Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

Cranial Nerves Examination: A Comprehensive Guide, Schemes and Mind Maps of Medicine

A detailed guide on how to perform a cranial nerves examination. It covers various aspects of the examination, including the positioning of the examiner and patient, essential steps, and the assessment of different areas. The document also mentions the nerves involved and the muscles tested.

Typology: Schemes and Mind Maps

2021/2022

Uploaded on 09/27/2022

arij
arij 🇺🇸

4.8

(8)

230 documents

1 / 12

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
Introduction to the Practice of Medicine 2
NEUROLOGIC EXAM DETAILS FROM NEURO EXAM VIDEO
WASH HANDS
(Patient is seated.)
Cranial Nerves:
1. Visual fields (screening test for CN2 & Visual system: peripheral vision)
A. Examiner is positioned:
a. in front of patient
b. about 2 feet away from patient
c. at eye level with the patient
B. Examiner instructs patient to stare at examiner’s nose (“Don’t move your eyes.”)
C. Examiner stares at patient’s nose
D. Both eyes are examined together (Both eyes are open)
a. Examiner holds out his or her index fingers in the periphery of the patient’s
vision, about 180o apart (e.g., above the patient’s right eye and below the
patient’s left eye), and slightly wiggles one index finger at a time.
b. The patient is asked to identify or point to the moving finger.
c. With the examiner’s fingers in the same position as in (a), both fingers are
wiggled at the same time, and the patient should identify that both are
simultaneously moving.
d. Examiner then “rotates” his or her extended index fingers about 90o from the
initial position (e.g., now above the patient’s left eye and below the patient’s
right eye), and slightly wiggles one index finger at a time.
e. With the examiner’s fingers in the same position as in (c), both fingers are
wiggled at the same time, and the patient should identify that both are
simultaneously moving.
f. Examiner holds his or her index fingers about 180o apart in the temporal visual
fields (e.g., left of patient’s left eye, right of patient’s right eye) in a horizontal
plane.
g. The patient is asked to identify or point to the moving finger.
h. With the examiner’s fingers in the same position as in (e), both fingers are
wiggled at the same time, and the patient should identify that both are
simultaneously moving.
E. Examiner should have his or her finger half way between the patient and his/herself,
and gradually move the wiggling finger more towards the center of vision, until it is
perceived by the patient.
F. Examiner “rotates” his or her index fingers, checking for the visual fields of both
eyes superiorly, inferiorly and temporally.
Any abnormality or problem with this screening test of visual fields, or a complaint of
visual loss, prompts retesting of visual fields one eye at a time (see Addendum later).
Failure of the patient to recognize both simultaneously moving fingers suggests visual
extinction from a parietal lobe lesion.
G:\IPM2\2004-05\Neuro_Exam_details.doc - 1 - Revised: 7/22/04
pf3
pf4
pf5
pf8
pf9
pfa

Partial preview of the text

Download Cranial Nerves Examination: A Comprehensive Guide and more Schemes and Mind Maps Medicine in PDF only on Docsity!

NEUROLOGIC EXAM DETAILS FROM NEURO EXAM VIDEO

WASH HANDS

(Patient is seated.) Cranial Nerves:

  1. Visual fields (screening test for CN2 & Visual system: peripheral vision) A. Examiner is positioned: a. in front of patient b. about 2 feet away from patient c. at eye level with the patient B. Examiner instructs patient to stare at examiner’s nose (“ Don’t move your eyes.” ) C. Examiner stares at patient’s nose D. Both eyes are examined together (Both eyes are open) a. Examiner holds out his or her index fingers in the periphery of the patient’s vision, about 180o^ apart (e.g., above the patient’s right eye and below the patient’s left eye), and slightly wiggles one index finger at a time. b. The patient is asked to identify or point to the moving finger. c. With the examiner’s fingers in the same position as in (a), both fingers are wiggled at the same time, and the patient should identify that both are simultaneously moving. d. Examiner then “rotates” his or her extended index fingers about 90o^ from the initial position (e.g., now above the patient’s left eye and below the patient’s right eye), and slightly wiggles one index finger at a time. e. With the examiner’s fingers in the same position as in (c), both fingers are wiggled at the same time, and the patient should identify that both are simultaneously moving. f. Examiner holds his or her index fingers about 180o^ apart in the temporal visual fields (e.g., left of patient’s left eye, right of patient’s right eye) in a horizontal plane. g. The patient is asked to identify or point to the moving finger. h. With the examiner’s fingers in the same position as in (e), both fingers are wiggled at the same time, and the patient should identify that both are simultaneously moving. E. Examiner should have his or her finger half way between the patient and his/herself, and gradually move the wiggling finger more towards the center of vision, until it is perceived by the patient. F. Examiner “rotates” his or her index fingers, checking for the visual fields of both eyes superiorly, inferiorly and temporally.

