabolic encephalopathy
liver disease, uremia, hypercapnia |
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What does winged scapula *****?
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serratus anterior mm weakness from injury to long thoracic nerve
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describe Alertness?
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An alert patient opens the eyes, looks at you, and responds fully and appropriately to stimuli (arousal intact).
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how to test for lethargy and what does it look like?
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Speak to the patient in a loud voice.
call the patient's name or ask “How are you?” appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep. |
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how to tests for obtundation and what does it look like?
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Shake the patient gently as if awakening a sleeper.
opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased. |
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How to test for stupor and what does it look like?
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Apply a painful stimulus.
pinch a tendon, rub the sternum, or roll a pencil across a nail bed. (No stronger stimuli needed!) arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment. |
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how to test for coma and what does it look like?
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apply repeated painful stimuli
remains unarousable with eyes closed. There is no evident response to inner need or external stimuli. |
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What signs of a coma strongly predict death?
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absent corneal response
absent pupillary response absent withdrawal response to pain no motor response |
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What does ABC of LOC mean?
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airway, breathing, and circulation
rate, rhythm, pattern of breathing skin color pulse, BP, temp |
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What not to do when assessing comatose pt?
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Don't dilate the pupils
the single most important clue to the underlying cause of coma (structural vs. metabolic) Don't flex the neck if there is any question of trauma to the head or neck. immobilize the cervical spine and get an x-ray first to rule out fractures of the cervical vertebrae that could compress and damage the spinal cord. |
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What does absence of light reaction in pupils indicate in comatose pt?
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structural cause of coma such as stroke, abscess, tumor
(rather than metabolic where light reaction is intact? |
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What is gaze preference is comatose pt?
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horizontal deviation of eyes to one side
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When do eyes "look away" in comatose pt?
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In irritative lesions from epilepsy or early cerebral hemorrhage
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when do eyes "look at lesion" in comatose pt?
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In structural hemispheric lesions
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When do the eyes look straight ahead in comatose pt?
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when oculomotor pathways are intact
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What is dolls eyes and what does it assess?
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oculocephalic reflex for brainstem function in response to comatose pt.
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What is a positive dolls eyes?
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In a comatose patient with an intact brainstem, as the head is turned, the eyes move toward the opposite side (the doll's eye movements).
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what is a negative dolls eyes?
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In a comatose patient with absence of doll's eye movements, the ability to move both eyes to one side is lost, suggesting a lesion of the midbrain or pons.
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What is cold calorics?
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oculovestibular reflex tested in a comatose pt
In the comatose patient with an intact brainstem, the eyes drift toward the irrigated ear. No response to stimulation suggests brainstem injury. |
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What is it called in comatose pt when the patient pushes the stimulus away or withdraws.
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normal avoidant
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What is it called in comatose pt when the stimulus evokes abnormal postural responses of the trunk and extremities
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Stereotypic
decorticate rigidity (bad) and decerebrate rigidity (hosed) |
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What is the source of visceral pain?
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internal organs
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What receptors are activated by visceral pain?
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nociceptors for stretch and inflammation and oxygen starvation in ischemia
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What are characteristics of visceral abdominal pain?
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often poorly localized
Gnawing burning vague deep ache cramping or colicky in nature frequently produces referred pain to the back |
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What is the source of parietal abdominal pain?
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parietal peritoneum
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What receptors are activated?
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Somatic innervation (spinal nerves).
from inflammation |
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What are characteristics of parietal abdominal pain?
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Precisely localized
Steady aching pain sharp Aggravated by movement, couching |
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What things should be assessed in PMH in GI?
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GERD, “heartburn”
Hepatitis Chirrosis Autoimmune d/o |
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What things should be assessed in SH in GI?
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IV drug use
Tobacco EtOH Travel to exotic destination Occupation |
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What things should be assessed in FH in GI?
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Hepatitis
CA Hereditary disorders |
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What things should be assessed in Surgical hx in GI?
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Prior abdominal surgery
Endoscopy, Colonoscopy |
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What medications should be assessed in GI hx?
