H & P Exam 3
Spring 2014 OMS I – Exam 3
Neurology Exam
 General appearance
 Vital signs
 CV – carotids, heart, peripheral
 Mental status – attention, orientation, language, fund of knowledge,
memory
 Visual-Spatial function: draw things – fill in clock & a time
 Abnormality  neglect drawing #s all on 1 side
 Aphasia: cortical dysfunction in speech
 Be able to recognize & categorize them
 Can people say things you understand, do they understand you, have
them say uncommon words, repetition, word substitutions
Neurology Exam
Cranial Nerves
 I: optional – anosmia (loss of smell – HTN meds, trauma)
 II: visual acuity, fields & fundi
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3ft apart, 4 quadrants
Optic radiations loop into temporal lobe
Papilledema – increased pressure, acute problems
Venous pulsations w. occular veins  normal CSF pressure
 III, IV, VI: pupils, eye movements
 Aniscoria – asymm. Pupil size
 Horner’s syndrome – IL symp NS loss, normal light reflex, loss of
sweating, ptosis, anhydrosis
 Nystagmus – rhythmic ossicilations (slow & fast phases)
 Phenytoin – causes it when looking L or R (not abnormal)
 1* gaze – abnormal
 Congenital – normal for them, they see normal
Neurology Exam
Cranial Nerves
 V: facial sensation, corneal reflex
 V1 (to tip of nose), V2, V3 sensation areas
 Jaw strength
 VII: facial symmetry & strength
 LMN – Bell’s palsy: entire ½ of face, no sensory loss – perceive
numbness b/c muscles aren’t working
 VIII: hearing, balance
 Vestibular neuropathy (vertigo)
 Whispered hearing test, tuning forks
 IX: palate movement
 X: autonomic function
 XI: SCM & Trapezius
 XII: tongue protrusion (points to side of lesion)
Neurology Exam
 Muscle Strength
 Weakness: a muscle cannot exert normal force
 UMN (increased tone & reflexes, Babinski sign) , LMN (decreased tone & reflexes,
fasciculations)
 Grading:
 (5) Normal power
 (4) Active movement against gravity & resistance
 (3) Active movement against gravity
 (2) Active movement only with gravity eliminated
 (1) Trace contraction (flicker)
 (0) No contraction
 Tone
 Cog wheel: passive movement, increased tension/tone causing catching (PD)
 Any atrophy or abnormal movements
 Fasciculations – muscle twitches, have to watch for a while
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Neurology Exam
 Muscle Coordination (cerebellar function – IL dysfunctions)
 Rapid alternating movements (flipping hands back n forth, touching each
fingertip to thumb in rapid succession)
 Heel-shin test
 Check test (hands in supination, and any drifting to pronation; push down on
extended arms – abnormal if can’t bring back up or overcompensate)
 Sensation (always compare symmetric areas)
 Touch (sharp & dull)– scatter yourself appropriately so patients don’t follow
your pattern, cover many dermatomes
 Vibration – use tuning fork on distal joints first (working proximal) & your
finger underneath the joint
 Proprioception – hold onto lateral aspect of phalange, patient’s eyes are closed
& you tell them what is up, down & neutral
 2 point discrimination
Neurology Exam
 Muscle Reflexes
 Grading:
 (4) – greatly increased, clonus
 (3) – somewhat increased
 (2) – normal
 (1) – diminished response
 (0) – no response
 Reinforcement: UE – clench teeth, LE – hands together & pull
 Levels:
 C5 - Biceps (antecubital fossa, press on it & hit your thumb)
 C6 - Brachioradialis (1/3 prox. Wrist, slight pronation, hit your thumb)
 C7 – Triceps (flex arm & shoulder, holding arm up with yours)
 L4 – Patellar
 S1 – Achilles (foot in dorsiflexsion, hit achilles tendon)
 Checking for clonus – support knee while supine, flex & point food then rapidly
dorsiflex
 Pathologic:
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Grasp – when they grab your hand after stroking it
Babinski – UMN, loss of cortical inhibition
Globellar – tap on patient’s forehead, no accommodation = abnormal
Jaw jerk – brisk (UMN), normal + hyperflexia elsehwere (LMN)
Musculoskeletal Exam
 Pain is a SYMPTOM not a diagnosis
 Diagnosis based on structure
 Hx – alleviating & aggravating factors & reproducing the pain
 Localized pain – MSK almost always localized, can radiate elsewhere
