Ch 22 & 23 musculoskeletal/nervous system

patient is brought to the emergency room following a diving accident in a swimming pool. You are told the patient is in spinal shock. What does this mean in terms of the patient's condition?

here is no motion or reflexes below the level of the spinal cord injury. A severe injury or complete transection of the spinal cord initially produces spinal shock, which is defined as no movement or reflex activity below the level of the lesion. Gradually, deep tendon reflexes reappear and become increased; flexor spasms occur, and these spasms lead to prevailing extensor tone.

On examination you find that your patient hears sound, but is unable to make any meaning out of it. You document this finding as _______ aphasia.

receptive Receptive aphasia is a condition that results after sustaining an injury to Wernicke's area. The patient may hear sound, but is unable to make any meaning out of it.

Mr. Yoder is a 49-year-old patient who comes to the clinic for a physical examination for his job. On examination, you perform a Phalen's test. For which disorder are you assessing?

Carpal tunnel syndrome A Phalen's test is used to assess for the presence of carpal tunnel syndrome. Subluxation of the elbow shows the forearm dislocated posteriorly. Range of motion is used to determine the presence of functional loss of the wrist. A bone density test is the only way to predict fracture risk and diagnose osteoporosis.

In previewing a patient's record, you see documentation of a positive Tinel sign. Which problem does this indicate?

Carpal tunnel syndrome A positive Tinel sign indicates carpal tunnel syndrome. To test for a Tinel sign, the median nerve is directly percussed at the wrist. In the normal hand, no symptoms result. In the presence of carpal tunnel syndrome, burning and tingling along the distribution of the nerve occurs.

For which problem are you assessing when you have the patient place the backs of the hands together while flexing the wrist 90 degrees?

Carpal tunnel syndrome Having the patient place the backs of the hands together while flexing the wrist 90 degrees assesses for the presence of carpal tunnel syndrome. Dupuytren's contracture is assessed by inspecting the hands and wrists on the dorsal and palmar sides, noting position, contour, and shape. A wrist ganglion is assessed by palpation and flexion of the wrist. Ankylosis, which is extreme flexion, is identified by inspection.

What do you ask the patient to do when you wish to assess the contracted temporalis and masseter muscles?

Clench the teeth To contract the temporalis and masseter muscles, the person must clench the teeth. These muscles are palpated and the right and left sides are compared for size and firmness. They are also compared for strength by asking the patient to move the jaw forward and laterally and also to open the mouth against your resistance.

A patient states, "I slipped and fell on the ice 2 days ago and now my knee just buckles." Which problem immediately comes to mind with this description?

Damaged ligament The sensation of the knee buckling or giving way is a classic sign of injury to ligaments, which give strength and stability to the joint. The most common symptoms of a fractured patella are pain and swelling in front of the knee, bruising, and inability to straighten the leg and walk. Bursitis of the knee is indicated by pain on the inside of the knee and in the center of the shin that increases with stair climbing or exercise. The rotator cuff is in the shoulder joint, not the knee.

You are examining an unconscious patient who sustained head trauma in a motor vehicle accident. The patient's elbow, wrist, and fingers are flexed and the arm is tight against the thorax. The lower extremities are extended and internally rotated and the feet are in plantar flexion. How do you describe this posture in your documentation?

Decerebrate rigidity Decerebrate rigidity is the posture in which the elbow, wrist, and fingers are flexed and the arm is tight against the thorax, with the lower extremities extended and internally rotated and the feet in plantar flexion.

You are examining extraocular movement of a 45-year-old female patient. During your assessment, you note that there are some back-and-forth oscillations of the eyes in the extreme lateral gaze. What conclusion do you draw regarding this finding?

this is an expected movement of the eyes during this procedure. During an examination for extraocular movement, an expected finding is the back-and-forth oscillations of the eyes in the extreme lateral gaze. Because the findings are normal, the patient does not need to be referred for a more complete exam, this finding does not indicate the presence of a vestibular disease, and the exam does not have to be repeated.

Which is a common cause of glove-and-stocking anesthesia?

Diabetes mellitus Diabetes mellitus is a common cause of glove-and-stocking anesthesia, which is a loss of all types of sensation in the extremities in a glove-and-stocking pattern (i.e., the loss is most severe distally, in the hands and feet, and gradually improves as the stimulus moves proximally). With meningioma and multiple sclerosis, there is a loss of pain and temperature sensation on the contralateral side starting one to two segments below the level of the lesion as well as loss of vibration and position discrimination on the ipsilateral side below the level of the lesion. Vascular occlusion results in a loss of all sensation in the distribution of the involved nerve.

During a well-child checkup, the mother of a 4-year-old speaks about her own mother's problems with osteoporosis and obesity and expresses the hope that her 4-year-old can avoid these problems. Which information about children's diets and the prevention of obesity and osteoporosis would be appropriate for you to share with her?

Diets should be low in fried foods and rich in dark green and deep yellow vegetables. Evidence from a study of children ages 3.8 to 7.8 years showed that diets low in fried foods and rich in dark green and deep yellow vegetables help prevent obesity and promote bone mass accrual.

Which term can be used to document fluid within a bursa that results in synovial thickening?

Effusion Effusion refers to fluid within the bursa that results in synovial thickening. Subluxation is the partial dislocation of a joint. Ankylosis is stiffness or fixation of a joint. Effleurage is a technique used in massage therapy.

A patient has a recent history of injury to Broca's area in the frontal lobe. Which problem would you likely find on examination?

