Chapter 1 - General physical examination
Questions
Define the following terms:
Battle sign, raccoon eyes, bruit, papilledema, myelopathy, radiculopathy, radiculitis, Lhermitte symptom, meningissmus, Brudzinski sign, Kernig sign, Patrick test.
Battle sign is suboccipital bruising that may be seen with basilar skull fractures.
“Racoon eyes” are the appearance of bruising (dusky bluish discoloration) around the eyes that is restricted within the margin of the eyelids (as opposed to the usual “black eye” that overlaps onto the cheek or forehead). It is a hint of possible basilar skull fracture.
A bruit is a pulsatile sound associated with turbulent blood flow.
Papilledema is swelling of the optic nerve head due to obstruction of venous outflow from the eyes (usually due to increased intracranial pressure).
Myelopathy is damage to the spinal cord for any reason.
Radiculopathy is damage to one or more nerve roots for any reason.
Radiculitis is irritation or inflammation of one or more nerve roots.
Lhermitte symptom is an "electrical sensation" radiating down the back and/or into the arms and legs separately or in combination, produced forcibly extending or flexing the neck. This is most often due to direct or indirect irritation of the spinal cord.
Meningissmus is a reflex resistance to passive neck flexion (usually accompanied by pain from meningial irritation).
lobe).
Brudzinski sign is reflex flexion of the lower limbs with passive neck flexion. This is due to irritation of the meninges.
Kernig sign is reflex flexion of the knees when the straight lower limb is passively flexed. It is due to meningeal or nerve root irritation.
Patrick test, in which the flexed hip is rotated, is a test of the hip joint. If this reproduces that patient’s pain, or if there is significant limitation in motion, hip joint pathology should be considered.
1-1. What happens to blood pressure and pulse with increased intracranial pressure?
Answer 1-1. Increased intracranial pressure usually increases blood pressure, with decreased pulse (Cushing sign).
1-2. What part of the brain contains the primary respiratory centers?
Answer 1-2. The medulla contains centers that are involved in generating respiration. These centers are under control from higher centers and abnormal patterns of respiration are seen with interruption of these higher centers at progressively more caudal levels.
1-3. What is the most common finding that differentiates orthostatic hypotension due to hypovolemia from that due to sympathetic failure?
Answer 1-3. With hypovolemia the pulse will increase in response to lowering blood pressure. Most causes of autonomic failure will also damage autonomic nerves to the heart, preventing the compensatory acceleration of heart rate.
1-4. Can the brain cause EKG changes that appear as ischemia?
Answer 1-4. Subarachnoid hemorrhage can cause EKG changes commonly found in cardiac ischemia, including elevation of ST segments and cardiac arrhythmia.
1-5. What is the most reliable finding of increased intracranial pressure in an infant?
Answer 1-5. A tense or bulging fontanelle in the seated or upright position is the most reliable sign.
1-6. Why is it important to measure cranial circumference in young children?
Answer 1-6. This can be an important sign of increase intracranial pressure, which can result from hydrocephaly, masses (such as tumors), subdural fluid accumulations or certain metabolic disorders that result in abnormal enlargement of the brain, itself. A small head may indicate failure of normal development. Standard charts are used.
1-7. What are some causes of cranial bruits?
Answer 1-7. Cranial bruits arise from turbulent blood flow. Although they are most often heard over stenotic major arteries, they can occur over the head. They may come from vascular malformations (including ateriovenous malformations and malformations of the great cerebral vein) or, in young children, from conditions that massively increase cranial blood flow (such as severe anemia or meningitis).
1-8. What are the major causes of increased intracranial pressure?
Answer 1-8. The major causes of increased intracranial pressure are cerebral edema, acute hydrocephalus (blockage of cerebrospinal fluid flow or deficiencies of absorption), mass lesions (e.g., neoplasm, abscess, hemorrhage), and venous occlusion (e.g., sagittal or transverse sinus thrombosis).
1-9. What is the most sensitive finding in increased intracranial pressure?
Answer 1-9. The first finding with increased intracranial pressure is loss of spontaneous venous pulsations seen in the region of the optic disc. Papilledema is usually a late finding (or one with rapid pressure elevations), consisting of swollen, blurred and elevated disk edges, engorged and pulseless veins, and increased vascularity of the disk margins.
1-10. What is the difference in appearance between papillitis (inflammation of the optic nerve head at the optic disc) and papilledema?
Answer 1-10. They can look identical. However, the patient with papillitis usually has severe vision loss while the patient with papilledema usually only has a mild enlargement of the physiologic blind spot (of which they are usually not aware). Also, papilledema is usually bilateral.
1-11. What is the difference between Lhermitte symptom produced by intramedullary disease as opposed to that caused by extramedullary compression?
Answer 1-11. Intramedullary lesions are more likely to result in Lhermitte symptom with neck flexion, while extramedullary lesions are more likely to result in the symptom upon neck extension.
1-12. What is Spurling maneuver and what does it show?
Answer 1-12. The Spurling maneuver involves extending the neck, rotating the head towards the affected side while the examiner pushes down gently on top of the head. This is positive when it reproduces arm symptoms due to compression of affected nerve roots at the intervertebral foramen.
1-13. What is the function of the straight leg-raising test?
Answer 1-13. This test stretches the lumbosacral nerve roots that contribute to the sciatic nerve and may reproduce lower extremity symptoms due to sciatic radiculitis.