Clinical Exam 1

Goniometry procedure

*** Assess normal using uninvolved side--> Verbal estimate of ROM and end feel on the opposite side (demonstrate motion pt is supposed to do, measure and record uninvolved ROM) *** When measuring: 1) Patient position 2) stabilization of proximal segment 3) Verbal estimate and end feel 4) Measurement with goniometer 5) Documentation

Deep Tendon Reflex Tests

-- Biceps Jerk (C5) -- Brachioradialis (C6), assessing elbow flexion, not radial deviation -- Triceps jerk (C7) -- Quadriceps femoris or knee jerk (L4) --Achilles or ankle jerk (S1)

Sensory loss patterns

-- Hemiparesis: entire L or R half of body is lost -- Spinal cord injury: entire lower half of body from umbilicus down is lost -- Peripheral neuropathy: stocking glove pattern found in diabetes, distal forearms and distal legs affected -- cauda equina injury/syndrome: medial areas of butt, legs extending to middle portion of midcalf

Documenting ROM (goniometry)

-- side tested, joint movement, AROM or PROM, degrees, end feel -- e.g.: R elbow flexion PROM 130degreees, soft end feel --lack of full extension: e.g..: elbow ext -20degrees, elbow flex 130deg OR elbow ROM 20-130degrees --hyperextension e.g.: elbow extension 10deg, elbow flex 130deg OR elbow ROM 10-0-130deg

Normal end feels and where they're found in body

--Hard: bone on bone (e.g.: elbow ext) --Soft: soft tissue approximation (e.g.: elbow flex, knee flex) --Firm: leathery feel as result of muscular, capsular or ligamentous stretch (e.g.: shoulder external rotation, MPJ extension

Abnormal end feels and examples

--Hard: e.g.: OA, loose body (fragment that breaks off joint and into joint space,limiting motion), fracture --Soft: e.g.: edema, synovitis, swelling --Firm: e.g.: capsular, muscular, ligamentous or fascial shortening --Springy: rebound or springy feel indicating internal derangement within joint (e.g.: meniscal tear) --Spasm: muscle spasm with vibrant twang, indicates severe lesion (with pain- fracture, without pain- CNS lesion) --Empty: no mechanical resistance felt but patient refuses to let you continue due to pain (e.g.: acute bursitis, extra-articular abscess, neoplasm)

L2 myotome (muscle, innervation, dermatome)

--Iliopsoas --Femoral n. --Upper thigh

Inert vs. contractile tissue lesions

--Inert: pain with active and passive movement in the SAME direction --Contractile: pain with active and passive movement in OPPOSITE directions

Inert tissue lesion diagnosis (PROM)

--Painless but full ROM: no lesion of inert tissues --Pain and limited in all directions: acute arthritis or capsulitis (capsular pattern, e.g.: frozen shoulder is limited in ext rotation>abduction>int rotation) --Pain and increased or decreased ROM in some, but not all directions (non capsular pattern, e.g.: ligament sprain, local capsular adhesion, internal derangement/pathology within joint) --Painless limited movement: abnormal bony end feel--> symptomless arthritis (only hurts when arthritis becomes inflamed)

What do you do to test a muscle where a two-joint muscle is the antagonist?

--Place 2 joint muscle on slack so prime mover is not working against the antagonist --e.g.: test anterior tibialis, put gastrocnemius on slack.

Stereognosis

--Place common objects (coins, keys, rings, paper clip) in pt's hand and ask the to identify If pt can manipulate but not identify the object then there's a dysfunction of sensory processing

Balance tests

--Romberg test (EO/EC)- no shoes and socks, grade based on amount of sway (1=minimal, 2=mild, 3-moderate, 4: step or fall), abnormal test (fall w eyes closed) indicates a proprioceptive deficit --Tandem romberg test- look at strategy they use to maintain balance, often demonstrated balance ability of back leg --Tandem GAIT test: info ab ability to control balance during challenging tasks --single leg stance: free leg flexed, not touching standing leg; largely indicates ability to stand on one leg during walking (proper GAIT), and hip and knee strength. Older adults: time decreases, <20 seconds indicates fall risk

How do sensory signals get transmitted to brain?