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NSAIDS
Bisphosphnates |
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What are S/S of UTI?
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Suprapubic pain
Flank pain Ureteral colic Dysuria Urgency Polyuria Nocturia Urinary incontinence Stress Urge Overflow Functional Hematuria |
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What order should the GI PE go in?
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Inspection
Auscultation Percussion Palpation |
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What should be inspected in the GI PE?
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Skin (Scars, Striae, Caput medussae, Rashes, lesions)
Umbilicus Contour of the abdomen Evidence of Peristalsis Pulsations |
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What should be evaluated in auscultation
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All 4 quadrant (Borborygmi, Hyperperistalsis)
Listen for bruits in : Aortic AA Renal AA Femoral AA Friction rub (Spleen, Liver) |
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What should be percussed in GI PE?
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All 4 quadrants to assess the distribution of tympany and dullness
(Gastric buble Note any large areas of dullness Mass, enlarged organ) |
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What should be palpated in GI PE?
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Position – supine, arms to the side
Assess painful areas last Feel for : Masses, Guarding, Pain, Referred pain Light palpation Deep palpation Rebound Tenderness (Peritoneal inflammation) |
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How do you measure the vertical span of the liver?
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Define the upper and lower border
Percussion will change from tympany to dullness |
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What is a normal size for liver borders?
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Midclavicluar line – 6-12 cm
Midline – 4-cm |
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What should a normal liver feel like?
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Soft
Sharp (distinct) edge Smooth surface |
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What is taube's space?
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area where spleen is
anterior to anterior axillary line and below bottom rib |
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What is CVA tenderness assess for?
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Indicative of renal disease particularly pyelonephritis or UTI
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What does the bladder feel like in palpation and when should you examine it?
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smooth and round
with c/o UTI or pelvic pain |
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How to test for AAA and what size is normal?
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pulse in abdomen and in ultrasound want it to be less than 3cm
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What is ascites?
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fluid in peritoneal cavity
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What are transudative causes of ascites?
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cirrhosis, CHF, hepatic vv occlusion
normal fluid |
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What are exudative causes of ascites?
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cancer, infection (TB), pancreatitis
infected fluid |
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What are S/S of ascites?
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Abdominal distension, bulging flanks, SOB, leg swelling, bruising, hematemesis, encephalopathy
Shifting dullness, fluid wave |
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What does "shifting dullness" test?
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ascites
Percussion of fluid – dullness Percussion of air filled bowel – tympany |
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What does fluid wave test for
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ascites
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What is appendicitis?
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inflammation of appendix
fecalith obstruction |
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What are S/S of appendicitis?
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“Classic” presentation: Pain, followed by, N/V, lastly fever
Diarrhea very unlikely |
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What tests should be done for appendicitis?
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Rovsing’s sign
Psoas sign Obturator sign Dunphy’s sign McBurney’s point |
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What is rovings sign?
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palpate in LLq and feel pain in RLQ
test for appendicitis |
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What is psoas sign?
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test for appendicitis
push down on extended raising leg |
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What is obturator sign?
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test for appendicitis
turn knee inward and leg outward |
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What is dunphy sign?
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pain in RLQ when coughing
test for appendicitis |
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What is McBurneys point?
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when appendix is located between pubic symphysis and illiac crest
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What is cholecystitis?
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inflammation of the gallbladder usually caused by cholelithiasis
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What are S/S of cholecystitis?
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RUQ pain – constant, severe, referred to groin or scapula, exacerbated by fatty/greasy foods
Low grade fever, N/V/D, granulocytosis High grade fever, shock, jaundice – indicate complications Abscess formation, ascending cholangitis, fistula |
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What is Murphys sign?
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pain in RUQ when palpating that causes them to stop breathing
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What is a hernia?
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protrusion of any organ, structure, or portion thereof through its normal anatomical confines
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What signs should you look for with a hernia?
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Incarceration
Strangulation |
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What is the most common type of hernia?
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Umbilical
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What is an umbilical hernia?
