Exam 1 Differential Diagnosis

What are the 7 major areas to assess in neurologic examination?

- Mental / Emotional Status

- Cranial Nerves

- Motor Function (gross/fine motor, coordination, gait, balance)

- Sensory Function

- Reflexes

-Neural Tension

-Vision

What are the 12 cranial nerves?

- CN 1 : Olfactory

- CN II : Optic

- CN III: Oculomotor

- CN IV: Trochlear

- CN V: Trigeminal

- CN VI: Abducens

- CN VII: Facial

- CN VIII: Vestibularcochlear

- CN IX: Glossopharyngeal

- CN X: Vagus

- CN XI: Accessory

- CN XII: Hypoglossal

What is LR6SO4R3 for?

Acronym for the CN innervating the eye muscles for movement. Time to break it down

What is LR6?

Lateral Rectus = CN VI

What is SO4?

Superior Oblique = CN IV

What CN innervates the rest of the muscles not mentioned?

- Rest of them = CN III

If there is a UMN Lesion what would expect to be effected?

- The brain and Spinal Cord (Central NS)

If there is a LMN Lesion what would expect to be effected?

The peripheral system

What are the classic signs of a UMN Lesion?

- Spasticity

- Hyperreflexia

- Clonus

-Weakness

- Positive Babinski

What are the classic signs of a LMN Lesion?

-Hyporeflexia

-Flaccidity

-Weakness

-Fasciculations

- Muscle atrophy

In sensory function, what information does the DCML sense?

- Proprioception, Vibration, Light touch

In sensory function, what information does the spinothalamic tract sense?

- Pain, Temperature, Light Touch

If a patient has a stereognosis deficit what would they not be able to do?

The patient will not be able to figure out what object that they are holding without help from vision.

What are the Reflex roots for Biceps, Brachioradialis, Triceps, Patella, Achilles

- Biceps: C5-C6

- Brachioradialis: C5-C6 (More C6)

-Triceps: C7-C8

-Patella: L3-L4

-Achilles: S1-S2

What is the scoring for DTRs?

0 = Absent

+1 = hyporeflexia

+2 = Normal

+3 = Normal to brisk

+4 = Hyperreflexia, Clonus

What is Neural Tension?

Inability for nerve to slide/glide in its protective sheath. Results in numbness, tingling, and pain

What does the Saccadic system do?

Directs eyes to an object of interest (rapidly moving eyes between targets is the testing for it)

What are abnormal findings in the saccadic system?

Hypometria - Undershooting the visual target

Hypermetrai - Overshooting the visual target

(you screen for accuracy of movement)

For the Vestibular Ocular Reflex system (VOR), it is comprised of the cranial nerves and semicircular canals. Are they peripheral or central structures?

Peripheral structures so you would expect to have peripheral issues (signs/symptoms)

What test would you use to test the VOR system and what must you do first before the test?

Head Impulse Test, clear the Cervical spine

What is the main role for the VOR system?

Allows patient to maintain gaze on target while moving their head

When testing the smooth pursuit system, are the structures central or peripheral?

- Central structures, coordination involved from the cerebellum based on input from retina

What is the Convergence systems function?

Tracking a near target toward patients eyes

What is an abnormal finding when testing the convergence system?

- When a patient is unable to see earlier clearly at a distance of more than 5 cm

Practice Questions

Know why its the answer not just remembering the answer

During smooth pursuit testing, you notice that the patient's right eye is unable to move medially. Which cranial nerve is likely involved?

a) CN III (oculomotor)

b) CN IV (Trochlear)

c) CN (abducens)

d) CN II (optic)

a) CN III (oculomotor) - LR6SO4R3

During sensation testing, the patient is unable to detect accurate painful stimuli during pinprick examination. This indicates a possible disruption of the ——- tract

a) DCML

b) Spinothalamic

c) Rubrospinal

d) Lateral Corticospinal

B) Spinothalamic

Two Case studies get ready

A 68 year old patient is referred to physical therapy for balancer impairments and generalized deconditioning following hospitalization.

Hx:

- Mild urinary urgency developing over the past months

-3 falls in last year

-Increasing difficulty climbing stairs

EXAMINATION FINDINGS:

- Mild bilateral lower extremity weakness (4/5)

- Patellar reflexes 3+

-Slightly wide-based gait

- Independent ambulation

-No bowel/bladder incontinence

-No acute neurologic changes

The therapist suspects the patient may have early neurologic involvement that has not yet been fully evaluated by a physician.