--Sensation is detected and travels down afferent (sensory) neuron towards spinal cord and brain --brain then sends response signal back down efferent (motor) neurons, which then cause the muscle or organ to then perform an action

Contractile tissue lesion diagnoses (RIM)

--Strong and pain free: no lesion to muscle tested --Strong and painful: local minor lesion of muscle or tendon, 1st or 2nd degree tear (strain) --Weak and painful: severe lesion about the joint such as a fx (weakness due to reflex inhibition of muscle) --Weak and painless: severe lesion of muscle (3rd degree muscle tear or a nerve supply problem, e.g.: achilles tendon rupture)

Babinski Reflex test

--Tests for UMN lesion in adult (positive test is normal for baby) 1) Use metal end of reflex hammer 2) Stroke lateral sole of foot to MT heads and continue across ball of foot to medial side **pressure should be firm and even, but not painful** --Normal response: flexion of toes --Abnormal response: extension of great toe and fanning of other toes (abduction), indicates UMN lesion **Document as present or absent

Femoral nerve neuropathy from poison, considerable weakness and decreased sensation to femoral nerve (weakness, decreased sensation and reflexes)

--Weakness: --Decreased sensation: --Decreased reflexes:

Larger herniated disc with a resulting compression of L5 and S1 nerve roots (weakness, decreased sensation and reflexes)

--Weakness: --Decreased sensation: --Decreased reflexes:

Complete severance of common peroneal nerve from boating accident (weakness, decreased sensation and reflexes)

--Weakness: extensor hallucis longus and brevis, extensor digitorum longus and brevis, anterior tibialis, peroneus tertius, peroneus longus and brevis --Decreased sensation: lateral leg and whole dorsum of foot --Decreased reflexes: None

L5 nerve root compression, presents with considerable weakness and decreased sensation to the L5 nerve root (weakness, decreased sensation and reflexes)

--Weakness: extensor hallucis longus, extensor digitorum longus and brevis, posterior tib and gluteus medius --Decreased sensation: lateral leg to central dorsum of foot to digits 2-4 --Decreased reflexes: none

S1 nerve root compression which presents with considerable weakness and decreased sensation to the S1 nerve root (weakness, decreased sensation, decreased reflexes)

--Weakness: peroneus longus and brevis, gastrocnemius-soleus, gluteus maximus --Decreased sensation: lateral border of foot and posterior foot --Decreased reflexes: achilles

Have compression of deep peroneal nerve at level of fibular head due to a tight cast (weakness, decreased sensation and reflexes)

--Weakness: peroneus tertius, extensor digitorum longus and brevis, extensor hallucis longus and brevis, anterior tibialis --Decreased sensation: first dorsal web space --Decreased reflexes: N/a

Recently fractured tibia (superior third), you have tibial nerve neuropathy bc of this.(weakness decreased sensation and reflexes)

--Weakness: plantarflexion, toe flexion --Decreased sensation: heel and plantar surface of foot --Decreased reflexes: achilles

Recovering from spinal stenosis surgery, demonstrate compression of L4 and L5 nerve roots (weakness, decreased sensation and reflexes)

--Weakness: tib ant, extensor hallucis longus, extensor digitorum longus and brevis, posterior tibialis, gluteus medius --Decreased sensation: medial and lateral leg and medial and central dorsum of foot to digits 1-4 --Decreased reflexes: patella ?

L4 myotome (muscle, innervation, dermatome)

--anterior tibialis --deep peroneal nerve --medial leg to great toe

Contraindications to ROM measurement

--dislocation or unhealed fracture --immediately after surgical procedures to tendons, ligaments, muscles, joint capsule or skin (MD order) --myositis ossificans: abnormal Ca buildup within a muscle

L5 myotome (muscle, innervation, dermatome)

--extensor hallucis longus, extensor digitorum longus and extensor digitorum brevis (deep peroneal nerve); posterior tibialis (tibial n); gluteus medius (superiror gluteal n) --lateral leg and dorsum of foot

