Phys Dx Test 3 NeuroMusculoskeletal System Ch



Phys Dx Test 3 NeuroMusculoskeletal System Ch. 20 &21

Principal Functions of the musculoskeletal system are to support and protect the body and to bring about movement of extremities for locomotion and the performance of tasks. Composed of –Bone -Skeletal Muscle -Ligaments and Tendons -Cartilage

1. Symptoms of Musculoskeletal System

|Pain |Bone: Deep, Dull, Intense |

| |Fracture: Sharp |

| |Muscle: Crampy |

| |Joint: Tenderness: movement worsens pain |

|Weakness |Proximal Weakness: Myopathy |

| |Distal Weakness: Neuropathy |

|Deformity |Congenital malformation or acquired condition |

|Limitation of movement |Changes in articular cartilage, scarring of joint capsule, |

| |muscle contractures |

|Stiffness |Common system, esp. with RA |

|Joint clicking |Associated w/ specific movements |

| |Typical w/: dislocation, displacement of tendon, DJD, Meniscus |

| |damage, TMJ |

2. MS change with Age

3. Provide a differential for: Low Back Pain, Neck Pain, Peripheral Jt. Pain

|Low Back Pain |Neck Pain |Joint Pain |

|Mechanical |Local tenderness, spasm, |Simple Stiff Neck |Acute Local mm |RA |Chronic Infl. Of |

| |loss of lumbar lordosis | |tenderness & pain w/ | |synovial membrane |

| | | |movement: not | | |

| | | |understood | | |

|Radicular |Dermatome loss, + SLR, mm |Aching Neck |Persistant Dull Ache |OA |Degenerative loss of|

| |weakness/atrophy: Herniated | |due to posture. Local| |cartilage w/in |

| |Disc | |mm tenderness | |joints |

|Lumbar Stenosis |Flexed forward, mm weakness, |Cervical Sprain |Whiplash: severe neck|Gouty Arthritis |Inflammation due to |

|(back and leg pain)|hyporeflexia: DJD combo w/ | |pain and mm tenderness| |micro crystals of |

| |OA narrow canal | | | |sodium urate |

|Chronic persistant |Loss lumbar lordosis, mm |Pain w/ dermatomal |Radiates down arm; |Chronic Tophaceous |Mult. Local |

|low back |spasm, limit ant. Lat. |radiation |Sharp, tingling mm |Gout |accumulation of |

|persisitance |Flexion: i.e. ankylosing | |tenderness, spasm; | |sodium urate in |

| |spondylitis; DISH | |compression of 1+ disc| |joints w/o |

| | | | | |inflammation |

|Aching Nocturnal |Local bone tenderness: |Pain from |Compression of 1+ |Polymyalgia |Assoc. w/ giant cell|

|Pain |Metastatic Malignancy |compression of Cord |disc; trauma; limit. |Rheumatica |arteritis |

| | | |ROM, | | |

| | | |weakness/paralysis; | | |

| | | |loss of senses; | | |

| | | |babinski + | | |

|Pain referred from |Spinal movements don’t cause | |Fibromyalgia |Widespread MS pain |

|abdomen, pelvis |pain: ulcer, pancreatitis, | |Syndrome |and tender jts. |

| |AAA | | | |

4. What are the features of OA and RA?

|Clinical Feature |RA |OA |

|Patients age |3-80 |Older than 45 |

|Morning stiffness |More than 1 hr |Less than 1 hr |

|Disability |Often Great |Variable |

|Joint Distribution | | |

| Distal interphalangeal jt |Rare |Very Common |

| Prox. Interphalangeal jt |Very Common |Common |

| Metacarpophalangeal jt |Very Common |Absent |

| Wrist |Very Common |Absent |

|Soft Tissue Swelling |Very Common |Rare |

|Interosseous muscle wasting |Very Common |Rare |

|Swan-necking |Common |Rare |

|Ulnar Deviation |Common |Absent |

RA: Most destructive and disabling of the principal jt. disease. Chronic Inflammation of jts. and other organs. Characteristic changes in the hand. Two main deformities:

-Swan-Necking: flexion MCP jts, hyperextension of PIP jts, flexion of DIP jts.

-Boutonniere: flexion deformity PIP jts. w/ hyperextension of DIP jts.