WHAT IS THE MOST APPROPRIATE ACTION?

a) Treat with PT only

b) Treat with PT and refer patient to neurologist

c) Immediately refer and withhold PT treatment

b) Treat with PT and refer patient to neurologist

67 year old woman presents to outpatient physical therapy via direct access w complaints of dizziness and imbalance that have progressively worsened over the past 6 months.

Hx

- 3 Falls in the last year

-Difficulty writing checks due to worsening hand coordination

-Intermittent double mission for the past several months

-Increasing fatigue

EXAMINATION REVEALS:

-Hyperreflexia +3 in both lower extremities

-Mild dysmetria during finger to nose testing

-Abnormal smooth pursuit

-Wide based gait

Vital signs are stable, and symptoms have remained relatively unchanged for the past several weeks.

WHAT IS THE MOST APPROPRIATE ACTION BY THE PHYSICAL THERAPIST?

A) Begin vestibular rehabilitation and monitor progress

b) Initiate physical therapy and refer the patient to a neurologist

c) Refer the patient immediately to the emergency department and withhold PT

d) Perform Cervical mobilization and reassess in 2 weeks

b) Initiate PT and refer patient to neurologist

What are 3 Risk Factors for Delirium?

- Hospitalization for serious illness, or surgery under general anesthesia

- Iatrogenic Delirium

- Associated w systemic conditions

What could fruity/sweet breath mean?

Possibly Diabetic ketoacidosis

If a patient has bad breath (Halitosis) what could be the cause?

Possibly dental decay, lung abscess, throat/sinus infection

What is something that is important to check that can give you a baseline of different systems?

Vital Signs

What is the normal range for resting HR or Pulse Rate?

60-100 Bpm

What is the scoring of pulse amplitude? (Strength of left ventricle ejection)

0 = absent

1+ = Pulse diminished

2+ = Normal

3+ = Full Pulse, increased strength

4+ = Bounding

What is normal respiratory rate?

12-20 breaths per minute, be aware of quality of breath and effort

What is the normal range for pulse oximetry?

95%-100%

What blood pressure level indicates if exercise is contraindicated?

> 200/110 mmHg

What amount of mmHg change for SBP and DBP puts someone at risk for OH (Orthostatic Hypotension)

+/- 20 mmHg for SBP

+/- 10 mmHg for DBP

What is normal pulse pressure?

40 mmHg

When resting pulse pressure is greater than 60-80mmHg what could that mean?

That is considered a yellow flag and is a risk factor for A-Fib

What is the normal for walking speed?

2 mph (Considered a vital sign)

What are the different stages of pressure injuries?

Stage 1 - Skin intact

Stage 2 - Dermis exposed, partial thickness skin loss

Stage 3 - Fat, Full thickness skin loss

Stage 4 - Inolvement of muscle, bone, tendon full thickness loss

What are the ABCDEs for skin screening?

Asymmetry

Border

Color

Diameter

Evolution/Elevation

What are signs of Arterial insufficiency?

-Decrease/absent pulses

-Pale on elevation

-Rubor on dependency

-Cool, Shiny, Thick nails

-Hair Loss

-Increase pain w exercise

What are the signs of Venous insufficiency?

- Normal pulses

-Pink/Cyanotic, Warm temp

-Edema

-Varicose veins

-Pain increased w standing/sitting

-Relieved with support hose (TED)

What is the normal range for Ankle Brachial Index Reading?

The normal range is 1.0-1.3

Less than 1.0 is indicative of occlusive arterial disease

What is the GLASS acronym for when dividing the abdomen into the 4 quadrants?

GL - Gallbladder and Liver (Quad Upper Right)

A- Appendix (Quad Lower Right)

SS - Stomach and Spleen (Quad Upper Left)

What are the main differences between acute pain and chronic pain?

-Acute pain is protective and useful, promotes healing and limits harmful movement

-Chronic pain persists beyond tissue healing, nervous system becomes more sensitive

In Mechanisms of referred visceral pain how could embryologic development play a role in pain?

- Pain is referred to a spot where the organ was located in fetal development

In Mechanisms of referred visceral pain what is multisegmental innervation?

-Visceral afferent fibers from an organ enter multiple spinal cord arguments and converge on same dorsal horn neurons as somatic adherents from corresponding dermatomes

- Example: referred pain from the heart during an MI is the left shoulder, arm, neck or jaw

In Mechanisms of referred visceral pain how does direct pressure and shared pathways play a role in pain?

Pressure from inflammation or other things can obstruct organs and bring them to contact w diaphragm.

