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Physical Diagnosis Chapter 17


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What are the four regions of the brain?
1. cerebrum 2. diencephalon 3. brainstem 4. cerebellum
Differentiate between gray matter and white matter
- gray matter consists of aggregations of neuronal cell bodies on the surfacve of the cerebral hemispheres, forming the cerebral cortex - white matter consists of neuronal axons coated with myelin
Name 2 structures in the diencephalon
thalmus and hypothalamus
What is the internal capsule?
a white-matter structure where myelinated fibers converge from all parts of the cerbral cortex and descend into the brainstem
Where is the reticular-articulating system located?
the diencephalon and upper brainstem
The cauda equina begins at which spinal vertebrae?
at L1 to L2
What type of nerve fiber is contained in the anterior (ventral) root?
efferent (motor) nerve fibers
What type of nerve fiber is contained in the posterior (dorsal) root?
afferent (sensory) nerve fibers
Which spinal segment is involved with the ankle reflex? knee reflex? brachioradialis? bicep? tricep?
1. Ankle reflex - primarily S1 2. Knee reflex - L2, L3, L4 3. Brachioradialis reflex - C5, C6 4. Bicep reflex - C5, C6 5. Tricep reflex - C6, C7
Which spinal segments are involved with the upper abdominal reflex? lower abdominal reflex? plantar response?
1. upper abdominal reflex - T8, T9, T10 2. lower abdominal reflex - T10, T11, T12 3. Plantar response - L5, S1
What are upper motor neurons?
- nerve cell bodies that are in the motor portion of the cerebral cortex and in several brainstem nuclei - their axons synapse with motor nuclei in the brainstem (for cranial nerves) and in the spinal cord (for peripheral nerves)
What are lower motor neurons?
- have cell bodies in the spinal cord called anterior horn cells - axons transmit impulses through the anterior roots and spinal nerves into peripheral nerves, terminating at the neuromuscular junction
What are the 3 kinds of motor pathways that impinge on anterior horn cells?
1. corticospinal tract 2. basal ganglia system 3. cerebellar system
What are characteristics of the corticospinal (pyramidal) tract?
- mediate voluntary movement and intergrate skilled, complicated, or delicate movements - tracts originate in the motor cortex, travel down into the lower medulla, where they form pyramids - fibers cross to the opposite, or contralateral side in the medulla. and continue downward - fibers then synapse with anterior horn cells or with intermediate neurons
What are corticobulbar tracts?
tracts that synapse in the brainstem with motor nuclei of the cranial nerves
What impairments occur when upper motor neuron system are damaged above the crossover in the medulla?
motor impairment develops on the opposite or contralateral side
What happens when upper motor neurons are damaged below the crossover in the medulla?
motor impairment occurs on the same or ipsilateral side of the body
How are muscle tone and DTRs affects in upper motor neuron lesions?
- muscle tone is increased - DTRs are exaggerated
What can damage to the lower motor neuron systems cause?
- ipsilateral weakness and paralysis - decreased or absent muscle tone and reflexes
What does damage to the basal ganglia system produce?
- changes in muscle tone (usually an increase) - disturbances in posture and gait - bradykinesia (slowness OR lack of spontaneous and autonomic movements)
What does damage to the cerebellum cause?
- impairs coordination, gait, and equilibrium - decreases muscle tone
What are the 2 pathways through which sensory impulses reach the sensory cortex of the brain?
1. spinothalamic tracts 2. posterior columns
Which sensations are conducted through the spinothalamic tracts?
pain, temperature and crude touch
Describe the pathway of the spinalthalmic tract.
1. fibers pass into the posterior horn of the spinal cord and synapse with secondary neurons 2. the secondary neurons crosss to the opposite side and pass upward into the thalamus 3. at the thalamus, the sensation is perceived but not finely distinct 4. a third group of neurons pass the sensation from the thalamus to the sensory cortex of the brain for higher-order discrimination
What type of sensations travel in the posterior columns?
sensations of position, vibration, and fine touch
Describe the pathway of the posterior column
1. the fibers pass into the posterior horn and travel upward to the medulla 2. the fibers synapse with secondary neurons in the medulla, cross to the opposite side, and continue towards the thalamus 3. at the thalamus, the fiber synapses with a third group of neurons and continue to the sensory cortex of the brain
What does bilateral proximal weakness suggest?
What does bilateral distal weakness suggest?
What does weakness made worse with repeated effort and improved with rest suggest?
myasthenia gravis
What are dysesthesias?