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Incomplete umbilical closure allows protrusion of omentum or bowel.
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What are DDx for umbilical hernia?
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Gastrochisis
Omphalocele |
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What is omphalocele?
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incomplete closure of umbilicus, abdominal contents herniate into the base of the umbilical cord
perinatal emergency |
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What is gastrochisis?
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No cover of herniated abdominal contents
Perinatal emergency |
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What is an incisional hernia?
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Protrusion of abdominal contents through a prior fascial incision
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What are causes of incisional hernias?
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MC deep wound infection
Obesity Steroid dependence Multiple prior operations |
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What are S/S of incisional hernias and how do you Dx it?
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bulge, pain, discomfort at site, bowel obstruction
Ct for dx |
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What is diastasis recti?
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Fascial weakness, not a true defect
Rectus mm separate in the upper midline Treatment: Reassurance Weight loss Abdominal mm strengthening |
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What is an epigastric hernia?
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Congenital or acquired
Herniation through the linea alba, superior to the umbilicus |
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What should you do when females come in with abdominal pain?
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Ask about pregnancy, LMP, “protection”
Get pregnancy test before CT, MRI Consider pelvic exam |
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What is surgical abdomen?
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??
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What are indications for nasogastric tube placement?
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Sampling gastric contents
Removal of air, blood, gastric contents (fluid, drugs…) Nutritional support |
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What are contraindications for NGT?
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Facial trauma or basilar skull fx
Esophageal stricture or burn Recent stomach or esophagus surgery History of bariatric surgery fig 14.1 |
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What are complications of NGT?
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Trauma to turbinates or nasopharynx (bleeding)
Placement of NGT into lungs (aspiration) Erosion- gastric, nasal Sinusitis NGT thru a break in path after trauma (into brain) |
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how to prep patient for NGT?
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Pt should be alert and cooperative
Explain and discuss procedure Importance of keeping head flexed to avoid placement into the trachea Normally causes pts to gag |
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What are NGT sizes?
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3-18 in French
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What are specialized NGT?
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Weighted ends
Double lumen Sump tubes |
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How do you place an NGT?
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Have all materials and people ready
Pt sitting up at least 45 degrees Personal protective equipment Determine which nostril to use Measure from tip of noseearlobexiphoid Mark insertion length KY to first 3” of tube Place beveled side of tube toward septum Pt to flex chin to chest Insert tube at 90 degrees to axis of head Have pt take small sips of water while advancing the tube into the stomach Check position of the tube Inject air while listening for gurgles Aspirate gastric contents- pH < 3 Get x-rays Tape tube in place |
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What are indications for anoscopy?
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Rectal bleeding
Pruritis or discharge Prolapse rectum Mass on DRE |
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What are contraindications for anoscopy?
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Severe rectal pain
Perirectal abcess, thrombosed hemorrhoid, anal fissure Severe anal stricture Pt unwilling or unable to cooperate |
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What are complications for anoscopy?
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Anal or perianal tears
Bleeding |
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What kind of pt preparation should be given before anoscopy?
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Adequate education
Address embarrassment Slightly painful May cause urge to defecate |
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What is assessed in DRE?
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Rectal canal for lesions/masses
Int hem and dentate line not palpable Assess prostate in male patient Check stool for occult blood FOBT, OBS |
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What are indications for flex sigmoidoscopy?
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Rectal bleeding (frank or occult)
Hemorrhoidal inflammation Anal fissure Polyp Inflammatory colon conditions Screening |
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What are contraindications of flex sig?
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Colitis- fulminant
Diverticulitis- severe or acute Toxic megacolon Peritonitis Poor bowel prep Poor patient cooperation Severe cardiopulmonary disease |
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What are complications of flex sig?
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Spotting and minor bleeding
Bowel perforation Tear at anastomosis sites |
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What should be included in flex sig pt prep?
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Explain procedure, answer questions
Informed consent Liquid diet for 24 hours prior Bowel prep Medications (no asa, nsaids, coumadin, and take abx for cardiac valvular disease) |
