Health Assessment exam 2

Alert

fully awake and alert, Oriented x3

Lethargic

Drowsy/ sleepy, quickly awaken with minimal stimulation, reduced alertness but not deeply unresponsive

Obtunded

Difficult to arouse, vigorous stimulation to awake, limited awareness, slow or confused responses

Stupor

Vigorous and repeated stimulation to awake, incomprehensible responses, minimal awareness, unresponsive state immediately when stimulation stops

Coma

Completely unresponsive, no eye opening, cannot be awake

CN I SENSORY

Olfactory- smell

CN II SENSORY

Optic- vision

CN III MOTOR

Oculmotor- Extraocular muscle movement, open eyelids, pupil constriction

CN IV MOTOR

Trochlear- downward and upward movement of eye

CN V BOTH

Trigeminal- mastication muscles, face and scalp sensation, cornea, mucus membrane of mouth and nose

CN VI MOTOR

Abducens - Lateral movement of eye

CN VII BOTH

Facial- facial muscles, closing eyes and mouth movement, taste flavor

CN VIII SENSORY

Acoustic- hearing and equilibruim

CN XI BOTH

glossopharyngeal- pharynx phonation, Gag reflex

CN X BOTH

Vagus- motor pharynx and larynx

CN XI MOTOR

Spinal accessory- movement of trapes

CN XII MOTOR

Hypoglossal- movement of tongue

Testing of CN I

close one nostril and identify different scents

testing of CN II

Snellen Chart and reading print

Testing CN III, IV, VI

Test eyemovement by having patient follow fingers in H, Shine light to have pupils constrict

testing CN V

Trigeminal: Gently touch patient with cotton on forehead, cheeks and jaw, clench jaw while palpate muscles

Testing CN VII

Facial: Frown, smile, puff cheeks, close eyes tightly and raise eyebrows

Testing CN VIII

Turning fork or whisper test

Testing IX and X

Ask patient to say AHH and test gag reflex

Testing CN XI

Shrugging shoulders and turning head against resistance

Testing CN XII

Stick out tongue and move side to side

Tandem Test

Heal-to-toe walk in a straight line

Romberg test

Patient close their eyes while you have both arms on the outside, test for swaying balance

Afferent fibers

Enter through posterior (dorsal) roots

Sensory

Efferent Fibers

Exit through anterior (ventral) roots

Motor

how many pairs of spinal nerves

31

Spinal

Thoracic

Lumbar

sacral

Coccygeal

POQ dermatome

Lumbar

heal to shin

Slide heel from knee to shin

Vertigo

Spinning sensation

Dizziness

Dysphasia

Difficulty with langue

Understanding or expressions of thoughts and ideas

DysARThria

Difficulty with speech ARTiculation

• trouble forming words due to muscle weakness or coordination

DysPhonia

Difficulty Producing voice sounds

• voice quality, pitch or volume

Stereognosis

Ability to identify an object by touching it with your eyes closed

Graphesthesia

Ability to identify numbers or letters traced on the skin

drawing on palm

Deep tendon Reflexes

Biceps, triceps, brachioradiallis, pateller (quadriceps), Achilles

2+ is normal grading

Hyperreflexia

Exaggerated, overly brisked reflexes

“Hyperactive 4+ with clonus, and upgoing toes in right leg"

Hyporeflexia

Diminished or absent reflexes

Clonus

Rhythmic, oscillating muscle contraction in response to sustained stretch, often seen with hyperreflexia

indicated upper motor neuron disease

what are the 3 levels of assessing consciousness using the Glasgow Coma Scale

• eye opening- assess arousal mechanism and brainstem function

• verbal response- evaluated orientation, coherence of speech and cognitive function

• motor response- tests the best motor response to stimulation, indicating brain and spinal cord function

Score of 13-15 for GCS

Mild brain injury

15 is the highest possible score

Score of 9-12 for GCS

Moderate Brain injury

Score of 3-8 of GCS

Severe brain injury/coma

3 is the lowest possible score

What is Flaccidity and when is it typically seen

Decreased or absent muscle tone with limp, weak muscles that cannot resist gravity

lower motor neuron lesions- spinal cord injury, peripheral nerve damage, and immediately after acute stroke or spinal shock