Any abnormality or problem with this screening test of visual fields, or a complaint of visual loss, prompts retesting of visual fields one eye at a time (see Addendum later). Failure of the patient to recognize both simultaneously moving fingers suggests visual extinction from a parietal lobe lesion.

Note: The examiner should be testing his/herself at the same time and comparing his/her answer to the patients – assuming the examiner has normal visual fields!

  1. Student inspected both eyes with the ophthalmoscope. (CN2) These are not essential; however doing these optimizes conditions to facilitate the exam: Proper patient position is helpful for ophthalmoscopy A. If the patient is “slouching” tell them to sit up straight so the examiner doesn’t have to bend over to attempt the exam B. If the patient is sitting too far back on the exam table, the examiner might ask patient to sit forward on the table. C. If patient is already in a good position, nothing may need to be changed These are essential (right-right-right, and left-left-left): A. Examiner holds ophthalmoscope with examiner’s right hand to look through examiner’s right eye when inspecting patient’s right eye. B. Examiner holds ophthalmoscope with examiner’s left hand to look through examiner’s left eye when inspecting patient’s left eye. C. Examiner darkens room (i.e., turn off or down lights, close shades, etc.) a. warn the patient you are going to do this! D. Patient is told to stare off in the distance or stare at the wall ( look at the clock on the wall) and not to look at the light from the ophthalmoscope or not to move their eyes during this exam. E. Examiner should stand right next to the patient’s mid thigh (you need to be next to the patient) a. You may need to tell patient to put their legs together so you can be close to them F. Hold the ophthalmoscope so that: a. the top of the scope is against your eyebrow b. the bottom of the scope is held against your upper cheek c. examiner’s head and the ophthalmoscope should move as “one” d. common error – examiner holds the ophthalmoscope too far from their face G. Examiner should start about 12 to 15 inches from the patient and slowly move forward to the patient’s eye. (Examiner should not” startle” the patient by moving towards the patient too quickly; a brief introductory statement lets the patient know what to expect.) H. Examiner looks approximately 15 degrees lateral to patient’s line of vision to see the disc a. common error – examiner is directly in patient’s line of vision and then can’t locate the disc I. Examiner begins about 12-15 inches from patient’s eye with the diopters reading at about +8 to +10 (either green or black numbers on ophthalmoscope) to first see the red reflex. While slowly changing the diopters towards 0 or a negative 1 or 2 (red numbers), the examiner approaches the patient to see the optic disc and retina. J. Examiner should systematically inspect: a. Optic disc: color, shape, margins, and cup-to-disc ratio
  1. Examiner asked patient to close his/her eyes and identify the examiner’s gentle rubbing of his/her fingers (or ticking watch or whispered word) –about 3 inches from right and left ear. (Auditory division, CN8)
  2. Examiner asks patient to “say ah.” Both sides of the palatal arch and the uvula should elevate symmetrically. (CN10, questionably CN9) The gag elicited by the palatal reflex is annoying to some patients, so this reflex should be checked only if palatal elevation upon saying “ah” appears abnormal, or the patient has complained of a problem with swallowing or speech. The peritonsillar area on each side is gently touched with a cotton swab (afferent is CN9) and symmetrical elevation of the palate and uvula occurs (efferent is CN10). It is doubtful that CN9 has any motor function regarding the palate, but it does supply sensory input for the gag (palatal) reflex.
  3. Examiner asks patient to cough. (CN10, Vagus nerve, innervates the vocal cords) Examiner may ask patient to turn their head so the patient does not cough on the examiner.
  4. Examiner assesses trapezius muscles (CN11, Spinal Accessory Nerve). Examiner places his/her hands on patient’s trapezii muscles and then asks patient to shrug both shoulders upward against his/her hands. Examiner notes strength and symmetry of contraction.
  5. Examiner assesses sternocleidomastoid muscles (CN11, Spinal Accessory Nerve). Examiner asks patient to turn the head to each side against resistance from the examiner’s hand. As the patient attempts to turn the head to each side, examiner observes the strength of the contraction of the OPPOSITE sternocleidomastoid muscle. ( The patient’s right SCM contracts and turns patient’s head to patient’s left)
  6. Examiner asked patient to protrude their tongue, and then to move it from side to side. (CN12) Normally, the tongue protrudes in the midline

Motor System: Examiner should inspect muscles for asymmetry, atrophy and fasciculations while testing muscle tone and strength.

