Docstoc
EXCLUSIVE OFFER FOR DOCSTOC USERS
Try the all-new QuickBooks Online for FREE.  No credit card required.

Action of

Document Sample
Action of Powered By Docstoc
					PD LAB EXAM 2 – COMPLETE EXAM REVIEW – Sue Bignami & Kristins Lab Groups

PART I – Mini Mental Exam
Materials
-wristwatch
-pencil
-blank paper
-card that reads “close your eyes”
-pen and blank paper
-picture with intersecting pentagons

Orientation (10 pts)
What is today‟s date? (1 pt.)
What is today‟s year? (1 pt.)
What is the month? (1 pt.)
What day of the week is it? (1 pt.)
Can you tell me what season it is? (1 pt.)
Can you also tell me the name of the hospital/clinic? (1 pt.)
What floor are we on? (1 pt.)
What town are we in? (1 pt.)
What country are we in? (1 pt.)
What state are we in? (1 pt.)

Immeadiate Recall (3pts)
Test the patient‟s memory by saying the words “ball”, “flag” and “tree” clearly
and slowly. Ask the patient to repeat the words back to you. The patient is
awarded 1 point for each correct response for a maximum of 3 points.

Attention and Calculation (5 pts)
Spelling Backwards - Have the patient spell the word “world” backwards. 1 point
is awarded for each letter for a maximum of 5 points. OR you can have them count
back from 100 by 7‟s

Recall (3 pts)
Have the patient recall the same three objects from the immediate recall.   1
point is awarded for each object for a maximum of 3 points.

Language (9 pts)
Naming - Show the patient a wristwatch and ask him what it is. Do the same with
a pencil. (1 pt each)
Repetition - Ask the subject to repeat the phrase “No ifs, ands, or buts.” (1
pt.)
Three Stage Command - Put a piece of paper in front the patient. Tell the
patient to take the paper in their right hand, fold it in half and place it on
the floor. (1 pt for each command)
Reading - Hold up a sign that says “Close your eyes.” Tell the patient to read
it and do what is says. (1 pt.)
Writing - Give the patient a pencil and paper and tell them to write a sentence.
The sentence needs to have a subject, verb, and be sensible, but it does not have
to have correct punctuation or grammar. (1 pt.)
Copying - Show the patient the picture of the two overlapping pentagons and ask
him to draw it. If ten angles are present and two intersect, the patient gets 1
point.
Total Number of Points Possible 30
Score is expressed as a fraction such as 20/30 or 25/30.
                                                                                   1
PART II – Cranial Nerves – Head to Toe Version
                    Action of C.N.        Tools       Test                     Notes
VII:                Testing the           Tuning       Assess hearing by      Abnormalities in
Vestibulocochlear   Vestibulo-            fork           occluding one ear     Rinne and Weber
                    cochlear/Acoustic                    and whispering in     indicate
                    nerve, will test                     the alternate ear     conductive or
                    hearing, balance,                  To further assess      sensorineural
                    and awareness of                     lateralization,       hearing loss.
                    position                             you would perform     Note any
                                                         the Weber test        deafness,
                                                       To further assess      tinnitus,
                                                         Air Conduction        vertigo, or
                                                         versus Bone           nystagmus.
                                                         Conduction,
                                                         perform the Rinne
                                                         Test

