The Neurological Examination

Dr. Ramadan Mohamed Ahmed

 The Components of the Neurological Examination

Cranial Nerve Examination

CN I to XII
Motor System Examination, including Cerebellar tests
Inspection of body position, Involuntary movements, muscle bulk,
Muscle Tone, Manual Motor Testing, Coordination, Deep tendon reflexes
and Gait

Sensory System Examination

Light touch, pain and temperature, position and vibration senses,
Descrimination modalities
Things needed for the neurological examination

Don’t forget: the ophthalmoscope for fundoscopy

Cranial Nerve I – Olfactory Nerve

Assessment:

• Ask patients about any recent

change in their sense of smell
(eg. Anosmia, parosmia)

2. Check for the patency of the nostrils

3. Examine each nostril in turn, using tobacco, coffee, or cinnamon

(use colored vials so that patient will not be able to identify the
test agents even before the procedure)

Tip: avoid using irritating substances (ammonia, alcohol) for these

substances could stimulate the trigeminal nerve endings, even
in anosmic patients!
Cranial Nerve I – Olfactory Nerve

Checking for the patency of each nostrils

Cranial Nerve I – Olfactory Nerve

Examine each nostril with the test agent, preferably with the examiner
closing each of the patient’s nostrils
Cranial Nerve I – Olfactory Nerve

• Unilateral loss of smell is usually asymptomatic

• Bilateral loss of smell is always associated with an altered

sense of taste

• Always examine the CN I in all patients with persosnality changes,

disinhibition, or dementia (frontal lobe involvement), and in
all cases of head trauma
Cranial Nerve II – Optic Nerve

Examine:

• Visual acuity using the Snellen chart

or a near chart

2. Peripheral field of vision by doing the Gross

Confrontational Test

3. Do the fundoscopy using the ophthalmoscope

4. Check for reaction of pupils (for CN II and III)

 Cranial Nerve II – Optic Nerve

Assessment using the Snellen chart:

• Position the patient 20 ft away from the chart

2. Ask the patient to read the smallest line of print possible,

coaxing him to read the next line may improve
performance

Ask the patient to cover one eye during the tests for each
eye

3. Determine the smallest line of print from which the

patient can identify more than half the letters

4. For those with refractive errors, use a pinhole to correct

the patient’s vision, and record the findings
Cranial Nerve II – Optic Nerve

Assessment using the near chart:

If the Snellen chart is not available, use the near chart. Hold the hand held chart 14
inches away, and do much the same procedure as using a Snellen chart
Cranial Nerve II – Optic Nerve

If the patient is unable to read the largest character, assess his ability to count
your fingers at 1 m (report as VA:CF)

If the patient cannot see your fingers, ask him to identify your moving hands
(report as VA:HM)

If the patient cannot see hand movements, flash light in front of his eyes (report as
VA:LP). If patient is unable to perceive light (VA:NLP), then the patient is
medically blind!
Cranial Nerve II – Optic Nerve

The Gross Confrontational Test

1. Sit or stand about 1 m from the patient with your eyes at the same horizontal
level

2. Ask the patient to look directly into your eyes and hold your hands halfway
between you and the patient
3. Ask the patient to point at your moving finger/s for you to assess his visual
fields (Make sure that the examiner’s visual field is normal before the
procedure!)

4. The patient’s visual field will match the examiner’s if the head positions are
exactly halfway between the examiner and the patient (this is seldom the case)
If a visual defect is detected, test one eye at a time.

In a right temporal field defect, ask the patient to cover the left eye, and with the
right eye, to look into your eye directly opposite. Then slowly move a
wriggling / moving finger from the defective area toward the better vision,
noting where the patient first responds.

Repeat this at several levels to determine the borders.

Your task: review the visual pathway and the visual field defects
that can be assessed using the Gross Confrontational test
 Cranial nerve II: Optic
<Visual Acuity>
nerve Chart) 
• Wall or hand chart(Snellen’s
count fingers  movement  light
• Refractive error: If acuity improved by
looking thru pinhole card

<Visual Field>
• Confrontation test:
約相距一隻手臂長 以 30cm 為半徑請病人試著
回答你哪一邊的手指在動
• Test Individual Eye
左眼注視你的右眼 ,  以病人的眼睛為中心劃一半
徑 30cm 的假想球面 使用白色大頭針 , 要求病
人告訴你何時最先看到大頭針 改用紅色大頭針再
測試一次
The Fundoscopic examination using the ophthalmoscope

