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Irene Gold: Neuromusculoskeletal Diagnosis

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Olfactory

Smell coffee or mint one nostril at a time with eyes closed. Anosmia is loss of smell. Parosmia is distorted sense of smell.
How do we test CN 1?
Optic

1. Snell chart for visual acuity
2. Direct Light Reflex (CN II and CN III)
3. Indirect (Consensual) Light Reflex (CN II and III)
4. Accommodation - Eyes converge, pupils constrict, lens convexity
How do we test CN 2?
1. Direct and indirect light reflex
2. Accommodation
3. Testing 6 cardinal fields of gaze
How do we test CN 3?
LR6, SO4, All others 3
CN 6: Lateral Rectus
CN 4: Superior Oblique
CN 3: All others
What muscles and CN's are tested with the 6 cardinal fields of gaze.
CN III (Oculomotor)
Ptosis can be caused by an issue with what cranial nerve?
Superior oblique testing (up down)
How do we test CN IV?
Trigeminal.

Sensory: Touch forehead, cheekbone, and chin with cotton wisp (testing divisons 1-3). Corneal Reflex (CN V afferent, CN VII efferent). Jaw jerk erflex. Oculocardiac Reflex (CN V afferent, CN X efferent) press on eyeball decrease HR. General sensation to the anterior 2/3 of the tongue.
Motor: Muscles of mastication
How do we test CN V?
Extreme, sporadic, sudden burning, or shock-like
Trigeminal Neuralgia feels like what?
Abducens
Motor: Lateral Rectus Muscle
How do we test CN VI?
Facial.

Sensory: Taste of anterior two thirds of tongue (sweet, sour, salty)
Muscles: Muscles of facial expression
How do we test CN VII?
Vestibulocochlear.

Sensory: Vestibular - balance (Mittelemeyer, Barany Caloric test, Romberg). Cochlear - Hearing (Weber, Rinne, Whisper, Auditory acuity/watch)
How do we test CN VIII?
Glossopharyngeal

Sensory: Gag Reflux (CN IX afferent, CN X efferent), Uvula reflux (CN IX afferent, CN X efferent), carotid reflix/massage carotids and heart drops (CN IX afferent, CN X efferent), taste to posterior 1/3 of tongue (bitter)
Motor: Stylopharyngeus muscle elevated pharynx and larynx; dilates pharynx to permit swallowing
How do we test CN IX?
Vagus.

Sensory: Epiglottis and laryngeal muscles of swallowing (palate, pharynx, contracting muscles)
Motor: Gag Reflex, cartoid reflux, uvular reflex
How do we test CN X?
Spinal Accessory

Motor: Trapezius and SCM muscles
How do we test CN XI
Hypoglossal.

Motor; Tongue muscles. Stick out tongue. Will deviate to the side of the lesion.Look for atrophy and fasciculations.
How do we test CN XII?
Westphal's sign
Absence of any DTR, especially patellar.
Wexler

0+: Absent with reinforcement (Jendrassik's)
1+: Hypoactive with no reinforcement or normal wtih reinforcement
2+: Normal
3+: Hyperactive
4+: Hyperactive with transient clonus
5+: Hyperactive with sustained clonus
What scale is used to assess deep tendon reflexes?
CN V: Jaw Jerk (via trigeminal nerve)
C5: Biceps (via musculocutanous nerve)
C6: Brachioradialis (via radial nerve)
C7: Triceps (via radial nerve)
L4: Patellar aka knee nerve (via femoral nerve)
L5: Medial Hamstring (via sciatic nerve)
S1: Achilles aka ankle jerk (Via tibial nerve)
Walk me through all the reflexes for MSRs.
Stroke inner thigh of male; ipsilateral rise in testes

Afferent: Femoral nerve
Efferent: Genitofemoral nerve
Cremasteric Reflex
Stroke up inner thigh of female; poupart's ligament contracts.

Afferent: Femoral nerve
Efferent: Genitofemoral nerve
Geigel's Reflex
Paralysis: Spastic
Deep Tendon Reflex: Hyperactive
Pathological Reflex: Present
Clonus: Present
Tone: Hypertonic
Reaction of Degeneration: Absent
Atrophy: Absent
Fasciculation: Absent
Superficial Reflexes: Absent
Give into for an Upper motor neuron lesion.

