Additional Exam 3 Study Guide

Know the order of the exam
1. Snellen alphabet chart: measures visual acuity—normal 20/20
2. Test 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 14/14
o Presbyopia suggested when person moves card farther from eye to see (loss of accommodation)
3. Confrontation test: gross measure of peripheral vision (test pt peripheral vision with your own—in older adults, this
screens for glaucoma)
4. Corneal light reflex (Hirschberg test): shine light on nose when pt looks straight ahead—should see refection of light in
same spot on both eyes
o Asymmetry of light reflex indicates deviation in alignment from eye muscle weakness or paralysis (if seen,
perform cover test)
5. 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 uncovered
o Phoria: mild weakness noted when fusion is blocked
o Tropia: more severe—constant malaignment of the eyes
6. Diagnostic positions test (note any nystagmus—fine oscillating movement best seen around the iris)—test six cardinal
positions of gaze
o Mild nystagmus at an extreme lateral gaze is normal
o Nystagmus occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis,
or brain lesion
7. Inspect external ocular structures
o Eyebrows: symmetrical (position and movement), no scaling or lesions; unequal or absent movement with
nerve damage, scaling with seborrhea
o Eyelids and lashes
Note any lid lag (results from hyperthyroidism), ptosis (drooping), periorbital edema, lesions
Incomplete closure risks corneal damage
8. Eyeballs: note protrusion or sunken appearance (exophthalmos or enophtalmos)
9. Conjunctive and sclera
o Conjunctive moist and glossy, clear with blood vessels shown through
o Sclera is china white (Africans may have gray-blue or muddy color; dark skinned people may have small
brown macules on sclera)
o 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)
10. Lacrimal apparatus
11. Inspect anterior eyeball structures
o Cornea and lens: should be no opacities (cloudiness) in cornea, anterior chamber, or lens behind pupil
o Iris 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 anisocoria
Test pupillary light reflex (note direct and consensual constriction)
Note size before light and after constriction
Test accommodation: note constriction and convergent of pupils and eyes when focus is brought
from far object to finger 3in from eyes
12. Inspect ocular fundus
13. Systematically inspect structures in ocular fundus
14. Retinal vessels
15. Optic disc
16. Macula
Central Vision—how tested and how scored.
Snellen alphabet chart: measures visual acuity
o Lines of letters arranged in decreasing size
o Place 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
o If person wears glasses or contact lenses, leave them on; remove reading glasses
o Ask to read smallest line of letters possible;
o Encourage trying next smallest line
o Normal visual acuity is 20/20
Peripheral Vision—how tested and interpreted
Confrontation Test
Gross measure of peripheral vision
o Position yourself at eye level with patient 2 feet away
o Direct patient to cover 1 eye, with other look straight at you
o Cover your own eye opposite patient’s covered eye
o Hold your finger as target midline between you & patient, slowly advance it in from periphery in several
o Ask person to say “now” as finger is first seen; this should be just as you see your finger
Know the eye anatomy, how tested, what is it tested for, and possible abnormalities
o Eyelids: protect eye
o Palpebral fissure: elliptical open space between eyelids (approximate completely when closed)
o Limbus: border between cornea and sclera
o Canthus: corners of eye where lids meet
o Caruncle: small, fleshy mass containing sebaceous glands
o Tarsal 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)
o Conjunctiva: transparent protective covering—thin mucous membrane folded line an envelope b/t eyelids
and eyeball
o Lacrimal apparatus: provides constant irrigation to keep conjunctiva and cornea moist and lubricated
o Muscles of eye
o Sclera: tough protective white covering
o Cornea:
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 brain
Facial nerve carries efferent message to blink
o Choroid: dark pigment to absorb light and prevent reflection; vascularized to deliver blood to retina
o Ciliary body (muscles): control thickness of lens – refraction of light and focus
o Iris: controls diameter of pupil and amount of light entering retina
o Pupil:
CN III: controls constriction of pupil (parasympathetic); sympathetic dilates pupil
o Anterior and posterior chambers filled with aqueous humor to deliver nutrients to enclosed structures and
drain metabolic waste
o Retina: 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 retina
Vessels 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  retina
What cranial nerves are associated with eye exam—and how tested
Extraocular muscles movement is stimulated by
o CN VI: abducens nerve, innervates lateral rectus muscle, which abducts eye
o CN IV: trochlear nerve, innervates superior oblique muscle, moves eye down & medially
o CN III: oculomotor nerve, innervates the superior, inferior & medial rectus & the inferior oblique muscles
Trigeminal nerve, CN V, carries afferent sensation to brain
Facial nerve, CN VII, carries efferent message to organ
Optic disc: where fibers in retina converge to form optic nerve
Constriction and dilation of pupil----what situations cause these to occur?