OA: Common DJD. Minimal inflammation compared to RA. Deformities:

-Heberden’s nodes: Enlargement of DIP jts.

-Bouchard’s nodes: Enlargement of PIP jts.

5. What are some of the indicators of muscular weakness when assessing functional activities

-Tone: tested by resistance to passive movement.

-Spasticity UML -Atrophy LMN

-Hyperreflexia UML -Fasciculations LMN

-Clonus UML -Decreased Tone LMN

-Babinski’s Sign UML -Hyporeflexia LMN

6. Joint Disorders and Evaluations

|Joint |Symptoms |Exam |Disorders |

|TMJ |Unilateral/bilateral pain with chewing; |Palpate in front of Tragus | |

| |clicking |feeling for least and last and | |

| | |smoothness | |

|Shoulder |May be referred from chest/abdomen. |Orthopedic Tests. |Impingement Syn. Tendonitis |

| |Muscle: pain worse @ night. Radiates |ROM, Inspect |Bursitis |

| |down arm, tenderness | |Arthritis |

| | | |Adhesive Capsulites |

| | | |Dislocation |

|Elbow |Local pain. Look @ radius and elbow. |Palpate; test flex/ext and |Tennis Elbow |

| | |sup/pron |RA OA PA |

| | | |Gout |

|Wrist |Pain, Numbness, Tingling, Loss of |Palpate. ROM of |Carpal Tunnel |

| |movement |dorsiflexion/palmar flexion; |RA OA PA |

| | |sup/pro; Tinel’s Sign |Acute Gout |

|Hand |Pain, Swelling |Palpate MCP PIP DIP, note |De Quervain’s * |

| | |swelling, redness, ROM, make |Carpal Tunnel |

| | |fist, spread fingers |OA RA PA |

| | | |Acute Gout |

|Spine |Pain |Inspect, Palpate muscles and |Cervical Rib |

| | |vert., ROM, Ortho Test |Sciatica |

| | | |Whiplash |

|Hip |Pain, Stiffness, Deformity, and a limp |Trendelenburg, Leg Length, ROM, |OA, Osteoporosis, Fractures, |

| | | |Strain/Sprain,TLF/ITB, Avascular |

| | | |necrosis |

|Knee |Pain, Swelling, Jt instability, limited |Palpate, Ballottement,* |Hemarthrosis* |

| |movement |Palpate collateral lig, Drawer |Locking* |

| | |Test, Ortho Test |Baker’s Cyst |

| | | |Knee Jt. Effusion |

| | | |Torn Meniscus |

| | | |Ra OA PA, Gout |

|Ankle & Foot |Pain, Swelling, Deformities |ROM, analyze gait, heel walk, |Cavus (high arch) |

| | |toe walk, Palpate Achilles T. |Flat foot, Atrophy, Reiter’s Syn. |

| | |Thompson-Dohery squeeze test |OA PA RA |

| | | |Gout, Hallux limitus, podagra |

*De Quervain’s is tenosynovitsi of the thumb abductors and extensors

*Hemarthrosis is synovial effusion or bleeding into the joint

*Locking is a result of small pieces of broken cartilage

*BallottementMaintain pressure on lat. Margins of patell, tap patella w/ opposite hand

Clininicopathologic Correlations Ch. 20

|Rheumatoid Arthritis |Chronic inflammation of joint and organs. Mostly characteristic in hands with swan-necking and |

| |boutonniere deformity of MCP, PIP, DIP and Wrist. There is bone erosion. Ulnar deviation @ MCP. |

|Osteoarthritis |DJD. Inflammatory response is minimal. Frequently found in DIP. Heberden’s nodes: enlarged DIP. |

| |Bouchard’s nodes: enlarged PIP. |

|Gout |Metabolic disease characterized by high levels of uric acid, recurrent attacks of acute arthritis, and |

| |deposition of urate crystals in/around joint. Pain 1st occurs in Big Toe upon waking. Joint is red, |

| |swollen, shiny. Tophi (subcutaneous & periarticular deposits of urate crystals) produces w/ increasing|

