What would you first observe when assessing nervous system?
LOC, posture, motor behavior, grooming/personal hygiene, affect (feelings), eye contact, A&Ox3, speech
If abnormal, you check MMSE.
(Mini-Mental State Examination/Folstein Test → Cognitive Impairment)
What is Cranial Nerve 1 and how do you test it?
Test each nares for sense of smell
→ask any changes in smell recently or taste in food
What is Cranial Nerve 2 and how do you test it?
*Test visual acuity*
1. Test vision with Rosenbaum Vision Chart → hold at 14 inches. Direct to read aloud the line they are able to see. (2 wrong is fail, one wrong is ok)
2. Ophthalmoscopic exam of fundi →Start at 0 on the dial and choose largest light source. Reminder: Left hand, left eye – testing pt’s left eye.
Side note: LLL for no kissy kiss with pt. Control distance between pt and yourself by placing hand on their shoulder or head.
How do you document your findings from Rosenbaum Vision Chart?
Documentation: → ex.) 20/40 OU with corrected – for glasses/contacts (OU-both, OD-right eye, OS-left eye)
→ If pt can’t identify all items correctly, number missed is listed after a ‘-‘ sign. Ex.) "20/40 – 2 OU" for 2 missed on 20/80 line
What is Cranial Nerve 3, 4, & 6 and how do you test it?
3- Oculomotor, 4-Trochlear, 6-Abducens
1. Test Corneal Light Reflex ASK: pt to look in the corner of the room. Shine light equally into both eyes. Looking for pinpoint of light reflected in the pupils. Stand about 2 feet away. Normal: Negative exotropia (outward), esotropia (inward), strabismus (squint). Symmetry in light reflection.
2. Test direct & consensual response • Shine a light in R eye: R pupil should constrict →Again shine light in R eye, though this time watch L pupil (should also constrict) • Shine a light in L eye: L pupil should constrict →Again shine light in L eye, though this time watch R pupil (should also constrict)
3. Test accommodation & EOMs Test: Patient doesn’t move head, following your finger w/their eyes as you trace out letter “H” → Constriction occurring when eye follow finger brought in towards pt, directly middle (looks cross eyed) →Alternatively, direct them to follow finger w/their eyes as you trace large rectangle. 4. Cover/uncover test
What is difference between direct and consensual response?
Direct: constriction in response to direct light
Consensual: constriction in response to light shined in opposite eye
What cranial nerve involves Ophthalmoscopic exam of fundi and what should be your normal finding?
Cranial nerve 2 - Optic
Normal finding: Able to see red reflex and visualize vessels for optic disk.
What is cranial nerve 4 and what is it testing
Testing internal rotation of the eye
What is cranial nerve 6 and what is it testing
Test lateral deviation of the eye
What is it when patient complains of partial loss of vision and abnormality in peripheral vision? and which cranial nerve is it?
Visual field defect - partial loss of vision when testing both eyes
Abnormality in peripheral vision = homonymous hemianopsia or quadrantanopsia with postchiasmal lesions (usually found in parietal lobe, associated findings with stroke*)
With CN 2&3: what is anisocoria?
Optic and Oculomotor
Inspect the size and shape of pupils - compare one side to other.
Anisocoria (difference of >0.4mm in diameter of one pupil compared to another) is seen in healthy individuals!
What 3 muscles are being tested with near response (pupillary constriction, convergence, accommodation of lens)?
1. Pupillary constriction = Pupillary constrictor muscle
2. Convergence = medial rectus muscles
3. accommodation of lens = ciliary muscles
CN 2 & 3
When inspecting the optic disk (CN2) - you find cup enlargement, what is this?
When inspecting the optic disk (CN2) - you find bulging and blurred margins, what is this?
When inspecting the optic disk (CN2) - you find it to be pallor what is this?
What is CN III palsy
Pupillary abnormality - large pupil reacting poorly to light or anisocoria worsening at night.