Afferent messages of light sent by CNII and efferent message to constrict pupil via CNIII
Direct light reflex: constriction of pupils when light shines on retina
Consensual light reflex: simultaneous constriction of other pupil
Blind eye has not CNII response and thus no direct or consensual response
What is the red glow noted with the oto-ophthalmoscope on the patient’s pupil?
Corneal light reflex, the Hirschberg test
Assess parallel alignment of eye axes
Direct patient to stare straight ahead as you hold light about 12 inches away
Note reflection of light on corneas; should be in exactly same spot on each eye
Know the order of the internal eye exam and what is the anatomy
Inspect ocular fundus
Ophthalmoscope - inspect: anterior chamber & retinal background
Ophthalmoscope contains lenses strength of each lens is diopter
Black numbers indicate positive diopter; use to focus on near objects
Red numbers show negative diopter, focus on objects farther away
Systematically inspect structures in ocular fundus
General background
Retinal vessels
o Follow a paired artery & vein to periphery in 4 quadrants note:
o Number: paired artery & vein pass in each quadrant; vessels look straighter at nasal side
o Color: arteries brighter red than veins; have arterial light reflex
o A:V ratio: ratio comparing artery-to-vein width is 2:3 or 4:5
o Caliber: arteries & veins show a decrease in caliber as they extend to periphery
Optic disc
o Most prominent landmark, located on nasal side of retina; explore these characteristics:
o Color: creamy yellow-orange to pink
o Shape: round or oval
o Margins: distinct & sharply demarcated, nasal edge may be slightly fuzzy
Located temporal to disc
o Inspect last in funduscopic exam; bright light may cause tearing, discomfort, pupillary constriction
o Normal even & color darker than rest of fundus
o Clumped pigment may occur with aging
General background of fundus
Color normally varies from light red to dark brown-red; view of fundus should be clear; no lesions should obstruct
retinal structures
Review eye abnormalities in lecture notes ANY loss of vision is a medical emergency
Common causes of decreased visual functioning:
o Cataract formation - protein growth that goes over pupil; film
o Glaucoma 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.
o 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 distress
Racial & ethnic variations in blindness
o Whites over age 40 years, leading cause of blindness is age-related macular degeneration (54%) followed by
cataracts (9%)
o African Americans older than 40 years, cataracts & open-angle glaucoma together cause 60% of blindness
o Hispanics older than 40 years, leading cause of blindness is open-angle glaucoma
Extraocular muscle dysfunction
o Strabismus - squinty, crossed-eyes
o Esotropia - inward turning of the eye
o Exotropia - outward turning of the eye
o Cover Test:
Esophoria: nasal (inward) drift
Exophoria: temporal (outward) drift
Abnormalities in the eyelids
o Periorbital edema - lids are swollen and puffy. Occurs w/ local infections, crying, allergies, hypothyroidism,
renal failure, heart failure
o Exophthalmos - forward displacement of eyeballs and widened palpebral fissures; note lid lag
o Enophthalmos - sunken in eyeballs; narrowed palpebral fissures; recessed eyeballs. Caused by lose of fat in
orbits; occurs with dehydration and chronic wasting illnesses.
o Ptosis - Droopy upper eyelid; occurs from neuromusclular weakness (MG), CNIII damage, or sympathetic
nerve damage (Horner’s syndrome)—sleepy appearance and impairs vision
o Upward palpebral slant - associated w/down syndrome; may be normal in children
o 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.
o Entropion - lower lid rolls in because of spasm of lids or scar tissue contracting. Constant rubbing of lashes
may irritate cornea—foreign body sensation
Lesions on the eyelids
o Blepharitis - 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)
o 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)
o Hordeolum - stye, localized staph infection of hair follicle at the lid margin
o Dacryocystitis - inflammation of lacrimal sac and duct
Vascular disorders of external eye
o Conjunctivitis - 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 URI
Symptoms: itching, burning, foreign body sensation, eyelids stuck together on awakening
o Subconjunctival 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,
o Iritis (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 pain
Warrants 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 shallow
Pt experiences a sudden clouding of vision, sudden eye pain, and halos around lights
Requires emergency treatment to avoid permanent vision loss
Cornea & Iris
o Pterygium - 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 vision
o Pinguecula - yellowish, elevated nodule due to thickening of bulbar conjunctive. From prolonged exposure to
sun, wind and dust. Like a yellow spot in your eye.
