cranial nerves & head to toe

Question 1

CN I

Answer 1

olfactory

test by sense of smell, on health history

Question 2

CN II

Answer 2

optic

test by visual acuity & confrontation

Question 3

CN III, IV, VI

Answer 3

ocularmotor, trochlear, abducens

test by six cardinal fields

Question 4

CN V

Answer 4

trigeminal nerve

test by clenching jaw & light touch on face

Question 5

CN VII

Answer 5

factial

test by having pt smile, wrinkle forehead, puff out cheeks

Question 6

CN VIII

Answer 6

Acoustic

test by whisper test

Question 7

CN IX, X

Answer 7

glossopharyngeal and vagus
test by having pt say “ahhh,” check gag reflex, swallowing, and taste
taste checking in health history

Question 8

CN XI

Answer 8

spinal accessory

test resistance of head rotation & shrug shoulders

Question 9

CN XII

Answer 9

hypoglossal

test by having pt stick out tongue & wiggle tongue

Question 10

Head to Toe

1st two steps

Answer 10

hand hygiene

pt’s general appearance

Question 11

Vital Signs (HtT, 2nd step)

Answer 11

pulse
respirations
temperature
BP
pain

Question 12

Head & Face (HtT, 3rd step)

Answer 12

• inspect & palpate scalp
• inspect face, expression, symmetry
• palpate temporal artery
• palpate temporomandibular joint as it opens & closes
• palpate sinuses
• have pt clench jaw & palpate (CN V)
• have pt smile, wrinkle forehead & puff cheeks (CN VII)

Question 13

Eyes (HtT, 4th step)

Answer 13

• inspect external eye structures
• inspect conjuntiva, sclera, cornea & iris
• corneal light reflex
• test confrontation (CN II)
• 6 cardinal positions (CN III, IV, VI)
• test pupil: sze, rxn to light, accommodation
• darken room, ophthalmoscope-inspect ocular fundus: red reflex, disc, vessels, & retinal background

Question 14

Ears (HtT, 5th step)

Answer 14

• inspect external ear, skin condition & auditory meatus
• move auricle & push tragus for tenderness
• w/ otoscope- inspect canal, tympanic membrane for color, position, landmarks, & integrity
• test hearing- whisper test (CN VIII)
• Wever & Rhine, AC>BC
• tuning fork on top of head

Question 15

Nose (HtT, 6th step)

Answer 15

-inspect the external nose
    symmetry
    lesions
-w/ speculum, inspect the nares
    nasal mucosa
    septum
    turbinates

Question 16

Mouth & Throat (HtT, 7th step)

Answer 16

• w/ penlight inspect mouth: buccal mucosa, teeth & gums, tongue, floor of mouth, palate, & uvula
• note mobility of uvula as person says “ahhh,” & test gag reflex (CN IX, X)
• have person stick out tongue and move it side to side (CN XII)

Question 17

Neck (HtT, 8th step)

Answer 17

• inspect the neck: symmetry, lumps, pulsations
• palpate the cervical lymph nodes
• inspect & palpate carotid pulse, listen for bruits
• palpate the trachea midline & have them swallow (tests thyroid)
• test ROM & muscle strength against resistance: shrug shoulders, head side to side, & head back & forward (CN XI)

Question 18

Heart (HtT, 9th step)

Answer 18

• inspect the precordium for any pulsations or heave
• palpate the apical pulse & note location
• palpate the precordium for any abnormal thrill
• auscultate apical rate & rhythm & carotids
• auscultate heart sounds w/ diaphragm
• auscultate heart sounds w/ bell (for murmurs)
• turn person to left side & auscultate apex w/ bell

Question 19

Peripheral Vascular System (HtT, 10th step)

Answer 19

• inspect lower legs for varicose veins, ulcers, discoloration, hair loss
• cap refill, <3sec
• assess pulses (bilaterally): radial, ulnar, brachial, popliteal, posterior tibial, dorsalis pedis

Question 20

Lungs (HtT, 11th step)

Answer 20

• inspect the chest & expansion (equally)
• palpate for expansion, lumps, or tenderness, & spinous processes
• percuss over lung fields
• percuss costovertebral angle, noting any tenderness (kidneys)
• auscultate breath sounds, compare bilaterally, note 28 points of auscultation