Paralysis:
Deep Tendon Reflex:
Pathological Reflex:
Clonus:
Tone:
Reaction of Degeneration:
Atrophy:
Fasciculation:
Superficial Reflexes:
Paralysis: Flaccid
Deep Tendon Reflex: Hypoactive/absent
Pathological Reflex: Absent
Clonus: Absent
Tone: Hypotonic
Reaction of Degeneration: Present
Atrophy: Present
Fasciculation: Present
Superficial Reflexes: Absent
Give into for an Lower motor neuron lesion.

Paralysis:
Deep Tendon Reflex:
Pathological Reflex:
Clonus:
Tone:
Reaction of Degeneration:
Atrophy:
Fasciculation:
Superficial Reflexes:
Visceral Organic Reflex (Brainstem integrated reflex, absent in UMNL and LMNL)

Pinch neck while noting dilation of the eyes. Accomplished via sensory from neck and cervical sympathetics.
Ciliospinal Reflex
Visceral Organic Reflex (Brainstem integrated reflex, absent in UMNL and LMNL)

Press on eye and see if heart slows by 10 BPM. (Via CN V and CN X)
Oculocardiac Reflex
Visceral Organic Reflex (Brainstem integrated reflex, absent in UMNL and LMNL)

Press on carotids sinus note slowing of heart and decreased pressure. (CN IX, CN X)
Carotid Sinus Reflex
Stroke lateral malleolus to fifth toe. Babinski-like response.
Chaddock
Stroke down to tibial crest to the ankle. Babinski like response.
Oppenheim
Squeeze calf below the knee. Babinski like response.
Gordon's Calf
Squeeze achilles tendon. Babinski-like response.
Schaefer
Tap ball of the foot. Plantar flexion of great toe with curling of the other toes.
Rossolimo
Examiner extends middle phalanx and flicks distal phalanx inferior. Response flexion and adduction of the thumb and flexion of the fingers.
Hoffman
Examiner sharply taps the tips of the middle 3 fingers. Response is flexion and adduction of the thumb and flexion of the fingers.
Tromner
Examiner strokes pisiform of the patient. Response is flexion of the wrist and fingers or thumb and index finger.
Gordon's Finger
Examiner strokes the distal ulnar side of the forearm near the wrist. Response is flexion of wrist with extension and fanning of the fingers.
Chaddock's Wrist
Motor: Deltoid (C5, Axillary Nerve), Biceps (C5, 6; Musculocutaneous N)
Reflex: Biceps (C5, C6)
Sensory: Lateral Deltoid (C5, Axillary Nerve)
What are the MSRs for C5?
Motor: Biceps (C5, 6; Musculocutaneous N), Wrist Extensors (C6 [radial], C7 [ulnar])
Reflex: Brachioradialis (C6)
Sensory: Lateral antebrachium to thumb index web (Musculocutaneous Nerve, C6)
What are the MSRs for C6?
Motor: Triceps (C7, Radial N), Wrist Flexors (C7; Median / Ulnar Ns)
Reflex: Triceps (C7)
Sensory: Middle finger, palmar (C7/digit 3, palmar)
What are the MSRs for C7?
Motor: Finger flexors (C8, T1, median Nerve)
Reflex: Finger Flexors (C8, T1)
Sensory: Ulnar aspect of the hand (Medial Antebrachial cutaneous Nerve)
What are the MSRs for C8?
Motor: Finger abductor/adductor (interossei)
Reflex: No Reflex
Sensory: Medial elbow (T1/medial antebrachial cutaneous Nerve)
What are the MSRs for T1?
Motor: Tibialis Anterior (L4; deep peroneal nerve)
Reflex: Patellar tendon (L2, L3, L4)
Sensory: L4 dermatome (Medial foot)
What are the MSRs for L4?
Motor: Extensor Hallicus Longus (L5; deep peroneal nerve)
Reflex: Medial hamstring (L4, L5, S1, S2)
Sensory: L5 Dermatome (Dorsal foot - including web between 1st and 2nd toes)
What are the MSRs for L5?
Motor: Peroneus Longus/Brevis (L5, S1; superficial peroneal nerve)
Reflex: Achilles tendon (S1)
Sensory: S1 dermatome (lateral foot)