Expressive aphasia An individual who sustains an injury to Broca's area in the frontal lobe will experience expressive aphasia. Broca's area mediates motor speech; when it is injured, the person cannot talk. The person can understand language and knows what he or she wants to say, but can produce only a garbled sound. Receptive aphasia is a condition that results after sustaining an injury to Wernicke's area. The patient may hear sound, but is unable to make any meaning out of it. Aphasia is not rated as primary or secondary, but rather receptive or expressive.

Mr. McKnight is a 37-year-old patient who presents to your office with a complaint of an unsteady gait. When you are testing the quadriceps reflex, what is the expected response?

Extension of the lower leg Extension of the lower leg is an expected response when you are testing the quadriceps reflex. The knee is flexed prior to testing, and the stimulus causes the lower leg and knee to extend. The foot plantar flexes as a result of testing the Achilles tendon. Contraction, not relaxation, of the quadriceps occurs when testing the quadriceps reflex.

Mrs. Garvin is a 55-year-old patient who presents for a follow-up examination. During your examination, you simultaneously touch her in two distinct areas of the body and ask how many stimuli are present. What are you testing?

Extinction phenomenon You are testing the extinction phenomenon. Two-point discrimination tests the person's ability to distinguish the separation of two simultaneous pinpoints on the skin. Superficial pain is tested by the person's ability to perceive a pinprick. Dermatome function testing is done by comparing sensations on symmetric parts of the body.

Mrs. Kinder brings her infant son in for a health assessment. On examination, you note polydactyly. What did you observe?

Extra digits An infant with polydactyly has extra digits, not just extra joints. Syndactyly is webbing between adjacent fingers or toes. Nonfunctional digits are not a manifestation of polydactyly.

Which is a manifestation of dysfunction of cranial nerve III?

Eyelid ptosis Cranial nerve III is the oculomotor nerve, the motor portion of which is responsible for most extraocular muscle (EOM) movement and opening of the eyelids. Thus ptosis of the eyelid is a sign of cranial nerve III impairment. Unilateral loss of smell, or neurogenic anosmia, occurs with impairment of cranial nerve I. Asymmetric jaw movement occurs with impairment of cranial nerve V and decreased visual field with impairment of cranial nerve II.

When guiding a patient in active range of motion for his elbow, which types of motion are included? (Select all that apply).

Flexion Extension Supination Pronation The elbow joint is capable of 150 to 160 degrees of flexion, extension at 0 (some people have ±5 to 10 degrees normally), and 90 degrees of pronation and supination.

When putting a patient's shoulder through its passive range of motion, which motions do you include? (Select all that apply).

Flexion Extension Abduction Adduction Internal rotation External rotation The shoulder is a ball-and-socket joint capable of 180 degrees of forward flexion, up to 50 degrees of hyperextension, 90 degrees of internal rotation and external rotation, 180 degrees of abduction, and 50 degrees of adduction.

For which problem does ballottement of the patella assess?

Fluid in the knee Ballottement of the patella is used to assess for fluid in the knee. McMurray's test indicates a torn meniscus. Fractures are identified through palpation and x-ray.

The rotator cuff is associated with which joint?

Glenohumeral joint The rotator cuff of the body is associated with the glenohumeral joint, the articulation of the humerus with the glenoid fossa of the scapula, in the shoulder. The wrist or radiocarpal joint is the articulation of the radius (on the thumb side) and a row of carpal bones. The temporomandibular joint is the articulation of the mandible and the temporal bone. The acetabular, or hip, joint is the articulation between the acetabulum and the head of the femur.

Mrs. Stephens is a 37-year-old patient who requires a complete neurologic examination. How will you test the sensory component of cranial nerve VII?

Have the individual identify specific tastes on the tongue. The sensory component of cranial nerve VII, the facial nerve, is tested by having the individual identify specific tastes on the tongue. Touching the individual's face at various points with a cotton wisp tests cranial nerve V. Touching the cornea with a wisp of cotton to elicit the corneal blink reflex tests cranial nerve V. Palpating the temporal and masseter muscles as the person clenches the teeth assesses the muscles of mastication, which are innervated by the motor component of cranial nerve V.

What is meant by using reinforcement when testing a patient's deep tendon reflexes (DTRs)?

Having the individual perform an isometric exercise in a muscle group a distance from the one being tested to reinforce the response. The concept of reinforcement refers to the fact that, if you are unable to initiate a DTR, having the individual perform an isometric exercise in a muscle group away from the one being tested will enhance the response. When testing the DTRs, you do not stimulate the tendon a second time; rather, you strike a brief, well-aimed blow on the muscle's insertion tendon, and bounce up promptly, not letting the hammer rest on the tendon.

Which sequence best describes the order in which sensory and motor development occurs in the infant?

Head, neck, trunk, extremities Sensory and motor development depends on myelinization of nerves in the infant, and this occurs in a cephalocaudal and proximodistal direction. This means that myelinization occurs from head to toe and from the center outward, so sensory and motor development occurs in the order of head, neck, trunk, and then extremities.

A mother reports her 18-month-old child had a seizure. What are some of the questions you should ask? (Select all that apply).

"Did the child lose consciousness?" "Were there any noticeable warning signs before the seizure began?" "Did the child have a high fever?" "What did the child do after the seizure?" Questions to ask about any seizure relate to the course and duration, motor activity during the seizure, any associated signs, what happened after the seizure, precipitating factors and medications taken, and coping. In the case of an infant, you must also determine if a fever was present as seizures can occur with fever in infants and toddlers, not just from neurologic disease.

