The CS III Midterm Review

(Credits:Loic Ngassa &

Fernando Herrera)
The entire thing
 Head & Face Examination Page 1
HEAD & FACE EXAMINATION

1. Recall and identify the bones and joints of the skull and face and anatomy of superficial temporal artery

Mneumonic: Some Angry Lady Figured out PMS:

Superior thyroid artery, ascending pharyngeal artery, lingual artery,

facial artery occipital artery, posterior auricular artery Maxillary artery,

Superficial temporal artery.

 Head & Face Examination Page 2
2. Recall and identify lymph node groups associated with the head and face

3. Recall innervation skin, muscles and glands of the head and face.

Facial nerve originates from 3 nuclei. Nuclei tractus solitarius, motor nucleus

of CNVII, and superior salivatory nucleus. The nuclei tractus solitarius is responsible for taste in the anterior two thirds of the tongue. THe motor nuclei is

responsible for innerverting all the facial expression muscles. The superior salivatory nucleus is responsible for parasumpathetic innerveration of lacrimal

and salivatory glands. Fibers from the nucleus solitarius and the motor nucleus merge to become the geniculate ganglion at the end of the internal auditory

canal in the medial inner ear. The superior salivatory nuclei

fibers are not technically part of the geniculate ganglion but from that area they become the great petrosal nerve. The greater petrosal nerve sends fibers to the

pterygloid ganglion in which fibers from the Sympathetic plexus of the internal carotid artery are also present. THose fibers are called the lower petrosal nerve.

The Branchiontor fibers (Special Visceral Efferent) come from the geniculate ganglion to innervate the facial expression muscles.
 Head & Face Examination Page 3

4. Demonstrate competency in basic clinical techniques of

examination of the head and face

a. What is CHVOSTEK SIGN?

when you tap the facial nerve at the angle of the jaw, the facial muscles contract temporarily. Sign is positive in hypothyroidism, hypoparathyroidism,

hypovitaminosis d

b. Describe head and neck exam

Inspect all the bones of the skull for depression, notice hair coarsness and pattern, face should be symetrical in size, shape, color, and contour, symmetry. palpate all

lympnodes starting from occipital in the back to ppost auriculular to auricular nodes to tonsilar nodes, maxillary nodes, submental nodes, then anterior auricular nodes

again. Palpate temporal arterys and ascultate temporal arteries. Palpate and percuss frontal sinuses in orbit of eye and maxillary sinuses under zygomatic bones. No

pain should be present. Palpate temporomandibular join. Have patient move jaw to Asses motor function of trigemenal nerve. To test facial nerve Have pt raise eye brows,

bare teeth, smile broadly, puff out cheeks and keep mouth closed as you try to open it.
 Cranial Nerve Examination pg.1
Cranial Nerve Examination
▪recall and describe the structural and functional organization of cranial nerves including classification

Key points:
1. Cranial nerves 1 and 2 are come from the forebrain while 3-12 come from the brainstem
2. Some Say Mary Money But My Brother Says Big Boobs Matter Most (sensory vs motor)
3. Functional components:

A.General Somatic Afferent (GSA): Innerverates skeletal muscle, skin, tendons, joints for sensory sensation. CN5,7,9,10.

B.General Visceral Afferent ( GVA Convey bodily sensations (blood pressure/O2 content or chemorecption) CN9 Glossopharyngeal, CN10 Vagus

C.Special Visceral Afferent (SVA): mediate taste and smell. CN7 Facial, CN9 Glossopharyngeal, CN10 Vagus, CN1 olfactory

D. Special Sensory Afferent: CN2 Optic, CN8 Vestibular choclear

E. General Somatic Efferent (GSE): skeletal muscles. CN3,4,6,12

F. General Visceral Efferent (GVE): Smooth muscles and glands: 3, 7, 9 , 10

G.Special visceral Efferent (SVE): Skeletal muscles derived from pharyngeal arches: 5,7,9,10,11