Your task: practice the procedure after the demonstration; make

sure that you know how to handle the instrument
before the session ends
Ophthalmoscope
This is the area that you will be able to see using
your ophthalmoscope
Cranial Nerve II, III – Optic and Oculomotor Nerves

Pupillary Light Reflexes

Ask the patient to fixate on a distant target and shine the light in each eye in turn
from the lateral side. Observe for the direct and consensual light reflexes
Accomodation Reflex
Accomodation Reflex
Cranial Nerve III, IV, VI – Oculomotor Nerve
Trochlear Nerve, Abducens Nerve

Inspect the eyes and note for the

position of the eyelids and the
presence of any strabismus and ptosis

Strabismus is concomitant if it remains

constant all throughout the range of eye
movement. It is inconcomitant
(paralytic) if it varies

Do pursuit and saccadic movements to

assess whether the eye movements are
conjugate, and to detect diplopia and
nystagmus
 nerve
Cranial nerve (IV) Trochlear
Nerve
Cranial nerve (VI) Abducens
• Saccade (Frontal)
Nerve
Frontal gaze center to PPRF (paramedian pontine reticular
formation) for rapid eye movements to view new objects on to
the fovea.

• Pursuit (Occipital lobe)

Parietal-occipital gaze center via cerebellar and vestibular
pathways; for eye movements to keep a moving image centered
on the fovea.

• Convergence (Midbrain)
optic pathways to oculomotor nuclei; keep image on fovea when
viewed object moved near

• Vestibulo-ocular reflex (Cerebellar vestibular

nuclei)
vestibular input; keeps image steady on fovea during head
movements.
Pursuit eye movements

Steady the pt’s. head and hold an

object (eg. pen) 4-5 cm in front of the
eye

Ask the pt. to follow the moving

object throughout the range of the
binocular vision in the horizontal and
vertical planes in an “H” pattern

Assess the smoothness, speed and

magnitude of the movements

Saccadic eye movements

Steady the pt’s. head and to look in all directions as quickly as possible. Assess the
velocity and the accuracy of the movements
Describe this patient’s EOM paralysis. (The patient was instructed to
look downwards!)
Describe this patient’s EOM paralysis. (The patient was instructed to
look to the left!)
Describe this patient’s EOM paralysis. (The patient was instructed to
look to the right!)
Describe each of the images and discuss the EOM findings
Cranial Nerve V – Trigeminal Nerve
Motor functions of the CN V

Inspect for wasting of temporalis muscle,

which produces hollowing above the
zygoma

Ask the patient to clench his teeth together

and palpate the temporalis and masseter
muscles

The pterygoids are assessed by resisting

the pt’s. attempts to open his mouth

In unilateral trigeminal lesions, the lower

jaw deviates to the paralytic side as the
mouth is opened
Sensory functions of the trigeminal nerve

Using light touch, test for the presence and

symmetry of the facial sensation

Test for pain sensation using a pin (with

blunt end) in the same fashion as you have
tested for fine touch

Reserve the tests for temperature and

proprioception if there’s an abnormal
finding with pain sensation
Sensory testing of the face

Always:

• instruct the patient on what to do

before proceeding with test
• show the test objects to be used
• ask the patient to close his eyes
throughout the procedure
Sensory testing of the face – fine touch

Note for symmetry of the sensation by comparing symmetrical dermatomal

segments on the face
Sensory testing of the face – pain sensation

Note for symmetry of the sensation by comparing symmetrical dermatomal segments

on the face
Sensory testing of the face – temperature sensation

Note for symmetry of the sensation by comparing symmetrical dermatomal segments

on the face
Corneal Reflex (CN V and VII)

Reserve this procedure if one

cannot test for the separate
functions of the V and VII cranial
nerves!
Cranial Nerve VII – Facial Nerve

Sensory testing for the taste (anterior 2/3 of the tongue has
less clinical benefit, thus, it is reserved for special cases
• VII: Facial
- raise both eyebrows
- frown
- close both eyes
tightly & try opening
- show both upper &
lower teeth
- smile
- puff out both cheeks
Motor functions of the CN VII

Always check for symmetry!!!

Your task: review the facial muscle innervation and differentiate
peripheral from central facial paralysis
Describe the facial paralysis of
this patient.

Does he has peripheral or central

facial palsy?
Cranial Nerve VIII – Vestibulocochlear Nerve

Clinical bedside assessment of hearing is not sensitive, and can

detect only gross hearing loss!