o 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
o Hyphema - blood in the anterior chamber. Serious result of herpes zoster infection or blunt force trauma, or
spontaneous hemorrhage
o Hypopyon - 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 diminish
Eyebrows may show loss of outer 1/3 to 1/2 of hair due to decrease in hair follicles; brow hair is coarser
Skin around eyes may show wrinkles due to atrophy of tissues; upper lid may be elongated & rest on lashes, resulting
in pseudoptosis
Eyes may appear sunken from atrophy of orbital fat
Lacrimal 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 slowed
Cornea may look cloudy with age
Arcus 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 canthus
Lens 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 70
Glaucoma: increased intraocular pressure—chronic open-angle glaucoma most common, involves loss of peripheral
Macular degeneration leading to loss of central vision (inhibits ability to read find print and skills that require visual
Know sections of the mental status exam: Appearance, Behavior, Cognitive Functions, and Thought Processes and
Perception—what goes in each section
o Posture - erect and position is relaxed.
Anxiety & Hyperthyroidism - sitting on edge of chair or curled in bed, tense muscles, frowning,
darting watchful eyes, restless pacing occur
Depression & some organic brain diseases - sitting slumped in chair, slow walk, dragging feet
o Body movements - voluntary, deliberate, coordinated, and smooth and even.
Anxiety - restlessness, fidgety movements or hyperkinetic appearance
Depression & dementia - apathy and psychomotor slowing
Schizophrenia - abnormal posturing and bizarre gestures
o Dress - appropriate for setting, season, age, gender, and social group. Clothing fits and is put on
Organic brain syndrome - inappropriate dress
Schizophrenia or Manic syndrome - eccentric dress combination and bizarre makeup.
o 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 trend
CVA - Unilateral neglect (total inattention to one side of body)
Depression and severe Alzheimer's - Inappropriate dress, poor hygiene and lack of concern
OCD - Meticulously dressed and groomed appearance and fastidious manner
o LOC - 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 conversation
Lethargic (drowsy), obtunded (confused)
o 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 expression
o Speech - 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 fluent
Articulation (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 loud
Parkinsonism & Depression - slow, monotonous speech
Dysarthria - 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 swings
Schizophrenia - bizarre mood
Cognitive function
o Orientation - ask person's address, phone number, health hx. Or can ask date
Time: Day of week, date, year, season
Place: where they live, present location, type of building, name of city ad state
Person: name, age, who examiner is, type of worker
Delirium & Dementia - disorientation occurs
Usually lost in this order: time, place, rarely to person
Attention 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, negativism
Recent 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 alcoholism
Remote 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
After 5 mins, ask them to recall words.
Then at 10 and 30 mins.
Normal: < 60 yo: recall 3-4
Alzheimer dementia score a 0 or 1.
Anxiety - impaired new learning ability occurs w/anxiety
Depression - due to lack of effort mobilized to remember
Judgment - 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 regimens
Mental retardation, emotional dysfunction, schizophrenia, and organic brain disease - impaired judgment
(unrealistic or impulsive decisions, wish fulfillment) occur
Thought processes - the way a person things should be logical, goal directed, coherent, and relevant. They should
complete a thought.
o 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)
o Thought Content - What the person says should be consistent and logical.
Obsessions and compulsions
Perception - 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 withdrawal
Know neurological system anatomy and major functions.
