Neuro I

III. Mood and Is the patient euphoric, agitated,

Mental Status & Cranial Nerve Examination affective responses giggling, silent, weeping, or angry?
Dr. Dennis Naval
November 06, 2023 Is the mood appropriate? Is the
patient emotionally labile?
Mental status & Higher Cortical Functions
● Difficult to test IV. Content of Does the patient have illusions,
thought hallucinations, delusions, and
➔ because some are subjective misinterpretations?

● Most of the data come from the
interview during history taking
➔ Observe also the patient’s
appearance; how the patient
talks to you
● Interview technique is everything
➔ Build a rapport so that the
patient will not feel invaded by
the questions being asked
Does the patient suffer delusions of
persecution and surveillance by
malicious persons or forces?
Is the patient preoccupied with bodily
complaints, fears of cancer, heart
disease, or other phobias?
V. Intellectual Is the patient bright, average, dull, or
capacity obviously demented or mentally
retarded?

● Proper timing to ask questions VI. Sensorium A. Consciousness

B. Attention span
● Patients will disclose their mental C. Orientation for time, place, and
state if you provide a free opportunity person
D. Memory, recent, and remote
E. Fund of information
F. Insight, judgment and planning
G. Calculation
Review daw yung MSE as per Doc
● Do the MSE in order

Components of Sensorium:
● Consciousness
● Attention span
● Orientation
● Memory
● Fund of information
● Insight, judgement and planning
Outline of Mental Status Examination ● Calculation

I. General Behavior Is the patient normal, hyperactive,

and Appearance agitated, quiet, immobile?
Is the patient neat or slovenly? Do
the clothes match the patient’s age,
peers, sex and background?
II. Stream of talk Does the patient converse normally?
Is the speech rapid, incessant, under
great pressure, or is it slow and
lacking in spontaneity and prosody?
Is the patient discursive, tangential,
and unable to reach a conversational
goal?
Consciousness:
➔ Is the patient awake? Is the patient
confused?
➔ Will lead you to a tailored neurological
examination
➔ Some parts of neurological exam cannot
be performed in certain individuals with
distorted consciousness

JEC 1
Levels of Consciousness
● Normal consciousness
➔ Normal person when awake
➔ Patient is fully responsive to a
thought or perception and
indicates by his behavior and
speech
➔ Same awareness of self and
environment as that of the
examiner
➔ There is attention to and
interaction with the immediate
surroundings
➔ Normal state may fluctuate
during the day
● Confusion
➔ Lacks precision but in
operational terms, it denotes an
inability to think with customary
speed, clarity and coherence
➔ There is a degree of
imperceptiveness and
distractibility
➔ Called in the past “clouding of
sensorium”
● Drowsiness
➔ Denotes an inability to sustain a
wakeful state without the
application of the external
stimuli
➔ Mental speech, physical activity
are reduced
➔ As a rule, some degree of
inattentiveness and mild
confusion are coupled with
drowsiness. Both improving with
arousal
JEC
● Stupor
➔ state in which the patient can be
aroused only a vigorous and
repeated stimuli, in which
arousal cannot be sustained
without repeated stimulation
● Coma
➔ patient is incapable of being
aroused by external stimuli or
inner need
➔ There are variations in the
degree of coma, findings and
signs depend on the underlying
cause of the disorder
❖ Obtundation
➔ Lighter stage of coma or
semi coma
➔ Most of the reflexes can
be elicited
➔ First thing to have
checked is the
sensorium
Read on….
● Vegetative state
➔ have sleep-wake cycles
➔ intact cardiorespiratory function
➔ primitive responses to stimuli
but without evidence of inner or
outer awareness present for at
least 1 month
➔ brain stem is intact
➔ For the first week or two after
severe cerebral injury, patients
are in a state of deep coma
➔ Then they begin to open their
eyes, at first in response to
painful stimuli, and later
spontaneously and for
increasingly prolonged periods
2
 ➔ Patient may blink in response to ❖ Alzheimer
threat or to light and ❖ Creutzfeldt-Jakob
intermittently the eyes move disease
from side to side, seemingly
following objects or fixating (where the pathologic changes are mainly
momentarily on the physician or cortical but may include the thalamus)
a family member and giving the
➔ prominent pathologic
erroneous impression of
changes are often in the
recognition
thalamic and subthalamic nuclei
➔ Respiration may quicken in
➔ a state in which the cortex is
response to stimulation, and
either diffusely injured or
certain automatisms—such as
effectively disconnected and
swallowing, bruxism, grimacing,
isolated from the thalamus, or
grunting, and moaning—may be
the thalamic nuclei are
observed
destroyed
➔ patient remains unresponsive
★ lack of consistent visual
and, for the most part,
following of objects, particularly
unconscious, does not speak,
because brief observation of
and shows no signs of
ocular movements is subject to
awareness of the environment
misinterpretation, and repeated
or inner need
examinations are required
➔ motor activity is limited to
Most Common Pathologic Basis of the
primitive postural and reflex
Vegetative state
movements of the limbs
● Diffuse cerebral injury as a result of
closed head trauma
➔ loss of sphincter control