  1. The examiner determined limb tone (resistance to passive stretch) in the upper limbs ______ RUE ______ LUE

The patient is asked to relax. The examiner supports the patient’s elbow, and grasping the patient’s hand passively flexes and extends the wrist, elbow and shoulder through a moderate range of motion. With practice, this can be combined into a single, smooth movement. Normal resistance is felt as mild resistance to passive stretching, which is felt evenly throughout the entire ROM at each joint in each extremity. Abnormal tone is either

decreased or increased (which is divided into “clasp-knife” spasticity or “lead pipe” rigidity)

  1. Examiner tested the muscle strength of the lower extremities (thigh, leg, foot). Student determined muscle power by gently trying to overpower contraction of each group of muscles one side at a time : lower extremities (ask examiner to grade each with 0-5 scale): ______ hip flexion (elevate one knee at a time off the examination table) (iliopsoas muscle - L2, L3, L4 –femoral nerve) ______ knee flexion (hamstrings - L5, S1, S2 –sciatic nerve) ______ knee extension (quadriceps - L2, L3, L4 – femoral nerve) ______ ankle dorsiflexion (L4, L5 – peroneal nerve) ______ ankle plantar flexion (S1, S2 – tibial nerve) (“step on the gas”)

Reflexes: Examiner elicited the following deep tendon reflexes bilaterally and graded with 0-4 scale : 0=absent reflex, no response 1=diminished, low normal (brought out with reinforcement = Jendrassik maneuver) 2=normal, average 3=brisker than average, possibly but not necessarily indicative of disease 4=hyperactive with clonus

Patient is sitting, relaxed, limbs are symmetrically positioned Examiner holds reflex hammer between their thumb and index finger Examiner swings the reflex hammer briskly (quick and direct) using a rapid wrist movement

If the reflexes appear asymmetrical, this may be due to the patient’s poor posture or tenseness. Retest the reflexes in the supine position on the examination table.

Examiner bilaterally tested the following reflexes:

  1. Biceps Reflex (C5, C6) A. Patient’s arms are partially flexed at the elbow B. Examiner places his or her thumb or index finger over biceps tendon C. Examiner then strikes his or her thumb/index finger
  2. Triceps Reflex (C7, C8) A. Flex the patient’s arm 90 degrees at the elbow, palm towards their body, pulled slightly across the chest B. Examiner directly strikes triceps tendon, just proximal to the olecranon OR C. Examiner positions and supports the patient’s arm so that it is horizontal and elbow is flexed to 90 degrees, with the forearm hanging limp D. Examiner directly strikes triceps tendon, just proximal to the olecranon
  1. Brachioradialis Reflex (C5, C6) A. Patient’s hand rests on his/her lap, with forearm halfway between supination and pronation B. Examiner strikes radius about 1 to 2 inches proximal to the wrist to see forearm flexion and supination.
  2. Knee Reflex (L2, L3, L4) A. Patient is sitting so that the legs are freely dangling (Patient’s feet should not be resting on the stoop) B. Patient’s legs should not be flush against the end of the exam table. C. Examiner should stand to patient’s side so as not to be hit by a brisk reflex! D. Examiner strikes patellar tendon just distal to patella. (Examiner may place his/her other hand on patient’s distal quadriceps muscle to feel for a contraction as they strike the tendon with the reflex hammer in the other hand.) (If done supine, see addendum later.)
  3. Ankle Reflex (S1) A. With the patient’s leg still dangling, examiner grasps patient’s foot and slightly dorsiflexes patient’s foot (foot should about be parallel to the floor) B. Examiner strikes Achilles’ tendon and watches and feels for plantar flexion. (If done supine, see addendum later.)
  4. Examiner tested for the plantar response (Babinski sign) on each foot. A. Examiner holds the patients heel and strokes the lateral side of the sole, beginning at the heel and moving to the ball of the foot, curving medially across the ball. B. Examiner begins with the lightest stimulation that provokes a response C. Patient’s toes normally flex D. A Babinski response = dorsiflexion of big toe, often accompanied by fanning of the other toes.

Sensory System:

  1. Examiner tested in all four extremities: A. Examiner first explained the step B. Examiner asked patient to close his/her eyes and report each time the soft touch or pain stimulus is detected equally (to the same degree) over all four limbs C. Light touch (both posterior column and spinothalamic tracts) with a wisp of cotton D. Pain (spinothalamic tract) sense with a splintered cotton tip applicator or broken tongue blade E. Begin testing over the feet, and alternating from side to side, quickly ascend up the legs and thighs. Repeat in the upper extremities, beginning at the hand and ascending up the forearm and arm, alternating side to side. (In a patient with peripheral neuropathy and distal sensory impairment, stimuli at the feet may be absent or reduced, becoming detectable or “sharper” more proximally. Also, a patient with a spinal cord lesion may not detect any sensation up to the dermatomal level involved.)

