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Contents 1) Basic Anatomy 2) General Inspection 3) Cranial Nerves 4) Mental Status / Awareness- Glasgow Coma Scale 5) Sensory Exam 6) Motor Exam 7) Reflexes (not Paediatric) 8) Final comments and questionshttps://www.dana.org/wp-content/uploads/2019/08/anatomy-function-brain-areas-basics-large.jpghttps://qbi.uq.edu.au/files/33952/Brain-lobes-traditional-QBI-sm.jpghttps://i.pinimg.com/originals/f9/1a/18/f91a1886599e2924204904286068a311.jpghttps://prod-images-static.radiopaedia.org/images/600/d678d4ae900cd8345625e3e0a42023_jumbo.jpeghttps://i.pinimg.com/564x/30/91/91/309191c45b31f651f9f0da5385a9a6f9.jpghttps://i.pinimg.com/originals/52/a4/df/52a4df6ce9c0d681fe3fa728270a85ef.jpg Equipment needed ● Pen torch ● Snellen chart ● Ishihara plates ● Ophthalmoscope ● Cotton wool / bud ● Neuro-tip ● Tuning fork, ideally 512Hz ● Glass of water https://upload.wikimedia.org/wikipedia/commons/b/b1/Ishihara_9.svg General Inspection ● Speech assessment ● Mood ● Facial asymmetry and abnormalities ● Inspect pupils ● Inspect limbs ● Additional - aids? https://sophisticatedhearing.com/wp-content/uploads/2018/08/hearing-loss-img7.jpgSpeech assessment ● Briefly test by asking patient to read or obey a simple written command and write a short sentence ● If problematic: ask progressively harder questions Pathologies : 1. Dysarthria- problem with articulation with intact language (writing) 2. Dysphonia - dysfunctional volume output 3. Dysphasia - defective speech, reading and writing. Can be expressive (Broca’s), Receptive (Wernicke’s), Conductive, Nominal and GlobalGait ● Can be observed informally as patient walks into clinic or asking them to stand and also conducting the Romberg’s test. Types: 1. Hemiplegic, asymmetric, one side is weaker. 2. Tredenlenburg, asymmetric, pathology of gluteus medius and minimus muscles. 3. Foot drop, asymmetric, after L4/5, Sciatic or common peroneal nerve lesion, “high-stepping” gait, failure to dorsiflex foot and increased flexion at hip and knee. 4. Parkisonism, flexed posture with small, shuffling steps. 5. Cerebellar ataxia, symmetric, broad based with lumbering body movements, difficulty turning. 6. Sensory ataxia, symmetric, loss of proprioception, “high-stepping” wide gait, need more sensory input to be sure of leg position. 7. Antalgic, symmetric and narrow based, due to pain from osteoarthritis, fracture, inflammatory disease. 8. Waddling, weakness of proximal lower limb muscles. 9. “Scissoring”, symmetric and narrow based, if both legs are spastic, toes drag on floor, trunk sways side to side.https://samarpanphysioclinic.com/wp-content/uploads/2019/03/AbnormalGait.pnghttps://1.bp.blogspot.com/- GyodZZO69h4/X2RpmKUzUoI/AAAAAAAAjRE/bSwbZ_JclpkjRWmKEItBUpgULz5LZklqQCLcBGAsYHQ/s500/Rombergs.webpCN I - Olfactory Nerve Function: Smell. Examination: ● Occlude one nostril and in the other present a stimulus such as coffee or spices. Repeat on other side. Pathologies: Anosmia / Hypo / Hyper, which are caused by inflammation (infections), trauma, Parkinson’s (early symptom), Covid-19 and tumour (Meningioma).https://passmyclinicalexamination.com/wp-content/uploads/2016/11/OPTIC-NERVE-2-X-IMAGE.001.jpeg CN II - Optic Nerve Examination What are we looking for / what is used? Examples of possible pathologies Inspection of pupils Size, shape & symmetry Synechiae, globe injury, CN III palsy, Horner’s syndrome Visual acuity Assessment of distance (Snellen’s chart) Refractive errors, amblyopia, cataracts, optic neuritis, pathway lesions Pupillary reflexes Direct pupillary reflex, consensual pupillary reflex, swingPupillary defects light test accommodation test, Colour vision assessment Ishihara plates Optic neuritis, Vitamin A deficiency Visual neglect Assessment (e.g. wiggling fingers) Central lesions Visual fields Assessment (e.g. with an Amsler chart) Scotoma, quadrant/hemianopias Geeky medics, Clinical Medicine (10 thed.) – Kumar & Clark’s & Oxford Handbook of Clinical Specialties (11 thed.) Anisocoria Amsler grids Ishihara plates https://www.msdmanuals.com/professional/eye-disorders/symptoms-of-ophthalmologic-disorders/anisocoria https://www.webeyeclinic.com/color-blind/ishihara-test https://eastvalleyeyecenter.com/medical-eyecare-services/age-related-macular-degeneration/amsler-grid/ CN III, IV + VI – Oculomotor, Trochlear + Abducens Nerves Function: CN III, IV + VI contain motor fibres. CN III also contains parasympathetic fibres. Examination What are we looking for / Examples of possible what is used? pathologies Eyelids Inspection for ptosis CN III pathology, Horner’s syndrome, MG Eye movements Abnormalities Palsy of each nerve th th Geeky medics, Clinical Medicine (10 ed.) – Kumar & Clark’s & Oxford Handbook of Clinical Specialties (11ed.) Horner’s syndrome Cover test https://litfl.com/horner-syndrome/ https://areaoftalmologica.com/en/terms-of-ophthalmology/cover-test/ CN V - Trigeminal Nerve Function: Sensory, motoric (muscles of mastication) and reflexes Examination: ● Sensory function - use cotton wool and gently touch along regions ● Motoric function (V3) - palpate temporalis, ask patient to clench teeth (masseter) and ask patient to open their mouth whilst you apply resistance underneath the jaw (lateral pterygoid muscles). ● Jaw jerk reflex - patient opens their mouth, place your finger under their chin and tap on the finger with a tendon hammer to elicit the closure of the mouth. ● Corneal reflex - use cotton wool and gently touch the cornea of one eye, the patient should involuntarily blink bilaterally. Pathology: Neuralgia and palsyhttps://i.pinimg.com/originals/1b/95/47/1b95472f2e19ba14aecea763cbd33b1e.jpghttps://www.registerednursern.com/wp-content/uploads/2018/11/test-cranial-nerve-V-5-trigeminal-04.pnghttps://medsim.in/help/MedSimSoftwareDocumentation.docx_files/image093.jpgCN VII - Facial Nerve Function: sensory, motoric (facial muscles) and autonomic (PNS supply to Lacrimal). Examination: ● Sensory function - ask if any change in sense of taste ● Motor function - ask if any changes to hearing? Inspect face for asymmetry particularly at the forehead, nasolabial folds and angle of the mouth. Pathology: Facial nerve palsy (unilateral), can be LMN (weakness of every ipsilateral facial muscle on affected side) or UMN (unilateral facial muscle weakness, upper muscles spared).https://epomedicine.com/wp-content/uploads/2014/05/facial-nerve-examination.pngCN VIII - Vestibulocochlear Nerve Function: sensory (hearing and balance). Examination: Hearing ● Simple: whispering into one ear from ~60cm and asking the patient to repeat. Repeat on other ear. ● Rinne’s test: tap a 512Hz tuning fork and hold adjacent to ear and then apply the base of the fork to the mastoid process. Normally= air > bone. ● Weber’s test: tap a 512Hz tuning fork and hold the base against the forehead midline, ask the patient if it sounds louder on any side. Pathology: neural and conductive deafness.https://pbs.twimg.com/media/DEU27MRUQAAXPIC.jpgCN VIII - Vestibulocochlear Nerve Examination: Vestibular function ● Turning test: ask the patient to stand opposite you, with their arms outstretched and ask them to march on the spot, then close their eyes ● Hallpike’s manoeuvre: to test benign positional vertigo, sit the patient facing away from the edge of the bed so that when they lie back their head will not be supported, turn their head to one side and ask them to look in that direction, lie them back quickly and support their head whilst doing so, so that it lies about 30° below the horizontal. Watch