● Widespread necrosis of the cortex after

➔ There may be arousal or
wakefulness in alternating
cycles as reflected in partial eye
opening, but the patient regains
neither awareness nor
purposeful behavior
➔ If the vegetative syndrome of
unconscious awakening persists
for 3 months after non traumatic
brain injury, and 12 months after
traumatic injury, the syndrome
has been termed the persistent
vegetative state
➔ may also be the terminal phase
of progressive cortical
degenerative processes such
as:
cardiac arrest or other form of anoxia
● Thalamic necrosis from a number of
causes
Criteria for Determination of Unresponsive
Wakefulness State (Formerly Known as
Vegetative State)
➔ No evidence of awareness of self or
surroundings. Reflex or spontaneous
eye opening may occur
➔ No meaningful and consistent
communication between examiner and
patient, auditory or written. Target stimuli
not usually followed visually, but
sometimes, visual tracking present. No
emotional response to verbal stimuli

JEC 3
 ➔ No comprehensible speech or mouthing behaviors that demonstrate a
of words degree of awareness

➔ Smiling, frowning, or crying ➔ a transitional or permanent

inconsistently related to any apparent condition, sometimes difficult to
stimulus separate from akinetic mutism

➔ Sleep-wake cycles present Causes and Pathologic changes underlying

Minimally conscious state
➔ Brainstem and spinal reflexes variable, ➔ frequent finding of thalamic lesion
(preservation of sucking, rooting, ➔ multiple cerebral lesion
chewing, swallowing, pupillary reactivity
to light, oculocephalic responses, and
● Locked-in syndrome / Deefferented
grasp or tendon reflexes)
state
➔ there is little or no disturbance
➔ No voluntary movements or behavior, no
of consciousness, but only an
matter how rudimentary; no motor
inability of the patient to respond
activity suggesting learned behavior; no
adequately with motor activity
mimicry. Withdrawal or posturing can
and speech
occur with noxious stimuli

➔ most often caused by a large

➔ Usually intact BP control and
lesion of the ventral pons (basis
cardiorespiratory function. Incontinence
pontis), usually as a result of
of bladder and bowel
occlusion of the basilar artery
● Minimally conscious state
➔ the damage essentially
➔ intermittently show signs of self
completely interrupts the
or environmental awareness
descending corticobulbar and
which may include:
corticospinal tracts, depriving
❖ Verbal command
the patient of speech and the
❖ Visual tracking
capacity to respond in any way
❖ Context-specific
except by voluntary vertical
emotional responses
gaze and by blinking
➔ less severe but still profound
➔ Infarction, hemorrhage, or
dementia
rarely, central pontine
myelinolysis may destroy the
➔ patient is capable of some
basis pontis, producing total
rudimentary behavior such as:
paralysis of the lower cranial
❖ Following a simple
command nerve and limb muscles, with
preserved alertness and
❖ Gesturing respiration

❖ Producing a single ● Akinetic mutism

words or brief phrases ➔ silent and inert as a result of
bilateral lesions of the anterior
➔ There is a preservation of the parts of the frontal lobes or in
ability to carry out basic motor the thalamus, leaving intact the