Reserve the oculovestibular reflex (Doll’s eye) in unresponsive

patients!
Grossly assess hearing in each ear while masking the hearing in the
other ear by occluding the external meatus with your index finger

Test the pt’s. sensitivity by whispering numbers into his ears and
asking him to repeat it
Weber test
Check for lateralization of sounds conducted through the bones
Rinne test

Compare air conduction and

bone conduction
Cranial Nerve IX, X - Glossopharyngeal Nerve, Vagus Nerve
This is the normal palatal arches as the patient opens his
mouth and when he says “ahhhhh”
• IX:
Glossopharyngeal
• X: Vagus
- voice
- swallowing
- movements of soft
palate & pharynx
- gag reflex
Note for gag reflex by touching the soft palate or the
pharyngeal walls separately
sensory: IX
motor: X

Observe for the patient’s voluntary swallowing

Describe the direction of the uvula
Describe the direction of the uvula
Cranial Nerve XI – Spinal Accesory Nerve
The function of the trapezius is
assessed by asking the pt. to
elevate his shoulders, first
without, then with resistance

The function of the sternocleidomastoids is assessed by

asking the patient to turn his head and applying resistance,
note for the bulk and strength of the muscles
Always check for symmetry of the bulk and strength
Always check for symmetry of the bulk and strength
• XI: Spinal
Accessory
- shoulder shrug
- turn head side-to-
side
Cranial Nerve XII – Hypoglossal Nerve
• XII: Hypoglossal
- move tongue from side
to side
Describe the findings in this patient when you ask
him to protrude his tongue
 Examination of the
motor nervous system
1- Muscle state (bulk).
2- Muscle power.
3- Muscle tone.
4- Superficial reflexes.
5- Deep reflexes.
6- Gait
7- Coordination of movement.
 Examination of the
motor nervous system
1- Muscle bulk

Causes of muscle atrophy:

1- Diabetic neuropathy.
2- Motor neuron diseases.
3- Disuse atrophy.
4- Rheumatoid arthritis.
5- Protein calorie malnutrition
Muscle power or strength
Power or strength is tested by asking the patient to move
actively against your resistance

Start proximally and move distally i.e. (arm, forearm & hands)
Always compare one side to the other
Impaired strength is known as (paresis)
Absence of strength is known as (plegia)
 Triceps muscle is
innervated by the C6 and
C7 nerve roots via the
radial nerve.

Wrist extensors are

innervated by C6 and C7
nerve roots via the radial
nerve

Finger flexion is
innervated by the C8
nerve root via the median
nerve
Testing for hand grip (C7-8, T1)
 Finger abduction or
"fanning" is innervated by
the T1 nerve root via the
ulnar nerve.

Thumb opposition is
innervated by the C8 and
T1 nerve roots via the
median nerve.

Hip flexion is innervated

by the L2 and L3 nerve
roots via the femoral
nerve.
 Abduction of the hip is
mediated by the L4, L5
and S1 nerve roots.

Hip extension is
innervated by the L4 and
L5 nerve roots via the
gluteal nerve .

Knee extension by the

quadriceps muscle is
innervated by the L3 and
L4 nerve roots via the
 Ankle dorsiflexion is
innervated by the L4 and
L5 nerve roots via the
peroneal nerve.

Ankle plantar flexion is

innervated by the S1 and
S2 nerve roots via the
tibial nerve.

Extensor halucis longus

muscle is innervated by
the L5 nerve root .
- Muscle tone
When a normal muscle with an intact nerve supply is relaxed
voluntarily, it maintains a slight residual tension known as muscle tone.
This can be assessed best by feeling the muscle’s resistance to
passive stretch.
Results of muscle tone examination:
A) Normotonia = normal tone

B) Hypertonia which may be:

i) Spastisity (Clasp knife-UMNL) increased
resistance at the beginning of movement only.
ii) Rigidity (Lead-pipe or cogwheel) increased
resistance through out the range of movement.
e.g. parkinsonism

C) Hypotonia as in cases of:

1- LMNL.
2- Acute stage of UMNL.
3- Chorea.
4- Cerebellar ataxia.
mparison of spasticity and rigi
Characteristics Rigidity Spasticity
Lesion Of extra-pyramidal origin Mostly due to internal
mostly corpus striatum lesion capsule lesion (UMNL )

Mechanism Due to increase discharge Due to increased discharge

from alpha neurons from gamma neurons

Resistance Resistance in muscle Of clasp knife rigidity

contraction is maintained all (velocity dependent )
over the movement
(velocity independent )

Tremors Associated usually with Usually there is loss of

spontaneous or involuntary voluntary movements
movements.

Tendon jerk Normal exaggerated

4-Reflexes
Superficial spinal reflexes:
Abdominal reflex.
Cremastric reflex.
Planter reflex.
Flexor withdrawal & crossed extensor reflex.
Positive supporting & negative supporting reflex.