When assessing a deep tendon reflex on a 16-year-old boy, you obtain the expected response. What score should you document?

2+ The score that should be documented for the expected deep tendon reflex response of a 16-year-old boy is 2+. A 3+ is brisker than average, which may indicate disease. A 4+ indicates very brisk, hyperactive with clonus, indicative of disease. A 1+ indicates diminished, low normal.

Mrs. Bicker brings her infant son to the health clinic for a routine examination. When performing Ortolani's maneuver on the newborn infant, you feel a "clunk" as you abduct the infant's legs and flexed knees. This clunk is indicative of which problem?

Hip dislocation Hip instability feels like a clunk as the head of the femur pops back into place. This is a positive Ortolani's sign and warrants referral for hip dislocation. Tibial torsion is a twisting of the tibia and is assessed by having the patient place both feet flat on the table and push up to flex the knees, placing your fingers on the malleoli, and noting if a line connecting the four malleoli is parallel to the table. Genu valgum (knock-knees) is present when there is more than 2.5 cm between the medial malleoli when the knees are together. Talipes equinovarus, also known as clubfoot, is a congenital, rigid, and fixed malposition of the foot, including (1) inversion, (2) forefoot adduction, and (3) foot pointing downward (equinus).

Mrs. Harris brings her newborn infant to the office for a routine health assessment. For which problem are you assessing when you measure the equality of the infant's leg lengths?

Hip dislocation Measuring for equal leg lengths is the Allis test, which assesses for hip dislocation. Talipes equinovarus (clubfoot) is a congenital deformity that is assessed via inspection, with the following findings: rigid and fixed malposition of foot, including (1) inversion, (2) forefoot adduction, and (3) foot pointing downward (equinus). Tibial torsion is a twisting of the tibia and is assessed by having the patient place both feet flat on the table and push up to flex the knees, placing your fingers on the malleoli, and noting if a line connecting the four malleoli is parallel to the table. A Colles' fracture is assessed with inspection and palpation, with findings of a wrist that looks puffy, with "silver fork" deformity, and a characteristic hump when viewed from the side.

Which are characteristics of upper motor neuron lesions? (Select all that apply).

Hyperreflexia Positive Babinski sign Absent abdominal reflexes With upper motor neuron lesions, muscle tone is increased; muscle bulk is basically normal, and there are no abnormal movements. Deep tendon reflexes (DTRs) are hyperreflexive; there is a positive Babinski sign and superficial abdominal reflexes are absent. With lower motor neuron lesions, muscle tone is lost, resulting in flaccidity. Muscle bulk is reduced as a result of atrophy. Fasciculations occur and reflexes are diminished or absent.

When you ask your patient to "open wide and stick out your tongue," you note that her tongue deviates to the right. A lesion of which cranial nerve would cause this finding?

Hypoglossal The tongue deviates to one side as a result of lesions of the hypoglossal nerve. When this occurs, deviation is toward the paralyzed side. The abducens nerve is responsible for lateral movement of the eye. The motor component of the glossopharyngeal nerve mediates phonation and swallowing. The motor component of the trigeminal nerve innervates the muscles of mastication.

Mrs. Bowers brings her newborn daughter for her first post-hospital visit. On examination, you note the presence of primitive reflexes. What does the presence of primitive reflexes in a newborn indicate?

Immaturity of the nervous system The presence of primitive reflexes in a newborn is normal and indicative of immaturity of the nervous system.

Mr. Lee comes to the office for a routine health assessment. Which assessments will you include in the musculoskeletal screening portion of the physical examination? (Select all that apply).

Inspection and palpation of joints Observation of ROM Age-specific measures Inspection and palpation of joints as different body parts are examined; observation of range of motion (ROM) as the patient proceeds through motions required in preparation for, and during, the exam; and age-specific measures are all included in the screening musculoskeletal exam. A screening musculoskeletal exam does not include testing the strength of major muscle groups.

In which way does the vagus nerve differ from the other cranial nerves?

It innervates organs outside the head and neck. The vagus cranial nerve differs from the other cranial nerves in that it innervates organs outside the head and neck. The vagus nerve (Lat. vagus, or wanderer, as in "vagabond") travels to the heart, respiratory muscles, stomach, and gallbladder, and it does not have a spinal nerve component to its origin and structure. Cranial nerves III to VII and IX to XII each have a motor component to them. Cranial nerves V, VII, IX, and X all have both sensory and motor components.

Which deformity would you expect to see in an individual with genu valgum?

Knock-knees A patient with genu valgum has knock-knees, whereas a person with genu varum has bowlegs. Toeing in or pigeon toes is tending to walk on the lateral side of the foot, making the longitudinal arch look higher than normal. A person with clubfoot has talipes equinovarus.

Which finding on physical examination is most indicative of a herniated nucleus pulposus?

Lateral tilt with a forward bend posture Lateral tilting with forward bending is a classic sign of a herniated nucleus pulposus. Palpable spasm of the paravertebral muscles is not a classic sign of a herniated nucleus pulposus. Uneven gluteal folds are seen with developmental dysplasia of the hips. Difference in levels of the iliac crests is a classic sign of scoliosis.

Which alteration in posture would you consider an expected finding in a pregnant woman?

Lordosis The most characteristic postural change during pregnancy is progressive lordosis, which compensates for the enlarging fetus by shifting the weight farther back on the lower extremities. Kyphosis is common during adolescence and in aging people. Scoliosis is most apparent during the preadolescent growth spurt. Listing is a leaning or slanting, which does not occur in pregnancy.

Which are characteristics of lower motor neuron lesions? (Select all that apply).