*Abnormal pupillary constriction
Reminder: Anisocoria (difference of >0.4mm in diameter of one pupil compared to another) is seen in healthy individuals!
When would you suspect Intracranial aneurysm
if ptosis and ophthalmoplegia present
What is Horner's syndrome & simple anisocoria
Both pupils react to light and anisocoria worsens in darkness, -
and small pupil has abnormal pupillary dilation
Reminder: Anisocoria (difference of >0.4mm in diameter of one pupil compared to another) is seen in healthy individuals!
What is Cranial Nerve 5 and how do you test it?
1. Palpate jaw muscles for tone & strength when pt clenches teeth
2. Close eyes and test sensation with touch to each side of forehead, cheek, and chin.
Assess TMJ (Temporomandibular Joint) for clicking, popping, crepitus, pain
“V” is for 5 for Cranial Nerve 5…
Ophthalmic VI Maxillary V2 Mandibular V3
What is Cranial Nerve 7 and how do you test it?
1. Raise eyebrows (Frontalis muscle)
2. Close eyes against resistance (Orbicularis oculi)
3. Smile & Frown (Orbicularis oris)
4. Clench teeth
5. Puff Cheeks (Buccinators) Looking for symmetry
What is Cranial Nerve 8 and how do you test it?
1. Whisper test → Use # or multi-syllable word covering one ear at a time standing 2 feet away ex.) “baseball”, “cupcake”…or “bacon”
2. Rinne’s Test → Strike tuning fork behind mastoid bone, when pt can’t hear sound, place fork next to ear. Should hear it again as air conduction>bone.
3. Weber’s Test → Strike TF (512 hz) on top of head (ask pt to close their eyes prior)
In Rinne's test for CN 8, what is it suggesting when bone conduction is better than air conduction?
If bone conduction Is better than air conduction, suggests conductive hearing loss.
In Weber's test for CN 8, what is an normal & abnormal finding?
Normal: Conducts to both sides (if sound hear both sides). Or without lateralization.
Abnormal: If conductive hearing loss (ex: ear wax on L), louder on Left*. If sensorineural on left, louder on right.
What is cranial nerve 9 and how do you test it
Ask to swallow
What is cranial nerve 10 and how do you test it
1. Inspect soft palate and uvula, stick out tongue, say “ahh
2. ASK: to say a sentence
Checking for : Symmetry, tongue midline & Clarity of voice (nasal or hoarse quality)
What is cranial nerve 11 and how do you test it
1. Shrug shoulders against resistance – your hands
2. Turn head to each side against resistance from your hands
Checking trapezius strength & Sternomastoid muscle
What is cranial nerve 12 and how do you test it
1. Inspect tongue in mouth & stick tongue out
2. Ask to push tip of tongue into inner cheek while you push from outside of cheek
Checking for atrophy, fasciculation (muscle twitch) & symmetrical
What is nystagmus
involuntary movement of eyes with quick and slow components
It is a cerebellar disease esp. with gait ataxia ( walking is uncoordinated and appears to be 'not ordered) and dysarthria (muscles of the mouth, face, and respiratory system may become weak, move slowly, or not move at all after a stroke)
what is ptosis
dropping of upper eyelids
-Ptosis suggests 3rd nerve palsy (CN3), Horner's syndrome and myasthenia gravis.
MG - autoimmune or congenital neuromuscular disease that leads to fluctuating muscle weakness and fatigue.
Bell's palsy is seen in injury to which cranial nerve
Cranial nerve 7 - Facial
- loss of taste, hyperacusis, and increase/decreased tearing
Hyperacusis - a health condition characterized by an over-sensitivity to certain frequency and volume ranges of sound
Whispered voice test sensitive, specific or both
both - when assessing presence of absence of hearing loss
Scale for grading muscle strength
Graded on 0-5 scale
0 - no muscular contraction
1 - barely detectable flicker or trace
2 - active movement of body part with gravity eliminated
3 - active movement against gravity
4 - active movement against gravity and some resistance
5 - active movement against full resistance without fatigue = this is normal strength
What does a + or - following the graded muscle strength mean?
