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EYESKnow the order of the examSnellen alphabet chart: measures visual acuity—normal 20/20Test near vision: for those who report difficulty reading or over 40; test with handheld vision screener w/ various sizes of print (held 14in or 35cm from eye)—normal is 14/14Presbyopia suggested when person moves card farther from eye to see (loss of accommodation)Confrontation test: gross measure of peripheral vision (test pt peripheral vision with your own—in older adults, this screens for glaucoma)Corneal light reflex (Hirschberg test): shine light on nose when pt looks straight ahead—should see refection of light in same spot on both eyesAsymmetry of light reflex indicates deviation in alignment from eye muscle weakness or paralysis (if seen, perform cover test)Cover test: first check uncovered eye for deviation (should have a fixed gaze); if muscle weakness exists the covered eye will move into a relaxed position when uncoveredPhoria: mild weakness noted when fusion is blockedTropia: more severe—constant malaignment of the eyesDiagnostic positions test (note any nystagmus—fine oscillating movement best seen around the iris)—test six cardinal positions of gazeMild nystagmus at an extreme lateral gaze is normalNystagmus occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis, or brain lesionInspect external ocular structuresEyebrows: symmetrical (position and movement), no scaling or lesions; unequal or absent movement with nerve damage, scaling with seborrheaEyelids and lashesNote any lid lag (results from hyperthyroidism), ptosis (drooping), periorbital edema, lesionsIncomplete closure risks corneal damageEyeballs: note protrusion or sunken appearance (exophthalmos or enophtalmos)Conjunctive and scleraConjunctive moist and glossy, clear with blood vessels shown throughSclera is china white (Africans may have gray-blue or muddy color; dark skinned people may have small brown macules on sclera)Scleral icterus: yellowing of sclera extending up to the cornea, indicating jaundice (not to be confused with normal yellowing fatty deposits beneath the lids away from the cornea in African’s)Lacrimal apparatusInspect anterior eyeball structuresCornea and lens: should be no opacities (cloudiness) in cornea, anterior chamber, or lens behind pupilIris and pupil: normally round, regular, and equal in size in both eyes (3-5mm)Pupil size differences may be normal in a small population—called anisocoriaTest pupillary light reflex (note direct and consensual constriction)Note size before light and after constrictionTest accommodation: note constriction and convergent of pupils and eyes when focus is brought from far object to finger 3in from eyesInspect ocular fundusSystematically inspect structures in ocular fundusRetinal vesselsOptic discMaculaCentral Vision—how tested and how scored.Snellen alphabet chart: measures visual acuityLines of letters arranged in decreasing sizePlace chart in a well-lit spot at eye level; position person exactly 20 feet from chart; hand person an opaque card with which to shield one eye at a time during test If person wears glasses or contact lenses, leave them on; remove reading glassesAsk to read smallest line of letters possible;Encourage trying next smallest line Normal visual acuity is 20/20Peripheral Vision—how tested and interpretedConfrontation TestGross measure of peripheral visionPosition yourself at eye level with patient 2 feet awayDirect patient to cover 1 eye, with other look straight at youCover your own eye opposite patient’s covered eyeHold your finger as target midline between you & patient, slowly advance it in from periphery in several directionsAsk person to say “now” as finger is first seen; this should be just as you see your fingerKnow the eye anatomy, how tested, what is it tested for, and possible abnormalitiesExternal:Eyelids: protect eyePalpebral fissure: elliptical open space between eyelids (approximate completely when closed)Limbus: border between cornea and scleraCanthus: corners of eye where lids meetCaruncle: small, fleshy mass containing sebaceous glandsTarsal plates: strips of connective tissue that give upper lid shape (contain meibomian glands—modified sebaceous glands that secrete oily lubricating material to stop tears from overflowing and forms airtight seal)Conjunctiva: transparent protective covering—thin mucous membrane folded line an envelope b/t eyelids and eyeballLacrimal apparatus: provides constant irrigation to keep conjunctiva and cornea moist and lubricatedMuscles of eyeInternal: Sclera: tough protective white coveringCornea: Tested by corneal reflex (blinking of both eyes when one cornea is touched with a wisp of cotton)Trigeminal nerve carries afferent sensation of cotton to brainFacial nerve carries efferent message to blinkChoroid: dark pigment to absorb light and prevent reflection; vascularized to deliver blood to retinaCiliary body (muscles): control thickness of lens – refraction of light and focusIris: controls diameter of pupil and amount of light entering retinaPupil: CN III: controls constriction of pupil (parasympathetic); sympathetic dilates pupilAnterior and posterior chambers filled with aqueous humor to deliver nutrients to enclosed structures and drain metabolic wasteRetina: visual layer- viewed with opthalmoscope Optic disc: area of convergence of fibers of retina to form optic nerve (nasal side of retina)Creamy yellow-orange to pink in color; margins distinct and sharply demarcated (esp. at temporal side); physiological cup in disc where blood vessels enter and exit retinaVessels of retina: Arteries are paired, appear brighter red and narrower than veins with a thin sliver of light on them (arterial light reflex)Macula contains the fovea centralis or area of sharpest and keenest vision (should be inspected last—may cause tearing of pt)Path of visual light through eye: Cornea aqueous humor lens vitreous humor retinaWhat cranial nerves are associated with eye exam—and how testedExtraocular muscles movement is stimulated byCN VI: abducens nerve, innervates lateral rectus muscle, which abducts eyeCN IV: trochlear nerve, innervates superior oblique muscle, moves eye down & mediallyCN III: oculomotor nerve, innervates the superior, inferior & medial rectus & the inferior oblique musclesTrigeminal nerve, CN V, carries afferent sensation to brain Facial nerve, CN VII, carries efferent message to organOptic disc: where fibers in retina converge to form optic nerveConstriction and dilation of pupil----what situations cause these to occur?Afferent messages of light sent by CNII and efferent message to constrict pupil via CNIIIDirect light reflex: constriction of pupils when light shines on retinaConsensual light reflex: simultaneous constriction of other pupil Blind eye has not CNII response and thus no direct or consensual responseWhat is the red glow noted with the oto-ophthalmoscope on the patient’s pupil?Corneal light reflex, the Hirschberg testAssess parallel alignment of eye axesDirect patient to stare straight ahead as you hold light about 12 inches awayNote reflection of light on corneas; should be in exactly same spot on each eyeKnow the order of the internal eye exam and what is the anatomyInspect ocular fundusOphthalmoscope - inspect: anterior chamber & retinal backgroundOphthalmoscope contains lenses strength of each lens is diopterBlack numbers indicate positive diopter; use to focus on near objectsRed numbers show negative diopter, focus on objects farther awaySystematically inspect structures in ocular fundusGeneral backgroundRetinal vesselsFollow a paired artery & vein to periphery in 4 quadrants note:Number: paired artery & vein pass in each quadrant; vessels look straighter at nasal sideColor: arteries brighter red than veins; have arterial light reflexA:V ratio: ratio comparing artery-to-vein width is 2:3 or 4:5Caliber: arteries & veins show a decrease in caliber as they extend to peripheryOptic discMost prominent landmark, located on nasal side of retina; explore these characteristics:Color: creamy yellow-orange to pinkShape: round or ovalMargins: distinct & sharply demarcated, nasal edge may be slightly fuzzyMaculaLocated temporal to discInspect last in funduscopic exam; bright light may cause tearing, discomfort, pupillary constrictionNormal even & color darker than rest of fundusClumped pigment may occur with agingGeneral background of fundusColor normally varies from light red to dark brown-red; view of fundus should be clear; no lesions should obstruct retinal structuresReview eye abnormalities in lecture notes ANY loss of vision is a medical emergencyCommon causes of decreased visual functioning:Cataract formation - protein growth that goes over pupil; filmGlaucoma or increased IOP - Acute narrow angle: pupil is oval, dilated; cornea looks "steamy". Occurs w/sudden increase in IOP from blocked outflow from anterior chamber. Experiences sudden clouding of vision, sudden eye pain, and halos around lights. Requires emergency treatment to avoid vision loss.Macular degeneration - Loss of central vision is most common cause of blindness; person is unable to read fine print or do fine work; loss of central vision may cause great distressRacial & ethnic variations in blindnessWhites over age 40 years, leading cause of blindness is age-related macular degeneration (54%) followed by cataracts (9%)African Americans older than 40 years, cataracts & open-angle glaucoma together cause 60% of blindnessHispanics older than 40 years, leading cause of blindness is open-angle glaucomaExtraocular muscle dysfunctionStrabismus - squinty, crossed-eyesEsotropia - inward turning of the eyeExotropia - outward turning of the eyeCover Test:Esophoria: nasal (inward) driftExophoria: temporal (outward) driftAbnormalities in the eyelidsPeriorbital edema - lids are swollen and puffy. Occurs w/ local infections, crying, allergies, hypothyroidism, renal failure, heart failureExophthalmos - forward displacement of eyeballs and widened palpebral fissures; note lid lagEnophthalmos - sunken in eyeballs; narrowed palpebral fissures; recessed eyeballs. Caused by lose of fat in orbits; occurs with dehydration and chronic wasting illnesses.Ptosis - Droopy upper eyelid; occurs from neuromusclular weakness (MG), CNIII damage, or sympathetic nerve damage (Horner’s syndrome)—sleepy appearance and impairs visionUpward palpebral slant - associated w/down syndrome; may be normal in children Ectropion - lower lid is lose and rolling outwards; doesn't approximate to the eyeball. The puncta can't siphon tears effectively—results in excess tearing. Eyes feel itchy and dry.Entropion - lower lid rolls in because of spasm of lids or scar tissue contracting. Constant rubbing of lashes may irritate cornea—foreign body sensationLesions on the eyelidsBlepharitis - inflammation of the eyelids: red scaly greasy flakes, and thickened crested lid margins. Occurs w/staph infections or seborrhetic dermatitis of the lid edges (burning, itching, tearing, foreign body sensation, and pain)Chalazion - beady nodule protruding on the lid, it is an infection or retention cyst of a meibomian gland. Nontender, firm, and discrete w/freely moveable skin overlying the nodule (Contrast with stye—when inflamed, points inside and not on lid margin)Hordeolum - stye, localized staph infection of hair follicle at the lid marginDacryocystitis - inflammation of lacrimal sac and ductVascular disorders of external eyeConjunctivitis - pink eye has red beefy looking vessels at the periphery; usually clear at the iris. Common from bacteria (purulent discharge) or viral infection; allergy or chemical irritation.Preauricular lymph node often swollen and painful, with Hx of URISymptoms: itching, burning, foreign body sensation, eyelids stuck together on awakeningSubconjunctival hemorrhage - red patch on the sclera; looks alarming but nothing serious. Sharp edges like a spot of paint. Occurs from IOP from coughing, vomiting, weight lifting, labor, straining when taking a dump, traumaIritis (circumcorneal redness) - deep dull red halo around iris and cornea...note halo is around iris vs. in conjunctivitis it is around at periphery.Photophobia, constricted pupils, blurred vision, and throbbing painWarrants immediate referral Acute glaucoma – acute narrow-angle glaucoma shows a circumcorneal redness around the iris with a dilated pupil; pupil oval, dilated; cornea looks steamy; anterior chamber shallowPt experiences a sudden clouding of vision, sudden eye pain, and halos around lightsRequires emergency treatment to avoid permanent vision lossCornea & IrisPterygium - a triangular, opaque wing of bulbar conjunctiva overgrowth toward the center of the cornea. Usually occurs from exposure to hot, sandy climate. Looks membranous, translucent, and yellow to white—obstructs visionPinguecula - yellowish, elevated nodule due to thickening of bulbar conjunctive. From prolonged exposure to sun, wind and dust. Like a yellow spot in your eye.Corneal abrasion - results from blunt eye injury, irregular ridges usually only visible w/fluorescein stain reveals yellow/green branching. Top layer of corneal epithelium is removed from scratches or poorly fitting or overworn contact lenses; symptoms include intense pain, foreign body sensation, and lacrimation, redness, and photophobia Hyphema - blood in the anterior chamber. Serious result of herpes zoster infection or blunt force trauma, or spontaneous hemorrhageHypopyon - purulent matter in anterior chamber; occurs w/iritis and w/inflammation of anterior chamber.What happens to eye with aging process?Visual acuity decreases (risk for falls)Central acuity may decrease, particularly after age 70; peripheral vision may also diminishEyebrows may show loss of outer 1/3 to 1/2 of hair due to decrease in hair follicles; brow hair is coarserSkin around eyes may show wrinkles due to atrophy of tissues; upper lid may be elongated & rest on lashes, resulting in pseudoptosisEyes may appear sunken from atrophy of orbital fatLacrimal apparatus may decrease tear production, causing eyes to look dry & lusterless, may report a burning sensation (lacrimal glands involute decreased tear production with feeling of dryness and burning)Pingueculae may show on sclera (yellowish, elevated nodules due to thickening of the bulbar conjunctiva from prolonged sun, wind, or dust exposure—appear at the 3 and 9 o’clock positions—first on nasal and then temporal side)Pupil size decreases in old age; pupillary light reflex may be slowedCornea may look cloudy with ageArcus senilis commonly seen around cornea (degenerative lipid material around the limbus—gray-white arc or circle, no effect of vison)Xanthelasma: soft, raised yellow plaques occurring on lids at inner canthusLens loses elasticity, becomes hard & glasslike, decreases ability to accommodate for near vision (presbyopia)By age 70, transparent fibers of lens begin to thicken, the beginning of cataracts (lens opacity resulting from a clumping of proteins in the lens)Visual acuity may diminish gradually after age 50, & more so after age 70Glaucoma: increased intraocular pressure—chronic open-angle glaucoma most common, involves loss of peripheral vision)Macular degeneration leading to loss of central vision (inhibits ability to read find print and skills that require visual acuity)MENTAL STATUS AND NEUROLOGICAL EXAMKnow sections of the mental status exam: Appearance, Behavior, Cognitive Functions, and Thought Processes and Perception—what goes in each sectionAppearancePosture - erect and position is relaxed.Anxiety & Hyperthyroidism - sitting on edge of chair or curled in bed, tense muscles, frowning, darting watchful eyes, restless pacing occurDepression & some organic brain diseases - sitting slumped in chair, slow walk, dragging feetBody movements - voluntary, deliberate, coordinated, and smooth and even. Anxiety - restlessness, fidgety movements or hyperkinetic appearanceDepression & dementia - apathy and psychomotor slowingSchizophrenia - abnormal posturing and bizarre gesturesDress - appropriate for setting, season, age, gender, and social