Coordination test check offs

--finger to nose: place PTs finger at arms length from pt, touch finger to nose-->PTs finger--> nose 5x, time with stopwatch. Look for dysmetria--> if they miss your finger or their nose (overshooting/undershooting), disjointed movement (tremors, should be smooth and precise), does it occur in a timely fashion --heel to shin: lower extremity version of finger-to-nose test, shoes off, ROM may not permit due to flexibility, strength, or lack of external rotation (not always coordination issue) --diadochokinesia: upper extremity is flipping of palms in lap and fingers to thumb test, lower extremity is tapping each foot as rapidly as possible; indicates dysdiadochokinesia (inability to rapidly alternate movement) --rebound: hold arms out in front of body w palms down, firmly press down pt's hands; look for excessive rebound past horizontal, also multiple oscillations (could indicate some type of cerebellar issue)

S2 myotome (muscle, innervation, dermatome)

--gastroc and soleus --tibial n --ischial tuberosities

When should you perform sensory testing?

--if someone has type II diabetes (potential for peripheral neuropathy) --spinal cord injury --all cervical and lumbar spine pathologies --patient report of numbness, pins/needles, tingling or other sensory loss descriptions --motor loss in peripheral nerve pattern --whenever you have orthopedic injury that doesn't make sense

Precautions for ROM testing

--infections or inflammation process --pain medication or muscle relaxant use --severe osteoporosis --hypermobile or subluxed joint (don't overstretch them, it's their genetics) --severe pain --hemophilia or hematoma --if bony ankylosis is suspected --acute soft tissue disruption injuries

Sensory testing documentation

--modality tested, findings (intact/normal, diminished, absent), area of deficit, side --e.g.: light touch diminished dermatome C6 on L e.g.: sharp/dull absent distribution median nerve on R

S1 myotome (muscle, innervation, dermatome)

--peroneus longus and brevis (superficial peroneal); gluteus maximus (inferior gluteal); hamstrings (tibial and peroneal); gastroc and soleus (tibial) --lateral foot and small toe

What is purpose of lower quarter screen?

--quick look at lumbar spine and lower extremity (saves time) --perform when pt history doesn't make sense with the injury (unspecified mechanism of injury with associated symptoms, e.g.: absence of trauma, unknown cause) --suspected lumbar spine involvement --shows whether certain activities provoke or change pt's pain

L3 myotome (muscle, innervation, dermatome)

--rectus femoris --Femoral n. --upper to medial thigh

MMT precautions

--risk or hx of CV disease, aneurysm, pacemaker, HTN, thrombophlebitis, recent embolus, marked obesity, CVA, MI --avoid Valsalva maneuver, especially w recent abdominal surgery --if fatigue can exacerbate pt's condition (e.g.: malnutrition, malignancy, COPD, multiple sclerosis, myasthenia gravis)

MMT documentation

--side tested, muscle tested, muscle grade, note any deviations --e.g.: R dorsiflexion (tib ant) 3+/5

Contraindications to MMT

--when AROM or PROM are contraindicated --when inflammation is present in region --when pain is present--> won't be accurate and could cause additional injury

Lower Quarter screen procedure

1) Ask if pt has had any recent changes with bowel or bladder control (S2-4 are mostly responsible for those, and thus we would refer them out if that was the issue as there is nothing a PT can do) 2) Posture in standing (spinal curvatures, postural landmark levels, leg length, pelvic symmetry)--> take off shoes, socks, and shirt, and stand ab shoulder-width apart, start posterior (Scoliosis), then side, then anterior (direction of feet and knee caps, height of ASIS's) 3) Lumbar clearing: a. flexion (stand behind and palpate PSIS, have pt tuck chin then slowly bend down) b. Extension (stand behind and slightly to side, palpate sacral sulci/medial and inferior to PSIS) c. Rotation (stabilize pelvis as they turn to look back towards you), d. Lateral (side) flexion *** ask if they have any symptoms or pain during all of these movements*** Document limitation and pain using the star diagram 4) Peripheral joint screen, AROM: A. Knee flexion - have pt stand and perform motions (short sitting for knee flexion); B. Hip- pt still standing (or short sitting) and test hip ext, abd and add (bring leg across body), then pt short sits to test hip flexion, internal and external rotation ; C. ankle- dorsiflex, plantar flex, inversion, eversion 5) Dermatomes (slide finger across dermatome regions, but explain it to them as you slide fingers across bilateral face first): bilateral and light touch 6) Myotomes (sitting): L2-3, L3, L4, L5, S1, S2, S3 7) Reflexes: **uninvolved side first, quads (L3-4), ankle jerk (S1), babinski 8) Straight leg raise (supine): pt has one leg extended and PT passively lifts extended leg up (both sides, one @ time)