- distorted sensations in response to a stimulus that may last longer than the stimulus intself - ex. a person may perceive a light touch or pinprick as a burning or tingling sensation that is irritating or unpleasant
What is pseydohypertrophy?
increased bulk with diminshed strength (seen in the Duchenne's Muscular Dystrophy)
What 4 areas of the nervous system must function for coordination of muscle movement?
1. Motor system - for muscle strength 2. Cerebellar system - for rhythmic movement and steady posture 3. Vestibular system - for balance andfor coordinating eye, head, and body movements 4. Sensory system - for position sense
Generally, what are the 4 types of test done to assess coordination?
1. rapid alternating movements 2. point-to-point movements 3. gait and other related body movements 4. standing in specified ways
What is dysdiadochokinesis?
- rapid alternating movements are slow, irregular, and clumsy - indicates cerebellar disease
What is dysmetria?
- when point-to-point movements are clumsy, unsteady, and inappropriately varying in speed, force, and direction - finger may initially overshoot target - indicates cerebellar disease
What are the names of the 2 tests performed with the patient standing?
1. Romberg Test 2. Test for pronator drift
What is analgesia? hypalgesia? hyperalgesia?
1. analgesia - absence of pain 2. hypalgesia - decreased sensitivity to pain 3. hyperalgesia - increased sensitivity to pain
Name 3 tests used to assess discriminative sensations
1. Stereognosis 2. Graphesithesia (number identification) 3. two-point discrimination 4. point localization - touch a point on the patient's skin. then ask the patient open both eyes and point to the place touched 5. Extinction - simultaneous timulate corresponding areas on both sides of the body. Ask where the patient feels your touch. Normally both stimuli are felt.
Impairment of stereognosis, number identification, and two-point discrimination indicate what?
posterior column disease
Name 3 tests to evaluate for meningitis
1. neck mobility 2. Brudzinski's sign 3. Kernig's sign
List general types of syncope
1. Vasovagal syncope - due to sudden peripheral vasodilatation w/o a compensatory rise in cardiac output 2. Postural (orthostatic) hypotension - due to inadequate vasoconstrictor reflexes OR hypovolemia 3. Syncope due to cardiovascular disorders - such as arrhythmias, aortic stenosis and hypertrophich cardiomyopathy, MI, or PE 4. Disorders Resembling Syncope (hypocapnia, hypoglycemia, hysterical fainting)
What are characteristics of partial seizures?
- start with focal manifestations - usually indicate a structural lesion in the cerebral cortex such as a scar, tumor, or infarction
Name and describe the 3 types of partial seizures
1. simple partial seizures: which do not impair consciousness 2. complex partial seizures: do impair consciousness 3. partial seizures that become generalized: resemble tonic-clonic seizures
What are the different types of simple partial seizures?
1. with motor symptoms - such as Jacksonian 2. with sensory symptoms - numbness, tingling; simple visual, auditory, or olfactory hallucinations 3. with autonomic symptoms - "funny feeling" in epigastrium, nausea, pallor, flushing lightheadedness 4. with psychiatric symptoms - anixety, fear, deja vu, dreamy states, rage, flashbacks, complex hallucinations
What are clinical manifestations of a complex partial seizure?
⬢ may or may not start with autonomic or psychic symptoms ⬢ impaired consciousness & patient appears confused ⬢ automatisms such as chewing, smacking the lips, walking, and unbuttoning clothers ⬢ patient may remeber initial symptoms (aura), but is amnesic for the rest of the seizure ⬢ may have temporary confusion & headache
What are characteristics of gneralized seizures?
⬢ begin with bilateral body movements, impaired consciousness, or both ⬢ suggest a widespread bilateral cortical disturbance
Generally, what is the etiology of a tonic-clonic seizure in a child or young adult?
hereditary etiology
Generally, what is the etiology of a tonic-clonic seizure that begains after age 30?
⬢ suspect either a partial seizure that has become generalized OR ⬢ a gneral seizure caused by a toxic or metabolic disorder
What are toxic or metabolic causes of seizures?
⬢ bacterial meningitis ⬢ hyponatremia ⬢ hypoglycemia ⬢ hyperglycermia ⬢ uremia ⬢ withdrawl from alcohol or other sedative drugs
What are the 4 types of generalized seizures?
1. Tonic-Clonic seizures (Grand Mal) 2. Absence 3. Atonic Seizure (or Drop attack) 4. Myoclonus
What are clinical manifestations of a tonic-clonic (grand mal) seizure?
