13. Do you experience any numbness or
tingling? When & where does this occur?
Do you experience seizure? How often?
Does anything seem to initiate a seizure?
Do you experience headaches/ When
do they occur & what do they feel like?
Do you have muscle weakness?
Do you have slurring of speech?
14. Any head injury with or w/o loss of
consciousness? What treatment did you
receive?
Have you ever had meningitis,
encephalitis, injury to spinal cord, stroke?
Family history of HPN, stroke, Alzhiemer’s?
15. Do you smoke?
Describe your usual diet?
Do you lift heavy objects?
16. Mental Status
Cranial Nerves
Motor & Cerebellar System
Sensory System
Reflexes
17. Provide information about cerebral
cortex function
4 major component:
(a) Appearance
(b) Behavior
(c) Cognition
(d) Thought process
19. LEVEL OF
CONSCIOUSNESS
LEVEL Response
Alert Responds fully & appropriately to
stimuli
Lethargic Drowsy, responds to questions then
fall asleep
Obtunded Open eyes, responds slowly,
confused
Stuporous Arouses from sleep only from painful
stimuli
Comatose Unarousable with eyes closed
20. Score
Eye Opening Response Spontaneous opening 4
To verbal command 3
To pain 2
No response 1
Most integral motor response Obeys verbal commands 6
Localizes pain 5
Withdraws from pain 4
Flexion (decorticate rigidity) 3
Extension (decerebrate rigidity) 2
No response 1
Most appropriate verbal response Oriented 5
Confused 4
Inappropriate words 3
Incoherent 2
No response 1
TOTAL SCORE 3-15
21.
22. Facial Expression
Speech
› Quantity
› Rate
› Volume
› Fluency & rhythm
Mood & Affect
› Mood – a sustained state of inner feeling
› Affect – how do the patient appear to you
(labile, blunted or flat)
23. Orientation – Person, place & time
Attention Span
Recent Memory
Remote Memory
New Learning
Judgment
25. Provide information regarding
transmission of motor & sensory
messages (head & neck)
Are evaluated during the head, neck,
eye & ear examinations
26. No. Cranial Nerve Function
I Olfactory Sense of smell
II Optic Vision
III Oculomotor Pupillary constriction, opening the eye & most
extraocular movements
IV Trochlear Downward, inward movement of the eye
V Trigeminal Motor – temporal & masseter muscles (jaw
clenching), lateral movement of the jaw
Sensory – facial. 3 divisions: (1) ophthalmic (2)
maxillary (3) mandibular
VI Abducens Lateral deviation of the eye
VII Facial Motor – facial movements: facial expressions,
closing the eye, closing the mouth
VIII Vestibulochoclear Hearing (cochlear division) & balance
(Acoustic) (vestibular division)
27. No. Cranial Nerve Function
IX Glossophrayngeal Motor – phraynx
Sensory – posterior portions of the eardrum
& ear canal, the phraynx, posterior tongue,
including taste
X Vagus Motor – palate, pharynx, larynx
Sensory – pharynx & larynx
XI Accessory Motor – sternocledomastoid & upper
portion of the trapezius
XII Hypoglossal Motor - tongue
28. Cranial Test
Nerve
I Smell
II Visual acuity, visual fields & ocular fundi
III, IV, VI Pupillary reactions, Extraocular movements
V Corneal reflexes, facial sensation & jaw movements
VII Facial movements
VIII Hearing
IX, X Swallowing & rise of the palate, gag reflex
V, VII, X, XII Voice & speech
XI Trapezius & Sternocleidomastoid contraction
XII Inspection of the tongue
30. Visual Acuity
-Test for near vision
Presbyopia –
impaired near
vision
-Test for distant
vision (Snellen’s Chart)
Myopia –
“nearsightedness”
Hyperopia –
“farsightedness”
31. Optic Fundi
Abnormalities :
Retrobulbar neuritis –
inflammatory process of
the optic nerve behind
the eyeball (MS)
Papilledema (choked
disk) swelling of the optic
nerve as it enters the
retina (tumors of
hemorrhage)
Optic atrophy – change
in color of the disc &
decreased visual acuity
(MS, tumor)
34. CN III, IV and VI
inspect margins of
eyelids – eyelid covers
2mm of iris
* Ptosis = weak eye
muscles
assess for extraocular
movements
> six cardinal fields:
H method or wheel
methods
Test for convergence
35. Muscle Cranial Nerve Function
Lateral Rectus VI Moves eye laterally
Medial Rectus III Moves eye medially
Superior Rectus III Elevates eye
Inferior Rectus III Depresses eye
Inferior Oblique III Elevates eye ; turns it laterally
Superior Oblique IV Depresses eye, turns it laterally
36. * Abnormal: strabismus ptosis
Nystagmus -
rythmic oscillation
of the eyes
Strabismus –
lack of muscle
coordination
diplopia
Diplopia –
double vision
37. Pupillary Reaction to Light
& Accomodation (PERRLA)
round, equal in size &
shape in the center of the
eye
Pupil inequality of <
0.5mm = ANISOCORIA
Direct light reflex =
pupillary constriction in the
same eye
Consensual light reflex =
pupillary constriction in the
opposite eye
* both pupils should
constrict briskly
38.