 Neck & arm, back & legs = units
 Primary pain generator = being able to reproduce pain via touch
 Gait Analysis
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Single sequence of functions of one limb consisting of two steps
Step length: distance between both heels
Stride length: distance between heel of same foot after two steps
Stance: time which limb is in contact with ground (60%)
Swing: time which foot is in the air for limb advancement (40%)
Cadence: number of steps per unit time
Speed: length per time
 Most energy efficient & comfortable – walking @ 3mph
 Decrease speed by decreasing cadence or increasing step length
Musculoskeletal Exam
Center of Gravity
Typically 5 cm anterior to S2 vertebra
Displaced 5 cm horizontally and 5 cm vertically during an average adult male
step
Base of Support
Space outlined by feet and any assistive device in contact with ground
Normally, 5 cm-10 cm between heels
Musculoskeletal Exam
Stance Phase
 Initial contact: time following initial contact of foot with ground
 Loading response: IC until contralateral foot lifted off ground. Weight shift
occurs. Body has lowest center of gravity.
 Midstance: LR until both ankles are aligned in frontal plane
 Terminal stance: MS until just prior to initial contact of contralateral heel
 Preswing: TS until just prior to ipsilateral unloading toe from ground
Swing Phase
 Initial swing: Lift of extremity from ground to maximum knee flexion
 Mid swing: KF to vertical tibia position
 Terminal swing: Vertical tibia position to just prior to initial contact
Musculoskeletal Exam
Gait Dysfunctions
 Antalgic gait: Stance phase is abnormally shortened relative to the swing phase, a
good indication of pain with weight-bearing
 Trendelenburg gait:
 Uncompensated: During stance phase, the weakened gluteus medius allows the pelvis to
tilt down on the opposite side. Bilateral = “Waddling” or “Myopathic” Gait
 Compensated: During stance phase, the trunk lurches to weak side to maintain a level
pelvis throughout the gait cycle.
 Foot drop: Dropping of the forefoot into plantarflexion due to significant tibialis
anterior weakness (1/5-2/5 strength) or damage to peroneal nerve
 Foot slap: Milder form of foot drop resulting in a “slapping” sound at initial
contact (3/5-4/5 strength)
 Steppage (Hip Hiking) gait: Swing leg excessively hip flexes so that the toes of
swing leg can clear the ground
Musculoskeletal Exam
Gait Dysfunctions
 Vaulting: Stance leg excessively plantar flexes to allow toes of swing leg to
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clear the ground
Circumduction: Swing leg excessively hip abducts so that the toes of
swing leg can clear the ground
Genu recurvatum: Backbending of knee causing excessive extension at the
tibiofemoral joint due to weak quads or limited ankle dorsiflexion /
excessive plantar flexion
Ataxic gait: unsteady, uncoordinated walk, employing a wide base and the
feet thrown out. Commonly seen with cerebellar pathology, classic
drunken appearance.
Festinating gait: Involuntary advancement of legs with short, accelerating
steps, often on tiptoes (shuffling). Seen with Parkinson’s Disease
Musculoskeletal Exam
 Muscle Testing
 5/5 Complete ROM against gravity with full resistance
 4/5 Complete ROM against gravity with some resistance
 3/5 Complete ROM against gravity
 2/5 Complete ROM with gravity eliminated (rare)
 1/5 Evidence of slight contractility with no joint movement
 0/5 No evidence of contractility (visual or tactile)
 Upper Limb
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C5: Biceps (EF)
C6: Extensor carpi radialis (WE)
C7: Triceps (EE)
C8: FDP D3 (FF)
T1: ADM (D5 Abduction)
 Lower Limb
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L2: Iliopsoas (HF)
L3: Quads (KE)
L4: Tibialis anterior (DF)
L5: Extensor hallucis longus (Great toe extension)
S1: Gastrocnemius-Soleus (PF)
Musculoskeletal Exam
 Deep Tendon Reflexes
0 - Absent (even with reinforcement)
1+ - Hypoactive
2+ - Normal
3+ - Hyperactive without clonus*
4+ - Hyperactive with clonus
 Clonus: Rapid alternating contractions and relaxations of muscle after forced stretch.