⬢ patient loses consciousness suddenly & body stiffens into tonic extensor rigidity ⬢ breathing stops & patient becomes cyanotic ⬢ then a clonic phase of rhythmic muscular contraction ⬢ noisy breathing with excessive salivation resumes ⬢ injury, tongue biting, and urinary incontinence may occur
Describe the postictal state of a tonic-clonic seizure
⬢ confusion ⬢ drowsiness ⬢ fatigue ⬢ headache ⬢ muscular aching ⬢ temporary persistence of bilateral neurologic deficits (ie hyperactive reflexes & Babinski responses) ⬢ amnesia for the seizure and recalls no aura
Describe clinical manifestations of an absence seizure
⬢ sudden brief lapse of consciousness ⬢ also has momentary blinking, staring, or movements of the lips and hands, but no falling
What are the 2 substypes of absence seizures?
1. Petit mal absences: last less than 10 sec. & stop abruptly 2. Atypical absences: may last more than 10 sec.
Describe the postictal state of an absence seizure
⬢ no aura recalled ⬢ Petit mal absences quickly return to normal ⬢ atypical absences has some postictal confusion
Describe the clinical manifestations and postictal state of an atonic seizure
⬢ manifests as a sudden LOC with falling but no movements. Injury may occur ⬢ postictal state is either a prompt return to normal OR a brief period of confusion
Describe clinical manifestations of a myoclonus seizure
sudden, brief, rapid jerks involving the trunk or limbs
Name and describe the 3 types of tremors
1. Resting Tremors: are most prominent at rest, and may decrease or disappear with voluntary movement (ex parkinson tremor) 2. Postural tremor: appear when the affected part is actively maintaining a posture 3. Intention tremors: are absent at rest and appear with activity and often get worse as the target is near (ex. disorders of cerebellar pathways such as multiple sclerosis)
What are characteristics of oral-facial dyskinesias?
⬢ rhythmic, repetitive, bizarre movements that mainly involve the face, mouth, jaw, and tongue ⬢ limbs and trunk are involved less often ⬢ can be caused by phenothiazines and long-standing psychosis
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Spasticity, which is increased muscle tone (hypertonia) is caused by a lesion in which part of the brain?
⬢ caused by an upper motor neuron lesion of the corticospinal tract ⬢ can occur at any point from the cortex to the spinal cord ⬢ common cause is a stroke
Rigidity can be caused by a lesion in what part of the brain?
⬢ can be caused by a lesion in the basal ganglia system (ex. Parkinsons)
Flaccidity, or hypertonia, is caused by a lesion in this part of the brain?
⬢ lower motor neuron at any point from the anterior horn cell to the peripheral nerves ⬢ common causes include Guillain-Barre sundrome, spinal cord injury, and stroke
What are characteristics of paratonia?
⬢ are sudden changes in tone with passive range of motion ⬢ lesions are located in both hemispheres, usually in the frontal lobes ⬢ common cause is dementia
What are typical findings of a lesion in the cerebral cortex?
⬢ motor: chronic contralateral upper motor neuron weakness; flexion > extension at the arm; plantar flexion > dorsiflexion; leg is externally rotated ⬢ sensory: contralateral sensory loss on the limbs and trunk ⬢ increased DTRs ⬢ ex. cortical stroke
What are typical findings of a lesion in the brainstem (ex. brainstem stroke or acoustic neuroma)?
⬢ Motor: contralateral weakness & spasticity; cranial nerve deficits such as diplopia and dysarthria ⬢ Sensory: variable ⬢ increased DTRs
What are typical findings of a lesion located in the spinal cord?
⬢ Motor: weakness & spasticity (can be bilateral if damage is to both sides); paraplegia or quadriplegia depending on level of injury ⬢ Sensory: dermatomal sensory deficit on the trunk bilaterally at the level of the lesion; sensory loss below level of the lesion ⬢ increased DTRs
What are typical findings from a lesion in the Basal Ganglia (such as Parkinson's disease)?
⬢ Motor: slowness of movement (bradykinesia), rigidity, and tremors ⬢ Sensory: not affected ⬢ normal or decreased DTRs
What are typical findings of a lesion located in the cerebellum?
⬢ Motor: hypotonia, ataxia, nystagmus, dysdiadochokinesis, and dysmetria ⬢ Sensation: not affected ⬢ normal or decreased DTRs

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