Question

For the following procedures, review how the test is preformed and why (what is being observed for):

- Mental Status (orientation and level of arousal)

- Cranial Nerves

1 – Olfactory

2 – Optic

3, 4 and 6 – Oculomotor, Trochlear and Abducens 5 – Trigeminal

7 – Facial

8 – Acoustic

9 – Glossopharyngeal

10- Vagus

11 – Spinal Accessory

12 – Hypoglossal

- Romberg Test

- Reflexes (Plantar/Babinski, patellar, biceps, etc.) - Dorsiflexion/Plantar Flexion

- Hand Grips

- Pronator/Palmar Drift

- Protective Sensation

- Nuchal Rigidity

- Kernig Sign

- Decorticate vs. Decerebrate Posturing

Answer 1

The cranial nerve exam is a type of neurological examination. It is used to identify problems with the cranial nerves by physical examination. It has nine components. Each test is designed to assess the status of one or more of the twelve cranial nerves

1 olfactory-

Smell, a function of the 1st (olfactory) cranial nerve, is usually evaluated only after head trauma or when lesions of the anterior fossa (eg, meningioma) are suspected or patients report abnormal smell or taste.

The patient is asked to identify odors (eg, soap, coffee, cloves ) presented to each nostril while the other nostril is occluded. Alcohol, ammonia, and other irritants, which test the nociceptive receptors of the 5th (trigeminal) cranial nerve, are used only when malingering is suspected.

2.optic

2nd (optic) cranial nerve, visual acuity is tested using a Snellen chart for distance vision or a handheld chart for near vision; each eye is assessed individually, with the other eye covered.

Color perception is tested using standard pseudoisochromatic Ishihara or Hardy-Rand-Ritter plates that have numbers or figures embedded in a field of specifically colored dots.

3.occulomotor, the 3rd (ocolomotor), 4th (trochlear), and 6th (abducens) cranial nerves, eyes are observed for symmetry of movement, globe position, asymmetry or droop of the eyelids (ptosis), and twitches or flutters of globes or lids. Extraocular movements controlled by these nerves are tested by asking the patient to follow a moving target (eg, examiner’s finger, penlight) to all 4 quadrants (including across the midline) and toward the tip of the nose; this test can detect nystagmus and palsies of ocular muscles. Brief fine amplitude nystagmus at end-lateral gaze is normal.

5-

For the 5th (trigeminal) nerve, the 3 sensory divisions (ophthalmic, maxillary, mandibular) are evaluated by using a pinprick to test facial sensation and by brushing a wisp of cotton against the lower or lateral cornea to evaluate the corneal reflex. If facial sensation is lost, the angle of the jaw should be examined; sparing of this area (innervated by spinal root C2) suggests a trigeminal deficit. A weak blink due to facial weakness (eg, 7th cranial nerve paralysis)

7-

The 7th (facial) cranial nerve is evaluated by checking for hemifacial weakness. Asymmetry of facial movements is often more obvious during spontaneous conversation, especially when the patient smiles or, if obtunded, grimaces at a noxious stimulus; on the weakened side, the nasolabial fold is depressed and the palpebral fissure is widened. If the patient has only lower facial weakness (ie, furrowing of the forehead and eye closure are preserved), etiology of 7th nerve weakness is central rather than peripheral.

8-

8th (vestibulocochlear, acoustic, auditory) cranial nerve carries auditory and vestibular input, evaluation involves

• Hearing tests

• Vestibular function tests

Hearing is first tested in each ear by whispering something while occluding the opposite ear. Any suspected loss should prompt formal audiologic testing to confirm findings and help differentiate conductive hearing loss from sensorineural hearing loss. The Weber and Rinne tests may be done

Vestibular function can be evaluated by testing for nystagmus. The presence and characteristics (eg, direction, duration, triggers) of nystagmus help identify vestibular disorders

9 Nd 10th

The 9th (glossopharyngeal) and 10th (vagus) cranial nerves are usually evaluated together. Whether the palate elevates symmetrically when the patient says "ah" is noted. If one side is paretic, the uvula is lifted away from the paretic side. A tongue blade can be used to touch one side of the posterior pharynx, then the other, and symmetry of the gag reflex is observed; bilateral absence of the gag reflex is common among healthy people and may not be significant.

11th (spinal accessory) cranial nerve is evaluated by testing the muscles it supplies:

• For the sternocleidomastoid, the patient is asked to turn the head against resistance supplied by the examiner’s hand while the examiner palpates the active muscle (opposite the turned head).

• For the upper trapezius, the patient is asked to elevate the shoulders against resistance supplied by the examiner.

The 12th (hypoglossal) cranial nerve is evaluated by asking the patient to extend the tongue and inspecting it for atrophy, fasciculations, and weakness (deviation is toward the side of a lesion).

ROMBERG TEST:The Romberg test is an appropriate tool to diagnose sensory ataxia, a gait disturbance caused by abnormal proprioception involving information about the location of the joints

The Romberg test is used for the clinical assessment of patients with disequilibrium or ataxia from sensory and motor disorders.

The test is performed as follows:

1. The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.
2. The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patients closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.
3. The Romberg test is scored by counting the seconds the patient is able to stand with eyes closed.
4.   The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, or even falling.