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Practical physiology cns

This document provides instructions for examining the sensory system during a medical examination. It discusses testing various types of superficial sensations like pain, temperature, light touch, and two-point discrimination. It also covers examining deep sensations like joint movement and position sense. The tests are to be performed on both sides of the body while comparing responses between areas. Sensations are tested using simple tools like pins, cotton, and vibrators while asking the patient closed-eyed questions about their perceptions.

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1 2020 5MEDX TEAM FOR 2nd YEAR MEDICAL STUDENTS Sensory System Examination
General considerations ‫بداية‬ ‫في‬ ‫ثابتة‬ ‫دي‬ ‫الخطوات‬ ‫و‬‫كل‬examination*‫علي‬ ‫همنحن‬ ‫كنا‬ ‫اننا‬ ‫حالة‬ ‫في‬ ‫دا‬patient* ❖ Explain each test before you do it ❖ Unless otherwise specified, the patient's eyes should be closed during the actual testing. ❖ Compare symmetrical areas on both sides of the body (right – left). ❖ Also compare distal and proximal areas of the extremities. ❖ When you detect an area of sensory loss, map out its boundaries in detail. (According to dermatomes) ❖ Begin distally and move proximally. ❖ The procedure: ❖ Ask the patient to close his eyes. ❖ Use a disposable neurological pin to apply pinprick to the skin. (Equipment) ❖ Ask the patient to report whether he feels the sharp end of the pin. ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Observe and report the response. I. Sensory System Examination 1. Superficial sensation a. examination of pain sensation ‫ب‬ ‫بعض‬ ‫زي‬ ‫تقريبا‬ ‫كله‬ ‫في‬ ‫الخطوات‬ ‫و‬ ... ‫للفهم‬ ‫اقراها‬ ‫لكن‬ ‫و‬ ‫فيها‬ ‫هنتسأل‬ ‫مش‬ ‫احنا‬ ‫للخطوات‬ ‫بالنسبة‬‫ا‬‫هعملهم‬ ‫دول‬ ‫و‬ ‫اتنين‬ ‫أو‬ ‫خطوة‬ ‫ختالف‬‫األحمر‬ ‫باللون‬ Question ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬:‫يسألك‬‫ليها‬ ‫أداة‬ ‫فيها‬ ‫صورة‬ ‫(أي‬sharp end) 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Pain sensation 2 What is the equipment (instrument) used to examine such sensation? ✓ A disposable neurological pin OR any object having a sharp end. 3 What is the tract that transmit this type of sensation? ✓ Anterolateral spinothalamic tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Anterolateral spinothalamic tract. 5 Mention another type of superficial sensation? ✓ Temperature – Light touch – 2-point discrimination ……. 6 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Temperature sensation. ONLY ✓ :‫بالك‬ ‫خد‬‫ال‬ ‫عملنا‬ ‫لو‬pain sensation‫طلع‬ ‫و‬normal‫ف‬ ‫نعمل‬ ‫اننا‬ ‫داعي‬ ‫مفيش‬ temperature sensation ‫ال‬ ‫بنفس‬ ‫بيتنقلوا‬ ‫النهم‬tract
The procedure: ❖ Use a test tube filled with warm or cold water ❖ Ask the patient to identify "hot" or "cold" (Equipment) ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Observe and report the response. Crude (light) touch ❖ Use a piece of cotton wool OR fine hair brush. (Equipment) ❖ Apply gentle touch (do not drag the cotton) to the skin. ❖ While the eyes are closed ask the patient to report "yes" every time they perceive the stimulus. ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Ask the patient to tell you if there is a difference from side to side. b. examination of temperature sensation Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫فيها‬ ‫صورة‬ ‫أي‬test tubes 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Temperature sensation 2 What is the equipment (instrument) used to examine such sensation? ✓ 2 test tubes (ONE containing warm water AND the other containing cold water) 3 What is the tract that transmit this type of sensation? ✓ Anterolateral spinothalamic tract. 4 If the sensation of this picture is lost, which tract is being damaged? OR where do you ecpect to find the lesion? ✓ Anterolateral spinothalamic tract. 5 Mention another type of superficial sensation? ✓ Pain – Light touch – 2-point discrimination ……. 6 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ pain sensation. ONLY ✓ c. examination of tactile mechanoreceptive sensation ‫ال‬ ‫خلصنا‬ ‫كدا‬2 sensations‫بـ‬ ‫بيتشالوا‬ ‫اللي‬Anterolateral spinothalamic tract‫بـ‬ ‫بيتشال‬ ‫جاي‬ ‫اللي‬ ‫كل‬ ‫و‬tractDorsal column
Fine touch o Tactile localization sensation The procedure ❖ Use a blunt object like a pen cover. (Equipment). ❖ While the eyes are closed ask the patient to localized the touched skin point every time the stimulus is perceived. ❖ Apply a gentle touch to the skin at one point. ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Ask the patient to tell you if there is a difference from side to side. o TWO-Point Discrimination The procedure ❖ Use either calipers OR a compass. (Equipment). ❖ Demonstrate to the patient, with eyes open, by applying either one or two points of the stimulus to the finger pad. ❖ Ask the patient to close his eyes. ❖ Apply the stimulus and ask the patient to report whether they feel one or two points. Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫فيها‬ ‫صورة‬ ‫أي‬Piece of cotton 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Light touch sensation 2 What is the equipment (instrument) used to examine such sensation? ✓ a piece of cotton wool OR fine hair brush 3 What is the tract that transmits this type of sensation? ✓ Dorsal column tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 5 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2-point discrimination – pressure sensation – joint position – vibration sensation 6 Mention another superficial sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 Point discrimination ONLY 7 Mention another type of superficial sensation? ✓ Temperature – pain – 2-point discrimination ……. 8 Mention another type of mechanoreceptive sensation. ✓ 2 Point discrimination ‫الـ‬test‫ال‬ ‫مكان‬ ‫يحدد‬ ‫بيقدر‬ ‫المريض‬ ‫بشوف‬ ‫اني‬ ‫فكرته‬ ‫هو‬ ‫و‬ .... ‫احتياطي‬ ‫اقراه‬ ‫لكن‬ ‫و‬ ‫الكلية‬ ‫بتاع‬ ‫الفيديو‬ ‫في‬ ‫مشروح‬ ‫مش‬ ‫دا‬touch‫ال‬ ‫ولة‬
❖ Alternate irregularly between one and two points of touch. ❖ Find the minimal distance at which the patient can discriminate two touched points as separate. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. point discrimination thresholds varies from place to place on the body and-The magnitude of TwoNOTE: is smallest where touch receptors are most abundant. Stimulus points on the back, must be separated by at least 65 mm before they can be distinguished as separated Whereas on the fingertips two stimuli are recognized if they are separated by as little as 2mm. Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫ليها‬ ‫أداة‬2 ends 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ 2-point discrimination 2 What is the equipment (instrument) used to examine such sensation? ✓ Calipers OR Compass OR Forceps 3 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 5 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Light touch – pressure sensation – joint position – vibration sensation 6 Mention another superficial sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Light touch ONLY 7 Mention another type of superficial sensation? ✓ Temperature – pain – Light touch. 8 Mention another type of mechanoreceptive sensation. ✓ Light touch ONLY Two point discrimination It is the ability to perceive, with closed eyes, two touch stimuli applied to the skin at the same time as two separate points of touch provided that the distance between the two points is more than a certain threshold variable in different areas of the body FORREADING
‫ش‬ The procedure: ❖ Demonstrate to the patient initially, with eyes opened, that you will move their digit up (towards their heads) or down (towards their feet). ❖ Ask the patient to close his eyes. ❖ Stabilize the distal interpharyngeal joint of the digit by its sides and make minimal movements upwards or downwards. ❖ Ask the patient to report after each movement whether the joint is moving and the direction of movement. ❖ Similarly in the lower extremities, stabilize the interpharyngeal joint and move the large toe up or down. ❖ If the patient can't accurately detect the distal movement then progressively test a more proximal joint until he can identify the movement correctly. 2. Deep sensation a. Sense of joint movement and position Proprioception OR conscious kinesthetic sensation Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫متني‬ ‫صوباع‬ 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Joint movement and position (Proprioception) (conscious kinesthetic) 2 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 3 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 4 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 point discrimination – pressure sensation – Light touch – vibration sensation 5 Mention another deep sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Pressure OR Vibration ONLY 6 Mention another type of deep sensation? ✓ Vibration - pressure
The procedure: ❖ Use a 128 hertz vibration fork. (Equipment) ❖ Ensure the patient understands that he feels vibration by placing the tuning fork on the chin before testing. ❖ Place the base of the fork over the bone or bony prominence. ❖ Ask the patient to tell you if he feels the vibration. ❖ If vibration sense is impaired proceed proximally: o In the upper part of the body: Wrists – Elbows – Clavicles – Spinous processes. o In the lower part of the body: Medial malleoli – Patella – Anterior superior iliac spine. ❖ Compare distal versus proximal, and right versus left. b. Vibration sense Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬Tuning fork 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Vibration sense. 2 What is the equipment (instrument) used to examine such sensation? ✓ 128 Hertz Tuning fork 3 Where do we this examination? Over any bony prominence ✓ In the upper part of the body: Wrists – Elbows – Clavicles – Spinous processes. ✓ In the lower part of the body: Medial malleoli – Patella – Anterior superior iliac spine. 4 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 5 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 6 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 point discrimination – pressure sensation – joint position – light touch 7 Mention another deep sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Joint movement and position OR pressure ONLY 8 Mention another type of deep sensation? ✓ Joint movement and position OR pressure
The procedure: ❖ Use different metal rings. (Equipment) ❖ Explain the test to the patient. ❖ With the patient's eyes closed, place a known number of rings on the patient's palm. ❖ Remove them and place a different number of rings in the patient's palm a second time still with eyes closed. ❖ Ask the patient's to identify whether the first or the second time feels heavier. ❖ Compare between both sides. ❖ Report your response. The procedure: ❖ Ask the patient to close his eyes. ❖ Give the patient any common and familiar object (Key – pen – coin- paper clip) ❖ Ask the patient to identify the object without looking at it. ❖ Record the response. c. Pressure sense It is the ability to discriminate different weights Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬metal ringsSeveral 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Pressure sense. 2 What is the equipment (instrument) used to examine such sensation? ✓ Metal rings of different weights 3 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 5 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 point discrimination – pressure sensation – joint position – light touch 6 Mention another deep sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Joint movement and position OR Vibration ONLY 7 Mention another type of deep sensation? ✓ Joint movement and position OR Vibration. 3. Stereognosis Is considered a cortical sensation that can be felt if the somatosensory cortex is intact
The test is based on the fact that a person requires at least two of the three following senses to maintain balance while standing: 1. Proprioception. 2. Vestibular function. 3. Vision A patient who has a problem with proprioception can still maintain balance by using vestibular function and vision. If this patient is asked to close his eyes he losses the visual adjustment for changes in body position, and tends to fall. The inability to identify an object placed in the hand with the eyes closed is called *Astereognosis* the somatosensory cortex.ations are intact, it indicates a lesion int occurs while other sensIf i Question 4. Romberg's test est is a test of the body's sense of positioning (Proprioception),Romberg's tPrinciple: which requires healthy functioning of the dorsal columns of the spinal cord ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬Tuning fork 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Stereognosis. 2 What is the equipment (instrument) used to examine such sensation? ✓ Any familial object to the patient. 3 The inability to identify familial object by touch is known as a …..‫سؤال‬ ‫أهم‬ ✓ Astereognosis. 4 If the sensation of this picture is lost, what does it indicate? OR if this sensation is lost, where do you expect the lesion to be? ✓ The lesion is in the somatosensory cortex. :‫بالك‬ ‫خلي‬ ‫ال‬ ‫صورة‬ ‫بين‬ ‫تتلغبط‬ ‫ممكن‬ ‫انت‬Pressure sense‫ال‬ ‫صورة‬ ‫و‬Stereognosis‫ازاااااي؟‬ ‫ايد‬ ‫صورة‬ ‫جاب‬ ‫لو‬‫فيها‬metal ring‫صورة‬ ‫تفكرها‬ ‫ممكن‬ ‫انت‬ ‫بس‬ ‫واحدة‬Pressure sense‫هي‬ ‫و‬stereognosis ‫ف‬ ‫ايد‬ ‫صورة‬ ‫تيجي‬ ‫لما‬ ‫كدا‬ ‫عشان‬‫يها‬ Several metal rings‫دا‬ ‫يبقي‬pressure ONLY one metal ring‫دا‬ ‫يبقي‬Stereognosis
In the Romberg's test, the standing patient is asked to close his eyes, if the patient tends to fall with the eyes close. This is interpreted as a positive Romberg's test. ‫دول‬ ‫من‬ ‫حاجتين‬ ‫األقل‬ ‫علي‬ ‫محتاج‬ ‫اتزانه‬ ‫علي‬ ‫يحافظ‬ ‫عشان‬ ‫االنسان‬ ‫.......و‬ ‫االتزان‬ ‫علي‬ ‫بتحافظ‬ ‫حاجات‬ 3 ‫فيه‬ ‫ان‬ ‫بمعني‬ ❖‫ال‬ ‫في‬ ‫مشكلة‬ ‫عنده‬ ‫مثال‬ ‫لو‬ ‫ف‬Proprioception‫التانيين‬ ‫االتنين‬ ‫خالل‬ ‫من‬ ‫اتزانه‬ ‫علي‬ ‫يحافظ‬ ‫يقدر‬ ‫هو‬ ‫ف‬ (Vestibular function + Vision) ❖‫ال‬ ‫من‬ ‫بنطلب‬ ‫دا‬ ‫االختبار‬ ‫في‬ ‫بقي‬ ‫احنا‬ ‫أما‬patient‫ال‬ ‫من‬ ‫عامل‬ ‫فقد‬ ‫هو‬ ‫كدا‬ ‫معني‬ ‫ف‬ ‫عينه‬ ‫يغمض‬ ‫انه‬3‫و‬ ‫ال‬ ‫هو‬vision ‫كدا‬ ‫معني‬ ..... ‫عينيه‬ ‫غمض‬ ‫لما‬ ‫توارنه‬ ‫يحفظ‬ ‫قدرش‬ ‫ما‬ ‫المريض‬ ‫لو‬ ‫ف‬‫ال‬ ‫في‬ ‫مشكلة‬ ‫عنده‬ ‫ان‬ Proprioception‫ال‬ ‫أو‬vestibular function‫ال‬ ‫من‬ ‫عاملين‬ ‫فقد‬ ‫كدا‬ ‫ف‬3 ✓‫ال‬ ‫عنده‬ ‫ان‬ ‫و‬ ‫سليم‬ ‫انه‬ ‫كدا‬ ‫معني‬ ‫ف‬ ....... ‫عينيه‬ ‫غمض‬ ‫لما‬ ‫توازنه‬ ‫علي‬ ‫يحافظ‬ ‫قدر‬ ‫المريض‬ ‫لو‬ ‫و‬3‫عوامل‬ intact The procedure: ❖ Be prepared to catch the patient if he is unstable. ❖ Ask the patient to stand, feet together and hands by the sides with eyes open, then with eyes closed without support. ❖ Watch the movement of the body in relation to a perpendicular object behind the subject (corner of the room – door – window). ❖ The test is said to be positive if the patient becomes unstable after closure of the eye (he sways and threatens to lose his balance). Proprioception Vestibular function Vision A positive Romberg's test indicated *Sensory Ataxia* which can occur due to: A lesion in the dorsal column of the spinal cord (by a tumor OR cord compression by a herniated disc) It can also occur in cases of peripheral neuropathy as that occurring with diabetes mellitus Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬ 1. Identify the test? ✓ Romberg's test. 2. If the test is positive, what could be the cause? ✓ Sensory Ataxia, which can occur due to o A lesion in the dorsal column of the spinal cord (by a tumor OR cord compression by a herniated disc) o It can also occur in cases of peripheral neuropathy as that occurring with diabetes mellitus
1 2020 5MEDX TEAM FOR 2nd YEAR MEDICAL STUDENTS Cranial Nerves Examination
By the end of this practical class, students should be able to: Identify all cranial nerves and their functions. Conduct different tests for cranial nerves examination. Differentiate between different cranial nerves lesions. ‫أي‬ ‫وظيفة‬nerve‫تكون‬ ‫ممكن‬ ❖Motor function‫يعني‬‫بيحرك‬skeletal muscle‫فبالتالي‬‫هيكون‬‫ال‬examination ‫بتاعه‬‫اني‬‫أشوف‬‫ال‬ ‫حركة‬skeletal muscle‫ال‬ ‫ولة‬ ‫شغالة‬ ‫دي‬. ❖Sensory function‫و‬‫ال‬sensation‫دا‬‫يكون‬ ‫إما‬ ‫ي‬ osensationGeneral‫يعني‬nerve‫مسئول‬‫ال‬ ‫عن‬somatic sensations‫ال‬ ‫زي‬pain – temperature – touch‫ال‬ ‫زي‬trigeminal nerve‫مثال‬‫ال‬ ‫عن‬ ‫مسئول‬general sensations from the face oSpecial sensation‫زي‬taste–hearing–vision–smell‫زي‬‫مثال‬ Olfactory nerve is responsible for smell sensation Optic nerve is responsible for vision ❖Autonomic function‫رقم‬ ‫هما‬ ‫و‬3‫و‬7‫و‬9‫و‬10‫أعمل‬ ‫أجي‬ ‫لما‬ ‫بالتالي‬ ‫ف‬ examination‫لل‬4 nerves‫بنسأل‬ ‫دول‬‫ال‬ ‫هي‬ ‫ايه‬Autonomic functions ❖Involved in reflex‫أي‬ ‫انه‬ ‫عارفين‬ ‫احنا‬ ‫ما‬ ‫زي‬ ‫و‬reflex‫ليه‬ Afferent‫شايل‬‫ال‬sensation from the receptor to the center Efferent‫شايل‬‫ال‬response from the center to the effector organ ‫الحظ‬‫في‬ ‫ان‬cranial nerves‫ليها‬ Sensory function ONLY: Contain only afferent fibers (1-2-8) o I Olfactory 1 o II Optic 2 o VII Vestibulocochlear 8 Motor function ONLY: Contain only efferent fibers (3-4-6-11-12) o III Oculomotor. 3 o IV Trochlear. 4 o VI Abducent. 6 o XI Accessory. 11 o XII Hypoglossal. 12 Mixed (Sensory + Motor): Contain both efferent and afferent fibers (5-7-9-10) o V Trigeminal. 5 o VII Facial. 7 o XI Glossopharyngeal. 9 o X Vagus. 10 II. Cranial nerves Examination
Before starting: ❖ Introduce yourself to the patient. ❖ Explain the examination and obtain his consent. ❖ Ensure that he is comfortable The procedure: ❖ Ask the patient if he has noticed a change in his sense of smell or taste. If he has, indicate that you would perform an olfactory examination. ❖ Before starting, check that there is free flow of air by occluding each nostril in turn and asking the patient to sniff in. ❖ Ask the patient to close his eyes. ❖ Smell is tasted in each nostril separately by placing stimuli under one nostril and occluding the opposing nostril. ❖ The stimuli used should be non-irritating and identifiable e.g. (coffee – tobacco – orange – vanilla) ❖ Ask the patient to identify each in turn. ❖ If you don't have such tools available, ask the patient to close his eyes and then hold a bar of soap under the patient's nose for them to smell. ❖ Assess the response. Loss of smell sensation is known as *Anosmia*, Types of Anosmia: *‫فيديو‬ ‫في‬ ‫لكن‬ ‫و‬ ‫الكتاب‬ ‫في‬ ‫مش‬‫المراجعة‬* Unilateral *‫أخطر‬* Bilateral Has great localizing value indicate involvement of one of the olfactory tracts in the floor of the anterior fossa as olfactory groove meningioma In blocked nasal passages in common cold causes of anosmia include: *‫في‬ ‫لكن‬ ‫و‬ ‫المراجعة‬ ‫فيديو‬ ‫في‬ ‫مش‬‫الكتاب‬* ▪ Nasal congestion from (Cold – allergy – sinus infection) ▪ Tumors of the nose or olfactory pathway. ▪ Exposure to toxic chemicals (Pesticides – Certain medications *Antibiotics / Antidepressants – Cocaine abuse) ▪ Degenerative causes as *Parkinson's disease – Alzheimer's disease* ▪ As a complication of radiation treatment. I. Olfactory nerve ‫في‬ ‫هنتسأل‬ ‫مش‬ ‫بس‬ ‫افهمها‬ ‫الخطوات‬
These 3 nerves are examined together as they control ❖ The intrinsic muscles (controlling the lens and pupil) ❖ External ocular muscles ❖ Pupillary light reflex Nerve III. Oculomotor nerve IV. Trochlear nerve VI. Abducent nerve Muscles suppling by this nerve ❖ All Extra-ocular muscles. EXCEPT SO4 *Superior oblique* LR6 *lateral rectus* ❖ Levator palparbrae superiosis. ❖ Ciliary muscle ❖ Sphincter pupillae (Autonomic function) ❖ SO4 *Superior oblique* ❖ Trochlear nerve typically allows a person to view the tip of his nose (Eye depression with medial rotation) *SO* LR6 *Lateral Rectus* (Lateral movement) ‫عشان‬‫ال‬ ‫نعرف‬lesions‫ايه‬ ‫عضلة‬ ‫كل‬ ‫وظيفة‬ ‫عارفين‬ ‫نكون‬ ‫الزم‬ Lesions ❖ Deviation of the eye down and out.(laterally) ❖ Ptosis ❖ Dilated pupil ❖ Loss of light and accommodation reflexes Inability to look down *LR* Inability to move the eye out. (lateral rotation) II. Optic nerve Visual acuity – Visual fields – Optic disc examination ‫بالتفصيل‬ ‫هناخده‬ ‫ال‬ ‫سكشن‬ ‫في‬ vision III. Oculomotor IV. Trochlear VI. Abducent 3)6LR4SO) Right eye Left eye MR *medial rectus* : Medial rotation LR *lateral rectus*: Lateral rotation SR *Superior rectus*: Upward movement + lateral rotation IR *Inferior rectus*: Downward movement + lateral rotation SO *Superior oblique*: Downward movement + medial rotation IO *Inferior oblique*: Upward movement + medial rotation ‫ال‬ptosis‫ال‬ ‫يعني‬upper eyelid‫ال‬ ‫الن‬ ‫واقع‬muscle‫و‬ ‫رفعه‬ ‫عن‬ ‫المسئولة‬‫هي‬Levator palparbrae superiosis ‫مشكلة‬ ‫فيها‬ ‫يكون‬ ‫ممكن‬
.... ‫يبص‬ ‫العيان‬ ‫خليت‬ ‫لو‬ ‫بـ‬ ‫كدا‬ ‫يبقي‬test..... ..... ‫بـ‬ ‫بتتغذي‬ ‫اللي‬ ‫لبرة‬laterally Lateral rectus Abducent nerve VI ‫لجوة‬medially Medial rectus Oculomotor nerve III ‫لتحت‬ ‫و‬ ‫لجوة‬downward and medially Superior Oblique Trochlear nerve IV ‫لجوة‬‫ل‬ ‫و‬‫فوق‬Upward and medially Inferior Oblique Oculomotor nerve III ‫لتحت‬ ‫و‬ ‫لبرة‬downward and laterally Inferior rectus Oculomotor nerve III ‫لفوق‬ ‫و‬ ‫لبرة‬Upward and laterally Superior rectus Oculomotor nerve III Examination: Inspect the eyes, ‫أشوف‬ ‫ما‬ ‫(أول‬‫أ‬ ‫أبدأ‬ ‫المريض‬)‫اختبار‬ ‫أي‬ ‫غير‬ ‫من‬ ‫دي‬ ‫الحاجات‬ ‫الحظ‬ ❖ paying particular attention to the shape, size and symmetry of the pupils ❖ Excluding  A visible ptosis (drooping of upper eyelid) defect in Levator palparbrae superiosis which supplied by oculomotor n.  Squint/ strabismus (misalignment of the two eyes so that both the eyes are not looking in the same direction. Test for ocular movements: *Extra-ocular muscles* ❖ Ask the patients to fix his head and move only his eyes. ❖ Hold out your extended right index finger about 40 cm in front of the patient. ❖ Ask the patient to follow your finger with their eyes through the six cardinal positions of gaze. (lateral – Superio-lateral – Inferio- lateral – Medial – Superio-medial – Inferio-medial) ❖ Examine each eye with the other covered. ❖ There should be a full range of movements of each eye. ❖ Observe the eye movements.
