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We're gonna be talking about neurology today, So we're gonna go through the neurological exam. I'm gonna give you a bit of background about the syriza's. This is the first lecture, and I'm going to introduce myself a little bit. And also, Steven is with me today. So this is the first in 11 weeks, Siris. We're gonna be talking about how to kind of master the physical examination through a variety of specialties, of course, medicine for the next 11 weeks. So wear planned. Teo, have a lecture every week, approximately until the last week off July. So stick around. There's a big incentive. It is to stick around to attend on. We're gonna talk about it the next line. So, um, I'm Guillain. I'm gonna be hosting this electron. Also giving a bit of content to this, Like trying to be talking about some of the cranial nerves later on related to ophthalmology, and Stephen is gonna be doing the rest. So with me today is Stephen Julia, just come in the frame. So, Doctor Steven Gopal here is recently graduated from Moderate University, and he's gonna be doing majority of the talking here today. Um, and he's also the coordinator for this series on Did it just in case you guys didn't know? We're both. We're both active members off. Um s on. Yeah, if you guys haven't heard of, um, s, then please check. Check you a mess out on Instagram, Facebook and all the social platforms I came. So before we just before we jump into the talk, I wanted to just give you a quick insurance Our series give away. So just very briefly how to how to be eligible for this for this. Give away. First of all, just do exactly what you're doing. Attend our live lectures a T end off the meeting. I will put a Q are going up, and we're gonna paste the link for the certificates on this is basically a feedback for which, upon completion you'll be you'll be emailed a nice certificate from one of our sponsors. Metal, um on that kind of goes into a day to log on. And at the end of the series at the end of July, we'll have a list of everyone who's attended on. We'll do like a random, random drawer. So if you've attended more than 80% of the lectures. You'll enterprise one drawer and you can see the price. One drawer is really fantastic. We've got a clinical examination book, clinical examination, practical skills, Oxford Handbook. We've got a six month question. It free membership and also very general. It's provided by us implants. Is this fantastic three D printed skull price twos for more than 60% of tendons on day 60 pills for 60% attendance. You can see we've got the my suture kits. This is a 11 kit for practicing your suture in skills on also a 12 month subscription freeze Prescription to port cases so you can see both cases here. So, for for all information related to our sponsors, please check out our social media platforms when we're gonna be talking more about them so you can get to know who they are. Okay, So without further ado, let's let's start this lecture on. But just a reminder again. We're gonna post the feedback feeling at the end of the call today to please stick around to the end. So I'm just going to switch now, and this Steven is gonna take over, okay? I'm one I drafting you again. So as um, as Dylan has a bully, describe the Siris on. He's showing you all of the fantastic price that you you could win. Um, for your attendance. Um, And without further ado, I will start the lecture. So today's lecture based on the neurology town? So during this neurology exam, I think it's been important of a basic on me. That's because we know the brain is a very complex organ. Um, and there's a lot of fundamental basics that we need Teo understand? Before we actually perform a comprehensive examination. So we talked about basic on at me, very basic. Nothing too much, which is kind of going to go over our heads. Um two. Do something. That's me. And then we'll talk about the general inspection. So the general inspection is much like any other specialties Examination. Just be talking about what we can see, what we can observe, and then we'll then go into the cranial nerves. Eso is Dylan mentioned. I will be covering most of the cranial nerves on. He will be talking about the the nerves which are more relevant. Teo Ophthalmology. So yeah, and then we will carry on Teo discuss mental status awareness gasket going to scale and the indications And what? What? The scale is itself in the century exam. Then the motor exam and then Teo finish himself. We'll be talking about reflexes. Um, I would be mentioning pediatric reflexes. I will save that for, um, following lectures now, which will be conducted by pediatricians. So, um, yeah, I would just discuss the simple tendon reflexes on that. You need to know to get by on the wood and then final comments or questions where we will also obviously post the feedback forms for you guys to fill out and get your certificates. And more importantly, um, be able Thio and I draw it the end of the series. So, as I mentioned, the brain is a very, very complex organ. I think this image, uh, really pays homage to the complexity off this organ just to give you a little bit of background about the brain. Eso the brain is on integral part of the central nervous system. Um, it contains three main parts. The cerebrum cerebellum in the brain stem. The cerebrum is the largest part of the brain on diet is responsible for higher body functions. For example, vision at hearing cognition, emotions learning and also find control of movement on the cerebellum sits right below the cerebral. And this regulates motor function Such a Z balance, coordination and also speech, um, and then the connecting part of the brain or the part that connects the brain to the spinal cord eyes. The brain stem brain stem is very important because it controls most of the basic body functions that is breathing. And the heart rate, Um, it's you can see here or you will see in the next falling slides. Um, that you can see that this load of, um, sockeye and grooves in things like that which, um, obviously divide lobes, which will be the next slide Onda. Basically, the lobes of the brain are divided by by these bumps on the cruise. Um, these are known as dry right on. So okay, on the folding of the brain on the resulting jar and sulk, I actually increases its surface area on enables More cerebral cortex matter. Teo actually fit inside the circle and for even local complex functions. So this is the, uh, this is the breakdown off the lobes. So uh, if you can see my my, my mouse. See? So this is the frontal lobe on the phone. The frontal lobe is separated from the parietal lobe, which is posterior to it by space called the Central So close, which is right here on from the temporal lobe by the the lateral soccer's here on what is the frontal? They do say the frontal lobe is generally where high executive functions such as emotional regulation, reasoning and also problem solving okay, on a little bit of a clinical been yet fun frontotemporal dementia, Um, is also where, uh is is where, um, that the frontal lobe is also where they're concerned of dementia on dot So personality changes, which is kind of this disease Pridol it is. Most men will see yeah, the price of babies off See posterior to the frontal lobe Onda. It's separated by the centers offices, as I mentioned on it, is responsible for integrating sensory information such as including touch, temperature, pressure and pain, and then the temporal lobe, which is this green highlighted located. Um, it's separated from the, uh, front of I, um by the lateral so close with a little fissure and it contains regions, um, which is dedicated to processing once again, sensory information, Uh, such a hearing, recognizing language on also forming memories. And they're the temporal ladies will say, um, responsible on it also contains the primary auditory cortex, which was which receives auditory information from the ears and secondary areas. So, basically, what it does is it helps us understand what we're hearing, um, and also certain areas of the temporal lobe Um ah. Also involved in complex visual information comprehension such a faces and also the scenes. So so, yeah, and then on the medial aspect of the temporal lobe, you can't see it in this image. And previously, if you could, um, media to is the campus, uh, which is a region of the brain important for memory learning. It also mentions. And then the last lab mass, but not least, is the occipital lobe, which is this pink colored load right back on. This is the major processing center in the brain. Make major visual processes, and from the brain on this is where the primary visual cortex is. Just be one on it receives visual information from the eyes, um, on this information is then related Teo. Several second really visual processing areas, which can then interpret the depth of the distance and also the location identity of the objects that we're seeing. This's just the kind of uh huh basic and after me off off the loads and the telencephalon. Really? What's What's more important is what what's just a simple thing is, um, these areas So this, uh, these areas are known is brought him in areas. Um, and the brain was basically, um, numbered and, um, broken. Broken down into 52 areas on these areas are actually defined by the site architectures by side by side of architectural. We mean the histological structure in the cellular organization Ondas. You can see on this image that many different areas in many different on lobes. And what's important to remember is that the same broad man area numbers in humans and prime it often do not translate to other species. Um, and on top of that on these, brought him in areas have bean widely be defined, um, discussed, debated, um, on the actual cytoarchitecture to the histology on the cortical functions and also the plasticity of the brain. But the most important Rodman areas that you should know is a student are areas 123, which primary cement? Essentially, cortex. You can't see it very clearly in this image. I do apologize, but this is usually postcentral gyrus. So, um, posterior to the central. So kiss on area for which is the primary motive cortexes precentral. Um, precentral jars areas five and six are related to some matter century association cortex and also promoter. And also supplementary motor cortex is Well, um, and then other areas of note are 17, which is the primary visual cortex. Be posterior in your symptoms on 22 which is the primary auditory cortex, which we mentioned is in the temple. Um, so so, yeah, and then we'll obviously have other different areas involved in speech from retention, which will be more in the frontal lobe in any lesions in these areas can cause, um, significant improvement off normal functions. Such a speech motive, movement, sensation. Um, except for is so so yeah, this is the problem in Aires. And this is a very nice and simple image describing where the cranial nerves originating from, um and also just where you can quite clearly. See the distance that some of these things nerves I'm actually spend too. Um, So there's 12 cranial nerves in total on the cranial, nerves are numbered by the location on their brain stem. So usually we, um, that the way that we branch, these screening merged. It's usually from superior to inferior and then medial to lateral on. Then in order of the exit as well, from the cranium through the numerous amount off. Or if this is, um, and canals in the base of the skull. So three or factory nerve, which is the first cranial nerve and the optic nerve, second grade and of originate from the cerebrum. Um, is you got? I don't know if you can see it yet. You can see here that this is where the olfactory or factory