What is spasticity

Increased muscle tone with stiff, rigid muscles and resistance to passive movement

hyperactive reflexes

upper motor neuron lesions- stroke, cerebral palsy, spinal cord injury

what is rigidity

Constant, uniform resistance to passive movement in all directions throughout the entire range of motion

affecting flexor and extensor muscles equally

associated with basal ganglia- parkinson’s disease

what is cogwheel rigidity

ratchet-like jerky resistance felt during passive movement, as if moving though a series of catches or stops

hallmark sign of parkinsons disease- rigidity and tremor in affected limb

Rest tremor

Body part is fully supported against gravity and not moving

RHYTHMIC SHAKING when muscles/limb is completely relaxed

disappears with voluntary movement

classic sign of parkinson’s disease

often described as pill-rolling

Intention Tremor

Voluntary movement and worsens as the target is approached

ABSENT at REST

appears or intensifies during purposeful movement toward a target

cerebellar disease/dysfunction

example: patient tries to touch their finger to their nose the tremor becomes more aggressive as the finger gets closer to the nose

DeCORTicate Rigidity/ Posturing

Arms flexed and bent towards the CORE/body

feet are flexed

legs are extended and internally rotated

less severe than decerebrate rigidity

Decerebrate rigidity/ posturing

Arms are extended and adducted (tight against sides)

flexed feet

indicates damage to the brainstem or midbrain

deeper and more severe brain injury

Thyroid Gland

It is normal for thyroid gland to move UPWARD when swallowing

recognize goiters or inflammed nodules

nonpalpative = normal finding

Normocephalic

normal size and porportiate head shape

Accommodation

tests eye adaptation for near vision, allows to shift focus from distant objects to close objects

types include:

Convergences: eyeballs moves medially (towards each other) as axes of the eyes turn inwards- cross eyed

Pupillary constriction: Pupils become smaller

PERRLA stands for

Pupils

Equal

Round

Reactive to

Light

accommodation

Cataract

Blurred and CLOUDY vision

lens loses elasticity becoming hard and glasslike, lens fibers thicken and yellow

risk factors: family history, smoking, overuse of alcohol, sun exposure

Glaucoma

asymptomatic

increased intraocular pressure damages optice nerve fibers

irreversible peripheral (side) vision loss

progresses to tunnel vision, affect gait

risk factors: older age, black people, family history

Age-related Macular Degeneration (AMD)

more prevalent in white people over 75yrs

affects central retina

risk factor: diet, smoking, intake of dark-green leafy vegetables, fish, or omega-3 fatty acids

Snellen eye chart

Test Visual Acuity Distance

Take READING glasses off

20/20 normal vision- can read at 20 feet what a person with normal vision reads at 20 feet

20/30 - can read at 20 feet what a person with normal vision reads at 30 feet

Presbyopia

decreased ability to see near vision

by age 40-45

treatment: magnifying reading glasses

Confrontation Test

gross measure of peripheral vision

compares the patients peripheral vision to yours (assuming yours is normal)

Diagnostic positions test

assess the function of the extraocular muscles (EOMs) and cranial nerves that control them ) CN III, IV, VI

look for parallel tracking, smooth/coordinated movements and any nystagmus

Nystagmus

fine, oscillating movement seen around the iris

eyes don’t move smoothly when following fingers

Pupillary Light Reflex

Stimulus to bright light

Pupils constrict

CN II → CN III

control subcortical reflex (involuntary)

Ptosis

Drooping of the upper eyelid

CN III is responsible

with aging, loss of skin elasticity causes wrinkling and drooping external eye structures

Sensorineural Hearing loss

involves inner ear, cranial nerve VIII, auditory areas of the cerebral cortex

increase in amplitude may not enable the person to understand words

quality of sound processing is impaired

Equilibrium

3 semicircular canals (Labyrinth) feed information to your brain about body position in space

labyrinth is inflamed- staggering gait and vertigo

Presbycusis

Gradual nerve degeneration that occurs with aging, a type of sensorineural HEARING LOSS that affects the inner ear structures, nerve cells in the inner ear, or cranial nerve VIII

High-frequency tone loss notice first

harder to hear consonants than vowels

words sound garbled

impaired ability to localize sound

accentuated difficulty with competing background noise

Tonsil grading

1+ visible behind tonsillar pillars

2+ midway between the tonsillar pillar

3+ touch the uvula

4+ touch each other