lab 4

[00:00:01]Come in.

[00:00:02]>> Hello, my name is Heather. I'm a student nurse practitioner. I'm going to be doing a physical exam on you on your neuromuscular system neurological system. How are you doing today?

[00:00:10]>> I'm doing good.

[00:00:10]>> Is it okay if I touch you?

[00:00:12]>> Yes.

[00:00:12]>> Okay.

[00:00:13]Um what is your name and date of birth?

[00:00:15]>> Mitchell Carter, February 23rd, 2011.

[00:00:18]>> Okay, so the first thing we're going to do um is we're going to assess your gait, okay? So let's We're going to walk back and forth and then you're going to do heels and then toes um on each of those, okay?

[00:00:28]All right, so let's go here.

[00:00:35]Okay, so patient's gait is normal, symmetric, and smooth, coordinated.

[00:00:41]Um you can go back.

[00:00:44]And um his stride is is normal. I do not see any abnormality. Stop for just a second. I have to see I'm going to see any um unilateral tilt that would indicate scoliosis. Okay, so now you're going to go on your heels back.

[00:01:00]Okay, so he's doing this is assessing the leg strength of the the legs there and that he did that without problem and were coordinated and smooth.

[00:01:09]Uh so now you're going to do tippy toes.

[00:01:13]Okay, his gait is normal, coordinated, and smooth. I do not see any unilateral tilt that would tilt tilt that would indicate um scoliosis.

[00:01:23]So now what we're going to do is we're going to assess your neck. We're just going to start there because that's where we're going to go right now.

[00:01:30]Okay, so we have we have uh so what I'm going to have you do is I'm going to have you put your chin not just yet, not until I tell you to, okay?

[00:01:38]We're going to have you put your chin to your chest and this is called flexion of your neck and I'm going to be feeling for crepitus and you're going to tell me if you have any pain or tenderness, okay? Ready?

[00:01:46]Chin to the chest. Do you have any pain or tenderness?

[00:01:48]>> No.

[00:01:49]>> I feel no crep- crepitus and I see no lesions, lumps, bruises around his neck.

[00:01:53]Okay, so that is flexion. Now we're going to do extension and extension is where you tilt your head back towards your back and I'm going to feel for crepitus. You're going to tell me if you have any pain or tenderness, okay?

[00:02:03]>> Okay.

[00:02:05]>> [clears throat] >> Do you have any pain or tenderness?

[00:02:06]>> No.

[00:02:06]>> I felt no crepitus. Okay, so now we're going to do a lateral turn.

[00:02:12]Okay. Do you have any pain or tenderness?

[00:02:14]No, it's that that's the lateral tilt.

[00:02:16]Let us just do lateral tilt. You put your ear to your shoulder.

[00:02:20]Do you have any pain or tenderness?

[00:02:22]>> No. [clears throat] >> Okay. And I feel no crepitus and I feel no swelling or edema on that on the neck.

[00:02:28]So, now we're going to do um You're going to shake your head like no. You're going to go shoulder to shoulder, side to side.

[00:02:35]Do you have any pain or tenderness?

[00:02:36]>> No.

[00:02:37]>> Okay, and I have no I felt no crepitus.

[00:02:39]So, now I'm going to assess the the strength of your neck.

[00:02:42]I'm going to put my hand on your forehead and I just want just relax.

[00:02:45]This this isn't just moving your head.

[00:02:48]I'm I want you to put your chin towards your chest.

[00:02:51]Okay, patient's strength inflection position is five out of five.

[00:02:55]So, now I'm going to put my hand on your shoulder and I want you to push against my hand in extension.

[00:03:01]Patient's strength in extension his neck is five out of five.

[00:03:05]Um lateral tilt, I'm going to take I'm going to put my hand here and you're going to push against my hand.

[00:03:11]Not your body, just your head.

[00:03:14]Okay.

[00:03:15]Patient's strength is five out of five.

[00:03:20]Patient's strength is five out of five.

[00:03:22]And then the other one What was the other one?

[00:03:25]The turning. Okay, cuz I got to put my hand on your shirt. So, I'm going to put my hand on your shoulder. I'm going to put my hand on your cheek and I want you to turn your turn your head.