is. This nerve here, and the optic nerve is originating from the Subaru. Um, whereas cream nerves three all the way to 12, uh, arising from the brain. Stand here. Um, said that this is the This is this's very easy. Teo. Identify which which pain? Enough. This is This is up to 27. Um, and then the others. You can you can work out for yourselves. Um, but But yet I said, as I mentioned, three all the way to 12 arise from the brain stem on. They can arise from specific parts off the brain stem. So from the midbrain pons on the medulla or from junction between these two cards from the mid brain on the truck and nerves comes from the posterior side of the mid brain. Um, and it has the longest intracranial length of all the renal know. So by that, we mean it's spending. It is the longest now, uh, which is navigating around the creamy before it, uh, intended It's insurgent little. Um, it's zonks. Well, site at the midbrain. Want injunction. We have the ocular motor nerve. Um, for the bones. As I mentioned, you have the trigeminal nerve. Um, and then the pontine medulla junction. You have the use it in the facial nerves. Um, and, uh, from the middle, a blonde gotta We then have, um, the glass of orange alert. Biggest accessory. Nerve on anterior to three olives. Um, the all it is Ah, anatomical landmark for I don't find the screening. They said all of the nerves coming from the medulla oblongata, usually prostate to the olive, whereas Theo only nerve, which is anterior to the only thing is the hypoglossal no criminal of 12. Well, that's, uh, a little bit about the origin of the labs to the next next life here. Um, I'm sure many of you have seen the's new Monix on. I'm sure many of you have also used the pneumonic Um, as you can see, this so many off them. Onda really depends on what works for you. But I think what's important, Teo always remember is that each cranial nerve has a function. So it could be one function, or it could be two functions or sometimes even even three. It could either be century, Could be motor could be both in something to also be autonomic A well, you know, discuss which pain loves have those functions. But what you need to know is three olfactory nerve is a century. Nerve optic nerve is also a century. Um and I'm sure you can go work out what the new Monix mean in reference to the cranial nerves. So but this is, um, about the function of the nerves. Right? This slide I don't think any of us particularly enjoy learning the slide. Um, during that maybe maybe for those of you were really enjoyed. Maybe Dylan, uh, enjoyed learning your enough to be thoroughly enjoyed learning a slide. Um, but for many, it's, uh, it's a headache. Um, and I'm looking to get into too much matter me today. Try and keep it simple. It's possible. But on the left side, uh, screen, you can see Theissen interact, and then on the right side, you can see the descending track. So in general Theus ending tract is usually central. It's really essential information, whereas thie descending is reeling motor information. So the spinal cord has numerous groups off know fighters I going towards on Does that come from the brain on? And we can break these down into ascending on decent intractable, called a Z. I mentioned these tracks are responsible for carrying a century and motor stimulate you to and from the periphery, respectively. So on the right side is I mentioned you have the motor track, so I'm going to get to each correct. But what's important to mention is that you still have a multiple tracks on the descending on the descending functions. Some of these are the course of a spinal tract particular spinal tract, blueberry spinal tract on their their before multiple functions. Corticospinal tract is responsible for voluntary, discreet and skilled on retroactivity is where is ridiculous. Spinal is responsible for excite your inhibitory regulation of voluntary leave mints, um, reflexes and reverse spinal prevents Flexer and inhibits extensive muscle act between, um, what's another key point to mention here is that it might be a very common sense observation from a low of you watching. But the left side is not just descending, and the right side is not just descending. Both of these cramps are mixed on this graphic is just a simplify what is on the ascending deciding what's on the descending side. Just in case any of you were wondering why Why? There's a have been bridge between them. That was the descending side. Um, and in terms of the ascending, uh, once again, you can see this is through a full tracks, which really important, too. Um, spinal thalamic tract, Especially eventually mental, um, spinal stomach that I can find it here. This is a ventral. I know. Spinous tendon contract here, Um, and this is responsible for pressure and crude type sensations. The dorsal column, which is all the way back here, is the area of prep reception, vibration on. Also, two point discrimination and the spine. It's good Cerebella tracks just lateral here, um, for conducting unconscious timidly for prep reception in joints and muscles, you may will save you wondering why of know mentioned gray matter and white matter, so I'm going to get it mentioned. Those so cross sectional analysis off the spinal cord reveals that is made up off a central areas of cell bodies. Um, which is butterfly shaped is you could quite clearly see in this image, and this is known it's green Matter on the peripheral area, which is used to have myelinating accents, is know his white matter in its myelinating because if there's mining in the matter, usually the nerve impulses travel much faster. Uh, as I mentioned, the gray matter is a butterfly shaped collection off cell bodies. Um, it can be divided once again. Teo the dorsal intermediate and ventral great condoms or water and wounds, um, and the white matter, much like the gray matter, Uh, can also be subdivided, but into into different terms of it can be anterior could be posterior and lateral segments, usually called finicky. Like, um, So this is these are the tracks on degree natural climatic that you need to remember because, for example, in multiple strokes, there may be a a single track which is affected, which is compromising. Ah, function off the brain on by by recollecting our anatomy knowledge. You know, we didn't sometimes pinpoint exactly what tractor, what the pathology could be. So, uh, now that we've discussed the anatomy, I I think we can We can get onto the the actual clinical part of this lecture. So, um, for any examination, you're going to need Teo gather all of the equipment. Um, this exam is no different. So the equipment needed, um, for the neurological exam. You can either pen talk, um, pen, torch, especially for ophthalmology. Now, which my cardio Dylan move. I don't mean to toe, um, still in charge. Now, once again for the optimal for the optimum, um, a logical exam if she horribly is, uh, which, which is what this is if you if you can remember from physiology and maybe in the comments you can you can let us know what what numbers you can see to make sure that you're you don't take none of it's working fine. Uh, pharmacy, obviously. And then cotton wool, cotton, but a newer tip Or, uh so our key tip having, wanting, but it tuning fork. I did the 512 hunts because that's a nice, um, values off weight lens of sound energy for or enough to pick up. And, ah, a glass of water, which I'm going to get into later on. So, as I mentioned at the start of electric with every single, um, example, have Teo observed, the patient have to inspect them. So in terms of a neurological exam, the first thing that you will probably pick up on when you see the patient where is your first? You think that you'll pick up on the speech? Um, and then we'll say whether whether they have any movement disorders or gait, for example, so speech I'm gonna get into in the next slide. New. Do you observe the mood whether they are erratic, um, erratic and aggressive, or whether there had been no low mood slightly depressed. Um, so, yeah, it's very important to you to observe that facial asymmetry on any abnormalities. So, for example, is there is a group. Um, does it look like there's some paralysis? Is Well, um, is there some Potosi's a swell, for example, and then inspect on the peoples been true turning from doing well, going to inspecting the limbs. So we're looking for for gait particularly. But we're also trying to observe if there's any weakness or police. Is that this this and spastic movement by spastic movement way mean, rigid, um, rigid movement, which is very, very difficult to kind of meet with the matter. And also, if there's any fasciculation, we'll get into that later on. Um, and then last but not least, Teo observe if they're if they have any AIDS on off, they usually eight. So it's very important to look for objects or coming on and around the patient. That may provide us useful insights into the medical history so that the current clinical status stable like I like I mentioned, it could be walking AIDS. Uh, could be here engaged. It could be visually, um, and then another thing we need to look into on going to ask you about is whether they're having a prescription. So this could be prescribing charge for personal prescriptions, which can provide useful information about the patient's recent medications in there and the current health conditions. Well, so right And this is the speech is excellent, so we can assess this in the most simple, simple ways by simply oscal and whether they can you can read or a bit a simple written commander and write a short sentence, um, to confirm that they comprehended it. Um, if that's problematic, uh, we can ask them progressively harder question. So these hard questions could be a simple yes know. They could be complicated sentences. And finally, we could ask them to repeat complex phrases or tongue twisters. Um, and at this point, it's very important. We confirmed that the patient is not deaf. We'll have the hearing aid and all that. The hearing aid isn't quite in tunes well and touch of pathologies that we can identify by just speaking to the patient on by observing how they comprehend the information can be can get with that the three main pathologies that we can we conclude with speech. The first one is dishcloth for you. So Dysarthria is a problem with articulation, but within type language so they can. Right, Uh, this can be caused by a cerebral cerebral. A decision could be a lower motor, neuron college E or even an extra pyramidal. Uh, I thought Oh, geez. Well, which could cause slurred speech, uh, could be slow. That could also be low volume as well. The next pathology could be dyspneic so dysfunctional. Volume out. Um, this kid, I mean, most of the time, this is usually caused by a syringe or diseases. Um, and sometimes it can also be functional. Psychological on very rarely can be caused by my steamier gravis. Um, which is a newer, muscular disorder. Perhaps in the comments, maybe you could tell us what you have is paying attention. What What myasthenia gravis is and what the pathology is. I didn't kill him, you know, Um and yes. So the last project is dysplasia. So dysplasia is usually the defective speech, reading and writing. There's multiple types of dysphasia taken. It could be expressive in the form of Broca's. So, by expressive, you mean says that they can They they received the information. We can understand the information they cannot. Is there output? Um, it could be the opposite, which is Vaniqa is which is receptive. They can they have good output, but they cannot, um, comprehend the information and break it down to, um uh did to understand it. Um, hum. We can also have conducted, um so conductive is usually when the patient