JEC 4
 motor and sensory pathways
➔ patient is profoundly apathetic,
lacking to an extreme degree
the psychic drive or impulse to
action
➔ There is a marked delay in
verbal and motor responses
(abulia)
➔ However, patient registers most
of what is happening about him
and if intensely stimulated, may
speak normally, relating events
observed in the recent and
distant past
● Catatonia
➔ unresponsive, in a state that
simulates stupor, light coma, or
akinetic mutism
➔ no signs of structural brain
disease, such as pupillary or
reflex abnormalities
➔ As in the normal awake state,
oculocephalic responses are
muted—that is, the eyes move
concurrently with the head as it
is turned
➔ there is a resistance to eye
opening, and some patients
display a waxy flexibility of
passive limb movement that
gives the examiner a feeling of
bending a wax rod (flexibilitas
cerea)
➔ there may also the retention for
a long period of seemingly
uncomfortable limb postures
(catalepsy)
➔ Peculiar motor mannerisms or
repetitive motions, seen in a
number of these patients, may
JEC
give the impression of seizures
➔ behavioral disturbance
characterized by wakeful
unresponsiveness with minimal
or no spontaneous purposeful
behavior or speech
➔ most commonly associated
with depression, schizophrenia,
toxic psychosis, or other brain
diseases
➔ there may be akinetic mutism,
grimacing, rigidity, posturing,
catalepsy, or excitement
➔ respirations are normal or rapid
➔ pupils are large but reactive,
eye movements are normal
➔ EEG are normal
● Brain death
➔ complete unresponsiveness to
all modes of stimulation, arrest
of respiration, and absence of
all EEG activity for 24 hours
➔ cerebrum and the brain stem
are both permanently destroyed
➔ only spontaneous activity is
cardiovascular
➔ apnea persists in the presence
of hypercarbia sufficient for
respiratory drive
➔ only reflexes present are those
mediated by the spinal cord
5
Central considerations in the diagnosis of
Brain Death
● Absence of all cerebral functions
● Absence of all brainstem functions,
including spontaneous respiration
● Irreversibility of the state
Diagnosis of Brain Death
● Absence of cerebral function
➔ presence of deep coma and
total lack of spontaneous
movement and of motor and
vocal responses to all visual,
auditory, and cutaneous
stimulation
● Spinal reflexes (deep tendons
reflexes) may persist
➔ toes often flex slowly in
response to plantar stimulation
● Complete absence of brainstem
function
➔ loss of spontaneous eye
movements
➔ resting position of both globes at
the meridian of the palpebral
fissures
➔ lack of response
oculocephalic and caloric
(vestibulo-ocular) testing
➔ presence of dilated or mid
position fixed pupils
(not smaller than 3 mm)
➔ Paralysis of bulbar musculature
(no facial movement or gag,
cough, corneal, or sucking
reflexes)|
➔ absence of motor and
autonomic responses to noxious
stimuli
JEC
➔ absence of respiratory
movements
Reference: Merritt's Neurology ; Adams &
Victor’s Principle of Neurology
Attention Span
➔ Can the patient attend to stimuli long
enough to comprehend and respond to
them , or attend to a task long enough to
complete it?
➔ Spell the word “WORLD” backward /
“MUNDO”
➔ Reciting the months of the year
backward
➔ Serial 7’s/3’s (Minus a 7 from 100)
(Minus 3 from 20)
➔ Take note of the educational attainment
Orientation
➔ Does the patient comprehend who and
where he or she is and when it is?
➔ Person: Does the patient recognize
himself and his role, the other people
present, and their roles?
➔ Place: Does the patient recognize the
to he is in the clinic or hospital, its name,
and the name of the place where the
establishment is?
➔ Time: Can the patient recite the time of
the day, day of the week, the month, and
the year?
★ In some conditions or natural
occurrences, what becomes affected
first is TIME. Then later on is PLACE,
and lastly is PERSON (especially with
persons with neurodegenerative
diseases such as Alzheimer’s)
6