Test for conjugate eye movements ❖ Ask the patient to look to the right, to the left, up and down with both eyes. ❖ Observe the eye movements, and note whether they move together. Test the direct and consensual pupillary light reflexes. (see vision section) ‫أي‬reflex‫ليه‬ ‫بيكون‬Afferent and efferent‫ال‬ ‫في‬ ‫هنا‬ ‫و‬pupillary light reflex ❖ The afferent *sensory limb* is Optic nerve II ❖ The efferent *motor limb* is Oculomotor III o‫ال‬ ‫في‬light reflex‫ال‬ ‫علي‬ ‫ضوء‬ ‫بنسلط‬pupil‫بتاعة‬one eye o‫هيحصل‬ ‫انه‬ ‫نالحظ‬ ‫و‬Constriction of the pupils of the both eyes‫عضلة‬ ‫بسبب‬ constrictor pupillae which supplied by oculomotor nerve III o‫محصلش‬ ‫لو‬constriction‫ي‬ ‫المشكلة‬ ‫ان‬ ‫أشك‬ ‫يبقي‬‫في‬ ‫اما‬Afferent (Optic II)‫أو‬‫في‬ Efferent (Oculomotor III) Test for accommodation reflex. (see vision section) ❖ Ask the patient to look at far object and then at a near object. ❖ The response: ✓ Constriction of the pupils ✓ Convergence ✓ Increase dioptric power of the lens symmetrical: The direct of the two eyes should beN.B asa lesion in the brainstematedn conjugate eye movements indicA defect i it integrates the functions of the oculomotor, trochlear and abducent nerves ‫بالتالي‬ ‫ف‬ ‫اليمين‬ ‫أقصي‬ ‫باصص‬ ‫العيان‬ ‫دي‬ ‫الصورة‬ ‫في‬ ‫هي‬ ‫اليمين‬ ‫العين‬ ‫في‬ ‫شغالة‬ ‫اللي‬ ‫العضلة‬lateral recuts ‫هي‬ ‫الشمال‬ ‫العين‬ ‫في‬ ‫شغالة‬ ‫اللي‬ ‫العضلة‬medial recuts Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫منهم‬ ‫عين‬ ‫مغطي‬ ‫مش‬ ‫انه‬ ‫الحظ‬‫كدا‬ ‫معني‬ ‫بي‬ ‫انه‬‫ال‬ ‫ختبر‬conjugate eye movements 1 Identify the test in this picture. ✓ Examination of Conjugate eye movement 2 It is the function of …… ✓ Brainstem
Question ‫دي‬ ‫الصورة‬ ‫في‬‫ن‬‫الشمال‬ ‫العين‬ ‫ان‬ ‫الحظ‬normal‫اليمين‬ ‫العين‬ ‫أما‬deviated laterally‫ال‬ ‫هي‬ ‫كدا‬ ‫لبرة‬ ‫العين‬ ‫حدفت‬ ‫و‬ ‫شغالة‬ ‫اللي‬ ‫العضلة‬ ‫ان‬ ‫كدا‬ ‫معني‬right lateral rectus‫بـ‬ ‫بتتغذي‬ ‫واللي‬right abducent nerve‫ال‬ ‫باقي‬ ‫أما‬ Extrinsic muscles‫الـ‬ ‫بيغذيهم‬ ‫اللي‬ ‫و‬ ‫شغالين‬ ‫مش‬right oculomotor nerve‫ال‬ ‫كدا‬ ‫يبقي‬nerveIIIlesion in right oculomotor Question ‫دي‬ ‫الصورة‬ ‫في‬‫ن‬‫ان‬ ‫الحظ‬Upper eyelid in the right eye‫واقع‬ )right ptosis(‫رف‬ ‫عن‬ ‫المسئولة‬ ‫العضلة‬ ‫ان‬ ‫كدا‬ ‫معني‬ ....‫مش‬ ‫لفوق‬ ‫عه‬ ‫هي‬ ‫و‬ ‫شغالة‬right levator palparbrae superiosis‫اللي‬ ‫و‬ ‫بـ‬ ‫بتتغذي‬Right Oculomotor nerve‫الـ‬ ‫كدا‬ ‫يبقي‬Lesion in nerveIIIright oculomotor Question ‫العيان‬ ‫دي‬ ‫الصورة‬ ‫في‬‫كان‬ ‫يمين‬ ‫بص‬ ‫لما‬normal‫اللي‬ ‫العضالت‬ ‫ان‬ ‫بحيث‬ ‫هي‬ ‫تحصل‬ ‫دي‬ ‫الحركة‬ ‫عشان‬ ‫اشتغلت‬ Left medial rectus + right lateral rectus ‫ال‬ ‫عشان‬ ‫المفروض‬ ‫ف‬ ‫المشكلة‬ ‫ظهرت‬ ‫شمال‬ ‫بص‬ ‫لما‬ ‫لكن‬ ‫و‬‫الزم‬ ‫تحصل‬ ‫دي‬ ‫حركة‬ ‫هي‬ ‫تشتغل‬ ‫اللي‬ ‫العضالت‬right medial rectus + left lateral rectus‫في‬ ‫المشكلة‬ ‫كدا‬ ‫يبقي‬ ‫النص‬ ‫في‬ ‫واقفة‬ ‫فضلت‬ ‫الشمال‬ ‫العين‬ ‫لكن‬ ‫و‬ left lateral rectus which supplied by left abducent nerve‫الـ‬ ‫كدا‬ ‫يبقي‬Lesion in left Abducent nerve Applied case A 65 year - old male presents with inability to move both his eyes to the left . His vision and his pupillary reflexes are normal in both eyes . He has normal sensation on his face and body and no other motor symptoms . Symptoms ❖ Has a left medial squint ( abnormal alignment of the eyes ) ❖ Has limited mobility in his left eye ( i.e. , it moves to the midpoint when he attempts to look to the left ) ❖ Cannot move both eyes toward his left . Therefore , the lesion is??????? Question ‫حادفة‬ ‫الشمال‬ ‫العين‬ ‫عنده‬ ‫و‬ ‫الشمال‬ ‫العين‬ ‫في‬ ‫المشكلة‬ ‫انه‬ ‫هنالقي‬ ‫األعراض‬ ‫نقرأ‬ ‫لما‬ ‫دي‬ ‫الحالة‬ ‫في‬medially‫ان‬ ‫كدا‬ ‫معني‬ ‫بتحركها‬ ‫اللي‬ ‫العضلة‬ ‫هي‬ ‫بايظة‬ ‫اللي‬ ‫العضلة‬laterally‫اللي‬‫هي‬left lateral rectus which supplied by left Abducent nerve‫الـ‬ ‫كدا‬ ‫يبقي‬rven left Abducent neLesion is i
▪ Sensory: Facial sensation (Somatic sensations from face and tongue *pain – touch – temperature – Proprioception*) ▪ Motor: Muscles of mastication *temporalis – Masseter – Pterygoid* ▪ Reflex: Corneal reflex. Examination: I Corneal reflex 1. Take a piece of cotton wool. 2. Ask the patient to look away from the side being tested. 3. Gently touch the cornea with the cotton wool, the patient will blink.(response) ❖ The Afferent of this reflex is the sensory part of CN V (Trigeminal) ❖ The Efferent of this reflex is the motor part of CN VII (Facial). II Facial sensation: (sensory function of trigeminal nerve) 1. Lightly touch each side of the face with a piece of cotton and then with blunt pin in three places on each side (Around the jawline – on the cheek – on the forehead). 2. Ask if it feels normal and symmetrical. 3. Test the areas supplied by (Ophthalmic – Maxillary – Mandibular) branches. Question ‫دي‬ ‫الصورة‬ ‫في‬‫موجودة‬ ‫حاجة‬ ‫علي‬ ‫تبص‬ ‫انها‬ ‫المريضة‬ ‫من‬ ‫طلبت‬‫تحت‬‫شمالها‬ ‫علي‬‫بالتالي‬ ‫ف‬‫العين‬ ‫هتبص‬ ‫الشمال‬Downward and laterally‫عضلة‬ ‫باستخدام‬Left inferior rectus‫و‬ ‫تمام‬ ‫شغالة‬ ‫دي‬ ‫تبص‬ ‫المفروض‬ ‫اللي‬ ‫اليمين‬ ‫العين‬ ‫لكن‬ ‫و‬Downward and medially‫ما‬‫اتحر‬‫يبقي‬ ‫كتش‬ ‫في‬ ‫مشكلة‬ ‫عندها‬ ‫كدا‬right superior oblique muscle which supplied by right trochlear nerve‫كدا‬ ‫يبقي‬Lesion is in right trochlear nerve V. Trigeminal nerve Question 1. Identify the reflex and mention its function. ✓ Corneal reflex - protective 2. The stimulus is …….. ✓ Gentle touch of lateral edge of the cornea using a piece of cotton. 3. Normal response is ……… ✓ Closure of the eye OR blinking 4. The muscle responsible for this response is ……… ✓ Orbicularis oculi 5. The Afferent nerve of this reflex is ……... and the Efferent nerve of this reflex is ……… ✓ Sensory part of trigeminal nerve – motor part of facial nerve
III Motor: 1. Ask the patient to perform side to side movement of the jaw (test of pterygoid). 2. Ask the patient to clench their teeth together. 3. Observing and feeling the bulk of the masseter and temporalis muscles. Both masseters should be firm and strong A lesion in the trigeminal nerve will result in: ❖ Loss of sensation in one or more divisions of the trigeminal nerve. ❖ Wasting of the masseter and temporalis muscles. ❖ When the jaw is opened it will deviate towards the side of the lesion. ❖ There is also absence of the corneal reflex the spinal nerves from segments C2,3 supply the face about 3N.B: fingers' breadth in front of the ear. On the forehead On the Cheek Around the jawline Ophthalmic division Maxillary division Mandibular division TemporalisMasseter Question ‫يفتح‬ ‫انه‬ ‫المريض‬ ‫من‬ ‫طلبت‬ ‫دي‬ ‫الصورة‬ ‫في‬lower jaw‫عشان‬test pterygoid muscle‫ف‬ ‫انه‬ ‫لقيت‬deviated towards the right‫قلنا‬ ‫و‬‫بي‬ ‫لما‬ ‫ان‬‫فيه‬ ‫كون‬lesion in the trigeminal nerve‫ال‬ ‫بيكون‬jaw deviated to the side of the lesion ‫عندنا‬ ‫كدا‬ ‫يبقي‬Lesion in the right trigeminal nerve ‫عندنا‬4 cranial nerves‫فيهم‬ ‫بيحصل‬ ‫لما‬lesion‫بيحصل‬deviations ‫رقم‬5‫و‬7‫و‬10‫و‬12 ‫رقم‬5‫و‬12‫ف‬ ‫بيحصل‬ ‫لما‬‫يهم‬lesion‫ال‬ ‫بيكون‬affected sidedeviation towards the)(5+12=17 ‫رقم‬7‫و‬10‫بيحصل‬ ‫لما‬lesion‫بيكون‬the healthy sidedeviation toward(7+10=17) ‫تاني‬ ‫قدام‬ ‫هنلخصها‬
❖ Involved in corneal reflex "Efferent part" ❖ Sensory function: Transmission of taste sensation from Anterior 2/3 of the tongue. "Special sensation" ❖ Motor function: Motor to muscles of facial expression. ❖ Secretory function "Automonic": To lacrimal and salivary glands (Sublingual – Submandibular) EXCEPT Parotid gland "glossopharyngeal" Examination Of Facial nerve VII: I Corneal reflex: o‫ال‬ ‫ذكرنا‬ ‫احنا‬corneal reflex‫في‬ ‫كدا‬ ‫قبل‬trigeminal nerve‫الـ‬ ‫كان‬ ‫ألنه‬Afferent part‫ال‬ ‫بتاع‬reflex‫هو‬sensory part of trigeminal o‫الـ‬ ‫ألن‬ ‫تاني‬ ‫هنا‬ ‫ذكرناه‬ ‫و‬Efferent‫الـ‬ ‫هو‬ ‫بتاعه‬Motor part pf facial nerve II Sensation (taste sensation of anterior 2/3 of the tongue) "Post 1/ 3 "glossopharyngeal"" 1. Ask the patient to protrude his tongue. 2. Use a cotton tip applicator dipped in a solution that is (sweet – salty – sour – bitter) 3. Apply to the extended tongue. 4. Ask the patient to tell you the taste before they pull their tongue back in the mouth. III Motor Inspect facial droop or asymmetry. Ask the patient to Observe / assess Look upward and wrinkle his forehead. "frontalis muscle" The wrinkles. Close eye tight "orbicularis Oculi" against resistance. Power of the orbicularis Oculi muscle Frown "‫يعبس‬ ‫أو‬ ‫يكشر‬" Show his teeth If there is any deviation of nasolabial fold. Purse his lips / whistle "‫يصفر‬" Power of orbicularis oris muscle VII. Facial nerve ‫هو‬ ‫اشتغل‬ ‫اللي‬ ‫العصب‬ ‫كدا‬ ‫يبقي‬ ‫لسانك‬ ‫عضيت‬ ‫لو‬Trigeminal nerve ‫بـ‬ ‫حاجة‬ ‫تذوقت‬ ‫لو‬ ‫أما‬Anterior 2/3‫هو‬ ‫اشتغل‬ ‫اللي‬ ‫العصب‬ ‫كدا‬ ‫يبقي‬facial nerve *supplies the muscles of facial expression* "start from the top and work down"
Blow his Cheek Power of buccinator muscle Facial nerve palsy results in: ❖ Paralysis of the facial muscles ❖ Failure to close the eye on the affected side. ❖ Deviation of the mouth to the healthy side ❖ Loss of forehead corrigations The common cause of facial nerve lesion: Bell'palsy which is unilateral peripheral affection of the facial nerve. ‫يك‬ ‫فمه‬ ‫انه‬ ‫المفروض‬ ‫يبتسم‬ ‫انه‬ ‫العيان‬ ‫من‬ ‫طلبت‬ ‫لو‬‫ون‬centrally‫شمال‬ ‫أو‬ ‫يمين‬ ‫حادف‬ ‫مش‬ ‫لقيته‬ ‫لو‬ ‫أما‬‫شمال‬ ‫حادف‬leftDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervefacialrighttheLesion in ‫بيكون‬ ‫الوش‬ ‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬deviated to the healthy side ‫يمين‬ ‫حادف‬ ‫لقيته‬ ‫لو‬ ‫أما‬rightDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervefaciallefttheLesion in ‫زي‬ ‫النه‬‫قلنا‬ ‫ما‬‫بيكون‬ ‫الوش‬ ‫انه‬deviated to the healthy side Question 1 2 3 ( ‫رقم‬ ‫الصورة‬ ‫في‬1:)‫ال‬ ‫لفوق‬ ‫حواجبه‬ ‫رفع‬ ‫لما‬ ‫المريض‬wrinkles‫ظهرت‬‫الشمال‬ ‫الناحية‬ ‫علي‬ ‫ظهرتش‬ ‫ما‬ ‫و‬ ‫اليمين‬ ‫الناحية‬ ‫علي‬ ‫فيه‬ ‫ان‬ ‫كدا‬ ‫معني‬Lesion of left facial nerve ( ‫رقم‬ ‫الصورة‬ ‫في‬2):‫لما‬‫يعمل‬ ‫ان‬ ‫المريض‬ ‫من‬ ‫طلبت‬Forced closure for his eyes ‫ف‬ ‫ان‬ ‫كدا‬ ‫معني‬ ‫ضعيفة‬ ‫كانت‬ ‫الشمال‬ ‫العين‬ ‫اما‬ ‫حلو‬ ‫غمضت‬ ‫اليمين‬ ‫العين‬‫يه‬lesion of left facial nerve ( ‫رقم‬ ‫الصورة‬ ‫في‬3:)‫ان‬ ‫الحظ‬‫الفم‬deviated to the right side‫دا‬ ‫ان‬ ‫بما‬ ‫و‬facial nerve‫فـ‬deviation is n the healthy sidei‫معني‬‫في‬ ‫ان‬ ‫كدا‬Lesion of left facial nerve Question ( ‫رقم‬ ‫الصورة‬ ‫في‬1:)‫فيه‬ ‫ان‬ ‫نالحظ‬deviation to the left "healthy side"‫فيه‬ ‫كدا‬ ‫معني‬ Lesion in the right facial nerve ( ‫رقم‬ ‫الصورة‬ ‫في‬2:)‫طبي‬ ‫بشكل‬ ‫قفلت‬ ‫الشمال‬ ‫العين‬ ... ‫عينيها‬ ‫تقفل‬ ‫حاولت‬ ‫البنت‬ ‫لما‬‫العين‬ ‫أما‬ ‫عي‬ ‫فيه‬ ‫ان‬ ‫كدا‬ ‫معني‬ ‫ضعيفة‬ ‫كانت‬ ‫اليمين‬Lesion of the right facial nerve 1 2
Sensory "Mostly": ❖ Mediate general sensations from the pharynx and middle ear. ❖ Carries taste sensation from the posterior 1/3 of the tongue Motor: To stylopharyngeus muscle "involved in swallowing" Secretory: To the parotid gland Involved in gag reflex "Afferent" Motor: For (Soft palate – Larynx – Pharynx) Sensory: To (Larynx – Pharynx – Esophagus – External ear – Aortic body – Thoracic – Abdominal viscera) Parasympathetic: To thoracic – abdominal viscera Involved in gag reflex "Efferent" Examination of Glossopharyngeal IX & Vagus X o Gag reflex Sensory Afferent : Glossopharyngeal IX Motor Efferent: Vagus X 1. Touching the pharynx with a tongue depressor. *Stimulus* 2. Watching the elevation of the palate and gagging reflex (tendency to vomit) *Normal Response* o Sensation (taste sensation of posterior 1/3 of the tongue) (Sensory IX) ‫الـ‬ ‫في‬ ‫شرحنا‬ ‫ما‬ ‫زي‬Ant. 2/3‫الـ‬ ‫في‬Facial nerve 1. Ask the patient to protrude his tongue 2. Use small bottles and a dropper. The bottles usually contain sugar or salt solution. 3. Apply to one side then the other side of the extended tongue. 4. Ask the patient to tell you the taste before they pull their tongue back in the mouth IX. Glossopharyngeal nerve X. Vagus nerve
o Motor: 1. Ask the patient to open his mouth wide and to say "ahh" ✓ Observe the movement of the palate (Symmetrical soft palate movement) ✓ The palate should rise symmetrically and there should be little nasal air escape. 2. Examine the palate for uvular displacement, the uvula should be central in position (Unilateral lesion: Uvula drawn to normal lesion). 3. Ask the patient to swallow; ask if there any difficulty. 4. Phonation should be clear. "‫بحة‬ ‫فيه‬ ‫ميكنش‬" Lesion of IX (Glossopharyngeal) Lesion of X (vagus) Loss of taste from Post.1/3 of the tongue Deviation of uvula to opposite side of lesion "Healthy side" Loss of sensation from the pharynx Difficulty in swallowing Loss of gag reflex Vocal cord weakness Loss of sensations from the larynx, pharynx, Esophagus, external ear. ‫انه‬ ‫العيان‬ ‫من‬ ‫طلبت‬ ‫لو‬"‫"آآآآه‬ ‫يقول‬ ‫و‬ ‫فمه‬ ‫يفتح‬‫انه‬ ‫المفروض‬Uvula‫تكون‬centrally‫حادف‬ ‫مش‬‫ة‬‫شمال‬ ‫أو‬ ‫يمين‬ ‫أما‬‫لقيته‬ ‫لو‬‫ا‬‫حادف‬‫ة‬‫شمال‬leftDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervevagusthe rightLesion in ‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬Uvula‫بيكون‬deviated to the healthy side ‫لو‬ ‫أما‬‫لقيته‬‫ا‬‫حادف‬‫ة‬‫يمين‬rightDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervevagusthe leftLesion in ‫قل‬ ‫ما‬ ‫زي‬ ‫النه‬‫انه‬ ‫نا‬Uvula‫بيكون‬deviated to the healthy side Normal Oropharynx Normal Uvula "Central" Question ‫ال‬ ‫ان‬ ‫الصورة‬ ‫في‬ ‫باين‬ ‫هنا‬Uvula ‫اليمين‬ ‫ناحية‬ ‫محدوفة‬Deviated to the right side‫ان‬ ‫كدا‬ ‫معني‬ ‫ف‬ ‫فيه‬Lesion in the left vagus
Examination of Trapezius muscles: ❖ From behind, look for atrophy or asymmetry of the trapezius muscles. ❖ Ask the patient to shrug his shoulder up and try to push them down (Trapezius muscles) Examination of Sternocleidomastoid muscles: ❖ Ask the patient to turn his head (Sternocleidomastoid muscles) against resistance. ❖ Watch and palpate the Sternocleidomastoid muscle on the opposite side. Lesion of the accessory nerve results in ✓ Weakness of head rotation towards the opposite side of the lesion. (Weakness of sternomastoid muscle) ✓ Inability to elevate the shoulder. (Weakness of Trapezius muscle) ‫الـ‬ ‫فيها‬ ‫اللي‬ ‫الناحية‬ ‫ان‬ ‫بالحظ‬ ‫(و‬lesion‫واقع‬ ‫الكتف‬ ‫بيكون‬"dropping of the shoulder) Examination: ❖ Inspect the tongue for wasting. ❖ Ask the patient to protrude his tongue and note any deviation. ❖ Ask the patient to move his tongue from side to side. IN case of lesion: ✓ The tongue deviate towards the paralyzed side ✓ There is also wasting of the tongue on the side of the lesion. ❖ Ask the patient to move his tongue from side to side. ❖ Ask the patient to press with his tongue against the inside of either cheek, or press with your finger on the outside of the patient's check to test the power. XII. Hypoglossal nerve Pure Motor to the intrinsic and extrinsic muscles of the tongue XI. Accessory nerve Pure Motor to Sternomastoid and Trapezius muscles :‫ان‬ ‫الحظ‬Right sternomastoid which supplied by right Accessory nerve XI‫اللي‬ ‫هي‬ ‫صحيح‬ ‫العكس‬ ‫و‬ ‫الشمال‬ ‫ناحية‬ ‫تتحرك‬ ‫الرأس‬ ‫ان‬ ‫بتساعد‬ Trapezius muscle sternomastoid muscle ‫ا‬ ‫دي‬ ‫الصورة‬ ‫في‬ ‫نالحظ‬‫ن‬‫و‬ ‫شوية‬ ‫واقع‬ ‫اليمين‬ ‫الكتف‬‫الـ‬Right trapezius‫الـ‬ ‫زي‬ ‫تنقبض‬ ‫عارفة‬ ‫مش‬ Left trapezius‫فيه‬ ‫ان‬ ‫كدا‬ ‫معني‬lesion in the right Accessory nerve‫ال‬ ‫شفت‬ ‫لو‬ ‫أكيد‬ ‫و‬ Right sternomastoid‫هالقيها‬ ‫أكيد‬paralyzed‫بنفس‬ ‫بيتغذوا‬ ‫ألنهما‬‫العصب‬ Question
Nerves of the tongue Responsible for intrinsic and extrinsic muscles of the tongue "Motor" Hypoglossal XII Taste sensation Anterior 2/3 Facial nerve VII Posterior 1/3 Glossopharyngeal IX General *somatic* sensation ""‫مثال‬ ‫اللسان‬ ‫عضة‬ ‫زي‬ Trigeminal nerve III ‫انه‬ ‫العيان‬ ‫من‬ ‫طلبت‬ ‫لو‬‫برة‬ ‫لسانه‬ ‫يطلع‬‫فم‬‫المفروض‬ ‫ه‬‫اللسان‬‫يكون‬centrally‫شمال‬ ‫أو‬ ‫يمين‬ ‫حادف‬ ‫مش‬ ‫حا‬ ‫لقيتها‬ ‫لو‬ ‫أما‬‫شمال‬ ‫دفة‬leftDeviated to the‫معني‬‫في‬ ‫ان‬ ‫كدا‬hypoglossalthe LeftLesion in nerve‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬‫اللسان‬‫بيكون‬deviated to the diseased side ‫يمين‬ ‫حادفة‬ ‫لقيتها‬ ‫لو‬ ‫أما‬rightDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬hypoglossalrighttheLesion in nerve‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬‫اللسان‬‫بيكون‬deviated to the diseased side ‫أخليه‬ ‫و‬ ‫المريض‬ ‫خد‬ ‫علي‬ ‫ايدي‬ ‫أحط‬ ‫ممكن‬ ‫قوة‬ ‫أشوف‬ ‫بحيث‬ ‫بلسانه‬ ‫ايدي‬ ‫يقاوم‬ ‫ال‬ ‫عضالت‬tongue‫كدا‬ ‫الصورة‬ ‫زي‬ Question ‫لسان‬ ‫يطلع‬ ‫انه‬ ‫المريض‬ ‫من‬ ‫طلبت‬ ‫لما‬ ‫دي‬ ‫الصورة‬ ‫في‬‫لقيت‬ ‫ه‬ ‫الشمال‬ ‫ناحية‬ ‫حادف‬ ‫لسانه‬ ‫ان‬Deviated to the left ‫في‬ ‫انه‬ ‫كدا‬ ‫معني‬Hypoglossallesion in the left ‫تجميعات‬
NO. Nerve Function In case of lesion I Olfactory Pure sensory *Special sensation: Smell* Loss of smell *Anosmia* in the affected side II Optic Pure sensory *Special sensation: Vision* See vision section III Oculomotor Motor: ❖ All extra-ocular muscles EXCEPT SO4 – LR6 ❖ Levator palpabrae superiosis muscle ❖ Deviation of the eye down and out. ❖ ptosis Autonomic: ❖ Ciliary muscle. ❖ Sphincter pupillae muscle ❖ Dilated pupil. ❖ Loss of light and accommodation reflexes Efferent in light and accommodation reflexes IV Trochlear Pure motor to SO Inability to look down VI Abducent Pure motor to LR Inability to move the eye out V Trigeminal Sensory: Facial sensation and somatic sensation from the tongue. ❖ Loss of sensation in one or more divisions of the trigeminal nerve. Motor: Muscles of mastication. ❖ Wasting of the masseter and temporalis muscles. ❖ When the jaw is opened it will deviate towards the side of the lesion. Reflex: Afferent in corneal reflex ❖ There is also absence of the corneal reflex VII Facial Sensory: Taste sensation from Ant. 2/3 of the tongue Loss of sensation from Ant. 2/3 of the tongue. Motor: Muscles of facial expression. ❖ Paralysis of facial muscles in the affected side. ❖ Deviation of the mouth to the healthy side. ❖ Loss of forehead corrigation. Secretory: Lacrimal – salivary glands
(Sublingual – submandibular) Reflex: Efferent in corneal reflex. Failure to close the eye on the affected side →Loss of corneal reflex VII Vestibulocochlear Hearing and balance See hearing section IX Glossopharyngeal Sensory: General sensations from pharynx and middle ear. Special sensation from post. 1/3 of the tongue ❖ Loss of sensation from the pharynx ❖ Loss of taste from Post.1/3 of the tongue Motor: Stylopharyngeus muscle Secretory: To parotid gland. Afferent in gag reflex Loss of gag reflex X Vagus Motor: TO soft palate – larynx – pharynx ❖ Deviation of uvula to opposite side of lesion "Healthy side" ❖ Difficulty in swallowing ❖ Vocal cord weakness Sensory: TO larynx – pharynx – Esophagus – External ear – Aortic body – Thoracic and abdominal viscera Loss of sensations from the larynx, pharynx, Esophagus, external ear. Autonomic: TO Thoracic and abdominal viscera Efferent in gag reflex Loss of gag reflex XI Accessory Pure motor to ❖ Sternomastoid ❖ Trapezius ❖ Weakness of head rotation towards the opposite side of the lesion. (Weakness of sternomastoid muscle) ❖ Inability to elevate the shoulder. (Weakness of Trapezius muscle) XII Hypoglossal Pure Motor to the intrinsic and extrinsic muscles of the tongue ✓ The tongue deviate towards the paralyzed side ✓ There is also wasting of the tongue on the side of the lesion.