can comprehend and respond, but they are unable to actually repeat the sentence can. Also, the nominal nominal is when everything is intact. Except the patient has a problem on naming objects. For example. They cannot recollect now that this is a glass that is water. Everything else is is using intact and last but not least global. The global is when, um the broker and the verdict is areas are are affected on D patient cannot speak or actually understand speech at all. On as you can imagine, a lot of these pathologies air very frustrating for the patient on their family members as well, to observe and to kind of live by. So it's very important that you remain empathetic and compassionate and try and understand the frustrations on, but it's very important to take care about asking about these things as well. From Yes, this is speak. And the other important, other important pathology will go. Observation of yours will notice is the gate. The gate can be observed informally as the patient walks into the clinic or when we ask him to stand. And then at that point when they're standing, we can also conduct the wrong burgs test, uh, which I'm going to get into much later on in terms of century time. Ah, how can you observe on the gate or help me examine the gate? We just ask the patient to to stand up and walk a few meters turning and walk back. Okay, So just just to describe the wrong bags test, I'm going to go into later on. But it might be wise just to talk about it. No, so that the Romberg's test is a test of the body sense off positioning. Positioning is pro perception on this requires healthy functioning off the daughter columns, as I mentioned in the earliest lights. Usually we use it to investigate the cause of loss of motor coordination. So the pathology when we lose my motor coordination is no ataxia so that, um in terms of results of a positive Romberg tests usually suggest that the techs here this century nature, um and depending on the loss of the proprioception if the patient is a taxi on the run burgs test is not positive. It suggests that be a taxi service nature, Um, and as a result, it can be localized to cellular dysfunction. Instead, we can also. So once I think I think I explained the wrong box test, actually, no, um, in terms of the gate, we cannot see break the gate into the different types of gait. But I thought what's really useful is, too, um, it's the group where it's a symmetrical or if it's symmetrical, and what's more important in terms of symmetrical is if it's a broad based gait or if it's a narrow based gait, so going to talk about the asymmetric ones first. So the first one we're gonna talk about is any plegic um on. It's asymmetric. As I mentioned, one side is weaker, usually due to a stroke. Um, the second is a treadmill in Berg on it's usually a pathology off the duties medias and the minimus muscles. It's been disputed. If there's even more pathology involved on, um, alongside the muscle theology isthmus, a little allergy that they can also be a basket disturbances as well, which once again cause this'll gait. Okay, And then the last one is through the federal. So this is usually after a lesion or traumatic injury, for example, to the the sciatic of the common peroneal nerve or sometimes even spinal nerve injuries as well at the level of L4 and L5 on this Ms causes a high stepping gait on a failure to dorsiflex prefer on, but also increase election. That happen. Need and parkinsonism. This is very actually, which is why I haven't, um, group day as a symmetric or symmetrical. Um, but in general, usually it's a flexed posture. We've been smalling and shoving steps. This's can sometimes look very similar to what, Ling, uh, gait. But with wobbling gait, there's a completely different pathology, which I'm going to going to, uh, in a in a few minutes. Okay. The first symmetrical gait is thie service cerebella ataxia. So this is broad based to patient usually has a wide gap between the legs when they walk on. It usually has lumbering body movements on day of difficulty. Turning the next is sensory ataxia. And so, once again, you will have the high stepping white gait on. Because this century will have loss of proprioception a Xarelto, the's patients usually need more sensory input to be sure of the leg position. Um, no. And Taligent, uh, this is symmetric and narrow. Based on do this is usually due to pain from osteoarthritis. Um, fret fractures on also inflammatory diseases in the joint, um, was well, And then the final gait is what lung gait, um, which is usually due to weakness off the proximal lower leg muscles completely different to parkinsonism, would say mentioned. Actually, the last one is a scissoring gait. Scissoring day is usually do Teo, uh, lesion off the upper motor neuron usually, and it's symmetrical, narrow based. And if both Alexa spastic, the toes drag on the floor and the trunks waste scientist side. So these are the nine most important case. There's many, many more gates that you can read about your own time, but he's in nine. I think the most important to remember when you're observing a patient in the neurological setting. So these are the different types of gets times a visual. Um, eight. First one is also chemically. Jake is you can see, um, and in the cases, it's weakness on one leg and behind Parkinson's shuffling gait. Um, and then the rest checking very self explanatory. This is the wrong box test. And as promised, um, so the way that we examine the wrong blood test is usually the osteo a shin to stand with the heels together first, um, and then first usually ask them to have my eyes open. Um, And then, uh, after a few moments, we asked them to close their eyes. It's very important that we stand behind them, Uh, and maybe that you may need someone else to actually support from front and behind to make sure that the patient didn't fall. Um, and as I mentioned before, the Romberg's test is, there is a test of the body centered positioning, um, so prep reception on it. It's used to investigate the cause of loss of coordination, which is ataxia, and if the Romberg's test is positive, we can see what we can. We can confirm that the pathology is century nature. Um, so, yeah, it's a very fun practical before physiology. No. Yeah, right. So, uh, the first, um, is the olfactory nerve. So, as I assume Sure, many recollect from anatomy thing. The olfactory nerve has sensory function, and it's main function is smell. So we're examining, um, smell when we examine the olfactory now. So how did we do this? Very simply, We can include one no school, and then the other we can present a stimulus. Um, such as coffee or spices or other. A pungent uh huh. Stimuli which can help the patient identify what stimulus is. And I'll see if they can even smell it. Just that the main use office. Uh, once we've tested one side of the nostril, as with anything, you have to test the other side. Simply repeat, Allah. Geez, um uh, and those means that means when you simply can't sell little of hyper as being a little high pounds more when we have increased sensitivity to smell and decrease in admitting to slow ast, different causes for these pathologies can be caused by inflammation in the form of infections, trauma which usually to bleeding on the blood. Actually prevents the function. Smell, um, Parkinson's, which is? Or, in the case of Parkinson's loss of all factory nerve functioning. It's one of the earliest symptoms and the hot topic off off the last year and a half. Couple 19. Um, it's also because off olfactory nerve dysfunction Onda last but not least, tumor. So usually team is a man caused by meningioma, um, which usually the base of the skull, which then infiltrating to be legal factory boat, um, preventing functional again to his Ah, nice visual, uh, visual representation off. How to for Ms Mr, I think it's very simple. You can see on the left side of the image the nervous or the nostril is being included, and then still in this is being, um the stimulus is being, uh, brought brought quest in the nostril for the patient to to smell. So then you repeated on the youngest night with that, um, I will know. Hand over to you to Dylan. Teo, talk about, um the optic nerve on day will take you through. Not bad. Not only that, but what's the the other ophthalmological? Um, now, since yep. Thank you. Full for paying attention in this first part of the mention her tea daily. Continue minimal. Okay. Hi, guys. Um, Stevens not gone. He's gonna come back. I'm just gonna do a few nerves. Eso second grade on the 3rd, 4th and 6. So I've got a few slides looked to get through, um, but very, very important examinations we need to perform. So Okay, let's make a start. So keeping with the same sort of format we're gonna talk about, I'm gonna talk about just the basic sort of modality of the nerves, and I'll talk about the examinations with people form, you know, I'll tell you what we're looking out for during the examination, and then I'll discuss possible pathologies which could be related to those two. Those findings. So the optic nerve, as we know, is a transmit sensory visual information. So it's a purely sensory nerve. Um, for those of you who remember from your anatomy, the first on the second cranial nerves are no, actually recognize is true cranial nerves without just a fun fact. It's because I don't originate from the brainstem and so back to the back to the electric. So it transmits sensory visual information from the ganglionic cells. The absence of the game we like cells which are lying. The retinas underlying the retina is on transmits them all the way to the brain on. There's obviously a very long, complex part way involved, which again you remember from anatomy. So there is important in there is no motor component added to the optic nerve is purely sensory. The intraocular and the extra ocular muscles are all controlled by other nerves which are discussed. Okay, so you can really nice to see on this table the examinations which you need to know which you need to be able to perform for innovation, presents to you. So first of all is the first thing to do is inspect the pupils. The first thing we always do before we before we jump in and start touching and palpating and auscultated is we inspect. So inspector people's first. So the people, as you know, the whole in the center of the virus, which allows light to enter through the eye and eventually reach the retina. So we have to assess the pupil size shape on the symmetry. So we have to compare both. So when we compare the size of its normal pupil size will vary from individual to individual on. It also does depend on lighting conditions as well. Eso the pupil size will be smaller, will be constricted in bright light environment on, and we start a larger in a darker lit room. They usually small an infant as well, but we're not talking about pediatrics there, just just adult medicine. When we talk about the people shape itself, there are many. Pathology is associated with abnormal shapes of pupils, so the people's as we know should be around should be perfectly. To be perfectly circular on anything abnormal is considered. The pathology could be congenital or a community acquired pathology as well. So I give. You can see some examples. Here I put Cindy ta on. So Sinica our decisions. There are two main types of sneaky other anterior posterior synechia. Um, obviously, any trauma as well to the to the global, to the eye global distort the people, in addition to the other, interrupted A structures. So we may see what's called a peak to people in the context. Off trauma. When we talk about symmetry, any asymmetry again, it's like pathological. Uh, well, I'll talk about. I'll talk about different isn't in having Sinus