II: Optic           Vision                Snellen        Visual acuity        Amaurosis is a
                                          Chart           using Snellen        lesion affecting
                                                         Visual field by      the optic nerve.
                                                          confrontation
                                                         Fundoscopic exam
III: Occulomotor    The occulomotor       Pen Light      Direct and           Note which
IV: Trochlear       nerve supplies the                    consensual           nerves
VI: Abducens        medial, superior,                     papillary response   correspond to
                    and inferior rectus                  Convergence          which eye
                    muscles as well as                   Cardinal Gaze        muscles and
                    the inferior                          (LR6SO4ROM3)         which direction
                    oblique muscles.                     Nystagmus            they turn the
                    Trochlear controls                   Ptosis               eye. Note any
                    Superior Oblique.                                          diplopia,
                    Abducens supplies                                          ptosis,
                    lateral rectus.                                            mydriasis or
                                                                               loss of
                                                                               accommodation.
I: Olfactory        Sense of smell        Scent bag   Ask your patient to      Hyposmia:
                                                      close their eyes and     impairment of
                                                      occlude on nostril.      smell
                                                      Examiner should have
                                                      a non irritating         Anosmia:
                                                      substance (coffee        Inability to
                                                      beans) and bring it      smell
                                                      close to the patients
                                                      other nostril. Ask
                                                      patient to identify
                                                      the substance. Test
                                                      each nostril
                                                      separately.



                                                                                                 2
                   Action of C.N.        Tools       Test                     Notes
V: Trigeminal      V: Motor to           Cotton       Check for facial       Lesions
VII: Facial        temporal and          swab with      symmetry; look for    affecting the
                   masseter muscles      tip            forehead wrinkling    trigeminal will
                   (jaw clenching) and   pulled to      and naso-labial       cause “numbness”
                   lateral movement of   a wisp         folds                 or weakness of
                   jaw                                Have pt „smile‟,       the jaw muscles.
                   VII: Motor to                        „show upper
                   muscles of facial                    teeth‟, „puff         With a lesion of
                   expression,                          cheeks‟               the facial
                   obicularis oris and                Inspect face-          nerve, patients
                   obicularis occuli.                   check eyebrows,       may complain of:
                                                        have pt raise         loss of taste
                                                        eyebrows against      (on ant 2/3),
                                                        pressure; test        dry mouth, loss
                                                        temporal and          of lacrimation,
                                                        masseter muscles      or paralysis of
                                                      Have patient           facial muscles.
                                                        clench jaw and
                                                        move jaw laterally
                                                      Corneal reflex-
                                                        sensory in by V
                                                        and motor out by
                                                        VII

VII: Facial        VII: Sensory          Lifesaver      Taste: Anterior      If nerve
IX:                division: taste to                    2/3 (VII) and        function is
Glossopharyngeal   anterior 2/3 of       Tongue          Posterior 1/3 (IX)   disrupted, the
X: Vagus           tongue                Depressor      Check for            uvula will
                   IX:                                   hoarseness (X)       deviate away
                   Glossopharyngeal                     Have pt open and     from the
                   Nerve supplies the                    say “Ah” look for    affected side.
                   posterior 2/3 of                      midline uvula and    Symmetrical
                   the tongue and the                    symmetric soft       elevation of the
                   TM as well as                         palate rise (IX      soft palate
                   secretory fibers of                   and X)               demonstrates
                   the parotid gland.                   Gag reflex           normal function
                   X: Output to the                      (sensory in by IX    of IX and
                   various organs in                     and motor out by     actually X.**
                   the body, conveys                     X)
                   sensory information                                        Ageusia: Loss of
                   about the state of                                         taste
                   the body's organs
                   to the CNS.
XII: Hypoglossal   Somatomotor that                     Ask pt to stick
                   innervates all                        out tongue to look
                   intrinsic and all                     for midline,
                   but one of the                        atrophy, or
                   extrinsic muscles                     fasiculations
                   of the tongue                        Have pt put their
                                                         tongue in cheek
                                                         against pressure
                                                         bilaterally




                                                                                             3
                 Action of C.N.        Tools      Test                    Notes
V: Trigeminal    Responsible for       Paper       Check sharp vs.
                 providing sensation   Clip          dull sensation on
                 to the face via                     each of the
                 three divisions-      Gauze         divisions. (Pts
                 Opthalmic,                          eyes closed)
                 Maxillary, and        Hot/Cold    If abnormal, check
                 Mandibular.           Item          hot and cold in
                                                     same manner
XI: Accessory    Provides motor                    Note the symmetry     Lesions
                 innervations to SCM                 of trapezii          affecting the
                 and Trapezius                     Have pt shrug         accessory nerve
                                                     their shoulders      can cause
                                                     against resistance   hoarseness,
                                                   Have pt turn their    weakness of the
                                                     head into your       head, neck and
                                                     hand (hand           should muscles.
                                                     providing
                                                     resistance to
                                                     contralateral SCM)