Reflexes Light reflex Accommodation reflex Corneal reflex Gag reflex Afferent Optic Trigeminal Glossopharyngeal Efferent Oculomotor Facial Vagus Cranial nerves having Autonomic function III "Oculomotor" VII "Facial" IX "glossopharungeal X "Vagus" ❖ Ciliary muscle. ❖ Sphincter pupillae muscle Secretory: Lacrimal – salivary glands (Sublingual – submandibular) Secretory: Parotid gland TO Thoracic and abdominal viscera Nerves causing deviation in case of lesion V "Trigeminal" XII "Hypoglossal" VII "Facial" X "Vagus" Test done Open the mouth Protrude the tongue Ask the patient to smile Open mouth & say "Ahh" Deviation of Lower jaw Tongue Angle of the mouth Uvula Side of deviation To diseases side (5+12=17) To healthy side (7+10=17)
1 2020 5MEDX TEAM FOR 2nd YEAR MEDICAL STUDENTS Motor System Examination
‫ازاي؟؟‬ ‫دا‬ ‫الجزء‬ ‫في‬ ‫هنتسأل‬‫صورة‬ ‫هتيجي‬ ❖ Examiner doing a certain test ❖ Sign ❖ Lesion ❖ Equipment ‫مثال‬ ‫زي‬ ‫أسئلة‬ ‫عليها‬ ‫دي‬ ‫الصور‬ ‫و‬ ❖ Identify- name the test? ❖ It is performed by ….. ❖ Normal response is …… ❖ Abnormal response is …….. ❖ Causes of abnormal response ………. ❖ Name the sign, mention the cause. ❖ Name the equipment, its use. ❖ Simple clinical scenario. ‫عن‬ ‫هنتكلم‬ ‫دا‬ ‫الشابتر‬ ‫في‬7‫حاجات‬ 1. Muscle status. 2. Muscle tone. 3. Muscle power. 4. Examination of deep reflexes (tendon jerk). 5. Examination of superficial reflexes. 6. Involuntary movements. 7. Coordination and Gait. ‫قدام‬ ‫اننا‬ ‫نتخيل‬Patient‫هنعملها‬ ‫حاجة‬ ‫أول‬ ‫ف‬Inspection‫علي‬ ‫أبص‬ ‫و‬status of the muscle‫أبص‬ ‫و‬‫علي‬ ‫ال‬right and the left together‫أشوفهم‬ ‫و‬Asymmetric‫ال‬ ‫ولة‬. 1. Assess muscle symmetry. ‫في‬ ‫لو‬ ‫نشوفها‬ ‫حاجة‬ ‫تاني‬ ‫و‬muscle weakness (atrophy)‫أو‬Increase muscle bulk (Hypertrophy) ‫ال‬ ‫نشوف‬ ‫و‬abnormality (atrophy – hypertrophy)‫موجودة‬unilateral or bilateral(‫في‬ ‫يعني‬‫ناحية‬ )‫ناحيتين‬ ‫ولة‬ ‫واحدة‬ 2. Observe any atrophy or hypertrophy Causes of muscle atrophy?? Lower motor neuron lesion (LMNL) → Cause of muscle atrophy (wasting) III. Motor System Examination ‫عددهم‬ ‫الكتاب‬ ‫في‬ ‫الموجودين‬ ‫ان‬ ‫بالنا‬ ‫ناخد‬5‫و‬ ‫بس‬ ‫زيادة‬ ‫في‬ ‫هنا‬2‫(رقم‬1‫ر‬ ‫و‬‫قم‬6‫اتقالوا‬ ‫عشان‬ ) ‫المراجعة‬ ‫فيديو‬ ‫في‬ 1. Muscle status
‫ال‬ ‫ان‬ ‫النظري‬ ‫من‬ ‫نفتكر‬ ‫لو‬muscle tone‫ال‬ ‫من‬ ‫جزء‬ ‫كان‬stretch reflex (static part)‫عن‬ ‫عبارة‬ ‫هو‬ ‫و‬certain degree of muscle contraction How To examine (Procedure) ❖ Ask the patient to relax (muscle should not do any work) ❖ Passively flex and extend the patient's joints (fingers – wrist – elbow – ankle – knee) ‫ال‬ ‫اتجاه‬ ‫نفس‬ ‫في‬ ‫يعني‬joint....‫بنـ‬ ‫اننا‬ ‫بالنا‬ ‫ناخد‬ ‫و‬examine right and left sides‫بيشتكي‬ ‫المريض‬ ‫لو‬ ‫حتي‬ ‫بس‬ ‫واحدة‬ ‫ناحية‬ ‫من‬ Response: ▪ Normal response: There is normally small continuous resistance to passive movement this is known as muscle tone. (static stretch reflex) ▪ Abnormal responses: Hypotonia Hypertonia Tone Decreased (flaccidity) Increased (spastic – rigid) As in cases of ❖ LMNL ❖ Neocelebellar syndrome ❖ UMNL (clasp knife) ❖ Parkinsonism (cog wheel/ lead pipe) 1. Ask the patient to perform movements against your resistance and gravity. ‫لصوابعه‬ ‫أعمل‬ ‫مثال‬ ‫بمعني‬ ‫يقاومني‬ ‫المريض‬ ‫أخلي‬ ‫يعني‬dorsiflexion‫يعمل‬ ‫بإنه‬ ‫يقاومني‬ ‫هو‬ ‫و‬planter flexion 2. Compare one side to the other. 3. Test the muscles responsible for movement of different joints of the upper and lower limbs. Movement Center Movement Center Flexion at elbow C5,6 (biceps) Extension at elbow C6,7,8 (triceps) Extension at wrist C6,7,8 (radial nerve) Squeeze 2 of your fingers as hard as possible C7,8 T1 Finger abduction C8 T1 ulnar nerve Opposition of the thumb C8 T1 Median n. Flexion at the hip L2,3,4 Iliopsoas Extension at the hips S1 (gluteus maximus) Extension at knee L2,3,4 (quadriceps) Flexion at knee L4,5 S1,2 (hamstrings) Dorsiflexion at ankle L4,5 Planter flexion S1 2. Muscle tone 3. Muscle power (strength)
Response: According to the grades Normal response Abnormal response Normal muscle power Muscle weakness In cases of: UMNL- LMNL in the affected segment ‫الكتاب‬ ‫في‬ ‫موجود‬ ‫كله‬ ‫مش‬ ‫دا‬ ‫فوق‬ ‫اللي‬ ‫الجدول‬ :‫بالك‬ ‫خد‬)‫باألصفر‬ ‫لملونة‬ ‫الكلمات‬ ‫(ماعدا‬‫في‬ ‫اتقال‬ ‫لكنه‬ ‫و‬ ‫زيها‬ ‫صورة‬ ‫تيجي‬ ‫ممكن‬ ‫عشان‬ ‫كويس‬ ‫اقراه‬ ‫لكن‬ ‫و‬ ‫الكتاب‬ ‫في‬ ‫مش‬ ‫دا‬ ‫جاي‬ ‫اللي‬ ‫الجزء‬ ‫كمان‬ ‫و‬ ‫المحاضرة‬ Wrist flexion (C7,8 T1) Have the patient try to flex his wrist as you provide resistance Test each hand separately Ask the patient to spread their fingers apart against resistance (abduction) Then squeeze them together, with your fingers placed in between each of their digits (adduction) Flexors of fingers (C7,8 T1) Ask the patient to make a fist, squeezing their hand around two of your fingers Elbow flexion (C5,6) The main flexor (and supinator) of the forearm is the Brachialis muscle (along with biceps muscle) Elbow extension (C7,8) The main extensor of the forearm is the triceps muscle. Have the patient extend their elbow against resistance Movement against gravity but not against the examiner's resistance Normal muscle strength Movement against gravity and resistance (weak) Movement with gravity eliminated Trace (flickers of movement) NO movement (complete paralysis What is meant by muscle weakness? Reduced or loss muscle strength If there is loss of movement → Paralysis
• Which test is performed by the examiner? ✓ Muscle power (strength) • What will be the result in case of UMNL? ✓ Muscle Weakness (loss of muscle power) (Decrease muscle power). General principles: ❖ Tendon jerk is a brief contraction of skeletal muscle elicited by tapping the tendon of the corresponding skeletal muscle sharply and strongly using a neurologic hammer (Dynamic stretch reflex). ‫ال‬ ‫بنخبط‬ ‫يعني‬tendon‫بـ‬hammer‫يحصل‬ ‫فـ‬contraction of the skeletal muscle‫ال‬ ‫يعتبر‬ ‫دا‬ ‫و‬ dynamic stretch reflex(‫ال‬ ‫ان‬ ‫قولنا‬ ‫اننا‬ ‫افتكر‬reflexchstatic stret‫ال‬ ‫كان‬muscle tone) ❖ Can be done in both sitting and supine position. ‫المريض‬ ‫حالة‬ ‫حسب‬ ❖ The limb should be placed in a position at which the muscle under test is in a neutral position OR mildly stretched. (not contracted). ❖ Valid test are best obtained when the patient s relaxed and not thinking about what you are doing. ❖ After obtaining the reflex on one side, always go immediately to the opposite side for the same reflex so that you can compare them. ❖ Deep reflexes Exaggerated In case of UMNL Diminished (absent) In case of LMNL ❖ If it is difficult to elicit the deep reflexes, reinforcement should be done. ‫أعمل‬ ‫ازاي‬reinforcement of the reflex In the upper extremity (Biceps – triceps) In the lower extremity (Ankle – knee) * Ask the patient to make a fist with one hand while the opposite extremity is being tested OR * By clenching of the teeth. * Ask the patient to perform the "Jendrassik maneuver" , the patient's fingers of each hand are hooked together so each arm can forcefully pull against the other. Ask the patient to pull his fingers while you're tapping on the tendon. Question The examiner is asking the patient to elevate his legs while the examiner is applying resistance 4. Examination of deep reflexes (tendon jerks) Neurologic hammer NOTE: reinforcement increase the sensitivity of the gamma fibers which supply the muscle spindles (receptors of stretch reflex), therefore, make them more sensitive
‫عن‬ ‫هنتكلم‬ ‫دلوقتي‬(Ankle – Knee – Biceps – triceps)4 jerks ‫ال‬ ‫عن‬ ‫عبارة‬ ‫دا‬ ‫األول‬ ‫الجزء‬steps‫نتبعها‬ ‫المفروض‬ ‫اللي‬‫تقراها‬ ‫ممكن‬ ‫لكن‬ ‫و‬ ‫الخطوات‬ ‫عن‬ ‫هنتسأل‬ ‫مش‬ ‫*احنا‬ ‫تفهم‬ ‫عشان‬*‫الصور‬ ‫علي‬ ‫تتعرف‬ ‫تعرف‬ ‫و‬ ‫أكتر‬ Preparing the patient ‫كله‬ ‫في‬ ‫ثابتة‬ ‫دي‬ ‫الخطوة‬ ‫و‬ ✓ Ask the patient to relax ✓ Explain what you are going to do Examination of ankle jerk (S1,2) 1. Position of the patient 2. Dorsiflex the foot slightly at the toes. 3. Hold the hammer with your fingers and use your wrist (not your arm) for the action. ‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 4. Strike the Achilles tendon with hammer sharply and strongly. 5. Distract the attention of the patient by talking with hm or asking him questions. ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬)‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ 6. Observe and record the response either as: ❖ Planter flexion of the foot. ❖ Seeing OR feeling the contraction of the gastrocnemius muscle by your hands. 7. Do the same steps on the other foot, and compare the response. 8. If the reflex: If the patient can set If the patient is in bed Ask him to sit at the edge of the examining couch or bed with the legs hanging freely. Ask him to extend both lower limb with the leg to be tested is crossed over the other leg. No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do Jendrassik maneuver *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for ankle clonus * Place the knee in a partly flexed position. * With the patient relaxed, the foot is dorsiflexed forcibly and maintained. * Observe the response:: clonus of the calf muscle and rhythmic oscillation of the foot.
Examination of Knee jerk (L3,4) 1. Position of the patient 2. Identify the patellar tendon by palpation below the patella. 3. Hold the hammer with your fingers and use your wrist (not your arm) for the action. ‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 4. Tap on the patellar tendon with hammer sharply and strongly using the hammer. 5. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ 6. Observe the response and rate the reflex (The response: Extension of the leg – movement of the leg forward – contraction of quadriceps femoris muscle) 7. Do the same steps on the other side, and compare. 8. If the reflex Examination of Biceps jerk (C5,6) 1. Ask the patient to sit with the forearm supported, either ✓ Resting on the patient's thigh OR ✓ Resting on the forearm of the examiner. The arm is midway between flexion and extension with the palm pronated Place your thumb firmly on the biceps tendon. If the patient can set If the patient is in bed Ask him to sit at the edge of the examining couch or bed with the legs hanging freely. Flex the knee slightly by placing your forearm under both knees. No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do Jendrassik maneuver *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for knee clonus * By forcible maintained pulling of the patella downwards, using the index finger and the thumb. * Observe the response:: clonus of the quadriceps muscle and rhythmic oscillation of the patella. * Patellar clonus is sign of (UMNL – supra spinal facilitation)
2. Hold the hammer with your fingers and use your wrist (not your arm) for the action.‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 3. Strike your finger which is placed on the tendon with the reflex hammer sharply and strongly. 4. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ 5. Observe and record the response either as: ❖ flexion of the elbow. ❖ Seeing OR feeling the contraction of the biceps muscle by your hands. 6. Do the same steps on the other hand, and compare. 7. If the reflex Examination of Triceps jerk (C6,7) 1. Ask the patient to flex his arm at the elbow (90°) and hold it close to the chest with the palm directed toward the body. 2. Hold the hammer with your fingers and use your wrist (not your arm) for the action. ‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 3. Identify the triceps tendon at its insertion on the olecranon above the elbow. 4. Strike the triceps tendon with hammer sharply and strongly. 5. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ 6. Observe and record the response either as: ❖ Extension of the forearm. ❖ Seeing OR feeling the contraction of the triceps muscle by your hands. 7. Do the same steps on the other hand, and compare. 8. If the reflex No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for clonus No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for clonus
‫الحظ‬‫ال‬ ‫كل‬ ‫في‬ ‫ان‬reflexes‫بيحصل‬(abnormal response) Decreased (Hyporeflexia) In case of LMNL Increased (Hyperreflexia) In case of UMNL Name & Center Stimulus Response Ankle (S1,2) Tapping on tendoachillis while the feet are slightly dorsiflexed. ✓ Contraction of gastrocnemias muscel ✓ Planter flexion. Knee (L3,4) Tapping on the patellar tendon while the leg is semiflexed. ✓ Contraction of quariceps ✓ Extension of the knee. Triceps (C6, 7) Tapping on triceps tendon. ✓ Extension of the elbow. ✓ contraction of the triceps muscle Biceps (C5,6) Tapping on biceps tendon while the forearm is pronated and semiflexed. ✓ Flexion of the elbow. ✓ contraction of the biceps muscle If the reflex is We do Diminished Reinforcement Exaggerated (hyperactive) Clonus ‫دا‬ ‫الجدول‬ ... ‫متقلقش‬ ‫ف‬ ‫دا‬ ‫فوق‬ ‫اللي‬ ‫الكالم‬ ‫كروت‬ ‫انت‬ ‫لو‬‫ف‬‫كلها‬ ‫الزتونة‬ ‫يه‬ dd ‫ألن‬ :‫غالبا‬muscle tone and deep reflex have the same supraspinal control ‫ال‬ ‫لزيادة‬ ‫يؤدي‬ ‫مرض‬ ‫في‬ ‫لو‬muscle tone‫فيه‬ ‫ان‬ ‫هنالحظ‬ ‫فغالبا‬hyperreflexia‫حالة‬ ‫(في‬UMNL) ‫ال‬ ‫لنقص‬ ‫يؤدي‬ ‫مرض‬ ‫في‬ ‫لو‬muscle tone‫فيه‬ ‫ان‬ ‫هنالحظ‬ ‫فغالبا‬hyporeflexia‫حالة‬ ‫(في‬UMNL) Question 1. The examiner is tapping on ………… tendon, to elicit ……. Jerk. 2. An abnormal response should be….. and is caused by……. ❖ The examiner is tapping on patellar / quadriceps tendon, to elicit knee / patellar Jerk. ❖ An abnormal response should be hyperreflexia and is caused by UMNL OR ❖ An abnormal response should be hyporeflexia and is caused by LMNL Remember NOTE: Clonus is repetitive rhythmic contraction of a muscle exposed to sudden maintained stretch. There are patellar and ankle clonus
Planter reflex (center S1,2) The procedure: 1. Stroke the sole of the foot with the back of your reflex hammer or key ❖ From lateral heel to lateral ball of foot. ❖ Then medially to medial ball of foot. 2. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ The observation Normal response Abnormal response Toes go down (planter flexion) (withdrawal) Extension of the big toe (big toe goes up) with fanning of the other toes *positive Babinski* NOTE Positive Babinski sign can be recorded Normally Pathologically During sleep Under anesthesia In infant below one year of age (due to incomplete myelination of the pyramidal tract) UMNL Abdominal reflex (center upper abdominal T7-10, Lower abdominal T10-T12) The procedure: 1. Ask the patient to expose his abdomen and relax with their arms by their side. 2. Use a blunt object such as a key or pen cover. Mechanism of clonus: The initial sudden muscle stretch will stimulate discharge from intrafusal fibers ( mainly nuclear bag ) resulting in muscle contraction . The tension developed in the muscle as a result is so high that the Golgi tendon organs become excited initiating inverse stretch reflex in the same muscle producing its relaxation , and as the stretch is maintained this process will be repeated rhythmically . This is detected in case of UMNL as a result of sparing of some of the facilitatory supraspinal discharge. FORREADING 5. Examination of superficial reflexes
3. Stroke the abdomen lightly on each side in an inward direction above and below the umbilicus. The observation: UMNL LMNL S (Strength) Lowered Lowered T (Tone) Increases Decreases O (others) Clonus Fasciculations/ fibrillations R (reflexes) Increased Decreased M (muscle mass) Slight loss Atrophy Baby – Babinski Positive negative UMNL LMNL Muscle wasting NO (EXCEPT from disuse *disuse atrophy*) Marked (atrophy) Tone Hypertonia *spasticity* (Called clasp- knife) Hypertonia *flaccidity* (Called flaccid paralysis) Clonus Present Absent Reflexes Exaggerated Diminished OR absent Extensor planter reflex Babinski sign (dorsiflexion of the big toe and fanning out of the other toes) Absent Abdominal reflexes Absent Absent Fasciculation No May occur Normal response Abnormal response Contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus. Absence of abdominal muscle contraction As in UMNL – LMNL ‫مجمعين‬ ‫دول‬ ‫الجدولين‬UMNL – LMNL‫بعده‬ ‫اللي‬ ‫شوف‬ ‫و‬ ‫عديها‬ ‫حابب‬ ‫مش‬ ‫لو‬ .. ‫هيفيدك‬ ‫تقراه‬ ‫حابب‬ ‫لو‬ ‫ف‬
❖ They are involuntary, rhythmic muscle contraction and relaxation involving oscillation or twitching movements of one or more body parts. ❖ It is the most common of all involuntary movements. ❖ Most tremors occur in hands. ❖ Observation: fine movement of the hands. ❖ Causes of tremors: Physiological Pathological Aging Anxiety Thyrotoxicosis Parkinsonism Cerebellar disease Difference between parkinson's disease & Neocerebellar syndrome Pakinson's disease Neocerebellar syndrome Cause Due to disturbance in indirect circuit (which inhibits unwanted movement) leading to hyperkinetic features. Due to absent damping function of the cerebellum. Type Resting/ static Kinetic/ intention Character Pill-rolling/ Coarse ‫محتاج‬ ‫مش‬ ‫(يعني‬Test)‫أشوفه‬ ‫عشان‬ Disappear During movement or sleep At rest and during sleep Begin in one extremity and spread to the others, affecting the distal joints of the limbs preferentially Particularly affects the head and the upper half of the body Other neurological signs Bradykinesia/ rigidity/ postural instability/ micrographia/ shuffling gait/ masked faces Often associated with dysmetria/ dyssynergia/ hypotonia To assess the cerebellar function NOTE: cerebellar function =Coordination of voluntary and involuntary movements 1. Rapid alternating movements: Ask the patient to perform rapid alternating movements as supination and pronation of the limb rapidly and successively. ‫عنده‬ ‫اللي‬ ‫للمريض‬ ‫صعبة‬ ‫هتبقي‬ ‫دي‬ ‫الحركة‬ ‫و‬cerebellar disease 6. Involuntary movements Tremors 6. Coordination and Gait
2. Finger to finger test – finger to nose test. Ask the patient to touch the tip of his index of one upper limb with the tip of the other upper limb several times. OR Ask the patient to touch the tip of his nose with the tip of his finger several times. Ask the patient to perform the previous movements several times with the eye closed. Observe the response. Compare right versus left. 3. Heel knee shin test The patient can sit at the edge of examination couch with the lower limbs hanging freely OR can lie down. Ask the patient to place one heel on the opposite knee and run it down the shin of the tibia to the big toe. Repeat the test with the patient's eyes closed. Observe the response. 4. Gait pattern You must be in a position to steady the patient should he threaten to fall Ask the patient to: Walk across the room, turn and come back observe the gait, whether: ▪ Symmetrical OR asymmetrical. (such as hemiplegic gait) ▪ Normal paced OR short stepping gait. ▪ Normal knee movement OR high stepping gait. ▪ Look at the pelvis normal webbing gait. Finger to finger test Finger to nose test Heel knee shin test: A test of voluntary motor coordination in which a patient is asked to slowly touch the knee with the heel of the opposite leg, which is altered in cerebellar dysfunction. Inability to slide the heel of one foot down the shin of the opposite leg; the heel will deviate to alternate sides
Future testing: Ask the patient to if unable this indicates Walk as if on a tight rope Unsteadiness due to various causes Walk on his heels Foot drop Walk on his toes Weakness of the gastrocnemius There are several types of gait abnormalities which occur due to certain diseases such as: Hemilplegia The foot is planter flexed and the leg is swung in a lateral arc (circumduction) Spastic paraparesis Scissoring gait Cerebellar Wide-based. Patient staggers towards side of cerebellar lesion. Posterior column lesion Patient slaps down feet on a broad base. Parkinson's disease Hesitation, shuffling, freezing gait Foot drop Hip stepping gait Proximal myopathy Wadding gait
1 2020 5MEDX TEAM FOR 2nd YEAR MEDICAL STUDENTS Practical Vision And Hearing
Visual acuity: ‫الرؤية‬ ‫حدة‬ ❖ It is the degree to which the details and contours of objects are perceived. ‫انها‬ ‫بما‬ ‫و‬ ‫كويسة‬ ‫بجوددة‬ ‫األشياء‬ ‫تفاصيل‬ ‫بشوف‬ ‫يعني‬details‫الـ‬ ‫وطيفة‬ ‫دي‬ ‫يبقي‬Foveal Cones ❖ It is usually defined in terms of the minimum separable "the shortest distance by which two lines can be separated and still be perceived as 2 lines" ‫الـ‬ ‫نحدد‬ ‫بنقدر‬Visual acuity‫خالل‬ ‫من‬charts‫الـ‬ ‫*أسامي‬ ‫مثال‬ ‫زي‬ ‫بعض‬ ‫تحت‬ ‫صفوف‬ ‫فيها‬ ‫بتكون‬Charts‫دي‬ *‫وضعوها‬ ‫اللي‬ ‫العلماء‬ ‫ألسامي‬ ‫نسبة‬ ❖ Snellen's chart (Alphabetical letters) ❖ Emarah's Arabic chart Practical vision and hearing Examination of vision Visual acuity Visual field Fundus examination ‫سنة‬ ‫في‬ ‫هناخده‬5‫الرمد‬ ‫راوند‬ ‫في‬ Visual acuity test a b ‫أشوف‬ ‫عشان‬ ‫يعني‬Details of object‫بذاتها‬ ‫مستقلة‬ ‫نقطة‬ ‫كل‬ ‫أشوف‬ ‫الزم‬ ‫أخدنا‬ ‫لو‬ ‫مثال‬ ‫يعني‬line from a‫و‬line from b‫تالقو‬ ‫الخطين‬ ‫ان‬ ‫هنالقي‬‫ا‬ ‫اسمها‬ ‫نقطة‬ ‫في‬nodal point‫في‬ ‫موجودة‬ ‫دي‬ ‫و‬Posterior 1/3 of the lens‫فيه‬ ‫ان‬ ‫هنالحظ‬ ‫و‬angle‫أشوف‬ ‫عشان‬ ‫ف‬ ‫دي‬ ‫النقطة‬ ‫عند‬2 points as 2 points‫بتساوي‬ ‫دي‬ ‫الزاوية‬ ‫تكون‬ ‫الزم‬1 minute ‫من‬ ‫أقل‬ ‫كانت‬ ‫لو‬1min‫نشوف‬ ‫هنقدر‬ ‫مش‬ ‫ف‬2points as 2points Nodal point 1 min 1 degree = 60 min Snellen's chart Emarah's Arabic chart Visual field is the fovealfunction of cones