[00:03:32]Patient's strength is five out of five.

[00:03:37]Patient's strength is five out of five.

[00:03:38]Okay, so that's good. So, now we're going to assess your shoulder strength.

[00:03:41]So, if you could just stand up, we're going to do the joints, okay?

[00:03:45]So, first what you're going to do is you're going to do adduction. You're going to put your hands over your head like here. That's adduction and you're going to take one hand and you're going to go across your body like this. That's abduction. Do you have any pain or tenderness in your shoulder?

[00:03:56]>> No.

[00:03:57]>> Okay. Now, put your hand back up, and do the other arm. Adduction.

[00:04:02]And that's adduction right here. Okay?

[00:04:05]Um and then put it back up.

[00:04:07]Okay. So, now I'm going to assess the strength of your shoulder. What I want to do is I'm going to apply resistance to your arm here, and what you're going to do is you're going to try to push Let me Let me do this. We'll We'll do You're going to try to push your arm up against my resistance. Okay? So, you were assessing shoulder strength, so you're going to go up like this. Okay?

[00:04:25]So, I want you to push up as easy as you can. Do not straighten your arm. Just Just your shoulder. There you go.

[00:04:31]Okay. Patient's shoulder strength is five out of five.

[00:04:34]And here we'll go here so you the camera can see. And I'm going to put my hand here. Wait a minute. That's how we can do this.

[00:04:41]Okay. So, now we're here. All right.

[00:04:42]We're going to Your arm is at your side.

[00:04:45]And then you're going to push at resistance. I'm applying resistance here, and you're going to push up with your arm arm bent.

[00:04:51]Just your shoulder. Push your other shoulder up. There you go. Very good.

[00:04:53]Okay. Shoulder strength is five out of five. Now, we're going to assess your biceps or your shoulder your elbows.

[00:04:59]So, your elbows Okay. So, I'm I'm holding his elbows to see if I have any crepitus. And I see no swelling, bruising, or lesions, or lumps. And I don't feel any nodules. Okay. So, what we're going to do is going to flex your arm.

[00:05:10]Do you have any pain or tenderness?

[00:05:12]>> No.

[00:05:12]>> Okay. And then lower it.

[00:05:14]Now, I'm going to apply resistance, and I want you to to try to flex your arm.

[00:05:19]Okay. Patient's strength is five out of five. Okay. We're going to go on the other side.

[00:05:23]I'm going to assess elbow. I don't feel any nodules. The patient doesn't have any tenderness or um doesn't have any uh lesions, lumps, or bruises over here. So, now I want you to flex your arm and extend it, and then flex it, and extend it. And now I'm going to apply resistance, and I want you to flex your arm.

[00:05:44]Patient's strength is five out of five.

[00:05:46]Okay. And I didn't feel any crepitus whenever he was bending his elbow.

[00:05:50]So, now we're going to do What can we do again?

[00:05:54]Oh, we're going to do the feet. Okay, so we'll do the feet. So, back up. We'll do this.

[00:06:01]So, now we're going to assess your ankles and your wrists. Or we'll do your ankles first, okay? So, I'm going to I'm going to put the chair first so you can stop falling.

[00:06:10]All right, this is correct. Okay.

[00:06:12]All right, so hold on to the chair and I want you to pick up this foot.

[00:06:16]And I want you to That's plantar extension. And I'm going to feel for crepitus. I want you to flex it towards your forehead.

[00:06:23]And that's plantar plantar flexion.

[00:06:26]And I feel no crepitus. I feel no swelling. There's no nodules that I'm feeling. So, put it towards the floor.

[00:06:32]That's plan- plantar extension. Okay, so now we're going to do the other side.

[00:06:38]Okay, lift your foot up.

[00:06:40]And then plantar ex- foot towards the floor board.

[00:06:44]Do you have any pain or tenderness?

[00:06:45]>> No.

[00:06:45]>> Now, towards your forehead.

[00:06:47]Pain or tenderness?

[00:06:48]>> No.

[00:06:48]>> And I don't see any swelling, bruising, or felt any felt any nodules. And I heard no felt no crepitus.

[00:06:54]So, now we're going to Okay, look at me.

[00:06:59]Um, so now we're going to do the hands.