- Diaphram innervated by C3-C5 and pain can radiate to somatic areas innervated by C3-C5

-Shoulder pain will be ipsilateral to organ

What are some ways to communicate and assess pain with a patient that is nonverbal?

- Facial Expressions

-Reactions

-Are they eating/drinking

-Pictures/Charts

What are key words that can help recognize a vascular issue?

-Throbbing

-Pounding

-Pulsing

-Beating

What are key words that can help with a neurologic issue?

-Sharp

-Pinching

-Burning

-Shooting

What key words help identify a MSK issue?

-Aching

-Sore

-Heavy

-Deep

-Dull

What is nociceptive pain?

-Pain that results from nociceptors due to actual or threatened tissue injury (predictable and improves w tissue healing)

What is neuropathic pain?

- Pain caused by a lesion or disease affecting the somatosensory nervous system (nerve related)

What is nociplastic pain?

- Pain arising from altered nociception without clear tissue damage or nerve injury

- Used to be known as central sensitization

(body communicating incorrectly w brain)

What is Central sensitization?

Amplification of neural signaling within the CNS that increases pain sensitivity

What is hyperalgesia?

- Pain response is greater than expected

What is allodynia?

Normally non-painful stimulus that becomes more painful

What is a big sign that usually can differentiate between a systemic or muskuloskeletal issue?

If you are awaken at night due to pain or some stimuli from the tissue

What are the 5 P's when having pain at rest?

- Pain

-Pallor

-Pulselessness

-Paresthiesia

-Paralysis

What is the Fear avoidance scale for and what do the scores mean?

The Fear avoidance scale tells a PT how fear of pain can inhibit the patients daily activities or physical activities.

0-48 =-48 Low levels of fear avoidance

49-64 = Moderate levels

65-96 =-31 High levels

Less than 30 is great likelihoods of returning to work

What is the Pain Catastrophizing scale (PCS) and what score is significant?

The PCS is how much a person overly and negatively thinks about their pain. A significant score is PCS ≥ 30

What is the meaning of a "yellow" flag in screening a patient and what screening tool can be used?

Yellow flags = slow down

The Optimal Screening for Prediction of Referral and Outcome for Yellow Flags is the tool or OSPRO-YF

What is the meaning of a "red" flag in screening a patient and what screening tool can be used?

Red flags = Stop and Evaluate (associated w high risk of serious disorders)

The Optimal Screening for Prediction of Referral and Outcome-Review of Systems is the tool or OSPRO-ROS

What are 3 main key factors to consider when screening a patient?

- Side effect of meds

- Comorbidities

- Visceral pain mechanisms

What is the difference of "Medical screening" compared to "screening for referral"?

Medical screening - Method for detecting disease or dysfunction before an individual would normally seek medical care

Screening for referral - Determining if the patient has a condition that can be addressed by PT or needs another health professional

What does Primary prevention mean?

-Stopping the process that led to disease/illness through education, reduction of risk factors, and health promotion

(dont get the disease)

What does Secondary prevention mean?

Early detection of disease through regular screening does NOT prevent condition but can decrease duration or severity

(Find the disease early)

What is Tertiary prevention?

Limiting the degree of disability by improving function in those with chronic or irreversible diseases

(Limit the consequences of the disease)

What are the 9 main constitutional symptoms?

-Fever

-Diaphoresis

-Sweats (anytime but typically night)

-Nausea

-Vomiting

-Diarrhea

-Dizziness/Syncope (Fainting and Red flags)

-Fatigue

-Weight Loss

Every Emergency Department Payment Is Outrageous

Examination Evaluation Diagnosis Prognosis Intervention Outcomes

What is the difference between signs and symptoms?

Signs - observable findings detected by PT

Symptoms - Indications of disease perceived by patient (cannot be observed by someone else)

For cardiac physician referral guidelines what is considered a vital sign in patients with CHF?

Check the weight of the patient to see accumulation of fluid, swelling, or some sort of edema

What does the CAUTION mnemonic mean ?

It is for early warning signs

C- Changes in bowl/bladder

A - A sore doesnt heal

U - Unusual bleeding or discharge

T - Thickening Lump

I - Indigestion

O - Obvious changes in worts/moles

N - Nagging Cough

What can happen with a patient that has back or shoulder pain that is known to be taking NSAIDs, especially w GI upset or blood in stool?

Gastric Ulcers

If a patient has Cervical Spine pain with urinary incontinence with no medical Dx or Hx what do you do?

SEND TO ER