| |uric acid. These found in Ear, DIP, elbow, Achilles T., big toe. |

|Psoriatic Arthritis |Asymmetrical arthritis involving 2-3 joints at a time. |

|Arthritis Mutilans |Most deforming type of psoriatic arthritis. Osteolysis of phalangeal and metacarpal joints, resulting |

| |in “telescoping of the digits” |

|Tuberous Sclerosis |Dominantly inherited . . Symptom Triad: Mental retardation, seizures, Adenoma sebaceum (Occurs near |

| |the nasolabial folds and over the cheeks. Facial angiofibromas) |

|Squamous Cell Carcinoma |Found on sun exposed areas… |

|Diabetic Foot |Chronic sensorimotor neuropathy, automonic neuropathy, poor peripheral circulation. Neurotrophic |

| |ulcers. Bacterial infections common |

|Bullosis Diabeticorum |Uncommon, non-inflammatory, blistering condition w/ unknown etiology seen in insulin-dependent |

| |diabetics.Tense bullae develop on normal skin in acral areas. Blisters intra/subepidermal boccur w/o |

| |trauma. |

|Tinea Pedis w/ bacterial |Produces macerated, scaling, fissured toe webs, inflammatory epidermis, and thick Hypertrophic, |

|infect. |discolored nails. |

|Necrotizing Faciitis |Severe form of cellulites in diabetic patients. Caused by mixture of aerobic and anaerobic |

| |gram-negative organisms. |

|Scleroderma |Progressive systemic sclerosis, is a chronic multisystem disease manifested by thickening of the skin |

| |and varying degree of organ involvement. I.E. Calcinosis, Raynaud’s phenomenon, Esophgeal motility |

| |problems, Sclerodactyly, and Telangiectasia (CREST). Calcification of soft tissues. Tapered |

| |appearance w/ tuft of scarred tissue. |

|Cutaneous Larva Migrans |Caused by animal hookworms from Ancylostoma braziliense or Ancylostoma caninum. Creeping eruptions |

| |when in contact w/ feces. Raised, Serpiginous, Erythematous, Pruritic eruption. |

|Plantar Fasciitis |Pain in the heel and pain in Big Toe. Inflammation caused by excessive stretching of plantar fascia |

| |(broad band of fibrous tissue that runs along bottom of foot). Caused by: Over-pronation, Flat feet, |

| |high arch, sudden increase in physical activity excessive weight, improper footwear |

|Sesamoiditis |Common in dancers. Pain in ball of foot on medial side. Pain of sesamoid bones. Gradual onset. |

|Morton’s Neuroma |Pain, Swelling, inflammation of an interdigital nerve.Neuroma formation due to compression. Sharp |

| |Pain, burning, paresthesia. Common w/ walking, standing, jumping, sprinting, high-heels. Elicits |

| |Mulder’s sign. |

|Heel Pain |Big Toe Pain |

|Plantar calcaneal spur (enthesopathy) |OA |

|Plantar fasciitis |Bursitis/capsulitis |

|Inferior calcaneal bursitis |Fracture |

|Atrophy of plantar fat pad |Sesamoiditis |

|RA |Gout |

|Ankylosing spondylitis |RA |

|Reiter’s Syndrome |Reiter’s Syndrome |

|Gout |Septic arthritis |

|Fracture | |

|Foreign body | |

|Neoplasm | |

|Nerve entrapment | |

7. What are some of the special tests for articular problems

8. What are some of the different types of spinal curvatures

-Scoliosis -Kyphosis -Lordosis

9. What is the grading system for muscular strength

0: Absent: No contraction detected

1: Trace: Slight contraction detected

2: Weak: Movement with gravity eliminated (sideways)

3: Fair: Movement against gravity (upward)

4: Good: Movement against gravity with some resistance

5: Normal: Movement against gravity with full resistance

10. What are some of the risk factors for Osteoporosis NOT FOUND IN BOOK

-Gender -Physical Inactivity

-Ethnic Origin -Nutritional Factors

-Low BMI -Low Vitamin D

-Menopause -Long term Corticosteroid Use

11. What are the symptoms of neurological disorder

|Symptoms | |

|Headache |See next question for types… |

| |Usually associated w/ visual phenomena, nausea, or vomiting |

|Loss of consciousness “Syncope” |Results from cardiovascular or neurologic causes. Can mean: |