[00:07:01]Okay, let's come over here.

[00:07:04]Now, we're going to do the hands.

[00:07:08]Okay, so I'm going to So, I want you to put your hands like this as assessing your joint mobility. Do you have any pain pain or tenderness? No. Okay.

[00:07:19]I want you to go like this.

[00:07:21]Put your hands.

[00:07:23]Okay, that is supination, pronation, supination, pronation. Do you have any pain or tenderness? No. Okay, so now I'm going to measure your grip strength.

[00:07:33]Grip strength is 5 out of 5.

[00:07:36]Um And we'll see what we can what else we You get in there. Hold on.

[00:07:42]Assess the joints of your knee and your hip. So, if you could just bend over and touch your toes and tell me if you have any pain in your hip area.

[00:07:49]Okay. Now, you can That's called flexion and this is extension. Standing up is extension. Now, flex and touch your toes. That's hip flexion. And stand up.

[00:07:57]That's hip extension. Do you have any pain? No. Now, okay. So, now if you could just bend your knee up and at a 90° angle. Right here. And let's put the chair in here. Okay.

[00:08:07]Okay. Now, bend your knee up.

[00:08:09]Do you have any pain? No. Tenderness?

[00:08:12]No. No. Okay. I feel no nodules, warmth, or swelling on his knee.

[00:08:17]Now, I'm going to do I'm going to do outside.

[00:08:21]Okay. And then bend your knee.

[00:08:24]Do you have any pain? No. Okay. So, I have no I feel no nodules, warmth, or swelling in his knee area.

[00:08:31]Um All right. So, let's go Okay. So, now we're going to assess the spine.

[00:08:36]All right. So, what I'm going to have you do is I'm going to This is actually This is I could have done this with him with the hip, but Okay. So, what we're going to do is we've got all this hair here. Okay. So, what we're going to do is we're going to bend over and we're going to I'm going to look over at your spinal cords. Actually, let's go this way.

[00:08:49]Okay. So, bend over touch your toes.

[00:08:52]Um I do see a little bit of There's no curvature here. There's no sign of scoliosis. He's not able to touch bend over very far, but that doesn't mean it's pathological. It just means that he's not very well conditioned physically. I don't see any abnormalities here. Can you Do you have any pain or tenderness there? No. Okay.

[00:09:11]So, now I'm going to support you. I'm going to stand up Stand up all the way.

[00:09:15]I'm going to support you right here and I want you to And this is called extension. So, you're going to extend.

[00:09:20]You know, lean back. You know, keep your hip here and push your chest back. There you go. Do you have any pain or tenderness?

[00:09:26]>> No.

[00:09:27]>> Okay. So, there's no abnormalities with his spine in in regards to um flexion and extension.

[00:09:36]Now, we're going to do twisting of the back to if he's able to do it without pain. Okay, so I just need you to twist back and forth.

[00:09:44]Does that hurt at all? No. Okay, very good. You can put your shirt back on.

[00:09:49]Okay, so we did our station and gate. We did walking on toes and heels. We forgot to do the tandem walk. Tandem walk is basically like a um if you go on the carpet so I can film you, Michelle.

[00:09:59]So what you're going to do is uh so you what you're going to do is look at me.

[00:10:05]So you can go like this.

[00:10:07]Heel to toe.

[00:10:09]I can't be doing this to me because I'm trying to get on camera. Okay, so go ahead.

[00:10:13]Heels to toe.

[00:10:15]Okay, so this is the tandem walk.

[00:10:26]Okay, patient's gait seems smooth, coordinated.

[00:10:29]It's a little bit hard for him to do but it's probably because he's never done it. I don't see it at any pathological signs of inability to do the tandem walk. Um next we're going to do a hop.

[00:10:38]You're going to hop. Can you hop for me?

[00:10:40]Stand back a little bit and just hop for me or just skip. Go back over there and just uh skip over here. Do you know how to skip?

[00:10:47]Yeah, I know how.

[00:10:50]Do it again. I didn't even see.

[00:10:52]Okay.

[00:10:56]That's not skipping. This is skipping.

[00:10:59]That's hopping. That's actually they wanted you to hop. Actually do this. Hop like this like this.

[00:11:05]>> That's a hop.