39.
40.
41.
42.
43.
44. Motor function
Temporal & masseter
mucsles contract bilaterally
Abnormal:
PNS or CNS dysfunction
(bilateral)
Lesion of CN V
(unilateral)
Sensory function
3 division: ophthalmic,
maxillary & mandibular
absence: lesion in the:
Trigeminal nerve
Spinothalamic tract
Posterior columns
Corneal Reflex
absence: lesions in the:
Trigemeinal nerve
Motor part of CN VII
45.
46. Motor Function:
Facial expressions
Movements –
symmetrical
Abnormal:
Bell’s Palsy
Paralysis
lower part of
the face
Sensory Function:
identify different
flavors
Abnormal: inability
to identify correct
flavor = CN VII
impairment
Corneal Reflex
regulates the
motor response
48. Weber’s Test
Evaluate conduction of sound
waves through bones
Helps distinguish between
conductive hearing & sensorineural
hearing
conductive hearing – sound
waves transmitted by the
external & middle ear
sensorineural hearing –
sound waves transmitted by
the inner ear
Normal:
vibrations heard equally
in both ears
Abnormal:
Tinnitus
deafness
Conduction hearing loss
Sensorineural hearing loss
49. Rinne Test
Compares air & bone conduction sounds
Normal:
Air conduction heard longer than bone
conduction
Abnormal:
Conductive hearing loss – BC > AC
Sensorineural hearing loss – AC > BC
50. Caloric Test
Test the vestibular
portion of the nerve
Performed only
when client is
experiencing
dizziness or vertigo.
51. Motor function: Sensory Function:
Normal: soft palate Gag Reflex
rises, uvula remains in Normal:
midline intact gag reflex
symmetrically diminished
Abnormal: or absent in some normal
> soft palate does people
not rise – bilateral lesion Abnormal:
of CN X risk for aspiration
> unilateral rising of
soft palate & deviation Motor activity of pharynx
of uvula to the normal Normal:
side – unilateral lesion swallows w/o difficulty
CN X no hoarseness noted
Abnormal:
Dysphagia
vocal changes
52. Trapezius Muscle
Normal:
> symmetric,
strong contractions
Abnormal:
> asymmetric
muscle contraction
> drooping of the
shoulder
53. Sternocleidomastoid
Muscle
Normal:
> ease of movement
> wide range of
motion
Abnormal:
> muscle weakness
> muscle atrophy
> uneven shoulders
54. Movement &
strength of tongue
Note atrophy,
tremors & paralysis
Normal:
> Movement is
symmetrical &
smooth
> Bilateral strength is
apparent
> tongue at midline
Abnormal:
> Fasciculation –
PNS disease
55. To determine functioning of the
pyramidal & extrapyramidal tracts
To determine balance & coordination
Focus on:
Body position
Involuntary movements
Characteristics of the muscles
Coordination
56. Natural walk
› Note posture, freedom of movement,
symmetry, rhythm & balance
› Normal: Steady; opposite arm swings
57. observe for:
stiffness or relaxation
equality of steps
pace of walking
position & coordination of arms
ability to maintain balance
58. Heel to toe walk on toes walk on heels
› Abnormal: Affected by disorder of the motor,
sensory, vestibular & cerebellar systems
: drug or alcohol intoxication, motor neuron
weakness or muscle weakness
59. Romberg’s Test
assesses coordination &
equilibrium (CN VIII)
note any unsteadiness or
swaying
Normal: stands erect with
minimal swaying with eyes
open or closed
Abnormal: swaying greatly
increases, moving feet apart =
disease of posterior columns ,
vestibular dysfunctions or
cerebellar disorders
65. Finger – to – nose Test
› Pass – point test