N.B.
All superficial reflexes are absent in UMNL &LMNL……???
The Planter reflex is only reflex which is modified and not absent in
UMNL..?
bdominal reflexes
Stimulus: Light stroke to the anterior
abdominal wall
Receptors: Superficial receptors in the
anterior abdominal wall
Afferents: Somatic sensory nerves to
anterior abdominal wall
Center:
Upper abdominal reflex: T 7-T 10.
Lower abdominal reflex : T10- T 12.
Efferent: Motor nerve to anterior
abdominal wall.
Response: Contraction of the anterior
abdominal wall with deviation of the
umbilicus to the scratched side.
• Superficial (abdominal Abdominal Reflex
reflex, Cremasteric
reflex)
• Visceral (pupillary
response to light)
Cremastic Reflex
PERRL
• Pathologic
– + Babinski in adults
• DTRs (e.g. knee)
Abdominal Reflex
Planter
reflex
Stimulus: Scratching lateral side of the sole of
foot by a blunt object from heel to toes.
Receptors: Superficial receptors in the skin of
the sole of foot.
Afferents: Somatic sensory nerves.
Center: S 1 & 2
Response: Planter flexion of all toes.
Abnormal planter reflex:
Loss of reflex ( areflexia )
1-Tabes dorsalis
2-LMNL.
Modified reflex (Babiniski’s sign)
Sure sign of UMNL
fanning of the 4 toes & dorsiflexion of big toe.
False positive Babiniski’s sign:
Deep sleep.
Coma.
Anesthesia.
Infants below 1 year
Babinski reflex - an UMN sign
Plantar reflex
Babinski Response
Babinski’s Reflex (Adult)
ep reflexes (tendon jerks
Tendon jerk:
It is a reflex rapid contraction of the skeletal muscle
following sudden tapping on its tendon.
e.g.
Biceps jerk.
Triceps jerk.
Knee jerk.
Ankle jerk.
Jaw jerk.
The Reflex Hammer

Technique:
• You will need to use a reflex hammer when performing this
aspect of the exam. Regardless of the hammer type, proper
technique is critical.
• The larger hammers have weighted heads, such that if you
raise them approximately 10 cm from the target and then
release, they will swing into the tendon with adequate force.
• The smaller hammers should be swung loosely between thumb
and forefinger.
Small Hammers
 REFLEX TESTING
Technique:
• The muscle group to be tested must be in a neutral position (i.e. neither
stretched nor contracted).
• The tendon attached to the muscle(s) which is/are to be tested must be
clearly identified. The extremity should be positioned such that the
tendon can be easily struck with the reflex hammer.
• If you are having trouble locating the tendon, ask the patient to contract
the muscle to which it is attached. When the muscle shortens, you should
be able to both see and feel the cord like tendon, confirming its precise
location. You may, for example, have some difficulty identifying the
Biceps tendon within the Antecubital Fossa. Ask the patient to flex their
forearm (i.e. contract their Biceps muscle) while you simultaneously
palpate the fossa. The Biceps tendon should become taut and thus readily
apparent.
• Strike the tendon with a single, brisk stroke. While this is done firmly, it
should not elicit pain. Occasionally, due to other medical problems (e.g.
severe arthritis), you will not be able to position the patient’s arm in such
a way that you are able to strike the tendon. If this occurs, do not cause
the patient discomfort. Simply move on to another aspect of the exam.
Ankle jerk (S1, S2):

Technique:
• This is most easily done with the patient seated, feet dangling over the edge of the exam
table. Other positions: supine, crossing one leg over the other in a figure 4 or a frog-type
position.
• Identify the Achilles tendon, a taut, discrete, cord-like structure running from the heel to
the muscles of the calf. If you are unsure, ask the patient to plantar flex (i.e. “step on the
gas”).
• Strike the tendon directly with your reflex hammer.
• Be sure that the calf if exposed so that you can see the muscle contract.
• NORMAL RESPONSE: plantar flexion (contraction of the Gastrocnemius).
Knee jerk (L2, 3, L4):

Technique:
• This is most easily done with the patient seated, feet dangling over the
edge the exam table.
• Identify the patellar tendon, a thick, broad band of tissue extending
down from the lower aspect of the patella (knee cap). If you are not
certain where it’s located, ask the patient to extend their knee. This
causes the quadriceps (thigh muscles) to contract and makes the attached
tendon more apparent.
• Strike the tendon directly with your reflex hammer. If you are having
trouble identifying the exact location of the tendon (e.g. if there is a lot
of subcutaneous fat), place your index finger firmly on top of it. Strike
your finger, which should then transmit the impulse.
• For the supine patient, support the back of their thigh with your hands
such that the knee is flexed and the quadriceps muscles relaxed.
• NORMAL RESPONSE: The lower leg will extend at the knee.
(contraction of the Quadriceps)
Knee jerk
BICEP REFLEX (C5, C6 – Musculocutaneous Nerve):