can look a swell, but it's not always. It's not always pathology, but we have the note. Any asymmetry between the size of the pupils and this is this is called an issue. Korea on on the next show you an image on this looks on this, and it's a Korea. It may be related sort of non pathological reasons, or it may be related to an underlying pathology, so it's always important to assess it. Always turn know down if we see any variation in the pupil size. If the people is more pronounced in bright light environments, this would suggest that the that the larger people is the abnormal one if it's more pronounced in darker environments, to suggest that the people at the smaller people is the abnormal one on examples of asymmetry will also include a large people in ocular motor nerve palsy, a small, reactive people in order syndrome. So this is the main thala GBC. When you Inspector People's, the next thing we're gonna do is we want to estimate the visual acuity. So how how far can a patient see? Really? And that's the true test is is estimating visual acuity on. We do this very simply with the statins up to type all cillins chart. I have actually included an image of this. I think it's chilly, quite self explanatory. You should know what an s and that's not in this chart. Is everyone seen on? We go to the optometrist opticians. We always always have a look at one of these. So we begin by assessing the acuity with one of these charts. If the patient normally uses glasses to correct the vision, we have to make sure that they are one during the assessment in terms of water. Then tell the patient we tell the patient to stand 6 m away from the sevens chart, and this may vary from country to country, but in the UK, at least, which is where we're basing all of our guidelines off for this lecture, we ask him to stand 6 m away from the statins shot. Then we ask the patient to cover one eye or we cover the iron for them on. Then they read the lowest line that they are able to read from top to bottom, and they stopped when they, when they feel they can no longer see the letters anymore way, have to then record obviously the lowest line that patients able to read on. Then we can devise. Ah, fraction. It looks like a fraction, but it's it's a it's a measure off the visual acuity. So there are two numbers. For example, 6/6, which is equivalent to 2020 vision essentially 2020 because it's 20 ft approximately s. So we use that term. Sometimes we can have the patient also read through a pin hole as well. To see if this improves Division it division does improve when the patient is looking at the optic type. Throw up in all this suggests that there is ah ah refractive component to the patient's pour vision on. We did the entire entire examination again, but with the other eye. Oh, when when it comes to recording, um, people's, the people we reflexes have to be assessed. Um, Andi, uh, there are many, many pupillary defect. I will just brush over them because it's more with in the room is the pathology. But just in terms of what we're looking at, when we look at the people's. The patient obviously should be seated. We dimmed the lights in the assessment room to allow to assess the pupillary reflex because we're controlling how much light enters into the eye. Um, so we have a direct people really reflex on. We have a consensual, popularly reflex. The direct one is when we shine the light from our pentagons Steven describe should be part of our equipment when we shine the pen towards into the lateral so that I that we are testing a normal direct people. A response or reflex involves the constriction off that people that the light is being shown into. That's what we'd expect to see, in contrast that consensual people reflexes to once again shine the light into from the pen towards into the same people. But this time we're observing that people really reflects in the contralateral life. So a normal again, a normal consensual people really reflects, involves the confidential people constricting in response to light, entering into the eye being tested. This is again This is a normal physiological test that we perform. I know the test we can do. Another test we can do to assess the people's is something called the swinging light test. And this is just where we move the pen towards very, very rapidly between the two peoples. On this is what we're doing here is we're trying to check for a what's what a relative afferent pupillary defect on. Discussed this in in a few moments. Accommodation reflects, as you can see here of the accommodation test eyes when we ask the patient to focus on a distant object. So, for example, a clock on the wall or a light switch or some sort of object in the room at a distance, Every place thing examiner places the finger approximately 20 to 30 centimeters in front of the eyes or in front of the nose. Um, alternatively, we can also patient to use their own thumb. We asked a patient that to switch from looking at the distant objects to the nearby objects. So if it's a finger thumb and we observe the people's whilst they're doing this on, we should see constriction of the people's on convergence bilaterally as we shift from a combination from far too near, then we have the people like the people who really like a reflex in general. So this is a bit of pathology. This is sorry. Bit of physiology. So you have to understand the Afrin on the effort Limb off the pupillary response. So each Afrin, um, has to effortless. It's okay again. Each Afrin to them of the pupillary reflects has to effort lives. One is it's a natural and one is contralateral. And this explains why we talked about when we talked about those two different reflexes. The African functions has fallen. So we have the sensory input, which is the in our example, like to being shown into the eye with the pen on. This is this light information is always it's transmitted to the retina through the photoreceptors along the ganglion XL layer of the retina of the optic nerve into the hips, electoral pretectal nucleus. And this is in the mid brain for the MS and stuff. And then we have two different limbs. So the motive motor output is transmitted from this same area of the brain stem the pretectal nucleus on it, uh, transmits to a new biologic nearby located nucleus, which is called the ending, always feel nucleus heading westbound nuclear skips rise to the effort fibers which will travel through the third cranial nerve, the ocular motor nerve. And they will innovate the scenery sphincter muscle on, then therefore enable people reconstruction. So the normal pupillary people really like reflex. We will rely on healthy functioning afferent on also effort pathways off this reflex arc being intact. So therefore we can assess both parts of this new in your pathway. When we perform these various examinations, the direct people who reflects which we discussed before the direct one will be showing light into the iron. We check in the same eye. This assesses the it's a natural afferent him on the Exelon Toral efferent limb off the part. In contrast, the consensual people really reflects again. Shine the light into one eye and we're checking the opposite of the contralateral I. This reflects assesses the contralateral effort into them off the pathway on the swinging like test, which I discussed briefly is used Teo detect relative afferent limb defect. So what is a relative afferent pupillary defect So normally, when light is shining toe, either I effort pathways should should be functioning normally physiologically when the Africa limb off one of the optic nerves is damaged there are many, many ways it could be damaged. But if there is some sort of damage either partial complete, both peoples will constrict slightly less. They will remain slightly dilated when light is shining to the affected I compared to the healthier, um, so there are different types of defects. And again, this is beyond the scope of this. This talk. We're just talking about examinations, but it's always important to think about these. Pupillary defect is Effort and Afrin defect. So next on the list because you call a vision assessment. So Steven had a nice picture, and I've got a similar picture coming up. Which shows you what we used to detect or to to diagnose color blindness, so to assess the color vision so it could be assessed using so called issue horror plates, each of which contains a combined sort of collective of circles or dots with different colors. Within the circles, we see a number or a shape or pattern, which is clearly visible to those with normal color vision on def. Those for those of us who have impaired color, vision, color blindness, for example, difficulty and seeing specific colors. For example, red green color vision defect, which is a very common they will not be able to see the numbers. They will not be able to identify the number or the pattern of the of the shape, for example, so how to be used. So if the patient uses glasses normally for reading like, for example, myself, we obviously ensure these are warned during assessment. We ask them to cover one eye for sure that the plates we show the patient plates on the vest. They would just give us feedback in terms of what they can see and what they can't see on. The same thing is done for the opposing I, um, in terms of color, vision, color, vision deficiencies, some of the possible pathologies. You can see the optic neuritis a bit of in a deficiency of optic neuritis. Results in reduction of color vision typically lost off the ability to see the color red vitamin A deficiency on also chronic solvent exposure as well chronic Sullivan exposure. I can also cause this color visual deficiency, so visual and neglect had attended in attention. This is a very, very simple test. This's a condition in which, in individual will develop some sort of deficit, uh, in their awareness off one side of their visual field. So I'm going to talk about visual. Field it a bit more detail next, but for visual neglect, this typically occurs in the context of ah parietal lobe injury after a stroke. So the individual patient is unable to perceive or process a very stimulating on one side of their body because they can't they lost. I've lost one of their to visual fields. Um, the side off the visual field that is affected is contralateral to the location off the parietal. Easy. So the left visual field has affected. We need to think. Okay, right. Parietal lobe has allusion. So the visual field neglect is not caused by optic nerve pathology on their four. This is not really tested is part of the cranial nerve exam. But I'm just including your just for completion. So how to be assessed this position yourself opposite the patient, approximately a mitro ways, you're quite close to them. Ask the patient to remain focused on a fixed point on your face so you can say focus on my nose, focus on my ear, for example on but uh uh. What we do then is we raised both of our hands in front of the patient eso We put her hands in either field. So for the left visual field of the patient, we raise our right hand on for the right visual field of the patient sitting opposite us. We raise our left hand, hold the hands out, sort of naturally on we move fingers. Okay, We move one at a time, so I don't know if you can see my fingers, but for example, you can see one of my fingers moving on my right hand on diff patient identifies this, they tell you. Okay, I can see which fingers moving. I can see which field My visual, which might eventually fields, is registering movement. So you do this for each hand, which is your field, and then you do both on been you little both simultaneously. We're trying to correctly the patient has probably correctly identify