▪ Describe how to perform cranial nerve examination properly within a primary care setting

a. Olfactory (CN1) have pt smell smoething through each nostril while the other is closed. Anosmia is lack of smell. Happens in head traumas, smoking, aging, sinus, use of
cocaine, and parkinsons

b. Optic (CN2) Inspect size of pupil. Inspect sclera and conjunctiva by having pt look up while you hold eyelids down. Check pupil reaction to light (direct and consensual).
Check field of vision test and visual acuity (snellens chart)

c. Oculomotor (CN3):

1. accommodation: Make pt focus on something (like a pencil) two feet out. Slowly bring the object closer to his nose. Pupils should constrict and converge.

2. Extraocular eye movements: Have pt focus on something 18 inches in front of him. Draw an H. watch for nystagmus or diplopia.
 Cranial Nerve Examination pg.2

3. Pupilary light reflex

d. Trochlear(CNIV) : Ask pt about experiences with double vision, have pt look at nose, look at pt head position (its cocked towards unaffect trochlear nerve side)watch for nystagmus

e. Trigeminal (CNV):

1. Pain/temp/touch in the face: Prick three area of trigeminal distribution, and use a cotton wool

2. Mastication: Ask pt to Open and close jaw against resistance. Ask Pt to perform grinding motion of teeth

3. Assessment of corneal reflex: stroke cotton swab in pt cornea. They should instinctively blink

f. Abducens (CNVI): have Pt look at the extreme lateral sides and look for nystagmus and diplopia

g. Facial (CN7):

1. Test power in muscles of facial expression: make pt raise eyebrows, blow out a candle, smile, puff their cheeks out and blow without letting air through, and show teeth

2. Test for taste in anterior two thirds of the tongue

h. Vestibulocochlear nerve (CN8):

1. Dolls head maneuver: have pt maintain his eyes on you while you make his head turn in different directions. If his eyes cant stay on you it indicates damage to the MLF

2. Caloric testing: When Pt is awake, pour warm or cold water in his ears and watch for the direction of nystagmus.COWS (Cold Opposite Warm Same)

3. Clinical Hearing test:

A.whisper somethign in pts ear and ask him to repeat. If hearing impairment suspected, do webers and rinnes test

B.Rinnes test: Put vibrating tuning fork on mastoid process (area beind ear). When pt cant hear it vibrating anymore bring it to the patients ear. In normal test pt should still be able to
hear vibrating. Air conduction>bone conduction. In conductive hearing pt wont hear tuning fork when its placed outside of ear due to middle ear damage. Bone conduction>air conduction.
In sensironeural deafness, Boneconduction=air conduction
 Cranial Nerve Examination pg.3

C. Webers test: place vibrating tuning fork in the midline of the forehead on head. In normal hearing, sound is present equally on both sides. In conductive hearing, affected ear hears
more. In sensorineural deafness sound is lateralized louder in normal ear.

i. Glossopharyngeal(CN9) and Vagus (CN10): Listen for hoarseness of pt voice, ask if they have trouble swallowing, ask patient to say ah and look for uvula deviation, pharyngeal
swelling, etc

j. Spinal Accesory (CN11): Ask pt to shrug shoulders against resistance and turn head both ways against resistance. This is checking trapezius and sternocleidomastoid

k. Hypoglossal (CN12): ask pt to protrude tongue and move it around. Uppermotor lesions
= contralateral tongue deviation to side of lesion
Lower motor lesion: ipsilateral deviation to side of lesion
 Sensory Examination, Motor Examination & Reflexes Page 1