❖ Landolt's chart (Incomplete circles) *Most common* The chart is placed at a distance of 6 meter from the tested person (TO relax the ciliary muscle). ‫عن‬ ‫قربنا‬ ‫لو‬6‫بنعمل‬ ‫كدا‬ ‫يبقي‬ ‫متر‬stimulation to accommodation reflex‫ال‬ ‫بشغل‬ ‫و‬ciliary muscle ‫انه‬ ‫بمعني‬ ‫علي‬ ‫بناءا‬ ‫الدواير‬ ‫أحجام‬ ‫و‬ ‫المسافات‬ ‫اختالف‬ ‫و‬ 12 Circles are arranged in 7 rows With the openings of the circles in different directions. distance in meters at which the edge of the openings makes visual angle of 1min at the nodal point of the lens. 60 36 24 18 6 9 ‫اإلنسان‬ ‫ف‬ ‫كبيرة‬ ‫دايرة‬ ‫في‬ ‫صف‬ ‫أول‬ ‫مسافة‬ ‫عند‬ ‫يشوفها‬ ‫يقدر‬ ‫الطبيعي‬60‫متر‬ ‫اإلنسان‬ ‫ف‬ ‫أصغر‬ ‫دواير‬ ‫في‬ ‫تحته‬ ‫اللي‬ ‫الصف‬ ‫و‬ ‫عن‬ ‫واضحة‬ ‫يشوفها‬ ‫يقدر‬ ‫الطبيعي‬‫مسافة‬ ‫د‬ 36‫الصفوف‬ ‫لباقي‬ ‫بالنسبة‬ ‫هكذا‬ ‫و‬ .... ‫متر‬ ‫عاملين‬ ‫اللي‬ ‫النقطتين‬ ‫بين‬ ‫المسافة‬ ‫بتكون‬ ‫كبيرة‬ ‫دايرة‬ ‫أول‬ ‫في‬ ‫*زي‬ ‫النقطتين‬ ‫من‬ ‫خط‬ ‫نرسم‬ ‫لما‬ ‫بالتالي‬ ‫ف‬ ‫كبيرة‬ ‫الدايرة‬ ‫فتحة‬ ‫تتكو‬ ‫الزم‬ *‫كدا‬ ‫الصورة‬‫ن‬Angle*‫عند‬nodal point* ‫مقدارها‬1min‫نشوف‬ ‫نقدر‬ ‫عشان‬2 points = 2 points‫و‬ ‫نشوف‬ ‫بالتالي‬‫ال‬ ‫و‬ ‫الدايرة‬ ‫بتاعة‬ ‫الفتحة‬Angle‫مش‬ ‫دي‬ ‫بعد‬ ‫علي‬ ‫اإلنسان‬ ‫كان‬ ‫إذا‬ ‫إال‬ ‫بتتحقق‬60‫أقرب‬ ‫أو‬ ‫الدايرة‬ ‫من‬ ‫متر‬ ‫فـ‬ ‫كدا‬ ‫من‬ ‫أبعد‬ ‫كان‬ ‫لو‬ ‫لكن‬ ‫و‬ ‫كدا‬ ‫من‬Angle‫من‬ ‫أقل‬ ‫هتكون‬ 1 min‫بوضوح‬ ‫الشكل‬ ‫يشوف‬ ‫هيقدر‬ ‫مش‬ ‫و‬. ‫بالنسبة‬ ‫هكذا‬ ‫و‬ ‫المسافة‬ ‫نقرب‬ ‫الزم‬ ‫الدايرة‬ ‫نصغر‬ ‫لما‬ ‫بالتالي‬ ‫ف‬ .....‫للباقي‬ Nodal point 1 min A person with normal vision is able to see accurately the directions of the opening in the 7 rows A diagram to demonstrate that the openings of the circles in the seven rows of Landolt chart make (at the distance of 60, 36, 24, 18, 12, 9 and 6 meters) one and the same visual angle of 1min Landolt's chart
‫ال‬ ‫قدام‬ ‫المريض‬ ‫قعدت‬ ‫كدا‬ ‫أنا‬ ‫طب‬chart‫أنهي‬ ‫لحد‬ ‫يشوف‬ ‫قدر‬ ‫هو‬ ‫وشفت‬row‫الـ‬ ‫نتيجة‬ ‫أكتب‬ ‫ازاي‬ .....test‫؟؟‬ :‫مثال‬‫الـ‬ ‫كدا‬ ‫يبقي‬ ‫الباقي‬ ‫يشوف‬ ‫يقدرش‬ ‫ما‬ ‫و‬ ‫بس‬ ‫صف‬ ‫أول‬ ‫يشوف‬ ‫قدر‬ ‫المريض‬ ‫لو‬ 6 60 Result =‫رقم‬ ‫و‬60 ‫عند‬ ‫يشوف‬ ‫قدر‬ ‫دا‬ ‫المريض‬ ‫ان‬ ‫كدا‬ ‫معني‬6‫عند‬ ‫يشوفه‬ ‫يقدر‬ ‫الطبيعي‬ ‫االنسان‬ ‫اللي‬ ‫متر‬60‫متر‬ :‫مثال‬‫صف‬ ‫آخر‬ ‫لحد‬ ‫يشوف‬ ‫قدر‬ ‫المريض‬ ‫لو‬ 6 6 Result =‫دا‬ ‫المريض‬ ‫كدا‬ ‫يبقي‬normal‫عند‬ ‫يشوف‬ ‫وقدر‬6‫اللي‬ ‫متر‬ ‫عند‬ ‫بيشوفه‬ ‫الطبيعي‬ ‫اإلنسان‬6‫متر‬. Procedure: *‫فوق‬ ‫قولناه‬ ‫اللي‬ ‫عن‬ ‫جديدة‬ ‫حاجة‬ ‫*مفيش‬ 1. The subject to be tested stands at 6 meters from the chart. 2. Cover one eye. 3. Ask the person to read the letters or to tell the direction of the circles beginning from the top row. 4. Note the last row he can read accurately. 5. Repeat with the other eye. Results: ✓ Record the visual acuity as 6 over the distance in meters written beside the last line read correctly by the subject. ✓ The normal visual acuity is 6/6 OR 20/20 if the distance is expressed in feet. The results are expressed as a fraction 𝑁𝑜𝑚𝑒𝑟𝑎𝑡𝑜𝑟 = 20𝑓𝑒𝑒𝑡𝑠 𝑂𝑅 6 𝑚𝑒𝑡𝑒𝑟 𝐷𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑜𝑟 = ? The distance at which the subject read the chart The greatest distance from the chart at which a normal individual can read the smallest line the subject can read Question 1. What do we mean by 6/60? ✓ This person sees at 6 meters (nominator) what the normal person sees at 60 meters (denominator) 2. What is the normal result? ✓ The normal result is 6/6 ‫تحته‬ ‫اللي‬ ‫الصفوف‬ ‫بعدين‬ ‫و‬ ‫دواير‬ ‫أكبر‬ ‫فيه‬ ‫اللي‬ ‫صف‬ ‫بأول‬ ‫االختبار‬ ‫بنبدأ‬ ‫احنا‬ ‫المسافة‬ ‫هقرب‬ ‫شايف‬ ‫مش‬ ‫قال‬ ‫و‬ ‫صف‬ ‫أول‬ ‫علي‬ ‫سألته‬ ‫لو‬*Decrease the distance*‫بدل‬ ‫يعني‬6‫أخليها‬ ‫متر‬ ‫أقل‬5-1‫دي‬ ‫الحالة‬ ‫في‬ ‫و‬ ‫متر‬ ‫لحد‬ ‫المسافة‬ ‫قللت‬ ‫لو‬1‫هعمل‬ ‫دايرة‬ ‫أكبر‬ ‫شايف‬ ‫مش‬ ‫بردوا‬ ‫و‬ ‫متر‬counting fingers‫و‬ ‫ايدي‬ ‫صوابع‬ ‫أطلع‬ ‫يعني‬ .‫كام‬ ‫عددهم‬ ‫أسأله‬ ‫ع‬ ‫مش‬ ‫لو‬‫أعمل‬ ‫أبدأ‬ ... ‫ارف‬hand movement‫ال‬ ‫ولة‬ ‫شايفها‬ ‫وأساله‬ ‫قدامه‬ ‫ايدي‬ ‫أحرك‬ ‫يعني‬ ‫أعمل‬ ‫أبدأ‬ ‫شايف‬ ‫مش‬ ‫لو‬Light perception‫ال‬ ‫ولة‬ ‫شايفه‬ ‫وأسأله‬ ‫عنيه‬ ‫علي‬ ‫ضوء‬ ‫أسلط‬ ‫يعني‬ ‫علينا‬ ‫مش‬ ‫دا‬ ‫الجزء‬
Tests for color blindness I Test A (colored tufts of wool) Procedure: 1. The person is given many tufts of wool whose colors cover the whole visual spectrum. 2. He is asked to group tufts of similar colors together. 3. Observe the patients' ability to discriminated colors. II Test B (the hidden figure test OR Ishihara's test) Principle: ❖ That test uses a series if Ishihara charts made up of sets of dots that differ in size and in depth of colors (some being paler – some more intense) ❖ Some of these spots are arranged to represent certain figures or numbers. ❖ People with good color discrimination associated together the dots of the same color and can see the figure. Procedure: ❖ Ask the patient to look at various color charts in bright light of sunlight at a distance of about 75 cm. from the eye for few seconds. ❖ Observe if they identify the number OR figure in the chart. Color vision ility of the eye to discriminate between: is the abColor sense colors excited by light of different wave lengths Color vision is a (soConesfunction of most developed at the fovea) Ishihara charts Inability to identify a number suggests some defect of color vision
Color blindness: Insensitivity to colors Some color blind individual are unable to distinguish certain colors, whereas others have only color weakness. 1. Red-green color blindness This occurs when either the red or green cones are lacking. 2. Blue weakness Abnormalities of red-green cones *More common than blue* Defect of the blue cones Inherited as Recessive X-linked Autosomal dominant SO Common in males ❖ As male has ONLY 1 X chromosome ❖ While female has 2 X chromosomes ‫االتنين‬ ‫الزم‬ ‫ف‬ ‫المرض‬ ‫يظهر‬ ‫عشان‬ ‫يتصابوا‬ Show no sexual selectivity ❖‫في‬ ‫بتحصل‬ ‫ألنها‬autosomal chromosomes NOT sex chromosomes How to examine the field? ❖ Confrontation ‫اللي‬ ‫االختبار‬ ‫دا‬ ‫*و‬*‫هنعمله‬ ❖ Perimeter *Automated* (computerized) Procedure: Confrontation 1. Sit opposite the patient 1m. away. Visual field test Visual field of each eye is the region of space that the eye can see looking straight ahead without movement of the head or the eyes Visual field ‫الـ‬ ‫بقارن‬Visual field‫بـ‬ ‫المريض‬ ‫بتاع‬Visual field‫بتاعي‬as examiner‫سليم‬ ‫اني‬ ‫باعتبار‬ Visual field is the function of rodsthe
2. Ask the patient to look at your eyes. 3. Test each eye separately. 4. Ask the patient to cover one eye and you should cover the opposite eye. 5. Move your hand out of the patient's visual field and then bring it back in. 6. The patient signals when your hand comes back into view. 1. Pupillary light reflex: Light → Eye →Moisis (Constriction of pupils) ❖‫الـ‬ ‫ان‬ ‫هنالحظ‬ ‫و‬Constriction‫في‬ ‫حصل‬Pupil of the eye‫الضوء‬ ‫عليها‬ ‫سلطت‬ ‫اللي‬ (Direct light reflex) ❖‫في‬ ‫حصل‬ ‫و‬other pupil(Consensual Or indirect light reflex) The procedure: 1. Explain that you are going to shine a bright light into the patient's eye and that this may feel uncomfortable. 2. Let the patient stare into the distance as you shine the penlight obliquely into each pupil. 3. Shine the light obliquely into his left eye (Direct reflex) and look for the pupil constriction. 4. Shine the light obliquely into his left eye once again, but this time look for pupil constriction in his right eye (Consensual reflex). 5. Repeat for the right eye. Eye reflexes
Pathway Optic chiasma Optic tract Edenger Westephal nucleus Light Left eye Left optic nerve Left optic tract Left optic Chiasma Left pretectal nucleus Left Edenger Westephal nucleus Right Edenger Westephal nucleus Left Oculomotor N. Right Oculomotor N. Right ciliary ganglionLeft ciliary ganglion Left constrictor pupillae Right constrictor pupillae Direct light reflex Indirect (Consesual) light reflex Right short ciliary nerveLeft short ciliary nerve
Causes of Consensual light reflex: 1. Partial decussation in Optic chiasma. 2. Pretectal nucleus sends innervations to Edinger Westiphal nucleus of both sides (right + left). 2. Accommodation reflex: Distant object →Near object (near to nose) The procedure: 1. Ask the patient to follow with his eyes your finger (distant object) as it comes closer into his nose (near object). 2. Observations: ❖ Pupil constriction. ❖ Lens accommodation (increase diopteric power of the lens) ❖ Convergence of the eyes. Example 1: If Left optic nerve is diseased and I shine the light on the left eye, Will light reflex happen (Direct OR Consensual)? NO ‫الـ‬ ‫ألن‬Afferent‫مفيش‬ ‫ف‬ ‫خالص‬ ‫باظ‬stimulus‫هيتنقل‬ Example 2: If left optic nerve is normal but right optic nerve is diseased and I shine the light on the left eye, what will happen? ❖ Direct light reflex on the left eye will happen ❖ Indirect (Consensual) light reflex on the right eye will happen too, because the left pretectal nucleus will give innervation to Edinger Westephal nucleus of both sides. Example 3: If I shine light on the left eye and the right and left optic nerve are intact but left oculomotor nerve is diseases, What will happen? ❖ Direct light reflex on the left eye won't happen due to the diseased left oculomotor ❖ Indirect (Consensual) light reflex on the right eye will happen normally.
Reflex Pupillary Light reflex Accommodation (Near) reflex Stimulus Light Blurred image Receptor In Retina In Retina Afferent *sensory* CN II Optic nerve CN II Optic nerve Center Pretectal nucleus Frontal eye field (area 8) Efferent *Motor* CN III Parasympathetic fibers of Oculomotor nerve CN III parasympathetic + motor fibers of Oculomotor Effector Constrictor pupillae muscles 1. Medial recti 2. Constrictor pupillae muscle. 3. Ciliary muscle Response Direct and indirect Constriction of the pupil *Moisis* 1. Convergence of eyeballs. 2. Constriction of pupil. 3. Increase lens curvature Pathway Optic nerve Optic Chiasma Optic tract Lateral geniculate body Optic radiation Visual cortex (area 17) Frontal eye field (area 8) Somatic motor nucleus of CN III Edenger Westephal nucleus of CN III Contraction of medial rectus Convergence of eyeballs Ciliary ganglion Short ciliary nerve Contraction of ciliary muscle Contraction of constrictor pupillae muscle Increase in anterior curvature of lens Constriction of pupil *Moisis*
Common Questions 1. Visual acuity is the function of foveal cones 2. Mention Charts used in visual acuity test. ‫صورة‬ ‫يجيب‬ ‫ممكن‬ ‫*و‬*‫اسمها‬ ‫علي‬ ‫يسألك‬ ‫و‬ ‫ليهم‬ o Snellen's chart and Landolt's chart 3. At which distance the patient is sitting during the visual acuity test? And Why? o 6 meters – To relax the ciliary muscle 4. Normal visual acuity is 6/6 Or 20/20 *In feet* 5. What do we mean by that the visual acuity is 6/18? o This person sees at 6 meters (nominator) what the normal person sees at 18 meters (denominator) 6. Color vision is the function of Cones 7. Types of color cones Red – green - Blue 8. Mention the tests used to examine the color vision. o Test A (Colored tufts of wool) o Test B (The hidden figure test Or Ishihara test) 9. If in the previous tests, the patient can't differentiate between colors, this means that he has Color blindness 10.Mention Types of color blindness. o Red-green color blindness o Blue weakness 11.Which color blindness is inherited as X-linked recessive? And mention if this blindness was common in males Or females. o Red-green blindness - males 12. Visual field is the function of rods 13.Mention the importance of light reflex. It is a protective reflex 14.Mention the components / effectors of near response. o Medial recti : Convergence / Ciliary muscle: increase dioptric power of lens / Constrictor pupillae: constriction of pupil
Types of sound transmission 1. Air conduction: (Sound vibration →Air →Cochlea) When sound vibrations are elicited in the air, it is conducted to cochlea by: Ossicular route secondary tympanic membrane that closes the round window transmission through the middle ear ossicles is the main pathway of normal hearing (the most efficient route). This process is unimportant in normal hearing because direct transmission from air to perilymph is associated with great loss of sound energy. ‫ال‬ ‫في‬ ‫موجودة‬ ‫اللي‬ ‫العظام‬ ‫عشان‬middle ear ‫هتعمل‬magnification to sound 2. Bone conduction: ❖ Is transmission of vibrations of the bones of the skull to the fluid of the inner ear. ❖ Considerable bone conduction occurs when tuning forks Or other vibrating bodies are applied directly to the skull. ❖ This rout also plays a role in transmission of extremely loud voice. Examination of hearing ‫حالتين‬ ‫في‬ ‫بيحصل‬ ‫حطيت‬ ‫اني‬tuning fork on the skull‫فيه‬ ‫أو‬Extremely loud voice Normally, air conducted sounds are louder and heard longer than bone conduction : Loss of hearingDeafness (partial Or complete)
The procedure: The base of a vibrating tuning fork is placed against the center of the person's forehead. The response: Normally In conductive deafness in one ear In nerve deafness *Sensorineural* (one side) It is heard equally on both sides. Sound is heard better on the diseased side than on the healthy side (because the masking effect of the environmental noise is absent on the diseased side) Sound is louder in the healthy side. ‫الـ‬ ‫بسبب‬ ‫انه‬ ‫بمعني‬obstruction in the diseased side‫كعازل‬ ‫بيعمل‬ ‫للـ‬Cochlea‫حواليا‬ ‫اللي‬ ‫الضوضاء‬ ‫عن‬ ‫ال‬ ‫و‬Cochlea is already intact‫من‬ ‫الرنة‬ ‫ف‬tuning fork ‫للـ‬ ‫هتوصل‬cochlea‫أوضح‬ ‫ال‬ ‫ألن‬ ‫كويس‬ ‫هتسمع‬ ‫السليمة‬ ‫الودن‬ ‫يعني‬ Cochlea‫ال‬ ‫الودن‬ ‫بعكس‬ ‫فيها‬ ‫شغالة‬ diseases Tuning fork tests Weber test Types of hearing loss according to causes: 1. conductive hearing loss ‫الـ‬ ‫في‬ ‫مشكلة‬ ‫لدوث‬ ‫نتيجة‬ ‫حصل‬Hearing pathway‫مثال‬ ‫زي‬Obstruction by wax – Perforation in ear drum – problem on ossicular system‫تعوق‬ ‫حاجة‬ ‫أي‬ ‫يعني‬Transmission of sound through the normal pathway *Air conduction pathway*‫ال‬ ‫يعني‬sound‫من‬ ‫يوصل‬ ‫قادر‬ ‫مش‬ear to inner ear ‫في‬ ‫مشكلة‬ ‫عندنا‬ ‫دي‬ ‫الحالة‬ ‫في‬air conduction‫الـ‬ ‫لكن‬ ‫و‬Bone conduction‫شغال‬normal‫علي‬ ‫بيعدي‬ ‫مش‬ ‫النه‬ ‫ال‬middle ear‫للـ‬ ‫بيروح‬ ‫و‬inner ear directly 2. Sensory neural hearing loss (nerve deafness) ‫الـ‬hearing pathway‫و‬ ‫سليم‬‫الـ‬ ‫في‬ ‫المشكلة‬ ‫لكن‬Sensory organ *cochlea*‫الـ‬ ‫في‬ ‫أو‬Cortex ‫في‬ ‫مشكلة‬ ‫عندنا‬ ‫دي‬ ‫الحالة‬ ‫في‬air conduction‫للـ‬ ‫وصل‬ ‫الصون‬ ‫ألن‬cochlea‫كمان‬ ‫عندنا‬ ‫و‬ ‫شغالة‬ ‫مش‬ ‫لكنها‬ ‫و‬ ‫الـ‬ ‫في‬ ‫مشكلة‬bone conduction Compare bone conduction in the two ears at the same time
The procedure: ❖ The base of a vibrating tuning fork is placed on the mastoid process until the subject no longer hears it, ❖ And then put it in the air next to the ear. The response: Normally In conductive deafness ‫أو‬ ‫مشكلة‬ ‫حصل‬Obstruction ‫في‬hearing pathway In nerve deafness (partial defect in one ear) The subject hears vibrations in air after bone conduction is over. The subject DOES NOT hear vibrations in air after bone conduction is over. The subject hears vibrations in air after bone conduction is over although hearing is reduced in both. Rinne' +ve Rinne' -ve Reduced Rinne' +ve ‫الـ‬ ‫عملت‬ ‫لو‬ ‫طب‬weber test‫اختيارين‬ ‫بين‬ ‫كدا‬ ‫أنا‬ ... ‫الشمال‬ ‫من‬ ‫أعلي‬ ‫اليمين‬ ‫الودن‬ ‫في‬ ‫سامع‬ ‫انه‬ ‫قالي‬ ‫و‬ ‫لمريض‬ ❖‫عنده‬ ‫يكون‬ ‫إما‬Conductive deafness‫الودن‬ ‫و‬‫اليمين‬‫الـ‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬diseased‫دا‬ ‫وسبب‬ ‫في‬ ‫مثال‬ ‫ان‬Wax‫ال‬ ‫في‬hearing pathway‫ال‬ ‫عازل‬cochlea‫ال‬ ‫عن‬environmental noise ❖‫عنده‬ ‫يكون‬ ‫أو‬nerve deafness‫الودن‬ ‫و‬‫اليمين‬‫الـ‬ ‫الودن‬ ‫ان‬ ‫دا‬ ‫سبب‬ ‫و‬ ‫السليمة‬ ‫الودن‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬ Diseased‫الـ‬ ‫عندها‬Cochlea‫شغالة‬ ‫مش‬ ‫نعمل‬ ‫ازاي؟؟‬ ‫نتأكد‬ ‫طب‬Rinne' test Rinne's test Compare air conduction and bone conduction of the same ear Differentiate between types of deafness ‫الخالصة‬ ❖Rinne' test‫بين‬ ‫نقارن‬ ‫عشان‬ ‫بيتعمل‬air conduction *AC*‫و‬bone conduction *BC*‫الودن‬ ‫نفس‬ ‫عند‬ ❖‫الـ‬ ‫بنحط‬ ‫اننا‬ ‫طريقة‬ ‫عن‬vibrating fork‫*علي‬ ‫ودنه‬ ‫جنب‬mastoid process‫ال‬ ‫سامع‬ ‫هل‬ ‫المريض‬ ‫بسأل‬ ‫و‬ *vibration ‫ان‬ ‫كدا‬ ‫معني‬ ‫سامع‬ ‫لو‬ ‫ف‬ ‫ال‬ ‫ولة‬Bone conduction.... ‫تمام‬‫حاجة‬ ‫سامع‬ ‫مبقاش‬ ‫انه‬ ‫يقولي‬ ‫ما‬ ‫لحد‬ ‫أستني‬ ‫وبعدين‬ ❖‫ال‬ ‫شايلة‬ ‫أقوم‬ ‫ف‬fork‫لو‬ ‫ف‬ ‫ال‬ ‫ولة‬ ‫سامع‬ ‫أسأله‬ ‫و‬ ‫ليه‬ ‫مالمسة‬ ‫مش‬ ‫انها‬ ‫بمعني‬ ‫الهوا‬ ‫في‬ ‫ودنه‬ ‫جنب‬ ‫أحطها‬ ‫و‬ ‫ودنه‬ ‫علي‬ ‫من‬ ‫ان‬ ‫كدا‬ ‫معني‬ ‫سامع‬air conduction‫تمام‬ ❖‫ن‬ ‫و‬‫ال‬ ‫ان‬ ‫بالنا‬ ‫خلي‬Air conduction‫علي‬ ‫بيعدي‬middle ear‫للصوت‬ ‫بيحصل‬ ‫يعني‬magnification‫في‬ ‫بالتالي‬ ‫ف‬ ‫الطبيعي‬Air conduction is louder than Bone conduction ‫يكون‬ ‫المريض‬ ‫ان‬ ‫هي‬ ‫نشوفها‬ ‫ممكن‬ ‫اللي‬ ‫االحتماالت‬
‫فوق‬ ‫قولناه‬ ‫اللي‬ ‫السؤال‬ ‫نكمل‬ ‫تعالوا‬ ‫طب‬ Normal **‫أحط‬ ‫لما‬ ‫هيسمع‬ ‫كدا‬ ‫هو‬ ‫ف‬ ‫ودنه‬ ‫علي‬ ‫الشوكة‬*bone conduction* **‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫بردوا‬ ‫هيسمع‬ ‫و‬ ‫الهوا‬ ‫في‬ ‫ودنه‬ ‫جنب‬*Air conduction* ‫ان‬ ‫قولنا‬ ‫ما‬ ‫زي‬ ‫لكن‬ ‫و‬AC > BC‫و‬ ‫فوق‬ ‫السبب‬ ‫عرفنا‬ Conductive deafness ‫في‬ ‫انه‬ ‫عارفين‬ ‫طبعا‬ ‫و‬Conductive deafness‫عائق‬ ‫في‬ ‫ان‬ ‫المشكلة‬ ‫بتكون‬ ‫في‬hearing pathway **‫هيسمع‬ ‫ودنه‬ ‫علي‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫ف‬ *bone conduction*‫مش‬ ‫ألنه‬ ‫علي‬ ‫بيعدي‬hearing pathway‫و‬ ‫للـ‬ ‫بيروح‬ ‫لكن‬Cochlea‫طول‬ ‫علي‬ **‫في‬ ‫ودنه‬ ‫جنب‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫لكن‬ ‫و‬ ‫حاجة‬ ‫هيسمع‬ ‫مش‬ ‫الهوا‬*air conduction*‫ال‬ ‫في‬ ‫يعدي‬ ‫الزم‬ ‫ألنه‬ hearing pathway‫فيه‬ ‫لكنه‬ ‫و‬ *‫*مسدود‬ ‫مشكلة‬ ‫بالتالي‬ ‫ف‬BC > AC Nerve deafness ‫في‬ ‫انه‬ ‫عارفين‬ ‫طبعا‬ ‫و‬nerve deafness‫المشكلة‬ ‫بتكون‬‫العصب‬ ‫في‬ ‫طريقة‬ ‫أثناء‬To the cortex‫ال‬ ‫في‬ ‫أو‬ Cortex‫في‬ ‫أو‬cochlea‫ناخد‬ ‫لكن‬ ‫*و‬ ‫عندنا‬ ‫دي‬ ‫الحالة‬ ‫في‬ ‫انه‬ ‫بالنا‬Partial defect‫ال‬ ‫يعني‬ *cochlea‫مش‬ ‫الـ‬ ‫الحالة‬ ‫زي‬ ‫شغالة‬normal‫لكنها‬ ‫و‬ ‫ضعيف‬ ‫بشكل‬ ‫بس‬ ‫بتسمع‬ **‫هيسمع‬ ‫ودنه‬ ‫علي‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫ف‬ *bone conduction*‫ضعيف‬ ‫لكن‬ ‫و‬ **‫الهوا‬ ‫في‬ ‫ودنه‬ ‫جنب‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫و‬ ‫هيسمع‬*air conduction*‫لكن‬ ‫و‬ ‫ضعيف‬ ‫بردوا‬ ‫بالتالي‬ ‫ف‬AC > BC‫و‬ ‫النورمال‬ ‫زي‬ ‫أضعف‬ ‫لكن‬ ‫الـ‬ ‫عملت‬ ‫لو‬ ‫طب‬Weber test‫اختيارين‬ ‫بين‬ ‫كدا‬ ‫أنا‬ ... ‫الشمال‬ ‫من‬ ‫أعلي‬ ‫اليمين‬ ‫الودن‬ ‫في‬ ‫سامع‬ ‫انه‬ ‫قالي‬ ‫و‬ ‫لمريض‬ ❖‫عنده‬ ‫يكون‬ ‫إما‬Conductive deafness‫الـ‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬ ‫اليمين‬ ‫الودن‬ ‫و‬diseased‫ان‬ ‫دا‬ ‫وسبب‬ ‫في‬ ‫مثال‬Wax‫ال‬ ‫في‬hearing pathway‫ال‬ ‫عازل‬cochlea‫ال‬ ‫عن‬environmental noise ❖‫عنده‬ ‫يكون‬ ‫أو‬nerve deafness‫الـ‬ ‫الودن‬ ‫ان‬ ‫دا‬ ‫سبب‬ ‫و‬ ‫السليمة‬ ‫الودن‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬ ‫اليمين‬ ‫الودن‬ ‫و‬ Diseased‫الـ‬ ‫عندها‬Cochlea‫شغالة‬ ‫مش‬ ‫نعمل‬ ‫ازاي؟؟‬ ‫نتأكد‬ ‫طب‬Rinne' test ✓‫ال‬ ‫عملت‬ ‫لو‬Rinne' test‫سمع‬ ‫المريض‬ ‫و‬ ‫اليمين‬ ‫الودن‬ ‫علي‬BC‫س‬ ‫ما‬ ‫و‬‫معش‬AC‫عنده‬ ‫ان‬ ‫كدا‬ ‫معني‬ conductive deafness‫الصح‬ ‫هو‬ ‫األول‬ ‫االحتمال‬ ‫و‬ ✓‫عادي‬ ‫االتنين‬ ‫سمع‬ ‫المريض‬ ‫لو‬ ‫أما‬(AC > BC)‫عنده‬ ‫هو‬ ‫و‬ ‫طبيعية‬ ‫دي‬ ‫الودن‬ ‫ان‬ ‫كدا‬ ‫معني‬nerve deafness‫في‬ .‫الصح‬ ‫هو‬ ‫التاني‬ ‫االحتمال‬ ‫يبقي‬ ‫و‬ ‫التانية‬ ‫الودن‬
Common Questions Question 1. Identify the test? Weber test. 2. What is the normal result? o It us heard equally on both sides. 3. What is the result in case of neural hearing loss (nerve deafness)? o Sound is louder in the healthy side. 4. What is the result in case of conductive hearing loss? And mention the cause. o Sound is better on the diseased side than on the healthy side o Because the masking effect of environmental noise is absent on the diseased side Question 1 Identify the test? Rinne' test. 2 What is the normal result? o The subject hears vibrations in air after bone conduction is over. AC>BC (Rinne' +ve) 3 What is the result in case of partial neural hearing loss (nerve deafness)? o The subject hears vibrations in air after bone conduction is over although hearing is reduced in both. AC>BC (reduced Rinne' +ve) 4 What is the result in case of conductive hearing loss? o The subject does not near vibrations in air after bone conduction is over. BC>AC (Rinne' -ve) 5 What is the meaning of Rinne'+ve? o The subject hears vibrations in air after bone conduction is over. AC>BC o What is the meaning of Rinne'-ve? o The subject does not hear vibrations in air after bone conduction is over. BC>AC o What is the meaning of reduced Rinne'+ve? o The subject hears vibrations in air after bone conduction is over although hearing is reduced in both. AC>BC.

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Practical physiology cns

  • 1.
    1 2020 5MEDX TEAM FOR 2ndYEAR MEDICAL STUDENTS Sensory System Examination
  • 2.
