1.2 Physical Examination.pdf

Physical Examination 7/18/24 Videos Vitals Cognitive Testing Vestibular Testing Motor/Sensory Testing Muscle Testing Deep Tendon Reflexes Cranial Nerves Spine/Pain Sample Exam Vitals O2 Saturation: Above 97% ◦ Anemia ◦ Overly sympathetic state that leads to constriction in the peripheral vascu...

Physical Examination 7/18/24 Videos Vitals Cognitive Testing Vestibular Testing Motor/Sensory Testing Muscle Testing Deep Tendon Reflexes Cranial Nerves Spine/Pain Sample Exam Vitals O2 Saturation: Above 97% ◦ Anemia ◦ Overly sympathetic state that leads to constriction in the peripheral vasculature. ◦ Poor breathing. Blood Pressure: 120/80 ◦ Sitting, Supine, Standing: BP: L ,R , Pulse ◦ Increased BP unilaterally is IP PMRF/CTX ◦ Normal is a 10-15 bpm change in heart rate between positions ◦ Over 30 bpm HR change -> dysautonomia (POTS) ◦ If HR goes down = increased NTS. If up = RVM ◦ Systolic drop 20mmHG or diastolic drop 10mmHG-> Orthostatic Hypotension ◦ Should not see significant changes in BP (5 up or down) Capillary refill rate: 2 Second perfusion BL ◦ Abnormal - Overly sympathetic state, metabolic disease, anemia ◦ Cold/sweaty palms – increased sympathetic ◦ Cold/dry – adrenals pushing too much epinephrine, or decreased sympathetic Red Desaturation: No asymmetry noted. ◦ Abnormal – one side darker, indicates increased sympathetic tone IP due to low perfusion of the ophthalmic artery  Cognitive Testing Oriented to self, time, and place. Well nourished and groomed. Attention and concentration appear intact. Digit span /7 with linear presentation, /7 with prosodic variation. ◦ Poorer on linear is left brain weakness, on prosodic is right brain weakness Serial 7s intact. ◦ L frontal Successfully repeats the phrase “BLUE, FISH, HOUSE” after both 30 seconds and 5 minutes. ◦ Working memory, PFC Spells “WORLD” accurately forwards and backwards. Visual/Vestibular Testing Observations: Patient's resting head position is normal. ◦ Abnormal yaw, roll, tilt – compensation due to paretic eye mm or change in integration of canals/otoliths ◦ Ptosis, lid lag – IP midbrain ◦ Decreased facial tone ◦ Entire face – IP CN VII ◦ Bottom half of face – CL CTX Fundoscopic exam: A/V ratio is 1:1 and all other findings normal. ◦ Increased A/V ratio - Increased sympathetic tone IP as vasoconstriction causes veins to bloat Park's 3 Step Test: No paretic muscle noted. ◦ Paretic eye muscle - poor integration of canals, end organ, nerve ◦ Can lay supine if findings are mixed to get rid of otolithic interference Convergence: Normal convergence. ◦ Convergence insufficiency BL or unilateral – weak midbrain, weak eye mm ◦ Convergence spasm – excessive midbrain, BG, otoliths ◦ Startle response – increased otoliths Gaze Holding: Stable gaze in all cardinal fields of vision. ◦ Titubation – midline cerebellum, cervical instability ◦ SWJ/gaze instability – PPRF, PMRF Visual/Vestibular Testing 2 Smooth Pursuits: No head movement and minimal total catch up saccades. ◦ Saccadic intrusions/head movement – IP parietal ◦ Horizontal – pontine ◦ Vertical - midbrain HEVM: Head-eye vestibular movement had normal gain bilaterally. ◦ Decreased gain – poor integration of cervical spine, eyes, and vestibular ◦ CL spasm of upper cervical spine ◦ Poor mapping of superior colliculus Saccades: Fast, accurate, symmetrical saccades in horizontal and vertical planes. ◦ Hypometric (0.80), decreased velocity (200ms), increased latency (250ms), head movement – CL frontal eye fields ◦ Horizontal – pontine ◦ Vertical - midbrain Antisaccades : Fast, accurate, symmetrical saccades in horizontal and vertical planes. ◦ Hypometric (0.80), decreased velocity (200ms), increased latency (340ms), head movement – CL frontal eye fields ◦ Increased error rate (20%) – IP DLPFC Optokinetic Reflexes: Normal in all directions. ◦ Decreased gain (0.70) – IP brain (parietal/frontal/PIVC) Vestibular Testing Gait: Normal with symmetrical arm swing. Dual tasking is normal. ◦ Decreased arm swing - decreased IP frontal w/ normal patients, CL frontal with Parkinson’s patients ◦ Worsens w/ dual tasking – can’t use direct frontal therapies due to instability. May need to give them oxygen or supplements ◦ Check for wide based gait, leaning more to one side (IP CB/vestibular), shorter stride length (IP PMRF) Fitz-Ritzen Testing: No dizziness or any other symptoms. ◦ Increased symptoms – cervicogenic etiology of symptoms Perceived Sway: Normal balance. Initial Sway: Normal balance. Sway Improved with: ◦ Determine canal that needs stimulation, apply both OPK and VOR stimulation to determine which is appropriate.  