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pupil size & shape

1. patient looks at you & you assess size & shape
2. compare to pupil gauge = normal is 2-6 mm
Abnormal = mitosis < 2 (eye drops), mydriasis >6 (drops, midbrain lesions, hypoxia, oculomotor damage); oval pupils (head injury, intracranial hemorrhage or pressure); aniscoria=unequal (congenital, medication, SNS or PNS destruction, eye surgery or trauma)

Reaction to light/consensual reaction (CN?)

1. dim lights & have them focus across the room
2. move penlight from outer edge of eye & then move into one eye and then the other
3. assess for change in size of both pupils
Abnormal = dysfunction of oculomotor nerve CN III or a mass in the brain; fixed or dilated=herniation of the medial temporal lobe

Accommodation (CN?)

1. patient focus on something in distance
2. Then patients focus on something close
distance = dilation; close = constrict
Abnormal = dysfunction of oculomotor nerve CN III or a mass in the brain; fixed or dilated=herniation of the medial temporal lobe

confrontation test

1. patient & nurse hold card over same eye, stand 2-3 feet apart.
2. move finger or pencil from periphery to median & when can patient see it?
Normal = 50-90°
Abnormal = if they can't see it same as you then peripheral field loss. if 20° or less then legally blind

Extraocular Muscle movement (CN?)

1. stand in front of patient 10"-12". have them follow your finger, with their eyes, while moving to 6 points.
Abnormal = Nystagmus (involuntary movement of eye) or ptosis (drooping eye lid, caused by abnormal function of CN III)

Hirschberg test (corneal reflex test)

Test for strabismus (ocular misalignment)
1. patient stares straight ahead, nurse shines light at bridge of nose (12-15") & light should be reflected symmetrically in eyes.
Abnormal = asymmetrical --> weak extraocular muscles

Rinne test

1. Place vibrating tuning fork on mastoid bone (behind ear). Have patient say when they can no longer hear & then place fork just outside ear and have them say when they can no longer hear
Normal = longer air conduction than bone 2:1
Abnormal = BC > AC which means hearing loss. It will be sensorneural loss if AC > BC but less than 2:1

Weber's test

1. place tuning fork on top of head, midline, & ask which ear the sound is heard louder.
Normal = heard equally
Abnormal = if defective ear hears louder → conductive hearing loss. If unaffected ear hears louder → sensor-neural hear loss on the defective ear

Transillumination of the sinus area

Test when patient has sinus pain or congestion
1. darken room. shine light patrol to nose & midline to eye & you should see illumination on palate of mouth
2. shine light on supraorbital rim of eye and you should see illumination above eyebrows
Abnormal = sinus congestion, tumor or other blockage

Sensation of light touch

1. have patient close their eyes and lightly swipe cotton over 3 areas on both sides of the face (anterior scalp, paranasal & jaw)
Abnormal = ↓ or unequal sensation which may indicate nerve damage


1. place your finger on the joint & have patient open & close their mouth
Abnormal = clicking with pain???

Tinel's sign

1. Tap firmly on palmer surface of the wrist where the median nerve passes thru the carpal tunnel
Abnormal = tingling sensation or pain → carpal tunnel syndrome

Phalen's test

1. Patient presses dorsal surface of both hands together for 1 minute.
Abnormal = numbness, paresthesia or pain → carpal tunnel syndrome

goniometer: Elbow joint

Purpose: used to measure ROM
Abnormal = rheumatoid arthritis; tenderness with pronation or supination or lateral side = tendonitis or epicondylitis (tennis elbow); medial side tenderness = medial tendonitis (golfer's elbow)

Romberg's test

purpose: cerebellar function
1. patient stands with feet together, arms at their side, eyes open & then closed
Abnormal: patient sways with eyes opened & closed. Causes = stroke, parkinson's or inner ear problems

Cerebellar function in LE: balance & coordination

tests for balance & coordination
- patient closes eyes & stands on 1 foot, then the other. S/B able to maintain for 5 seconds.
- hop on 1 foot, deep knee bends or walk on toes & heels
Coordination: patient is supine & drag heel from knee to ankle
Abnormal = cerebellar tumors, stroke, Parkinson's or inner ear problems

Two-point discrimination

1. Patient has eye closed & can they distinguish between one point or two, alternate touching
Abnormal = impairment of sensory (afferent nerves) or parietal lobe

Thomas test

Purpose: evaluate flexion contractures of the hip
1. patient is supine, bring flexed knee to chest. other leg should remain on table.
Abnormal: other leg lifts → hip flexion contracture. tightness of psoas muscle

Straight leg raise test (CN?)