    General considerations ‫بداية‬ ‫في‬‫ثابتة‬ ‫دي‬ ‫الخطوات‬ ‫و‬‫كل‬examination*‫علي‬ ‫همنحن‬ ‫كنا‬ ‫اننا‬ ‫حالة‬ ‫في‬ ‫دا‬patient* ❖ Explain each test before you do it ❖ Unless otherwise specified, the patient's eyes should be closed during the actual testing. ❖ Compare symmetrical areas on both sides of the body (right – left). ❖ Also compare distal and proximal areas of the extremities. ❖ When you detect an area of sensory loss, map out its boundaries in detail. (According to dermatomes) ❖ Begin distally and move proximally. ❖ The procedure: ❖ Ask the patient to close his eyes. ❖ Use a disposable neurological pin to apply pinprick to the skin. (Equipment) ❖ Ask the patient to report whether he feels the sharp end of the pin. ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Observe and report the response. I. Sensory System Examination 1. Superficial sensation a. examination of pain sensation ‫ب‬ ‫بعض‬ ‫زي‬ ‫تقريبا‬ ‫كله‬ ‫في‬ ‫الخطوات‬ ‫و‬ ... ‫للفهم‬ ‫اقراها‬ ‫لكن‬ ‫و‬ ‫فيها‬ ‫هنتسأل‬ ‫مش‬ ‫احنا‬ ‫للخطوات‬ ‫بالنسبة‬‫ا‬‫هعملهم‬ ‫دول‬ ‫و‬ ‫اتنين‬ ‫أو‬ ‫خطوة‬ ‫ختالف‬‫األحمر‬ ‫باللون‬ Question ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬:‫يسألك‬‫ليها‬ ‫أداة‬ ‫فيها‬ ‫صورة‬ ‫(أي‬sharp end) 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Pain sensation 2 What is the equipment (instrument) used to examine such sensation? ✓ A disposable neurological pin OR any object having a sharp end. 3 What is the tract that transmit this type of sensation? ✓ Anterolateral spinothalamic tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Anterolateral spinothalamic tract. 5 Mention another type of superficial sensation? ✓ Temperature – Light touch – 2-point discrimination ……. 6 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Temperature sensation. ONLY ✓ :‫بالك‬ ‫خد‬‫ال‬ ‫عملنا‬ ‫لو‬pain sensation‫طلع‬ ‫و‬normal‫ف‬ ‫نعمل‬ ‫اننا‬ ‫داعي‬ ‫مفيش‬ temperature sensation ‫ال‬ ‫بنفس‬ ‫بيتنقلوا‬ ‫النهم‬tract
  • 3.
    The procedure: ❖ Usea test tube filled with warm or cold water ❖ Ask the patient to identify "hot" or "cold" (Equipment) ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Observe and report the response. Crude (light) touch ❖ Use a piece of cotton wool OR fine hair brush. (Equipment) ❖ Apply gentle touch (do not drag the cotton) to the skin. ❖ While the eyes are closed ask the patient to report "yes" every time they perceive the stimulus. ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Ask the patient to tell you if there is a difference from side to side. b. examination of temperature sensation Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫فيها‬ ‫صورة‬ ‫أي‬test tubes 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Temperature sensation 2 What is the equipment (instrument) used to examine such sensation? ✓ 2 test tubes (ONE containing warm water AND the other containing cold water) 3 What is the tract that transmit this type of sensation? ✓ Anterolateral spinothalamic tract. 4 If the sensation of this picture is lost, which tract is being damaged? OR where do you ecpect to find the lesion? ✓ Anterolateral spinothalamic tract. 5 Mention another type of superficial sensation? ✓ Pain – Light touch – 2-point discrimination ……. 6 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ pain sensation. ONLY ✓ c. examination of tactile mechanoreceptive sensation ‫ال‬ ‫خلصنا‬ ‫كدا‬2 sensations‫بـ‬ ‫بيتشالوا‬ ‫اللي‬Anterolateral spinothalamic tract‫بـ‬ ‫بيتشال‬ ‫جاي‬ ‫اللي‬ ‫كل‬ ‫و‬tractDorsal column
  • 4.
    Fine touch o Tactilelocalization sensation The procedure ❖ Use a blunt object like a pen cover. (Equipment). ❖ While the eyes are closed ask the patient to localized the touched skin point every time the stimulus is perceived. ❖ Apply a gentle touch to the skin at one point. ❖ Select areas from different dermatomes and peripheral nerves in both upper and lower extremities. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. ❖ Ask the patient to tell you if there is a difference from side to side. o TWO-Point Discrimination The procedure ❖ Use either calipers OR a compass. (Equipment). ❖ Demonstrate to the patient, with eyes open, by applying either one or two points of the stimulus to the finger pad. ❖ Ask the patient to close his eyes. ❖ Apply the stimulus and ask the patient to report whether they feel one or two points. Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫فيها‬ ‫صورة‬ ‫أي‬Piece of cotton 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Light touch sensation 2 What is the equipment (instrument) used to examine such sensation? ✓ a piece of cotton wool OR fine hair brush 3 What is the tract that transmits this type of sensation? ✓ Dorsal column tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 5 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2-point discrimination – pressure sensation – joint position – vibration sensation 6 Mention another superficial sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 Point discrimination ONLY 7 Mention another type of superficial sensation? ✓ Temperature – pain – 2-point discrimination ……. 8 Mention another type of mechanoreceptive sensation. ✓ 2 Point discrimination ‫الـ‬test‫ال‬ ‫مكان‬ ‫يحدد‬ ‫بيقدر‬ ‫المريض‬ ‫بشوف‬ ‫اني‬ ‫فكرته‬ ‫هو‬ ‫و‬ .... ‫احتياطي‬ ‫اقراه‬ ‫لكن‬ ‫و‬ ‫الكلية‬ ‫بتاع‬ ‫الفيديو‬ ‫في‬ ‫مشروح‬ ‫مش‬ ‫دا‬touch‫ال‬ ‫ولة‬
  • 5.
    ❖ Alternate irregularlybetween one and two points of touch. ❖ Find the minimal distance at which the patient can discriminate two touched points as separate. ❖ Compare between dermatomes, distal versus proximal, and right versus left for the upper and lower extremities. point discrimination thresholds varies from place to place on the body and-The magnitude of TwoNOTE: is smallest where touch receptors are most abundant. Stimulus points on the back, must be separated by at least 65 mm before they can be distinguished as separated Whereas on the fingertips two stimuli are recognized if they are separated by as little as 2mm. Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫ليها‬ ‫أداة‬2 ends 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ 2-point discrimination 2 What is the equipment (instrument) used to examine such sensation? ✓ Calipers OR Compass OR Forceps 3 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 5 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Light touch – pressure sensation – joint position – vibration sensation 6 Mention another superficial sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Light touch ONLY 7 Mention another type of superficial sensation? ✓ Temperature – pain – Light touch. 8 Mention another type of mechanoreceptive sensation. ✓ Light touch ONLY Two point discrimination It is the ability to perceive, with closed eyes, two touch stimuli applied to the skin at the same time as two separate points of touch provided that the distance between the two points is more than a certain threshold variable in different areas of the body FORREADING
  • 6.
    ‫ش‬ The procedure: ❖ Demonstrateto the patient initially, with eyes opened, that you will move their digit up (towards their heads) or down (towards their feet). ❖ Ask the patient to close his eyes. ❖ Stabilize the distal interpharyngeal joint of the digit by its sides and make minimal movements upwards or downwards. ❖ Ask the patient to report after each movement whether the joint is moving and the direction of movement. ❖ Similarly in the lower extremities, stabilize the interpharyngeal joint and move the large toe up or down. ❖ If the patient can't accurately detect the distal movement then progressively test a more proximal joint until he can identify the movement correctly. 2. Deep sensation a. Sense of joint movement and position Proprioception OR conscious kinesthetic sensation Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫متني‬ ‫صوباع‬ 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Joint movement and position (Proprioception) (conscious kinesthetic) 2 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 3 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 4 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 point discrimination – pressure sensation – Light touch – vibration sensation 5 Mention another deep sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Pressure OR Vibration ONLY 6 Mention another type of deep sensation? ✓ Vibration - pressure
  • 7.
    The procedure: ❖ Usea 128 hertz vibration fork. (Equipment) ❖ Ensure the patient understands that he feels vibration by placing the tuning fork on the chin before testing. ❖ Place the base of the fork over the bone or bony prominence. ❖ Ask the patient to tell you if he feels the vibration. ❖ If vibration sense is impaired proceed proximally: o In the upper part of the body: Wrists – Elbows – Clavicles – Spinous processes. o In the lower part of the body: Medial malleoli – Patella – Anterior superior iliac spine. ❖ Compare distal versus proximal, and right versus left. b. Vibration sense Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬Tuning fork 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Vibration sense. 2 What is the equipment (instrument) used to examine such sensation? ✓ 128 Hertz Tuning fork 3 Where do we this examination? Over any bony prominence ✓ In the upper part of the body: Wrists – Elbows – Clavicles – Spinous processes. ✓ In the lower part of the body: Medial malleoli – Patella – Anterior superior iliac spine. 4 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 5 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 6 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 point discrimination – pressure sensation – joint position – light touch 7 Mention another deep sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Joint movement and position OR pressure ONLY 8 Mention another type of deep sensation? ✓ Joint movement and position OR pressure
  • 8.
    The procedure: ❖ Usedifferent metal rings. (Equipment) ❖ Explain the test to the patient. ❖ With the patient's eyes closed, place a known number of rings on the patient's palm. ❖ Remove them and place a different number of rings in the patient's palm a second time still with eyes closed. ❖ Ask the patient's to identify whether the first or the second time feels heavier. ❖ Compare between both sides. ❖ Report your response. The procedure: ❖ Ask the patient to close his eyes. ❖ Give the patient any common and familiar object (Key – pen – coin- paper clip) ❖ Ask the patient to identify the object without looking at it. ❖ Record the response. c. Pressure sense It is the ability to discriminate different weights Question ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬metal ringsSeveral 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Pressure sense. 2 What is the equipment (instrument) used to examine such sensation? ✓ Metal rings of different weights 3 What is the tract that transmit this type of sensation? ✓ Dorsal column tract. 4 If the sensation of this picture is lost, which tract is being damaged? ✓ Dorsal column tract. 5 Mention another sensation which is also transmitted by the same tract as the sensation of the picture? ✓ 2 point discrimination – pressure sensation – joint position – light touch 6 Mention another deep sensation which is also transmitted by the same tract as the sensation of the picture? ✓ Joint movement and position OR Vibration ONLY 7 Mention another type of deep sensation? ✓ Joint movement and position OR Vibration. 3. Stereognosis Is considered a cortical sensation that can be felt if the somatosensory cortex is intact
  • 9.
    The test isbased on the fact that a person requires at least two of the three following senses to maintain balance while standing: 1. Proprioception. 2. Vestibular function. 3. Vision A patient who has a problem with proprioception can still maintain balance by using vestibular function and vision. If this patient is asked to close his eyes he losses the visual adjustment for changes in body position, and tends to fall. The inability to identify an object placed in the hand with the eyes closed is called *Astereognosis* the somatosensory cortex.ations are intact, it indicates a lesion int occurs while other sensIf i Question 4. Romberg's test est is a test of the body's sense of positioning (Proprioception),Romberg's tPrinciple: which requires healthy functioning of the dorsal columns of the spinal cord ‫فيها‬ ‫صورة‬ ‫أي‬ :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬Tuning fork 1 Identify the sensation examined in this picture. OR what is the type of sensation examined in the following picture? ✓ Stereognosis. 2 What is the equipment (instrument) used to examine such sensation? ✓ Any familial object to the patient. 3 The inability to identify familial object by touch is known as a …..‫سؤال‬ ‫أهم‬ ✓ Astereognosis. 4 If the sensation of this picture is lost, what does it indicate? OR if this sensation is lost, where do you expect the lesion to be? ✓ The lesion is in the somatosensory cortex. :‫بالك‬ ‫خلي‬ ‫ال‬ ‫صورة‬ ‫بين‬ ‫تتلغبط‬ ‫ممكن‬ ‫انت‬Pressure sense‫ال‬ ‫صورة‬ ‫و‬Stereognosis‫ازاااااي؟‬ ‫ايد‬ ‫صورة‬ ‫جاب‬ ‫لو‬‫فيها‬metal ring‫صورة‬ ‫تفكرها‬ ‫ممكن‬ ‫انت‬ ‫بس‬ ‫واحدة‬Pressure sense‫هي‬ ‫و‬stereognosis ‫ف‬ ‫ايد‬ ‫صورة‬ ‫تيجي‬ ‫لما‬ ‫كدا‬ ‫عشان‬‫يها‬ Several metal rings‫دا‬ ‫يبقي‬pressure ONLY one metal ring‫دا‬ ‫يبقي‬Stereognosis
  • 10.
    In the Romberg'stest, the standing patient is asked to close his eyes, if the patient tends to fall with the eyes close. This is interpreted as a positive Romberg's test. ‫دول‬ ‫من‬ ‫حاجتين‬ ‫األقل‬ ‫علي‬ ‫محتاج‬ ‫اتزانه‬ ‫علي‬ ‫يحافظ‬ ‫عشان‬ ‫االنسان‬ ‫.......و‬ ‫االتزان‬ ‫علي‬ ‫بتحافظ‬ ‫حاجات‬ 3 ‫فيه‬ ‫ان‬ ‫بمعني‬ ❖‫ال‬ ‫في‬ ‫مشكلة‬ ‫عنده‬ ‫مثال‬ ‫لو‬ ‫ف‬Proprioception‫التانيين‬ ‫االتنين‬ ‫خالل‬ ‫من‬ ‫اتزانه‬ ‫علي‬ ‫يحافظ‬ ‫يقدر‬ ‫هو‬ ‫ف‬ (Vestibular function + Vision) ❖‫ال‬ ‫من‬ ‫بنطلب‬ ‫دا‬ ‫االختبار‬ ‫في‬ ‫بقي‬ ‫احنا‬ ‫أما‬patient‫ال‬ ‫من‬ ‫عامل‬ ‫فقد‬ ‫هو‬ ‫كدا‬ ‫معني‬ ‫ف‬ ‫عينه‬ ‫يغمض‬ ‫انه‬3‫و‬ ‫ال‬ ‫هو‬vision ‫كدا‬ ‫معني‬ ..... ‫عينيه‬ ‫غمض‬ ‫لما‬ ‫توارنه‬ ‫يحفظ‬ ‫قدرش‬ ‫ما‬ ‫المريض‬ ‫لو‬ ‫ف‬‫ال‬ ‫في‬ ‫مشكلة‬ ‫عنده‬ ‫ان‬ Proprioception‫ال‬ ‫أو‬vestibular function‫ال‬ ‫من‬ ‫عاملين‬ ‫فقد‬ ‫كدا‬ ‫ف‬3 ✓‫ال‬ ‫عنده‬ ‫ان‬ ‫و‬ ‫سليم‬ ‫انه‬ ‫كدا‬ ‫معني‬ ‫ف‬ ....... ‫عينيه‬ ‫غمض‬ ‫لما‬ ‫توازنه‬ ‫علي‬ ‫يحافظ‬ ‫قدر‬ ‫المريض‬ ‫لو‬ ‫و‬3‫عوامل‬ intact The procedure: ❖ Be prepared to catch the patient if he is unstable. ❖ Ask the patient to stand, feet together and hands by the sides with eyes open, then with eyes closed without support. ❖ Watch the movement of the body in relation to a perpendicular object behind the subject (corner of the room – door – window). ❖ The test is said to be positive if the patient becomes unstable after closure of the eye (he sways and threatens to lose his balance). Proprioception Vestibular function Vision A positive Romberg's test indicated *Sensory Ataxia* which can occur due to: A lesion in the dorsal column of the spinal cord (by a tumor OR cord compression by a herniated disc) It can also occur in cases of peripheral neuropathy as that occurring with diabetes mellitus Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬ 1. Identify the test? ✓ Romberg's test. 2. If the test is positive, what could be the cause? ✓ Sensory Ataxia, which can occur due to o A lesion in the dorsal column of the spinal cord (by a tumor OR cord compression by a herniated disc) o It can also occur in cases of peripheral neuropathy as that occurring with diabetes mellitus
  • 11.
    1 2020 5MEDX TEAM FOR 2nd YEARMEDICAL STUDENTS Cranial Nerves Examination
  • 12.
    By the endof this practical class, students should be able to: Identify all cranial nerves and their functions. Conduct different tests for cranial nerves examination. Differentiate between different cranial nerves lesions. ‫أي‬ ‫وظيفة‬nerve‫تكون‬ ‫ممكن‬ ❖Motor function‫يعني‬‫بيحرك‬skeletal muscle‫فبالتالي‬‫هيكون‬‫ال‬examination ‫بتاعه‬‫اني‬‫أشوف‬‫ال‬ ‫حركة‬skeletal muscle‫ال‬ ‫ولة‬ ‫شغالة‬ ‫دي‬. ❖Sensory function‫و‬‫ال‬sensation‫دا‬‫يكون‬ ‫إما‬ ‫ي‬ osensationGeneral‫يعني‬nerve‫مسئول‬‫ال‬ ‫عن‬somatic sensations‫ال‬ ‫زي‬pain – temperature – touch‫ال‬ ‫زي‬trigeminal nerve‫مثال‬‫ال‬ ‫عن‬ ‫مسئول‬general sensations from the face oSpecial sensation‫زي‬taste–hearing–vision–smell‫زي‬‫مثال‬ Olfactory nerve is responsible for smell sensation Optic nerve is responsible for vision ❖Autonomic function‫رقم‬ ‫هما‬ ‫و‬3‫و‬7‫و‬9‫و‬10‫أعمل‬ ‫أجي‬ ‫لما‬ ‫بالتالي‬ ‫ف‬ examination‫لل‬4 nerves‫بنسأل‬ ‫دول‬‫ال‬ ‫هي‬ ‫ايه‬Autonomic functions ❖Involved in reflex‫أي‬ ‫انه‬ ‫عارفين‬ ‫احنا‬ ‫ما‬ ‫زي‬ ‫و‬reflex‫ليه‬ Afferent‫شايل‬‫ال‬sensation from the receptor to the center Efferent‫شايل‬‫ال‬response from the center to the effector organ ‫الحظ‬‫في‬ ‫ان‬cranial nerves‫ليها‬ Sensory function ONLY: Contain only afferent fibers (1-2-8) o I Olfactory 1 o II Optic 2 o VII Vestibulocochlear 8 Motor function ONLY: Contain only efferent fibers (3-4-6-11-12) o III Oculomotor. 3 o IV Trochlear. 4 o VI Abducent. 6 o XI Accessory. 11 o XII Hypoglossal. 12 Mixed (Sensory + Motor): Contain both efferent and afferent fibers (5-7-9-10) o V Trigeminal. 5 o VII Facial. 7 o XI Glossopharyngeal. 9 o X Vagus. 10 II. Cranial nerves Examination
  • 13.
    Before starting: ❖ Introduceyourself to the patient. ❖ Explain the examination and obtain his consent. ❖ Ensure that he is comfortable The procedure: ❖ Ask the patient if he has noticed a change in his sense of smell or taste. If he has, indicate that you would perform an olfactory examination. ❖ Before starting, check that there is free flow of air by occluding each nostril in turn and asking the patient to sniff in. ❖ Ask the patient to close his eyes. ❖ Smell is tasted in each nostril separately by placing stimuli under one nostril and occluding the opposing nostril. ❖ The stimuli used should be non-irritating and identifiable e.g. (coffee – tobacco – orange – vanilla) ❖ Ask the patient to identify each in turn. ❖ If you don't have such tools available, ask the patient to close his eyes and then hold a bar of soap under the patient's nose for them to smell. ❖ Assess the response. Loss of smell sensation is known as *Anosmia*, Types of Anosmia: *‫فيديو‬ ‫في‬ ‫لكن‬ ‫و‬ ‫الكتاب‬ ‫في‬ ‫مش‬‫المراجعة‬* Unilateral *‫أخطر‬* Bilateral Has great localizing value indicate involvement of one of the olfactory tracts in the floor of the anterior fossa as olfactory groove meningioma In blocked nasal passages in common cold causes of anosmia include: *‫في‬ ‫لكن‬ ‫و‬ ‫المراجعة‬ ‫فيديو‬ ‫في‬ ‫مش‬‫الكتاب‬* ▪ Nasal congestion from (Cold – allergy – sinus infection) ▪ Tumors of the nose or olfactory pathway. ▪ Exposure to toxic chemicals (Pesticides – Certain medications *Antibiotics / Antidepressants – Cocaine abuse) ▪ Degenerative causes as *Parkinson's disease – Alzheimer's disease* ▪ As a complication of radiation treatment. I. Olfactory nerve ‫في‬ ‫هنتسأل‬ ‫مش‬ ‫بس‬ ‫افهمها‬ ‫الخطوات‬
  • 14.
    These 3 nervesare examined together as they control ❖ The intrinsic muscles (controlling the lens and pupil) ❖ External ocular muscles ❖ Pupillary light reflex Nerve III. Oculomotor nerve IV. Trochlear nerve VI. Abducent nerve Muscles suppling by this nerve ❖ All Extra-ocular muscles. EXCEPT SO4 *Superior oblique* LR6 *lateral rectus* ❖ Levator palparbrae superiosis. ❖ Ciliary muscle ❖ Sphincter pupillae (Autonomic function) ❖ SO4 *Superior oblique* ❖ Trochlear nerve typically allows a person to view the tip of his nose (Eye depression with medial rotation) *SO* LR6 *Lateral Rectus* (Lateral movement) ‫عشان‬‫ال‬ ‫نعرف‬lesions‫ايه‬ ‫عضلة‬ ‫كل‬ ‫وظيفة‬ ‫عارفين‬ ‫نكون‬ ‫الزم‬ Lesions ❖ Deviation of the eye down and out.(laterally) ❖ Ptosis ❖ Dilated pupil ❖ Loss of light and accommodation reflexes Inability to look down *LR* Inability to move the eye out. (lateral rotation) II. Optic nerve Visual acuity – Visual fields – Optic disc examination ‫بالتفصيل‬ ‫هناخده‬ ‫ال‬ ‫سكشن‬ ‫في‬ vision III. Oculomotor IV. Trochlear VI. Abducent 3)6LR4SO) Right eye Left eye MR *medial rectus* : Medial rotation LR *lateral rectus*: Lateral rotation SR *Superior rectus*: Upward movement + lateral rotation IR *Inferior rectus*: Downward movement + lateral rotation SO *Superior oblique*: Downward movement + medial rotation IO *Inferior oblique*: Upward movement + medial rotation ‫ال‬ptosis‫ال‬ ‫يعني‬upper eyelid‫ال‬ ‫الن‬ ‫واقع‬muscle‫و‬ ‫رفعه‬ ‫عن‬ ‫المسئولة‬‫هي‬Levator palparbrae superiosis ‫مشكلة‬ ‫فيها‬ ‫يكون‬ ‫ممكن‬
  • 15.
    .... ‫يبص‬ ‫العيان‬‫خليت‬ ‫لو‬ ‫بـ‬ ‫كدا‬ ‫يبقي‬test..... ..... ‫بـ‬ ‫بتتغذي‬ ‫اللي‬ ‫لبرة‬laterally Lateral rectus Abducent nerve VI ‫لجوة‬medially Medial rectus Oculomotor nerve III ‫لتحت‬ ‫و‬ ‫لجوة‬downward and medially Superior Oblique Trochlear nerve IV ‫لجوة‬‫ل‬ ‫و‬‫فوق‬Upward and medially Inferior Oblique Oculomotor nerve III ‫لتحت‬ ‫و‬ ‫لبرة‬downward and laterally Inferior rectus Oculomotor nerve III ‫لفوق‬ ‫و‬ ‫لبرة‬Upward and laterally Superior rectus Oculomotor nerve III Examination: Inspect the eyes, ‫أشوف‬ ‫ما‬ ‫(أول‬‫أ‬ ‫أبدأ‬ ‫المريض‬)‫اختبار‬ ‫أي‬ ‫غير‬ ‫من‬ ‫دي‬ ‫الحاجات‬ ‫الحظ‬ ❖ paying particular attention to the shape, size and symmetry of the pupils ❖ Excluding  A visible ptosis (drooping of upper eyelid) defect in Levator palparbrae superiosis which supplied by oculomotor n.  Squint/ strabismus (misalignment of the two eyes so that both the eyes are not looking in the same direction. Test for ocular movements: *Extra-ocular muscles* ❖ Ask the patients to fix his head and move only his eyes. ❖ Hold out your extended right index finger about 40 cm in front of the patient. ❖ Ask the patient to follow your finger with their eyes through the six cardinal positions of gaze. (lateral – Superio-lateral – Inferio- lateral – Medial – Superio-medial – Inferio-medial) ❖ Examine each eye with the other covered. ❖ There should be a full range of movements of each eye. ❖ Observe the eye movements.
  • 16.
    Test for conjugateeye movements ❖ Ask the patient to look to the right, to the left, up and down with both eyes. ❖ Observe the eye movements, and note whether they move together. Test the direct and consensual pupillary light reflexes. (see vision section) ‫أي‬reflex‫ليه‬ ‫بيكون‬Afferent and efferent‫ال‬ ‫في‬ ‫هنا‬ ‫و‬pupillary light reflex ❖ The afferent *sensory limb* is Optic nerve II ❖ The efferent *motor limb* is Oculomotor III o‫ال‬ ‫في‬light reflex‫ال‬ ‫علي‬ ‫ضوء‬ ‫بنسلط‬pupil‫بتاعة‬one eye o‫هيحصل‬ ‫انه‬ ‫نالحظ‬ ‫و‬Constriction of the pupils of the both eyes‫عضلة‬ ‫بسبب‬ constrictor pupillae which supplied by oculomotor nerve III o‫محصلش‬ ‫لو‬constriction‫ي‬ ‫المشكلة‬ ‫ان‬ ‫أشك‬ ‫يبقي‬‫في‬ ‫اما‬Afferent (Optic II)‫أو‬‫في‬ Efferent (Oculomotor III) Test for accommodation reflex. (see vision section) ❖ Ask the patient to look at far object and then at a near object. ❖ The response: ✓ Constriction of the pupils ✓ Convergence ✓ Increase dioptric power of the lens symmetrical: The direct of the two eyes should beN.B asa lesion in the brainstematedn conjugate eye movements indicA defect i it integrates the functions of the oculomotor, trochlear and abducent nerves ‫بالتالي‬ ‫ف‬ ‫اليمين‬ ‫أقصي‬ ‫باصص‬ ‫العيان‬ ‫دي‬ ‫الصورة‬ ‫في‬ ‫هي‬ ‫اليمين‬ ‫العين‬ ‫في‬ ‫شغالة‬ ‫اللي‬ ‫العضلة‬lateral recuts ‫هي‬ ‫الشمال‬ ‫العين‬ ‫في‬ ‫شغالة‬ ‫اللي‬ ‫العضلة‬medial recuts Question :‫يسألك‬ ‫و‬ ‫مثال‬ ‫دي‬ ‫زي‬ ‫صورة‬ ‫هتيجي‬‫منهم‬ ‫عين‬ ‫مغطي‬ ‫مش‬ ‫انه‬ ‫الحظ‬‫كدا‬ ‫معني‬ ‫بي‬ ‫انه‬‫ال‬ ‫ختبر‬conjugate eye movements 1 Identify the test in this picture. ✓ Examination of Conjugate eye movement 2 It is the function of …… ✓ Brainstem
  • 17.