+ indicates good but not full strength.
- indicates trace of weakness
What parts of spinal cord are associated with flexion and extension at the elbow? How do you test for it?
Flexion - C5, C6 - biceps
Extension - C6, C7, C8 - triceps
Test: patient pulls and pushes against your hand
What parts of spinal cord are associated with extension at the wrist? How do you test for it?
Extension at the wrist - C6, C7, C8, radial nerve - extensor carpi radialis longus and brevis
Test: have patient to make a fist and resist your pulling it down
Weakness of extension is seen in what disease(s)?
Peripheral nerve disease such as radial nerve damage
Central nervous system disease producing hemiplegia such as stroke or MS
What parts of spinal cord are associated with grip? How to test?
C7, C8, T1
Test: ask patient to squeeze 2 of your fingers as hard as possible and not let them go
A weak grip is associated with?
Radiculopathy, de Quervain's tenosynovitis, carpal tunnel syndrome, arthritis, epicondylitis
What parts of spinal cord are associated with finger abduction? How to test?
C8, T1, ulnar nerve
Test: position patient's hand palm down, fingers spread & tell patient not let you move the fingers as you try to force them together
Weak finger abduction associated with?
ulnar nerve disorders
What parts of spinal cord associated with opposition of thumb? How to test?
C8, T1, median nerve
Test: patient should try to touch the tip of the pinky with the thumb against your resistance
Weak opposition of thumb is associated with?
Median nerve disorders such as carpal tunnel syndrome
What parts of spinal cord associated with flexion at the hip? How to test?
L2, L3, L4, iliopsoas
Test: place your hand on patient's thigh and ask patient to raise his leg against your hand
What parts of spinal cord associated with adduction at the hips? How to test?
L2, L3, L4, adductors
Test: place hands firmly on bed between patient's knees, ask patient to bring both legs together
Symmetric weakness of proximal muscles suggest? Symmetric weakness of distal muscles suggests?
Proximal muscles: myopathy or muscle disorder
Distal muscles: polyneuropathy or disorder of peripheral nerves
What parts of spinal cord associated with extension at the hips? How to test?
S1, gluteus maximus
Test: patient pushes the posterior thigh down against your hand
What parts of spinal cord associated with extension at the knee? How to test?
L2, L3, L4, quadriceps
Test: support knee in flexion and ask patient to straighten leg against your hand
* should be forceful response
What parts of spinal cord associated with flexion at the knee? How to test?
L4, L5, S1, S2, hamstrings
Test: put patient's leg with the knee's flexed and foot resting on the bed, tell patient to keep foot down as you try to straighten the leg
What parts of spinal cord associated with dorsiflexion and plantar flexion at the ankle? How to test?
dorsiflexion: mainly L4, L5, tibialis anterior
plantar flexion: mainly S1, gastrocnemius, soleus
Test: ask paitent to pull up and push down against your hand
4 areas of nervous system function required for muscle movement coordination? And purpose of each?
1. motor system - muscle strength
2. cerebellar system - rhythmic movement, steady posture
3. vestibular system - balance and coordinating eye, head, body movements
4. sensory system - position sense
What to look for in cerebellar disease?
Nystagmus, dysarthria, hypotonia, ataxia
How do you assess coordination?
Observe patient's performance in:
1. rapid alternating movements
2. point to point movements
3. gait and other related body movements
4. standing in specified ways
Rapid alternating movements in arms? Observe for?
Have patient as rapidly as possible: strike one hand on the thigh, raise hand, turn it over, strike the back of the hand down on the same place. Repeat with other hand.
Have patient tap distal joint of thumb with tip of index finger as rapidly as possible.
Observe for: speed, rhythm, smoothness of movements
* nondominant hand often perfoms less well
Rapid alternating movements in legs? Observe for?
Ask patient to tap your hand as quickly as possible with the ball of each foot.