group. Clothing fits and is put on anic brain syndrome - inappropriate dressSchizophrenia or Manic syndrome - eccentric dress combination and bizarre makeup.Grooming and hygiene - clean and well groomed; hair is neat and clean; women have moderate or no makeup; men are shaved, or beard or mustache is well groomed. Nails are clean (some jobs leave nails chronically dirty). Note: a disheveled appearance in a previously well-groomed person is significant. Use care in interpreting clothing that is disheveled, bizarre, or in poor repair, piercings, and tattoos, sometimes these reflect a person's economic status or a deliberate fashion trendCVA - Unilateral neglect (total inattention to one side of body)Depression and severe Alzheimer's - Inappropriate dress, poor hygiene and lack of concern w/appearanceOCD - Meticulously dressed and groomed appearance and fastidious mannerBehaviorLOC - person is awake, alert, aware of stimuli from the environment and w/in the self, and responds appropriately and reasonable soon to stimuli.Falls asleep, loses track of conversationLethargic (drowsy), obtunded (confused)Facial expression - look is appropriate to situation and changes appropriately w/the topic. There is comfortable eye contact unless precluded by cultural norm (e.g., Am. Indian)Parkinsonism & Depression - flat, masklike expressionSpeech - Judge the quality of speech by noting the person makes laryngeal sounds effortlessly and shares conversation appropriately.pace of conversation is moderate, and stream of talking is fluentArticulation (ability to form words) is clear and understandable.Word choice - effortless and appropriate to educational level. Person completes sentences, occasionally pausing to think. Speech disorders - Dysphonia is abnormal volume, pitch.Monopolizes interview. Silent, secretive, or uncommunicative.Manic syndrome - rapid-fire, pressured and loudParkinsonism & Depression - slow, monotonous speechDysarthria - distorted speech. Misuses words; omits letters, syllables, or words; transposes words (occurs w/Aphasia).Unduly long word-finding or failure in word search (occurs w/Aphasia).Mood and affect - based on body language and facial expression and by asking, "How do you feel today," or "How do you usually feel?" The mood should be appropriate to person's place and condition and change appropriately w/topics. Person is willing to cooperate w/you.Manic syndrome - wide mood swingsSchizophrenia - bizarre moodCognitive functionOrientation - ask person's address, phone number, health hx. Or can ask dateTime: Day of week, date, year, seasonPlace: where they live, present location, type of building, name of city ad statePerson: name, age, who examiner is, type of workerDelirium & Dementia - disorientation occursUsually lost in this order: time, place, rarely to personAttention span - person's ability to concentrate by noting whether he or she completes a thought w/o wandering. Note any distractibility of difficulty attending to you. Or give a series of directions to follow and note the left hand, drink from it, shift it to your right hand, and set it on the table. Anxious, fatigued or drug intoxicated people have impaired attention span.Digression from initial thought, irrelevant replies to questions. Easily distracted; "stimulus bound" (i.e., an new stimulus quickly draws attention).Confusion, negativismRecent memory - 24-h diet recall or ask time the person arrived. Ask questions you can corroborate. This screens for occasional person who confabulates or makes up answers to fill in the gaps of memory loss.Recent memory loss occurs w/delirium, dementia, amnestic syndrome or Korsakoff's syndrome in chronic alcoholismRemote memory - ask verifiable past events; for example, ask to describe past health, first job, DO, and anniversary dates, and historical events that are relevant for person.Remote memory lost when cortical storage area for that memory is damaged (e.g., Alzheimer dementia or any disease that damages the cerebral cortex)New learning - The Four Unrelated Words Test - tests person's ability to lay down new memories. Highly sensitive and valid memory test. Requires more effort than does the recall of personal or hx events. Also avoids danger of unverifiable material.Say four words, have them repeat (should be semantic and phonetically different)After 5 mins, ask them to recall words.Then at 10 and 30 mins.Normal: < 60 yo: recall 3-4Alzheimer dementia score a 0 or 1.Anxiety - impaired new learning ability occurs w/anxietyDepression - due to lack of effort mobilized to rememberJudgment - when he/she can compare and evaluate alternatives in a situation and reach and appropriate course of action. Use daily or long-term life goals, the likelihood of acting in response to delusions or hallucinations, and capacity for violent or suicidal behavior. Ask job plans, social or family obligations, and plans for future. They should be realistic, considering person's health situation.ask them to describe the rationale for personal health care and how he/she decided about whether or not to comply w/prescribed health regimensMental retardation, emotional dysfunction, schizophrenia, and organic brain disease - impaired judgment (unrealistic or impulsive decisions, wish fulfillment) occurThought processes - the way a person things should be logical, goal directed, coherent, and relevant. They should complete a thought.Does this person make sense?Illogical, unrealistic thought processes. Digression from initial thought. Ideas run together. Evidence of blocking (person stops in the middle of the thought)Thought Content - What the person says should be consistent and logical.Obsessions and compulsionsPerception - Person should be consistently be aware of reality. their perceptions should be congruent w/yours. Ask:How do people treat you?Do other people talk about you?Do you feel like you are being watched, followed?Is your imagination very active?Have you ever heard your name when alone?Illusions, hallucinations. Auditory and visual hallucinations occur w/psychiatric and organic brain disease and w/psychedelic drugs. Tactile hallucinations occur w/alcohol withdrawalKnow neurological system anatomy and major functions. Cerebral cortexCerebrum’s outer layer of nerve cellsGray matter- lacks myelinGoverns: thought, memory, reasoning, sensation, voluntary movementEach half of cerebrum is hemisphereLeft is dominant in 95% of humansEach hemisphere has 4 lobes: frontal, parietal, temporal & occipitalWernicke’s area in temporal lobe associated with language comprehensionWhen damaged in the dominant hemisphere, receptive aphasia results (hear sounds but can’t comprehend—like a foreign language)Broca’s area in frontal lobe mediates motor speech When injured in dominant hemisphere, expressive aphasia results (can understand words, knows what they want to say, but when attempting to talk words come out garbled)Basal gangliaBands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (extrapyramidal system)Initiate & coordinate movements, controls automatic movements of body (arms swing alternating with the legs during walking)Pathology of basal ganglia: Parkinson’s Disease, Huntington’s Disease & Cerebral PalsyThalamusPaired lobed mass of grey matter on top of the brain stemMain relay station: sensory pathways of spinal cord, cerebellum & brain stem form synapsesInvolved in sensory perception & regulation of motor functionsPathology of thalamus: thalamic CVA, Thalamic Syndrome (Dejerine-Roussy), schizophrenia & lesionsHypothalamusSize of an almond, inferior to the thalamus, above the midbrainLinks the CNS to the endocrine systemControl center for many autonomic functions of the PNSMajor respiratory centerControls temperature, appetite, sex drive, HR, BP control, sleep center, posterior pituitary gland regulator, and coordinator of ANS activity and stress responsePathology: tumorsGliomashamartomas CerebellumCoiled structure at base of skull under occipital lobes Relays information between muscles & cerebral cortexControls, adjusts & corrects voluntary motor