| |actual loss of consciousness, dimming of vision, decreased |

| |awareness or environment. Common with Epileptic seizures. |

|Dizziness |Vertigo, ataxia, lightheadedness, Meniere’s Disease: results in |

| |protracted attacks of severe vertigo with vomiting. |

|Ataxia |Disruption of the vestibule-ocular-cerebellar control. It is |

| |persistent unsteadiness while upright. Caused by: syphilis |

| |(damage post. Column), vitamin B12 def., multiple sclerosis. |

|Changes in consciousness |May be related to attention span, perception, arousal. Caused |

| |by: |

| |Head Trauma |

| |Supratentorial Lesions: |

| |Brainstem Lesions |

| |Psychiatric illness |

| |Metabolic changes |

|Visual Disturbance |Acute painless visual loss: vascular accident or a retinal |

| |detachment, acute narrow glaucoma. |

| |Amaurosis fugax: transient visual loss lasting upt o 3 minutes: |

| |interal carotid artery dx. |

| |Diplopia: Ocular motor palsies, thyroid abnormalities, |

| |myasthenia gravis, brainstem lesions. |

|Dysphasia |Abnormalities in speech. May be seen in stroke patients. |

| |Expressive aphasia: speech is hesitant and labored w/ poor |

| |articulation. |

| |Receptive aphasia: speech is rapid and appears fluent but is |

| |full of syntax errors w/ omission of many words. |

|Dementia |Failing Memory. Alzheimer’s Disease, Parkinson’s Disease, |

| |vascular disorders, metabolic disorders, drugs, tumors, vitamin |

| |B12 def., normal pressure hydrocephalus. |

|Cerebrovascular accident |Strokes. Most ore Thromboembolic (80%) some are hemorrhagic |

| |(20%). Results in unilateral paralysis of 1 limb. TIA: focal |

| |neurologic dysfunction. |

|Gait disturbance |May change b/c: local foot pain, joint pain, claudication of |

| |hip/leg, bone disease, vestibular problems, extrapyramidal |

| |disorders. Spinal cord lesions: spastic paralysis affecting both|

| |legs. |

|Tremor |Rhythmic motion of distal parts of limbs or head. Parkinson’s |

| |Disease, Intention tremor, Multiple Sclerosis, Metabolic |

| |problems. Chorea: jerky motions of face/limbs. Huntington’s |

| |Disease: chorea + brain failure. |

|Numbness |Indicates many problems. “Pins and Needles” |

|Weakness |Motor symptom. Proximal and Distal limb weakness. Face droop |

| |and weakness ore common signs of a stroke. |

|Pain |Infrequent. Trigeminal neuralgia “Tic douloureux”: occurrence |

| |of severe, jabbing pain lasting only seconds in the distribution |

| |of maxillary or mandibular divisions of trigeminal nerve. |

| |Herpes Zoster, Sciatica, Meningitis. |

12. Provide a differential diagnosis for a headache

|Type |Epidemiology |Location |Signs & Symptoms |

|Migraine |Family History |Bifrontal |Nausea |

| |Young adults | |Vomiting |

| |Female | |Possible neurologic deficits |

|Cluster |Adolescent male |Orbitofrontal |Unilateral nasal congestion |

| | |Unilateral |Lacrimation |

|Tension |Female |Bilateral | |

| | |Generalized or Occipital | |

|Hypertensive |Family History |Variable |Hypertensive retinopathy |

| | | |Possible papilledema |

|Increased Intracranial Pressure | |Variable |Nausea |

| | | |Vomiting |

| | | |Papilledema |

|Meningitis | |Bilateral |Nuchal rigidity |

| | |Often Occipital |Fever |

|Temporal arteritis |Older adults |Unilateral |Tender temporal artery |

| | |Over Temporal artery |Loss of vision in ipsilateral |

| | | |eye |

*Migraine: Biphasic with a prodromal phase (aura) followed by headache phase. Aura phase symptoms include: transient autonomic, visual, motor, or sensory phenomena, photophobia, blurred vision, and scotomata. It is usually unilateral and pulsating lasting days to hours. Can be triggered by: stress, anxiety, birth control pills, excitement, hormonal changes, hunger, and certain foods such as: chocolate, cheese, cured meats, spicy food.