Memory
● Note how well the patient recalls and
relates the events of the medical
history
➔ If there are some lapses or
inconsistencies that’s a red flag
or a possible memory lapses
● “Does your memory work all right”
➔ To see if a patient has a good
insight and be able to tell about
it
● “Do you have trouble with your
memory?”
● Provide 3 random words
➔ Have the patient repeat the
words immediately & ask them
again if they can recall the 3
words after 5 minutes
➔ “Mangga, Mesa, Pera”
JEC
● Determine whether patient differs in
the ability to recall recent or remote
events
➔ To see if the short term memory
/ long term memory is impaired
➔ Ribot’s Law
➢ Short term memory gets
affected first more than
the long-term memory
➢ Example: Alzheimer’s
Disease
Fund of Information
● Ask about current activities or events
Insight, Judgment, Planning
● Ask the patient what he plans to do
➔ If a patient has a good insight, it
should be tailored to his / her
capabilities
● Do the goals and plans match the
physical and mental capabilities?
➔ Example: patient who recently
had a stroke with complete
paralysis of one side of the
body, ask the patient about his
goal and told you he wanted to
be an olympian, maybe there
are some problem in the
patient’s insight
● Does the patient recognize the illness
and its implications?
Calculation
● Simple mathematical equations
➔ Take note / consider the
patient’s educational
background
● Indirectly assessed the Serial of 7s*
➔ Primarily to test for attention
span
7
Affective Responses
● Appropriateness of affect
➔ If the patient says he is happy
but looks sad, ther’;s
incongruency between the affect
and the mood
● Affective lability
➔ Patient will be laughing then
later on crying just a few
seconds
➔ Common in patients with
Pseudo bulbar palsy and diffuse
brain diseases
● Affective blunting
Perceptual Distortions / Thought Content
● Illusions
➔ false sensory perception based
on natural stimulation of a
sensory receptor
➔ Example: Mistaking a towel to a
ghost
● Hallucination
➔ false sensory perception not
based on natural stimulation of
a sensory receptor
➔ A person is seeing, hearing or
feeling things or tasting without
the actual stimulus
● Delusions
➔ false belief that reason cannot
dispel
Thought Process
● Distractibility
➔ A person may begin talking with
one thing and completely shifts
topics before completing the
sentence
➔ Often due to a nearby stimuli
that interfere with the thought
JEC
process
● Circumstantial thinking
➔ When a person talks in circles,
providing excessive and
unneccesary detail before
getting to the point
● Tangential thinking
➔ Occurs when someone moves
from thought to thought but
never seems to get to the main
point
➔ Instead the thoughts are
somewhat connected but in a
superficial or tangential way
➔ There are close associations but
the patient never seems to get
the point (if you ask a question,
hindi niya masasagot)
● Derailment or loose associations
➔ Thoughts loose almost all
connections with one another
and become disconnected and
disjointed
● Clang associations
➔ When a person chooses words
based on sound rather than
meaning
➔ “Rhyming”
➔ They may also used made up
words or neologisms and may
speak in a flat or unusual
sounding voice
● Incoherence
➔ People with a very severe
disordered thinking
➔ There are no discernable
connections between words
➔ “Word salad”
(Remember daw sabi ni Doc)
8

Higher Cortical Function
● Agnosia
➔ “Not knowing”
➔ Inability to understand the
meaning, import, symbolic
significance of ordinary sensory
stimuli even though the sensory
pathways and sensorium are
relatively intact
➔ Cannot be checked if the patient
is confused or drowsy
➔ Recognize the individual immediately by
the voice sound when the person
speaks
➔ Inferomedial temporo-occipital region
➢ Lesion is usually bilateral
Agnosias of Body Scheme
● Body scheme or “SomatOgnosia”
(Normal)
➔ Awareness of one’s own body
parts, boundaries and postures
● Pathological: SomatAgnosia

Necessary conditions to diagnose Agnosia: ● Topagnosia:

● Sensory pathways are relatively intact
● Sensorium and mental status are
relatively intact
● Previously understood the symbolic
significance of the stimulus
➔ Inability to localize skin stimuli
➔ Ask the patient to close their
eyes and touch a specific body
part and ask them to locate
where he was touched

● An organic cerebral lesion causes the

● Autotopagnosia:
deficit
➔ Inability to locate, identify and
Agraphesthesia orient one’s own body parts
➔ One common Agnosia
➔ Ask the patient to close their
➔ With the patient’s eyes eyes. Instruct them to point a
closed, trace letter or
specific body part (nose, right
numbers between 1 and 10
on the skin of the palm or ear, etc)
fingertips. Use any blunt tip
(cap end of the pen) ➔ Part of Gertsmann syndrome
➔ Lesion: Left angular gyrus
➔ Important to assess first the
sensory (see if the sensory is
intact) Testing for Autotopagnosia:
● Tactile finger agnosia
➔ Happens if there is a problem ➔ With patient’s eyes closed,
in the parietal lobe
randomly touch a digit on the
Graphanesthesia right or left hand

● Apraxia ➔ Ask the patient to identify the

● Aphasia finger

● Right-left disorientation
Prosopagnosia ➔ “Touch your left ear with your
➔ Inability to recognize faces in person or right hand”
in photos

JEC 9
Hemispatial Inattention
● Neglect
➔ Patient ignores persons,
objects, or any stimuli from the
affected side, fails to dress that
side, and fails to eat the food
from half of the plate
Inattention to Double Simultaneous
Cutaneous Stimulus
● Sensory extinction
● Sensory suppression
● Sensory inattention
➔ Sensory pathways must be intact
➔ Simply touch both right and left hand
simultaneously

Pointers for Agnosias:

★ Lesions of either parietal lobe may
cause contralateral loss of asterognosis
but hemispatial inattention and
anosognosia are more common with
either parietal lobe lesions

★ Finger agnosia and R-L disorientation

are more common with dominant
posterior parasylvian lesions

Apraxia
➔ inability to perform a voluntary act even
though the motor system, sensory,
system and mental status are relatively
intact

➢ (Image above) These are some tests to
check for neglect
➢ Ask the patient to draw a cross or any
symmetrical figure (bicycle, face of a
clock)
➔ Praxis: ability to execute a voluntary act
Criteria to distinguish apraxia from other
motor deficits:
● Motor system is sufficiently intact to
execute the act

Anosognosia ● Sensorium is sufficiently intact to

➔ Lack of awareness of any bodily defect understand the act

➔ Seen in parietal lobe lesions ● Organic cerebral lesion as the cause

of the deficit
➔ Ask the patient if anything is wrong with
the affected side
Test for Apraxia:
● Routine commands:
➔ Ask the patient to move the affected arm
➔ “Stick out your tongue”
despite hemiplegia
➔ “Make a fist”
➔ “Walk across the room”
➔ The patient will deny a problem on that
● If a patient cannot do the command/s,
part
he / she has a tongue, hand and gait
apraxia

JEC 10
 ● Face-tongue apraxia|
● Arm (ideomotor) apraxia
➔ Ask the patient to demonstrate a
sequence
➔ Example: Lighting a candle
using a matchstick / Show how
to fry an egg
● Constructional apraxia
➔ Ask the patient to copy
geometric figures such as:
❖ Intersecting shapes
● Dressing apraxia
➔ Asking the patient how to dress
➔ Example: Buttoning /
Unbuttoning clothes
● Ideational apraxia
➔ Inability to plan movements
related to interaction with
objects
Speech Disturbances
● Dysphonia:
➔ Lack of production of sounds in
the larynx
➔ Parang ngo-ngo
➔ Usually in brainstem strokes
● Dysarthria:
➔ Disorder in articulating speech
sounds
➔ Medyo utal
➔ Usually in affectation of
corticobulbar tract
● Dysprosody:
➔ scanning speech in (cerebellar
pathologies)
➔ plateau speech in
(parkinsonism)
JEC
➔ stuttering, cluttering, and
absence of emotional inflection
● Dysphasia:
➔ disturbance in the
understanding or expression of
words as symbols for
communication
Aphasia:
● Inability to understand or
express words as symbols for
communication (even though
the primary sensorimotor
pathways to receive and
express language and the
mental status are relatively
intact)
Can be detected during History Taking:
● Searching for words, pauses,
and hesitations
● Substitution of the wrong words
or phonemes
● Poverty of speech or the
converse, excessive production
of sounds that resemble words
but fail to communicate
● Puzzlement and hesitations in
response to ordinary statements
made in the course of
conversation
● Loss of intonation and prosody
● Frequent dysarthria
● Irritation or distress at the
inability to communicate
Operational Steps in Examining for Aphasia:
● During history taking, listen for word
choice, word substitutions, a searching
for words, articulation, hesitations,
prosody, and the quantity of speech
11
 ● Ability to repeat words spoken by the than the left, which is committed
examiner to language

● Test word comprehension by questions Gertsmann Syndrome:

and commands ➔ Dysgraphia
➔ Dyscalculia
● Show common objects to name (pen, ➔ Finger agnosia
coin, watch) ➔ Right-left disorientation

● Have the patient write a sentence ➢ Lesion of the left angular gyrus,
at the parieto-occipito-temporal
● Have the patient read and interpret a junction
sentence
(Please see appendix for Tables)
Classification of Aphasias

Read On…
● Role of the right hemisphere in
language
➔ have a role in the implicit
communication of emotion
through the subtleties of
propositional language

➔ These modulative aspects of

language are subsumed under
the term prosody, by which is
meant the melody of speech, its
intonation, inflection, and
pauses, all of which have
emotional overtones

➔ prosodic components of speech

and the gestures that
accompany them enhance the
meaning of the spoken word
and endow speech with its
richness and vitality

➔ more involved in
affective-emotional experience

JEC 12
 Neuropsychologic Categories of Memory
Long-term memory

Explicit Implicit

Immediate recall Working Memory Semantic Episodic Procedural Visual

Function Repetition Short-term recall of Recall for facts and Recall for Operational recall Recall of visual
objects, plans, names, their relationships temporally (“how to do”) representations
sequencing organized events