movement, coordination, balance, equilibrium &?muscle toneOperates below conscious levelBrain StemLower section of the brain, continuous with the?spinal cordConnects motor & sensory tracts from the brain to the body Assists in regulation of cardiac & respiratory functionRegulates the CNS, helps maintain consciousness & regulates?sleep Consists of 3 areas:Midbrain; contains motor neurons and tractsPons; has ascending sensory and descending motor tracts. Has two respiratory centers (pneumotaxic and apneustic) that coordinate the main resp center in the medulla. Medulla; contains all ascending and descending fiber tracts. Has vital autonomic centers (respiration, heart, GI function), nuclei for CN VIII, through XII. Pyramidal decussation occurs here.Spinal Cord Descends from medulla down the back, surrounded by meninges & protected by the vertebral columnExtends to 1st - 2nd?lumbar vertebraeVertebral canal continues beyond the cord, lumbar cistern spaceWhite matterGray matterWhat is central nervous system and what structures does it include p 621-626Includes the brain and the spinal cord. Includes cerebral cortex, the hemispheres that divide into the lobes. Basal ganglia, helps to initiate and coordinate movements and control automatic associated movements of the body. Thalamus is the main relay station where sensory pathways of the SC, cerebellum, and brainstem form synapses on their way to the cerebral cortex. Hypothalamus, major respiratory center with basic vital functions like temperature, appetite, sex drive, HR, & BP, sleep center, ant and post pit gland regulator and coordinator of ANS activity and stress response. Cerebellum under occipital lobe deals with motor coordination of voluntary movement, equilibrium and muscle tone. Doesn’t initiate movement but coordinates and smooth’s it. Brainstem, see above for detail. Spinal cord; occupies the upper 2/3 of the vertebral column from the medulla to L1-L2 is a highway for ascending and descending fiber tracts that connect the brain and the Spinal nerves. Mediates reflexes of posture control, urination and pain response. The vertebral canal continues down beyond the SC for several inches. What is peripheral nervous system and what structures does in include p 626 Carries input to the CNS via their sensory afferent fibers and deliver output from the CNS via efferent fibers. What are the autonomic nervous system, sympathetic and parasympathetic nervous systems?ANS; composed of cranial nerves and spinal nerves. They carry fibers that can be divided functionally in two parts- somatic and autonomic. Somatic innervate the skeletal (voluntary) muscles. Autonomic innervate smooth (involuntary) muscle, cardiac and glands. Mediates unconscious activity. What is the difference between vertigo, dizziness and tinnitus?Syncope: sudden loss of strength, a temporary loss of consciousness (fainting) due to lack of cerebral blood flow (such as low BP)Vertigo: rotational spinning caused by neurologic disease in the vestibular apparatus in the ear or in the vestibular nuclei in the brainstem.Rotational spinning.Objective vertigo: room is spinningSubjective vertigo: feel like you are spinningDizziness: light headed, swimming sensation, feeling of falling (not spinning)Tinnitus: ringing crackling or buzzing in your ears. Originates within person accompanies some hearing or ear disorders. Know the 12 cranial nerves—sensory, motor or both; how tested and expected findings—abnormalitiesCN I: Olfactory, sensoryTest sense of smell in those who report loss of smell, head trauma, abnormal mental status, when presence of intracranial lesion suspectedWith person’s eyes closed, occlude one nostril & present familiar aromatic substance, e.g., coffee, orange, vanilla, soap or peppermintNormally, person can identify an odor on each side of nose; normally decreased with agingAnosmia = loss of smell (occurs bilaterally with tobacco smoking, allergic rhinitis, and cocaine use; unilateral loss in absence of disease is neurogenic anosmia); cribiform plate or ethmoid fractures; tumor in olfactory bulb or tractCN II: Optic, sensoryTest visual acuity (Snellen chart) & visual fields by confrontation (test peripheral vision)Using ophthalmoscope, examine ocular fundus to determine color size, & shape of optic discCN III, IV & VI: Oculomotor, Trochlear & Abducens, motorPalpebral fissures are equal in widthCheck pupils for size, regularity, equality, direct & consensual light reaction & accommodationAssess extraocular movements by cardinal positions of gazeAssess for nystagmus (occurs with disease of vestibular system, cerebellum, or brainstem)CN V: Trigeminal: sensory & motor3 divisions of CN V: ophthalmic, maxillary, mandibularMotor function: assess muscles of mastication by palpating temporal & masseter muscles as person clenches teeth; try to separate jaws by pushing down on chin; normally you cannotSensory function: with eyes closed, test light touch sensation by touching a cotton wisp to: forehead, cheek & chin, perform bilaterallyCorneal reflex: omit, unless abnormal facial sensation or movement Person looking forward, bring wisp of cotton in from side, lightly touch cornea, not conjunctivaNormally, person will blink bilaterallyCN VII: Facial, sensory & motorMotor function:Note mobility & symmetry as person: smiles, frowns, closes eyes tightly (against your attempt to open them), lifts eyebrows, shows teeth, puff cheeks, then press puffed cheeks in, normally air escapes equally from both sidesSensory function: Test when you suspect facial nerve injuryTest sense of taste by applying cotton applicator covered with solution of sugar, salt or lemon juice to anterior 1/3 of tongue, ask to identify CN VIII: Acoustic (Vestibulocochlear), sensoryTest hearing acuity by ability to hear normal conversation & by whispered voice testCN IX & X: Glossopharyngeal & Vagus: sensory & motorMotor functionDepress tongue with tongue blade, note pharyngeal movement as person says ahhh; uvula & soft palate should rise in midline & tonsillar pillars should move medially (absence or asymmetry of soft palate movement or tonsillar pillar movement follows stroke)Touch posterior pharyngeal wall with blade, note gag reflexVoice sounds smooth, not strainedSensory functionCN IX mediates taste on posterior one third of tongueCN XI: Spinal Accessory: motorExamine sternomastoid & trapezius muscles for symmetry Check equal strength by asking person to rotate head against resistance applied to side of chinAsk person to shrug shoulders against resistance Movements should feel equally strong on both sidesCN XII: Hypoglossal: motorInspect tongue; no wasting or tremorsNote forward thrust in midline as person protrudes tongueTongue will deviate to the side with the lesion of the hypoglossal nerve (deviation toward paralyzed side)Ask person to say “light, tight, dynamite,” note lingual speech (sounds of letters l, t, d, n) are clear & distinctKnow common abnormalities as noted on lecture notes—e.g. peripheral neuropathy, chorea, ataxia, Abnormal Findings Abnormalities in Muscle MovementParalysis: decreased or loss of motor power due to problem with motor neuron or muscle fibers. Fasciculation: rapid continuous twitching of resting muscle or part of muscle without movement of limbTic: involuntary compulsive, repetitive twitching of muscle group (wink, grimace, head movement, shoulder shrug); neurologic cause (Tourette’s or tardive dyskinesia) or psychogenic cause (habit tic)Myoclonus: rapid sudden jerk, or short series of jerk, at fairly regular intervals (hiccup is a myoclonus of the diaphragm; sudden jerk when falling asleep; severe jerks with grand mal seizure)Tremor: involuntary contraction of apposing muscle groups, may occur at rest or with voluntary movements, all disappear while sleep (rhythmic back and forth movement of one or more joints)Rest tremor: occurs when muscles are quiet and supported against gravity (hand in lap), but will disappear with voluntary movementIntention tremor: occurs with cerebellar disease or MS; worse with voluntary movement