that we're moving both hands. Um, Andi, if a visual neglect is present, the patient will only report one of the hands moving. Um on there will only report the hand which is moving in the unaffected visual field. eso. This is the Exelon actual, so it's a natural to the brain lesion, basically. So now on the visual field, so you can see here Assessment here is with namely with an Amazon chart. So for the visual field, this is a method which is relying on the patients comparing visual fields. Sorry, replied reliable, comparing the patient's visual field with your own visual field. So therefore, again, you need to. Position is offering correctly on do need to have the examining needs to have a normal visual field in normal blind spot as well. So we sit again directly opposite the patient, a distance of approximately 1 m. We asked the patient to cover one of their eyes with one hand or weaken cover, cover them, cover the visual, field ourselves with a device I'll show you in the next light, Um, on. Then we are so patient to focus again on part of one part of our face. So whether it's nose focus on my ear on, Bush did the same thing again. We should we should do the same thing as we're asking. The patient to do is over asking the patient to focus on our nose. We should be looking at banners. Um, so as a screen for central visual field loss or distortion, we have to ask the patient if any part of your face or you ask the patient Is any part of my face missing or distorted on? But this is very subjective. Another way we can assess is with, as you can see on a slide, use of an answer chart on Amsler grid. I've got an image of this in the next light. Um, so we move on, object a pin or a finger around the answer chart on the patient will register, but they will sit there, will tell you. Okay, well, there is some distortion in these lines on on this chart on that can confirm there is some sort of problems on pathology with the visual field in one of the quadrants. There are many different types of visual field defects. Um, we can divide the each left and right visual field, as you remember, from apology and off, um, ology into quadrants. If a quadrant is affected, we call this a quadrantanopia. If two quadrants are affected in the same hemisphere, this is called a hemianopsia So, for example, bitemporal hemianopsia. This's the loss of the temporal visual field in both eyes, so we know we have a nasal and temporal visual fields. So loss of the both temporal visual fields can result in what's called central tunnel. Vision is they can only see the central part of their visual field, and it's typically result as ah. This typically occur so as a result of an optic chiasm compression. So this could be from a pituitary adenoma or a craniopharyngioma as well. And that's just simply relates to the fibers in the optic chiasm, which are transmitting this temporal information. Um, other defects as well. Patients may recognize scatomas. This's an area of an abscess, a zone area of absence or a reduced visual field vision, which is affected. There's a wide range of etiologies as well. That could be a demyelinating disease is, for example, like multiple sclerosis or diabetic related maculopathy says Well, so there are many different possible etiologies behind, um, behind school time of development. Next is blind spot, so from physiology, maybe a room. But we have way have, uh, different ways of message of assessing the blind spot. The simplest way to sit directly opposite the patient again. Distance approximately a meter. We ask the patient again to cover 11 eye with one hand on. If the patient covers there right eye, you should cover your left eye the base. So mirror the patient. Ask the patient to focus on one part of your face again. So nose, for example on tell them not to move their head or they're eyes during the assessment. Then we can use a, um, some sort of marker pen happen or cotton, but, for example, which is staying very easy to see on. We start by identifying and assessing the blind spot so we start on. So this is basically assessing the patient's blood sport in comparison with your own. So the object, but you're gonna be moving needs to the position on an equal distance between you and the patient for this to work so roughly in the middle. So we asked a patient to say when the red part or the Connor part of this device for using disappears and whilst continuing to focus on the same part of your face. So we start from midline and we slowly move naturally. naturally laterally on there will come a point where the object will disappear. And this is where the blind spot is now located. And we can assess when the patient we ask the patient. Okay, What took? You have to keep moving the pin and you ask the patient. Okay, when does this object reappear on? This is the end of the bone spots. So we've we've narrowed down the margins of are blind spot. Now, um, this can obviously give us information about possible papilledema, which is the optic disc pathology or a chiasma lesion as well. Just temporal defect. So if the blind spot is a little larger than it should be larger than physiological, this is related to some sort of degeneration and damage to the optic disc itself. And it's a very subjective test, eh? So we need to perform something else if we suspect some sort of papilledema and that something else is usually fundoscopy. So this is obviously a bit more specialist. And again it's for examining the optic disc eso in the context off this, you know, cranial nerve examination for endoscopy is just used to assess the optic disc. It could be used for many other things as well on we're just trying to diagnose papilledema. Um so that is kind of a summary of optic nerve examinations on this. Like, you can see some of the things I mentioned. So and it's a Korea. When recessing, we're expecting the pupil. Size is shapes and symmetries quite nicely. Here, you can see the left patient left pupil is significantly smaller, significant constricted when patients rights people issue, or a place in the bottom left of this image for color, color, vision detection. You can see the numbers are quite clearly or perhaps also clearly on these plates here on the arms legs. Or it is for detecting a visual field defects. So you can see on the left this is what it should normally look like. And if you do have a visual field defect, it looks slightly distorted, and the patient will report seeing something, as you can see on on a slight Be So I've got one side here talking about what we're going to talk about. The 3rd, 4th and the sixth cranial nerves. So third or fourth instruct you on the 60 is the abdomen, so we know that the nerves or contain motor fibers on the third cranial nerve the curriculum. I have also contains um, parasympathetic fibers, which come from the nucleus, which you may remember I mentioned previously, the adding westbound nucleus on this, The's fibers, or this nucleus rather is responsible for pupillary constriction. So the islands of the first things we assess, then we look at the eye movements, and then finally, then light reflexes. And so I'm on the side again. It's a similar sort of structure to how I made things that last time. So, first of all, with the island's inspection, okay, we always inspect the eyelids for evidence of Tosis stopped. OSIs is the drooping of the eyelids or dripping of one of the islands, and this could be associated with many different pathologies. Ocular motor nerve, uh, pathology up a policy. Horner's syndrome, My myasthenia gravis, obviously other newer, muscular pathologies. But myasthenia gravis is one of the examples, Um, my movements. We have to assess for any abnormality, so we always position ourselves in front of the patient. We hold out finger or a pin approximately 30 centimeters from the patient's nose or from the patients I've on. We asked them to focus on it. Look at their eyes in the primary positions. That means just staring straight at you. On we assess for any deviations are abnormal movements. It's also a good opportunity to look for any nystagmus. Now, I think, Steven, we'll talk about this later. Slide oxidation to keep the head still. And you you asked the patient to follow your finger or whichever object it is. And as you move your thing that you have to kind of cover every single direction. So you move the finger to your right thumb to your left up, down on, do you could move it some. Some textbooks say we can use a hate shape pattern so you can use, like a letter Hate, for example, in front of you on What we're doing is we're observing for any kind of restriction of eye movement. On note, any nystagmus between may see this stagnants maybe evidence off vestibular nerve pathology or even a stroke. Okay, so, uh, when we're doing this, when we're checking for eye movements in the back of our minds, we have to think of the extra ocular muscles so very, very quick overview. We have superior rectus inferior rector's medial rectus lateral rectus to four rectus muscles initially have to oblique muscles so superior oblique muscle on an inferior oblique muscles. I'm not gonna go through all the functions, but just very briefly on the innovations, the ocular motor nerve innovates. You can just remember it. Um, it's just I remember talking about it innovates all of them with the exception off, Um, the superior oblique muscle on the media rectus muscle. Um, sorry, Sorry. The natural rectus muscle so natural rectus muscle for the trump clear on the abdomen is with the super oblique muscles. So policies or any damage to these things cranial nerves can result in paralysis off these respective extra ocular muscles. So we obviously we can identify organ about another policy which can affect majority of these muscles Mean it that mainly directors muscles are gonna motor. Nerve palsy can also cause ptosis because this is due to a loss of innovation to another muscle, which I didn't mention, but it's most of it's called the Levitra proper. Very superior. It's muscle. Um, as this elevates your upper eyelid a swell. It's causes misery RCIs because of loss of parasympathetic fibers. So if we remove parasympathetic innovation, we can cause memory aces. Which is the dietician off the pupil dropping a posey mentioned. Is it innovates the sorry I made a mistake. Trochlea nerve enervates the superior believe muscle on a Xarelto. The palsy may result in diplopia, so seeing double when looking down looking in theory, if this muscle is paralyzed on dosing, is nerve innovates a lateral rectus muscle or six in the policy. Sometimes it's called on gift. The lateral rectus muscle is paralyzed on this consult in what's called a converging squint. One other thing to mention is draw business so we can assess strabismus with many different techniques. Light reflex, cover test. Um, and it's dry. Business is generally defined as any kind of condition, which in which the eyes are not properly aligned when looking more focusing on an object. So one of the two eyes are the two. Blood is misaligned on. There again, many different names related. Teo the positioning of the eyes So ectropion ectropion hyperopia on. And I'm not gonna discuss each one in this in this lecture today, but the to examinations we conform to assess number one that the light reflex number to cover test It's the light reflex, also known as the corneal reflex is will be asked a patient to focus on on a target, which is approximately 50 centimeters away on when we shine the pen towards towards both eyes. What we're doing is we're inspecting the corneal reflex on each eye. So if their alignment of the eyes is normal, the light reflex will be positioned centrally and symmetrically in each pupil. So a corneal reflects again. This