*Cluster Headaches: Oculosympathetic disturbances. Usually middle-aged man describes pain as recurrent pain centered around eye lasting 1 hr. Usually awaken pt. from sleep for 2-4 weeks. Ipsilateral miosis, ptosis, conjunctival edema, tearing, and nasal stuffiness are common. Alcohol may precipitate this headache.

13. What are 2 primary categories for seizures and what features provide differentiation

Focal: Clinical seizure reflects the effect of the excessive discharge in that area of the body.

Generalized: results from a discharge in the subcortical structures such as the thalmocortical radiations. i.e. Petit mal, Grand mal, Myoclonic

|Epileptic Seizures |Caused by sudden, excessive, disorderly discharge of neurons. |

|Petit mal Seizure |Characterized by a sudden attack of unconsciousness lasting only about 10 seconds usually w/o |

| |warning. Pt. appears to be daydreaming, no falling or involuntary limb motion. |

|Grand mal Seizure |Major motor convulsion. Pts lose consciousness and many fall rigidly to the floor. Pts. have |

| |aura of giddiness, involuntary twitching, change in mood, confusion, or epigastric discomfort |

| |as the seizure starts. |

| |Tonic Phase: increase in muscle tone, resulting in rigid posture. |

| |Clonic phase: involuntary movements of the body, salivation, eye rolling, incontinence. |

|Myoclonic Seizure |Minor motor seizure characterized by sudden muscle contrations of face and upper extremitites. |

|Febrile Convulsions |Common in children from 6 months to 6 years old. Similar to grand mal. Occurs when child has |

| |a high fever, lasting less than 10 minutes. The younger a child is when they first have this |

| |seizure, the greater likelihood that it will recur. |

14. Explain the 3 common postures in a comatose pt

|Posture |Description |Lesion |

|Decorticate |Rigidity, |Cerebral hemispheric dysfunction or |

| |Arms adducted and |destructive lesion of pyramidal tracts. |

| |Elbows, wrists, fingers, are flexed. | |

| |Legs are internally rotated. | |

|Decerebrate |Rigidity, |Midbrain or pons lesion |

| |Arms are adducted, | |

| |Elbows Extended | |

| |Forearms pronated | |

| | | |

15. What is Syncope? Explain levels of consciousness.

-Syncope is a loss of consiousness commonly termed blackout. Manifests with actual loss of consciousness, dimming of vision, or decreased awareness of environment without actual loss of consciousness.

16. What are Broca’s and Wernike’s aphasia and what are their features

17. Describe some of the features of abnormal gait patterns and their sig.

|Hemiplegia |Tends to drag or circumduct a weak and spastic leg. Arm is frequently flexed @ elbow across |

| |abdomen. |

|Parkinson’s disease |Shuffles, with short, hurried steps. Head is bowed with the back bent over. |

|Cerebellar Ataxia |Wide-based gait. Feet are far apart and patients staggers from side to side |

|Foot Drop |Has a characteristic slapping gait resulting from weakness of the dorsiflexors of the ankle |

|Sensory Ataxia | High-stepping gait. Slaps feet down firmly |

18. Describe features that may differentiate muscular vs. neurologic involvement

19. What features are evaluated when determining a pts mental status

• Level of Consciousness

• Speech

• Orientation

• Knowledge of current events

• Judgment

• Abstraction

• Vocabulary

• Emotional responses

• Memory

• Calculation ability

• Object recognition

• Praxis

20. Discuss distinguishing features of depression vs dementia

21. Be familiar with evaluation of the cranial nerves

|Cranial Nerve |Function |Clinical Findings |Test |

|I: Olfactory |Smell |Anosmia |Sniff Test |

|II: Optic |Vision |Amaurosis |Visual acuity, ophthalmoscopic |

| | | |exam |

|III: Oculomotor |Eye movements; papillary |Diplopia; ptosis; mydriasis; |Pupillary Light Reflex |

| |constriction; accommodation |loss of accommodation |Confrontation testing, Follow |

| | | |finger in H |

|IV: Trochlear |Eye movements |Diplopia |Confrontation, Follow Finger in |

| | | |H |

|V: Trigeminal |General sensation of face, |Numbness of face; weakness of |S&M: Bite Down |