Loss of muscle tone Muscle atrophy Fasciculations With lower motor neuron lesions, muscle tone is lost, resulting in flaccidity. Muscle bulk is reduced as a result of atrophy. Fasciculations occur, and reflexes are diminished or absent. With upper motor neuron lesions, muscle tone is increased, muscle bulk is basically normal, and there are no abnormal movements. Deep tendon reflexes (DTRs) are hyperreflexive; superficial abdominal reflexes are absent, and there is a positive Babinski sign.

When previewing a new patient's chart, you note that the patient is documented as having Brown-Séquard syndrome. Which findings do you expect on examination of the patient? (Select all that apply).

Loss of pain sensation on the opposite side from the causative lesion and a little below it. Loss of temperature sensation on the opposite side from the causative lesion and a little below it. Loss of vibration and position discrimination on the same side and at the same level as the causative lesion. Brown-Séquard syndrome is also known as spinal cord hemisection and is caused by lesions such as meningioma, neurofibroma, cervical spondylosis, and the lesions of multiple sclerosis. It is the loss of pain and temperature sensation on the contralateral side from the lesion and starting about two segments below its level. It also involves loss of vibration and position discrimination on the ipsilateral side below the level of the lesion.

Mr. Shea is a 50-year-old patient with chronic obstructive pulmonary disease and a history of smoking two packs per day. On examination, which alteration related to cranial nerve function should you expect?

Loss of smell bilaterally On examination, you would expect to find a loss of smell. Anosmia, which is the technical term, occurs with tobacco smoking, allergic rhinitis, and cocaine use.

What three structures comprise the brainstem?

Midbrain, pons, and medulla The three structures that comprise the brainstem are the midbrain, pons, and medulla. The midbrain, which contains many motor neurons and tracts, is the most anterior part of the brainstem and still has the tubular structure of the spinal cord. The pons contains ascending sensory and descending motor tracts as well as the pneumotaxic and apneustic respiratory centers, which coordinate with the main respiratory center in the medulla. The medulla is the continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts, the vital autonomic centers for respiration, heart, and gastrointestinal function, as well as the nuclei for cranial nerves VIII through XII. The medulla is where pyramidal decussation occurs.

To test a patient's position sense, what should you ask him or her to do?

Move the patient's finger or big toe up or down and ask the patient which way it is moved. Position sense is the ability to perceive passive movements of the extremities. It is tested by moving a patient's finger or big toe up and down and asking the patient to tell you which way it moved without looking. When performing this test, hold the digit to be moved by its sides and vary the way you move it. Normally movement of a few millimeters can be detected.

hich signs are suggestive of a hemorrhagic stroke? (Select all that apply).

Nausea and vomiting Focal seizures Sudden severe headache Nausea and vomiting, focal seizures, and sudden, severe headache are signs of hemorrhagic stroke, as is sudden loss of consciousness. Arm drift, loss of balance, and unilateral facial droop along with weakness or paralysis on one side of the body, difficulty with speech, confusion, and clouding of vision are signs of ischemic stroke.

Observation of Heberden's and Bouchard's nodes on a patient's hands supports your conclusion that the patient has which problem?

Osteoarthritis Heberden's and Bouchard's nodes are hard and nontender and are associated with osteoarthritis. Boutonnière deformity (flexion of proximal interphalangeal joint with compensatory hyperextension of distal interphalangeal joint) occurs in rheumatoid arthritis, and the knuckle looks as if it is being pushed through a buttonhole. Dupuytren's contracture refers to chronic hyperplasia of the palmar fascia, which causes flexion contractures of the digits, first in the fourth digit, then the fifth digit, and then the third digit. The condition occurs commonly in men older than 40 years of age, is usually bilateral, and occurs with diabetes, epilepsy, and alcoholic liver disease and as an inherited trait. Flexion contracture of the metacarpophalangeal joint, then hyperextension of the proximal interphalangeal joint, and flexion of the distal interphalangeal joint resembles the curve of a swan's neck.

Mrs. Landers is a 53-year-old patient with rheumatoid arthritis. On examination, which finding would you expect?

Painful motion Painful motion is found in patients with rheumatoid arthritis. Dislocation is not a symptom of rheumatoid arthritis. Decreased, not increased, range of motion (ROM) is indicative of rheumatoid arthritis. Rheumatoid arthritis is a chronic, systemic inflammatory disease of joints and surrounding connective tissue, and muscle spasms are not part of the symptoms.

Which is a test of the motor function of the trigeminal nerve?

Palpate the temporal and masseter muscles as the patient clenches the teeth. To assess the motor function of the trigeminal nerve (cranial nerve V), the temporal and masseter muscles are palpated bilaterally while the patient clenches the teeth. The muscles should feel equally strong on both sides. Next, the examiner should try to separate the jaws by pushing down on the chin; normally the jaws cannot be opened. All other actions test the motor component of the facial nerve.

A patient complains of a sensation of burning and tingling in his or her right arm. Which term is appropriate in describing this complaint?

Paresthesia An abnormal sensation of burning and/or tingling is termed paresthesia. Kinesthesia refers to position sense. Paresis is a partial or incomplete paralysis. Dysmetria is the inability to control range of motion of muscles.

Mr. Walker is a 45-year-old diabetic patient. During his health history, he reports experiencing some numbness and tingling in the extremities. Which term should you use in documenting this information?

Paresthesia numbness and tingling in the extremities would be documented as paresthesia.

On examining a new patient, you note the presence of a resting tremor, bradykinesia, loss of balance, and cogwheel rigidity. Which problem do you suspect?