[00:11:06]>> Well, yeah, you didn't do that. You said skip.

[00:11:08]>> Well, that was a nice skipping.

[00:11:10]>> Good.

[00:11:11]>> Okay, that's good. He does a wonderful hop. Great job.

[00:11:15]Okay, so now we're going to do the what's called the Romberg test. What you're going to do is you're going to go close Okay, I just need you to listen to what I'm telling you to do, okay?

[00:11:22]What you're going to do is you're going to stand still and I you're going to close your eyes but don't close your eyes just yet. I'm telling you what to do. This is called the Romberg test.

[00:11:29]And you're going to I'm just going to see if it's easy for if you start swaying If you're if it's if you're finding it hard to feel balanced, okay?

[00:11:35]So, you got your you're in your normal standing position.

[00:11:38]>> Yes.

[00:11:38]>> Okay, close your eyes.

[00:11:42]Patient appears to be able to stand still without any having any kind of dizziness or any kind of feeling that you're not able that you're about to fall over.

[00:11:51]>> No.

[00:11:52]>> Okay, so that is a negative Romberg sign. He's not swaying or moving when he's when his eyes are closed.

[00:11:59]>> Do fingers to nose.

[00:12:01]>> Fingers to nose, okay.

[00:12:02]So, what you're going to do is you're going to go from my finger touch take my take your finger touch your nose touch my finger.

[00:12:13]But, what you're going to look you're not going to look at me.

[00:12:16]You're going to look at my finger, okay?

[00:12:18]So, you're going to touch there and there. There you go.

[00:12:23]Now, do it Now, just once you're going to do it a couple times.

[00:12:29]Okay, now take the other hand.

[00:12:33]Very good.

[00:12:35]Wow, you nailed that.

[00:12:36]Good job.

[00:12:37]>> Mhm.

[00:12:38]>> Um Now, we're going to do thigh tapping.

[00:12:42]This is This is just to see if you're able to do rapid movements, okay? So, what you're going to do is you're going to go like this.

[00:12:49]You're going to bend over like I am.

[00:12:51]At your hips, not your not like this.

[00:12:54]Like you're going to bend at your hip right here.

[00:12:56]Like at your hip. Keep your shoulders back. And at your hip, like you're bending over, okay? And then just Okay, good job.

[00:13:09]We're going to do foot tapping. I just need you to tap your foot. Just have your foot down.

[00:13:15]Your heel is on the ground. There you go, good job. Other foot.

[00:13:21]Listen to that music.

[00:13:23]>> Okay.

[00:13:26]>> Okay, then we're going to do the heel to shin test. You can do this either standing or lying down. The only thing you're going to do is is you're going to take your heel and put it along your shin.

[00:13:39]Okay, good job. And then the other one.

[00:13:44]Very good. You passed that one.

[00:13:49]The heel to shin test and the tapping of the foot assessed coordination and the smoothness of uh motor control.

[00:13:59]Okay, I'm going to attempt to do the deep tendon reflexes. I have to warn you he's not being uh relaxing. He's he's not relaxing, but I'm trying to to get the the correct Okay, so now I'm doing the brachioradialis.

[00:14:11]I'm just going to strike the brachialis tendon right here.

[00:14:14]I saw a slight slight titch twitch.

[00:14:17]I'm just going to do one arm.

[00:14:23]There we go. I saw a twitch there. Okay, so now I'm going to do the brachial reflex.

[00:14:37]He's he's very tense. Like he just relaxed.

[00:14:45]I'm getting no reflex there. Okay, so I I I I don't think this is a neurological thing. I think it's just he's not able to relax. So now I'm going to do the um And then over here the bis- triceps tendon.

[00:15:01]Deep tendon reflex.

[00:15:10]Okay, good job. That was a reflex. Okay, now can you sit back in the table? Like sit back.

[00:15:14]Okay, so now I'm going to do the There we go. That was a good one.

[00:15:21]Okay, so now I'm going do the Achilles tendon.

[00:15:31]So the foot should It's It's It's flexing a little bit.

[00:15:39]Okay, so there is that. And then now we're going to do the Babinski sign to see if his curls to his toes curl.