› Assesses coordination & equilibrium
› Observe for movement of arms
Smoothness of movement
Point of contact of finger
› Normal: able to touch fingers to nose with
smooth, accurate movements with little
hesitation
› Abnormal: cerebellar disease
66. Finger – to –
nose – test
a.Normal
b.Ataxia
c.Intention
Tremor
67. Test for Pronator Drift
Normal:
Able to hold arm in
this position well
Abnormal:
Downward
movement of arm w/
flexion of fingers &
elbow
68. Rapid alternating movements
observe rhythm, rate &
smoothness of the movements
Normal:
able to touch finger to
thumb rapidly
rapidly turns palms up &
down
Abnormal:
Unable to perform rapid
alternating movementrs =
cerebellar disease, upper motor
neuron weakness
Uncoordinated movements or
tremors ( dysdiadochokinesia –
impairment of the power to
perform alternating movements
in rapid, smooth & rhythmic
succession)
69. Heel to shin Test
Normal:
able to run each
heel smoothly
down each shin
Abnormal:
Deviation of heel
to one side =
cerebellar disease
70. Test several kinds of sensation:
› Pain & temperature (spinothalamic
tracts)
› Position & vibration (posterior columns)
› Light touch ( both of these pathways)
› Discriminative sensations
71. Pay special attention to:
› Where there are symptoms such as
numbness or pain
› Where there are motor or reflex
abnormalities that suggest a lesion of the
spinal cord or PNS
› Where there are trophic changes
72. Sensory Function
Test for senses and stimulus response
General Approach:
Instruct the patient to identify the
sensations as you change stimulus and
respond to your questions as needed
Keep the patient’s eyes closed
Do the procedures in random, letting the
patient assess location of the area tested
73. Test for spinothalamic tract
› Light touch
Abnormal:
Anesthesia - absence of touch sensation
Hypoesthesia – decreased sensitivity to touch
Hyperesthesia – increased sensitivity to touch
› Sharp and Dull test
Abnormal:
Analgesia –absence of pain sensation
Hypoalgesia – decreased sensitivity to pain
Hyperalgesia – increased sensitivity to pain
› Temperature testing
74. Test for Posterior Column Tract
A. Vibration
› Tuning fork over bony prominences (toes,
ankle, knee, iliac crest, spinal process,
fingers, sternum, wrist, elbow)
› Inability = posterior column disease or
peripheral neuropathy (DM, chronic alcohol
abuse)
75. Test Stereognosis
ability to identify
object without
seeing it
astereognosis –
inability to identify
object correctly
77. Test for Two point
Discrimination
ability to identify the
smallest distance
between two points
Distances & locations:
Fingertips - 0.3 to 0.6cm
Hands & feet 1.5 – 2cm
Lower leg 4cm
Abnormal: cortical disease
78. Test Topognosis
- ability to identify an area that has been
touched
Abnormal: sensory or cortical disease
Test position sense of joint movement
- great toe is dorsiflexed, plantar flexed
or abducted
79. Reflect integrity of the reflex at specific
spinal levels and cerebral cortex function
Approach
› Done last
› Patient in sitting position
› Limbs to be tested should be relaxed,
partially stretched
Clenching teeth, humming, counting
ceiling blocks, interlocking of hands
80. Reflex hammer
Hold handle of the reflex
hammer between
thumb & index finger so
it swings freely
Palpate the tendon that
you will need to strike
Tap the tendon, not the
muscle or bone!