such as reaching toward a visually guided target (essential tremor most common with older people and is benign—improves with admin of sedatives, propranolol, or alcohol)Chorea: sudden rapid jerky purposeless movement, involving limbs, trunk, face, irregular intervals, not rhythmic or repetitive, disappear in sleep, seen in Huntington’s (more convulsive than a tic)Athetosis: slow twisting, writhing, continuous movements resembling snake or worm, involves distal more than proximal part of limb; occurs with cerebral palsy. Disappears with sleep; flexion and extending of different fingers on same handAbnormal GaitsSpastic hemiparesis: arm is immobile against body, with flexion of shoulder, elbow, wrist, and fingers, adduction of shoulder, does not swing freely; leg is stiff and extended and circumducts with each step (drag toe in semicircle)UMN lesion of the corticospinal tract (CVA, trauma)Cerebellar ataxia: staggering wide based gait, difficulty with turns, uncoordinated movement with positive Romberg’s sing—Upper motor neuron lesions: MS; Acute cerebellar dysfunction: alcohol intoxication Parkinsonian (festinating): stooped truck is pitched forward, elbows, hops, and knees are flexed steps are short and shuffling. Hesitation to begin walking, diff to stop suddenly. Person holds the body rigid; walks and turns body as one fixed units. Difficult with any change in directionScissors: knees cross or in contact, like holding an orange between thighs. Short step and walking requires effort (paraparesis of legs of MS)Steppage or footdrop: slapping quality—looks as if walking up stairs and finds no stair there. Lifts knee and foot high and slaps it down hard and flat to compensate for footdrop (weakness of perineal and anterior tibial muscles; due to LMN lesion at the spinal cord such as polio)Waddling: weak hip muscles. When pt takes step, opposite hip drops, which allows compensatory lateral movement of pelvis. Often, the pt also has marked lumbar lordosis and a protruding abdomen (hip girdle muscle weakness due to muscular dystrophy, dislocation of hips)Short leg: leg length discrepancy >2.5 cm (1 in) vertical telescoping of affected side, which dips as the pt walks. Appearance of gait varies depending on amount of accompanying muscle dysfunctionDysmetria: clumsy movement with overshooting the mark and occurs with cerebellar disorders or acute alcohol intoxication Common Patterns of sensory lossPeripheral neuropathy: loss of sensation involves all modalities. Loss is most severe distally (feet and hands); response improves as stimulus is moved proximally (glove-and-stocking anesthesia) anesthesia zone gradually merges into a hypoethesia zone, and then gradually normalDM, chronic alcoholism, nutritional deficiencyIndividual nerves or roots: decrease or loss of all sensory modalities. Area of sensory loss corresponds to distribution of the involved nerveTrauma or vascular occlusionSpinal cord hemisection (Brown-Séquard syndrome): loss of pain and temperature, contralateral side, starting one to two segments below the level of the lesion. Loss of vibration and position discrimination on the ipsilateral side, below the level of the lesionsMeningioma, neurofibroma, cervical spondylosis, MSComplete transection of spinal cord: complete loss of all sensory modalities below the level of the lesion. Condition is associated with motor paralysis and loss of sphincter controlSC trauma, demyelinating disorders, tumorThalamus: loss of all sensory modalities on the face, arm, and leg on the side contralateral to the lesionVascular occlusionCortex: because pain, vibration, and crude touch are mediated by thalamus, little loss of these sensory functions occurs with a cortex lesion. Loss of discrimination occurs on the contralateral side. Loss of graphesthesia, sterognosis, recognition of shapes and weights, finger finding.Cerebral cortex, parietal lobe lesion (CVA or stroke)Abnormal posturesDecorticate rigidity: upper extremities—flexion of arm, wrist, and fingers; adduction of arm (ie tight against thorax). Lower extremities—extension, internal rotation, plantar flexion. This indicates hemispheric lesion of cerebral cortexDecerebrate rigidity: upper extremities stiffly extended, adducted, internal rotation, palms probated. Lower extremities stiffly extended, planter flexion; teeth clenched; hyperextended back. More ominous than decorticate rigidity; indicates lesion in brainstem at midbrain or upper ponsFlaccid quadriplegia: complete loss of muscle tone and paralysis of all four extremities, indicating completely nonfunctional brainstemOpisthotonos: prolonged arching of back, with head and heels bent backward. This indicates meningeal irritationHow is intracranial pressure assessed by a nurse post neurosurgery?Increasing Intercranial pressure is signal of impending cerebral disaster and death Test with abbreviated neurological exam Level of Consciousness Assess AAOx4 and GCS and ability to follow verbal commands (if person is not fully alert, increase amount of stimulus)If pt is intubated, ask questions that the pt can nod or shake head to respondMotor function Check CNII by facial movements; test strength to assess upper and lower motor neurons; test for drifting by having pt hold arms extended outward in front of them; assess for localizing to painful stimulation (pushing away your hand)—considered a purposeful movement 3. Pupillary response: assess direct and consensual movements 4. Vital signs: changes are late signs of rising ICPHow is the motor system tested—what is a positive Romberg test?Balance TestsGaitRomberg test: Positive = loss of balance that occurs when closing the eyes; you eliminate the advantage of orientation with the eyes, which had compensated for sensory loss; positive sign occurs with cerebellar ataxia (MS, alcohol), loss of proprioception, and loss of vestibular function Coordination and skilled movementsRapid Alternating Movements (RAM)Finger-to-finger testFinger-to-nose testHeel-to-shin testKnow reflexes—deep tendon and superficial. How tested and expected responsesDeep tendon receptorsMeasurement of stretch reflexes reveals intactness of reflex arc at specific spinal levelsLimb should be relaxed & muscle partially stretchedStimulate reflex by directing short, snap of reflex hammer onto muscle’s insertion at tendonCompare sides: should be equalUtilize reinforcementDTRs graded on a 4-point scale4 = very brisk, hyperactive with clonus, indicative of disease3 = brisker than average, may indicate disease2 = Average, normal1 = diminished, low normal or occurs with reinforcement0 = no responseSubjective scale requires clinical practiceBiceps reflex, C5 - C6Support person’s forearm on yours; place your thumb on biceps tendon & strike your thumbNormal response is contraction of biceps muscle & flexion of forearmTriceps reflex, C7 - C8Tell person to let arm hand as you strike triceps tendon directly just above the elbowNormal response is extension of forearmBrachioradialis reflex, C5 to C6Hold person’s thumb to suspend forearms in relaxation & strike forearm directly, about 2 - 3 cm above radial styloid processNormal response is flexion & supination of forearmQuadriceps reflex, L2 to L4 (knee jerk)Let lower legs dangle freely to flex knee & stretch tendons; strike tendon directly below patellaNormal response is extension of lower legAchilles reflex, L5 to S2 (ankle jerk)Position person with knee flexed; hold foot in dorsiflexion & strike Achilles tendon directly Normal response is foot plantar flexes against your handSensory receptorsSensory receptors in skin; motor response is localized muscle contractionAbdominal reflexes: upper: T8 - T10; lower: T10 - T12Person in supine position, knees slightly bent; use handle end of reflex hammer to stroke skinMove from each corner toward midline at both upper & lower abdominal levelsNormal response is ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward strokeCremasteric reflex, L1 to L2 On male, lightly stroke inner aspect of thigh with reflex hammer or tongue bladeNote elevation of