Technique:
• Identify the location of the biceps tendon in the antecubital fossa. The
tendon will look and feel like a thick cord.
• The patient’s arm can be positioned in one of two ways:
A. Allow the arm to rest in the patient’s lap, forming an angle of slightly
more then 90 degrees at the elbow.
B. Support the arm in yours, such that your thumb is resting directly over
the biceps tendon (hold the right arm with your right)
• It may be difficult to direct your hammer strike such that the force is
transmitted directly on to the biceps tendon, and not dissipated amongst
the rest of the soft tissue in the area. If you are supporting the patient’s
arm, place your thumb on the tendon and strike this digit. If the arm is
unsupported, place your index or middle fingers firmly against the tendon
and strike them with the hammer.
• NORMAL RESPONSE: elbow flexion
BICEP REFLEX TESTING
BICEP REFLEX TESTING
 Biceps and brachioradialis
reflexes are mediated by
the C5 and C6 nerve roots.

Triceps reflex is mediated

by the C6 and C7 nerve
roots, predominantly by
C7.

Positive Hoffman response

is indicative of an upper
motor neuron lesion
affecting the upper
extremity in question.
 Knee jerk reflex is
mediated by the L3 and L4
nerve roots, mainly L4.
Pendular reflexes

Ankle jerk reflex is

mediated by the S1 nerve
root.

Positive Babinski's sign is

indicative of an upper
motor neuron lesion
affecting the lower
extremity in question.
• Triceps (C6, C7)
- flex px’s arm at the
elbow, w/ palm toward
the body, pull it
slightly across the
chest
- strike the triceps
tendon above the
elbow
- watch for contraction
of the triceps muscle &
elbow extension
BRACHIORADIALIS REFLEX (C5, C6 – Radial Nerve):

Technique:
• This is most easily done with the patient seated. The lower arm
should be resting loosely on the patient’s lap.
• The tendon of the Brachioradialis muscle cannot be seen or well
palpated, which makes this reflex a bit tricky to elicit. The tendon
crosses the radius (thumb side of the lower arm) approximately 10
cm proximal to the wrist.
• Strike this area with your reflex hammer. Usually, hitting anywhere
in the right vicinity will generate the reflex.
• NORMAL RESPONSE: elbow flexion and supination of the
forearm (turn palm upward).
BRACHIORADIALIS REFLEX
BRACHIORADIALIS REFLEX
TRICEPS REFLEX (C6, C7):

Technique:
• Identify the triceps tendon, a discrete, broad structure that can be
palpated as it extends across the elbow to the body of the muscle,
located on the back of the upper arm. Ask the patient to extend their
lower arm at the elbow while you observe and palpate in the appropriate
region
• The arm can be placed in either of 2 positions:
A. Gently pull the arm out from the patient’s body, such that it roughly
forms a right angle at the shoulder. The lower arm should dangle
directly downward at the elbow.
B. Have the patient place their hands on their hips.
• NORMAL RESPONSE: the lower arm to extend at the elbow and swing
away from the body. If the patient’s hands are on their hips, the arm will
not move but the muscle should shorten vigorously .
TRICEP REFLEX (C6, C7 – Radial Nerve):
 Biceps and brachioradialis
reflexes are mediated by
the C5 and C6 nerve roots.

Triceps reflex is mediated

by the C6 and C7 nerve
roots, predominantly by
C7.

Positive Hoffman response

is indicative of an upper
motor neuron lesion
affecting the upper
extremity in question.
 Knee jerk reflex is
mediated by the L3 and L4
nerve roots, mainly L4.
Pendular reflexes

Ankle jerk reflex is

mediated by the S1 nerve
root.