| |scalp, and teeth; chewing |jaw muscles |S: Lightly touch face w/ cotton|

| |movements | |balls, |

| | | |Corneal Reflex |

|VI: Abducens |Eye movements |Diplopia |Confrontation, |

| | | |Follow finger in H |

|VII: Facial |Taste; general sensation of |Loss of taste on anterior 2/3 of|Smile |

| |palate and external ear; |tongue; dry mouth; loss of |Taste: sweet/salty |

| |lacrimal gland and submandibular|lacrimation; paralysis of facial| |

| |and sublingual gland secretion; |muscles | |

| |facial expression | | |

|VIII: Vestibulocochlear |Hearing; equilibrium |Deafness; tinnitus; vertigo; |Hearing and balance. Stand, |

| | |nystagmus |close eyes. |

|IX: Glossopharyngeal |Taste; general sensation of |Loss of taste on posterior 1/3 |Say “Ah.” (symmetrical elevation|

| |pharynx and ear; elevates |of the tongue; anesthesia of |of soft palate). |

| |palate; parotid gland secretion |pharynx; partially dry mouth |Gag Reflex |

|X: Vagus |Taste; general sensation of |Dysphagia; hoarseness; palatal |Same as IX |

| |pharynx, larynx, and ear; |paralysis | |

| |swallowing; phonation; | | |

| |parasympathetic to heart | | |

|XI: Spinal Accessory |Phonation; head, neck, and |Hoarseness; weakness of head, |Turn head against resistance, |

| |shoulder movements |neck, and shoulder muscles |Shrug shoulders |

|XII: Hypoglossal |Tongue movements |Weakness and wasting of tongue. |Stick out tongue (look for |

| | | |deviation toward the lesion) |

22. What procedures evaluate proprioception and cerebellar function

|Proprioception |Cerebellar |

|Light Touch |Finger-to-Nose test |

|Pain Sensation |Heel-to-knee-test |

|Vibration sense |Rapid alternating movement |

|Tactile Localization |Romberg Test |

|Discriminative sensations (two point, stereognosis, |Gait assessment |

|graphestheisa, point localization) | |

23. What procedures evaluate cortical sensory functions

|Light Touch |Lightly touch pt. with gauze with eyes closed and tell what they |

| |feel |

|Pain sensation |Prick pt. w/ safety pin and have them tell you what they feel w/ |

| |eyes closed Whether it is Sharp or Dull. |

|Vibration sense |Use 128-Hz tuning fork on a bony prominence and have pt tell you |

| |with eyes closed when they no longer feel the vibration |

|Proprioception |Dr. manually move pts. finger up and down and w/ pts. eyes |

| |closed, have pt. tell you if you move it up or down. |

|Tactile localization |Have pt. close eyes and id where touch is felt. |

|Discriminative sensations |Two-point; stereognosis; graphesthesia; point localization |

24. What is the scale of responses for deep tendon reflexes

0: No Response

1+: Diminished Anterior horn cell disorders and myopathies

2+: Normal

3+: Increased

4+: Hyperactive Pyramidal tract disease

25. What are the clinical signs of upper vs lower motor neuron lesion

|Effect |UMNL |LMNL |

|Voluntary control |Lost |Lost |

|Muscle Tone |Spastic, Increased |Flaccid, Decreased |

|Reflex Arcs |Present |Absent |

|Pathologic Reflexes |Present |Not Present |

|Muscle Atrophy |Little or None |Significant |

|UMNL |LMNL |

|Spasticity |Atrophy |

|Hyperreflexia |Fasciculations |

|Clonus |Decreased Tone |

|Babinski’s Sign |Hyporeflexia |

26. What do the following terms mean: Stereognosis, Tactile agnosis, Graphesthesia, Clonus.

| |Definition |Test |

|Stereognosis |Integrative function of the parietal and |Identify object in hands w/ eyes closed |

| |occipital lobes | |

|Tactile agnosis |Inability to recognize an object by | |

| |palpation | |

|Graphesthesia |Is the ability to identify a number |Have pt. close eyes and i.d. # (0-9) you |

| |“written” in the palm of one’s hand |write on their palm |

|Clonus |Involuntary muscle contractions due to | |

| |stretching indicating UMNL | |

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