for nystagmus.https://multimedia.elsevier.es/PublicationsMultimediaV1/item/multimedia/S1808869415301063:gr1.jpeg?xkr=ue/ImdikoIMrsJoerZ+w9xMbaXYzIj2UVZ9WuQ9rDVcCk/jSInH8zfFEkCTBR2+UewNUN hDYczZ4+mvtXdqpipP35vmNDcRNr5S8Shz/kQlm31EsN6kvfZ6BK093b4tsGbGXRBuNKENFGrDruCiK3Fno8YP0HXCa1Qr/Z6GKOY+QgCgWHITn0g3+kSLArLwKL6QzLhJ4nyOZ9rgU+I5+me0Al7 NiEM0AKmFYbNGiN8zvq5DGUqJSVatssGWX3Q2Wr8Y3JPGIw5xCkvhq4OGGTW1KQaHcrHxOzXzj+WCrgxKk6KhE3nhE8eA2bfHMZ2HYCN VIII - Vestibulocochlear Nerve Hallpike’s manoeuvre results: ● No nystagmus - normal. ● Nystagmus , with ~ 10s delay and fatigable = BPV. ● Nystagmus, no delay and no fatiguing = central vestibular syndrome.CN IX - Glossopharyngeal Nerve Function: motor (stylopharyngeus), sensory (taste from posterior ⅓ of tongue) and gag reflex (afferent limb). Examination: ● Ask the patient to open their mouth and inspect the uvula and soft palate for any deviation. Ask the patient to say “ahh” and cough. ● Assess and observe the patient swallow water. ● Stimulate the posterior part of the tongue by using a tongue depressor, eliciting gagging. Pathology: nerve lesions.https://europepmc.org/articles/PMC4239699/bin/nihms642510f2.jpgCN X - Vagus Nerve Function: motor (muscles of mouth) and gag reflex (efferent). Examination: ● Ask the patient to open their mouth and inspect the uvula and soft palate for any deviation. Ask the patient to say “ahh” and cough. ● Stimulate the posterior part of the tongue by using a tongue depressor, eliciting gagging. Pathology: nerve lesionshttps://samarpanphysioclinic.com/wp-content/uploads/2019/02/TEST-SENSATION.jpgCN XI - Accessory Nerve Function: motor function - sternocleidomastoid and trapezius. Examination: ● Inspect the muscles for any wasting and ask the patient to raise their shoulders whilst you push them downwards. ● Ask the patient to turn their head left, once again against resistance and repeat on the other side. Pathology: palsy.http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/phydx/s4m.jpgCN XII - Hypoglossal Nerve Function: motor signals to extrinsic muscles of the tongue. Examination: ● Ask patient to open their mouth and inspect the tongue for wasting or fasciculations at rest and any deviation. ● Place finger on patient’s cheek and ask the patient to push their tongue against it. Pathology: palsy causing deviation to side of lesion and atrophy.https://uploads-ssl.webflow.com/6011a994ad210082aa98b668/606d945c9f916d0822bf5c7d_hypoglossal- nerve-examination.jpeghttps://passmyclinicalexamination.com/wp-content/uploads/2016/12/Screen-Shot-2016-12-06-at-19.16.39.png Glasgow Coma Scale When? Brain trauma What? https://www.bmj.com/content/bmj/365/bmj.l1296/F1.medium.jpghttps://www.bmj.com/content/bmj/365/bmj.l1296/F2.large.jpgMotor exam Assessing: ● Muscle bulk, should remain symmetrical throughout limbs. ● Muscle tone evaluation, resistance of muscle to passive stretch, increased or decreased. ● Observing for spontaneous movements, are there any fasciculations, tremor, chorea and athetosis. ● Muscle power test. Pronator drift 16/nejmicm1213343/20190517/images/img_medium/nejmicm1213343_f1.jpegntent/nejm/2013/nejm_2013.369.issue- Power test https://geekymedics.com/wp-content/uploads/2019/05/MRC-Muscle-Power-Scale.jpg Sensory exam https://geekymedics.com/wp-content/uploads/2018/05/Screen-Shot-2018-05-14-at-09.59.16-scaled.jpghttps://geekymedics.com/wp-content/uploads/2018/05/dermatomes_torso.jpghttps://geekymedics.com/wp-content/uploads/2018/05/lower_limb_dermatomes_with_sacral.jpg Reflexes https://i.pinimg.com/originals/a9/35/4e/a9354e062575897c3d08a2b76382f311.pnghttps://www.tekportal.net/wp-content/uploads/2018/11/abdominal-reflexes.jpghttps://post.medicalnewstoday.com/wp-content/uploads/sites/3/2020/03/131317-babinski-reflex-1296x728- body.jpg