Cerebral cortex
o Cerebrum’s outer layer of nerve cells
Gray matter- lacks myelin
o Governs: thought, memory, reasoning, sensation, voluntary movement
o Each half of cerebrum is hemisphere
Left is dominant in 95% of humans
o Each hemisphere has 4 lobes: frontal, parietal, temporal & occipital
Wernicke’s area in temporal lobe associated with language comprehension
o When 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
o 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 ganglia
o Bands 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 Palsy
o Paired lobed mass of grey matter on top of the brain stem
o Main relay station: sensory pathways of spinal cord, cerebellum & brain stem form synapses
o Involved in sensory perception & regulation of motor functions
o Pathology of thalamus: thalamic CVA, Thalamic Syndrome (Dejerine-Roussy), schizophrenia & lesions
o Size of an almond, inferior to the thalamus, above the midbrain
o Links the CNS to the endocrine system
o Control center for many autonomic functions of the PNS
o Major respiratory center
o Controls temperature, appetite, sex drive, HR, BP control, sleep center, posterior pituitary gland regulator,
and coordinator of ANS activity and stress response
o Pathology: tumors
o Coiled structure at base of skull under occipital lobes
o Relays information between muscles & cerebral cortex
o Controls, adjusts & corrects voluntary motor movement, coordination, balance, equilibrium & muscle tone
o Operates below conscious level
Brain Stem
o Lower section of the brain, continuous with the spinal cord
o Connects motor & sensory tracts from the brain to the body
o Assists in regulation of cardiac & respiratory function
Regulates the CNS, helps maintain consciousness & regulates sleep
Consists of 3 areas:
Midbrain; contains motor neurons and tracts
Pons; 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
o Descends from medulla down the back, surrounded by meninges & protected by the vertebral column
o Extends to 1st - 2nd lumbar vertebrae
o Vertebral canal continues beyond the cord, lumbar cistern space
o White matter
o Gray matter
What is central nervous system and what structures does it include p 621-626
Includes 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 partssomatic 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.
o Objective vertigo: room is spinning
o Subjective vertigo: feel like you are spinning
Dizziness: 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
Know the 12 cranial nerves—sensory, motor or both; how tested and expected findings—abnormalities
CN I: Olfactory, sensory
o Test sense of smell in those who report loss of smell, head trauma, abnormal mental status, when presence of
intracranial lesion suspected
o With person’s eyes closed, occlude one nostril & present familiar aromatic substance, e.g., coffee, orange,
vanilla, soap or peppermint
o Normally, person can identify an odor on each side of nose; normally decreased with aging
o Anosmia = 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 tract
CN II: Optic, sensory
o Test visual acuity (Snellen chart) & visual fields by confrontation (test peripheral vision)
o Using ophthalmoscope, examine ocular fundus to determine color size, & shape of optic disc
CN III, IV & VI: Oculomotor, Trochlear & Abducens, motor
o Palpebral fissures are equal in width
o Check pupils for size, regularity, equality, direct & consensual light reaction & accommodation
o Assess extraocular movements by cardinal positions of gaze
o Assess for nystagmus (occurs with disease of vestibular system, cerebellum, or brainstem)
CN V: Trigeminal: sensory & motor
o 3 divisions of CN V: ophthalmic, maxillary, mandibular
o Motor 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 cannot
o Sensory function: with eyes closed, test light touch sensation by touching a cotton wisp to: forehead, cheek &
chin, perform bilaterally
o Corneal reflex: omit, unless abnormal facial sensation or movement
Person looking forward, bring wisp of cotton in from side, lightly touch cornea, not conjunctiva
Normally, person will blink bilaterally
CN VII: Facial, sensory & motor
o Motor 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 sides
o Sensory function:
Test when you suspect facial nerve injury
Test 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), sensory
o Test hearing acuity by ability to hear normal conversation & by whispered voice test
CN IX & X: Glossopharyngeal & Vagus: sensory & motor
o Motor function
Depress 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 reflex
Voice sounds smooth, not strained
o Sensory function
o CN IX mediates taste on posterior one third of tongue
CN XI: Spinal Accessory: motor
o Examine sternomastoid & trapezius muscles for symmetry
o Check equal strength by asking person to rotate head against resistance applied to side of chin
o Ask person to shrug shoulders against resistance
o Movements should feel equally strong on both sides
CN XII: Hypoglossal: motor
o Inspect tongue; no wasting or tremors
o Note forward thrust in midline as person protrudes tongue
Tongue will deviate to the side with the lesion of the hypoglossal nerve (deviation toward
paralyzed side)
o Ask person to say “light, tight, dynamite,” note lingual speech (sounds of letters l, t, d, n) are clear & distinct
Know common abnormalities as noted on lecture notes—e.g. peripheral neuropathy, chorea, ataxia,
Abnormal Findings Abnormalities in Muscle Movement
o Paralysis: decreased or loss of motor power due to problem with motor neuron or muscle fibers.