Process of Clinical examination

1) Chart review 2) initial observation 3) Interview 4) physical examination 5) other components (CV, respiratory, cognitive, functional) 6) Diagnosis/evaluation 7) Set goals 8) Develop treatment plan 9) treat 10) re-evaluate

DTR Testing Documentation

1) Indicate which reflex was tested 2) Record as R side over L (R/L) 3) Indicate whether reinforcement was used --e.g.: Biceps reflex 2+/1+R ORRR DTR C5 2+/1+R

First thing you do for Nervous system testing

1) Observations of trunk or limbs, asymmetry of muscle size, fasciculations or twitches (LMN), tremors or akinesia, abnormal GAIT, dyskinesias

MMT procedure

1) Patient instruction- explain you're testing their muscle strength and that exerting their maximal effort is important 2) Patient positioning- no restricted motion, gravity-resisted position, proximal segment of joint optimally stabilized 4) Demonstrate motion to patient by passively moving the distal segment through full available ROM--> **assess for available ROM while you do this 5) Palpate muscles being tested and stabilize proximal segment, then have patient perform the motion --if they can hold for 5 seconds, begin applying resistance

Steps of testing goniometry

1) Patient positioning- no barriers preventing pt from achieving full ROM, start in neutral, make note of position you initially test them in. 2) Stabilization of proximal segment 3) Verbal estimate and end feel- passively move distal joint to end of PROM--> make estimate on their ROM and determine the end feel 4) Measurement with goniometer- position goniometer before motion is performed--> patient actively moves through ROM, then therapist moves segment through the final few degrees

Order of physical examination

1) Structural inspection (initial posture inspection we performed in LQS) 2) Upper/Lower quarter screen (only if necessary) **warn patient that they may have soreness** 3) ROM testing (AROM and PROM) +RIM 3a) perform goniometry after RIM 4) Strength evaluation (RIM/MMT/Myotomes) 5) Reflex/sensory testing (optional) 6) Joint play/accessory movements 7) Special tests 8) Palpation 9) CV exam, respiratory exam, perceptual/cognitive exam, functional exam

Deep Tendon Reflex signaling

1) Tap tendon which elicits tiny stretch on that part of tendon 2) Muscle spindle detects stretch and impulse is transmitted to spinal cord level via afferent (sensory) neuron 3) Signal never reaches brain, but that spinal cord level then sends impulse reaction to efferent (motor) neuron which causes the reflex to occur. 4) At same time, interneuron is effected and causes reciprocal inhibition of antagonist muscle (e.g. hamstrings in knee jerk reflex)

Deep tendon reflex procedure

1) muscles on slight stretch with patient looking away and eyes closed 2) **Test non-involved side first ALWAYS both sides 3) strike tendon briskly and firmly with reflex hammer--> if no DTR occurs after first time, use the reinforcement "Jendrassik" maneuver 3a) Jendrassik maneuver: upper extremities--> have pt squeeze both knees together as hard as they can and try again. Lower extremities--> have pt grab each hand with arms out in front of them bent and pull as hard as they can. Then perform reflex test again.

DTR Testing Grading

4+: very, very brisk response usually associated with clonus (rhythmic muscle spasm) 3+: very brisk response, stronger than normal 2+: NORMAL response 1+: suppressed or dampened response 0: no response 1+R: suppressed or dampened response that required a Jendrassik maneuver 0R: no response with Jendrassik maneuver **R denotes reinforcement used

Grading of MMT

5: Can hold for 5sec against maximal resistance 4: Can hold for 5sec against moderate resistance 3+: can hold for 3-5sec against minimal resistance 3: immediately breaks after pressure is applied 3-: Can move through >50% of ROM 2+: can move through <50% of ROM 2: moves through full ROM in gravity eliminated position 2-: moves through >50% of ROM in gravity eliminated position 1+: moves through <50% of ROM in gravity eliminated position 1: no movement but can feel contraction 0: No movement and no contraction at all in gravity-eliminated position