Consciousness Yes Yes Yes Yes Usually No

Anatomic Perisylvian cortex of Prefrontal cortex, medial Anterior, Inferior Association Premotor and Motor Occipital lobes
regions dominant hemisphere temporal lobes, temporal lobes; cortex cortex, Basal ganglia,
involved dorsomedial thalamus Frontal lobes Cerebellum

Conditions that Agitation, Confusion Wernicke-Korsakoff Alzheimer’s Hippocampal Alzheimer’s disease Alzheimer’s disease, other
disturb (Impaired attention) syndrome, Herpes disease, infarction, and other CNS CNS degenerative
memory encephalitis, Infarction of Fronto-temporal Alcoholic degenerative disorders, Encephalitis,
Hippocampi, Dorsomedial dementia, Korsakoff disorders, Tumors
thalamus Encephalitis, syndrome, Encephalitis, Chronic
Chronic toxins, Alzheimer’s Toxic exposure,
Tumors disease & other Tumors
CNS
degenerative
disorders,
Encephalitis,
Chronic toxin
exposure,
Tumors
 Classification of Aphasias
Type of Aphasia Fluency Understands Repetition Naming Lesion location

Broca’s Poor ; Effortful Good Poor Poor Left Posterior Inferior Frontal
Operculum

Wernicke’s Good ; Fluent Poor Poor Poor Posterior Parasylvian, Temporal

sounds but “word Operculum
salad”

Conduction Good ; Poor Good Poor Poor Posterior Parasylvian

Articulation

Transcortical motor Poor Good Good May be normal Frontally and Superiorly, extending
inward to striatum

Transcortical sensory Good Poor Good Usually normal Parietal, Temporal involving the
thalamocortical circuit

Global None or scanty; or Very poor Very poor Very poor Entire parasylvian area
expletive only
Neuro I
Mental Status & Cranial Nerve Examination
Dr. Dennis Naval
November 06, 2023

Visual Field
● Confrontation testing
Cranial Nerve I (Olfaction) ➔ In front of the patient at a
● Inspect for any nasal obstruction that distance of 50cm
may affect the result of the test
➔ clogged nose, congestion
➔ Ask the patient to directly look
● Instruct patient to close the eyes and into your eyes
cover one of the nostrils (one at a time)
➔ Check the periphery. Ask the
● Hold the vial in front of the open nostril patient, how many fingers am I
and instruct the patient to sniff the holding
odorant

● Ask the patient to identify the odor ➔ It should be done in the:

(usual odorants used: coffee, lemon, ➢ Upper quadrant
cigarette) ➢ Lower quadrant

● Avoid introducing irritating test materials ➔ Also do it to the other eye

(alcohol, ammonia) → stimulating
cranial nerve V
➔ Modification of this test is
Cranial Nerve II (Optic / Vision) wriggling fingers (ask the
● Order of test: least to most invasive patient to say “now” if he sees
● Test of visual acuity the wriggling fingers)

Visual Acuity
● Test one eye at a time
● “Bad eye” vs “good eye”
● Wear corrective lenses
● Chart should be held at least 14 inches
away / arm length
(Sorry Doc ikaw ang model hahaha)

➔ Pocket sized snellen chart can be used

JEC 13
 ➔ Importance of checking for the visual
field is actually a form of localization
Optic pathway
➔ Optic nerve converges to become the
optic chiasm. Some fibers of the optic
nerve decussate to the other side and
some remain on the same side
(temporal fibers) [A]
➔ While the nasal fibers, upon crossing
the optic chiasm go to the other side
Letter (A) If there is a lesion in the optic
nerve, there will be a Complete
blindness of the left eye
Letter (B) If there is a lesion in the optic
chiasm, it will produce a peculiar visual
field defect – Complete bitemporal
hemianopia (both the temporal sides
are blind while the nasal portion are
intact because of the crossing of the
fibers) ; caused by brain tumors:
Pituitary adenoma, Meningioma
Letter (D) Post-chiasmatic or after
crossing the optic chiasm, the lesion
becomes more of a Complete right
homonymous hemianopia (the right
portion of each one side of the eye is
affected). If the left optic tract is
involved, it will produce a right
homonymous hemianopia. The lesion
/ manifestation occur contralaterally
JEC
Letter (E) Usually produced by a lesion
in the inferior fibers (pie in the sky) –
Complete right superior
homonymous quadrantanopia
(common in lesion in temporal fibers)
Letter (F) lesion in parietal fibers of the
optic pathway – Complete right inferior
homonymous quadrantanopia (pie on
the floor)
Letter (G) If occipital lobe is affected, it
will produce Complete right
homonymous hemianopia
Cranial Nerve II & III
● Pupillary light reflex
➔ CN II (Afferent) ; sensory portion
➔ CN III (Efferent) ; motor portion
➔ Observe pupil of equal sizes, if
its round, if its reactive
➔ Check for Direct and
Consensual pupillary light reflex
How do pupils react simultaneously?
➔ Pupillary light reflex pathway wherein
when you shine a light on one eye, the
stimulus will travel all the way from the
brainstem reaching the pretectal nuclei
➔ The pretectal nuclei will stimulate both
sides of Eddinger-Westphal nucleus of
CN III (parasympathetic component)
14
 ➔ The right and left sides of ➔ Seen in Optic neuritis / Multiple sclerosis
Eddinger-Westphal nuclei generate
action potentials through the right and ➔ Paradoxical dilatation of the pupil
left oculomotor nerves, causing both indicates a defect in the afferent limb of
pupils to constrict the affected eye pupillary reflex