 Reinforcement requires maximal isometric contraction of muscles at a remote part of the body (clench jaw,
lock fingers “Jendrassik Maneuver”) in order to distract the patient for voluntary suppression and by
decreasing the amount of descending inhibition
 Locations:
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C5 - Biceps tendon
C6 - Brachioradialis tendon
C7 - Triceps tendon
L4 - Patellar tendon
L5 - Medial hamstring (unreliable)*
S1 - Achilles tendon
 Sensation
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Normal
Increased (hyperesthetic)
Decreased (hypoesthetic)
Unpleasantly altered (dysesthetic)
Not unpleasantly altered (paresthetic)
Absent (anesthetic)
Root Level
Muscle Weakness
Reflex Abnormality
Sensory Deficit
C5
Biceps
Biceps
Lateral Arm (Lateral
Anticubital Fossa)
C6
Extensor Carpi Radialis
Brachioradialis
Lateral Forearm (Dorsal
Proximal D1)
C7
Triceps
Triceps
Middle Finger (Dorsal
Proximal D3)
C8
Flexor Digitorum Profundus (D3)
None
Medial Forearm (Dorsal
Proximal D5)
T1
Abductor Digiti Minimi (D5)
None
Medial Arm (Medial
Antecubutal Fossa)
L2
Iliopsoas
None
Medial Anterior Thigh
L3
Quadriceps
Patellar
Medial Anterior Knee
L4
Tibialis Anterior
Patellar
Anterior Thigh / Medial Calf /
Medial Malleolus
L5
Extensor Hallucis Longus
Medial Hamstring
(unreliable)
Lateral Calf / Dorsal base of
3rd MT)
S1
Gastronemius-Soleus
Achilles
Post. Calf / Lateral Heel
Musculoskeletal Exam
 TMJ dysfunction: deviation, popping or clicking of the TMJ with range of motion
 Herberden’s nodes: bony enlargements of DIP joint found in osteoarthritis
 Bouchard’s nodes: bony enlargements of the PIP joint assoc. w. osteo &
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rheumatoid arthritis
Rotoscoliosis: lateral curvature of the spine
Pes planus: loss of foot arch
Ballottement: technique used to identify fluid w/in the joint space where the
provider rapidly taps the patella posteriorly & assesses for its bobbing up if
excessive fluid is present
Valgus stress test: MCL assessment, provider holds the supine patients
straightened leg @ ankle & places other hand along lateral aspect of the knee
 Ankle pushed laterally as medial pressure applied at the knee
 Varus stress: LCL assessment, provider holds the supine patients straightened leg
@ ankle & places other hand along medial aspect of the knee
 Ankle pushed medically as lateral pressure applied at the knee
Musculoskeletal Exam
 Anterior Drawer Test: ACL assessment, patient is supine with knee bent @
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60* & foot anchored, provider grasps lower leg behind the knee & applies
anterior displacement, noting shift of tibia from under femur
Posterior Drawer Test: PCL assessment, patient is supine with knee bent
@ 60* & foot anchored, provider grasps lower leg behind the knee &
applies posterior displacement, noting shift of tibia backward under femur
Meniscal tear: tear of the medial or lateral menisci
McMurray’s sign: clicking or pain in the knee suggesting a meniscal tear
elicited as provider places the supine patient’s lower leg in first internal
rotation w. varus pressure on the knee while taking the knee & hip thru
flexion & extension to asses the LM then reversing the forces to ext. rotate
w., valgus pressure to assess the MM
Apley Grind: meniscal tear test, patient prone, knee flexed at 90*, apply
downward pressure with internal & external rotation, feeling for grinding
or popping
Musculoskeletal Exam
 Straight leg raise: assess for a herniated lumbar disc
 Carpal tunnel syndrome: compression of the median nerve as it passes through the
carpal tunnel, causing numbness, paresthesia & hand weakness
 Phalen’s sign: undsidedown prayer motion – CTS test
 Tinel’s sign: CTS, percuss over extended wrist
 Rotator cuff: complex of tendinous insertions of supraspinatus, infraspinatus, teres
minor, subscapularis muscles
 Arm drop test – supraspinatus tendon assessment (hold at 120* then slowly drop
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looking for fluidity)
Empty Can test – supraspinatus integrity, abduct arm to 90* then internally rotate arm
as if emptying the can then externally rotate arm against provider’s resistance
Push-off test – subscapularis integrity, arm behind patient’s back and they push off with
the hand from the back
Passive painful arc test – provider passively moves patient’s arm while stabilizing the
shoulder
Sulcus sign – pull patient’s arm downward while stabilizing the shoulder, assessing for
laxity of the joint (abnormal = >2cm movement)
Apprehension test
Psych Exam
 A structured observation of patient’s current appearance, attitude,
behavior, mood and affect, speech, thought process, thought content,
perception, cognition, insight and judgment.