o Fasciculation: rapid continuous twitching of resting muscle or part of muscle without movement of limb
o Tic: 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)
o 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)
o 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)
o Rest tremor: occurs when muscles are quiet and supported against gravity (hand in lap), but will disappear
with voluntary movement
o Intention 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)
o 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)
o 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 hand
Abnormal Gaits
o Spastic 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)
o 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
o 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 direction
o Scissors: knees cross or in contact, like holding an orange between thighs. Short step and walking requires
effort (paraparesis of legs of MS)
o 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)
o 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 dysfunction
o Dysmetria: clumsy movement with overshooting the mark and occurs with cerebellar disorders or acute
alcohol intoxication
Common Patterns of sensory loss
o Peripheral 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 normal
DM, chronic alcoholism, nutritional deficiency
o Individual nerves or roots: decrease or loss of all sensory modalities. Area of sensory loss corresponds to
distribution of the involved nerve
Trauma or vascular occlusion
o Spinal 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 lesions
Meningioma, neurofibroma, cervical spondylosis, MS
o Complete 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 control
SC trauma, demyelinating disorders, tumor
o Thalamus: loss of all sensory modalities on the face, arm, and leg on the side contralateral to the lesion
Vascular occlusion
o Cortex: 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 postures
o Decorticate 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 cortex
o Decerebrate 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 pons
o Flaccid quadriplegia: complete loss of muscle tone and paralysis of all four extremities, indicating completely
nonfunctional brainstem
o Opisthotonos: prolonged arching of back, with head and heels bent backward. This indicates meningeal
How 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
1. Level of Consciousness
a. Assess AAOx4 and GCS and ability to follow verbal commands (if person is not fully alert, increase
amount of stimulus)
b. If pt is intubated, ask questions that the pt can nod or shake head to respond
2. Motor function
a. 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 ICP
How is the motor system tested—what is a positive Romberg test?
Balance Tests
o Gait
o Romberg 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 movements
o Rapid Alternating Movements (RAM)
o Finger-to-finger test
o Finger-to-nose test
o Heel-to-shin test
Know reflexes—deep tendon and superficial. How tested and expected responses
Deep tendon receptors
o Measurement of stretch reflexes reveals intactness of reflex arc at specific spinal levels
o Limb should be relaxed & muscle partially stretched
o Stimulate reflex by directing short, snap of reflex hammer onto muscle’s insertion at tendon
o Compare sides: should be equal
o Utilize reinforcement
o DTRs graded on a 4-point scale
4 = very brisk, hyperactive with clonus, indicative of disease
3 = brisker than average, may indicate disease
2 = Average, normal
1 = diminished, low normal or occurs with reinforcement
0 = no response
o Subjective scale requires clinical practice
o Biceps reflex, C5 - C6
Support person’s forearm on yours; place your thumb on biceps tendon & strike your thumb
Normal response is contraction of biceps muscle & flexion of forearm
o Triceps reflex, C7 - C8
Tell person to let arm hand as you strike triceps tendon directly just above the elbow
Normal response is extension of forearm
o Brachioradialis reflex, C5 to C6
Hold person’s thumb to suspend forearms in relaxation & strike forearm directly, about 2 - 3 cm
above radial styloid process
Normal response is flexion & supination of forearm
o Quadriceps reflex, L2 to L4 (knee jerk)
Let lower legs dangle freely to flex knee & stretch tendons; strike tendon directly below patella
Normal response is extension of lower leg
o Achilles 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 hand
Sensory receptors
o Sensory receptors in skin; motor response is localized muscle contraction
o Abdominal reflexes: upper: T8 - T10; lower: T10 - T12
Person in supine position, knees slightly bent; use handle end of reflex hammer to stroke skin
Move from each corner toward midline at both upper & lower abdominal levels
Normal response is ipsilateral contraction of abdominal muscle with observed deviation of
umbilicus toward stroke
o Cremasteric reflex, L1 to L2
On male, lightly stroke inner aspect of thigh with reflex hammer or tongue blade
Note elevation of ipsilateral testicle
o Plantar reflex, L4 to S2
Position thigh with slight external rotation
With 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 forefoot
How are sensory tests done—and what to look for
Ask person to identify various sensory stimuli in order to test intactness of peripheral nerve fibers, sensory tracts &
cortical discrimination
o Routine screening includes testing superficial pain, light touch & vibration in few distal locations & testing
Spinothalamic tract
o Pain
o Temperature
o Light touch
Posterior column tract
o Vibration
o Position (kinesthesia)
o Stereognosis
o Graphesthesia
o Two-point discrimination
o Extinction
o Point location
What is mapping
Mapping is process of locating nerve dysfunction
What are dematones
Dermatome is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular
spinal nerve
Differentiate upper motor neuron disease and lower motor neuron disease—common abnormalities
Upper motor neurons
o Spacicity
o Located within CNS; convey impulses from motor areas of cerebral cortex to lower motor neurons
o Complex of all descending motor fibers that influence lower motor neurons
o Examples of upper motor neurons: corticospinal & extrapyramidal tracts
o Examples of upper motor neuron diseases are CVA, cerebral palsy & multiple sclerosis
Lower motor neurons
o Flaccidity
o Primarily in PNS
o Provides contact with muscle
Movement must be translated into action by motor neuron fibers
Examples of lower motor neurons are cranial & spinal nerves
Examples of lower motor neuron diseases are spinal cord lesions, poliomyelitis & amyotrophic
lateral sclerosis
What happens in the neurological system with aging?