[00:15:54]Okay, his toes curled. That's a positive Babinski sign. So all of his deep tendon reflexes um were his biceps were a three. He He didn't or or a one. He didn't have much of a deep tendon reflex there.

[00:16:11]And uh the I did see a twitch whenever I did the brachioradialis. He's just not He's just not very uptight. He's not relaxed at all. I saw a two-plus reading uh which is a normal finding on the um the knee. And I found no reflex in the in the Oh, that's actually I just did it. I said for the So the bi- triceps I just had a reflex of two-plus. So I finally got it. Let me see if I can get the right Relax, Mitchell. Relax. Stop Just relax, okay?

[00:16:41]So Okay, so ready?

[00:16:44]I can't go on relax. I apologize. He There's no pathological things going on with this patient. He's just very tense, okay?

[00:16:52]Okay, so now I'm going to do the stereogenesis assessment.

[00:16:57]And I'm going to put something in your hand without opening your eyes, sir. Can you please tell me what I am putting in your hands?

[00:17:05]What that What that is?

[00:17:07]>> nail clipper >> It is a nail clipper.

[00:17:12]Okay, so now I'm going to have have you keep your eyes closed.

[00:17:16]And I'm going to put do the assessment for graphesthesia.

[00:17:21]And I'm going to do I it was to where he would be able to identify what I'm doing. Okay, so I'm going to do something on his hand here.

[00:17:29]So, I'm going to put a number on your hand draw a number on your hand and I want you to tell me what number it is, okay?

[00:17:35]You ready?

[00:17:35]>> Okay.

[00:17:38]Three.

[00:17:39]>> It was letter three. Okay, so then I'm going to do a letter on your left hand and you tell me what letter it is, okay?

[00:17:46]>> Okay.

[00:17:49]F.

[00:17:50]>> That's right.

[00:17:53]Okay, so this is supposed to be a two-point videos and I'm going to do it on the bottom of your foot. How about that?

[00:17:57]>> Cool.

[00:17:58]>> So, [clears throat] tell me what Give me the bottom of your foot. And then I'm going to tell me what what I Close your eyes.

[00:18:05]Okay, so now I'm going to do something on the bottom of your foot here.

[00:18:10]Okay, so ready?

[00:18:11]>> Mhm.

[00:18:11]>> [clears throat] >> What was that?

[00:18:15]>> Four?

[00:18:16]>> No, this is a letter. Okay, ready?

[00:18:24]It's sort of like a four, but it's a letter. Okay, so we'll do a different letter.

[00:18:30]>> Oh.

[00:18:31]>> Yes, O.

[00:18:32]It was the first letter was an H.

[00:18:35]So, I did the two-point I did one on his hand and one on his feet.

[00:18:39]What I'm going to do is I'm going to hit this hammer here and I'm going to put it on some part of your upper body and you're going to tell me if you can feel it and you're going to and then I'm going to put it on on like your foot and then you're going to upper and lower part of your body and I'm going to you tell me if you feel the vibration.

[00:18:55]>> I feel the vibration.

[00:18:56]>> You do?

[00:18:59]>> Feel the vibration.

[00:19:00]>> Okay, good. So, that was the um That was a vibration upper and lower.

[00:19:08]Okay, now we're going to do light um light and soft touch.

[00:19:14]Can you close your eyes for me?

[00:19:16]Okay, so I want you to tell me whenever I touch you with this um object, which is a Q-tip, where I'm touching you.

[00:19:25]>> My wrist.

[00:19:26]>> What arm?

[00:19:28]>> Left.

[00:19:28]>> Left arm. Okay.

[00:19:30]And then I'm going to do one more time with the light touch.

[00:19:36]>> My knee on my right foot.

[00:19:38]>> Your knee on your right foot.

[00:19:40]>> Knee of my knee.

[00:19:41]>> Your knee on your right leg?

[00:19:43]>> Mhm.

[00:19:43]>> Okay. And then now I'm going to use a sharp object, but I'm not going to hurt you, okay?

[00:19:48]So this is a sharp object. I'm going to touch you somewhere. I want you to tell me if you can tell me where I'm touching you with a sharp object.

[00:19:57]>> Uh on my arm my arm my left arm. Or right arm.

