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NEUROMUSCULAR EXAM OVERVIEW • • • • • • Mini-Mental Status Exam (MMSE) CN I-XII Reflexes Tone Strength Sensory (Pinprick and Cotton Wisp) Proprioception and Vibration • Romberg • Gait MMSE • Orientation Person: What is your name? Place: Where are you? Time: What is today’s date? CRANIAL NERVES • • • • • • • • • • • • I- Olfactory (Special Sensory) II- Optic (Special Sensory) III- Oculomotor (Motor, Parasympathetics) IV- Trochlear (Motor) V- Trigeminal Ophthalmic (Sensory) Maxillary (Sensory) Mandibular (Sensory, Motor) VI- Abducens (Motor) VII- Facial (Motor, Special Sensory, Parasympathetics) VIII- Vestibulocochlear (Sensory, Special Sensory) IX- Glossopharyngeal (Sensory, Special Sensory, Motor) X- Vagus (Sensory, Special Sensory, Motor, Parasympathetics) XI- Accessory (Motor) XII- Hypoglossal (Motor) http://www.brianjogrady.com/neurosurgery.ht ml CNI-OLFACTORY • Sense of Smell Test using common scent (coffee grounds) Eyes closed One nostril at a time CNII- OPTIC • Visual Acuity • Visual Fields • Pupillary Reflex Direct Consensual http://medicaldictionary.thefreedictionary.com/paradoxical+pupillary+reflex CNIII- OCULOMOTOR • Motor (External Ocular Movements) Superior Rectus, Medial Rectus, Inferior Rectus, Inferior Oblique CNIII Palsy eyes look down and out Ask and test for double vision • Parasympathetics Accommodation (near sight) Constriction Pupillary Reflex Direct Consensual Picture: Medial Rectus http://www.postoconnorkadrmas.com/common-eye-problems/strabismus-eyePalsy turn.html EXTRAOCULAR EYE MOVEMENTS http://clinicalexamskills.blogspot.com/2010/10/cranial-nerves-iii-iv-andvi.html CNIV- TROCHLEAR • Motor (Superior Oblique) Moves eyes down and in Trochlear palsy Trouble walking down stairs (unable to look down) Patient may have compensatory head tilt toward affected eye CNV- TRIGEMINAL • Ophthalmic Sensory (Bridge of nose to vertex of skull) • Maxillary Sensory (Above the mouth to beneath the eyes) • Mandibular Sensory (Beneath the mouth along the mandible) Motor (Muscles of mastication, tensor tympani, tensor veli palatini, myelohyoid, anterior belly of digastric) • Test sharp/ dull separately in all three divisions carefully comparing bilaterally CNVI- ABDUCENS • Lateral Rectus Moves eyes out Most commonly affected EOM Ask about and test for double vision Double vision worse when look toward deficit (laterally) http://meded.ucsd.edu/clinic almed/eyes.htm Palsy seen with: increased intraocular pressure (pseudotumor cerebri), diabetic neuropathy CNVII- FACIAL • Motor Muscles of facial expression Wrinkle forehead (bilateral innervation) Deficit suggests LMN injury Smile (contralateral innervation) Either UMN or LMN injury Look for facial droop and asymmetry • Special Sensory Chordae tympani Sense of taste anterior 2/3 of tongue • Parasympathetics Submandibular, submental, lacrimal, and all minor salivary glands CNVIII-VESTIBULOCOCHLEAR • Sensory Vestibular (balance) • Special Sensory Audition Rinne Place 512Hz tuning fork on mastoid process Move in front of EAM once patient can no long hear on mastoid Normal: Air conduction>Bone conduction Ossicles amplify sound If: Bone conduction> Air conduction→ Conductive hearing loss Weber Place 512Hz tuning fork at skull vertex Ask where sound is coming from Normal: Same both ears http://www.google.com/imgres?q=weber+rinne+test&um=1&hl=en&safe=off&sa=N&biw=1144&bih=678&tbm=isch&tbnid=E49qzh8Qq2_MPM:&imgrefurl=http://www.netteri mages.com/image/6928.htm&docid=zg8q_5VgYXAR4M&imgurl=http://www.netterimages.com/images/vpv/000/000/006/69280550x0475.jpg&w=475&h=550&ei=0vdQT6jhO5SEtgeCuOG6DQ&zoom=1 CNIX- GLOSSOPHARYNGEAL • Sensory- oropharynx Gag Reflex Afferent: Glossopharyngeal Efferent: Vagus (Pharyngeal constrictors) • Special Sensory Taste: Posterior 1/3 tongue • Motor Stylopharyngeous CNX- VAGUS • Sensory Laryngopharynx External ear • Special Sensory Taste: Epiglottis • Motor http://meded.ucsd.edu/clinicalmed/head.ht Muscles of soft palate, pharynx, and larynx m Efferent of gag reflex Test by looking for symmetric elevation of uvula “ahhh” • Parasympathetics Thoracic and abdominal viscera until splenic flexure CNXI- ACCESSORY • Motor Trapezius Test with shoulder shrug Compare strength bilaterally Sternocleidomastoid Test with turning head against hand Turns head to contralateral side Compare strength bilaterally http://theartofads.blogspot.com/2010/01/lie-to-me109.html CNXII- HYPOGLOSSAL • Motor Movements of the tongue Genioglossus Protrudes tongue Test by having patient stick tongue out Tongue deviates towards deficit Hypoglossus Myeloglossus Palatoglossus http://www.johnnysilva.com/physicalexamination/right-eardrum-1.html CN REFLEXES • Pupillary Afferent: Optic Efferent: Oculomotor Remember: “In on 2, out on 3” • Accomodation Afferent: Optic Efferent: Oculomotor • Gag Afferent: Glossopharyngeal Efferent: Vagus • Cough Afferent: Vagus Efferent: Vagus REFLEXES • Grade 0: Absent 1: Hyporreflexic (Illicited with distraction) 2: Normal 3: Hyperreflexic (Spreading of reflexes) 4: Clonus • Test Biceps (C5, C6) Brachioradialis (C6) Triceps (C7) Patellar (L4, L5) Achilles (S1, S2) TONE • Passive motion of extremities Test Both upper and lower extremities Spasticity: UMN Injury Flaccid: LMN Injury or spinal shock STRENGTH • Corticospinal Tract (Pyramidal Tract) Decussation at junction of medulla and spinal cord • Grade 5: Full Strength 4: Decreased compared to contralateral side 3: Movement against gravity only 2: Movement within a plane only 1: Flicker 0: Absent • Compare bilaterally • Differentiate decreased strength vs. Giveway True neuromuscular deficiency Testing limited by pain or malingering SENSORY EXAM • Pain/ Temperature Anterolateral Spinal Tract Ascends Contralaterally in spinal cord →Test with Pinprick and Cold (Tuning Fork) • Dull/ Vibration Dorsalcolumn Medial Lemniscus Ascends Ipsilaterally in spinal cord →Test with cotton whisp/ 128Hz Tuning Fork PROPRIOCEPTION • Have patient close eyes Move distal phalynx of great toe up or down • Romberg Test Patient stands with feet together Raises hands outstretched in front Closes eyes Test for at least 30 sec *Be positioned to catch patient Positive Romberg = loss of balance on exam http://www.jaoa.org/content/111/6/382.abstrac t GAIT • • • • Patient walks across room Returns walking on toes Walks back on heels Returns with tandem walk (heel-to-toe)