What are the MSRs for S1?
Motor: Trunk Flexion
Muscle: Rectus abdominus
Sensory: T5-T12, follow vertebral level
Motor, Muscle, and Sensory test for T5-T12.
Motor: Hip Flexion
Muscle: Iliopsoas
Sensory: Inguinal ligament (L1), oblique below L1 (L2), and oblique across the knee (L3)
Motor, Muscle, and Sensory test for L1-L3
Motor: Hip flexion and adduction, knee extension
Muscle: Quadriceps, adductors
Motor and muscle test for L2-4
Motor: Anal wink
Muscle: Levator ani/coccygeus
Sensory: Perianal
Motor, Muscle, and Sensory test for S2-4
Motor: Arm abduction
Muscle: Deltoid and Teres minor
Sensory: lateral arm
Motor, Muscle, and Sensory test for axillary nerve
Motor: Wrist and finger extension, thumb abduction
Muscle: Wrist/finger extensors, triceps
Sensory: Dorsal web between thumb and index
Motor, Muscle, and Sensory test for radial nerve
Motor: elbow flexion
Muscle: BBC
Sensory: lateral forearm
Motor, Muscle, and Sensory test for musculocutaneous
Motor: Thumb pinch, opposition of the thumb
Muscle: Wrist and thumb flexors. Thumb abductors, thenar
Sensory: Distal radial hand, 2nd digit
Motor, Muscle, and Sensory test for median nerve
Motor: Abduction of 5th digit, and adduction of thumb
Muscle: Finger ab/adductors, and thumb adductors
Sensory: Distal radial hand, 2nd digit
Motor, Muscle, and Sensory test for ulnar
Motor: Elevation and retraction of scapula
Muscle: Rhomboids and levator scapula
Sensory: NA
Dorsal scapular
Motor: Protraction of the scapula
Muscle: Serratus anterior
Sensory: NA
Motor, Muscle, and Sensory test for Long Thoracic
Motor: Hip adduction
Muscle: Hip adductor muscles
Sensory: Medial thigh
Motor, Muscle, and Sensory test for obturator nerve
Motor: hip flexion, knee extension
Muscle: iliopsoas, quadriceps
Sensory: anteromedial thigh and leg
Motor, Muscle, and Sensory test for femoral nerve
Motor: flexion of the knee
Muscle: Hamstrings
Sensory: Ant/Posterior leg, sole/dorsum of foot.
Motor, Muscle, and Sensory test for sciatic nerve
Motor: Foot dorsiflexion, inversion, eversion
Muscle: Tip anterior, toe extensors, peroneals
Sensory: Anterior leg and dorsum of foot
Motor, Muscle, and Sensory test for peroneal nerve
Motor: toe flexion
Muscle: toe flexor muscles
Sensory: NA
Motor, Muscle, and Sensory test for medial plantar nerve
Cutaneous. Anteromedial knee and medial leg.
Saphenous nerve innervates where?
C5 and C6
Disorders of what nerves can result in Erb's Palsy?
Radial nerve (C7)
Disorders of what nerves can result in wrist drop?
Lateral femoral cutaneous nerve (L1-3)
Disorders of what nerves can result in meralgia paresthetica?
L4-5
Disorders of what nerves can result in foot drop?
Axillary
Glenohumeral dislocation can harm what nerve?
C8-T1
Nerves involved with Klumpke's palsy.
DR CUMA
Drop Wrist
Radial Nerve
Claw Hand
Ulnar Nerve
Median Nerve
Ape Hand
What is the cause of

Drop Wrist:
Claw Hand:
Ape Hand:
Medial Plantar Nerve
Tarsal Tunnel Syndrome is associated with what nerve?
Pain along the course of the dermatome due to irritation of a nerve root.
Define redicular.
Pain along scleroderm of origination involving more than one kind of tissue (shared pathway)
Define referred.
Muscle: Cramping, spasm, aching, dull
Nerve: Shooting, radiating, burning
Circulation: Throbbing, pulsating
Bone Cancer: Constant, deep, boring, nocturnal
Sclerotogenous: Poorly localized, dull, ache
Myofascial: Trigger point
Describe these types of pain.