Sensory Examination, Motor Examination & Reflexes

1. Define the fundamental process and objective underlying the conduct of a sensory and motor exam
2. Recall the basic anatomy of motor and sensory systems including concept of motor unit, dermatomal and myotomal maps of the body, sensory and motor tracts of spinal cord and
functions performed by various muscle groups of body
3. Describe the techniques for assessment of muscle tone, power, deep tendon reflexes and how to grade muscle power & reflexes in primary care setting
a. Muscle bulk: Look at the size and contour of muscles, especially in the calves, the hands, the shoulders, and thighs. Look to see if theyre concave or wasting away. Atrophy and
fasiculationsindicate lower motor neuron damage. Diseases of the muscles themselves do not cause fasiculations
b. Muscle tone: muscle tone is the slight tension present when a patient is relaxing his muscle. To test for muscle tone youre testing their resistance to passive stretches. The patient relaxes
and you flex and extend their fingers, wrist, albow, and arm, and monitor the resistance. Decreased resistance indicate disease of PNS, cerebellum, or spinal cord. If Increased resistance
present you must decide if its spastic (velocity dependent) or rigid (velocity independent resistance). Spastic resistance indicates upper motor neuron or corticospinal tract injusry. This
is usually caused by a stroke. Increased rigidity indicates Basal ganglia disease such as parkinsons. Pronator drift is also a muscle tone test. Have pt hold hands straight out with palms
up, usually they hold it will. If one arm is faced in and downards it indicates contralateral corticospinal tract diseases. Then you ask them to close their eyes and keep their arm where it
is as you briskly push it down.
Usually it goes back to normal spot but in cerebellar dysfunction it overshoots
c. Muscle power: apply resistance and have pt push against it. Grading scale is 1-5. 5=pt able to apply force against full resistance
4= able to apply some force against resistance 3=able to apply force against gravity
2=able to apply force when gravity is eliminated 1=barely a flicker of force felt
0=no muscle contraction
4. Describe the techniques for clinical assessment of the following conscious sensations in the upper and lower limbs; i.e., tactile sensation, pain, two point discrimination, vibration,
joint position sense, stereognosis and graphesthesia
a. Position test: Rombergs test descriminates between cerebellar ataxia and sensory ataxia. Pt closes eyes and if he cant keep his balance its a positive rombergs test and he could have
sensory ataxia or cerebellar ataxia. If he has trouble maining balance while his eyes are open or closed then its cerebellar ataxia
b. Pain: use a broken cotton swab and apply the lightest pressure needed to elicit pain. Ask pt if it feels dull or sharp. Analgesia is absence of pain. glesia=pain
 Sensory Examination, Motor Examination & Reflexes Page 2
c. Temperature: omitted if pain sensation normal. Otherwise use a heated or cooled tuning fork
d. Tactile sensation (light touch?) use a cotton swab and apply light pressure.
Anesthesia is absence of touch sensation
e. Vibration: take a tuning fork and place it in pts toe joints and ask them to tell you when vibration stops. Do this at different bony prominences. Vibration is one of the first
senses to go in diabetic neuropathy
f. Joint position sense: move the pts toes up and down. Have them close their eyes and tell you when their toe is up or down. Impairment to this indicates DCML damage
seen in tertiary syphilis, multiple sclerosis, b12 deficiency, and diabetic neuropathy
g. Stereognosis: stereognosis is the inability to identify an object by feeling it. To test this, place a familiar object in pts hand and have them tell you what it is. Astereognosis
refers to the inability of pt to identify the object. This is impaired in posterior column diseases.
h. Graphesthesia: graphesthesia is the inability to identify numbers. To test this draw a number on a pts hand and have them tell you the number. Inability to do this
indicates a sensory column injury
i.
5. Describe the techniques for deep tendon and cutaneous reflexes
a. Deep tendon: tapping the tendon of a muscle tests the neuromuscular junction, motor nerve fibers, spinal cord synapse, etc.
Bicep test (C5, C6): flex elbow and put finger over bicep tendon. Tap with reflex hammer and watch for arm flexion
Brachioradialis test (C5 C6): hold pt wrist down on leg and tap middle edial forearm watch for flexion at elbow and supination of forearm
Tricep test (C6,C7): Hold tricep up and have pt let it go limp. Tap triceps tendon just above elbow joint and watch for extension at the elbow
Patellar/Quadricep test (L2,L3,L4) tap patellar tendon just below the patella and watch for knee extension
Achilles tendon test (s1): tap achilles tendon and watch for plantar flexion
Watch for upper motor neuron and lower motor neuron signs. Reflexes graded from 1-4. 0 being no reflex, 1 being diminished or requiring reinforcement, 2 being normal, 3
being slightly hyperreflexia potentially indicative of disease, 4 being very brisk with clonus. To test for clonus, dorsiflex and plantar flex the foot a couple times, then hold
the foot in dorsiflexion. If there are clonic beats present (tremors) it indicates damage to corticospinal tract
b. Cutaneous reflexes:
A. Abdominal reflex: lightly stroke above t8 t9 and t10 on both sides in a diagonal motion towards the center of the abdomen, and below the umbilicus (below t10-12).
Watch for contraction. Present in both CNS and PNS nerve damage
B. Anal reflex: lightly scratch on anus and watch for contraction of external spchincter. Lack of contraction indicates damage to s2-3-4 reflex arc seen in cauda equina
syndrome
C. Plantar reflex(L5,s1): trace lightly on lateral aspect of heel up the foot and go across the ball. Normal reflex = plantar flexion. Positive babinskis= dorsiflexion