Aging causes atrophy with a steady loss of neuron structure in brain & spinal cord & causes….
o Loss of weight & volume of cerebral cortex
o Reduced subcortical brain structures
o Expansion of the ventricles
Muscle 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 reflexes
Nerve conduction decreases
Increased delay at synapses
Progressive decrease in cerebral blood flow & oxygen consumption
Decrease in taste and smell
Senile tremors occasionally occur (intention tremor of the hands, head nodding, and tongue protrusion)
o Dyskinesias: repetitive stereotyped movements in the jaw, lips, or tongue may accompany senile tremors with
no associated rigidity
Gait may be slower and more deliberate and may deviate slightly form midline path
Alternating movements may be more difficult
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 Cancer
o The most common cause of death from CA in men over age 75
o Rarely found in men younger than 50
o Men who are at higher risk include
African-American (more likely to be dx'd at advanced stage and mortality rates are 2x's higher—
/oat risk if >45y
Older than 50-60
Father or brother with prostate CA
Multiple family Hx and >40y/o
BRCA2 mutations [more aggressive type, younger]
Other men at risk include:
Exposed to agent orange
Diet high in fat (animal & saturated fats), red meat, processed meats, and dairy products
Tire plant workers
Less common in vegetarians
o Prostate Screening start at age 50 if not at risk
Prostate specific antigen (PSA) at or below 4.0 ng/mL
Digital rectal exam
If abnormal…
Prostate biopsy
Transurethral ultrasound
CT or bone scan
Cervical cancer
o Risk:
Risky sexual practices
Not receiving the HPV vaccine
Poor economic status
Women whose mothers took the drug DES (diethylstilbestrol)
Weakened immune system
Hispanic women, African-American
o Screen:
Pap smear once sexually active or age 21until age 65
Screening recommended every 3 years
HPV screening
Colorectal cancer
o Risk:
Over 60
African American or eastern European descent
Diet high in red or processed meats
Have CA elsewhere in the body
Have colorectal polyps
Have IBD
Family hx of colon CA
Personal hx of breast CA
o Screening:
Beginning at age 50 for men & women
At age 45 for African Americans & if at risk
To detect polyps & early CA
ABD & rectal exam
Annual FOBT (guaiac-based or fecal immuno-chemical test)
Colonoscopy (q10yrs with bowel prep and conscious sedation) & sigmoidoscopy
CA 19-9 [marker]
Differentiate direct, indirect, and femoral hernias
Indirect Inguinal
Direct Inguinal
Sac herniates through
Directly behind and through
Through femoral ring and
internal inguinal ring;
external inguinal ring, above
canal, below inguinal
Can remain in canal or pass
inguinal ligament; rarely
ligament, more often on right
into scrotum
enters scrotum
Clinical Signs & Symptoms
Pain w/straining
Usually painless; round
Pain may be severe
Soft swelling that increases
swelling close to the pubis in
May become strangulated
w/increased intra-abdominal
area of internal inguinal ring;
easily reduced when supine
May decrease when lying
Most common
Less common; occurs most
Least common
60% of all hernias
often in men older than 40
4% of all hernias
More common in infants < 1
years, rare in women
More common in women
y and
In males 16-20 y
Congenital or
Acquired weakness; brought
on by heavy lifting, muscle
Due to increased abdominal
atrophy, obesity, chronic
pressure, muscle weakness, or
cough, or ascites
frequent stooping.
How is the TSE performed?
T - TIMING (once a month)
S - Shower, warm water relaxes scrotal sac
hands are warm and soapy
cold hands stimulate a muscle (cremasteric) reflex, retracting scrotal contents.