Alternatives to Babinski's test

All ways to test for UMN lesions in adults --Chaddock reflex (irritate lateral malleolus) --Gordon's reflex (squeeze calf) --Oppenheim's reflex (reflex hammer dragged down shin)

Temperature sensory test

Carried by anterolateral (spinothalamic) cell columns 1) Put hot and cold tap water in same size test tubes, with outsides being dry 2) Randomly apply test tubes with same pressure for at least 2 seconds, have pt indicate hot or cold

Graphesthesia test

Draw something on patients body and they tell you what you drew --Pt MUST be attentive and eyes closed

L1 Dermatome

Groin to inguinal area

Abdominal Reflexes

Indicates lesion to peripheral or central sensory pathways when absent (not reliable) 1) Perform in supine and use metal end of reflex hammer 2) quickly stroke lateral to medial direction (towards umbilicus) in one quadrant of abdomen at a time Normal response: contraction of abdominal muscle under skin that is tested w deviation of umbilicus toward stimulus Abnormal: no response

Lower body dermatome testing

L1- right near inguinal crease L2- across thigh L3- across knee L4- medial lower leg to top of toe L5- Lateral lower leg to dorsum of digits 2-4 S1- Lateral foot, bottom of foot, and back of lower leg First dorsal web space for deep peroneal

Myotome nerve roots and associated muscles

L2-3: iliopsoas L3: rectus femoris L4: tibialis anterior L5: extensor hallucis longus (toe extension), posterior tibialis (they invert and you try to push them out), gluteus medius S1: peroneii (glut max, hamstrings, gastroc/soleus)--> they evert and you try to push them in S2: gastroc/soleus (better done standing) S3: bowel/bladder, genitals

Myotome tests

Part of LQS --have patient walk on heels with toes dorsiflexed --have pt do 5 calf raises on one leg at a time, each side ***While short sitting: --L2 hip flexion: have pt lift knee up to flex hip while resisting agains the downard pus of PT --L3 knee extension: stabilize thigh, have pt leg extended halfway @ midrange, have them try to extend leg against PTs downward resistance --L4 dorsiflexion: pt flexes feet and resists against you as you try to push them down into plantar flexion --L5 extensor hallucis longus: pt brings toes up towards themselves and resist against you --L5 tib post have them invert against PT --S1 gastroc: push both feet down against PT into plantar flexion --S1 peroneus longus and brevis: have them evert against PT

What do you do when testing a two joint muscle at 1 joint?

Put the second, non-test joint in mid-range

What do you do when testing a 1-joint muscle at a joint crossed by a 2-joint muscle?

Put the two joint muscle on slack (e.g.: test gluteus maximus, put hamstrings on slack (flex knee)

Hoffman sign of UE

Reflex test that indicates UMN lesion 1) Flick fingernail of middle finger with wrist slightly extended 2) Index finger and thumb will flex in presence of UMN lesion

Quadriceps femoris or knee jerk DTR

Test L4 1) pt's legs dangling off table 2) find patella tendon and strike with back side of hammer, looking for knee extension/kick

Biceps jerk DTR

Tests C5 1) use same side arm as the one you're testing on pt to stabilize their arm. 2) place thumb in cubital fossa and have them resist elbow flexion to find distal biceps tendon 3) Place thumb firmly on tendon and use POINTY end of hammer to strike your thumb (placed over tendon) **have pt look away w eyes closed**

Brachioradialis DTR

Tests C6 1) use same side arm as one you're testing on pt to stabilize their arm. 2) Pt has arm resting with thumb up to ceiling 3) Tap 1/3 of way up radiocarpal joint w back side of hammer, looking for ELBOW FLEXION

Triceps jerk DTR

Tests C7 1) Bring arm up to 90degrees abduction, hand facing down 2) Tap distal triceps tendon with back side of hammer

Achilles or ankle jerk DTR

Tests S1 1) Test from outside of patient 2) Hold foot neutral but not hard enough that you won't get plantar flexion 3) Tap achilles tendon w back side of hammer and look for PLANTAR FLEXION

