Download Examination of the Cranial Nerves

Neurological examination
Neurology
RHS 332
Practical Lecture 1
Mrs: Muneera AL-murdi
Neurological examination
The neurological examination is primarily
carried out to localize the site of the pathology
in the neuraxis, innervations pattern of the
cranial and peripheral nerves, and the major
fiber tracts in the brain and spinal cord.
Neurological examination
The international classification of impairment, disability and
handicap.
Impairment
Disability
Handicap
Loss or abnormality of
body structure or
appearance, organ or
system function
resulting from any
cause.
Ex. Muscle weakness
of lower limbs.
Lack or restriction of
ability ,resulting from
impairment ,
representing
disturbance at the
level of the person.
Ex. Inability to climb
stairs.
The disadvantage
experienced by the
individual, as a result
of impairments or
disabilities which
prevent them from
fulfilling their normal
role.
Ex. Mobility- social
restriction of being
confined to one level.
General neurological assessment :

Reading file
History taking( present and past
history)
Family history
Taking patient’s history is often more
important than the clinical examination.
Examination of the mental functions
 level of consciousness
 Orientation for time and place
Memory assessment ( recent,
immediate and remote memory)
Examination of the mental functions
AMNESIA is diminution of memory, which
includes:
 Anterograde amnesia: loss of memory for
immediate and recent events.
Retrograde amnesia: loss of memory for
remote events.
Transient global amnesia: sudden total
loss of memory for less than one day.
Examination of the mental functions
 patient’s Mood
Intelligence
behaviour
Examination of speech
The main speech disturbances include:
 Aphasia: inability to formulate speech.
Types: 1. sensory aphasia
2. motor aphasia
dysarthria: difficulty to articulate speech
properly.

Neurological examination
1. Sensory examination:
• Superficial sensation
• Deep sensation
2. Motor examination
Neurological examination
Superficial sensation:
•Pain
•Temperature
•Light touch
•Light pressure
Neurological examination
Deep sensation
(proprioceptive):
1. Kinesthesia
2. Position sense
3. Vibration
Neurological examination
Deep sensation:
Combined (cortical ) sensation:
1. Stereagnosis
2. bargnosis
3. Tactile pressure
4. Two point discrimination
5. Graphethesia
6. Recognition of texture
Examination of the Cranial Nerves
Cranial
Nerve
I
Olfactory nerve
II
Optic nerve
III, IV,VI
Ocular nerve
V
Trigeminal nerve
VII
Facial nerve
VIII
Cochlear-vestibular nerve
IX,X,XI,XII Glossopharyngeal, vagus,cranial accessory and hypoglossal
Examination of the Cranial Nerves
I - Smell
II - Visual acuity, visual fields
III - Pupillary reactions
III,IV,VI - Extra-ocular movements, including opening of the eyes
V - Facial sensation, movements of the jaw, and corneal reflexes
VII - Facial movements and gustation
VIII - Hearing and balance
Examination of the Cranial Nerves
(CN I ) :
Smell
(CN II): Visual acuity,
and visual fields
Examination of the Cranial Nerves
Extra-ocular movements
(oculomotor, trochlear,
and abducent nerve)
The Trochlear nerve
(CN IV) is tested along
with the oculomotor
nerve as it is also
involved in eye
movements.
Examination of the Cranial Nerves
The Trigeminal nerve (CN V) is involved in
sensory supply to the face and motor
supply to the muscles of mastication.
• test the sensory branches by by lightly
touching the face with a piece of cotton
wool on three places on each side –
around the jawline, on the cheek and on
the forehead
Examination of the Cranial Nerves
Examination of the Cranial Nerves
For the motor part. (1) ask
the patient to clench their
teeth together, observing and
feeling the bulk of the
masseter muscles.
(2) jaw reflex
Examination of the Cranial Nerves
The Abducent nerve (CN
VI) is tested in the same
manner as the oculmotor
nerve, again in eye
movements.
Examination of the Cranial Nerves
The Facial nerve (CN VII) supplies motor
branches to the muscles of facial
expression. Therefore, this nerve is tested
by asking the patient to crease up their
forehead (raise their eyebrows), close their
eyes and keep them closed against
resistance, puff out their cheeks and show
you their teeth.
Examination of the Cranial Nerves
(CN VII) facial nerve, motor part of upper and
lower parts of the face.
Examination of the Cranial Nerves
Examination of the Cranial Nerves
The Vestibulocochlear nerve (CN VIII)
provides innervation to the hearing
apparatus of the ear
•List of Dermatomes of Commonly Injured Nerve
Roots
C5 – The area over the shoulder.
C6 – The thumb and part of the forearm.
C7 – The middle finger.
C8 – The smallest fingers and part of the forearm.
L4 – The thigh.
L5 – The medial part of the calf and foot, the big toe.
S1 – The lateral part of the calf and foot, the smaller
toes.
Examination of the muscle tone
Muscle tone may be abnormally increased
(hypertonia) or decreased (hypotonia).
The main types of hypertonia are:
Spasticity
Rigidity
Examination of the muscle tone
Clinically, usually assesses muscle tone in
two ways:
1. By passive movement
2. By shaking method for wrist and ankle
only to observe how a limb responds.
The greater resistance to movement ( the
greater muscle tone).
Examination of muscle tone
Spasticity: is a velocity-dependent increase
in resistance to passive stretch of a
muscle with exaggerated tendon reflexes.
Rigidity: increased resistance to relatively
slowly imposed passive movements
Comparison of spasticity and rigidity
spasticity
rigidity
Pattern of muscle
involvement
Upper limb flexors, lower
limb extensors
Distal more than proximal
Flexors and extensors
equally
Proximal more than
distal
Nature of tone
Velocity –dependent
increase in tone (claspknife)
Constant throughout
movement , (lead
pipe)or (cog-wheel)
intermittent
deep reflexes
hyperreflexia
hyporeflexia
Clinical significance
Upper motor neurone
(pyramidal) sign
Extrapyramidal sign
Modified Ashworth scale for grading spasticity
grade
description
0
No increase in muscle tone
1
Slight increase in muscle tone at the end of ROM
1+
Slight increase in muscle tone less than half of the ROM
2
More marked increase in muscle tone through most of the ROM (
more than half) but affected parts easily moved.
3
Considerable increase in muscle tone, passive movement
difficult.
4
Affected parts are rigid
Deep tendon reflexes
•
•
•
•
•
Biceps reflex
Triceps reflex
Hamstring reflex
Patellar reflex
Ankle reflex
Reflexes
• Babiniski-sign reflex: is a scratching
method on the lateral aspect of the
sole of the foot from the heel towards
the toes.
• Clonus reflex: is a rhythmical series of
contractions in response to sudden
stretch of the tendon of the muscle.
( ex, ankle & wrist)
Balance assessment
good balance requires a well integrated
nervous system with a adequate afferent
information, joints, and muscles. Faults in
any of theses factors will influence the
patient’s ability to balance.
Balance is the ability to maintain a position
1. Static balance
2. Dynamic balance
Coordination assessment
coordination is the ability to perform smooth,
accurate and controlled movements.
Coordinated movements are characterized
by appropriate speed, distance, direction,
and rhythm.
Balance and coordination
Balance and coordination depend on the
interaction of multiple body organs and
systems including the eyes, ears, brain
and nervous system, cardiovascular
system, and muscles.
Examination of any of these organs or
systems may be necessary to determine
the causes of disturbance of balance.
Coordination assessment
 Finger to finger
 Finger to doctor’s finger
 Finger to nose
 Finger opposition
 Pronation and supination
 Patting
 Heel to knee to toe
 Tapping foot
 Walking