E - Examine, check for changes, report changes immediately
Step 1
Hold 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 movable
Feels 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 worrisome
Firm, 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,
Dysuria - pain or burning during urination is common w/acute cystitis, prostatitis, urethritis
Nocturia- occurs together w/frequency and urgency in urinary tract disorders. Other origins: cardiovascular, habitual,
diuretic meds
Polyuria – excessive volume
Hematuria - blood in urine
Cryptorchidism - absence of one or both testicles (undescended testes)
Menopause – cessation of the menses, usually occurring around 48-51 years of age
Perimenopausal - 40-55 y, has hormone shifts, resulting in vasomotor instability
What 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 flow
Ovaries stop producing progesterone and estrogen (decreased estrogen brings about dramatic physical changes)
o uterus shrinks in size due to decreased myometrium
o Ovulation may still occur sporadically after menopause
o Sacral ligaments relax and pelvic musculature weaknes—uterus droops (may protrude or prolapse into
o Cervix shrinks and looks paler with a thick glistening epithelium
o Vagina becomes shorter, narrower, and less elastic d/t increased connective tissue; atrophy with less sexual
activity (1/2 its normal length and width)
o More fragile mucosa with risk for bleeding and vaginitis
o Decreased secretions with dryness—risk for irritation and pain with intercourse (dyspareunia)
o pH more alkaline and glycogen content decreases from the decreased estrogen (increase risk for vaginitis)
o Mons pubis looks smaller d/t atrophy of fat pad
o Labia and clitoris decrease in size
o Pubic hair thins and more sparse
Symptoms: hot flash, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings,
vaginal dryness, itching
SE’s of Hormone Replacement Therapy: fluid retention, breast pain, vag bleeding, and breast cancer risk
Know anatomy terminology in lab manual
Know terms—such as flexion, extension, lateral bending, rotation, etc., and how tested
Flexion: bending limb at joint
Extension: straightening limb at joint
Abduction: moving limb away from midline of body
Adduction: moving limb toward midline of body
Pronation: turning forearm so that palm is down
Supination: turning forearm so that palm is up
Circumduction: moving arm in circle around shoulder
Inversion: moving sole of foot inward at ankle
Eversion: moving sole of foot outward at ankle
Rotation: moving head around central axis
Protraction: moving body part forward, parallel to ground
Retraction: moving body part backward, parallel to ground
Elevation: raising a body part
Depression: lowering a body part
Differentiate rheumatoid arthritis and osteoarthritis p 608
RA is chronic systemic inflammatory disease of joints and ct. inflammation of synovial membrane lead to thickening
o Then to fibrosis which limits motion
o Finally to bony ankylosis,.
o Is quite painful, bilateral, and symmetric.
o Associated with fatigue, weakness, anorexia, weight loss, low-grade fever and lymphadenopathy.
Swan neck and boutonneire deformity.
o Systemic inflammatory disease bilateral small joints
o Pain worse in morning when arising; pain lessens with movement
OA (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.
o Happens from injury from sports accidents for example. Aging increase incidence.
o Nearly all adults > 60y have it to some degree.
o Affected joints have stiffness, swelling with hard bony protuberances, pain with motion and limitation of
o 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 joints
Pain becomes worse throughout the day; worsens with more movement
Describe osteoporosis—signs/symptoms/treatment p 573 & 608
The 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 vertebrae
Treatment/prevention: diet adequate calcium and vit D, weight bearing exercise, avoid smoking and excessive alcohol,
bone density tests, supplements
Differentiate—tendons, joints, muscles
o Connect muscle to bone
o Connect bone to bone
o Help prevent movement in undesirable directions.
o Point where 2 or more bones meet
o They are the functional units of the musculoskeletal system because they permit the mobility needed for
o 40% to 50% of body’s weight
o Three types: skeletal, smooth & cardiac
o Skeletal muscles are under conscious control
o Cardiac & smooth muscles are not
o Skeletal muscle are composed of fasciculi
o Skeletal muscle attached to bone by tendon
How are joints inspected and inspected for what
Note size & contour of joint
o Presence of swelling is significant and signals joint irritation.
o Swelling can be excess joint fluid, thickening of the synovial lining, inflammation of surrounding soft tissue
(bursae, tendons), or bony enlargement.
o 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 deformity
o Swelling is significant and signals joint irritation
What are joints palpated for?
