INTERNAL MEDICINE II Neurology
Cranial nerves examination

CN I (Olfactory nerve)´

 

The patient is asked to identify odors (eg, soap, coffee, cloves) presented to each nostril while the other nostril is occluded.

´Patient to close both eyes during the examination

CN II (optic nerve)

Visual acuity

 

Using the Snellen visual acuity chart. Ensure VA is tested with glasses on. Stand 6 metres away and ask the patient to cover one of their eyes completely with their hand and read the lowest line on the chart possible. Repeat the test covering the opposite eye. If the patient has difficulty reading a selected line, ask them to read the one above. Note the visual acuity for each eye.

 

Visual fields

Check visual fields by confrontation test. Test for both the temporal and nasal fields in each eye respectively using an object from the periphery to the centre

 

Direct and indirect light reflex

Uses a bright torch light to examine and compare both pupils size. Shine to the ipsilateral pupil  (direct) and note the pupil constriction and then to the opposite pupil (indirect/consensual)

•Accommodation reflex: instruct patient to look far ahead and then focus on a near object.

•Observe for convergence, miosis of pupils

 

Funduscopy

´Examine in a darken room, ask patient to look at the same point as far as possible in the room

´Use your right hand & your right eye to look at the patient’s right eye.

´Look through the funduscope

´Adjust the focus wheel and look for the red reflex

Look for the optic disc and the retina

 

CN III (oculomotor), IV (trochlear), VI (abducens)

´Student to sit facing the patient at about 3 feet away.

´Extraocular movements (CN III, IV, VI) are examined by asking the patient to follow a finger or pen or card with the eyes.

 

CN V (Trigeminal)

´The 3 sensory divisions (ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to test facial sensation

´Corneal reflex: brushing a wisp of cotton against the lower or lateral cornea

 

 

 

´Trigeminal motor function is tested by palpating the masseter and temporalis  muscles while the patient clenches the teeth

´Lateral and medial pterigoids: cannot open jaw or move it from side to side against resistance.

 

´Jaw jerk: ask patient to open the jaw slightly, percuss on the chin and observe & feel jaw movement

 

CN VII (Facial)

 

´Motor component: Observe for hemifacial weakness. Look for asymmetry of facial movements

´Ask patient to smile, frown, close eyes against resistance, show teeth, raise eyebrows and puff cheeks

´Sensory: taste on anterior 2/3 tongue (apply cotton applicator to tongue with salt/sugar)

CN VIII (vestibular)

´Bed side test: whisper some words into patient’s ear and ask patient to repeat the word

´Examine the external ear and use otoscope to look into the ear canal.

´Weber test: Place the tuning fork on the head midway and  patient should hear on both ears

´Weber: lateralised to affected ear with conductive HL

´              Lateralised to unaffected ear with sensorineural HL

 

Rinne test

´Place the tuning fork at the mastoid process and wait till the vibration of the fork stops

´Next place the tuning fork next to the patient’s ear till vibration stops.

´AC better than BC

 

CN IX (glossopharygeal) CN X (vagus)

´Motor function: depress tongue with spatula and note pharyngeal movements as patient says ‘ahh’

´Touch on the soft palate and back of throat (gag reflex)

´Sensory function: test taste on posterior 1/3 tongue

 

CN XI (accessory) 

´Turn head to the side against resistance

´Shrug shoulders against resistance

 

CN XII (hypoglossal)

´Ask patient to protrude the tongue

´Look for any wasting, fasciculations

´Test the muscle power by pushing the tongue against the inner part of the mouth

Examination of the limbs

General

Look at the whole patient and note any features of Parkinsons, stroke etc

Look for any deformity, fasciculations, scars, muscle wasting, tremors, involuntary movements. Tap on the muscles to look for any fasciculations.

Check for the gait 

Motor 

Tone :Check for the tone of the upper limbs by moving joints passively (shoulder, elbow and wrists, knees and ankles ) and compare both sides

Muscle power

Shoulder

Abduction: Instruct the patient to abduct his arms with  elbows flexed and not to let you push them down.

Adduction: Instruct the patient to adduct his arms with elbows flexed against your resistance.

Elbow

  • Flexion: Instruct the patient to bend his elbow and pull and not to let you straighten it.
  • Extension: Instruct the patient to straighten his elbow against resistance

Wrist

  • Dorsiflexion/Extension: Instruct patient to dorsiflex his wrist and not to let you bend it.
  • Palmarflexion: Instruct the patient to bend his wrist against resistance.

Hip

  • Flexion:  Ask the patient to lift up his straight leg and not to let you push it down
  • Extension: Ask the patient to push down his leg against resistance.
  • Abduction: Ask the patient to abduct his leg and not to let you push it in
  • Adduction: Ask the patient to adduct his legs and not to let you push it out.

Knee

Flexion: Instruct the patient to bend his knee and not to let you straighten it.

Extension: Instruct the patient to straighten his knees and not to let you bend it.

Ankle

  • Plantar Flexion: Instruct the patient to push his foot down and not to let you push it up.
  • Dorsiflexion: Instruct the  patient to pull his foot up and not to let you bend it
  • Eversion: Instruct the patient to push his foot outwards and not to let you push it in.
  • Inversion: Instruct the patient to push his foot inwards and not to let you push it out.

 

Grading of muscle power

  • 5 normal power
  • 4. Movement against gravity and some resistance
  • 3. Movement against gravity
  • 2. Movement only horizontally
  • 1. Flicker of movement
  • 0. Complete paralysis

Tendon reflexes: tap on the tendon with the patellar /tendon hammer and note its reflexes

Absent: if still unable to elicit after Jendrassik manoeuvre (the patient clenches the teeth, flexes both sets of fingers into a hook-like form, and interlocks those sets of fingers together. The muscle tendon is then hit with a tendon hammer to elicit the tendon reflex)

  • 1+: reduced
  • 2+: normal
  • 3+: increased or exaggerated

 

  1. Biceps (C5-C6)
  2. Triceps  (C7-C8)
  3. Supinator (C5-C6)
  4. Knee (L3L4)
  5. Ankle (L5-S1)

Plantar response:  when the sole of the foot is stimulated by stroking on the lateral side of the plantars with a blunt instrument. Normal: the plantar reflex causes a downward response (downward/flexion)

Positive Babinski sign: when the big toe bends up and back to the top of the foot and the other toes fan out

Sensory examination

Examine with a cotton wool for light touch, a sharp object for pinprick to test for pain sensation, a tuning fork (128Hz) for vibration and propioception.

See the attached dermatomes

Coordination

Test for pastpointing by instructing patient to point his index finger from his nose to your finger with his outstretched hands. Perform rapid alternating movements of the palms on the contralateral hand to detect for dysdiadokokinesia. 

Lower limbs: Perform the heel shin test by asking the patient to slide his heel down from the opposite knee to the ankle and note for any incoordination of movements.

 

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