Muscle:
Nerve:
Circulation:
Bone Cancer:
Sclerotogenous:
Myofascial:
Right shoulder, inferior scapula
Gallbladder issues refer to where?
spine at T10-T12 level
Pancreas issues refer to where?
Periumbilical
Intestinal issues refer to where?
Early: Epigastric
Late: RLQ
Appendix issues refer to where?
Groin
Ureter issues refer to where?
Flank
Kidney issues refer to where?
Suprapubic
Bladder issues refer to where?
Weak opponens pollicis
Ape hand appearance caused by what muscle weakness?
Entrapment of anterior interosseous nerve between the heads of pronator teres at the elbow

Pain and paresthesia on the volar aspect of forearm, lateral palm, and lateral digits. Pain will be aggravated with pronation, wrist flexion.

Will have thenar atrophy
Pronator Teres Syndrome (etiology and symptoms)
Pinch grip test
How do we test for Pronator Teres Syndrome?
Tunnel of guyon (under hook of hamate) and cubital tunnel.
What are the two most common places for ulnar nerve entrapment?
tingling in last two fingers and weakness of adductor pollicus (resulting in claw hand) and hypothenar atrophy
Ulnar nerve entrapment presents with what?
Sensory pain in posterior buttocks, thigh, leg down to floor. Weakn knee flexion and decreased achilles reflex (DDX with facet).
Sciatica presents with...
Deep Peroneal nerve
What nerve is involved in anterior compartment syndrome of the calf?
A deformity in which the fingertip is curled in and cannot straighten itself. This deformity usually results from injury, which either damages the tendon or tears the tendon from the bone.
Mallet Finger
Hyper-flexion of the DIP and hyper-extension of the POP. Seen with RA.
Swan Neck Deformity
Hyper-extension of the DIP and hyper-flexion of the PIP. Seen with RA.
Boutonniere Deformity
An abnormal thickening underneath the skin of the palm and fingers. Causes the last two fingers to curl into the palm. Later on, the middle finger may become involved.
Dupuytren's Contracture
A finger becomes locked in a flexion position. The finger locked in a flexed position. The finger locks when one of the tendons that flex the fingers becomes inflamed and swollen. To straighten the finger, a person must force the swollen area into the sheath to produce a popping or snapping.
Trigger Finger
Inflammation of the extensor polliciis brevis and abductor pollicis longus tendons on the side of the wrist at the base of the thumb. Can be brought on by simple strain injury. Treated by bracing the thumb and wrist. (Finkelstein's test is positive)
De Quervain's Tendosynovitis
Finkelstein's
What ortho test is positive in De Quervain's Tendosynovitis?
Pain and temperature
The lateral spinothalamic tract does what?
Lateral spinothalamic tract
Where do you find syringomylias?
Crude light touch
Anterior spinothalamic tract
Sensory and motor interpretation, language, etc
Cerebrum
Balance, coordination, etc
Cerebellum
Two point discrimination, vibration, and joint position sense.
Posterior Columns
Voluntary motor, flexors of the hands and feet
Corticospinal (Pyramidal)
Balances reflexes and postural muscles.
Vestibulospinal
Muscle tone and synergy to proximal flexors of the extremities
Rubrospinal
Muscle tone and synergy to voluntary extensor of the extremities
Reticulospinal
Crosses at medullary pyramids and travels to flexors of the extremities
Lateral Corticospinal (where does it cross?)
Crosses at the segmental level and then to the flexors of the trunk
Ventral Corticospinal
Pathological longitudinal cyst of central canal of spinal cord. Fluid filling cavities expand in adult years.

Loss of sense of pain and temperature over the shoulders and back in a cape like distribution.
Syringomyelia
Demyelination of the CNS (Oligodendrocytes myelinate) producing demyelination of the spinal cord and later on the brain. BOTH motor and sensory cords are affected. Most common in females aged 20-40. Worse when moving from cold to warm climates.

Diplopia, scotomas, transient blindness, optic neuritis, pain vertigo, and UMN in the legs causing distal weakness.
Multiple Sclerosis (Info and symptoms)
Positive Lhermitte's test.