Observe for: any slowness or awkwardness
* feet perfom less well than the hands normally
What is dysdiadochokinesis and how is it related to cerebellar disease? What else can impair rapid alternating movements?
With cerebellar disease, one movement cannot be followed quickly by its opposite and movements are slow, irregular, and clumsy. This abnormality is dysdiadochokinesis. Upper motor neuron weakness and basal ganglia disease can impair rapid alternating movement.
Point to point movements for arms?
Finger to nose test. Have patient touch your index finger and then hi/her nose alternatley several times. Move your index finger around to alter directions and extend arm fully.
Heel to shin test. Have patient place one heel on opposite knee and the run it down the shin to the big toe.
Observe for: accruacy, smoothness of movements, tremors
Functioning areas of the brain
Spinal cord and what area of the body is affected if injured
Cranial nerves are limited motor or sensory functions - which CN are specialized?
Specialized CN are:
1 - smell
2 - vision
8 - hearing
What are 4 different kinds of impaired strength/paresis?
1. Paralysis - absence of strength
2. hemiparesis - weakness of one 1/2 of body
3. paraplegia - paralysis of legs
4. quadriplegia - paralysis of all four limbs
Cerebellar disease causes...
- incoordination (point to point movements) that worsens with eyes closed
- repetitive and consistent deviation to one side reffered as past pointing
- worse with eye closed suggest cerebellar or vestibular disease*
A gait that lacks coordination with reeling and instability
- Ataxia can be due to cerebellar disease, loos of position sense or intoxication
- You can test this by tandem walking ( walk heel to toe in straight line)
How do you test Shallow knee bend? and what difficulty in it mean?
Picture shows how
- Difficulty in doing a shallow knee bend suggests proximal weakness (extensors of the hip), weakness of quadriceps (extensor of knee) or both
What is light touch and what are abnormal findings
With fine wisp of cotton, touch skin lightly - whenever a touch is felt, pt should compare one area to another.
1. Anesthesia - absence of touch sensation
2. Hypesthesia - decreased sensitivity
3. Hyperesthesai - increased sensitivity
Testing vibration & abnormal findings
With 128hz tuning fork, place over interphalangeal joint of big toe. Ask pt to tell you when it stops and then touch the fork to stop it. If vibration sense is impaired, proceed to more bony prominenes (wrist, elbow, patella)
Abnormal: Vibration sense is first to be lost in peripheral neuropathy
Common causes: Diabetes and alcohol
Vibration sense is also lost in posterior column disease ex.) tertiary syphilius or vitamin b12 deficiency
Loss of position sense like loss of vibration sense is seen in tabes dorsalis, multiple sclerosis, b12 deficiency from posterior column disease
and in peripheral neuropathy from diabetes
Stereognosis & Number identification (graphesthesia)
- Stereognosis ability to identify an object by feeling it
- Number identification (graphesthesia) - picture
-Astereognosis refers to inability to recongize objects placed in the hand.
band of skin innervated by the sensory root of single spinal nerve
Scale for grading reflexes
When to use reinforcement
If patient's reflexes are symmetrically diminished or absent - use reinforcement up to 10 seconds
Biceps reflex (C5, C6)
Pt's arm partially flexed at elbow with palm down. Place finger over bicep tendon and strike reflex hammer
Triceps Reflex ( C6, C7 )
Flex pt's arm at elbow and pull slightly towards chest. Stirke tricepts tendon above the elblow.
Watch for contraction of triceps muscle and extension at the elbow.
Supinator or brachioradialis reflex (C5, C6)
Strike 1 - 2 inches above the wrist. Watch for flexion and supination of forearm.
Knee reflex (L2, L3, L4)
Briefly tap patella tendon below patella.
Observe contraction of quadriceps with extension of knee.
A hand on patient's anterior thigh lets you feel this reflex.
Ankle reflex (S1)
Pt sitting, dorsiflex the foot at the ankle. Strike achilles tendon. Watch for plantar flexion at the ankle.