PART III – The Motor System
Observe muscle for bulk, tone, and strength. Always compare bilaterally. Look for
any atrophy. Test Pt strength against your active resistance. Also look for any
involuntary movements – tics, tremors. Note where, how long, how intense etc.
Upper Extremity
-Arm ABduction
- Forearm Flexion and Extension
- Wrist Flexion and Extension
- Finger adduction – have Pt grasp your fingers
- Finger ABduction – keep fingers spread against resistance
- Thumb adduction – keep thumb at base of 5th digit against resistance
Lower Extremity
-Hip adduction – Pt supine, spreads legs and attempts to close against active
resistance against medial aspect of knee.
-Hip ABduction – Pt supine, attempts to open legs against active resistance
against the lateral aspect of knee
-Hip/Thigh flexion – Pt supine, attempts to flex hip against active resistance.
- Knee Flexion- Pt supine, places sole of foot on bed. Pt attempts to hold down
foot while you try to extend the leg
- Knee extension – Pt supine, places sole of foot on bed. Pt attempts to extend
knee while you apply downward resistance on shin.
- Ankle dorsiflexion- place hand on dorsum of foot. Pt attempts to dorsiflex
against your resistance
- Ankle plantarflexion – place hand on sole of foot. Pt attempts to plantar flex
against your resistance.
-Great toe dorsiflexion – place hand on dorsum of big toe. Pt attempts to
dorsiflex against your resistance
-Great toe plantar flexion – place hand on sole of big toe. Pt attempts to flex
against your resistance.

Test for ankle clonus – passively dorsiflex and plantar flex the foot several
times ending in dorsiflexion.
     (+) clonus – rhythmic involuntary dorsi and plantar flexion result

                                                                                            4
PART IV – Sensory Testing
Materials:
    Gauze
    Q-tip
    Tuning Fork
    Tweezers
    Quarter
    Key

  1. Light Touch – Gauze. Pt closes eyes, start distally, tell pt to say when
     felt. Sensory level – spinal cord level below where below there is marked
     decreased sensation.
  2. Pain Sensation – Q-Tip. Sharp and dullloses eyes. Start at fingers/toes.
     Ask “is this sharp/dull?” Check UE & LE.
  3. Vibration – Tuning Fork. Place tuning fork on distal bony prominence. Ask
     Pt to say when it is no longer felt. If there is absence move proximal to
     next bony prominence. Do UE & LE
  4. Proprioception – Grap Lateral aspect of distal phalynx, move up & down,
     telling the PT “this is up, this is down”. Have pt close their eyes, move
     digit up & down & stop. Ask Pt if the digit is up or down. Repeat on great
     toe.
  5. Tactile Localization – double stimultaneous. Pt w/ eyes closed. Touch in
     two places. Ask, “Where did I touch you?”
  6. Two Point Discrimination – Tweezers. Using tweezers, touch Pt fingerpad.
     Slowly bring them closer together. At 2mms apart, the sensation will be
     felt as one point. Performed Bilaterally.
  7. Stereognosis – Key/ Quarter. Place object in pts hand with their eyes
     closed. Ask them to identify it. Do bilaterally, do not use the same
     object in both hands.
  8. Graphesthesia – Write a number in the palm of the patients hand. Do
     bilaterally. Inability to identify # may be parietal lobe dx.
  9. Point Localization – Pt closes their eyes. Touch them. Ask them to point
     where you have touched them.