Parkinson's disease Resting tremor, bradykinesia, loss of balance, and cogwheel rigidity are classic symptoms of parkinsonism. Other symptoms of Parkinson's disease are cognitive decline, depression, urinary incontinence, flat facial expression, excessive salivation, reduced eye blinking, and stooped posture.

Which finding is a cause for further investigation when assessing a 2-month-old infant?

Persistent one-hand preference Persistent one-hand preference in an infant less than 18 months old may indicate a motor deficit on the opposite side, so further investigation would be needed. Fists are held in tight flexion for the first 3 months, and the head flops forward upon being pulled to a sitting position until 4 months of age. Babbling also occurs at 4 months of age.

Which motions are being tested when you ask the patient to hold his hand with the little finger horizontal to the table and then touch the front and back sides of the hand to the table?

Pronation/supination Pronation and supination of the elbow joint are being tested with this action. Flexion and extension are tested by asking the patient to bend and straighten the elbow. The elbow is a hinge joint and not capable of other motions such as adduction, abduction, or internal or external rotation.

Mrs. Moyer comes to the ambulatory health center with a variety of health concerns. Based on her history and physical examination, you suspect rheumatoid arthritis (RA). Which characteristics that differentiate RA from other musculoskeletal conditions would you have considered?

RA involves symmetric joints. RA involves symmetric joints; other musculoskeletal illnesses involve isolated or unilateral joints. Stiffness associated with RA occurs mostly in the morning and after rest periods, not at night. Pain associated with RA is worse in the morning, not at night. Movement increases most joint pain except in RA, in which movement decreases pain.

When you assess an individual for the presence of a herniated nucleus pulposus, which maneuver do you ask the individual to perform?

Raise the legs straight while keeping the knees extended. When assessing an individual for the presence of a herniated nucleus pulposus, you ask the individual to raise the legs straight while keeping the knees extended. You check range of motion (ROM) of the spine by asking the person to bend forward and touch the toes. Having the patient do a deep knee bend provides data on the ROM of the knee. ROM of the hip is assessed by asking the patient to abduct and adduct the legs while keeping the knees extended.

What type of testing is specifically associated with the assessment of cerebellar function?

Rapid alternating movements Rapid, alternating movements is a procedure that is specifically associated with testing cerebellar function. Normally the person can pat the knees with both hands, turn the hands over, and pat the knees with the backs of the hands in a quick, rhythmic pace. Lack of coordination is demonstrated by a slow, clumsy, sloppy performance and occurs with cerebellar disease. Stereognosis and two-point discrimination are tests of the dorsal column tract, and testing of superficial pain and touch assesses the spinothalamic tract.

The examiner obtains specific information regarding the intactness of which component of a patient's nervous system when the deep tendon reflexes are tested?

Reflex arc at specific levels in the spinal cord Testing the deep tendon reflexes gives the examiner specific information regarding the intactness of the reflex arc at specific levels in the spinal cord. Testing the deep tendon reflexes would give the examiner information regarding the intactness of the lower motor neurons, but not the upper motor neurons. The corticospinal tract is an example of an upper motor neuron, which cannot be tested by a deep tendon reflex. The medulla is the continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts connecting the brain and spinal cord; however, testing of the deep tendon reflexes provides more specific information on the intactness of the reflex arcs.

A postmenopausal patient is concerned about osteoporosis and appropriate preventative measures. She begins her discussion with you by asking "Why do older adults develop osteoporosis?" Which statement could you correctly use as the basis for your answer to this question?

Resorption of bone occurs at a greater rate than its deposition. Osteoporosis in older adults is due to resorption (loss of bone matrix) at a greater rate than deposition (new bone growth). All other statements are false.

You note crepitation as you move a patient's shoulder through its range of motion. What conclusion do you draw from this finding?

Roughened articular surfaces are moving over each other. Crepitation is an audible sound that is produced by roughened articular surfaces moving over each other. Tendons or ligaments slipping over bone produce a discrete "crack" heard during motion, such as when you do a knee bend. This is not crepitation. Joints that are stretched, as when placed in hyperflexion or hyperextension, do not make an audible sound. An inflamed bursa does not create sound.

Ms. Wilson is a 46-year-old patient who presents for a neurologic examination. During the examination, you note clonus when testing deep tendon reflexes. What did you see?

Set of short, jerking contractions of the same muscle Clonus is characterized by a set of short, jerking contractions of the same muscle. Tremor is an involuntary contraction of opposing muscle groups, which results in rhythmic, back-and-forth movement of one or more joints, and may occur at rest or with voluntary movement. All tremors disappear while sleeping. Tremors may be slow (3 to 6 per second) or rapid (10 to 20 per second). Athetosis is a slow, twisting, writhing, continuous movement, resembling a snake or worm. It involves the distal part of the limb more than the proximal part, occurs with cerebral palsy, disappears with sleep, and is characterized by "athetoid" hand—some fingers are flexed and some are extended. Contraction of the muscle appears after hitting the tendon the first time, not the second time, as each strike is a single blow.

On range of motion assessment, you find the internal rotation of a 76-year-old patient's hip to be 30 degrees. How do you interpret this finding?

Sign of early hip disease Limited internal rotation of the hip is an early and reliable sign of hip disease. Normal internal rotation for all age groups is 40 degrees, so 30 degrees is a sign of early hip disease.

After examination of a patient with cerebellar disease, you document dysdiadochokinesia. What did you find on examination?