General sensory testing procedure

Would only do upper or lower body 1) Explain to pt what you're doing and start by brushing area that wouldn't be affected by any major nerve (e.g.: sides of face)--> "Do you have sensation to both sides of your face?" If yes then brush it with two fingers. 2) Then use two fingers to briefly brush each dermatome bilaterally (first dorsal web space of hand is deep radial, C2 is upper head, C3 is lower head, C4 is shoulders) 3) Pt indicates whether sensation was same or different on each side **After general, then perform SPECIFIC sensory testing (e.g.: Light touch test: using qtip to tap in and outside of the area where you found a deficit--> trying to find boundaries of sensory deficit. pt says yes each time they can feel it) or e.g.: sharp-dull test with sharp and dull side of needle or temperature testing

CN 6 test

abducens nerve --visual tracking: rotates eye outward (lat rect)

CN XI tests

accessory nerve --trapezius muscle: shrugs shoulders resisting against PTs pressure down --sternocleidomastoid muscle: pt turns head all the way to one side, PT applies pressure to area above ear on opposite side as pt tries to turn head resisting against PT

S3 myotome

bowel bladder and genitals --perianal area

Upper Motor Neuron lesion

damage to brain or spinal cord --leads to loss or decrease in function (negative sign) due to flaccid paralysis initially AND/OR --leads to uncontrolled expression of function/increased muscle tone (positive sign) --e.g.: increased stretch reflexes (hyperreflexia), increase tone (spastic paralysis), present Babinski reflex, clonus (w rapid ankle dorsiflexion, muscle repeatedly and rhythmically continues to contract --e.g.: flaccid shoulder and spastic elbow extensors, inability to produce movement (akinesia) and tremors (e.g.: pill rolling tremor found in parkinson's disease), stroke, spinal cord injury

Lower Motor Neuron lesion

damage to motor neurons of ventral horn (gray matter) or their axons, lesion that occurs to any periopheral nerve outside of CNS --leads to decrease in function (called negative sign) --weak or absent stretch reflexes (hyporeflexia) --decreased or absent muscle tone (flaccid paralysis is absent) --muscle atrophy --fasciculations (muscle twitches seen w naked eye) --fibrillations: cannot be seen, requires EMG to detect --can be accompanied by senory loss if mixed nerve is involved or lesion affects both ventral and dorsal roots --e.g.: damaged afferents from ms spindle (decrease muscle tone), damage cutaneous afferents (decreased ability to sense stimuli), damaged efferents to skeletal ms (weakness in muscle), peripheral neuropathies (progressive damage to peripheral nerves, occurs distal to proximal, due to toxins or autoimmune disease, e.g.: bilateral finger and hand numbness that spreads proximally, often caused by diabetes) damage to visceral efferents (sympathetic trunk, e.g.: loss of sweating) loss of bowel and bladder control (cauda equina, loss of afferent information as to bladder distension, involvement of pelvic splanchnic nerves [S2-4]) loss of viseral efferent control of bladder smooth muscle (involvement of pelvic splanchnic nerves) loss of somatic motor efferents to external urethral spinchter (involvement of pudendal nerve)

CN 7 tests

facial nerve --CORNEAL REFLEX: have them look up and away from you, lightly touch the white of their eye with something soft (qtip, stick w tissue over it), motor response of blinking --MUSCLES OF FACIAL EXPRESSION: raise eyebrows and wrinkle forehead (frontalis), close eyes tightly (orbicularis oculi), smile (zygomaticus major), whistle (orbicularis oris), depress lips and tense neck (platysma); LMN lesion (weakness on entire side of face ipsilateral to the lesion), UMN lesion (weakness on lower half of face contralateral to side of lesion bc of corticobulbar fibers innervating both sides of forehead) --TASTE: use qtip soaked in diluted soln of salt or sugar and place on anterior 2/3 of pt's tongue, one side at a time

CN 9 test

glossopharyngeal nerve --gag reflex: touch one side of pharynx (back of throat) w tongue compressor, tests CN 10 (motor response of gag reflex) and CN 9 (sensation of touch to pharynx). IF no response elicited, ask if they felt it

CN XII test

hypoglossal nerve --tongue protrusion: have pt stick tongue out, it deviates to the side of the lesion

