How and what part of the nervous system are we checking? Light
touch Pinprick Temperature Vibration Joint position sense Checking
a level Romberg- correct positioning!
Slide 9
VIBRATION 128 hz tuning fork JOINT POSITION SENSE PIN PRICK
TEMPERATURE Start distally and move proximally
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Grading system 0: absent 1+: hyporeflexia 2+: normal 3+: brisk,
without clonus 4+: brisk, with clonus
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BICEPS BRACHIORADIALIS TRICEPS KNEE ANKLE
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Planar reflex(S1) Normal- On stroking the lateral border of the
sole there is flexion of the big toe and other toes.
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Extensor plantar response Babiniski sign Dorsiflexion of the
big toe and ankle joint and fanning of the other toes.
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I - OLFACTORY DONT USE A NOXIOUS STIMULUS COFFEE, LEMON EXTRACT
II - OPTIC VISUAL ACUITY VISUAL FIELDS FUNDOSCOPIC EXAM
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III/IV/VI OCULMOTOR, TROCHLEAR, ABDUCENS PUPILLARY RESPONSE EYE
MOVEMENTS 9 CARDINAL POSITIONS OBSERVE LIDS FOR PTOSIS V -
TRIGEMINAL MOTOR - JAW STRENGTH SENS - ALL 3 DIVISIONS
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VII - FACIAL OBSERVE FOR FACIAL ASYMMETRY FOREHEAD WRINKLING,
EYELID CLOSURE, WHISTLE/PUCKER VIII - VESTIBULAR ACUITY RINNE,
WEBER
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IX/X - GLOSSOPHARYNGEAL, VAGUS GAG XI - SPINAL ACCESSORY
STERNOCLEIDOMASTOID M. TRAPEZIUS MUSCLE XII - HYPOGLOSSAL TONGUE
STRENGTH RIGHT XII THRUSTS TONGUE TO LEFT
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ATROPHY FASCIULATIONS
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TREMOR REST WITH ARMS OUTSTRETCHED INTENTION CHOREA ATHETOSIS
ABNORMAL POSTURES
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RAPID ALTERNATING MOVEMENTS FINGER TO FINGER TO NOSE TESTING
HEEL TO SHIN GAIT TANDEM
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Stand with feet together - assure patient stable - have them
close eyes Romberg is positive if they do worse with eyes closed
Measures Cerebellar function Frequently poor balance with eyes open
and closed Proprioception Frequently do worse with eyes closed
Vestibular system
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Tone Muscle bulk Strength: check agonist/antagonist pairs
Abnormal movements Motor
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STRENGTH GRADED 0 - 5 0 - NO MOVEMENT 1 - FLICKER 2 - MOVEMENT
WITH GRAVITY REMOVED 3 - MOVEMENT AGAINST GRAVITY 4 - MOVEMENT
AGAINST RESISTANCE 5 - NORMAL STRENGTH
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UPPER AND LOWER EXTREMITIES DISTAL AND PROXIMAL MUSCLES GRIP
STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH SUBTLE WEAKNESS TOE
WALK, HEEL WALK OUT OF CHAIR DEEP KNEE BEND
1. Ask the subject if he/she has a subjective olfactory
problem. 2. Check for rash, deformity of nose. 3. One nostril is
occluded while examining the other. Use pleasant odor substances
like tea or rose water. Dont use irritating substances
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There are three main aspects to this nerve: visual acuity,
visual fields, and fundi opticus. 1. Examine visual acuity: 2.
Examine visual fields: 3. Look into the fundi:
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CN III Oculomotor: Eyelid and eyeball movement CN IV Trochlear:
Innervates superior oblique Turns eye downward and laterally CN VI
Abducens: Turns eye laterally Cranial Nerves III, IV and VI supply
the muscles of eye movement and are tested as a unit.
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1. Appearance of eyes: 2. Eyeball movement: 3. Look at pupils:
4. Test pupillary light reaction: 5. Pupillary reaction to
convergence and accommodation reflex:
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Functions: Chewing Face & mouth touch & pain 1. Facial
sensation: 1) Use sterile sharp item on forehead, cheek and jaw. 2)
If abnormal, then test temperature [water-heated/cooled tuning
fork], light touch [cotton].
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2. Motor: Subject opens mouth, clenches teeth. 1) Palpate
temporal, masseter muscles as they clench. 2) Subject opens mouth;
assess the symmetry of the mouth.
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3. Corneal reflex: Ask the patient looks up and straight. 1)
Touch cotton wool to the sclera on the other side. 2) Look for
blink in both eyes, ask if subject can sense it. 3) Repeat on the
other side.
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4. Test jaw jerk: 1) Examiner places finger on tip of jaw. 2)
Grip patellar hammer halfway up shaft and tap examiner s finger
lightly. 3) Usually nothing happens, or just a slight closure
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Functions: controls most facial expressions, secretion of tears
& saliva, taste 1. Muscles of facial expression: 2. Check the
sense of taste:
1. Sternocleidomastoid Press a hand against the patient's jaw
and have the patient rotate the head against resistance. Pressing
against the right jaw tests the left sternocleidomastoid and vice
versa. 2. Trapezius Have the patient shrug shoulders against
resistance and assess weakness.
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1. Listen to articulation. 2. Inspect tongue in mouth for
wasting, fasciculations. 3. Protrude tongue: deviates to affected
side.
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TREMORS They are regular rhythmic movements. STATIC TREMOR
1.parkinsonism 2.senile POSTRUAL TREMORS Anxiety Familial
Hyperthyroidsm
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Some useful tests for detection of deficiencies in motor
function of the palate, pharynx, and larynx are described below.
Sensory function needs to be checked if one suspects cranial
neuropathy or a brain stem lesion. 1. Palatal Elevation 2. Gag
reflex (afferent IX, efferent X) 3. Sensory function 4. Voice
Quality 5. Taste test see CN VII
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INTENTION TREMORS Cerebellar Severe parkinsonism HYSTERICAL
TREMORS
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Quick jerky irregular brief movements. Causes Infections
Hereditary Endocrine Collagen disorders Liver disease like Wilson
disease Myoclonus Muscular contractions
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Grading of level of coma Grade -0 Fully conscious
Grade1-Drowsy,but responds to verbal commands Grade 2-Unconscious
but responds to minimal pain Grade3-unconscious but responds to
deep pain Grade4- Unconscious with no response to pain
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The sum of these values is calculated. The minimum GCS is 3
(deep coma) The maximum is 15 GCS 11-15 good prognosis GCS 5-10
intermediate GCS 3-4 poor prognosis
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RAPID ALTERNATING MOVEMENTS FINGER TO FINGER TO NOSE TESTING
HEEL TO SHIN GAIT TANDEM
Slide 56
Stand with feet together - assure patient stable - have them
close eyes Romberg is positive if they do worse with eyes closed
Measures Cerebellar function Frequently poor balance with eyes open
and closed Proprioception Frequently do worse with eyes closed
Vestibular system
Kernigs sign With the hip flexed the knee is extended. Normally
it can be done upto 135 degree. In meningitis it is restricted due
to spasm of the hamstrings.
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