For testing the Cranial Nerve II and III:
● Shine the light from the periphery
● Observe for pupil reaction and do it on
the other side
Argyll Robertson Pupil
➔ There is a “light-near dissociation”
➔ “No to light, yes to accommodation”

● In doing the Indirect/ Consensual

pupillary light reflex, 2 penlights are
needed
➔ One is for tangential lighting, as
not to stimulate the pupil then
shine a light on the other side of
the eye but you’ll be observing
the reaction of the eye with the
tangential lighting

Adie tonic pupil

➔ Also has “light-near dissociation”

➔ Pupils constrict only to accommodation

and remains tonically constricted
(pupils re-dilates slowly)

Horner syndrome
➔ Think about the sympathetic pathway
➔ Oculosympathetic paralysis
➔ Triad of:
❖ Miosis
Pathologies of the Pupils
❖ Ptosis
❖ Anhidrosis
Marcus Gunn Pupil
➔ Or Relative afferent
➔ Lesion is anywhere along the
pupillary defect
sympathetic tract to pupillary dilatation
(RADP)

➔ There is a slow
pupillary response to
direct light stimulus /
“paradoxical
dilatation” /
Swinging flashlight
test

➔ Lesion in the optic nerve / retina

JEC 15
Ophthalmoscopy / Fundoscopy ➢ Arterial venous ratio of 2:3
➔ In some, before doing the ➢ No AV crossing
ophthalmoscopy, check your equipment
if the battery is working, is the light
sufficient to view the eye

➔ Keep both the examiner’s and patient

eye open

➔ Instruct the patient to focus on a distant

object

➔ If you are going at the right eye of the

patient, the examiner must use the
ophthalmoscope using the right eye as
well. Otherwise, it will not be effective

➔ Ophthalmoscope should be closed to

the examiner’s eyes. Your head and the Papilledema Pseudopapilledema
equipment should move together as one
unit

➔ While doing the test, inspect the optic

disk (note the color, shape, margin,
ratio)

➔ Check for the vessels, note for any
obstruction, the caliber, the arterial
venous ratio, presence of arterial
venous leaking and arterial light reflex
➔ Check for the background by inspecting
for pigmentation, hemorrhages
➔ Look for the macula
Primary optic atrophy
● Important to check the fundus of
patients with headache to check if the
headache is cause by space occupying
lesion like a tumor ; edema of the optic
disk – patient may be having increased
intracranial pressure (ICP) → Do a CT
Scan or MRI to rule out a possibility of a
brain tumor

Cranial Nerve III, IV, VI

● III - inspect for ptosis and primary gaze
➔ Primary gaze (midline, deviated)

● Test for extraocular movements

Normal view of the eye in fundoscopy ● Test for accommodation
➢ Disc margins should be sharp ● Patient might be having a
➢ Color should be yellowish-orange to Horner syndrome, (presence of
creamy pink ptosis)
➢ Round or oval in shape
➢ Cup to disk ratio should be less than
half

JEC 16
 ● Sensory:
● 1st, 2nd pic ➔ V1 to V3 using
- right eye is different
slightly deviated modalities
medially (touch,
(Esotropia) temperature)

● 3rd pic
- eye is deviated Corneal reflex
outward / laterally ● Usually not routinely
(Exotropia) done in conscious
patients (inconvenient
● 4th pic for the patient) ; if the
- (Hypertropia) eye is deviated upward patient has really a
(Hypotropia) eye is deviated downward problem in the CN V,
this might be done