Slow, clumsy, sloppy movements when performing rapid alternating hand movements. A patient with dysdiadochokinesia demonstrates slow, clumsy, sloppy movements when performing rapid alternating hand movements.

FAST is an acronym to aid in remembering the sudden signs of a stroke. In this acronym, the S stands for _____ _____ (two words).

Speech difficulty The S is for speech difficulty. The F is for face drooping, the A is for arm weakness, and the T is for Time to call 9-1-1.

Which structures control motor activity in the newborn infant?

Spinal cord and medulla In the newborn, motor activity is under the control of the spinal cord and medulla.

Which pathways in the spinal cord carry sensory impulses to the brain?

Spinothalamic tract and posterior columns The spinothalamic (anterolateral) tract and posterior (dorsal) columns of the spinal cord carry sensory impulses to the brain. Sensation begins at the sensory receptors found throughout the body, which monitor conscious sensation, internal organ functions, body position, and reflexes. It then travels in the afferent fibers in a peripheral nerve, through the posterior (dorsal) root, and into the spinal cord, where it travels in either the spinothalamic (anterolateral) tract or the posterior (dorsal) columns.

Which direction would you give a patient when performing a Romberg test?

Stand with your feet together, arms at sides; close your eyes." The Romberg test is a test of balance in which a person is asked to stand with feet together and arms at sides. Once stable in this position, the person is asked to close the eyes and hold the position. Normally the person can do this, sometimes with slight swaying for the test period of 20 seconds. If the person sways significantly, falls, or widens the base of the feet to avoid falling, it is a positive Romberg sign. This occurs with cerebellar ataxia, loss of proprioception, and loss of vestibular function.

Which pair represents a type of reflex followed by an example of it?

Superficial—abdominal Superficial—abdominal is the correct answer. There are four types of reflexes: deep tendon, superficial, visceral, and pathologic. Examples of superficial reflexes are the abdominal reflex and the corneal reflex. The Babinski reflex is an example of a pathologic reflex, and the knee jerk is a deep tendon reflex.

Mrs. Painter is a 62-year-old patient who comes to the clinic for a follow-up health assessment for complaints of joint tenderness. On examination, you note a joint that has a "boggy," soft feel to palpation. Which problem does this finding suggest?

Synovial thickening A boggy, soft feel on palpation of a joint is indicative of synovial thickening. With rheumatoid arthritis, crepitation, not bogginess, presents. Joint subluxation, which is a partial dislocation, does not feel boggy. Crepitation is an audible sound that is produced by roughened articular surfaces moving over each other.

Which consideration should the examiner keep in mind when testing the neurologic system of the aging adult?

The aging individual may need stronger stimuli to elicit appropriate responses. When testing the neurologic system of the aging adult, the examiner should keep in mind that the individual may need stronger stimuli to elicit the appropriate response. By age 80, the nervous system undergoes a general atrophy with a steady loss of neurons in the brain and spinal cord. Both the sensory and motor areas are affected as the aging process continues. As the muscle mass of the individual diminishes, the ability to elicit the Achilles reflex, not all DTRs, diminishes.

In which part of the brain is the extrapyramidal system located?

The basal ganglia The extrapyramidal system is located in the basal ganglia. The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system. They help to initiate and coordinate movement and control automatic associated movements of the body.

Use of the Glasgow Coma Scale (GCS) provides the health care provider with which type of information?

The level of consciousness Use of the Glasgow Coma Scale (GCS) provides the health care provider with a measure of the level of consciousness. The GCS assesses the functional state of the brain as a whole, not the function of any part in particular. It does not identify the site of brain trauma or the degree of neurologic dysfunction, nor does it differentiate between upper motor neuron dysfunction and lower motor neuron dysfunction.

During your examination of a 45-year-old female, she indicates that frequently when she is falling asleep, she experiences sudden jerks of her arm or leg. Which is the fact upon which your response to her should be based?

These are normal experiences of individuals when falling asleep. The experiences of sudden jerks of an arm or leg when falling asleep are normal experiences of individuals. Seizures occur with epilepsy (not latent), a paroxysmal disease characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances. Symptoms of Parkinson's disease include tremor, rigidity, and slowness and weakness of voluntary movement, not jerks on falling asleep. Huntington's chorea presents with spontaneous, initiated, voluntary acts of sudden, rapid, jerky, purposeless movement involving the limbs, trunk, or face, not just the arm and/or leg.

When observing a toddler get up from a lying position, you note that he positions himself on all four extremities and then climbs up himself until he is upright. What meaning do you assign to this observation?

This child needs to be screened for muscular dystrophy. A toddler who gets up from a lying position by positioning himself on all four extremities and then climbing up himself until he is upright is exhibiting Gower's sign. This is indicative of weak pelvic muscles, which is a sign of muscular dystrophy. Normally, the child curls up in the midline to sit up, then pushes off with both hands against the floor to stand.

You are requested to examine a newborn in the nursery unit of the hospital. Your initial observation indicates that the infant prefers to maintain a flexed position. What meaning do you assign to this finding?

This is an expected position for a newborn to assume. Flexion is the expected position for a newborn to assume, so this is a normal finding. Spasticity is an early sign of cerebral palsy. After releasing flexed knees, the legs will quickly extend and adduct, even to a "scissoring" motion when spasticity is present. Also, the baby often resists head flexion and extends back against your hand when spasticity is present. Maintenance of a flexed position by an infant does not indicate a problem with muscle development nor a developmental growth delay.

For what purpose might you use the NIH Stroke Scale with a patient?

