Nervous System part III

EXAMINATION cranial NERVE

A. Olfactory nerve (N. I)

These nerves are not routinely checked, but it should be done if there is a history of loss of sense of taste and smell, if the patient experienced moderate or severe head injury, and or suspected diseases of the basal frontal lobe.

To test the olfactory nerve does not stimulate the use of materials such as coffee, tobacco, perfumes or spices. Put one of these materials in front of one person's nostril while the other nostril is closed and the patient closes his eyes. Then the patients were asked to tell when it began to smell the smell materials and identify materials that may smell the scent.

B. Optic nerve (N. II)

Includes examination of central vision (visual acuity), peripheral vision (visual field), pupillary reflex, ocular fundus examination and color tests. Examination of central vision (visual acuity). Central vision checked with Snellen cards, finger and hand movements.

Snellen card

On examination the card requires a distance of six feet between patients with tables, if there is no room large enough, this examination can be done with mirrors. Normal visual acuity when the line is marked 6 can be read correctly by each eye (visual acuity 6/6).

Fingers

Normal fingers can be seen at a distance of 3 meters, but could see at a distance of 2 meters, then the estimate visusnya is approximately 2/60.

Hand movements

Normal movement of the hand can be seen at a distance of 2 meters but can be seen at a distance of 1 meter means visusnya approximately 1/310.

Examination of Peripheral Vision

Examination of peripheral vision can yield information about the optic nerve and visual trajectory from dair eye to occipital cortex. Peripheral vision is checked by confrontation tests or by perimetri / kompimetri.

Confrontation tests

The distance between the examiner - patients: 60 - 100 cm. Objects in motion should be right in the middle distance. The object that is used (2 finger examiner / ballpoint) in motion from right and left visual field (lateral and medial), above and below where the other eye is closed and eyes should be examined lururs looked forward and should not be glanced toward the object. Terms of visual field examination should be normal examiner.

Perimetri / kompimetri

More rigorous test of confrontation. Examination results in the form of an image projected on a card.

Pupil reflexes

Afferent nerves from the optical nerve while nerves from the nerve occulomotorius aferennya. There are two kinds of pupillary reflex, namely:

- Response to direct light.

Use a small flashlight, point the light from the side (so that patients do not focus on the light and not berakomodasi) in the direction of one pupil to see his reaction to light. Inspection of both pupil and repeat this procedure on the other side. In normal circumstances an illuminated pupil will shrink.

- Response consensual light

If the pupil is a pupil illuminated by the other simultaneously shrunk in size.

Occuli fundus examination (fundoscopy)

Used equipment ophthalmoscope. Turn the lens in the direction of O diopters the focus can be directed to the fundus, lens opacities (cataracts) can interfere with fundus examination. When the retina is first focused look optic disc. The trick is to follow the journey retinalis large vein in the direction of the disc. All these veins out of the optic disc.

Color test

To find out the existence of polyneuropathy in the optic nerve.

C. Okulomotoris nerve (N. III)

Examination include; Ptosis, eye movement and pupil

A. Ptosis

In normal circumstances when a person looking ahead it will limit the upper eyelid cut slices at the same point bilaterally. Suspected ptosis eyelid when one of the slices cut lower than in the other eye, or if the patient is tilted back fist / to the top (for compensation) are chronic or chronic raised eyebrows as well.

2. Eyeball movement.

Patients were asked to look at and follow the movement of a finger or a ballpoint to the medial direction, up and down, asked the sekligus double vision (diplopia) and visible presence or absence of nystagmus. Prior to the movement of the eyeball (the rest) has seen a strabismus (crossed eyes) and conjugate deviation to one side.

3. Pupil

Examination includes pupil shape and size of the pupil, right and left pupil ratio (pupil diameter of 1mm, the difference is still considered normal), pupillary reflex.This examination includes examination of:

-Direct light reflex (with N. II)

Light-reflex is not alngsung (with N. II)

Pupil-reflex accommodative or convergence

When one looks at objects near the eye (see his own nose) both medial rectus muscles will contract. Movement of both eyes is called convergence. Along with the movement of the eyeball is the second pupil will shrink (siliaris muscle contraction).

D. Trochlear nerve (N. IV)

Examination include:

A. Lateral movement of the eye to the bottom

2. Convergent strabismus

3. Diplopia

E. Trigeminal nerve (N. V)

Examination include; sensibility, motor and reflex

A. Sensibility

There are three sensory branches, the ophthalmic, maxillary, mandibular.Examination performed on the three branches of the nerve by comparing one side to the other side. At first tests with the sharp edge of a new needle. The patient closes his eyes and a needle inserted gently on the skin, the patient was asked if feels sharp or blunt. Loss of sensation of pain will cause puncture was blunt.

Areas that showed a blunted sensation should be drawn and checks to be made of the area that feels dull to the area that feels sharp. Also made of the area that feels dull to the area that feels sharp. Also do tests on the area above the forehead to the back of the head over the top. If the branches affected ophthalmicus sensation will arise again when it reaches the C2 dermatome.

Temperatures are not routinely checked except siringobulbia suspect, because the loss of temperature sensation occurs in a state of loss of sensation of pain, the patient remains closed his eyes and do the test for fine touch with the new cotton in the same way. Patients were told to say "yes" every time he felt a touch of cotton on the skin.