 A comprehensive cross-sectional description of the patient's mental state
 Unstructured observation and focused questions about current symptoms
 Theoretical foundations:
 Empathic descriptive phenomenology
 Empirical clinical observation. **most important**
 Objective descriptions of a patient signs and symptoms, and patient's
subjective experience.
Psych Exam
Recording (receiving isn’t necessarily in this order)
 Appearance
 Attitude (patient’s approach to the interview)
 Behavior (level of activity & arousal, body movements)
 Abnormal movements: choreoathetoid (involuntary, rapid complex jerky
movements), anti-emetic can cause achethesia (intense restlessness)
 Mood (a person's predominant internal feeling state at any one time)
 Described using the patient's own words,
 Euthymic, Dysphoric, Euphoric, Angry, Anxious or Apathetic.
 Alexithymic - unable to describe their subjective mood state.
 Anhedonic - An individual who is unable to experience any pleasure
Psych Exam
Recording
 Affect (the external and dynamic manifestations of a person's internal emotional
state)
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the apparent emotion conveyed by the person's nonverbal behavior
Intensity, range, reactivity and mobility.
Appropriate or inappropriate
Congruent or incongruent with their thought content
Constricted or labile.
 Speech (Production of speech rather than the content of speech)
 Thought Process
 Quantity, tempo and logical coherence
 Cannot be directly observed but can only be described by the patient, or
inferred from a patient's speech.
Psych Exam
Recording
 Thought Content
 Delusion - a false, unshakeable idea or belief out of keeping with the patient's
educational, cultural and social background and held with extraordinary
conviction and subjective certainty [ + mood congruent vs incongruent]
 Preoccupations - thoughts which are not fixed, false or intrusive, but have an
undue prominence in the person's mind
 suicide, homicidal thoughts, suspicious or fearful beliefs
 Overvalued ideas – hypochondriasis, dysmorphophobia, anorexia nervosa
 Obsessions - Undesired, unpleasant, intrusive thought that cannot be
suppressed through volition
 Phobias - dread of an object or situation that does not in reality pose any threat,
and the patient is aware that the fear is irrational.
Psych Exam
Recording
 Perceptions (any sensory experience)
 Hallucination - a sensory perception in the absence of any external stimulus, and is
experienced as external
 Can occur in any of the five senses, although auditory and visual hallucinations are
encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste)
hallucinations
 Illusion is defined as a false sensory perception in the presence of an external stimulus,
and may be recognized.
 Cognition
 Patient's level of alertness, orientation, attention, memory, visuospatial
functioning, language functions and executive functions.
 The mini–mental state examination (MMSE) or Folstein test is a brief
30-point questionnaire test that is used to screen for cognitive impairment.
Psych Exam
Recording
 Insight
 Recognition that one has an illness
 Compliance with treatment
 The ability to re-label unusual mental events (such as delusions and
hallucinations) as pathological.
 Insight is on a continuum
 Capacity to consent to treatment
 Judgement
 Capacity to make sound, reasoned and responsible decisions.
 How the patient has responded or would respond to real-life challenges and
contingencies.
 Executive system capacity in terms of impulsiveness, Social cognition, self-awareness
and planning ability.
 Impaired judgment is not specific to any diagnosis
 Has implications for the person's safety or the safety of others