Positive Babinski's sign is

indicative of an upper
motor neuron lesion
affecting the lower
extremity in question.
Reinforcement of the jerk (Jandrassik’s
manoeuvre):
Jaw jerk

Put the thumb on chin with the mouth

half open in relaxed state.
Tap on your finger by hammer.
Normally this jerk is absent.
Sudden closure of the mouth indicates
hyper-reflexia= bilateral upper motor
neuron lesion of the trigeminal nerve.
Clonus
ABNORMAL REFLEXES IN PYRAMIDAL TRACT DISEASE

Hoffmann’s Sign
Have pt present pronated hand with fingers
extended and relaxed. With your thumb, press his
fingernails to flex the terminal digit and stretch his flexor
Abnormal response: flexion and adduction of thumb
 Sensory
Examination
 Sensory
• Fine touch, Vibration, and
Proprioception- Posterior column

• Light touch, Pain, and

Temperature­- Spinothalamic
tract
The essential aim of examination of any
sensation is to examine the integrity
of the sensory pathways.
Principles of sensory examination
1- Subjects should be sufficiently undressed.
2- We have to explain each test to the subject.
3- Eyes must be closed.
4- Be systematic, begin distally, move proximally.
5- Using the same strength of stimulus during
examination.
6- When necessary assess for a sensory level, peripheral
nerve or dermatomal sensory impairment.
7- Compare the corresponding areas on the 2 sides
together.
 Pain Light touch

Joint position Discrimination

 Stereognosia
• Shoulders (C4)
• Lateral aspect of the upper arms (C5)
• Medial aspect of the lower arms (T1)
• tip of the thumb (C6)
• tip of the middle finger (C7)
• tip of the pinky finger (C8)
Graphesthesia
• Thorax, nipple level (T4)
• Thorax, umbilical level (T10)
• Upper part of the upper leg (L2)
• Lower-medial part of upper leg (L3)
• Medial lower leg (L4)
• Lateral lower leg (L5)
• Sole of foot (S1)
 Sensory Function Tests:
Sensory Exam: Light Touch
Sensory Function Tests:
Sensory Exam: Vibration
Testing vibratory sensation
Sensory Function Tests:
Sensory Exam: Vibration
 Sensory Function Tests:
Proprioception: Position sense
Sensory Function Tests:
Stereognosis
Sensory Function Tests:
Graphesthesia
 Sensory Function Tests:
Two-point discrimination
Sensory Function Tests:
Dermatomes
DERMATOMES
 Primary Sensation
•Light Touch
•Pinprick
•Vibration
•Joint Position
•Temperature
•Two point discrimination
•The pattern of sensory loss can provide important information that helps
localize lesions to particular nerves, nerve roots, and regions of the spinal
cord, brainstem, thalamus, or cortex
 Cortical sensations

•Graphesthesia
•Sterognosis
•Double Simultaneous Stimulation
•Intact primary sensation with deficits in cortical sensation such as
agraphesthesia or astereognosis suggests a lesion in the contralateral sensory
cortex. Note, however, that severe cortical lesions can cause deficits in
primary sensation as well. Extinction with intact primary sensation is a form of
hemineglect that is most commonly associated with lesions of the right
parietal lobe. Extinction can also be seen in right frontal or subcortical lesions,
or sometimes in left hemisphere lesions causing mild right hemineglect

http://www.neuroexam.com/
Special Sense
Examination
 Visual Field
The visual field of one eye (monocular) is the maximum area of space
that can be seen by this eye (while it is fixed).

Importance of visual field examination: (uses of perimeter)

1) Diagnosis of lesions in the visual pathway.

2) Diagnosis of blind areas in the visual field:

- Physiological blind spot (optic disc).

-Pathological blind spot (Scotoma).

3) Diagnosis of retinitis pigmentosa - multiple scotomas.

Normal field: It is not circular, it extends 50 degrees upwards, 70 degrees

downwards, 60 degrees nasally and more than 90 degrees temporally.
Confrontation test
 Visual fields
-Used to evaluate peripheral vision
• Two Methods
– Confrontational
Method
– Perimetry - assesses
peripheral vision,
visual fields
PERIMETRY
Demonstration of blind spot (blind spot card )
You can discover the blind spot in your left eye by closing your right eye and
holding this picture about 4 inches (arm length) from your face.
While focusing on the cross, gradually move the picture away from you until the
circle vanishes from view. At this time, the image of the circle is striking the blind
spot of your left eye.
Pupillary light reflex:
It is a reflex constriction of both
pupils when one eye is exposed to light.
In a dark room ask the subject to focus on
distant object and observe the size an
symmetry of both pupils.
Expose one eye to light from the lateral
side after separation of both eyes by barrier
on the nose and observe both pupils.
The normal response is constriction of both pupils.
Constriction of the exposed eye is called direct light
reflex
Constriction of unexposed eye is called consensual light
reflex.