Purpose: evaluate for nerve root irritation or lumbar disk herniation
1. patient is supine, raise one leg (keep knee straight), may feel tightness in hamstring but no pain)
Abnormal = sciatic nerve impingement, pressure on peripheral nerve.

Rapid alternating movements (coordination)

Patient rapidly pronates & supinates hands while touching thighs
Abnormal = Dysdiadochokinesia, caused by lesions to the cerebellum, MS

Achilles reflex

1. Place one hand under the sole & dorsiflex the foot. Then strike the Achilles tendon.
Normal = causes plantar flexion of foot (contraction os gastrocnemius muscle)
Abnormal: Diabetes, abnormal muscles, sensory neurons, lower motor neurons & neuromuscular junction,
Reflex: graded on scale of 0-4

Babinski's reflex

Start at lateral aspect of foot (near the heel) and stroke upwards & over to the medial aspect
Normal = plantar flexion of all toes
Abnormal = dorsiflexion of great toe with fanning of other toes → upper motor neuron, like a spinal cord injury or stroke

DTR: Brachioradial reflex (SN?)

C5 & C6
Hold arm with hand slightly pronated, tap the brachioradialis tendon 1-2 inches above the wrist.
Normal = muscle contraction in the forearm
Abnormal = hyperactive → stroke/head injury, Lou Gerhig, MS or hypoactive → trauma to a nerve or herniated disk in the back

DTR: Patellar reflex (SN?)

L2, L3, L4
tap patellar tendon
Normal = contraction of quadriceps muscle
Abnormal = hyperactive → stroke/head injury, Lou Gerhig, MS or hypoactive → trauma to a nerve or herniated disk in the back

DTR: Biceps Reflex (SN?)

C5 & C6
hold patient's arm elbow flexed, thumb over biceps
Normal: contraction of bicep muscle causing visible or palpable flexion of elbow

DTR: Triceps reflex (SN?)

C6, C7 & C8
hold patients arm at elbow, with hand hanging freely & strike triceps tendon
Normal = contractions of triceps muscle causing visible or palpable extension of elbow

McMurray's test

Purpose: evaluate the presence of damage to medial or lateral meniscus of the knee
1. Patient is supine, place thumb & index finger on either side of flexed knee. Raise leg parallel to table & rotate knee externally (test lateral) and internally (test medial)
Abnormal = damage to medial or lateral meniscus

Bulge sign

Milk medial aspect & immediately tap lateral side of patella.
Abnormal = fluid wave/bulge → accumulation of exudate as part of inflammatory process, such as osteoarthritis

Lower Extremities for Vibratory Neuropathy

Patient close eyes, strike tuning fork & place on bony area. ask when they 1st feel sensation & when stops
Abnormal = unequal sensation or absent sensation → nerve damage, DM, CVA or spinal cord injury

Kernig's sign

1. flex patient's legs at hip and knee, then extending the knee, while supine
Abnormal = pain along vertebral column → irritation of meninges. meningitis or subarachnoid hemorrhage

Brudzinski's sign

1. flex patient's neck toward chest, while supine
Abnormal = pain along vertebral column & passively flexes the hip & knee (knees bend reflex) → meningitis or subarachnoid hemorrhage

Glasgow coma scale

Purpose: documents LOC
1. eye opening response
2. best verbal response
3. best motor response
Normal = 15 score
Abnormal = 3-8 is coma

Cerebellar function: UE (4 tests)

1. Alternating finger movements to thumb
2. Rapid alternating hand pronation/supination
3. Rapid alternating nose touching
4. Rapid movement of index finger from nose to examiner's finger
Abnormal = cerebellar tumors, stroke, Parkinson's or inner ear problems

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