If the reflexes seem hyperactive, test for clonus.
Support the knee at in partly flexed position and with other hand dorsiflex and plantar flex a foot few times to get pt to relax.Then sharply dorsiflex the foot and maintain it at dorsiflexion. Look and feel for rhythmic oscillations.
Normal - ankle does not react to this stimulus
Abnormal - few clonic beats can be seen and felt
Stroke each side of abdomen
- above (T8, T9, T10)
- below (T10, T11, T12)
Observe contraction of abd muscles and devation of the umbilicus otward the stimulus.
-Obesity may mask abd reflex. Use your giner to retract patient's umbilicus away from side to be stiumlated. Feel with your tretracting finger for muscular contraction.
Plantar reflex (L5, S1)
With an object like applicator stick, stroke lateral aspect of sole from heel to ball of foot.
Observe movment of big toe and plantar flexion.
- A marked Babinski response is sometimes accompanied by reflex flexion at hip and knee.
With dull object like cotton swab, stroke outward in four quadrants of anus.
Observe reflex contraction... of anus muscle. (no picture..hah!)
-Loss of anal reflex suggest lesion of S2-3-4 reflex arc a d seen in cauda equina lesions.
(cauda equina syndrome, a rare disorder affecting the bundle of nerve roots)
What signs are important if you suspect meningeal inflammation from meningitis or subarachnoid hemmorhage
1. Neck mobility/nuchal ridgidity
2. Brudzinski's sign
3. Kernig's sign
Neck mobility/nuchal rigidity
Check chin to chest for neck movement
- Inflammation of subarachnoid space causes resistance to movements like neck flexion that stretches spinal nerves, the femoral nerves in Brudzinski's sign and sciatic nerve in kernig's sign.
As you flex the neck, watch hips and knees reaction to the manueuver.
Normal - remain relaxed and motionless.
Abnormal - flexion of both hips and knees = POSITIVE BRUDZINSKI'S SIGN
Flex pt's leg and both hip and knee and straighten the knee.
Normal - discomfort behind the knee during full extension but not pain
Abnormal - pain and increased resistance to extending knee = POSITIVE KERNIG'S SIGN
Lumbosacral Radiculopathy - Straight leg raise
Patient has low back pain with nerve pain that radiates down the leg = sciatica
So test pt by raising pt's relaxed straight leg, flexing leg at hip, then dorsiflex foot.
Normal - tightness or discomfort in buttocks or hamstrings is common - do not interpret this as radiating pain or positive test
Abnormal - pain radiating into ipsilateral (same side) leg = POSITIVE STRAIGHT LEG TEST for lumbosacral radiculopathy
Increased pain in the contralateral (opposite) healthy leg is raised is POSITIVE CROSSED STRAIGHT LEG RAISING SIGN
Neurologic Evaluation - ocular movement
Observe position of eyes and eyelids at rest. Check for horizontal deviation of the eyes to one side (gaze preference). When oculomotor pathways are intact, eyes look straight ahead.
Neurologic Evaluation - Oculocephalic Reflex (doll's eye movements)
Oculocephalic Reflex (doll's eye movements) helps assess brainstem function in comatose patient.
- Holding the upper eyelids open, turn head quickly, first to one side then other.
- In comatose patient with intact brainstem, as head is turned the eyes will move toward the opposite side (doll's eye movements).
Ex.) Head turned right, eyes moved left
Neurologic Evaluation - Oculovestibular reflex (with Caloric Stimulation)
If the oculocephalic reflex (doll's eye movments) is absent, you need to go further and test for oculovestibular reflex (to test brainstem).
- Elevate the pt's head 30 degrees and inject ice water through large syringe into ear canal.
-Observe for deviation of eyes in the horizontal plane. (Can use up to 120ml for response)
-Comatose pt with Intact brainstem = eyes drift toward the irrigated ear.
-Comatose pt with brainstem injry = no response.