The afferent limb is the optic nerve while the

efferent limb is the parasympathetics of
occulomotor nerve.
 Nervous pathway
Stimulus:
Exposure of the eye to light.
Receptors:
Photoreceptors (rods & cones in the retina).
Afferent:
Optic nerve to optic chiasma where nasal
fibers cross to the optic tract of the opposite
side. While the temporal fibers pass into
optic tract of the same side.
The fibers responsible for the light reflex leave
the optic tract at the posterior 1/3 of optic tract
to relay in pretectal nucleus on both sides.
Center:
Pretectal nucleus in midbrain.
Efferent:
Occulomotor nerve (3rd cranial nerve).
Response:
Bilateral meiosis (direct &indirect reactions to
light).
 Accommodation reflex (near reponse)

1- Meiosis (pupillary
constriction)
To prevent spherical and
chromatic aberrations.

2- Accommodation : Increase
refractive power of the lens by
increasing its anterior curvature
due to contraction of the ciliary
muscle..

3- Convergence of eyeballs by
contraction of the medial recti
muscles to
allow light rays to fall on fovea
centralis.
 Fundus examination
(Ophthalmoscope)

Formed of light source, mirror to reflect light

into the eye. Two groups of lenses:
-ve (biconcave) used in myopia,
+ve (biconvex) used in hypermetropia. We
use the
lenses to see the clearest picture even if the
examiner or the patient has error of refraction.
 Ophthalmoscope

• Used to inspect eye structures:

– Retina
– Choroid
– Optic nerve disc
– Macula
– Retinal vessels

Figure 13-4
Importance of the fundus examination
1- Optic disc.
2- Macula.
3- Retinal and choroidal blood vessels.
4- The retina and peripheral parts of fundus.
1- The Optic Disc
a) In case of increased intra-ocular tension (Glaucoma):
Larger and deeper cup. (Cup represent more than 1/3 of the disc).
b) In case of increased intracranial tension
There is swelling of the optic disc due to its oedema. papilloedema
2- Retinal Blood Vessels

Retinal Arteries
smaller. Orange-red, do not pulsate and are somewhat angular.
They cross and more commonly are crossed by retinal veins.
Retinal Veins
larger than retinal arteries and are a dusky red.less angular than
arteries, they pulsate.
4- The retina

Normally the retina appears pink due to choroidal vascularity

because retina is transparent.
In retinitis pigmentosa: there are dark patches on the
periphery of the retina. (dark pigments deposited in the rods)
Fundus examination is used to diagnose some disorders:

1- Diabetes mellitus: is characterized by hemorrhage and micro-

aneurysms. There are cotton wool spots.

2- Hypertension:
Diffuse and focal or segmental constriction of the retinal arteries, Disc
edema, Retinal hemorrhages, Exudates (spots, streaks, and clusters of
white to gray material in the retina)

3-The lenses required to focus on the patient's retina give an indication of

any optical abnormality.

Myopia : Minus (concave) lenses are required.

Hypermetropia : Plus (convex) lenses are required.
Ishihara’s color plate’s book
Test for visual acuity

Landolt's chart for

measuring visual acuity Snellen's chart
Snellen Chart

Figure 13-7
 • clouding or interference in the cornea,
lens, aqueous or vitreous space
• malfunction of the retina, optic nerve or
intracranial visual pathway
• flashing or flickering light- may indicate
retinal traction or migraine
• floating spots – may represent normal
vitreous body strands or pathologic
presence of blood, pigment, or
inflammatory cells in the vitreous body
DIPLOPIA • Diplopia – double vision, may be caused
by refractive correction, muscle
imbalance, neurologic d/o
RETINAL DETACHMENT
NORMAL
VISION
MACULAR DEGENERATION
- loss of central vision
 GLAUCOMA
-loss of peripheral vision
 CATARACT
-hazy & out of focus
DIABETIC RETINOPATHY
- blind spot
AUDITORY SYSTEM

Hearing and balance problems

can reduce the ability to
communicate, limit social
activities, and hinder the
constructive use of leisure time.
The ears are a pair of complex
sensory organs for both hearing
and balance. Their location on
either side of the head produces
binaural hearing, allows the
detection of sound direction, and
aids in maintaining equilibrium.
 Hearing Examination
Types of Hearing Loss:
Conductive hearing loss:
Occurs when sound is not conducted efficiently through the outer
ear canal to the ear drum and the bones of the middle ear.
Blocking of ext ear e.g. wax, ruptured ear drum, diseases of the
middle ear and stiffening of foot of stapes (otosclerosis).

Sensorineural hearing loss:

Occurs when there is damage to the inner ear (cochlea) or to the
nerve pathways from the inner ear to the brain.