Palpate each joint: assess temperature, muscle contour, bony articulations & area of joint capsule
Note 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.
o Palpable fluid is abnormal.
o 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 joint
Active (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.
o If a limitation is noticed, gently attempt Passive ROM.
o 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.
o Normal ranges of ACTIVE & PASSIVE ROM should be the same.
Temporomandibular joint
Cervical Spine
Inspect 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
They should feel firm, w/no muscle spasm
or tenderness.
Inspect and compare both shoulders
posteriorly and anteriorly
Check the size and contour of the joint, and
compare shoulders for equality of bony
Normally, no redness, muscular atrophy,
deformity or swelling is present.
Check anterior aspect of the joint capsule
and the subacromial bursa for abnormal
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.
Elbow p 583
Inspect 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
Palpate for are of olecranon bursa for heat,
swelling, tenderness, consistency, or
ROM test
Open mouth maximally.
Partially open mouth, protrude
lower jaw, and move it side to
Stick out lower jaw.
Flexion (45°) &
Hyperextension (55°)
Lateral Bending (40°)
Rotation (70°)
Chin to chest and toward
ceiling; Ears to shoulders;
Rotate chin toward shoulders
Expected Finding
Vertical motion. You can
measure the space between
the upper and lower incisors.
Normal is 3-6 cm or three
fingers inserted sideways.
Inspection: Swelling looks like around
bulge over the joint, although it must be
moderate or marked to be visible.
Crepitus and pain occur w/TMJ
Lateral motion. Normal
extent is 1-2 cm
Protrude w/o deviation
Head tilted to one side.
Asymmetry of muscles.
Tenderness and hard muscles w/muscle
Limited ROM
Pain w/movement
Person can't hold flexion
Repeat motions while applying
opposing force.
Person can normally maintain
flexion against your full
resistance (this also tests the
integrity of cranial nerve XI
Test ROM by asking them to
perform 4 motions:
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.
Forward flexion (180°)
Hyperextension (50°)
Internal/External rotation (90°)
Abduction (180°)/Adduction
Cup one hand over the
shoulder during ROM to note
any crepitation, normally none
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
Hard muscles w/muscle spasm.
Tenderness or pain
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 510 of full extension and
others have 5-10 of
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
Local heat or redness (signs of
inflammation) can extend beyond synovial
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 584
Flexion (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
Hyperextension of 70 when
bed the hand up at the wrist.
Loss of ROM is most common and most
significant functional loss of the wrist.
Palmar flexion of 90 when
bend hand down at the wrist
Limited motion.
Pain on movement.
Flexion 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
Phalen test: ask pt to hold both
hands back to back while
flexing wrists 90˚ and hold for
Tinel sign: directly percuss
median nerve at the wrist
Lower Extremity p 588
Knee p 589
Bulge 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 meniscus
Raise each leg with knee
Bend each knee up to the chest
while keeping the other leg
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.
Bend each knee
Extend each knee.
Check ROM while ambulating
Positive phalen test: produces numbness
and burning in persons with carpal tunnel
Hip flexion of 90’
Hyp flexion of 120’ the
opposite thigh should remain
on the table.
Internal rotation of 40’
external rotation of 45’
Positive Tinel sign: percussion of medial
nerve produces burning and tingling along
its distribution (positive for carpal tunnel
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.
Abduction of 40-45’
Adduction of 20-30’
Hyperextension of 15’ when
Flexion 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 592
Point toes toward the floor
Point toes toward the nose
Turn 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’
Spine; p 594
Bend forward and touch toes.
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
Straight 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 sideways
Bend backwards.
Twist shoulders to one side,
then to the other.
Limited ROM
Pain with motion
Limited ROM
Pain 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 force
Note: muscle status and joint status are interdependent and should be interpreted together
Full ROM against gravity, full resistance
Full ROM against gravity, some
Full ROM w/gravity
Full ROM w/gravity eliminated (passive
Slight Contraction
No contraction
What happens to the musculoskeletal system with aging?
Bone remodeling is a cyclic process of resorption & deposition; after age 40 resorption occurs more rapidly than
Net effect is loss of bone density or osteoporosis
o Postural changes, decrease in height
o 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)
o 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 younger
o Begin to lose fat in face & deposit it in abd & hips
In 80s & 90s, fat further decreases in periphery
Loss of subcutaneous fat leaves bony prominences more noticeable
Loss in muscle mass occurs (decease in size or atrophy producing weakness)
Contour of muscles becomes more prominent, muscles & tendons feel more distinct
Lifestyle affects musculoskeletal changes