is a bit of recap for the, um, ology. We're checking the culture of the eye on, but we're looking at how the light is reflecting from the cornea. Cover test is slightly different. This's used to determine if there is a heterotopia tropia on gas, the patient again to sort of fixate on it on a target in the room. This could be a clot. Could be a light switch. Could be something else, including one of patients I see on. We ask all we can ask them to include an oil we concluded them ourselves on. We asked them Teo to focus on that distant object whilst we're assessing the confidential I If there is no shift in fixation as we cover one eye and cover the other, then this is normal alignment. If there is a shift, then we need to, uh, think about possible strabismus on. Obviously. Repeat, Repeat this for both eyes. So the next line you can see a couple of images. The things I talked about illness syndrome, you can see ptosis drooping of the left eye on the cover test, which I just mentioned is used. You can see in this case for pediatric patient to assess strabismus. So I'm now we're going to switch over back to Stephen. He's gonna talk about the remainder of the cranial nerves and then continue the lecture. Um, so I didn't I get one? Well, thank you. Didn't for explaining the, uh, the cranial nerves really to talk marginal. It's really nice on. I have already found that really informative s. So I'm not going to carry on from here on out. Todo us the rest of the cranial nerves and then we'll talk about the motor century Gaspin skill. Right. So you carried on. The first of that will discuss is no need to be the trigeminal no. Um, so the trigeminal nerve has both century functional, so it might function. Um, no mention this, um, in the slide. But it Vesely has three branches, um, and so has a one branch as a B two and the three the one is opthalmic. V two is maxillary and both be one and be to actually century functions. V three is the mandibular bunch, and the mandibular branch has been a century and motor function. Um, and as you can see, the trigeminal of its functions are sensorimotor IQ muscles of mastication and also the reflexes, which all discussed so in terms off examine, uh, the first thing we should do when we examined the trigeminal nerve should be about using the cotton ball or a cotton bud on gently touching along the region's off the different branches. They just mentioned, um, to assess century function to the motor function. Um, we should inspect. Firstly, you should always inspect. I haven't mentioned it here, but we should always inspect a temporal. It's which is located on in the temple reaching right here. And the massive muscle is well, which is located posterior to the jaw. Um, And what we're looking for here is if there are any signs of wasting. Um, And if if there's any signs of wasting, this is typically the, um, most noticeable in the temporal. It's muscle. Um, where we can see a hollowing effect in the temporal region. Um, it might be Halloween growth on that. We might Onda in terms of the palpations know that we've you've inspected, we should always pop it the than massive muscle should get a the posterior draw, um, bilaterally with both of a hand, whilst asking the patient, Teo clench their teeth to allow you to assess and then compare the muscle bulk on on either side. Um, and then we can ask the patient to open them out. Must replace um, resistance under the rule, uh, once again, bilaterally to assess the electoral terrible in muscles, um, on any inability to Europe in the drawer against resistance or if there's a slight deviation to either side. Um, maybe very indicative. Off a lesion on bet may also ca in trigeminal nerve palsy. So that's the sensory and the metric function examined. Now we talked about the Georgia reflex in the following slides. I'll actually explain these things tests, but the Georgia reflexes is simply when it's a stretch reflex, actually, which involves on the slide, jerking off the jaw upwards in response to the downtown. Um, and what we see is when we asked the patient open their mouth. You place our finger just under virgin and using a tendon hammer, we just tap Jimmy Teo, elicit the closure of the month. Like I can't perform myself right now. I don't have a tender having with me, but, um, yeah, this is doing this point now. He he could do it. Um, And in terms of pathology for this, usually it's exaggerated. In in patients were on upper motor neuron lesion. Um, this is because they're both the Afrin and the different pathways of Georgia reflects are involved in the trigeminal nerve. Um, what's also quite important is that way. Explain what we're what we're going to perform to the patient. Otherwise, it may be incredible. Strange for the patient if we don't explain what we're what we're going to do. Um, so this is the Georgia, and then the the final reflects is that the corneal reflex? Eso once again how to examine the corner or reflex in simply, What we do is use a cotton ball and just a small amount of bottle when we gently touch the cornea off one eye on what that should illicit is involuntary blinking bilaterally. Evening video on the right eye on the left eye, I'm willing, Um, but it's always good to test it. A testicle your reflects on both eyes to make sure that there is no pathology on one's, even though bilaterally, they should blink involuntarily because of the pathways andan terms of pathology for for the trigeminal nerve, it can be a trigeminal neuralgia could be dry general policies or any type of lesion in the brain as well. On this column, I'm thinking she's This is the sensory distribution off the trigeminal nerve as I mentioned V one, and the two are sensory, whereas mandibular it this century, and it is also a motor. Um, and I think it's it's a very easy to memorize this this'll image visually in order to try and stooping president on patients when you're examined them. Um so, yeah, this is the century examination off it. Almost this nerve at the next image. 2. 50 Oh, could be excited that the second image is examining Lee the lateral pterygoid. So this is when we apply a little bit of resistance under the jaw is to make sure that the natural, terribly muscle, which is one of the muscles of mastication, is functioning. Okay, finally, we have the doorjamb reflex. Um, as as I always do one, um, very nicely. Sure. Do you have to perform it? But basically, we're putting a finger underneath the gender. Well attended home. You're hitting it. What's the mouth is open on d d d nerve should cause the mouth closed. Um, offer it. That that's a trigeminal nerve. Uh, now we're on to the facial nerve. So facial nerve you can see here as has door function century and Motrin. Also, autonomic is well, motor function is usually facial muscles on. It also has some autonomic function is well in terms of the parasympathetic nervous system supply to the lacrimal gland. Okay, examination. So we can ask the patient if they sensed any changing sense of taste. Uh, that's because the facial now it is actually providing innovation. Two parts of the tongue which involved in century taste, um, metric function. Um, we can ask if there are any changes to the hearing. Um, we can. Obviously, the reason why we ask that they change this to their hearing is because the facial nerve is actually innovating the stapedius muscle, Um, in the in a which was responsible for hearing, um And after that, we should inspect the face many asymmetry. Because, as I mentioned, we are obviously observing any facial muscle dysfunction group, uh, to use is no, no protested. And any proof that any muscle wasting, um and the region's that were kind of talking to the metric function is actually a forehead at the nasal labial folds and the the angle of the middle. So there's a lady falls. Okay, sign any angle here on both allergies, uh, for the facial nerve, Right? Peaches? Yep. So, in terms of pathology of the facial nerve, the the most common pathology that we all know his facial nerve palsy, Um, this is usually unilateral face. It can be low amount in your or a promoting urine. So lower motor neuron is usually weakness of every every dips, a little facial muscle on the affected side. So if the lesion is on the right side. Weakness off every it off every facial muscle on the right side. However, if it's up the motor neuron, you will still have unilateral facial muscle weakness. But the upper muscles will be spared on the reason why the upper muscles usually spared, is because of bilateral innovation to both sides of the face. Um, yeah, so also pathologies. What's the most common cause of low Merton? Your own weakness? Usually there's a bell's palsy, Um, and, uh, upper motor neuron reliance on usually stroke. It's the most common cause of patients. Um, posing here. You can nicely see uh, the type of, uh, kind of facial reactions that you kind of patient to perform say increasing or so surprised, Um, if they can keep that iced closed against resistance once we what we prevent them from open your eyes, teeth smile and puffing out cheeks is well, all right. Vestibular copy of these. Different said, I will be talking about the nystagmus, the stagnants dysfunction here. Um, so the vestibular copy nerve. It's It's a century. Same essentially function. No, Um, hearing in balance comprises of two parts, so there's a There's a completely aspect of the nerve. And then there's a stimulant part of that. So the copy branch usually originate in the the organ of the quarter, which is in the knee. Um, well, it's the testicular component of the nerve arises in the you tickle and the same cyclic announce on down as you didn't. Um, Joe, as you can see from where the origin is, it's very, very relevant function. Just balance. How do you examine it? So I'm gonna break it down into how we can examine the hearing first, and then how we can examine the buttons. So, in terms of hearing, we can ask them in the most simple of times. You can Can you, um, can you repeat back to me what I just told you? Usually we do that from about 60 centimeters away. Um, you have to come closer. That's what this li in a a sign of some type of, uh, dysfunction, but usually 60 centimeters whispering to the ask the patient to repeat, repeat on the other side, that's the most simplest way of assessing doing a more complex test that we could perform. That is, ah, Ryan's test. So Ryan's test is when we tap a tuning fork on. We called it adjacent to the year or just away from the when we apply the base of the floor. For example, if I If I use this if this is, uh, on a great description, Um, But if this is the base of the fork on and the fork, um, we call it adjacent to the year and then from the base you bring it right to a master week process. Usually, Uh, usually, um, the air conduction is is better and faster than than bone. Conduction can also be a weather's test. So once again, if they use mine when I found whole day, So once again we tap the tuning fork and we called the base against the forehead, too. You know that I had a tuning fork right when I thought I had, like this or can put it on the on the middle of the head. Um, and at that point, you can ask the patient if the sound is particularly lot louder on any side. Um, the's a test next side. I'm not gonna talk about Teo Teo to actually examine them, and and the results pathologies. I've seen your old and conductive definite soon as you can quite clearly see here, the weather is when you put the tuning fork on the midline, Uh, Ryan test is outside the ear and little mastoid uh, in general, um, if there's conductive loss in terms of the weather test, it's usually a normal result will be when there's equal distribution of the of the sound. Where's if there's