Hearing tests
Diagnosis of deafness Diagnosis & types Diagnosis, types & degree

Watch test Rinne & Weber tests Audiometry

Watch test

Ask your partner to close one ear with the finger.

Slowly bring a watch with a loud click near the other ear.
Notice the distance at which the ticking of the watch is first heard.
Compare this with the other ear.
Ask your partner to cup his hand over his ear and repeat steps (2&3).
Grossly assess hearing in each ear while masking the hearing in the
other ear by occluding the external meatus with your index finger

Test the pt’s. sensitivity by whispering numbers into his ears and
asking him to repeat it
 C. Tests for Auditory Acuity
• – assessment of
the middle and
inner ear for
hearing.

• • Whispered
voice or ticking
watch test
Weber test
Check for lateralization of sounds conducted through the bones
 C. Tests for Auditory Acuity
• • Weber test
Rinne test

Compare air conduction and

bone conduction
Interpretation of Rinne test:
Normally air conduction continue for 45 sec. after ending
of bone conduction (Rinne positive).
In conductive hearing loss, bone conduction is greater
than air conduction (Rinne negative).
In sensorineural deafness, air conduction is greater than
bone conduction but in reduced form than normal
(reduced Rinne positive ).

Interpretation of Weber test:

Normally, the sound is heard in the center of the head
or equally in both ears.
Sound localizes toward the poor ear with
a conductive loss.
With a sensorineural hearing loss, sound
localizes toward the good ear.
 C. Tests for Auditory Acuity
• • Rinne Test
Coordination
Examination of the cerebellar functions

To assess coordination, observe the patient’s performance

in:

Tests for rapid alternating movements.

Tests for point to point movements.
Gait examination.
Romberg,s test.
Tests for pronation drift.
Tests for overshooting (arm flexion test).
I- Rapid alternating movements (diadochokinesia)
 II- Point to point movements

1) Finger to nose test (eye closed)

2) Fully extend his arm trying to
touch your thumb, first with his
1) Finger to nose test (eye closed)
eyesto touch
Ask the patient closed the tipthen with
of his nose witheyes
his indexopen
finger.
several times.
3) Finger to finger (toe) test

Failure to do this test with eyes opened= motor ataxia

Failure to do this test with eyes closed= sensory ataxia (Loss of position
sense).
Legs
Heel- knee (chin) test
Ask the patient to run his heel down his chin smoothly and quickly

In cerebellar disease, the heel may overshoot the knee

and then oscillate from side to side down the chin. When
position sense is lost the heel is lifted too high and the
patient rises to look, with eyes closed performance is poor.
Wrist slapping test
 Arm flexion (pulling) test (rebounding)

cerebellum.
 Arm flexion (pulling) test (rebounding)

cerebellum.
 Arm flexion (pulling) test (rebounding)

cerebellum.
 Cerebellar Function
1. Gait and posture
– Heel to toe in
straight line
– Walking on toes
and heels
– Hop on one foot

Note width of gait

Cerebellar Function
 Cerebellar Function, con’t

2. Coordination of hands and legs

– RAM
– nose to examiner’s finger
– heel to shin coordination
Cerebellar Function, con’t
RAM
Cerebellar Function, con’t
RAM
 Deltoid muscle is
innervated by the C5
nerve root via the axillary
nerve.

Pronator Drift

Biceps muscle is
innervated by the C5 and
C6 nerve roots via the
musculocutaneous nerve.
Cerebellar Function, con’t
Nose –to - Finger Test
Cerebellar Function, con’t
Heel to Shin
 Romberg test

•With the eyes open, three sensory systems provide input to the
cerebellum to maintain truncal stability. These are vision,
proprioception, and vestibular sense. If there is a mild lesion in the
vestibular or proprioception systems, the patient is usually able to
compensate with the eyes open. When the patient closes their eyes,
however, visual input is removed and instability can be brought out. If
there is a more severe proprioceptive or vestibular lesion, or if there is
a midline cerebellar lesion causing truncal instability, the patient will
be unable to maintain this position even with their eyes open

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 Cerebellar con’t
3. Romberg:
Stand upright, place feet
together, then close eyes
• loss of balance means +
Romberg test

Be prepared to protect client

from falling!
• Romberg test
Coordination
睜眼和閉眼都搖晃 cerebellar deficit
(cerebellar ataxia)
睜眼正常，閉眼搖晃 (positive Romberg’s
sign) proprioceptive deficit (sensory
ataxia)

• Tandem gait:
ethanol intoxication, weakness, poor
position
sense, vertigo and leg tremors
Thank
you
for
your
attent
ion!!!
Coordination
Coordination