Motor/Sensory Testing Touch localization: Normal bilaterally. ◦ Greater than 1 inch off – CL CB if there’s tremors, IP parietal Finger to nose: Normal bilaterally both sitting and supine. ◦ Tremors, dysmetria, poor coordination – IP CB w/ tremors, CL parietal if inaccurate without tremor Heel to Shin: Normal coordination bilaterally. ◦ Dysmetria, poor coordination – IP CB (vermis/fastigial) Finger Tap: Normal bilaterally. ◦ Hesitations, freezes, facial recruitment, low amplitude – IP CB, CL Frontal ◦ G1 – 1-2 hesitations, slight slowing, decreased amplitude near end of 10 taps ◦ G2 – 3-5 hesitations, mild slowing, decreased amplitude midway 10 taps ◦ G3 – 5+ hesitations or 1 freeze, moderate slowing, decreased amplitude after 1 tap ◦ G4 – Cannot or barely perform due to slowing, freezing Alternating Finger Tap: Normal bilaterally. ◦ See finger tap Hand Supination/Pronation: Normal bilaterally with arms by side and in front of body. ◦ See finger tap Luria Sequencing: Normal coordinated movement bilaterally. ◦ See finger tap Pinwheel: Normal upper and lower extremities. ◦ Decreased or increased sensation – nerve, CL parietal, IP brainstem (face), poor integration of sensory maps Applause sign is normal. ◦ More than 4 claps or difficulty stopping/initiating – BG Muscle Testing Muscle strength UE: 5/5 bilaterally. ◦ Neuropathy, muscle disease, CL parietal, IP CB, CL frontal ◦ 5 – Full ROM against gravity w/ maximum resistance ◦ 4 – Full ROM against gravity w/ moderate resistance ◦ 3 – Full ROM against gravity w/ no resistance ◦ 2 – 50% ROM or less in anti gravity position or holding resistance in antigravity position ◦ 1 – No visible movement or contraction Muscle strength LE: 5/5 bilaterally. ◦ See UE  Deep Tendon Reflexes (DTR) Biceps C5-6: 2+ on the right and 2+ on the left. ◦ Asymmetry is abnormal - hyper/hypo on both sides can be normal. ◦ Hypo – mm disease, CL parietal, neuropathy ◦ Hyper – CL frontal Triceps C7-8: 2+ on the right and 2+ on the left. Brachioradialis C5-6: 2+ on the right and 2+ on the left. Patellar L2-4: 2+ on the right and 2+ on the left. Achilles S1-2: 2+ on the right and 2+ on the left. Negative for all other pathological reflexes. ◦ CL frontal Percussive myotonia absent bilaterally. ◦ TND, caffeine/stimulants ◦ If unilateral=CL CTX. ◦ Treat the ctx and recheck ◦ BL is metabolic is most common is oxygen depletion ◦ Adjust ribs, 4-4-8 breathing  Cranial Nerves 1-Nasal Passages are patent, smell intact and has recognition to coffee and cinnamon ◦ Loss of smell – sinus issues, allergies, damage to cribriform plate, BL but more CL temporal ◦ Smell recognition – BL but more CL frontal 5 - Jaw is normal with opening and closing. See spine/pain section for TMJ findings. ◦ Pain, tight/taut fibers, improper opening/closing - TMJD 5, 7 - Corneal blink reflex is normal bilaterally ◦ V1 – afferent, CNVII (temporal/zygomatic) – efferent, pons 7 - Facial paresis is absent bilaterally in upper and lower quadrants. Facial muscle tone is normal bilaterally. Smile is present and symmetrical with command and w/ joke ◦ Whole face drooping – IP CNVII ◦ Lower half face drooping – CL frontal lobe 8 - Finger rub is 12" on right and left. Weber's is normal and does not lateralize. Rinne reveals that AC>BC ◦ Weber’s ◦ If lateralizes – can try putting head in direction of canal/roll, will normalize in position of weakness ◦ Unilateral sensorineural hearing loss – lateralizes to unaffected ear ◦ Meniere, acoustic neuroma, fistula, SSCD, age ◦ Unilateral conductive hearing loss – lateralizes to bad ear ◦ Earwax, infection, eardrum issues ◦ Bilateral conductive hearing loss – no lateralization ◦ Rinne ◦ If AC0.8 ◦ Saccadic intrusions – IP parietal, PPRF ◦ Look for separation in the graphs – paretic eye mm ◦ Excessive vertical movement - eye or head movement (titubations). ◦ Note speed that saccadic intrusions appear – rehab at that speed Vertical Pursuit: ◦ Gain>0.8 ◦ Saccadic intrusions – Midbrain ◦ Lateropulsions – IP PMRF Horizontal Saccades (Gap Saccades): ◦ Looking for 2 main things: ◦ Are they fast? ◦ Functionally: Latencies should be below 200 ms ◦ Pathologically: Latencies should be below 250 ms ◦ Velocities above the curve (200 ms) ◦ Are they accurate? ◦ Above 80 put WNL (75 is the medical range for hypometric saccades) ◦ Note relative asymmetry from the data to determine hemisphericity ◦ Correlate that with looking at the graph for hypermetric or hypometric saccades to the L/R. ◦ Hypermetric saccades – pathologically, IP fastigium/CL dorsal vermis Vertical Saccades (gap saccades, prosaccade): ◦ Use the normative data from horizontal saccades as markers. ◦ Look for the same markers as horizontal saccades (latencies, velocities, accuracy, asymmetries up/down). ◦ Hypermetric saccades are always considered to be pathological, so you don’t have to put WNL. ◦ Overactive midbrain  VNG 3 Horizontal OPK: ◦ Look for 4 main things: ◦ Decreased gain (