PART V – Cerebellar function

Finger to nose              Heel-to-knee test          Rapid alternating movements
Romberg test                Gait assessment      Asreixis
   1. Finger to nose test: have pt. touch his or her nose and the examiners
   finger alternately as quickly, smoothly and accurately as possible.
   2. Heel to knee test: Pt should lie on his or her back and slide the heel of
   one foot down the shin of the other lower extremity. A smooth movement should
   be seen with the heel staying on the shin.
   3. Rapid alternating movements: “diadochokinesia”, can be tested on both upper
   and lower extremities. The pt should be asked to pronate and supinate one hand
   and then the other.
   4. Rhomberg Test: have the pt stand in front of the examiner with their feet
   together so that the heels are touching. Pt should extend both arms with their
   palms facing upward. If the patient can maintain this position without moving
   the test is negative. The test is positive if the pt begins to sway and has to
   move the feet for balance. Another common finding is for 1 of the arms to drift
   downward with flexion of the fingers. This is called pronator drift.
   5. Gait assessments: This is the foremost in the assessment of cerebellar
   function. The pt is asked to walk straight ahead, returning on their tip toes,
                                                                                 5
  walk away again on their heels, and then finally to walk back in a tandem gait
  with the heel of 1 foot touching the toes of the other on each step. Look for
  posture balance and smooth swing of the extremities.
  6. Astreixis: Astreixis is seen in pts with hepatic encephalopathy. Have the
  pt hold both arms forward with hands cocked up and fingers spread. Watch for
  sudden, brief, nonrhythmic flexion of the hands and fingers (abnormal).
  Normally, there is no movement of the hands or fingers.


PART VI – Reflexes
Deep Tendon Reflexes
     1. Biceps-
           Pronate forearm partially flexed.
           Examiner should place thumb on biceps tendon.
           Strike examiner‟s thumb.
           Observe biceps and elbow flexion (C5-C6).
     2. Brachioradialis-
           The arm is rested on the patient‟s knee and held in semi-flexion and
     pronation.
           Strike styloid process of the radius, 1-2 inches above wrist.
           Observe for flexion at the elbow and supination of the forearm (C5-
     C6).
     3. Triceps
           Flex the patient‟s elbow and pull forearm toward chest.
           The arm should be midway between flexion and extension.
           Strike tendon 1-2 inches above Olecranon process.
           Observe for contraction of triceps and extension of elbow (C6-C8).
     4. Patellar Tendon
           Patient should sit with legs dangling off the table.
           Place your hands on quadriceps muscle.
           Strike patellar tendon.
           Feel for contraction of the quads and knee extension (L2-L4).
     5. Achilles Tendon (Ankle Reflex)
           Patient should sit with feet dangling off bed.
           The examiner should dorsiflex the patient‟s foot.
           Strike the Achilles tendon just above its insertion on the posterior
aspect of calcaneous.
           Observe ankle plantar flexion.
Superficial Reflexes
     1. Abdominal
           Patient should lie in supine position.
           With tongue blade, quickly stroke horizontally laterally to medially
toward umbilicus.
           Observe for contraction of abdominal muscles with umbilicus deviating
           toward the stimulus.
     2. Cremasteric (Men Only)
           Lightly stroke inner aspect of thigh with applicator stick.
           Observe for elevation of the testicle on same side.
Babinski‟s sign
           Use a key to Stroke lateral aspect of the sole from the heel to the
           ball of the foot and curved medially across the heads of the
           metatarsals.
           Observe for plantar flexion of the big toe. –Normal
           Observe for dorsiflexion of the big toe, with fanning of the other
toes -*Pathological*

                                                                                   6
Meningeal Tests – not on test, but know them
     Brudzinski‟s Sign
           Examiner places his/her hands behind pt‟s head and flexes the neck
forward until chin               reaches chest.
           Observe for resistance or pain. A positive Brudzinski’s sign is when
           the patient’s hips and knees flex with this maneuver.
     Kernig‟s Sign
           Flex patient‟s leg and hips at knee and then straighten knee
           Observe for resistance, which is a positive test




                                                                                  7

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:6
posted:8/24/2011
language:English
pages:7