conductive loss? You? She's going to the same ear with the sensorineural loss. It's usually the opposite rhyme test, as I mentioned, and conduction should be much faster than bone conduction. Uh, however, if bone conduction is greater than a conduction, uh, then this is quite indicative conducted loss. This is healing. Now we're gonna talk about balance and vestibular function. So there's two tests that we performed for testicular function. First one is the turning test. So we asked the patient to stand opposite us with their arms outstretched, and then we asked them to much on the spot, and then they close the eyes. Second is whole legs. What's important, Teo in here is that both of the tests we observing for any kind of dysfunction or any kind of, uh, issues with the balance, whether it was leaning towards ones, it'll, you know, finding them that they're finding that they cannot maintain a a center or a point of center of gravity. Um, they're they're kind of leaning towards the swaying away from tonight inside. Onda hold Heitzmann. Either, which is specific for nystagmus. A little benign positional. Vertigo is when the patient is set facing away from the edge of the bed. Um, so that when we bring the head down gently, the head is not supported by the bed. Um, but But before that, what we do is we We get the patient, Teo like, or to sit actually on on the edge of the bed and get them to face at roughly 30 degrees in either direction. And then we very quickly bring them down whilst there was the head is not being supported against the the bed and wasp whilst this is happening, we observed that, um, this is this is the image of the test in terms of its results. I'm gonna discuss them in the next slide. Um, it's very I think it's very simple to do, and I think you did. The nystagmus is is very evident very quickly. Uh, when you perform this test, Okay, right. So in terms of the results, if there's no nystagmus, there's normal function. If there's no stagnants with roughly about 10 seconds delay on day for teachable fatigueability. Really, uh, this could be usually is benign. Positional vertigo. You might be thinking, What do I mean by fatigue? A bowl. So by pretty evil, I mean that one's the test is being performed. We can't repeat it properly again for 10 to 15 minutes because of this vertigo. If there's an established with no dilly and there's no fatigue, this is usually central vestibular syndrome. Says that the eight cream on it now on to the glass of orange or no on the vagus nerve. Um, we were when? When it When it comes to testing both of these nerves, ast. This is so closely related, usually tested together on. But if I didn't know talk about a glass of orange ulnar, Nerve said has a dual function motor function and sensory function, and there's also a gag reflex, which is coming from the Afrin to them off the glass of Angel nerves. The metric function is innovating the study for injuries. So the standard fringes is usually elevated. Um, what the fax is elevated during swelling in speech was the century, um, central component of the nerve is innovating. The taste centers from the posterior third of the time. How do we examine it? Well, as I mentioned, we have to examine the Motrin function. How do we assess the Motrin function? We asked the patient to open their mouth and inspect the evil earn on the soft palate for any deviation. Also, any weakness or, um, loss of tone that we asked the patient to say, Uh and cough when the patient says are usually the evil is should stay in the midline on the palate and the evil A should elevates symmetrically. If there's any pathology, uh, very ironical that if there's any pathology that the evil it or the panic could actually do it themselves the next. The next test is way asked the patient Teo, to swallow the water on. And you know this is this is purely for the swelling assessment, uh, which is actually an alternative to the final test. I will talk to you about, which is the gag reflex. Um, once again, if there's any pathology than usually is caused by a car for, there's a change in the quality of the voice. Um, but wanting anything is very simple. One. Listen, it's very easy to, uh, Teo interpret what's going on. The intention of Final Thing is the the gag reflex. So we performed the gag reflex by using a tongue depressor, which is usually a cardboard, um, carpal kind of stick on you, obviously depressed in the posterior aspect off the tongue. Very uncomfortable test. Very annoying for the patient. And but for the clinician as well, and usually if you hold it long enough interest a listen again on the gag reflex involves breath the ninth of having the temp. Now, they just now, um, And as I mentioned before, it can be quite unpleasant on there for the swallow test is our alternative. Okay, if there's an absence of the gag reflex, this is usually highly, um, but the course of this is usually due to a nerve agent and a script. Okay, so this is the, uh, aspect of the exam. Where were testing me? The metric function moved off the ninth nerve vagus nerve. As I mentioned once again, both on response. Both the muscles, the mouth and the gag reflex. Same as the last slide reading. Mm. Once again. Now, lesions. This is the the gag reflex is eliciting it. So using the time depressive depressing the tongue. And you can see here that the nerve or the lesion here or Sorry, Not not. Not on either of those. D The usual left is deviated towards, um, the right side off the patient's mouth, which is used et tou the lesion on the right side. Just look wanted, um, 11th now. So this is the accessory nerve accessory Nerve only has one function, which is motor function. It's responsible for standing quite a masculine muscle, which is a very big muscle here and the trapezius. Okay, how do we examine it? So we are inspecting the muscles first or any wasting on down? We're asking the patient to to raise their shoulders whilst we are pushing them down to see if there's a solitary functioning really is good. Functional. Well, it's feeding this. Okay? You can also ask the patient to turn the head left to check the sternocleidal Master, wait here. We'll have to write. Have you want to put it in? Once again? We're testing that against resistance to make sure that been nervous. Functioning well, Repeat on the other side, as always, If there's a pathology is usually a nerve palsy on, they'll be dysfunctional off the muscle. Then here is Here is a visual representation of how we're performing the, um the in this in this male patient here, you can see that we're preventing or we're providing resistance against the the trapezius muscle. Uh, very clear into the last pregnancy. Nerve serious the hypoglossal have. It's a medic function nerve. It's usually signaling to the extreme taking muscles of the tongue. How do you examining? So we asked the patient type in the mountain. Me ask. We asked the patient, um, if there's any so we don't ask the patient. We ask patients look in the mouth and then inspect the tongue for any wasting or for circulation is at rest and then deviations the tongue as well. Um, in terms of fasciculation, as I mentioned earlier, if the situation is kind of like a spastic motion spasm in the tongue and usually it's it's usually present more arrest, know when, when when the time is actually moving. And then we asked the patient, You know, we placed the way we placed her finger on the patient's cheek and Yassin to push the tongue against. It just is a Is that perform for you now? Um, very simple to be very easy. 30. There's a If there's a policy could cause deviation to the side of the lesion again and that be wasting and then atrophy. This's this is the mail sticking their tongue out, I think 12 nerve in this image, we were testing if they can, if they have good power over their tongue as well by right, by placing your finger and getting to push against a And with this, this is the end of the cranial nerves. Um, so now I'm gonna be talking to you about mental how to assess er and neurological patient mental status and their awareness on by the glass go through the skin. There's also a lot of other tests which we can perform, but I really just want to kind of her in, In on the glass. The current scale. Mm so when to be performed. The glass you can scale so usually perform the glass of came in scale when, um, a patient is coming with the brain. So our brain injury what? This? The glass could come in the skin, so the glasses a coma scale is there is a clinical scale. Um, and it's very reliable because we can measure a patient's level of consciousness after a brain injury on. But we're assessing. Here is we're assessing a person's ability to perform. I'm movements, um, speak and move their body. And these three behaviors make up the three elements off the scale. Um, so very, very usually we can, you know, in terms of the ir, the eyes moving spontaneously. Um, do we have to say their name? For example, Steven, can you please move your eyes and then their eyes move to pain so you don't want to pinch them on? I'm leaving. It's great if there's no response than that. The computers stand of verbal response on it. Orientated. Did they know where they are? Um e I didn't know what year is example to the next, Um um in terms of great full sentences of the verbal response. You know, they're speaking. You're here. Um, Are they saying I like breakfast, dinner buying or something like that? Very, very random words, But they are made. They're speaking in sentences. Um, for the third, it's word. Say inappropriate words. I won't mention, uh, what this result made. A quick. Uh, So I said, Yeah, but inappropriate words. Second great to sound. So could be strange. Grunting, different weird type of noises which wouldn't be commonly seen in, um, in in a lot of patients. First grade is no response and then motor responsible Going to repeat this. But you can quite clearly see what we're trying to trying to assess it in terms of the grade. Um, anything about 13 is just a mild head injury. Usually, the patient is is more than aware of what's going on. They're very alert. Um, and there's no, uh, there's not too many concerns used to that point. GCS 9 to 12. It's slightly worrying on you, she indicated for moderate head injury, and anything less than eight is a severe head injury in usually. Um, and any statistic has to intubate the patient because there's a big risk of not being able to maintain the ventilation, uh, by by the patient themselves on anything less than three. Unfortunately means death onto the motor exam in so motor exam. Right when we went recessing yet? Uh, actually, t scribe the motor exam when we were when they're forming the motor exam on a patient presenting the weakness Usually it is important to remember the weakness could be a result of the vision at any point in the your access. So it could be in the hemisphere is, um it could be in the brain stem so it could be in the spinal cord as well, even personally. Um, another important distinction in the evaluation weakness is whether the weakness has a has a characteristic. Um, is there upper motor neuron pattern with their alarm motor neuron patent. Upper motor neuron will be spastic. That will be rigid. If there's a lower motor neuron patent will be, will be the paralysis and beef less ID. Um, how do we assess this? So we're setting four things here. Um, we're assessing the muscle bulk. So usually it should remain, um, symmetrical throughout the limbs on did usually, um, approximately and distantly as well, and the loss of muscle bulk is using NAS atrophy on the scene in a few pathological settings. The next thing we're assessing is muscle tone, so my muscle tone muscle tone is defined. It's the resistance of the muscle