    Question ‫دي‬ ‫الصورة‬ ‫في‬‫ن‬‫الشمال‬‫العين‬ ‫ان‬ ‫الحظ‬normal‫اليمين‬ ‫العين‬ ‫أما‬deviated laterally‫ال‬ ‫هي‬ ‫كدا‬ ‫لبرة‬ ‫العين‬ ‫حدفت‬ ‫و‬ ‫شغالة‬ ‫اللي‬ ‫العضلة‬ ‫ان‬ ‫كدا‬ ‫معني‬right lateral rectus‫بـ‬ ‫بتتغذي‬ ‫واللي‬right abducent nerve‫ال‬ ‫باقي‬ ‫أما‬ Extrinsic muscles‫الـ‬ ‫بيغذيهم‬ ‫اللي‬ ‫و‬ ‫شغالين‬ ‫مش‬right oculomotor nerve‫ال‬ ‫كدا‬ ‫يبقي‬nerveIIIlesion in right oculomotor Question ‫دي‬ ‫الصورة‬ ‫في‬‫ن‬‫ان‬ ‫الحظ‬Upper eyelid in the right eye‫واقع‬ )right ptosis(‫رف‬ ‫عن‬ ‫المسئولة‬ ‫العضلة‬ ‫ان‬ ‫كدا‬ ‫معني‬ ....‫مش‬ ‫لفوق‬ ‫عه‬ ‫هي‬ ‫و‬ ‫شغالة‬right levator palparbrae superiosis‫اللي‬ ‫و‬ ‫بـ‬ ‫بتتغذي‬Right Oculomotor nerve‫الـ‬ ‫كدا‬ ‫يبقي‬Lesion in nerveIIIright oculomotor Question ‫العيان‬ ‫دي‬ ‫الصورة‬ ‫في‬‫كان‬ ‫يمين‬ ‫بص‬ ‫لما‬normal‫اللي‬ ‫العضالت‬ ‫ان‬ ‫بحيث‬ ‫هي‬ ‫تحصل‬ ‫دي‬ ‫الحركة‬ ‫عشان‬ ‫اشتغلت‬ Left medial rectus + right lateral rectus ‫ال‬ ‫عشان‬ ‫المفروض‬ ‫ف‬ ‫المشكلة‬ ‫ظهرت‬ ‫شمال‬ ‫بص‬ ‫لما‬ ‫لكن‬ ‫و‬‫الزم‬ ‫تحصل‬ ‫دي‬ ‫حركة‬ ‫هي‬ ‫تشتغل‬ ‫اللي‬ ‫العضالت‬right medial rectus + left lateral rectus‫في‬ ‫المشكلة‬ ‫كدا‬ ‫يبقي‬ ‫النص‬ ‫في‬ ‫واقفة‬ ‫فضلت‬ ‫الشمال‬ ‫العين‬ ‫لكن‬ ‫و‬ left lateral rectus which supplied by left abducent nerve‫الـ‬ ‫كدا‬ ‫يبقي‬Lesion in left Abducent nerve Applied case A 65 year - old male presents with inability to move both his eyes to the left . His vision and his pupillary reflexes are normal in both eyes . He has normal sensation on his face and body and no other motor symptoms . Symptoms ❖ Has a left medial squint ( abnormal alignment of the eyes ) ❖ Has limited mobility in his left eye ( i.e. , it moves to the midpoint when he attempts to look to the left ) ❖ Cannot move both eyes toward his left . Therefore , the lesion is??????? Question ‫حادفة‬ ‫الشمال‬ ‫العين‬ ‫عنده‬ ‫و‬ ‫الشمال‬ ‫العين‬ ‫في‬ ‫المشكلة‬ ‫انه‬ ‫هنالقي‬ ‫األعراض‬ ‫نقرأ‬ ‫لما‬ ‫دي‬ ‫الحالة‬ ‫في‬medially‫ان‬ ‫كدا‬ ‫معني‬ ‫بتحركها‬ ‫اللي‬ ‫العضلة‬ ‫هي‬ ‫بايظة‬ ‫اللي‬ ‫العضلة‬laterally‫اللي‬‫هي‬left lateral rectus which supplied by left Abducent nerve‫الـ‬ ‫كدا‬ ‫يبقي‬rven left Abducent neLesion is i
  • 18.
    ▪ Sensory: Facialsensation (Somatic sensations from face and tongue *pain – touch – temperature – Proprioception*) ▪ Motor: Muscles of mastication *temporalis – Masseter – Pterygoid* ▪ Reflex: Corneal reflex. Examination: I Corneal reflex 1. Take a piece of cotton wool. 2. Ask the patient to look away from the side being tested. 3. Gently touch the cornea with the cotton wool, the patient will blink.(response) ❖ The Afferent of this reflex is the sensory part of CN V (Trigeminal) ❖ The Efferent of this reflex is the motor part of CN VII (Facial). II Facial sensation: (sensory function of trigeminal nerve) 1. Lightly touch each side of the face with a piece of cotton and then with blunt pin in three places on each side (Around the jawline – on the cheek – on the forehead). 2. Ask if it feels normal and symmetrical. 3. Test the areas supplied by (Ophthalmic – Maxillary – Mandibular) branches. Question ‫دي‬ ‫الصورة‬ ‫في‬‫موجودة‬ ‫حاجة‬ ‫علي‬ ‫تبص‬ ‫انها‬ ‫المريضة‬ ‫من‬ ‫طلبت‬‫تحت‬‫شمالها‬ ‫علي‬‫بالتالي‬ ‫ف‬‫العين‬ ‫هتبص‬ ‫الشمال‬Downward and laterally‫عضلة‬ ‫باستخدام‬Left inferior rectus‫و‬ ‫تمام‬ ‫شغالة‬ ‫دي‬ ‫تبص‬ ‫المفروض‬ ‫اللي‬ ‫اليمين‬ ‫العين‬ ‫لكن‬ ‫و‬Downward and medially‫ما‬‫اتحر‬‫يبقي‬ ‫كتش‬ ‫في‬ ‫مشكلة‬ ‫عندها‬ ‫كدا‬right superior oblique muscle which supplied by right trochlear nerve‫كدا‬ ‫يبقي‬Lesion is in right trochlear nerve V. Trigeminal nerve Question 1. Identify the reflex and mention its function. ✓ Corneal reflex - protective 2. The stimulus is …….. ✓ Gentle touch of lateral edge of the cornea using a piece of cotton. 3. Normal response is ……… ✓ Closure of the eye OR blinking 4. The muscle responsible for this response is ……… ✓ Orbicularis oculi 5. The Afferent nerve of this reflex is ……... and the Efferent nerve of this reflex is ……… ✓ Sensory part of trigeminal nerve – motor part of facial nerve
  • 19.
    III Motor: 1. Askthe patient to perform side to side movement of the jaw (test of pterygoid). 2. Ask the patient to clench their teeth together. 3. Observing and feeling the bulk of the masseter and temporalis muscles. Both masseters should be firm and strong A lesion in the trigeminal nerve will result in: ❖ Loss of sensation in one or more divisions of the trigeminal nerve. ❖ Wasting of the masseter and temporalis muscles. ❖ When the jaw is opened it will deviate towards the side of the lesion. ❖ There is also absence of the corneal reflex the spinal nerves from segments C2,3 supply the face about 3N.B: fingers' breadth in front of the ear. On the forehead On the Cheek Around the jawline Ophthalmic division Maxillary division Mandibular division TemporalisMasseter Question ‫يفتح‬ ‫انه‬ ‫المريض‬ ‫من‬ ‫طلبت‬ ‫دي‬ ‫الصورة‬ ‫في‬lower jaw‫عشان‬test pterygoid muscle‫ف‬ ‫انه‬ ‫لقيت‬deviated towards the right‫قلنا‬ ‫و‬‫بي‬ ‫لما‬ ‫ان‬‫فيه‬ ‫كون‬lesion in the trigeminal nerve‫ال‬ ‫بيكون‬jaw deviated to the side of the lesion ‫عندنا‬ ‫كدا‬ ‫يبقي‬Lesion in the right trigeminal nerve ‫عندنا‬4 cranial nerves‫فيهم‬ ‫بيحصل‬ ‫لما‬lesion‫بيحصل‬deviations ‫رقم‬5‫و‬7‫و‬10‫و‬12 ‫رقم‬5‫و‬12‫ف‬ ‫بيحصل‬ ‫لما‬‫يهم‬lesion‫ال‬ ‫بيكون‬affected sidedeviation towards the)(5+12=17 ‫رقم‬7‫و‬10‫بيحصل‬ ‫لما‬lesion‫بيكون‬the healthy sidedeviation toward(7+10=17) ‫تاني‬ ‫قدام‬ ‫هنلخصها‬
  • 20.
    ❖ Involved incorneal reflex "Efferent part" ❖ Sensory function: Transmission of taste sensation from Anterior 2/3 of the tongue. "Special sensation" ❖ Motor function: Motor to muscles of facial expression. ❖ Secretory function "Automonic": To lacrimal and salivary glands (Sublingual – Submandibular) EXCEPT Parotid gland "glossopharyngeal" Examination Of Facial nerve VII: I Corneal reflex: o‫ال‬ ‫ذكرنا‬ ‫احنا‬corneal reflex‫في‬ ‫كدا‬ ‫قبل‬trigeminal nerve‫الـ‬ ‫كان‬ ‫ألنه‬Afferent part‫ال‬ ‫بتاع‬reflex‫هو‬sensory part of trigeminal o‫الـ‬ ‫ألن‬ ‫تاني‬ ‫هنا‬ ‫ذكرناه‬ ‫و‬Efferent‫الـ‬ ‫هو‬ ‫بتاعه‬Motor part pf facial nerve II Sensation (taste sensation of anterior 2/3 of the tongue) "Post 1/ 3 "glossopharyngeal"" 1. Ask the patient to protrude his tongue. 2. Use a cotton tip applicator dipped in a solution that is (sweet – salty – sour – bitter) 3. Apply to the extended tongue. 4. Ask the patient to tell you the taste before they pull their tongue back in the mouth. III Motor Inspect facial droop or asymmetry. Ask the patient to Observe / assess Look upward and wrinkle his forehead. "frontalis muscle" The wrinkles. Close eye tight "orbicularis Oculi" against resistance. Power of the orbicularis Oculi muscle Frown "‫يعبس‬ ‫أو‬ ‫يكشر‬" Show his teeth If there is any deviation of nasolabial fold. Purse his lips / whistle "‫يصفر‬" Power of orbicularis oris muscle VII. Facial nerve ‫هو‬ ‫اشتغل‬ ‫اللي‬ ‫العصب‬ ‫كدا‬ ‫يبقي‬ ‫لسانك‬ ‫عضيت‬ ‫لو‬Trigeminal nerve ‫بـ‬ ‫حاجة‬ ‫تذوقت‬ ‫لو‬ ‫أما‬Anterior 2/3‫هو‬ ‫اشتغل‬ ‫اللي‬ ‫العصب‬ ‫كدا‬ ‫يبقي‬facial nerve *supplies the muscles of facial expression* "start from the top and work down"
  • 21.
    Blow his CheekPower of buccinator muscle Facial nerve palsy results in: ❖ Paralysis of the facial muscles ❖ Failure to close the eye on the affected side. ❖ Deviation of the mouth to the healthy side ❖ Loss of forehead corrigations The common cause of facial nerve lesion: Bell'palsy which is unilateral peripheral affection of the facial nerve. ‫يك‬ ‫فمه‬ ‫انه‬ ‫المفروض‬ ‫يبتسم‬ ‫انه‬ ‫العيان‬ ‫من‬ ‫طلبت‬ ‫لو‬‫ون‬centrally‫شمال‬ ‫أو‬ ‫يمين‬ ‫حادف‬ ‫مش‬ ‫لقيته‬ ‫لو‬ ‫أما‬‫شمال‬ ‫حادف‬leftDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervefacialrighttheLesion in ‫بيكون‬ ‫الوش‬ ‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬deviated to the healthy side ‫يمين‬ ‫حادف‬ ‫لقيته‬ ‫لو‬ ‫أما‬rightDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervefaciallefttheLesion in ‫زي‬ ‫النه‬‫قلنا‬ ‫ما‬‫بيكون‬ ‫الوش‬ ‫انه‬deviated to the healthy side Question 1 2 3 ( ‫رقم‬ ‫الصورة‬ ‫في‬1:)‫ال‬ ‫لفوق‬ ‫حواجبه‬ ‫رفع‬ ‫لما‬ ‫المريض‬wrinkles‫ظهرت‬‫الشمال‬ ‫الناحية‬ ‫علي‬ ‫ظهرتش‬ ‫ما‬ ‫و‬ ‫اليمين‬ ‫الناحية‬ ‫علي‬ ‫فيه‬ ‫ان‬ ‫كدا‬ ‫معني‬Lesion of left facial nerve ( ‫رقم‬ ‫الصورة‬ ‫في‬2):‫لما‬‫يعمل‬ ‫ان‬ ‫المريض‬ ‫من‬ ‫طلبت‬Forced closure for his eyes ‫ف‬ ‫ان‬ ‫كدا‬ ‫معني‬ ‫ضعيفة‬ ‫كانت‬ ‫الشمال‬ ‫العين‬ ‫اما‬ ‫حلو‬ ‫غمضت‬ ‫اليمين‬ ‫العين‬‫يه‬lesion of left facial nerve ( ‫رقم‬ ‫الصورة‬ ‫في‬3:)‫ان‬ ‫الحظ‬‫الفم‬deviated to the right side‫دا‬ ‫ان‬ ‫بما‬ ‫و‬facial nerve‫فـ‬deviation is n the healthy sidei‫معني‬‫في‬ ‫ان‬ ‫كدا‬Lesion of left facial nerve Question ( ‫رقم‬ ‫الصورة‬ ‫في‬1:)‫فيه‬ ‫ان‬ ‫نالحظ‬deviation to the left "healthy side"‫فيه‬ ‫كدا‬ ‫معني‬ Lesion in the right facial nerve ( ‫رقم‬ ‫الصورة‬ ‫في‬2:)‫طبي‬ ‫بشكل‬ ‫قفلت‬ ‫الشمال‬ ‫العين‬ ... ‫عينيها‬ ‫تقفل‬ ‫حاولت‬ ‫البنت‬ ‫لما‬‫العين‬ ‫أما‬ ‫عي‬ ‫فيه‬ ‫ان‬ ‫كدا‬ ‫معني‬ ‫ضعيفة‬ ‫كانت‬ ‫اليمين‬Lesion of the right facial nerve 1 2
  • 22.
    Sensory "Mostly": ❖ Mediategeneral sensations from the pharynx and middle ear. ❖ Carries taste sensation from the posterior 1/3 of the tongue Motor: To stylopharyngeus muscle "involved in swallowing" Secretory: To the parotid gland Involved in gag reflex "Afferent" Motor: For (Soft palate – Larynx – Pharynx) Sensory: To (Larynx – Pharynx – Esophagus – External ear – Aortic body – Thoracic – Abdominal viscera) Parasympathetic: To thoracic – abdominal viscera Involved in gag reflex "Efferent" Examination of Glossopharyngeal IX & Vagus X o Gag reflex Sensory Afferent : Glossopharyngeal IX Motor Efferent: Vagus X 1. Touching the pharynx with a tongue depressor. *Stimulus* 2. Watching the elevation of the palate and gagging reflex (tendency to vomit) *Normal Response* o Sensation (taste sensation of posterior 1/3 of the tongue) (Sensory IX) ‫الـ‬ ‫في‬ ‫شرحنا‬ ‫ما‬ ‫زي‬Ant. 2/3‫الـ‬ ‫في‬Facial nerve 1. Ask the patient to protrude his tongue 2. Use small bottles and a dropper. The bottles usually contain sugar or salt solution. 3. Apply to one side then the other side of the extended tongue. 4. Ask the patient to tell you the taste before they pull their tongue back in the mouth IX. Glossopharyngeal nerve X. Vagus nerve
  • 23.
    o Motor: 1. Askthe patient to open his mouth wide and to say "ahh" ✓ Observe the movement of the palate (Symmetrical soft palate movement) ✓ The palate should rise symmetrically and there should be little nasal air escape. 2. Examine the palate for uvular displacement, the uvula should be central in position (Unilateral lesion: Uvula drawn to normal lesion). 3. Ask the patient to swallow; ask if there any difficulty. 4. Phonation should be clear. "‫بحة‬ ‫فيه‬ ‫ميكنش‬" Lesion of IX (Glossopharyngeal) Lesion of X (vagus) Loss of taste from Post.1/3 of the tongue Deviation of uvula to opposite side of lesion "Healthy side" Loss of sensation from the pharynx Difficulty in swallowing Loss of gag reflex Vocal cord weakness Loss of sensations from the larynx, pharynx, Esophagus, external ear. ‫انه‬ ‫العيان‬ ‫من‬ ‫طلبت‬ ‫لو‬"‫"آآآآه‬ ‫يقول‬ ‫و‬ ‫فمه‬ ‫يفتح‬‫انه‬ ‫المفروض‬Uvula‫تكون‬centrally‫حادف‬ ‫مش‬‫ة‬‫شمال‬ ‫أو‬ ‫يمين‬ ‫أما‬‫لقيته‬ ‫لو‬‫ا‬‫حادف‬‫ة‬‫شمال‬leftDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervevagusthe rightLesion in ‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬Uvula‫بيكون‬deviated to the healthy side ‫لو‬ ‫أما‬‫لقيته‬‫ا‬‫حادف‬‫ة‬‫يمين‬rightDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬nervevagusthe leftLesion in ‫قل‬ ‫ما‬ ‫زي‬ ‫النه‬‫انه‬ ‫نا‬Uvula‫بيكون‬deviated to the healthy side Normal Oropharynx Normal Uvula "Central" Question ‫ال‬ ‫ان‬ ‫الصورة‬ ‫في‬ ‫باين‬ ‫هنا‬Uvula ‫اليمين‬ ‫ناحية‬ ‫محدوفة‬Deviated to the right side‫ان‬ ‫كدا‬ ‫معني‬ ‫ف‬ ‫فيه‬Lesion in the left vagus
  • 24.
    Examination of Trapeziusmuscles: ❖ From behind, look for atrophy or asymmetry of the trapezius muscles. ❖ Ask the patient to shrug his shoulder up and try to push them down (Trapezius muscles) Examination of Sternocleidomastoid muscles: ❖ Ask the patient to turn his head (Sternocleidomastoid muscles) against resistance. ❖ Watch and palpate the Sternocleidomastoid muscle on the opposite side. Lesion of the accessory nerve results in ✓ Weakness of head rotation towards the opposite side of the lesion. (Weakness of sternomastoid muscle) ✓ Inability to elevate the shoulder. (Weakness of Trapezius muscle) ‫الـ‬ ‫فيها‬ ‫اللي‬ ‫الناحية‬ ‫ان‬ ‫بالحظ‬ ‫(و‬lesion‫واقع‬ ‫الكتف‬ ‫بيكون‬"dropping of the shoulder) Examination: ❖ Inspect the tongue for wasting. ❖ Ask the patient to protrude his tongue and note any deviation. ❖ Ask the patient to move his tongue from side to side. IN case of lesion: ✓ The tongue deviate towards the paralyzed side ✓ There is also wasting of the tongue on the side of the lesion. ❖ Ask the patient to move his tongue from side to side. ❖ Ask the patient to press with his tongue against the inside of either cheek, or press with your finger on the outside of the patient's check to test the power. XII. Hypoglossal nerve Pure Motor to the intrinsic and extrinsic muscles of the tongue XI. Accessory nerve Pure Motor to Sternomastoid and Trapezius muscles :‫ان‬ ‫الحظ‬Right sternomastoid which supplied by right Accessory nerve XI‫اللي‬ ‫هي‬ ‫صحيح‬ ‫العكس‬ ‫و‬ ‫الشمال‬ ‫ناحية‬ ‫تتحرك‬ ‫الرأس‬ ‫ان‬ ‫بتساعد‬ Trapezius muscle sternomastoid muscle ‫ا‬ ‫دي‬ ‫الصورة‬ ‫في‬ ‫نالحظ‬‫ن‬‫و‬ ‫شوية‬ ‫واقع‬ ‫اليمين‬ ‫الكتف‬‫الـ‬Right trapezius‫الـ‬ ‫زي‬ ‫تنقبض‬ ‫عارفة‬ ‫مش‬ Left trapezius‫فيه‬ ‫ان‬ ‫كدا‬ ‫معني‬lesion in the right Accessory nerve‫ال‬ ‫شفت‬ ‫لو‬ ‫أكيد‬ ‫و‬ Right sternomastoid‫هالقيها‬ ‫أكيد‬paralyzed‫بنفس‬ ‫بيتغذوا‬ ‫ألنهما‬‫العصب‬ Question
  • 25.
    Nerves of thetongue Responsible for intrinsic and extrinsic muscles of the tongue "Motor" Hypoglossal XII Taste sensation Anterior 2/3 Facial nerve VII Posterior 1/3 Glossopharyngeal IX General *somatic* sensation ""‫مثال‬ ‫اللسان‬ ‫عضة‬ ‫زي‬ Trigeminal nerve III ‫انه‬ ‫العيان‬ ‫من‬ ‫طلبت‬ ‫لو‬‫برة‬ ‫لسانه‬ ‫يطلع‬‫فم‬‫المفروض‬ ‫ه‬‫اللسان‬‫يكون‬centrally‫شمال‬ ‫أو‬ ‫يمين‬ ‫حادف‬ ‫مش‬ ‫حا‬ ‫لقيتها‬ ‫لو‬ ‫أما‬‫شمال‬ ‫دفة‬leftDeviated to the‫معني‬‫في‬ ‫ان‬ ‫كدا‬hypoglossalthe LeftLesion in nerve‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬‫اللسان‬‫بيكون‬deviated to the diseased side ‫يمين‬ ‫حادفة‬ ‫لقيتها‬ ‫لو‬ ‫أما‬rightDeviated to the‫في‬ ‫ان‬ ‫كدا‬ ‫معني‬hypoglossalrighttheLesion in nerve‫انه‬ ‫قلنا‬ ‫ما‬ ‫زي‬ ‫النه‬‫اللسان‬‫بيكون‬deviated to the diseased side ‫أخليه‬ ‫و‬ ‫المريض‬ ‫خد‬ ‫علي‬ ‫ايدي‬ ‫أحط‬ ‫ممكن‬ ‫قوة‬ ‫أشوف‬ ‫بحيث‬ ‫بلسانه‬ ‫ايدي‬ ‫يقاوم‬ ‫ال‬ ‫عضالت‬tongue‫كدا‬ ‫الصورة‬ ‫زي‬ Question ‫لسان‬ ‫يطلع‬ ‫انه‬ ‫المريض‬ ‫من‬ ‫طلبت‬ ‫لما‬ ‫دي‬ ‫الصورة‬ ‫في‬‫لقيت‬ ‫ه‬ ‫الشمال‬ ‫ناحية‬ ‫حادف‬ ‫لسانه‬ ‫ان‬Deviated to the left ‫في‬ ‫انه‬ ‫كدا‬ ‫معني‬Hypoglossallesion in the left ‫تجميعات‬
  • 26.
    NO. Nerve FunctionIn case of lesion I Olfactory Pure sensory *Special sensation: Smell* Loss of smell *Anosmia* in the affected side II Optic Pure sensory *Special sensation: Vision* See vision section III Oculomotor Motor: ❖ All extra-ocular muscles EXCEPT SO4 – LR6 ❖ Levator palpabrae superiosis muscle ❖ Deviation of the eye down and out. ❖ ptosis Autonomic: ❖ Ciliary muscle. ❖ Sphincter pupillae muscle ❖ Dilated pupil. ❖ Loss of light and accommodation reflexes Efferent in light and accommodation reflexes IV Trochlear Pure motor to SO Inability to look down VI Abducent Pure motor to LR Inability to move the eye out V Trigeminal Sensory: Facial sensation and somatic sensation from the tongue. ❖ Loss of sensation in one or more divisions of the trigeminal nerve. Motor: Muscles of mastication. ❖ Wasting of the masseter and temporalis muscles. ❖ When the jaw is opened it will deviate towards the side of the lesion. Reflex: Afferent in corneal reflex ❖ There is also absence of the corneal reflex VII Facial Sensory: Taste sensation from Ant. 2/3 of the tongue Loss of sensation from Ant. 2/3 of the tongue. Motor: Muscles of facial expression. ❖ Paralysis of facial muscles in the affected side. ❖ Deviation of the mouth to the healthy side. ❖ Loss of forehead corrigation. Secretory: Lacrimal – salivary glands
  • 27.
    (Sublingual – submandibular) Reflex: Efferentin corneal reflex. Failure to close the eye on the affected side →Loss of corneal reflex VII Vestibulocochlear Hearing and balance See hearing section IX Glossopharyngeal Sensory: General sensations from pharynx and middle ear. Special sensation from post. 1/3 of the tongue ❖ Loss of sensation from the pharynx ❖ Loss of taste from Post.1/3 of the tongue Motor: Stylopharyngeus muscle Secretory: To parotid gland. Afferent in gag reflex Loss of gag reflex X Vagus Motor: TO soft palate – larynx – pharynx ❖ Deviation of uvula to opposite side of lesion "Healthy side" ❖ Difficulty in swallowing ❖ Vocal cord weakness Sensory: TO larynx – pharynx – Esophagus – External ear – Aortic body – Thoracic and abdominal viscera Loss of sensations from the larynx, pharynx, Esophagus, external ear. Autonomic: TO Thoracic and abdominal viscera Efferent in gag reflex Loss of gag reflex XI Accessory Pure motor to ❖ Sternomastoid ❖ Trapezius ❖ Weakness of head rotation towards the opposite side of the lesion. (Weakness of sternomastoid muscle) ❖ Inability to elevate the shoulder. (Weakness of Trapezius muscle) XII Hypoglossal Pure Motor to the intrinsic and extrinsic muscles of the tongue ✓ The tongue deviate towards the paralyzed side ✓ There is also wasting of the tongue on the side of the lesion.
  • 28.
    Reflexes Light reflex Accommodation reflex Corneal reflex Gagreflex Afferent Optic Trigeminal Glossopharyngeal Efferent Oculomotor Facial Vagus Cranial nerves having Autonomic function III "Oculomotor" VII "Facial" IX "glossopharungeal X "Vagus" ❖ Ciliary muscle. ❖ Sphincter pupillae muscle Secretory: Lacrimal – salivary glands (Sublingual – submandibular) Secretory: Parotid gland TO Thoracic and abdominal viscera Nerves causing deviation in case of lesion V "Trigeminal" XII "Hypoglossal" VII "Facial" X "Vagus" Test done Open the mouth Protrude the tongue Ask the patient to smile Open mouth & say "Ahh" Deviation of Lower jaw Tongue Angle of the mouth Uvula Side of deviation To diseases side (5+12=17) To healthy side (7+10=17)
  • 29.
    1 2020 5MEDX TEAM FOR 2nd YEARMEDICAL STUDENTS Motor System Examination
  • 30.
    ‫ازاي؟؟‬ ‫دا‬ ‫الجزء‬‫في‬ ‫هنتسأل‬‫صورة‬ ‫هتيجي‬ ❖ Examiner doing a certain test ❖ Sign ❖ Lesion ❖ Equipment ‫مثال‬ ‫زي‬ ‫أسئلة‬ ‫عليها‬ ‫دي‬ ‫الصور‬ ‫و‬ ❖ Identify- name the test? ❖ It is performed by ….. ❖ Normal response is …… ❖ Abnormal response is …….. ❖ Causes of abnormal response ………. ❖ Name the sign, mention the cause. ❖ Name the equipment, its use. ❖ Simple clinical scenario. ‫عن‬ ‫هنتكلم‬ ‫دا‬ ‫الشابتر‬ ‫في‬7‫حاجات‬ 1. Muscle status. 2. Muscle tone. 3. Muscle power. 4. Examination of deep reflexes (tendon jerk). 5. Examination of superficial reflexes. 6. Involuntary movements. 7. Coordination and Gait. ‫قدام‬ ‫اننا‬ ‫نتخيل‬Patient‫هنعملها‬ ‫حاجة‬ ‫أول‬ ‫ف‬Inspection‫علي‬ ‫أبص‬ ‫و‬status of the muscle‫أبص‬ ‫و‬‫علي‬ ‫ال‬right and the left together‫أشوفهم‬ ‫و‬Asymmetric‫ال‬ ‫ولة‬. 1. Assess muscle symmetry. ‫في‬ ‫لو‬ ‫نشوفها‬ ‫حاجة‬ ‫تاني‬ ‫و‬muscle weakness (atrophy)‫أو‬Increase muscle bulk (Hypertrophy) ‫ال‬ ‫نشوف‬ ‫و‬abnormality (atrophy – hypertrophy)‫موجودة‬unilateral or bilateral(‫في‬ ‫يعني‬‫ناحية‬ )‫ناحيتين‬ ‫ولة‬ ‫واحدة‬ 2. Observe any atrophy or hypertrophy Causes of muscle atrophy?? Lower motor neuron lesion (LMNL) → Cause of muscle atrophy (wasting) III. Motor System Examination ‫عددهم‬ ‫الكتاب‬ ‫في‬ ‫الموجودين‬ ‫ان‬ ‫بالنا‬ ‫ناخد‬5‫و‬ ‫بس‬ ‫زيادة‬ ‫في‬ ‫هنا‬2‫(رقم‬1‫ر‬ ‫و‬‫قم‬6‫اتقالوا‬ ‫عشان‬ ) ‫المراجعة‬ ‫فيديو‬ ‫في‬ 1. Muscle status
  • 31.