To predict a stroke patient's outcome. The National Institutes of Health (NIH) Stroke Scale provides a quantitative measure of stroke-related neurologic deficit. It is widely used as a clinical assessment tool to evaluate acuity and predict patient outcome.

During the performance of McMurray's test, you hear and feel a click. Which meaning do you assign to this finding?

Torn meniscus A click heard and felt while doing McMurray's test is an indication of a torn meniscus. Sudden buckling, or "giving way," indicates ligament injury. The "click" heard in McMurray's test is positive for a meniscal tear, not subluxation of the knee. Ortolani's maneuver or the Allis test can be used to determine the presence of dislocation of the femoral head, which is signaled by a "clunk" felt as the head of the femur pops back into place.

Observation of normal rooting and sucking reflexes in an infant allows the examiner to infer proper functioning of which cranial nerve?

V The presence of normal rooting and sucking reflexes allows proper function of cranial nerve V to be inferred. Proper function of cranial nerve VII is indicated by facial movements. Proper function of cranial nerves IX and X is inferred by the presence of swallowing, the gag reflex, and coordinated sucking and swallowing.

Which sensations are transmitted by the posterior (dorsal) columns?

Vibration, position, and fine touch The posterior (dorsal) columns are responsible for transmitting the sensations of vibration, position, and fine touch. The spinothalamic tract is responsible for transmitting the sensations of crude touch, pain, and temperature.

Documentation of a patient's range of motion includes the notation of "radial deviation 20 degrees." How do you interpret this information?

With the palms flat on a table, the patient can turn them in 20 degrees. Radial deviation refers to the normal motion of the wrist and hand in which palms flat on a table can be moved radially (toward the thumb) 20 degrees. Normal ulnar deviation is 50 to 60 degrees.

On which patient would you perform a McMurray's test?

A 29-year-old who fell skiing and states that her knee "locks." McMurray's test is done when a patient has a reported history of trauma followed by locking, giving way, or localized pain in the knee. A positive McMurray's test, which is indicated by a click when the maneuver is carried out, indicates a torn meniscus. McMurray's test is not used on the hip, arm, or foot.

Which sign do you interpret as indicating an increase in fluid within a bursa?

A bulge that appears on the opposite side of the joint after pushing on the other side An increase in fluid within a bursa is manifested by a bulge that appears on the opposite side of the joint after pushing on the other side. A decrease in the expected range of motion (ROM) refers to a limitation in joint movement. It can occur for many reasons, but increased fluid in a bursa alone is not one of them. Crepitus is an audible sound that is produced by roughened articular surfaces moving over each other. Subluxation is a partial dislocation of a joint and is not related to increased fluid in a bursa.

Which finding would you describe as functional scoliosis?

A lateral spinal curvature that is visible in the standing position but disappears when the individual bends over An individual with functional scoliosis demonstrates a lateral spinal curvature that is visible in the standing position but disappears when the individual bends over. Structural scoliosis, not functional scoliosis, remains when the individual bends over to touch the toes. A lateral spinal curvature of less than 20 degrees is not a characteristic of scoliosis. Scoliosis is defined as involving both the thoracic and lumbar areas.

When guiding a patient through range of motion of the shoulder, you direct him or her, "Starting with your arms straight down by your sides, bring both arms up and around in a big circle until the palms of your hands meet above your head." Which motion is this?

Abduction These directions guide the patient in abducting the shoulder. For flexion and extension, the patient is directed to start with arms straight by the sides and to move both arms forward and up in a wide vertical arc and then move them back. For internal rotation, the patient rotates the arms internally behind the back and places the back of the hands as high as possible toward the scapulae. For adduction, the patient brings the arms back down to the sides and across the front of the body.

A functional assessment is primarily concerned with gathering information related to which area?

Activities of daily living A functional assessment is primarily concerned with gathering information related to activities of daily living. The musculoskeletal exam is primarily concerned with gathering information on range of motion. The cultural assessment is primarily concerned with gathering information related to cultural beliefs and practices. The developmental assessment is primarily concerned with gathering information related to developmental capabilities.

When documenting results of your assessment of a patient with nystagmus, one of the descriptors you use is "fine." Which aspect of nystagmus are you describing?

Amplitude Amplitude is the degree of movement in nystagmus and is described as fine, medium, or coarse. Plane refers to movement that is horizontal, vertical, rotary, or a combination. Frequency refers to whether the movement is constant or fades after a few beats. The movements of nystagmus are also described as either pendular or jerk. In pendular movement, the oscillations move equally left and right; with jerk movement there is a quick movement in one direction and a slow movement in the other.

When testing the deep tendon reflexes (DTRs) of a 74-year-old male, you find hyperreflexia. What does this finding tell you about the underlying problem?

An upper motor neuron lesion exists. Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels. This occurs with upper motor neuron lesions. Sensory afferents, motor efferents, and anterior horn cells are part of the lower motor neuron.

Mr. Cole is a 46-year-old patient who presents for a routine examination. As part of his history, he tells you he has allergic rhinitis. Which abnormal finding would you consider to be expected?

Anosmia Anosmia is a frequent occurrence in persons with allergic rhinitis and therefore would be considered an expected finding. Aphasia is an abnormality of language that can occur with stroke. Anasarca is a term for pronounced, generalized edema. Amblyopia refers to dimness of sight without an organic defect.

A patient comes to the clinic because of pain in her wrist. Assessment of range of motion (ROM) in the affected joint finds limitation in all planes of ROM with both active and passive movement. What conclusion can you draw from this finding?