Best: MRI to confirm
How can we diagnose MS?
Charcot's Neurological Triad:

Scanning speech, intention tremors, nystagmus (SIN)
Charcot's Triad (MS)
Cholinesterase Inhibiting Drugs
Myasthenia Gravis is treated with what?
Myasthenia Gravis
Diagnosed with Tensilon test.
Corticospinal tract and anterior horn. Begins in hands/feet. Fasciculation's are present as well as spasticity and increased DTR's.

LMNL in the arms, UMNL in the legs (DDX with lateral canal stenosis)
ALS affects what? It usually begins where? Symptoms?
Degeneration of the posterior columns and the corticospinal tracts as a result of a B12 deficiency. Neurological symptoms are irreversible.

Glove and stocking paresthesia.
PLS affects what? Symptoms?
Shilling
PLS will have a positive ___________ test.
A hemisection (partially severed) spinal cord usually caused by an injury.

Ipsilateral loss of motor function and dorsal columns (proprioception) with contra-lateral loss of pain and temperature.
Brown Sequard (Info and symptoms)
A non-progressive motor disorder of the cerebral cortex due to anoxia to the brain prenatally or during birth trauma.

Will have scissor gait, spastic paralysis, athetoid (MC), and choreiform movements, normal intelligence levels.
Cerebral Palsy (Info and symptoms)
Chronic progressive condition associated with loss of dopamine in substanta nigra causing basal ganglionic dysfunction. Extra-pyramidal tract involvement.

Gradual onset over age 50.

Symptoms include: Resting tremors, mask like face, festinating gait, cogwheel/lead pipe rigidity, forward stooped posture, bradykinesia.
Parkinson's Disease (Info and symptoms)
Inflammatory polyneuropathy of the PNS linked to recent immunization or seen after recent flu infection.

Symptoms include: Ascending paralysis (beginning in the legs) and sensory symptoms. Can become medical emergency if it reaches the diaphragm.
Guillian-Barre Syndrome (Info and symptoms)
Clinical condition of tertiary syphilis; wasting away of the posterior columns.

Symptoms include irregularities of the pupil (argyll Robertson's pupil), coordination and balance issues, slappage gait.
Tabes Dorsalis (info and symptoms)
Sex linked recessive disorder seen in young boys.

Symptoms: Proximal muscle weakness causing a waddling gait; toe walking, hyperlordosis (pot belly stance); pseudohypertrophy of the calves; Gower's sign
Muscular Dystrophy (Erb Duchenne) (Info and Symptoms)
CPK (CK-MM)
What ezyme will be positive in Erb Duchenne?
hereditary condition that affects both motor and sensory nerves.

Symptoms: Weakness of foot and lower leg muscles (can result in foot drop and high steppage gait with frequent trips/falls). Lower leg atrophy will occur.
Charcot Marie Tooth Disease (Info and symptoms)
Autopsy
How can you definitively diagnose alzheimer's disease?
Neurodegenerative Genetic Disorder. Affects muscle coordination; cognitive decline; dementia
Huntington's Chorea
Stance Phase: 60%. Here one leg is supporting itself. This phase is comprised of heel strike (heel hits ground), foot strike (when heel of the foot is on the ground), toe off (when up on toe and about to kick off)
Swing Phase: 40%. One leg is swinging. Is made up of early swing and late swing.
Describe gait cycle.
Iliopsoas and rectus femoris
What muscles are responsible for gait acceleration?
Hamstrings (which is why they are pulled by athletes who decelerate quickly)
What muscles are responsible for gait deceleration?
Dorsiflexors (anterior tibial group: tibial anterior etc, deep fibular nerve). This muscle group eccentrically contracts and lowers the foot to the ground. Quadriceps ecentrically contract to absorb energy as knee goes into 5 degrees of flexion; this prevents the knee from buckling.
What muscles are responsible for gait's Heel strike?
Abductors to contract to hold body up. As center of body moves forward the plantar flexors (triceps surae: gastrocnemius, soleus, and plantaris) contract to push body ahead.
What muscles are responsible for foot strike in gait?
Quadriceps concentrically contract to help the plantar flexors push body ahead by elongating lower limbs.
What muscles are responsible for Toe off in gait?
Parkinsons
Propulsion/festinating/shuffling gait is seen in what condition?
Cerebral palsy (knee crosses midline)
Scissor gait is seen in...
Muscular dystrophy
Waddling gait is seen in...
Anterior compartment syndrome, foot drop, etc
Steppage Gait is seen in...
Posterior column disease
Slappage/sensory ataxia gait is seen in...
Stroke (swinging, unilateral, spastic hemplegia)
Circumduction/hemiplegic gait is seen in...
UMNL
Spastic gait is seen in...
Cerebellum issues. Wide based gait.
Drunken/Motor ataxic gait is seen in.....
50
_____% of flexion and extension occurs at C0-C1
50
____% of rotation occurs between C1-C2
...
Look at Orthopedic tests flashcards or look at page 15 of Neuromuscular diagnosis section.
Patient extends the head back. Examiner slightly abducts arm and then applies downward traction on arm while taking pulse.