    ‫ال‬ ‫ان‬ ‫النظري‬‫من‬ ‫نفتكر‬ ‫لو‬muscle tone‫ال‬ ‫من‬ ‫جزء‬ ‫كان‬stretch reflex (static part)‫عن‬ ‫عبارة‬ ‫هو‬ ‫و‬certain degree of muscle contraction How To examine (Procedure) ❖ Ask the patient to relax (muscle should not do any work) ❖ Passively flex and extend the patient's joints (fingers – wrist – elbow – ankle – knee) ‫ال‬ ‫اتجاه‬ ‫نفس‬ ‫في‬ ‫يعني‬joint....‫بنـ‬ ‫اننا‬ ‫بالنا‬ ‫ناخد‬ ‫و‬examine right and left sides‫بيشتكي‬ ‫المريض‬ ‫لو‬ ‫حتي‬ ‫بس‬ ‫واحدة‬ ‫ناحية‬ ‫من‬ Response: ▪ Normal response: There is normally small continuous resistance to passive movement this is known as muscle tone. (static stretch reflex) ▪ Abnormal responses: Hypotonia Hypertonia Tone Decreased (flaccidity) Increased (spastic – rigid) As in cases of ❖ LMNL ❖ Neocelebellar syndrome ❖ UMNL (clasp knife) ❖ Parkinsonism (cog wheel/ lead pipe) 1. Ask the patient to perform movements against your resistance and gravity. ‫لصوابعه‬ ‫أعمل‬ ‫مثال‬ ‫بمعني‬ ‫يقاومني‬ ‫المريض‬ ‫أخلي‬ ‫يعني‬dorsiflexion‫يعمل‬ ‫بإنه‬ ‫يقاومني‬ ‫هو‬ ‫و‬planter flexion 2. Compare one side to the other. 3. Test the muscles responsible for movement of different joints of the upper and lower limbs. Movement Center Movement Center Flexion at elbow C5,6 (biceps) Extension at elbow C6,7,8 (triceps) Extension at wrist C6,7,8 (radial nerve) Squeeze 2 of your fingers as hard as possible C7,8 T1 Finger abduction C8 T1 ulnar nerve Opposition of the thumb C8 T1 Median n. Flexion at the hip L2,3,4 Iliopsoas Extension at the hips S1 (gluteus maximus) Extension at knee L2,3,4 (quadriceps) Flexion at knee L4,5 S1,2 (hamstrings) Dorsiflexion at ankle L4,5 Planter flexion S1 2. Muscle tone 3. Muscle power (strength)
  • 32.
    Response: According tothe grades Normal response Abnormal response Normal muscle power Muscle weakness In cases of: UMNL- LMNL in the affected segment ‫الكتاب‬ ‫في‬ ‫موجود‬ ‫كله‬ ‫مش‬ ‫دا‬ ‫فوق‬ ‫اللي‬ ‫الجدول‬ :‫بالك‬ ‫خد‬)‫باألصفر‬ ‫لملونة‬ ‫الكلمات‬ ‫(ماعدا‬‫في‬ ‫اتقال‬ ‫لكنه‬ ‫و‬ ‫زيها‬ ‫صورة‬ ‫تيجي‬ ‫ممكن‬ ‫عشان‬ ‫كويس‬ ‫اقراه‬ ‫لكن‬ ‫و‬ ‫الكتاب‬ ‫في‬ ‫مش‬ ‫دا‬ ‫جاي‬ ‫اللي‬ ‫الجزء‬ ‫كمان‬ ‫و‬ ‫المحاضرة‬ Wrist flexion (C7,8 T1) Have the patient try to flex his wrist as you provide resistance Test each hand separately Ask the patient to spread their fingers apart against resistance (abduction) Then squeeze them together, with your fingers placed in between each of their digits (adduction) Flexors of fingers (C7,8 T1) Ask the patient to make a fist, squeezing their hand around two of your fingers Elbow flexion (C5,6) The main flexor (and supinator) of the forearm is the Brachialis muscle (along with biceps muscle) Elbow extension (C7,8) The main extensor of the forearm is the triceps muscle. Have the patient extend their elbow against resistance Movement against gravity but not against the examiner's resistance Normal muscle strength Movement against gravity and resistance (weak) Movement with gravity eliminated Trace (flickers of movement) NO movement (complete paralysis What is meant by muscle weakness? Reduced or loss muscle strength If there is loss of movement → Paralysis
  • 33.
    • Which testis performed by the examiner? ✓ Muscle power (strength) • What will be the result in case of UMNL? ✓ Muscle Weakness (loss of muscle power) (Decrease muscle power). General principles: ❖ Tendon jerk is a brief contraction of skeletal muscle elicited by tapping the tendon of the corresponding skeletal muscle sharply and strongly using a neurologic hammer (Dynamic stretch reflex). ‫ال‬ ‫بنخبط‬ ‫يعني‬tendon‫بـ‬hammer‫يحصل‬ ‫فـ‬contraction of the skeletal muscle‫ال‬ ‫يعتبر‬ ‫دا‬ ‫و‬ dynamic stretch reflex(‫ال‬ ‫ان‬ ‫قولنا‬ ‫اننا‬ ‫افتكر‬reflexchstatic stret‫ال‬ ‫كان‬muscle tone) ❖ Can be done in both sitting and supine position. ‫المريض‬ ‫حالة‬ ‫حسب‬ ❖ The limb should be placed in a position at which the muscle under test is in a neutral position OR mildly stretched. (not contracted). ❖ Valid test are best obtained when the patient s relaxed and not thinking about what you are doing. ❖ After obtaining the reflex on one side, always go immediately to the opposite side for the same reflex so that you can compare them. ❖ Deep reflexes Exaggerated In case of UMNL Diminished (absent) In case of LMNL ❖ If it is difficult to elicit the deep reflexes, reinforcement should be done. ‫أعمل‬ ‫ازاي‬reinforcement of the reflex In the upper extremity (Biceps – triceps) In the lower extremity (Ankle – knee) * Ask the patient to make a fist with one hand while the opposite extremity is being tested OR * By clenching of the teeth. * Ask the patient to perform the "Jendrassik maneuver" , the patient's fingers of each hand are hooked together so each arm can forcefully pull against the other. Ask the patient to pull his fingers while you're tapping on the tendon. Question The examiner is asking the patient to elevate his legs while the examiner is applying resistance 4. Examination of deep reflexes (tendon jerks) Neurologic hammer NOTE: reinforcement increase the sensitivity of the gamma fibers which supply the muscle spindles (receptors of stretch reflex), therefore, make them more sensitive
  • 34.
    ‫عن‬ ‫هنتكلم‬ ‫دلوقتي‬(Ankle– Knee – Biceps – triceps)4 jerks ‫ال‬ ‫عن‬ ‫عبارة‬ ‫دا‬ ‫األول‬ ‫الجزء‬steps‫نتبعها‬ ‫المفروض‬ ‫اللي‬‫تقراها‬ ‫ممكن‬ ‫لكن‬ ‫و‬ ‫الخطوات‬ ‫عن‬ ‫هنتسأل‬ ‫مش‬ ‫*احنا‬ ‫تفهم‬ ‫عشان‬*‫الصور‬ ‫علي‬ ‫تتعرف‬ ‫تعرف‬ ‫و‬ ‫أكتر‬ Preparing the patient ‫كله‬ ‫في‬ ‫ثابتة‬ ‫دي‬ ‫الخطوة‬ ‫و‬ ✓ Ask the patient to relax ✓ Explain what you are going to do Examination of ankle jerk (S1,2) 1. Position of the patient 2. Dorsiflex the foot slightly at the toes. 3. Hold the hammer with your fingers and use your wrist (not your arm) for the action. ‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 4. Strike the Achilles tendon with hammer sharply and strongly. 5. Distract the attention of the patient by talking with hm or asking him questions. ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬)‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ 6. Observe and record the response either as: ❖ Planter flexion of the foot. ❖ Seeing OR feeling the contraction of the gastrocnemius muscle by your hands. 7. Do the same steps on the other foot, and compare the response. 8. If the reflex: If the patient can set If the patient is in bed Ask him to sit at the edge of the examining couch or bed with the legs hanging freely. Ask him to extend both lower limb with the leg to be tested is crossed over the other leg. No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do Jendrassik maneuver *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for ankle clonus * Place the knee in a partly flexed position. * With the patient relaxed, the foot is dorsiflexed forcibly and maintained. * Observe the response:: clonus of the calf muscle and rhythmic oscillation of the foot.
  • 35.
    Examination of Kneejerk (L3,4) 1. Position of the patient 2. Identify the patellar tendon by palpation below the patella. 3. Hold the hammer with your fingers and use your wrist (not your arm) for the action. ‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 4. Tap on the patellar tendon with hammer sharply and strongly using the hammer. 5. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ 6. Observe the response and rate the reflex (The response: Extension of the leg – movement of the leg forward – contraction of quadriceps femoris muscle) 7. Do the same steps on the other side, and compare. 8. If the reflex Examination of Biceps jerk (C5,6) 1. Ask the patient to sit with the forearm supported, either ✓ Resting on the patient's thigh OR ✓ Resting on the forearm of the examiner. The arm is midway between flexion and extension with the palm pronated Place your thumb firmly on the biceps tendon. If the patient can set If the patient is in bed Ask him to sit at the edge of the examining couch or bed with the legs hanging freely. Flex the knee slightly by placing your forearm under both knees. No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do Jendrassik maneuver *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for knee clonus * By forcible maintained pulling of the patella downwards, using the index finger and the thumb. * Observe the response:: clonus of the quadriceps muscle and rhythmic oscillation of the patella. * Patellar clonus is sign of (UMNL – supra spinal facilitation)
  • 36.
    2. Hold thehammer with your fingers and use your wrist (not your arm) for the action.‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 3. Strike your finger which is placed on the tendon with the reflex hammer sharply and strongly. 4. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ 5. Observe and record the response either as: ❖ flexion of the elbow. ❖ Seeing OR feeling the contraction of the biceps muscle by your hands. 6. Do the same steps on the other hand, and compare. 7. If the reflex Examination of Triceps jerk (C6,7) 1. Ask the patient to flex his arm at the elbow (90°) and hold it close to the chest with the palm directed toward the body. 2. Hold the hammer with your fingers and use your wrist (not your arm) for the action. ‫جامدة‬ ‫متكنش‬ ‫الضربة‬ ‫عشان‬ 3. Identify the triceps tendon at its insertion on the olecranon above the elbow. 4. Strike the triceps tendon with hammer sharply and strongly. 5. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ 6. Observe and record the response either as: ❖ Extension of the forearm. ❖ Seeing OR feeling the contraction of the triceps muscle by your hands. 7. Do the same steps on the other hand, and compare. 8. If the reflex No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for clonus No response *diminished* Hyperactive *Exaggerated* * Ask the patient to do *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for clonus
  • 37.
    ‫الحظ‬‫ال‬ ‫كل‬ ‫في‬‫ان‬reflexes‫بيحصل‬(abnormal response) Decreased (Hyporeflexia) In case of LMNL Increased (Hyperreflexia) In case of UMNL Name & Center Stimulus Response Ankle (S1,2) Tapping on tendoachillis while the feet are slightly dorsiflexed. ✓ Contraction of gastrocnemias muscel ✓ Planter flexion. Knee (L3,4) Tapping on the patellar tendon while the leg is semiflexed. ✓ Contraction of quariceps ✓ Extension of the knee. Triceps (C6, 7) Tapping on triceps tendon. ✓ Extension of the elbow. ✓ contraction of the triceps muscle Biceps (C5,6) Tapping on biceps tendon while the forearm is pronated and semiflexed. ✓ Flexion of the elbow. ✓ contraction of the biceps muscle If the reflex is We do Diminished Reinforcement Exaggerated (hyperactive) Clonus ‫دا‬ ‫الجدول‬ ... ‫متقلقش‬ ‫ف‬ ‫دا‬ ‫فوق‬ ‫اللي‬ ‫الكالم‬ ‫كروت‬ ‫انت‬ ‫لو‬‫ف‬‫كلها‬ ‫الزتونة‬ ‫يه‬ dd ‫ألن‬ :‫غالبا‬muscle tone and deep reflex have the same supraspinal control ‫ال‬ ‫لزيادة‬ ‫يؤدي‬ ‫مرض‬ ‫في‬ ‫لو‬muscle tone‫فيه‬ ‫ان‬ ‫هنالحظ‬ ‫فغالبا‬hyperreflexia‫حالة‬ ‫(في‬UMNL) ‫ال‬ ‫لنقص‬ ‫يؤدي‬ ‫مرض‬ ‫في‬ ‫لو‬muscle tone‫فيه‬ ‫ان‬ ‫هنالحظ‬ ‫فغالبا‬hyporeflexia‫حالة‬ ‫(في‬UMNL) Question 1. The examiner is tapping on ………… tendon, to elicit ……. Jerk. 2. An abnormal response should be….. and is caused by……. ❖ The examiner is tapping on patellar / quadriceps tendon, to elicit knee / patellar Jerk. ❖ An abnormal response should be hyperreflexia and is caused by UMNL OR ❖ An abnormal response should be hyporeflexia and is caused by LMNL Remember NOTE: Clonus is repetitive rhythmic contraction of a muscle exposed to sudden maintained stretch. There are patellar and ankle clonus
  • 38.
    Planter reflex (centerS1,2) The procedure: 1. Stroke the sole of the foot with the back of your reflex hammer or key ❖ From lateral heel to lateral ball of foot. ❖ Then medially to medial ball of foot. 2. Distract the attention of the patient by talking with hm or asking him questions. )‫بعمله‬ ‫اللي‬ ‫في‬ ‫يركزش‬ ‫ما‬ ‫عشان‬ ‫يعني‬ ‫تانية‬ ‫بحاجة‬ ‫(أشغله‬ The observation Normal response Abnormal response Toes go down (planter flexion) (withdrawal) Extension of the big toe (big toe goes up) with fanning of the other toes *positive Babinski* NOTE Positive Babinski sign can be recorded Normally Pathologically During sleep Under anesthesia In infant below one year of age (due to incomplete myelination of the pyramidal tract) UMNL Abdominal reflex (center upper abdominal T7-10, Lower abdominal T10-T12) The procedure: 1. Ask the patient to expose his abdomen and relax with their arms by their side. 2. Use a blunt object such as a key or pen cover. Mechanism of clonus: The initial sudden muscle stretch will stimulate discharge from intrafusal fibers ( mainly nuclear bag ) resulting in muscle contraction . The tension developed in the muscle as a result is so high that the Golgi tendon organs become excited initiating inverse stretch reflex in the same muscle producing its relaxation , and as the stretch is maintained this process will be repeated rhythmically . This is detected in case of UMNL as a result of sparing of some of the facilitatory supraspinal discharge. FORREADING 5. Examination of superficial reflexes
  • 39.
    3. Stroke theabdomen lightly on each side in an inward direction above and below the umbilicus. The observation: UMNL LMNL S (Strength) Lowered Lowered T (Tone) Increases Decreases O (others) Clonus Fasciculations/ fibrillations R (reflexes) Increased Decreased M (muscle mass) Slight loss Atrophy Baby – Babinski Positive negative UMNL LMNL Muscle wasting NO (EXCEPT from disuse *disuse atrophy*) Marked (atrophy) Tone Hypertonia *spasticity* (Called clasp- knife) Hypertonia *flaccidity* (Called flaccid paralysis) Clonus Present Absent Reflexes Exaggerated Diminished OR absent Extensor planter reflex Babinski sign (dorsiflexion of the big toe and fanning out of the other toes) Absent Abdominal reflexes Absent Absent Fasciculation No May occur Normal response Abnormal response Contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus. Absence of abdominal muscle contraction As in UMNL – LMNL ‫مجمعين‬ ‫دول‬ ‫الجدولين‬UMNL – LMNL‫بعده‬ ‫اللي‬ ‫شوف‬ ‫و‬ ‫عديها‬ ‫حابب‬ ‫مش‬ ‫لو‬ .. ‫هيفيدك‬ ‫تقراه‬ ‫حابب‬ ‫لو‬ ‫ف‬
  • 40.
    ❖ They areinvoluntary, rhythmic muscle contraction and relaxation involving oscillation or twitching movements of one or more body parts. ❖ It is the most common of all involuntary movements. ❖ Most tremors occur in hands. ❖ Observation: fine movement of the hands. ❖ Causes of tremors: Physiological Pathological Aging Anxiety Thyrotoxicosis Parkinsonism Cerebellar disease Difference between parkinson's disease & Neocerebellar syndrome Pakinson's disease Neocerebellar syndrome Cause Due to disturbance in indirect circuit (which inhibits unwanted movement) leading to hyperkinetic features. Due to absent damping function of the cerebellum. Type Resting/ static Kinetic/ intention Character Pill-rolling/ Coarse ‫محتاج‬ ‫مش‬ ‫(يعني‬Test)‫أشوفه‬ ‫عشان‬ Disappear During movement or sleep At rest and during sleep Begin in one extremity and spread to the others, affecting the distal joints of the limbs preferentially Particularly affects the head and the upper half of the body Other neurological signs Bradykinesia/ rigidity/ postural instability/ micrographia/ shuffling gait/ masked faces Often associated with dysmetria/ dyssynergia/ hypotonia To assess the cerebellar function NOTE: cerebellar function =Coordination of voluntary and involuntary movements 1. Rapid alternating movements: Ask the patient to perform rapid alternating movements as supination and pronation of the limb rapidly and successively. ‫عنده‬ ‫اللي‬ ‫للمريض‬ ‫صعبة‬ ‫هتبقي‬ ‫دي‬ ‫الحركة‬ ‫و‬cerebellar disease 6. Involuntary movements Tremors 6. Coordination and Gait
  • 41.
    2. Finger tofinger test – finger to nose test. Ask the patient to touch the tip of his index of one upper limb with the tip of the other upper limb several times. OR Ask the patient to touch the tip of his nose with the tip of his finger several times. Ask the patient to perform the previous movements several times with the eye closed. Observe the response. Compare right versus left. 3. Heel knee shin test The patient can sit at the edge of examination couch with the lower limbs hanging freely OR can lie down. Ask the patient to place one heel on the opposite knee and run it down the shin of the tibia to the big toe. Repeat the test with the patient's eyes closed. Observe the response. 4. Gait pattern You must be in a position to steady the patient should he threaten to fall Ask the patient to: Walk across the room, turn and come back observe the gait, whether: ▪ Symmetrical OR asymmetrical. (such as hemiplegic gait) ▪ Normal paced OR short stepping gait. ▪ Normal knee movement OR high stepping gait. ▪ Look at the pelvis normal webbing gait. Finger to finger test Finger to nose test Heel knee shin test: A test of voluntary motor coordination in which a patient is asked to slowly touch the knee with the heel of the opposite leg, which is altered in cerebellar dysfunction. Inability to slide the heel of one foot down the shin of the opposite leg; the heel will deviate to alternate sides
  • 42.
    Future testing: Ask thepatient to if unable this indicates Walk as if on a tight rope Unsteadiness due to various causes Walk on his heels Foot drop Walk on his toes Weakness of the gastrocnemius There are several types of gait abnormalities which occur due to certain diseases such as: Hemilplegia The foot is planter flexed and the leg is swung in a lateral arc (circumduction) Spastic paraparesis Scissoring gait Cerebellar Wide-based. Patient staggers towards side of cerebellar lesion. Posterior column lesion Patient slaps down feet on a broad base. Parkinson's disease Hesitation, shuffling, freezing gait Foot drop Hip stepping gait Proximal myopathy Wadding gait
  • 43.
    1 2020 5MEDX TEAM FOR 2ndYEAR MEDICAL STUDENTS Practical Vision And Hearing
  • 44.
    Visual acuity: ‫الرؤية‬‫حدة‬ ❖ It is the degree to which the details and contours of objects are perceived. ‫انها‬ ‫بما‬ ‫و‬ ‫كويسة‬ ‫بجوددة‬ ‫األشياء‬ ‫تفاصيل‬ ‫بشوف‬ ‫يعني‬details‫الـ‬ ‫وطيفة‬ ‫دي‬ ‫يبقي‬Foveal Cones ❖ It is usually defined in terms of the minimum separable "the shortest distance by which two lines can be separated and still be perceived as 2 lines" ‫الـ‬ ‫نحدد‬ ‫بنقدر‬Visual acuity‫خالل‬ ‫من‬charts‫الـ‬ ‫*أسامي‬ ‫مثال‬ ‫زي‬ ‫بعض‬ ‫تحت‬ ‫صفوف‬ ‫فيها‬ ‫بتكون‬Charts‫دي‬ *‫وضعوها‬ ‫اللي‬ ‫العلماء‬ ‫ألسامي‬ ‫نسبة‬ ❖ Snellen's chart (Alphabetical letters) ❖ Emarah's Arabic chart Practical vision and hearing Examination of vision Visual acuity Visual field Fundus examination ‫سنة‬ ‫في‬ ‫هناخده‬5‫الرمد‬ ‫راوند‬ ‫في‬ Visual acuity test a b ‫أشوف‬ ‫عشان‬ ‫يعني‬Details of object‫بذاتها‬ ‫مستقلة‬ ‫نقطة‬ ‫كل‬ ‫أشوف‬ ‫الزم‬ ‫أخدنا‬ ‫لو‬ ‫مثال‬ ‫يعني‬line from a‫و‬line from b‫تالقو‬ ‫الخطين‬ ‫ان‬ ‫هنالقي‬‫ا‬ ‫اسمها‬ ‫نقطة‬ ‫في‬nodal point‫في‬ ‫موجودة‬ ‫دي‬ ‫و‬Posterior 1/3 of the lens‫فيه‬ ‫ان‬ ‫هنالحظ‬ ‫و‬angle‫أشوف‬ ‫عشان‬ ‫ف‬ ‫دي‬ ‫النقطة‬ ‫عند‬2 points as 2 points‫بتساوي‬ ‫دي‬ ‫الزاوية‬ ‫تكون‬ ‫الزم‬1 minute ‫من‬ ‫أقل‬ ‫كانت‬ ‫لو‬1min‫نشوف‬ ‫هنقدر‬ ‫مش‬ ‫ف‬2points as 2points Nodal point 1 min 1 degree = 60 min Snellen's chart Emarah's Arabic chart Visual field is the fovealfunction of cones
  • 45.
    ❖ Landolt's chart(Incomplete circles) *Most common* The chart is placed at a distance of 6 meter from the tested person (TO relax the ciliary muscle). ‫عن‬ ‫قربنا‬ ‫لو‬6‫بنعمل‬ ‫كدا‬ ‫يبقي‬ ‫متر‬stimulation to accommodation reflex‫ال‬ ‫بشغل‬ ‫و‬ciliary muscle ‫انه‬ ‫بمعني‬ ‫علي‬ ‫بناءا‬ ‫الدواير‬ ‫أحجام‬ ‫و‬ ‫المسافات‬ ‫اختالف‬ ‫و‬ 12 Circles are arranged in 7 rows With the openings of the circles in different directions. distance in meters at which the edge of the openings makes visual angle of 1min at the nodal point of the lens. 60 36 24 18 6 9 ‫اإلنسان‬ ‫ف‬ ‫كبيرة‬ ‫دايرة‬ ‫في‬ ‫صف‬ ‫أول‬ ‫مسافة‬ ‫عند‬ ‫يشوفها‬ ‫يقدر‬ ‫الطبيعي‬60‫متر‬ ‫اإلنسان‬ ‫ف‬ ‫أصغر‬ ‫دواير‬ ‫في‬ ‫تحته‬ ‫اللي‬ ‫الصف‬ ‫و‬ ‫عن‬ ‫واضحة‬ ‫يشوفها‬ ‫يقدر‬ ‫الطبيعي‬‫مسافة‬ ‫د‬ 36‫الصفوف‬ ‫لباقي‬ ‫بالنسبة‬ ‫هكذا‬ ‫و‬ .... ‫متر‬ ‫عاملين‬ ‫اللي‬ ‫النقطتين‬ ‫بين‬ ‫المسافة‬ ‫بتكون‬ ‫كبيرة‬ ‫دايرة‬ ‫أول‬ ‫في‬ ‫*زي‬ ‫النقطتين‬ ‫من‬ ‫خط‬ ‫نرسم‬ ‫لما‬ ‫بالتالي‬ ‫ف‬ ‫كبيرة‬ ‫الدايرة‬ ‫فتحة‬ ‫تتكو‬ ‫الزم‬ *‫كدا‬ ‫الصورة‬‫ن‬Angle*‫عند‬nodal point* ‫مقدارها‬1min‫نشوف‬ ‫نقدر‬ ‫عشان‬2 points = 2 points‫و‬ ‫نشوف‬ ‫بالتالي‬‫ال‬ ‫و‬ ‫الدايرة‬ ‫بتاعة‬ ‫الفتحة‬Angle‫مش‬ ‫دي‬ ‫بعد‬ ‫علي‬ ‫اإلنسان‬ ‫كان‬ ‫إذا‬ ‫إال‬ ‫بتتحقق‬60‫أقرب‬ ‫أو‬ ‫الدايرة‬ ‫من‬ ‫متر‬ ‫فـ‬ ‫كدا‬ ‫من‬ ‫أبعد‬ ‫كان‬ ‫لو‬ ‫لكن‬ ‫و‬ ‫كدا‬ ‫من‬Angle‫من‬ ‫أقل‬ ‫هتكون‬ 1 min‫بوضوح‬ ‫الشكل‬ ‫يشوف‬ ‫هيقدر‬ ‫مش‬ ‫و‬. ‫بالنسبة‬ ‫هكذا‬ ‫و‬ ‫المسافة‬ ‫نقرب‬ ‫الزم‬ ‫الدايرة‬ ‫نصغر‬ ‫لما‬ ‫بالتالي‬ ‫ف‬ .....‫للباقي‬ Nodal point 1 min A person with normal vision is able to see accurately the directions of the opening in the 7 rows A diagram to demonstrate that the openings of the circles in the seven rows of Landolt chart make (at the distance of 60, 36, 24, 18, 12, 9 and 6 meters) one and the same visual angle of 1min Landolt's chart
  • 46.