With a relaxed hold,
Apply a short, quick &
direct blow using the
reflex hammer onto the
muscle’s insertion
tendon
• Pointed end - smaller
target (finger)
• Flat end – wider
target, produce
diffuse impact
81. Evaluation
0 NR
1+ Diminished
2+ Normal
3+ Brisk, above normal
4+ Hyperactive
82. Biceps Reflex
Evaluates function of spinal
levels C5 & C6
Approach:
Partially bend patient’s
arm with elbow with palm
up
Place your thumb over
the biceps tendon
Strike your thumb with the
reflex hammer
Normal: 1+ to 3+ flexion &
contraction of biceps muscle
Abnormal: NR or exaggerated
83. Triceps Reflex
Evaluates function of spinal
levels (C6 & C7)
Approach:
Ask patient to hang his
arm freely while
supported with your
nondominant hand
With elbow flexed, tap
the tendon above the
olecranon process
Normal:
1+ to 3+ elbow extends,
triceps contracts
Abnormal:
NR or exaggerated
84. Brachioradialis Reflex
Evaluates function of
spinal levels C5 & C6
Approach:
Ask patient to flex elbow
with palm down
Hand resting on
abdomen or lap
Tap the tendon of the
radius (2 inches above
wrist)
Normal:
1+ to 3+ forearm flexes
& supinates
Abnormal:
NR or exaggerated
85. Patellar/Knee Reflex
Evaluates function of spinal
levels L2, L3 & L4
Approach:
Ask patient to hang both
legs freely off examination
table
Tap the patellar tendon
located just below the
patella
Normal:
1+ to 3+, knee extends,
quadriceps muscle
contracts
Abnormal:
NR or exaggerated
86. Achilles Reflex
Evaluates function of spinal
levels S1 & S2
Approach:
Patient’s leg hanging
freely, dorsiflex the foot
Tap achilles tendon with
the reflex hammer
Normal:
1+ to 3+, plantar flexion of
the foot
Abnormal:
NR or exaggerated
* May be absent or difficult to
elicit for older clients
87. Ankle Clonus Testing
(Hyperreflexia)
Done when other reflexes have
been hyperactive
Approach:
Place one hand under the
knee to support leg
Briskly dorsiflex the foot
toward the client’s head
Normal:
No rapid contractions or
oscillations (clonus) of the
ankle
Abnormal:
Repeated rapid
contractions or oscillations
of ankle & calf muscle
( lesions of upper motor
neurons)
88. Plantar/Babinski Reflex
Evaluates function of spinal levels
L5, S1
Approach:
Use the end of the reflex
hammer
Stroke lateral aspect of the
sole from heel to the ball of
the foot
Curve medially across the
board
Normal:
Flexion of the toes
Abnormal:
Extension (dorsiflexion) of the
big toe & fanning of all toes =
normal in children 2 yrs &
below, lesions of UMN, drug &
alcohol intoxication, brain
injury, subsequent epileptic
seizure
89.
90. Abdominal Reflexes
Evaluates function of spinal levels T8,
T9, T10 for upper & T10, T11, T12 for
lower)
Approach:
Use the wooden end of a
cotton tipped applicator
Lightly & briskly stroke each
side of the abdomen
Above & below the umbilicus
Normal:
Abdominal muscles contract
Umbilicus deviates toward the
side being stimulated
Abnormal:
Absent = LMN or UMN lesions
* Abdominal reflex may be concealed
because of obesity or muscular
stretching from pregnancy
91. Hyperreflexia = UMN lesion
Hyporeflexia = LMN lesion
Clonus = severe hyperreflexia
- repeated rhythmic contraction elicited
by striking a tendon/dorsiflexing the ankle
92. Neck Mobility
Make sure there is no cervical vertebrae or
cervical cord injury
Approach:
› supine position
› Place hand behind patient’s head
› Flex neck forward until chin touches the chest if
possible
Normal:
› supple neck
› Easily bend head & neck forward
Abnormal: Nuchal Rigidity
› Pain in the neck
› Resistance to flexion
Meningeal irritation, arthritis or neck injury
94. 2. Kernig’s Sign
Approach:
Flex patient’s leg at
both the hip & knee
Then straighten the
knee
Normal:
Discomfort behind
the knee during full
extension
No pain is felt
Abnormal:
Pain & increased
resistance to
extending the knee
Bilateral = meningeal
irritation