ipsilateral testiclePlantar reflex, L4 to S2Position thigh with slight external rotationWith reflex hammer, draw a light stroke up lateral side of sole of foot & inward across ball of foot, like an upside-down “J”Normal response is plantar flexion of toes & inversion & flexion of forefootHow are sensory tests done—and what to look forAsk person to identify various sensory stimuli in order to test intactness of peripheral nerve fibers, sensory tracts & cortical discriminationRoutine screening includes testing superficial pain, light touch & vibration in few distal locations & testing stereognosis Spinothalamic tractPainTemperatureLight touchPosterior column tractVibrationPosition (kinesthesia)StereognosisGraphesthesiaTwo-point discriminationExtinctionPoint locationWhat is mappingMapping is process of locating nerve dysfunctionWhat are dematonesDermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerveDifferentiate upper motor neuron disease and lower motor neuron disease—common abnormalitiesUpper motor neuronsSpacicityLocated within CNS; convey impulses from motor areas of cerebral cortex to lower motor neurons Complex of all descending motor fibers that influence lower motor neuronsExamples of upper motor neurons: corticospinal & extrapyramidal tractsExamples of upper motor neuron diseases are CVA, cerebral palsy & multiple sclerosisLower motor neuronsFlaccidityPrimarily in PNSProvides contact with muscleMovement must be translated into action by motor neuron fibersExamples of lower motor neurons are cranial & spinal nerves Examples of lower motor neuron diseases are spinal cord lesions, poliomyelitis & amyotrophic lateral sclerosisWhat happens in the neurological system with aging?Aging causes atrophy with a steady loss of neuron structure in brain & spinal cord & causes….Loss of weight & volume of cerebral cortexReduced subcortical brain structures Expansion of the ventriclesMuscle bulk loss (most apparent in hands—guttering between metacarpals—hand grip strength remains relatively good), loss of muscle tone in face, neck & around spine, decreased muscle strength, impaired fine coordination & agility, loss of vibratory sense at ankle, decreased or absent Achilles reflex, pupillary miosis, irregular pupil shape & decreased pupillary reflexesNerve conduction decreasesIncreased delay at synapsesProgressive decrease in cerebral blood flow & oxygen consumptionDecrease in taste and smellSenile tremors occasionally occur (intention tremor of the hands, head nodding, and tongue protrusion)Dyskinesias: repetitive stereotyped movements in the jaw, lips, or tongue may accompany senile tremors with no associated rigidityGait may be slower and more deliberate and may deviate slightly form midline path Alternating movements may be more difficultMALE/FEMALE/ANUS /RECTUMREVIEW VIDEOS…What are risk factors for cervical cancer, prostate cancer, colon-rectal cancer, ovarian cancer, uterine cancer and testicular cancer. What are the screening tests and how often should they be done.Prostate CancerThe most common cause of death from CA in men over age 75Rarely found in men younger than 50Men who are at higher risk includeAfrican-American (more likely to be dx'd at advanced stage and mortality rates are 2x's higher—/oat risk if >45yOlder than 50-60Father or brother with prostate CAMultiple family Hx and >40y/o BRCA2 mutations [more aggressive type, younger]Other men at risk include:Exposed to agent orangeAlcoholicsFarmersDiet high in fat (animal & saturated fats), red meat, processed meats, and dairy productsTire plant workersPaintersLess common in vegetariansProstate Screening start at age 50 if not at riskProstate specific antigen (PSA) at or below 4.0 ng/mLDigital rectal examIf abnormal…Prostate biopsyTransurethral ultrasoundCT or bone scanCervical cancerRisk:Risky sexual practicesNot receiving the?HPV vaccinePoor economic statusWomen whose mothers took the drug DES (diethylstilbestrol)Weakened immune systemSmokingHispanic women, African-AmericanScreen:Pap smear once sexually active or age 21until age 65Screening recommended every 3 yearsHPV screeningBiopsyMRIColorectal cancerRisk:Over 60African American or eastern European descentDiet high in red or processed meatsHave CA elsewhere in the bodyHave?colorectal polypsHave IBDFamily hx of colon CAPersonal hx of breast CAScreening:Beginning at age 50 for men & women At age 45 for African Americans & if at riskTo detect polyps & early CAABD & rectal examAnnual FOBT (guaiac-based or fecal immuno-chemical test)Colonoscopy (q10yrs with bowel prep and conscious sedation) & sigmoidoscopyCBC CA 19-9 [marker]Differentiate direct, indirect, and femoral herniasIndirect InguinalDirect InguinalFemoralCourseSac herniates through internal inguinal ring;Can remain in canal or pass into scrotumDirectly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotumThrough femoral ring and canal, below inguinal ligament, more often on right sideClinical Signs & SymptomsPain w/strainingSoft swelling that increases w/increased intra-abdominal pressureMay decrease when lying downUsually painless; round swelling close to the pubis in area of internal inguinal ring; easily reduced when supinePain may be severeMay become strangulatedFrequencyMost common60% of all herniasMore common in infants < 1 y andIn males 16-20 yLess common; occurs most often in men older than 40 years, rare in womenLeast common4% of all herniasMore common in womenCauseCongenital orAcquired Acquired weakness; brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascitesAcquired;Due to increased abdominal pressure, muscle weakness, or frequent stooping.How is the TSE performed?T - TIMING (once a month)S - Shower, warm water relaxes scrotal sachands are warm and soapycold hands stimulate a muscle (cremasteric) reflex, retracting scrotal contents.E - Examine, check for changes, report changes immediatelyStep 1Hold scrotum in palm of hand and gently feel each testicle using your thumb and first two fingers.If it hurts, you are using too much pressure. Testicle is eggs-shaped and movableFeels rubbery w/a smooth surface, like a peeled hard-boiled egg.Epididymis is on top and behind the testicle (it feels a bit softer)Abnormal lumps are very rare and usually not worrisomeFirm, painless lump, a hard area, or an overall enlarged testicle needs further eval.Define associated terminology in lab manual e.g. dysuria, nocturia, polyuria, hematuria, cryptorchidism, menopause, perimenopausalDysuria - pain or burning during urination is common w/acute cystitis, prostatitis, urethritisNocturia- occurs together w/frequency and urgency in urinary tract disorders. Other origins: cardiovascular, habitual, diuretic medsPolyuria – excessive volumeHematuria - blood in urineCryptorchidism - absence of one or both testicles (undescended testes)Menopause – cessation of the menses, usually occurring around 48-51 years of agePerimenopausal - 40-55 y, has hormone shifts, resulting in vasomotor instabilityWhat are the signs/symptoms of menopause—treatment?Cessation of the menses usually occurring around 48 to 51 years (may occur 38 to 60)Stage of menopause includes the preceding 1-2 yrs of decline in ovarian function, shown by irregular menses that gradually become farther apart and produce a lighter flowOvaries stop producing progesterone and estrogen (decreased estrogen brings about dramatic physical changes)Signs: uterus shrinks in size due to decreased myometriumOvulation may still occur sporadically after menopauseSacral ligaments relax and pelvic musculature weaknes—uterus droops (may protrude or prolapse into vagina)Cervix shrinks and looks paler with a thick glistening epithelium Vagina becomes shorter, narrower, and less elastic d/t increased connective tissue; atrophy with less sexual activity (1/2 its normal length and width)More fragile mucosa with risk for bleeding and vaginitis Decreased secretions with dryness—risk for irritation and pain with intercourse (dyspareunia)pH more alkaline and glycogen content decreases from the decreased estrogen (increase risk for vaginitis)Mons