    ‫ال‬ ‫قدام‬ ‫المريض‬‫قعدت‬ ‫كدا‬ ‫أنا‬ ‫طب‬chart‫أنهي‬ ‫لحد‬ ‫يشوف‬ ‫قدر‬ ‫هو‬ ‫وشفت‬row‫الـ‬ ‫نتيجة‬ ‫أكتب‬ ‫ازاي‬ .....test‫؟؟‬ :‫مثال‬‫الـ‬ ‫كدا‬ ‫يبقي‬ ‫الباقي‬ ‫يشوف‬ ‫يقدرش‬ ‫ما‬ ‫و‬ ‫بس‬ ‫صف‬ ‫أول‬ ‫يشوف‬ ‫قدر‬ ‫المريض‬ ‫لو‬ 6 60 Result =‫رقم‬ ‫و‬60 ‫عند‬ ‫يشوف‬ ‫قدر‬ ‫دا‬ ‫المريض‬ ‫ان‬ ‫كدا‬ ‫معني‬6‫عند‬ ‫يشوفه‬ ‫يقدر‬ ‫الطبيعي‬ ‫االنسان‬ ‫اللي‬ ‫متر‬60‫متر‬ :‫مثال‬‫صف‬ ‫آخر‬ ‫لحد‬ ‫يشوف‬ ‫قدر‬ ‫المريض‬ ‫لو‬ 6 6 Result =‫دا‬ ‫المريض‬ ‫كدا‬ ‫يبقي‬normal‫عند‬ ‫يشوف‬ ‫وقدر‬6‫اللي‬ ‫متر‬ ‫عند‬ ‫بيشوفه‬ ‫الطبيعي‬ ‫اإلنسان‬6‫متر‬. Procedure: *‫فوق‬ ‫قولناه‬ ‫اللي‬ ‫عن‬ ‫جديدة‬ ‫حاجة‬ ‫*مفيش‬ 1. The subject to be tested stands at 6 meters from the chart. 2. Cover one eye. 3. Ask the person to read the letters or to tell the direction of the circles beginning from the top row. 4. Note the last row he can read accurately. 5. Repeat with the other eye. Results: ✓ Record the visual acuity as 6 over the distance in meters written beside the last line read correctly by the subject. ✓ The normal visual acuity is 6/6 OR 20/20 if the distance is expressed in feet. The results are expressed as a fraction 𝑁𝑜𝑚𝑒𝑟𝑎𝑡𝑜𝑟 = 20𝑓𝑒𝑒𝑡𝑠 𝑂𝑅 6 𝑚𝑒𝑡𝑒𝑟 𝐷𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑜𝑟 = ? The distance at which the subject read the chart The greatest distance from the chart at which a normal individual can read the smallest line the subject can read Question 1. What do we mean by 6/60? ✓ This person sees at 6 meters (nominator) what the normal person sees at 60 meters (denominator) 2. What is the normal result? ✓ The normal result is 6/6 ‫تحته‬ ‫اللي‬ ‫الصفوف‬ ‫بعدين‬ ‫و‬ ‫دواير‬ ‫أكبر‬ ‫فيه‬ ‫اللي‬ ‫صف‬ ‫بأول‬ ‫االختبار‬ ‫بنبدأ‬ ‫احنا‬ ‫المسافة‬ ‫هقرب‬ ‫شايف‬ ‫مش‬ ‫قال‬ ‫و‬ ‫صف‬ ‫أول‬ ‫علي‬ ‫سألته‬ ‫لو‬*Decrease the distance*‫بدل‬ ‫يعني‬6‫أخليها‬ ‫متر‬ ‫أقل‬5-1‫دي‬ ‫الحالة‬ ‫في‬ ‫و‬ ‫متر‬ ‫لحد‬ ‫المسافة‬ ‫قللت‬ ‫لو‬1‫هعمل‬ ‫دايرة‬ ‫أكبر‬ ‫شايف‬ ‫مش‬ ‫بردوا‬ ‫و‬ ‫متر‬counting fingers‫و‬ ‫ايدي‬ ‫صوابع‬ ‫أطلع‬ ‫يعني‬ .‫كام‬ ‫عددهم‬ ‫أسأله‬ ‫ع‬ ‫مش‬ ‫لو‬‫أعمل‬ ‫أبدأ‬ ... ‫ارف‬hand movement‫ال‬ ‫ولة‬ ‫شايفها‬ ‫وأساله‬ ‫قدامه‬ ‫ايدي‬ ‫أحرك‬ ‫يعني‬ ‫أعمل‬ ‫أبدأ‬ ‫شايف‬ ‫مش‬ ‫لو‬Light perception‫ال‬ ‫ولة‬ ‫شايفه‬ ‫وأسأله‬ ‫عنيه‬ ‫علي‬ ‫ضوء‬ ‫أسلط‬ ‫يعني‬ ‫علينا‬ ‫مش‬ ‫دا‬ ‫الجزء‬
  • 47.
    Tests for colorblindness I Test A (colored tufts of wool) Procedure: 1. The person is given many tufts of wool whose colors cover the whole visual spectrum. 2. He is asked to group tufts of similar colors together. 3. Observe the patients' ability to discriminated colors. II Test B (the hidden figure test OR Ishihara's test) Principle: ❖ That test uses a series if Ishihara charts made up of sets of dots that differ in size and in depth of colors (some being paler – some more intense) ❖ Some of these spots are arranged to represent certain figures or numbers. ❖ People with good color discrimination associated together the dots of the same color and can see the figure. Procedure: ❖ Ask the patient to look at various color charts in bright light of sunlight at a distance of about 75 cm. from the eye for few seconds. ❖ Observe if they identify the number OR figure in the chart. Color vision ility of the eye to discriminate between: is the abColor sense colors excited by light of different wave lengths Color vision is a (soConesfunction of most developed at the fovea) Ishihara charts Inability to identify a number suggests some defect of color vision
  • 48.
    Color blindness: Insensitivityto colors Some color blind individual are unable to distinguish certain colors, whereas others have only color weakness. 1. Red-green color blindness This occurs when either the red or green cones are lacking. 2. Blue weakness Abnormalities of red-green cones *More common than blue* Defect of the blue cones Inherited as Recessive X-linked Autosomal dominant SO Common in males ❖ As male has ONLY 1 X chromosome ❖ While female has 2 X chromosomes ‫االتنين‬ ‫الزم‬ ‫ف‬ ‫المرض‬ ‫يظهر‬ ‫عشان‬ ‫يتصابوا‬ Show no sexual selectivity ❖‫في‬ ‫بتحصل‬ ‫ألنها‬autosomal chromosomes NOT sex chromosomes How to examine the field? ❖ Confrontation ‫اللي‬ ‫االختبار‬ ‫دا‬ ‫*و‬*‫هنعمله‬ ❖ Perimeter *Automated* (computerized) Procedure: Confrontation 1. Sit opposite the patient 1m. away. Visual field test Visual field of each eye is the region of space that the eye can see looking straight ahead without movement of the head or the eyes Visual field ‫الـ‬ ‫بقارن‬Visual field‫بـ‬ ‫المريض‬ ‫بتاع‬Visual field‫بتاعي‬as examiner‫سليم‬ ‫اني‬ ‫باعتبار‬ Visual field is the function of rodsthe
  • 49.
    2. Ask thepatient to look at your eyes. 3. Test each eye separately. 4. Ask the patient to cover one eye and you should cover the opposite eye. 5. Move your hand out of the patient's visual field and then bring it back in. 6. The patient signals when your hand comes back into view. 1. Pupillary light reflex: Light → Eye →Moisis (Constriction of pupils) ❖‫الـ‬ ‫ان‬ ‫هنالحظ‬ ‫و‬Constriction‫في‬ ‫حصل‬Pupil of the eye‫الضوء‬ ‫عليها‬ ‫سلطت‬ ‫اللي‬ (Direct light reflex) ❖‫في‬ ‫حصل‬ ‫و‬other pupil(Consensual Or indirect light reflex) The procedure: 1. Explain that you are going to shine a bright light into the patient's eye and that this may feel uncomfortable. 2. Let the patient stare into the distance as you shine the penlight obliquely into each pupil. 3. Shine the light obliquely into his left eye (Direct reflex) and look for the pupil constriction. 4. Shine the light obliquely into his left eye once again, but this time look for pupil constriction in his right eye (Consensual reflex). 5. Repeat for the right eye. Eye reflexes
  • 50.
    Pathway Optic chiasma Optic tract Edenger Westephal nucleus Light Left eye Leftoptic nerve Left optic tract Left optic Chiasma Left pretectal nucleus Left Edenger Westephal nucleus Right Edenger Westephal nucleus Left Oculomotor N. Right Oculomotor N. Right ciliary ganglionLeft ciliary ganglion Left constrictor pupillae Right constrictor pupillae Direct light reflex Indirect (Consesual) light reflex Right short ciliary nerveLeft short ciliary nerve
  • 51.
    Causes of Consensuallight reflex: 1. Partial decussation in Optic chiasma. 2. Pretectal nucleus sends innervations to Edinger Westiphal nucleus of both sides (right + left). 2. Accommodation reflex: Distant object →Near object (near to nose) The procedure: 1. Ask the patient to follow with his eyes your finger (distant object) as it comes closer into his nose (near object). 2. Observations: ❖ Pupil constriction. ❖ Lens accommodation (increase diopteric power of the lens) ❖ Convergence of the eyes. Example 1: If Left optic nerve is diseased and I shine the light on the left eye, Will light reflex happen (Direct OR Consensual)? NO ‫الـ‬ ‫ألن‬Afferent‫مفيش‬ ‫ف‬ ‫خالص‬ ‫باظ‬stimulus‫هيتنقل‬ Example 2: If left optic nerve is normal but right optic nerve is diseased and I shine the light on the left eye, what will happen? ❖ Direct light reflex on the left eye will happen ❖ Indirect (Consensual) light reflex on the right eye will happen too, because the left pretectal nucleus will give innervation to Edinger Westephal nucleus of both sides. Example 3: If I shine light on the left eye and the right and left optic nerve are intact but left oculomotor nerve is diseases, What will happen? ❖ Direct light reflex on the left eye won't happen due to the diseased left oculomotor ❖ Indirect (Consensual) light reflex on the right eye will happen normally.
  • 52.
    Reflex Pupillary Lightreflex Accommodation (Near) reflex Stimulus Light Blurred image Receptor In Retina In Retina Afferent *sensory* CN II Optic nerve CN II Optic nerve Center Pretectal nucleus Frontal eye field (area 8) Efferent *Motor* CN III Parasympathetic fibers of Oculomotor nerve CN III parasympathetic + motor fibers of Oculomotor Effector Constrictor pupillae muscles 1. Medial recti 2. Constrictor pupillae muscle. 3. Ciliary muscle Response Direct and indirect Constriction of the pupil *Moisis* 1. Convergence of eyeballs. 2. Constriction of pupil. 3. Increase lens curvature Pathway Optic nerve Optic Chiasma Optic tract Lateral geniculate body Optic radiation Visual cortex (area 17) Frontal eye field (area 8) Somatic motor nucleus of CN III Edenger Westephal nucleus of CN III Contraction of medial rectus Convergence of eyeballs Ciliary ganglion Short ciliary nerve Contraction of ciliary muscle Contraction of constrictor pupillae muscle Increase in anterior curvature of lens Constriction of pupil *Moisis*
  • 53.
    Common Questions 1. Visualacuity is the function of foveal cones 2. Mention Charts used in visual acuity test. ‫صورة‬ ‫يجيب‬ ‫ممكن‬ ‫*و‬*‫اسمها‬ ‫علي‬ ‫يسألك‬ ‫و‬ ‫ليهم‬ o Snellen's chart and Landolt's chart 3. At which distance the patient is sitting during the visual acuity test? And Why? o 6 meters – To relax the ciliary muscle 4. Normal visual acuity is 6/6 Or 20/20 *In feet* 5. What do we mean by that the visual acuity is 6/18? o This person sees at 6 meters (nominator) what the normal person sees at 18 meters (denominator) 6. Color vision is the function of Cones 7. Types of color cones Red – green - Blue 8. Mention the tests used to examine the color vision. o Test A (Colored tufts of wool) o Test B (The hidden figure test Or Ishihara test) 9. If in the previous tests, the patient can't differentiate between colors, this means that he has Color blindness 10.Mention Types of color blindness. o Red-green color blindness o Blue weakness 11.Which color blindness is inherited as X-linked recessive? And mention if this blindness was common in males Or females. o Red-green blindness - males 12. Visual field is the function of rods 13.Mention the importance of light reflex. It is a protective reflex 14.Mention the components / effectors of near response. o Medial recti : Convergence / Ciliary muscle: increase dioptric power of lens / Constrictor pupillae: constriction of pupil
  • 54.
    Types of soundtransmission 1. Air conduction: (Sound vibration →Air →Cochlea) When sound vibrations are elicited in the air, it is conducted to cochlea by: Ossicular route secondary tympanic membrane that closes the round window transmission through the middle ear ossicles is the main pathway of normal hearing (the most efficient route). This process is unimportant in normal hearing because direct transmission from air to perilymph is associated with great loss of sound energy. ‫ال‬ ‫في‬ ‫موجودة‬ ‫اللي‬ ‫العظام‬ ‫عشان‬middle ear ‫هتعمل‬magnification to sound 2. Bone conduction: ❖ Is transmission of vibrations of the bones of the skull to the fluid of the inner ear. ❖ Considerable bone conduction occurs when tuning forks Or other vibrating bodies are applied directly to the skull. ❖ This rout also plays a role in transmission of extremely loud voice. Examination of hearing ‫حالتين‬ ‫في‬ ‫بيحصل‬ ‫حطيت‬ ‫اني‬tuning fork on the skull‫فيه‬ ‫أو‬Extremely loud voice Normally, air conducted sounds are louder and heard longer than bone conduction : Loss of hearingDeafness (partial Or complete)
  • 55.
    The procedure: The baseof a vibrating tuning fork is placed against the center of the person's forehead. The response: Normally In conductive deafness in one ear In nerve deafness *Sensorineural* (one side) It is heard equally on both sides. Sound is heard better on the diseased side than on the healthy side (because the masking effect of the environmental noise is absent on the diseased side) Sound is louder in the healthy side. ‫الـ‬ ‫بسبب‬ ‫انه‬ ‫بمعني‬obstruction in the diseased side‫كعازل‬ ‫بيعمل‬ ‫للـ‬Cochlea‫حواليا‬ ‫اللي‬ ‫الضوضاء‬ ‫عن‬ ‫ال‬ ‫و‬Cochlea is already intact‫من‬ ‫الرنة‬ ‫ف‬tuning fork ‫للـ‬ ‫هتوصل‬cochlea‫أوضح‬ ‫ال‬ ‫ألن‬ ‫كويس‬ ‫هتسمع‬ ‫السليمة‬ ‫الودن‬ ‫يعني‬ Cochlea‫ال‬ ‫الودن‬ ‫بعكس‬ ‫فيها‬ ‫شغالة‬ diseases Tuning fork tests Weber test Types of hearing loss according to causes: 1. conductive hearing loss ‫الـ‬ ‫في‬ ‫مشكلة‬ ‫لدوث‬ ‫نتيجة‬ ‫حصل‬Hearing pathway‫مثال‬ ‫زي‬Obstruction by wax – Perforation in ear drum – problem on ossicular system‫تعوق‬ ‫حاجة‬ ‫أي‬ ‫يعني‬Transmission of sound through the normal pathway *Air conduction pathway*‫ال‬ ‫يعني‬sound‫من‬ ‫يوصل‬ ‫قادر‬ ‫مش‬ear to inner ear ‫في‬ ‫مشكلة‬ ‫عندنا‬ ‫دي‬ ‫الحالة‬ ‫في‬air conduction‫الـ‬ ‫لكن‬ ‫و‬Bone conduction‫شغال‬normal‫علي‬ ‫بيعدي‬ ‫مش‬ ‫النه‬ ‫ال‬middle ear‫للـ‬ ‫بيروح‬ ‫و‬inner ear directly 2. Sensory neural hearing loss (nerve deafness) ‫الـ‬hearing pathway‫و‬ ‫سليم‬‫الـ‬ ‫في‬ ‫المشكلة‬ ‫لكن‬Sensory organ *cochlea*‫الـ‬ ‫في‬ ‫أو‬Cortex ‫في‬ ‫مشكلة‬ ‫عندنا‬ ‫دي‬ ‫الحالة‬ ‫في‬air conduction‫للـ‬ ‫وصل‬ ‫الصون‬ ‫ألن‬cochlea‫كمان‬ ‫عندنا‬ ‫و‬ ‫شغالة‬ ‫مش‬ ‫لكنها‬ ‫و‬ ‫الـ‬ ‫في‬ ‫مشكلة‬bone conduction Compare bone conduction in the two ears at the same time
  • 56.
    The procedure: ❖ Thebase of a vibrating tuning fork is placed on the mastoid process until the subject no longer hears it, ❖ And then put it in the air next to the ear. The response: Normally In conductive deafness ‫أو‬ ‫مشكلة‬ ‫حصل‬Obstruction ‫في‬hearing pathway In nerve deafness (partial defect in one ear) The subject hears vibrations in air after bone conduction is over. The subject DOES NOT hear vibrations in air after bone conduction is over. The subject hears vibrations in air after bone conduction is over although hearing is reduced in both. Rinne' +ve Rinne' -ve Reduced Rinne' +ve ‫الـ‬ ‫عملت‬ ‫لو‬ ‫طب‬weber test‫اختيارين‬ ‫بين‬ ‫كدا‬ ‫أنا‬ ... ‫الشمال‬ ‫من‬ ‫أعلي‬ ‫اليمين‬ ‫الودن‬ ‫في‬ ‫سامع‬ ‫انه‬ ‫قالي‬ ‫و‬ ‫لمريض‬ ❖‫عنده‬ ‫يكون‬ ‫إما‬Conductive deafness‫الودن‬ ‫و‬‫اليمين‬‫الـ‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬diseased‫دا‬ ‫وسبب‬ ‫في‬ ‫مثال‬ ‫ان‬Wax‫ال‬ ‫في‬hearing pathway‫ال‬ ‫عازل‬cochlea‫ال‬ ‫عن‬environmental noise ❖‫عنده‬ ‫يكون‬ ‫أو‬nerve deafness‫الودن‬ ‫و‬‫اليمين‬‫الـ‬ ‫الودن‬ ‫ان‬ ‫دا‬ ‫سبب‬ ‫و‬ ‫السليمة‬ ‫الودن‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬ Diseased‫الـ‬ ‫عندها‬Cochlea‫شغالة‬ ‫مش‬ ‫نعمل‬ ‫ازاي؟؟‬ ‫نتأكد‬ ‫طب‬Rinne' test Rinne's test Compare air conduction and bone conduction of the same ear Differentiate between types of deafness ‫الخالصة‬ ❖Rinne' test‫بين‬ ‫نقارن‬ ‫عشان‬ ‫بيتعمل‬air conduction *AC*‫و‬bone conduction *BC*‫الودن‬ ‫نفس‬ ‫عند‬ ❖‫الـ‬ ‫بنحط‬ ‫اننا‬ ‫طريقة‬ ‫عن‬vibrating fork‫*علي‬ ‫ودنه‬ ‫جنب‬mastoid process‫ال‬ ‫سامع‬ ‫هل‬ ‫المريض‬ ‫بسأل‬ ‫و‬ *vibration ‫ان‬ ‫كدا‬ ‫معني‬ ‫سامع‬ ‫لو‬ ‫ف‬ ‫ال‬ ‫ولة‬Bone conduction.... ‫تمام‬‫حاجة‬ ‫سامع‬ ‫مبقاش‬ ‫انه‬ ‫يقولي‬ ‫ما‬ ‫لحد‬ ‫أستني‬ ‫وبعدين‬ ❖‫ال‬ ‫شايلة‬ ‫أقوم‬ ‫ف‬fork‫لو‬ ‫ف‬ ‫ال‬ ‫ولة‬ ‫سامع‬ ‫أسأله‬ ‫و‬ ‫ليه‬ ‫مالمسة‬ ‫مش‬ ‫انها‬ ‫بمعني‬ ‫الهوا‬ ‫في‬ ‫ودنه‬ ‫جنب‬ ‫أحطها‬ ‫و‬ ‫ودنه‬ ‫علي‬ ‫من‬ ‫ان‬ ‫كدا‬ ‫معني‬ ‫سامع‬air conduction‫تمام‬ ❖‫ن‬ ‫و‬‫ال‬ ‫ان‬ ‫بالنا‬ ‫خلي‬Air conduction‫علي‬ ‫بيعدي‬middle ear‫للصوت‬ ‫بيحصل‬ ‫يعني‬magnification‫في‬ ‫بالتالي‬ ‫ف‬ ‫الطبيعي‬Air conduction is louder than Bone conduction ‫يكون‬ ‫المريض‬ ‫ان‬ ‫هي‬ ‫نشوفها‬ ‫ممكن‬ ‫اللي‬ ‫االحتماالت‬
  • 57.
    ‫فوق‬ ‫قولناه‬ ‫اللي‬‫السؤال‬ ‫نكمل‬ ‫تعالوا‬ ‫طب‬ Normal **‫أحط‬ ‫لما‬ ‫هيسمع‬ ‫كدا‬ ‫هو‬ ‫ف‬ ‫ودنه‬ ‫علي‬ ‫الشوكة‬*bone conduction* **‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫بردوا‬ ‫هيسمع‬ ‫و‬ ‫الهوا‬ ‫في‬ ‫ودنه‬ ‫جنب‬*Air conduction* ‫ان‬ ‫قولنا‬ ‫ما‬ ‫زي‬ ‫لكن‬ ‫و‬AC > BC‫و‬ ‫فوق‬ ‫السبب‬ ‫عرفنا‬ Conductive deafness ‫في‬ ‫انه‬ ‫عارفين‬ ‫طبعا‬ ‫و‬Conductive deafness‫عائق‬ ‫في‬ ‫ان‬ ‫المشكلة‬ ‫بتكون‬ ‫في‬hearing pathway **‫هيسمع‬ ‫ودنه‬ ‫علي‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫ف‬ *bone conduction*‫مش‬ ‫ألنه‬ ‫علي‬ ‫بيعدي‬hearing pathway‫و‬ ‫للـ‬ ‫بيروح‬ ‫لكن‬Cochlea‫طول‬ ‫علي‬ **‫في‬ ‫ودنه‬ ‫جنب‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫لكن‬ ‫و‬ ‫حاجة‬ ‫هيسمع‬ ‫مش‬ ‫الهوا‬*air conduction*‫ال‬ ‫في‬ ‫يعدي‬ ‫الزم‬ ‫ألنه‬ hearing pathway‫فيه‬ ‫لكنه‬ ‫و‬ *‫*مسدود‬ ‫مشكلة‬ ‫بالتالي‬ ‫ف‬BC > AC Nerve deafness ‫في‬ ‫انه‬ ‫عارفين‬ ‫طبعا‬ ‫و‬nerve deafness‫المشكلة‬ ‫بتكون‬‫العصب‬ ‫في‬ ‫طريقة‬ ‫أثناء‬To the cortex‫ال‬ ‫في‬ ‫أو‬ Cortex‫في‬ ‫أو‬cochlea‫ناخد‬ ‫لكن‬ ‫*و‬ ‫عندنا‬ ‫دي‬ ‫الحالة‬ ‫في‬ ‫انه‬ ‫بالنا‬Partial defect‫ال‬ ‫يعني‬ *cochlea‫مش‬ ‫الـ‬ ‫الحالة‬ ‫زي‬ ‫شغالة‬normal‫لكنها‬ ‫و‬ ‫ضعيف‬ ‫بشكل‬ ‫بس‬ ‫بتسمع‬ **‫هيسمع‬ ‫ودنه‬ ‫علي‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫ف‬ *bone conduction*‫ضعيف‬ ‫لكن‬ ‫و‬ **‫الهوا‬ ‫في‬ ‫ودنه‬ ‫جنب‬ ‫الشوكة‬ ‫أحط‬ ‫لما‬ ‫و‬ ‫هيسمع‬*air conduction*‫لكن‬ ‫و‬ ‫ضعيف‬ ‫بردوا‬ ‫بالتالي‬ ‫ف‬AC > BC‫و‬ ‫النورمال‬ ‫زي‬ ‫أضعف‬ ‫لكن‬ ‫الـ‬ ‫عملت‬ ‫لو‬ ‫طب‬Weber test‫اختيارين‬ ‫بين‬ ‫كدا‬ ‫أنا‬ ... ‫الشمال‬ ‫من‬ ‫أعلي‬ ‫اليمين‬ ‫الودن‬ ‫في‬ ‫سامع‬ ‫انه‬ ‫قالي‬ ‫و‬ ‫لمريض‬ ❖‫عنده‬ ‫يكون‬ ‫إما‬Conductive deafness‫الـ‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬ ‫اليمين‬ ‫الودن‬ ‫و‬diseased‫ان‬ ‫دا‬ ‫وسبب‬ ‫في‬ ‫مثال‬Wax‫ال‬ ‫في‬hearing pathway‫ال‬ ‫عازل‬cochlea‫ال‬ ‫عن‬environmental noise ❖‫عنده‬ ‫يكون‬ ‫أو‬nerve deafness‫الـ‬ ‫الودن‬ ‫ان‬ ‫دا‬ ‫سبب‬ ‫و‬ ‫السليمة‬ ‫الودن‬ ‫هي‬ ‫دي‬ ‫أعلي‬ ‫سامعة‬ ‫اللي‬ ‫اليمين‬ ‫الودن‬ ‫و‬ Diseased‫الـ‬ ‫عندها‬Cochlea‫شغالة‬ ‫مش‬ ‫نعمل‬ ‫ازاي؟؟‬ ‫نتأكد‬ ‫طب‬Rinne' test ✓‫ال‬ ‫عملت‬ ‫لو‬Rinne' test‫سمع‬ ‫المريض‬ ‫و‬ ‫اليمين‬ ‫الودن‬ ‫علي‬BC‫س‬ ‫ما‬ ‫و‬‫معش‬AC‫عنده‬ ‫ان‬ ‫كدا‬ ‫معني‬ conductive deafness‫الصح‬ ‫هو‬ ‫األول‬ ‫االحتمال‬ ‫و‬ ✓‫عادي‬ ‫االتنين‬ ‫سمع‬ ‫المريض‬ ‫لو‬ ‫أما‬(AC > BC)‫عنده‬ ‫هو‬ ‫و‬ ‫طبيعية‬ ‫دي‬ ‫الودن‬ ‫ان‬ ‫كدا‬ ‫معني‬nerve deafness‫في‬ .‫الصح‬ ‫هو‬ ‫التاني‬ ‫االحتمال‬ ‫يبقي‬ ‫و‬ ‫التانية‬ ‫الودن‬
  • 58.
    Common Questions Question 1.Identify the test? Weber test. 2. What is the normal result? o It us heard equally on both sides. 3. What is the result in case of neural hearing loss (nerve deafness)? o Sound is louder in the healthy side. 4. What is the result in case of conductive hearing loss? And mention the cause. o Sound is better on the diseased side than on the healthy side o Because the masking effect of environmental noise is absent on the diseased side Question 1 Identify the test? Rinne' test. 2 What is the normal result? o The subject hears vibrations in air after bone conduction is over. AC>BC (Rinne' +ve) 3 What is the result in case of partial neural hearing loss (nerve deafness)? o The subject hears vibrations in air after bone conduction is over although hearing is reduced in both. AC>BC (reduced Rinne' +ve) 4 What is the result in case of conductive hearing loss? o The subject does not near vibrations in air after bone conduction is over. BC>AC (Rinne' -ve) 5 What is the meaning of Rinne'+ve? o The subject hears vibrations in air after bone conduction is over. AC>BC o What is the meaning of Rinne'-ve? o The subject does not hear vibrations in air after bone conduction is over. BC>AC o What is the meaning of reduced Rinne'+ve? o The subject hears vibrations in air after bone conduction is over although hearing is reduced in both. AC>BC.