● Usually done in unconscious

patient to see if the brainstem is
still intact

● Use wisp of cotton

● Usually done in patients with a

decreased sensorium
Cranial Nerve V
● Have motor & sensory function ● For conscious patient, instruct
● Motor part: Jaw closure the patient to look to the
➔ Ask the patient to take a bite opposite side
➔ Examiner to palpate the
muscles if its intact, if there’s no Cranial Nerve VII
atrophy
❖ Masseter Summary of Tests of Facial Muscles Innervated
❖ Temporalis by CN VII
❖ Medial pterygoid Examiner’s Observation Muscle tested
command
● Lateral jaw
“Wrinkle up your Inspect for Frontalis
movements forehead” asymmetry
➔ Try to oppose them
➔ Check the lateral “Look up at the
pterygoid ceiling”

“Close your eyes Inspect for Orbicularis

Inspection: Temples & tight & don’t let me asymmetry of oculi
Cheeks for atrophy of open them” wrinkles; try to pull
eyelids apart
temporalis & masseter
muscles “Pull back the Inspect for Buccinator
corners of your asymmetry of
Palpation: Masseter atrophy → clench teeth mouth, as in smiling nasolabial fold
together and unclench

JEC 17
 babalik yung dila paloob, baka mag-bias
“Wrinkle up the skin Inspect for Platysma
on your neck” asymmetry at malasahan

“Pull down hard on Cranial Nerve VIII

the corners of your
mouth” ● Otoscope
➔ Check the patency of
the canal in the eardrum

➔ Ensure that the external

auditory canals are
open and that eardrums
are normal

● Gross hearing
➔ Rubbing fingers
together beside one of
the patient’s ear then
the other ear

➔ Sometimes you can

place a watch near the
patient’s ear if he will
hear the ticking of the
clock
2nd picture - there is a problem in the
supranuclear (above the facial nerve nuclei) → Weber and Rinne Test
Central facial palsy (commonly seen in stroke ● To check if the
patients) patient has a
conductive or
3rd picture - there is a problem in the sensorineural
infranuclear → affected are upper and lower part hearing loss
of the face (Peripheral facial nerve palsy) seen ● Place the
in patients with Bell’s Palsy tuning fork on a
middle part on
● innervates the a bony
anterior 2/3 of the prominence
tongue (forehead or glabella)
● In testing, ask the ● Strike the tuning fork until it
patient to close their vibrates. Place it in the forehead
eyes and ask the patient if he can
● Introduce a taste hear the sound on both sides
stimuli (sugar or salt). Ideally, the taste equally or does it localize to one
stimuli should be mixed with powder / in ear
a solution for easy stimulation of the ● Normal findings: felt on both
tongue receptors ears
● You may use cardboard with the word ● Do the Rinne test to confirm
sweet or salty, then the patient will just ● Put the tuning fork in the
point out, kasi pag nag salita si patient, mastoid
● Normal findings: AC > BC

JEC 18
 to turn into the opposite side) then you
● Conductive hearing loss: BC > AC resist the force. Observe the muscle

Cranial Nerve IX, X Cranial Nerve XII

● Speech ● Inspection of tongue at rest
➔ Screen articulation during the ➢ Hemiatrophy
interview ➢ Fasciculation
➔ Ask the patient to pronounce: ➔ (good way to test if you
Ma, Ka, La are suspecting a patient
➔ Ma (Labial), Ka (Lateral), La with a motor neuron
(checking for lingual dysarthria) disease [ALS])

● Neurologic examination of palate and ● Test for motility and deviation

larynx ➔ Midline or deviated
➔ Inspect the tonsillar pillars for
asymmetry as they arch upward ➔ Checking the strength of
and medially to form the palate genioglossus muscle

● Tongue strength
➔ Ask the patient to press the
tongue against the cheek
➔ Examiner to try to resist the
tongue / force

- END -

● Gag reflex Reference:

➔ Introduce the stimulus on the ● Dr. Naval’s PPT and synchronous
side lecture

Cranial Nerve XI
● Inspect the SCM /
Sternocleidomastoid and
Trapezius muscle for
size and asymmetry

● Palpate the muscles at

rest and as they exert
their actions

● Ask the patient to

elevate the muscles &
push them downward as
the patient resist the
force

● In checking the SCM, (if

you’re going to check
the right, ask the patient

JEC 19