[00:20:00]>> Right arm. Okay. And then I'm going to touch somewhere else and I want you to tell me where I'm touching you.

[00:20:07]>> My Achilles on my uh right foot.

[00:20:10]>> And is that a sharp or a soft touch?

[00:20:12]>> Sharp.

[00:20:13]>> Okay, good job. So you had a sharp and a soft touch in two different spaces.

[00:20:17]Okay, now we're going to assess the cranial nerves. I need you to keep your eyes closed and tell me what you smell.

[00:20:26]>> Coffee.

[00:20:26]>> That's coffee, right.

[00:20:28]Okay, now we're going to assess your vision.

[00:20:30]Um visual acuity. I want you to hold this I'm going to hold this at 14 um 14 in away from your face and I just need you to tell me what's the smallest line that you can read.

[00:20:43]>> Uh at 2020.

[00:20:47]Uh L T F P H.

[00:20:53]>> Okay, so he has 2020 vision.

[00:20:55]That's visual acuity.

[00:20:57]Then we're going to check your um three, four, and six ocular nerves. We're going to do check your extraocular um using the extraocular motion. I'm going to I want you to just follow my fingertip, okay? And when I'm we're checking um, I think it's three, four, and six cranial cranial nerves, okay? So, watch my fingers. We're going to go in a letter H.

[00:21:21]Patient is following I see no nystagmus.

[00:21:25]No delay in his movement.

[00:21:30]Patient's eyes move smoothly and coordinated and symmetrically.

[00:21:38]So, now we're going to assess cranial nerve um, five.

[00:21:43]I'm going to um, I need you to close your eyes. I'm just going to touch your face in three different spaces and tell me if you feel.

[00:21:53]>> My cheek.

[00:21:54]>> Where at? Left or right?

[00:21:56]>> Left.

[00:21:58]My eyelid on my right side of my face.

[00:22:02]My chin.

[00:22:03]>> Okay, very good. So, now I'm going to test your TMJ. I just want you to open and close your mouth.

[00:22:10]Okay. I want you to open and close your mouth.

[00:22:15]Okay. Um, it's intact. Um, and if you could open your eyes.

[00:22:19]Now, smile.

[00:22:21]Puff your cheeks.

[00:22:24]And um, stick out your tongue. Go up, down, side, side. Okay, now I'm going to assess your teeth um, your tongue strength. I want you to push your tongue against your teeth.

[00:22:36]And now on the other side. Very good.

[00:22:40]Assess I'm going to assess cranial nerve um, eight with the whisper test. I'm going to press on your tragus here and I'm going to whisper a word and I want you to tell me what word I whisper.

[00:22:57]What word am I whispering? Okay, ready?

[00:23:02]>> Dog.

[00:23:02]>> Okay, good.

[00:23:04]Pass that one.

[00:23:05]Okay, and then we're going to do the Okay, now I'm going to check your cranial nerve. I just want you to say ah.

[00:23:15]Okay, so his uvula is vibrating. Keep saying ah.

[00:23:18]His uvula vibrating as expected.

[00:23:23]Okay, good job.

[00:23:27]Okay, I'm also going to assess your speech. Can you say Peter Piper picked a pickled pepper peppers?

[00:23:33]>> Peter Piper picked a pickled >> Peter Piper picked a pickled peppers.

[00:23:37]>> Peter Piper picked a Peter Piper picked a pickled peppers.

[00:23:42]>> Very good. Okay, so that cranial nerve is in check. Okay, so then So the last assessment I'm going to do for cranial nerve nine is I'm going to have you kind of like hold yourself up a little bit and swallow.

[00:23:57]Okay, swallowing is intact so cranial nerve nine is good.

[00:24:01]The last test we're going to do is arm strength, okay? So I just want you to stand up and I need you to You have to give me a big hug, okay?

[00:24:14]It's going to be a big hug, okay?

[00:24:18]No, you got to It's got to It's got to be like a good big hug.

[00:24:21]Wait a minute.

[00:24:24]Okay, so it is. Okay, so ready?

[00:24:27]Like a Like a good hug.

[00:24:35]>> [laughter] >> Okay, so arm strength is five out of five.

[00:24:41]Did you eat the whole the rest of the brownies?

[00:24:43]>> No.