pubis looks smaller d/t atrophy of fat padLabia and clitoris decrease in sizePubic hair thins and more sparseSymptoms: hot flash, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, itchingSE’s of Hormone Replacement Therapy: fluid retention, breast pain, vag bleeding, and breast cancer riskMUSCULOSKELETAL SYSTEMKnow anatomy terminology in lab manualKnow terms—such as flexion, extension, lateral bending, rotation, etc., and how testedFlexion: bending limb at jointExtension: straightening limb at jointAbduction: moving limb away from midline of bodyAdduction: moving limb toward midline of bodyPronation: turning forearm so that palm is downSupination: turning forearm so that palm is upCircumduction: moving arm in circle around shoulderInversion: moving sole of foot inward at ankleEversion: moving sole of foot outward at ankleRotation: moving head around central axisProtraction: moving body part forward, parallel to groundRetraction: moving body part backward, parallel to groundElevation: raising a body partDepression: lowering a body partDifferentiate rheumatoid arthritis and osteoarthritis p 608RA is chronic systemic inflammatory disease of joints and ct. inflammation of synovial membrane lead to thickeningThen to fibrosis which limits motionFinally to bony ankylosis,. Is quite painful, bilateral, and symmetric. Associated with fatigue, weakness, anorexia, weight loss, low-grade fever and lymphadenopathy. Swan neck and boutonneire deformity. Systemic inflammatory disease bilateral small jointsPain worse in morning when arising; pain lessens with movementOA (degenerative joint disease) is non-inflammatory, localized, progressive disorder involving deterioration of articular cartilage and subchondral bone and formation of new bone at joint surfaces. Happens from injury from sports accidents for example. Aging increase incidence. Nearly all adults > 60y have it to some degree. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion and limitation of motion. Oseophytes (bony overgrowths) are hard nontender nodules 2-3mm in size—at interphalangeal joints called Heberden nodes—proximal are called Bouchard nodes. Wear and tear unilateral large jointsPain becomes worse throughout the day; worsens with more movementDescribe osteoporosis—signs/symptoms/treatment p 573 & 608The gradual loss of bone density due to menopause and the lack of estrogen production (accelerates bone loss). Bone resorption is greater than that of bone formation. Increases risk for stress fractures, esp. to wrist, hip, and vertebrae. S&S postural changes, decreased height, kyphosis, slight flexion of hips and knees. Sedentary lifestyle hastens musculoskeletal changes- increases physical activity delays or prevents bone loss by increasing skeletal mass. Fast walking can help prevent osteoporosis, also strengthens reducing risks of falling. Bone remodeling is cyclic process after age 40 resorption occurs more rapidly than deposition net effect is loss of bone density or osteoporosis main cause is menopause often asymptomatic discovered when minor fall results in fracture especially wrist hip and vertebraeTreatment/prevention: diet adequate calcium and vit D, weight bearing exercise, avoid smoking and excessive alcohol, bone density tests, supplementsDifferentiate—tendons, joints, musclesTendonsConnect muscle to boneLigamentsConnect bone to boneHelp prevent movement in undesirable directions. JointsPoint where 2 or more bones meetThey are the functional units of the musculoskeletal system because they permit the mobility needed for ADLsMuscle40% to 50% of body’s weight Three types: skeletal, smooth & cardiacSkeletal muscles are under conscious controlCardiac & smooth muscles are not Skeletal muscle are composed of fasciculiSkeletal muscle attached to bone by tendonHow are joints inspected and inspected for whatNote size & contour of jointPresence of swelling is significant and signals joint irritation.Swelling can be excess joint fluid, thickening of the synovial lining, inflammation of surrounding soft tissue (bursae, tendons), or bony enlargement.Deformities include dislocation (complete loss of contact between the 2 bones in a joint); Subluxation (2 bones in a joint stay in contact but their alignment is off); contracture (shortening of a muscle leading to limited ROM of joint), or ankylosis (stiffness or fixation of a joint)How is the skin around joints inspected and for what?Inspect skin & tissues over joints for color, swelling or deformitySwelling is significant and signals joint irritationWhat are joints palpated for?Palpate each joint: assess temperature, muscle contour, bony articulations & area of joint capsuleNote heat, tenderness, swelling, or masses. Joints normally are not tender to palpation, if it does occur, try to localize it to specific anatomic structures (e.g., skin, muscles, bursae, ligaments, tendons, fat pads, or joint capsule)Synovial membrane normally is not palpable. When thickened, it feels "doughy" or "boggy"Small amount of fluid is present in normal joint, but is not palpable.Palpable fluid is abnormal. Because fluid is contained in an enclosed sac, if you push on one side of the sac, the fluid will shift and cause a visible bulging on another side.What is ROM—what should the expected findings be with full ROM, and know ROM tests for each jointActive (voluntary) ROM - while stabilizing the body area proximal to that being moved. You should familiarize the type of each joint and its normal ROM to be able to recognize its limitations. If a limitation is noticed, gently attempt Passive ROM.Passive ROM - w/person's muscles relaxed and w/you moving the body part. Anchor the joint w/one hand while your other hand slowly moves it to its limit.Normal ranges of ACTIVE & PASSIVE ROM should be the same.JointROM testExpected FindingAbnormalitiesTemporomandibular jointOpen mouth maximally.Partially open mouth, protrude lower jaw, and move it side to sideStick out lower jaw.Vertical motion. You can measure the space between the upper and lower incisors. Normal is 3-6 cm or three fingers inserted sideways.Lateral motion. Normal extent is 1-2 cmProtrude w/o deviationInspection: Swelling looks like around bulge over the joint, although it must be moderate or marked to be visible.Crepitus and pain occur w/TMJ dysfunction.Cervical SpineInspect the alignment of the head and neck. The spine should be straight and the head erect. Palpate the spinous processes and the sternomastoid, trapezius, and paravertebral muscles. They should feel firm, w/no muscle spasm or tenderness.Flexion (45°) & Hyperextension (55°)Lateral Bending (40°)Rotation (70°)Chin to chest and toward ceiling; Ears to shoulders; Rotate chin toward shouldersRepeat motions while applying opposing force. Person can normally maintain flexion against your full resistance (this also tests the integrity of cranial nerve XI [spinal])Head tilted to one side.Asymmetry of muscles.Tenderness and hard muscles w/muscle spasm.Limited ROMPain w/movementPerson can't hold flexionUPPER EXTREMITY p 582ShoulderInspect and compare both shoulders posteriorly and anteriorlyCheck the size and contour of the joint, and compare shoulders for equality of bony landmarks. Normally, no redness, muscular atrophy, deformity or swelling is present. Check anterior aspect of the joint capsule and the subacromial bursa for abnormal swelling.While standing in front of person, palpate both shoulders, note any muscular spasm or atrophy, swelling, heat or tenderness.Start at clavicle and methodically explore the acromioclavicular joint, scapula, greater tubercle of humerus, area of the subacromial bursa, the biceps groove, and anterior aspect of the glenohumeral joint. Palpate the pyramid-shaped axilla; no adenopathy or masses should be present.Test ROM by asking them to perform 4 motions:Forward flexion (180°)Hyperextension (50°)Internal/External rotation (90°)Abduction (180°)/Adduction (50°)Cup one hand over the shoulder during ROM to note any crepitation, normally none present.Test strength of shoulder muscles by asking