Articular disease exists. Limitation in all planes of ROM with both active and passive movement is a sign of articular (inside the joint capsule) disease. Limitation of ROM only in certain planes and especially on active motion is a sign of extra-articular disease such as injury to a tendon, ligament, or nerve.

Mr. Sanchez is a 62-year-old patient who presents for a complete neurologic examination. How will you test for the transmission of pain sensation in the spinothalamic tract?

Ask him to identify when the skin is being touched with the sharp or dull end of a pin/broken tongue blade. The spinothalamic tract transmits the sensations of pain, temperature, and crude or light touch. To test for the transmission of pain in the spinothalamic tract, the patient is asked to identify when the skin is being touched with the sharp or dull end of a pin/broken tongue blade.

A patient presents with symptoms suggestive of carpal tunnel syndrome and you decide to do a Phelan's test. Which do you do?

Ask the patient to hold his hands back to back with wrists flexed 90 degrees for 1 minute and report what is felt. For a Phelan's test, the patient holds his hands back to back with wrists flexed 90 degrees for 1 minute. No symptoms occur in the normal hand but numbness and burning occur with carpal tunnel syndrome. Having the patient flex the wrist against your resistance at the palm is a test of muscle strength. Percussing the median nerve and checking for resultant burning and tingling over its distribution is testing for a positive Tinel sign, which is also indicative of carpal tunnel syndrome. Checking the ability to feel vibrations of a tuning fork over bony prominences is an assessment of vibration sense that requires intact nerve pathways.

Ms. Parsons is a 43-year-old patient with multiple sclerosis. On examination, which findings would you classify as clinical manifestations of the disease? (Select all that apply).

Babinski sign Diplopia Impaired balance Weakness Clinical manifestations of multiple sclerosis are varied and include Babinski sign, diplopia, loss of balance, and weakness. Other common manifestations are spasticity, not flaccidity, nystagmus, hyperreflexia, and extreme fatigue.

Which finding when a patient performs a straight leg-raising test indicates a herniated nucleus pulposus?

Back and leg sciatic pain When the nucleus pulposus ruptures into the spinal canal, it puts pressure on the local spinal nerve root, and straight leg-raising tests reproduce sciatic pain in the back and leg. Phalen's test reproduces numbness and burning in the wrist in persons with carpal tunnel syndrome. Limited internal rotation of the hip is an early and reliable sign of hip disease. A "click" when the knee is extended and externally rotated is a positive McMurray's test and indicates a torn meniscus.

Mrs. Jones is a 32-year-old patient who is 6 months pregnant and comes to the clinic for a routine health assessment. She asks about discomfort to be expected during the third trimester of her pregnancy. Which discomfort would you discuss?

Back pain Back pain is a common finding in the third trimester of pregnancy and is due to is progressive lordosis, which compensates for the enlarging fetus and in turn creates strain on the low back muscles. Stiffer joints are a symptom of rheumatoid arthritis, not pregnancy. Osteoporosis generally begins after the age of 40 and is not the cause of discomfort in pregnancy. Kyphosis is common during adolescence and in aging people, not in pregnancy.

How do you expect a synovial membrane to feel if it is thickened?

Boggy When the synovial membrane is thickened, it feels "doughy" or "boggy." Pliable describes the normal feel of synovial fluid on a joint. Rigid and constricted do not apply.

An unconscious patient is brought into the emergency room after falling off a third-floor balcony. On examination, you find that his upper extremities are stiffly extended, adducted, and internally rotated and his palms are pronated. His lower extremities are also stiffly extended, his feet are in plantar flexion, his teeth are clenched, and his back is hyperextended. What does this finding indicate?

Brainstem lesion at midbrain or pons Upper extremities stiffly extended, adducted, and internally rotated with palms pronated and lower extremities stiffly extended with feet in plantar flexion, teeth clenched, and back hyperextended is the posture of decerebrate rigidity, which indicates a lesion in the brainstem at the level of the midbrain or upper pons.

Mr. Jenkins is a 43-year-old patient who goes to the ambulatory health center with complaints of muscle pain. When testing for muscle strength, the examiner:

applies an opposing force against the individual's actions during ROM of a joint. When testing for muscle strength, the examiner applies an opposing force against the individual's actions during range of motion (ROM) of a joint. Asking the individual to try to stop the examiner's joint movements during ROM could result in harm to the patient. Muscle tension is not measured when testing for muscle strength. Active ROM does not indicate that muscle strength is fully developed.

Your patient can understand language and knows what he or she wants to say, but can produce only a garbled sound. Which area of the brain do you conclude is damaged?

Broca's area Broca's area in the frontal lobe is responsible for mediating motor speech. When it is damaged, the patient can understand language, knows what he or she wants to say, but can produce only garbled sound. Wernicke's area in the temporal lobe is associated with language comprehension. The basal ganglia are additional bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system). They control automatic associated movements of the body (e.g., the arm swing alternating with the legs during walking). The postcentral gyrus of the parietal lobe is the primary center for sensation.

A patient presents with a history that suggests he or she may have meningitis. For which reflexes would you check? (Select all that apply).

Brudzinski Kernig Brudzinski and Kernig reflexes indicate meningeal irritation. The Brudzinski reflex consists of flexion of the hips and knees when the neck is flexed. The Kernig reflex consists of pain in the lower back and resistance to straightening the leg when it is flexed at the knee or, alternatively, resistance to raising the leg straight when lying flat in the supine position with the thigh flexed on the abdomen. The snout reflex is a sign of frontal release. The Gordon and Oppenheim reflexes occur with corticospinal disease such as trauma or stroke.