Foot droppage or steppage gait

indicates peroneal nerve damage

CN3 tests

oculomotor nerve --VISUAL TRACKING: H pattern w finger 1ft away from face. CN3 lesion--> drooping eyelid, non-constricting pupil, and c/o double vision (sup, med, inf recti, inf oblique, levator palpebrae superioris). CN4--> c/o double vision, tilt of head to accomodate lesion (sup oblique), CN VI--> c/o double vision (lat rectus) --ACCOMMODATION: ciliary muscles adjust lens PS --PUPILLARY LIGHT REFLEX: sphincter pupillae PS

CN 1 test

olfactory nerve --covering one nostril on outside, testing one at a time, have them smell different common items (chocolate, oranges, cinnamon) with them smelling coffee grinds in b/w to clear nose --Lesion: usually unilaterally and something major; often result of trauma (skull fracture, TBI), neoplasms or infection --keep in mind patient could just have a cold or illness and not be able to smell well at the time

CN 2 tests

optic nerve --ACUITY: Snellen eye chart (with shapes if they don't know alphabet), one eye covered at a time, line 8 is 20/20 (normal) **DOES NOT necessarily indicate cranial nerve damage --VISUAL FIELD: pt looks forward, PT is directly in front and wiggles their finger as they move it from pt's periphery towards midline in ALL 4 quadrants, one eye at a time ----IPSILATERAL unilateral complete loss of vision --> optic nerve lesion ----optic chiasm lesion (pituitary tumor)--> bitemporal hemianopia (loss of temporal vision fields in both eyes) ----optic tract, primary visual cortex, or lateral geniculate body of thalamus lesion--> homonomous hemianopia (loss of visual field to CONTRALATERAL side --ACCOMMODATION: hold finger 1ft from pt's nose and slowly move it closer to bridge of nose, say when it gets blurry or double; indicates CN3 lesion as well (adduction or inability to constrict pupil due to PS CN3 loss), --PUPILLARY LIGHT REFLEX: look for pupil constriction in both eyes, one side at a time as you slide the light infront of their eye while they're looking at distant object, tests CN3 lesion as well (eye you shine light in doesn't constrict but other eye does indicates problem with PS part of CN3 pupil constriction); if neither eye constricts with light in 1 eye, indicates CN2 lesion

CN 5 tests

trigeminal nerve --OPTHALMIC: sensory to face using qtip for soft touch, sharp/dull discrimination- use shard and dull end of pin to lightly touch patients face --MAXILLARY: sensory to face --MANDIBULAR: sensory to face --CORNEAL REFLEX: pt looks up and away from PT, lightly touch white of eye with folded tissue--> sensation of tissue is CN 5, but blinking motor response is CN 7 --MUSCLES OF MASTICATION: pt opens mouth, deviates jaw to each side, apply resistance as they bring jaw back to neutral, then bite down (look for deviations to one side more than another, could indicate weakness on associated side) --JAW JERK REFLEX: pt mouth slightly open, PT's finger placed horizontally on pt's chin and taps finger w reflex hammer (slight closure of mouth should occur)

CN4 test

trochlear nerve --visual tracking: testing downward and outward (superior oblique abducts and depresses eye)

CN X tests

vagus nerve --GAG REFLEX: motor response of gag reflex --PALATAL ELEVATION: phonation test, press tongue down w tongue depressor as pt says "ahh" x3, look for uvula movement (uvual deviation indicates lesion in contralateral side of nerve), and equal soft palate elevation (soft palate will elevate to the side that the lesion is on)

CN 8 tests

vestibulocochlear nerve --GROSS HEARING TEST (COCHLEAR): rub thumb and first two fingers together standing behind patient starting far away w pt indicating when they hear it as you move closer (~2ft), look for delayed response or inability to hear --RINNE TEST: hit tines of a 512Hz tuning fork and place step on pt's mastoid process, then hold the tines parallel to pt's ear, ask which is louder (2 sounds equal or bone conduction is louder indicates lesion) --NYSTAGMUS: pt moves eye all directions and PT observes for beating of eyeball or abnormal motions --FINGER-TO-NOSE (past pointing): if unilateral vestibular problem, finger will drift towards the side of the lesion