to you, passive stretching, and we assess it by moving a relaxed limb passively through an entire range of relations. We asked him to rest, and then we leave their limbs. Um, if it's increased or if it's decreased. It's obviously a pathology. As I mentioned, if it's increased spasticity class family, for example, um, usually this is upper motor neuron lesion. There's decreased. Flaccid itty is the limb. Usually this is a little motor neuron lesion could even be a spinal injury like spinal shot is well, and it can also be acutely in for stroke. A. Well, next thing we're observing that we're assessing here is spontaneous movements. Other any for circulations. Is the patient performing, or do they have a tremor? Are they showing correct? Movement is the Actos sis, So for situations are worm like contractions of the muscle spasms basically on there, usually seen with anterior world disorders like airless, most common be on. They can also be, for example, following exercise, and there really are no clinical consequences in that setting. Airless. It's more of a problem. Um, if they example, if they are correct, will be there showing at apoptosis used it. It's a brief, very short, irregular, asymmetric living movement off basal ganglia origin. Um, and I'm a quick on that dance like movements and they usually distal as well, whereas apoptosis is a more proximal but more slow movement. Nothing that I have not mentioned here is my clonus. So my clearness is a Southern contraction off of a muscle group of muscles and then even entirely, um, across the joint, we can usually see my clearness mean you're entering neurologic disorders and just a metabolic disorders as well. And then, lastly, tremor, it's it's a tremor. Is a rhythmic oscillatory movement off the trunk or the limb? Um, didn't a number of causes. This could be cerebellar lesions being motor system lesions, sensory systems, lesions in the basal ganglia. Um, but usually it's, um, hallmark of of Parkinson's disease. Um, we can also differenciate the tremor into resting tremor war. Is it an actual come in, uh, action criminal can usually be seen the lesions off the cerebellum for the century system. Um, and I cannot see the idea that thing where is a resting tremor is, as I mentioned, you see in Parkinson's and it's usually at rest is the next test. Yeah, The last thing is the muscle power test. So this is usually two things that we performed. Teo Assess, Muscle power. Uh, I'll talk to them in the next light now. So first thing we can assess in terms of muscle power is pretty to drift. So pronator drift is another very important functional muscle test for the upper extremities. Usually on this test is performed by having the patient hold both her hands outstretched with the palms up and the eyes closed. Um, the patient Stephen School. See? Yeah. Okay, so, uh, asked at the start way asked the patient. Have that palms facing upwards? You ask them to close your eyes, but there's any kind of blocking, or there's any you're turning or rotator movement. It's usually very. It's usually very subtle, Um, and it's usually strongly especially in pronation. Information is is closing off the the the hand where super Nation is, uh, everything and, um, pronation off, um is it's very subtle, but it's very indicative of upper motor neuron dysfunction. And it's our job to observe this and to see the type of pattern that that the patient is showing. It's a pronated river. Second one is the MRC muscle power scale. Um, this isn't usually easiest of things to remember, but I think it's worthwhile knowing is it is a student. So in this test of this scale, we're assessing every muscle in the body or, you know, any any muscle that we think we potentially affected. And we're assessing the flexion extension, abduction and reduction of this muscle so it could be, for example, up a little we could ask them to, uh, we we could provide resistance is be patient to abduct. Um, okay. The a section function in which which we're assessing, and this is a very formal, um, scale. It's grouped on zero defying. Um, and usually, um, we are basing it on the ability of the muscles to oppose gravity. Um, and as you can see, you know, heroes know contraction on. Then as you go along the scale, there's normal power. That's normal movement was normal function. Nothing. Um, factor here is that, um the scale was actually devised in the UK Azarias. All of the polio happened in the pearly epidemic. Uh, because obviously there was a lot of floppy paralysis. Associate it with you leaving on, say, their sensory exam. Um, this is something with unfortunately have to memorize, and then you have to kind of come up with ways of memorizing whether damage terms are, you know, which between is effective, which which, except for it's set for. But when we're evaluating a patient sensory disfunction, it's important to keep in mind that all of the levels of the nervous system which lesion can produce essentially dysfunction so it can be peripheral can be break your number six equal plexus Could be the nerve root. Could be the spinal cord brain stem to be anywhere. Really, it's very important to Teo. Remember the levels here that we're dealing with and the the century examination is largely a subjective examination that requires a very alert, cooperative patient. Firstly, because where when we need the patient to be able to provide reliable, subjective impressions, very standing it so it could be example, need passing my finger through for the lateral aspect of the And if they're the comatose, for example, if they're not alert and GCS is the biller, they're not gonna be providing reliable data to you will realize that information, um, engine century symptoms. So, for example, the patient actually not being able to receive, uh, they they cannot comprehend pain Will they can assess temperature usually proceeds century signs on the sensory examination may know always be revealing early on in the course of intravenous that produces central dysfunction. Another important thing is that when we're performing this, we need to look for any asymmetry. Is, um Andi. These asymmetries may may die that's more, more as well to to any potentially with ology way. You see, um, divide the examine Teo primary mentalities, courting or sensual modalities and then the wrong bag test, which I mentioned earlier. Now I'm going to too much off the primary and the court ago century. But I think it's just important that we we know the damage tones and the different peripheral level is a swell. Uh, it's very important. In room, you can see down terms of the torso, the next night, you're gonna see lower limb damage. Tums. Um, but probably the most important one here is going to be discussed in the next next line. When you talk about the reflex is Well, there's two. Really? This is the learning damage Tums. And then no to the final final section of this lecture. Um so reflexes. So I think even you can all read here. What would have a panel I'm talking about is gonna be discussing biceps reflex brachioradialis triceps on the patella tendon in the the Achilles as well. But evaluation of the reflex is is perhaps especially the tendon reflexes, if perhaps the most objective way to examine the nervous system. Because not only are they helpful in evaluating with the patients is a wig, but they will say invaluable in examining comatose patients as well, on a completely different to the cranial nerve reflexes which which I mentioned and Dylan also mentioned. But the reflexes are very important because they can be divided into nonpathologic on pathologic. A swell nonpathologic reflexes include that muscle strength in flexes example in deep tendon reflexes. You can see on the screen here and then the room, the following slide on the superficial The cutaneous reflexes discuss, um, and the pathological reflexes, for example, been ski sign? Um, well, it's the frontal release sign is Well, um, so you need a tendon home for this? Uh, usually, uh, the muscle stretch reflex is a monosynaptic spinal cord reflex on when we get the muscle tendon on this stretches the spindle and the Afrin information is being carried out. Um, by the by the f rinse country know fibers to the spinal cord, and eventually, you know, to the Ventolin and etcetera, etcetera, um, to it's very important to know which tendon is being tested for, for which level? Yeah, especially when we're talking about the deep tendon reflexes. Just so these are the five most important tendon reflexes deep tendon reflexes. Might my tad normal reflexes. This's this along with a few others are, you know, the superficial cutaneous reflexes. Usually they're polysynaptic um no, no, no susceptive reflexes that are elicited by stimulating the skin on. But obviously we would observe a contraction of the corresponding muscles and in the four superficial reflexes that we usually test. But the abdominal reflex, um, the anal wink reflex the cremasteric reflex and the bulb cavernous from flexing is you can imagine there's a lot of reflexes, which I can show you, and I cannot perform in front of a camera asleep. But these are very had. These are very important to keep in mind when we're when we're performing a cutaneous week. Um, and that's been released. Is the divinsky, um, reflex with the babinski sign so you can use a tuning fork? You can use anything really with it, with a blunt with a sharp point, and we work from the lateral aspect off the foot, and we just it's it's hard to describe it. Actually, I can breathe, but we're working from the lateral aspect way, bringing the stop object right above the base off the off the toes. And the Babinski sign is perhaps the most important reflex that you need to know in urology and probably most importantly, effects in neurology. Um, and a normal response usually consists of flexion off the great too, so the little rice will be flexed. Abnormal, positive responses usually dorsiflexion so the total will be back. I will be pointing backwards. They could also be fanning of the other types of standing is spreading of each two on the positive babinski sign or basically response is highly indicative off on upper motor neuron dosing. Okay, Um, so So, yeah, you know, once once you find out that there's an upper motor neuron lesion, then on you can start start Teo developing in devising and management on along with your colleagues, um, to treat it or Christine as it does he's gets better or worse. That Sinus is always present. You may disappear is well, um, And with that, um, with been skin reflex, um, I think we we can end this lecture. Say, thank you very much for all of you Through the have stayed this far. It's been a pleasure to to teach a wall. And I really hope that you found this very informative, Um, and and Sinus. Well, um, so he These are the next events way we have coming up eso on the 26th, we will be discussing the abdominal exam on the second of June. You have a general pediatrics exam, the 12th of June. We'll be talking about respiratory and way going to be confirming the times very, very soon. Let then 17th of June, there will be a cardiology or cardiovascular exam. And I just like to take, uh, this opportunity, Teo, to think our sponsors Um, yeah, it's implants. My seizure cares med on odd cases. And lastly, is a medal for the partnerships. And one for all of their support in providing the's lectures and also a lot of the feedback forms and stiff gets which will be handed out to you directly after you fill out the feedback fall on once you fill out the feedback for a week and then, um, our, um uh, rules, which I think is getting really, really fun. Um, there's a lot of next using and one for gifts. 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