2. Motor

Examination begins with inspection of the temporalis muscle atrophy and masseter. Then the patients were told to set his teeth and did palpation of masseter contraction over the mandible. Then the patients were told to open his mouth (pterigoideus muscles) and keep it open while the examiner tried to close it. Unilateral lesion of the motor branch causes the jaw deviates toward the weak side (affected).

3. Reflex

Examination of corneal reflex reflex include direct and indirect. On direct examination the patient was asked laterosuperior glanced at, then from the other direction the cotton touched the cornea, eg, patients were asked to glance towards the top right of the cotton touched on the left cornea and do the opposite in the other eye. Then compare the strength and speed of the right and left reflex afferent nerves originating from N. V but eferannya (blinking) is derived from N.VII.

On examination of indirect (consensual), a touch of cotton on the cornea reflex will cause a blind eye to left eye and vice versa usability consensual corneal reflex examination is the same as consensual light reflex, which is to see the path where the damaged (afferent or efferent).

There is also to see the presence of UMN lesions (certico bultar) the patient opened his mouth to taste (not too wide) then the chin be backed with a sudden knock on your fingers the examiner with a reflex hammer. The normal response would be negative ie no positive weak closure of the mouth or the closing of the mouth lightly. In contrast to the UMN lesion will be seen the closure of the mouth are strong and fast.

F. Abdusens nerve (N. VI)

Examination covering the lateral eye movements, convergent strabismus and diplopia are signs to look best when the affected side and the image that arises is located horizonatal and parallel to each other.

G. Facial nerve (N. VII)

Facial nerve examination performed while the patient still and on the orders (muscle strength tests) when the patient is still considered the asymmetry of the face. VIII nerve paralysis can cause a decrease in unilateral corners of the mouth and forehead wrinkles disappeared, and nasolabial folds, but the bilateral facial nerve paralysis of the face still looks symmetric. Abnormal movements (facial tics, grimacing, seizures tetanus / rhisus sardonicus tremor and so on), expression of the face (sad, happy, scared, like a mask)

Facial muscle strength tests

A. Raised eyebrows, compare right and left.

2. Close your eyes tight it (note the asymmetry) kemudioan examiner tried to open both eyes to compare the power of the right and left.

3. Showing the teeth (asymmetry)

4. Memoncongkan whistling and mouth (asymmetry / deviation of the end of the lips)

5. Blowing so tight, compare uadara strength of each cheek.

H. Vestibulo kokhlearis nerve (N. VIII)

There are two kinds of checks that hearing and vestibular function tests.

1) Examination of hearing.

Inspection akternus acoustic meatus of the patient to find the wax or other obstruction and the tympanic membrane to determine the presence of inflammation or perforation and do a hearing test using a friction finger, second watch, and audiogram. Audiogram is used to distinguish the nerve deafness conduction deafness and tesWeber Rinne test is used. PadaTesRinne, a tuning fork with frequency 256 Hz initially performed on the mastoid process, behind the ear, and when the place is no longer heard the sound of a tuning fork is parallel to the acoustic meatus oksterna. Under normal circumstances can still be heard in the external acoustic meatus. At the hearing you still hear the nerves in the external acoustic meatus. This situation is called a negative Rinne. At 512 Hz tuning fork Webber placed at the center of the forehead in a normal state of the sound will be heard at the nerve center of the forehead on deaf ears the sound is delivered to normal in conductive deafness tedengar sound louder in the abnormal ear.

2) PemeriksaanFungsiVestibuler.

Vestibular function tests include: nystagmus, Romberg test, and run straight with eyes closed, head tilt test (Nylen - Baranny, dixxon - Hallpike) is a test for postural nystagmus.

I. Glosofaringeus nerve (N. IX) and vagus nerve (N. X)

Examination N. IX and X. N because it is clinically difficult to separate the usually discussed together, the history includes kesedak / choking (palatom paralysis), difficulty swallowing, and dysarthria (typical stained nose / nasal tone). Patients were told to open his mouth and palate inspection with a flashlight see if there is a shift uvula, then the patient was told to say "aaaa" if the uvula is located to one side then this indicates the existence of unilateral paralysis of the nerve X note that the uvula attracted towards the healthy side.

Now do the test with a soft gag reflex (IX is a component of the sensory nerves and motor nerve X is a component). Touch the back of the pharynx on each side with spacula, do not forget to ask the patient if he felt the touch of a spatula (N. IX) each time to do.

In normal circumstances, there is a reflex contraction of the soft palate. If konraksinya no sensation intact and then this shows the X nerve paralysis, and patients were told to speak in order to assess the presence of hoarseness (unilateral recurrent laryngeal nerve lesions), and then asked to cough, the test also taste like ketchup on a regular basis on the posterior tongue (N. IX ).

J. Accessory nerve (N. XI)

Accessory nerve examination by asking the patient shrugged his shoulders and then Touch trapezius muscle mass and try to squeeze his shoulders down, and patients were told to turn his head against resistance (the examiner's hand) and also touched sternokleido mastoid muscle mass.

K. Hipoglosus nerve (N. XII)

Hipoglosus neurological examination by inspection of the tongue in the mouth is based at rest, determine the presence of atrophy and fasciculations (irregular contractions of smooth muscle and not rhythmic). Can be unilateral or bilateral fasciculations. Patients are asked to stick out its tongue deviates toward the weak side (exposed) if there are lesions of unilateral upper or lower motorneuron.

UMN lesion of N XII is usually bilateral and caused a small tongue and immobile.The combination of bilateral UMN lesion N. IX. X, XII called pseudobulbar paralysis.

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