Positive: Alteration in amplitude of radial pulse
Indicates: Cervical rib issues
Halstead's test
Patient actively abducts shoulder to 90 degrees, with elbow flexed to 90 degrees and then extends the shoulder. Now the patient extends the elbow.

Positive: Resistance and increased radicular pain.
Indicates: TOS, brachial plexus neuritis, meningeal irritation.
Bikele's sign
Supraspinatus -> suprascapular nerve
Infraspinatus -> Suprascapular nerve
Teres Minor -> Axillary nerve
Subscapularis -> Subscapular nerve
What nerves innervate what rotator cuff muscles?
Serratus Anterior
What muscle does PROTRACTION of the scapula?
Well-leg raise test
Fajerstazn's test
patient supine with affected leg raised slowly while hand is under the lumbosacral portion of the spine. Repeat on other side.

Positive: Pain
Indicates: 0-30 SI joint, 30-60 Lumbosacral joint, 60-90 lumbar spine or contralateral SI joint
Goldthwait's sign
12-24 hours
Meniscal tear, swelling will occur how soon after injury?
Patellofemoral tracking disorder. Patella is being pulled laterally by vastus lateralis muscle. Walking downstairs is most provocative. Tested via clark's and fouchet's
Chondromalacia patella
AVN, knee locks out on extension. Wilson's sign.
Osteochondritis Dessicans
Prepatellar bursitis after repetitive pressure on the knee
Housemaid's knee
Patellar tendonitis
Jumper's knee
Patient is supine with the leg in the 90/90 position. Dr. applies pressure to lateral femoral condyle while extending the knee.

positive: Pain over area of pressure
indicates: TFL syndrome
Noble Compression Test
MC birth defect where heel is elevated and foot is turned inward. Called clubfoot at birth.
Talipes Equinovarus
Metatarsal stress fracture
March Fracture
Patient kneels on table 18 inches from floor, bends forward at the trunk, and touches the floor. Doctor holds ankles.

Positive: Patient refuses to perform.
Indicates: Malingering
Burn's Bench Test
Patient Supine. Doctor places one hand under each heel and asks patient to lift affected limb.

Positive: Dr doesn't feel the affected side pressing downward.
Indicates: Malingering
Hoover's Sign
Patient is sitting upright on the edge of the table or chair which has no backrest. Examiner faces the patient and usually under the guise of "checking circulation" extends the patient's legs below the knee one at a time so the limb is parallel to the floor.

Positive: No pain when there had been a positive SLR.
Indicates: Malingering
Lasegue's Sitting
At beginning of case history, ask patient to point to the site of pain on the back; examiner marks it with a skin pencil. Later on, patient is again asked to point to the site of pain.

Positive: Patient does not point to the same point.
Indicates: Malingering.
Magnusson's
Doctor takes resting pulse rate. Dr. then applies pressure over painful area and takes pulse rate again.

Positive: Increase of 10 beats per minute.
Indicates: Not a malingerer. Real pain.
Mannkopf's sign
Patient asked to go from a side lying position to a seated position.

Positive: Localized thoracolumbar pain and lack of ROM
Indicates: AS, IVD syndrome, or severe sprain/strain
Amoss Sign
When arising from seated position, patient turns to prone position and then climbs up themselves.

Indicates Muscular dystrophy
Gower's sign
Dr. applies finger pressure over mastoid process. Pressure increased until patient expresses discomfort. Determines pain threshold of patient.
Libman's