person to shrug the shoulders, flex forward and up and abduct against your resistance. The shoulder shrug also tests the integrity of cranial nerve XI, the spinal accessory.Redness.Inequality of bony landmarks.Atrophy, shows as lack of fullness.Dislocated shoulder loses the normal rounded shape and looks flattened laterally.Swelling from excess fluid is best seen anteriorly. Considerable fluid must be present to cause a visible distention.Shoulder pain can be from local causes or referred pain from a hiatal hernia or a cardiac or pleural condition.Swelling of subacromial bursa is localized under deltoid muscle and may be accentuated when person tries to abduct the arm.SwellingHard muscles w/muscle spasm.Tenderness or painElbow p 583Inspect size and contour of the elbow in both flexed and extended positions. Look for deformity, redness, or swelling. Check olecranon bursa and the normally present hollows on either side of olecranon process for abnormal swelling.Palpate w/elbow flexed about 70 and relaxed. Use left hand to support person's left forearm, and palpate the extensor surface of the elbow-the olecranon process and the medial and lateral epicondyles of humerus.Palpate for are of olecranon bursa for heat, swelling, tenderness, consistency, or nodules.Flexion (160°)Extension (0°)Pronation (90°)Supination (90°)Testing muscle strength:Stabilize the person's arm w/one hand. Have person flex the elbow against your resistance applied. then ask person to extend the elbow against your resistance.Flexion of 150-160; extension at 0. Some healthy people lack 5-10 of full extension and others have 5-10 of hyperextension.Subluxation of elbow shows the forearm dislocated posteriorly.Swelling and redness of olecranon bursa are localized and easy to observe.Effusion or synovial thickening shows first as a bulge or fullness in groove on either side of the olecranon process and occurs w/gouty arthritis.Soft, boggy, or fluctuant swelling in both grooves occurs w/synovial thickening or effusion.Local heat or redness (signs of inflammation) can extend beyond synovial membrane.Subcutaneous nodules are raised, firm, and nontender, and overlying skin moves freely. Common sites are in olecranon bursa and along extensor surface of the ulna. Wrist & Hand p 584Flexion (90°)Extension (70°)Hyperextension (30°)Ulnar deviation (55°)Radial deviation (20°)For muscle testing, position person's forearm supinated (palm up) and resting on table. Ask person to flex wrist against your resistance at the palm.Phalen test: ask pt to hold both hands back to back while flexing wrists 90? and hold for 60secTinel sign: directly percuss median nerve at the wristHyperextension of 70 when bed the hand up at the wrist.Palmar flexion of 90 when bend hand down at the wristFlexion of 90/Hyperextension of 30, when bend the fingers up and down at metacarpophalangeal joints.Abduction of 20; fist tight. The responses should be equal bilaterally.Person is able to touch the thumb to each finger and to the base of little finger--responses should be equal bilaterally.Loss of ROM is most common and most significant functional loss of the wrist.Limited motion.Pain on movement.Positive phalen test: produces numbness and burning in persons with carpal tunnel syndromePositive Tinel sign: percussion of medial nerve produces burning and tingling along its distribution (positive for carpal tunnel syndrome)Lower Extremity p 588HipRaise each leg with knee extended. Bend each knee up to the chest while keeping the other leg straight. Flex knee and hip to 90’. Stabilize by holding the thigh with one hand and the ankle with the other hand swing the foot outward. Swing the foot inward. (foot and thigh move in opposite direction).Swing leg laterally, then medially with knee straight. Stabilize pelvis by pushing down on the opposite ant sup iliac spine.When standing, swing straight leg back behind body have person bend over a table and tp support the trunk on the table or lay prone on a table.Hip flexion of 90’ Hyp flexion of 120’ the opposite thigh should remain on the table.Internal rotation of 40’ external rotation of 45’Abduction of 40-45’Adduction of 20-30’Hyperextension of 15’ when stabilized.Limited motion or pain with motion.Flexion flattens the lumbar spine. If this reveals a flexion deformity in the opposite hip it represents a positive Thomas test.Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip diseases.Knee p 589Bulge sign; determines if damage is soft tissue swelling or fluid accumulation in joint. Firmly strike up on the medial aspect of the knee 2-3X to displace fluid. Tap lateral aspect and watch medial aspect for appearance of bulge. Ballottement of the patella; push the patella sharply against the femur. If no fluid is present the patella is already snug against the femur. McMurry test; hx of trauma followed by locking or giving way or knee pain. Person supine, hold heel and flex the knee and hip. Externally rotate the leg and push inward stress on the knee. Then extend knee. Normally extends without pain. + sign is indicative of torn meniscusBend each kneeExtend each knee.Check ROM while ambulatingFlexion of 130-150’A straight line of 0’ in some people. A hyperextension of 15’ in others.Sudden locking, person unable to extend knee fully. Occurs with painful and audible pop or click. Sudden buckling or giving way occur with ligament injury which causes weakness and instability.Ankle and foot p 592Point toes toward the floorPoint toes toward the noseTurn soles of feet out, then in, stabilize ankle with one handhold heel with the other to test subtalar joint.Plantar flexion of 45’Dorsi flexion of 20’Eversion of 2-‘ and inversion of 30’Limited ROMPain with motionSpine; p 594Straight leg raising or Lasegue test; straighten left while keeping the knee extended normally produces no pain. Raise affected leg just short of the point where it produces pain. Then dorsiflex the foot. + Sign if sciatic pain is produced. Confirms presence of nucleus pulposus.Bend forward and touch toes. Bend sidewaysBend backwards.Twist shoulders to one side, then to the other.Flexion 75-90’ with smooth symmetrical movement. Spine should be convex and C shaped.Lateral bending of 35’ Hyperextension of 30’Rotation of 30 degrees bilaterally.Limited ROMPain with motion.How are muscles tested –and describe the strength testing process and how graded (0=5)? What do these numbers mean?Testing the strength of the prime mover muscle groups for each joint.Repeat the motions for Active ROM.Ask person to flex and hold as you apply opposing force Muscle strength should be equal bilaterally and should fully resist your opposing forceNote: muscle status and joint status are interdependent and should be interpreted togetherGRADEDESCRIPTION% NORMALASSESSMENT5Full ROM against gravity, full resistance100Normal4Full ROM against gravity, some resistance75Good3Full ROM w/gravity50Fair2Full ROM w/gravity eliminated (passive motion)25Poor1Slight Contraction10Trace0No contraction0ZeroWhat happens to the musculoskeletal system with aging?Bone remodeling is a cyclic process of resorption & deposition; after age 40 resorption occurs more rapidly than depositionNet effect is loss of bone density or osteoporosis Postural changes, decrease in height Kyphosis-w/backward head tilt to compensate.Progressive decrease in height at age 40 for males and 43 for females (not significant until age 60)70-80’s – greater decrease as a result of osteoporotic collapse of vertebrae (shorter trunk and comparatively long extremities)Distribution of subcutaneous fat changes; contour different, even if weight is same as when youngerBegin to lose fat in face & deposit it in abd & hipsIn 80s & 90s, fat further decreases in peripheryLoss of subcutaneous fat leaves bony prominences more noticeableLoss in muscle mass occurs (decease in size or atrophy producing weakness)Contour of muscles becomes more prominent, muscles & tendons feel more distinctLifestyle affects musculoskeletal changes ................
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