Gait/Station (Patient is standing)

  1. Romberg test (for position sense) A. Examiner instructed patient to stand (eyes open), feet together with arms at their side Examiner then instructed patient to close his/her eyes for 20-30 seconds and stand still. (Examiner should be close enough to patient to catch patient if patient loses their balance) B. Normally, only minimal swaying occurs and patient can maintain an upright posture ( + Romberg = patient can stand still with eyes open, but loses balance with eyes closed ) (With cerebellar ataxia =patient cannot stand still with eyes either open or closed .) ( Note: elderly, frail patients may be anxious and fearful of falling, or are often dizzy. They may sway during the Romberg test for these reasons. Position sense can be tested during the sensory examination described above.)
  2. Gait Testing A. Examiner instructed patient to walk barefoot back and forth across the exam room (Examiner observes for posture, balance, and arm swing.) B. Examiner instructed patient to walk heel-to-toe (tandem) in a straight line. (Examiner should be near enough to catch patient if necessary) Tip – examiner may ask patient to walk on a line in the tile floor if available. (If the gait here appears abnormal, or the patient has complained of gait difficulty, test gait in more detail: Examiner instructed patient to walk on his/her heels across room Examiner instructed patient to walk on his/her tiptoes across room)

Addendum The above is a screening Neurological Examination. Additional testing is indicated if certain abnormalities are detected on the screening examination, or if the patient has specific complaints in certain areas: Cranial Nerves ™ CN1 and CN7: Olfaction or smell and taste should be tested if the patient complains of abnormalities with either. With the eyes closed, the patient should identify “coffee” or “soap” when these are held under each nostril. With the eyes closed, the patient should identify “sweet” or “salty” when these solutions are swabbed onto either side of the tongue. ™ CN2: Visual acuity should be measured if the patient complains of visual impairment, or abnormalities are noted on the visual field or ophthalmoscopic examination. Distant visual acuity is ideally tested several feet away on a Snellen wall chart. If unavailable, a pocket screener is used as described below, although near visual acuity is often decreased due to presbyopia: Examiner tested visual acuity in each eye separately (CN2) ¾ a pocket screener is used ¾ it is held at a distance of 12-14 inches from patient’s face ¾ checked in each eye separately (cover one eye) ƒ ask patient to cover their eye with the palm of their hand and not with their closed fingers (patients can open up their fingers and peek!)

¾ record the acuity as the line at which the patient can read ≥ half the letters correctly ƒ 20/200 means the patient can read at 20 feet what a normal patient can read at 200 ft. ¾ if a patient has contacts in or wears glasses, they should stay on during the test ™ CN2: Visual fields should be more accurately examined one eye at a time if the patient complains of visual impairment, or there are abnormal signs from the visual examination, including visual field screening with both eyes at the same time: ¾ The examiner and patient face one another (as for the visual field screening, described earlier), but one eye is covered (e.g., examiner’s left eye, patient’s right eye). ¾ The examiner wiggles his/her index finger in the periphery of the visual field of the patient’s open eye, asking the patient to “say ‘yes’ when you see the wiggling finger.” (superior, inferior, nasal and temporal quadrants should be tested, always compared to those of the examiner). The finger is initially placed peripherally, and gradually moved closer to the center of vision. ¾ The test is similarly repeated for the visual field of the other eye. ™ CN2 and 3: Accommodation and convergence should be tested if the patient complains of blurry or double vision, or there are abnormalities involving the pupillary light reflex or eye movements (gaze): ¾ Examiner checked for accommodation and convergence (CN2 and 3) ƒ This is usually done during the test for the cardinal positions of gaze ƒ Both eyes are open ƒ Examiner asks patient to follow their finger or other object (pencil/penlight) as examiner moves from about 12 inches away to about 2- 3 inches away in the patients midline (toward the patient’s nose) ƒ The patient’s pupils should constrict as the eyes converge ™ CN5 and 7: Corneal reflex should be tested if the patient complains of facial numbness. Explain the test to the patient, and have the patient look laterally toward the left, with their eyelids wide open (or lightly held open by the examiner). Using a wisp of cotton, approach the patient’s right eye from the right side, and lightly touch the cornea, observing a bilateral eye blink. (Contact lenses must be removed for this test.) Repeat again, with patient looking to the right, and lightly touching the left cornea. ™ CN5: Motor division (Masseter and temporalis muscles) should be checked if the patient complains of trouble speaking, chewing or swallowing: ¾ Examiner assessed motor division of CN5 (Trigeminal nerve) ƒ Examiner places their right and left finger pads at two places on the patient:

  • Masseter muscles at the bite line and asks patient to “clench their teeth” or “ bite down” ♦ Examiner should note symmetric contraction
  • Temporal muscles (in the right and left temporal fossas) ♦ Examiner again asks patient to “clench their teeth” or “bite down” ♦ Examiner should note slight and symmetric bulging as they contract ™ CN8: Rinne and Weber tests for should be performed, and the ear canals examined when there are findings or complaints of hearing loss ¾ Weber test: Examiner places the base of a lightly vibrating tuning fork in the middle of the patient’s forehead. The patient is asked where the sound or vibration is heard (normally in the midline, or equally in both ears).