Question 21

Abdomen (HtT, 12th step)

Answer 21

• inspect abdomen
• auscultate bowel sounds
• auscultate abdominal aorta
• percuss all quadrants
• palpate all quadrants: light palpation, deep palpation

Question 22

Neurological (HtT, 13th step)

Answer 22

• Test sensation in selected areas on face, arms or hands, and legs or feet: superficial pain, light touch
• Test position sense of finger, one hand; their finger to your finger and then move your hand
• Test stereognosis, using a familiar object
• Test cerebellar function of the upper extremities using finger-to-nose test; patient’s eyes closed
• Elicit deep tendon reflexes: biceps, triceps, brachioradialis
• Test cerebellar function of the lower extremities by asking the person to run each heel down the opposite shin
• Elicit deep tendon reflexes: patellar and Achilles

Question 23

Musculoskeletal (HtT, 14th step)

Answer 23

• Ask the person to walk across the room in his/her regular walk, turn, and then walk back toward you in heel-to-toe fashion
• Ask the person to walk on the toes for a few steps, then to walk on the heels for a few steps
• Stand close and check Romberg’s sign; feet together, hands at side, eyes closed for 20 seconds
• Ask the person to hold the edge of the bed and to perform a shallow knee bend, one for each leg
• Stand behind and check the spine as the person touches the toes
• Check the range of motion of spine, hyperextends, rotates, and laterally bends

Question 24

Normal Response

skin

Answer 24

warm, dry, intact
skin turgor good
no lesions, birthmarks

Question 25

Normal Response | hair

Answer 25

normal distribution & texture

Question 26

Normal Response | Nails

Answer 26

no clubbing or discolorations

Question 27

Normal Response | head

Answer 27

normocephalic, no lesions, lumps or tenderness | face- symmetric

Question 28

Normal Response | eyes

Answer 28

visual fields full by confrontation EOMs intact, no lesions or redness Pupils- PERRLA, red flex & optic disc normal

Question 29

Normal Response | ears

Answer 29

no mass, lesion, or tenderness tympanic membrane-pearly gray, no perforation whispered words heard bilaterally

Question 30

Normal Response | nose

Answer 30

no deformities or tenderness | Nares- patent, septum midline, no sinus tenderness

Question 31

Normal Response | mouth

Answer 31

mucosa pink, no lesions or bleeding | tongue- symmetric, uvula rises, tonsil +1, gag reflex present

Question 32

Normal Response | neck

Answer 32

supple w/ full ROM, no masses, tenderness, lymphadenopathy, trachea midline, thyroid non palpable, no JVD, no carotid bruits

Question 33

Normal Response | spine & back

Answer 33

no scoliosis, no tenderness over spine, no CVA tenderness

Question 34

Normal Response | thorax & lungs

Answer 34

clear to auscultation, no tenderness on palpation

Question 35

Normal Response | heart

Answer 35

S1, S2 regular, no S3, S4, no murmurs or bruits noted

Question 36

Normal Response | abdomen

Answer 36

soft, non-tender, bowel sounds present in all 4 quadrants

Question 37

Normal Response | extremities

Answer 37

color (tan-pink), no cyanosis, no edema, peripheral pulses present +2 bilaterally

Question 38

Normal Response | musculoskeletal

Answer 38

TMJ- no crepitation or slipping, extremities have full ROM, no pain or crepitation, muscle strength +2 bilaterally

Question 39

Normal Response | neurologic

Answer 39

appearance, behavior, speech appropriate, A&O x3, cranial nerves I-XII intact, deep tendon reflexes intact & +2

Question 40

Deep Tendon Reflexes

Answer 40

4+ very brisk, hyperactive w/ clonus, indicative of disease 3+ brisker than average, may indicate disease, probably normal 2+ average, normal 1+ diminished, low normal, or occurs only w/ reinforcement 0 no response

Question 41

Muscle strength

Answer 41

- 5 full ROM against gravity & resistance, normal - 4 full ROM against gravity & some resistance, good - 3 full ROM w/ gravity, fair - 2 full ROM w/ gravity eliminated, poor - 1 slight contraction, trace - 0 no contraction, zero