6. Accurately record findings on motor and sensory examination

 Meningeal signs, Radiculopathies, Winging of scapula & Flapping tremor Meningeal signs, Radiculopathies, Winging of scapula & Flapping tremor pg.1

At the end of this lab-session students should be able to evaluate patients for signs of-

1. Meningeal irritation

a. Neck mobility/Nuchal Rigidity: have pt lay down and passively flex neck to touch chin to chest. Inflammation causes resistance

b. Kernig's test: have pt lay down. Lift leg till knee is at a 90 degree angle. Extend knee.
Pain in lower back and resistance to knee straightening=positive kernigs

c. Brudzinski's test: have pt lie supine. Passively flex their neck. Bening of knee or tension at hip= positive brudzinski.

2. Cervical and lumbar radiculopathies

Radiculopathy is compression of nerves at root. Could be due to inflammation, herniated disk, neighboring muscle tone, bone, cartilage, etc. Clinical presentations are pain, paresthesia, and
muscle weakness

Lower Limb myotomes:

a. Hip flexion: femoral nerve (L1, L2)
b. Hip extension: Inferior gluteal nerve (L5, S1)
c. Hip abduction: superior gluteal nerve (L4, L5)
d. hip adduction: obturator nerve (L2, L3, L4)
e. Knee flexion: Sciatic nerve(L5, S1)
f. Knee extension: Femoral (L3, L4)
g. Dorsiflexion: Deep peroneal ( L4)

Upper Limb myotomes:

a. Deltoid: Axillary nerve (C5, C6), shoulder abduction
b. Bicep + brachioradialis: musculocutaneous+radial nerve (C5, C6), elbow flexion
c. Parlmaris longus: Median + ulnar nerve (C7, C8) wrist flexion
d. Wrist extension: Radial nerve (C7)
e. Thumb extension: Posterior interosseous nerve (C7)
f. Thumb opposition: Median nerve (T1)
g. Finger flexion: Median+ulnar nerve (C7)
h. Finger extension: posterior interosseous muscle (C7)
i. Finger abduction: Ulnar nerve (T1)
 Upper limb dermatomes: Meningeal signs, Radiculopathies, Winging of scapula & Flapping tremor pg.2

a. Base of neck to upper shoulder (C3,C4)

b. Lateral arm: C5
c. Lateral forearm+thumb: C6
d. Middle finger+dorsal surface of forearm (C7)
e. Pinky+medial forearm (C8)
f. Middle of forearm to axilla (T1)
g. Some upper medial arm and skin of axilla (T2)
A. Cervical radiculopathy tests:

1. Sperlings maneuver to check for disk herniation: have pt hyperextend and flex neck on both sides. Positive sign if he feel radicular pain

2. Motor Exam: check for muscle wasting, muscle tone, grip strength,

3. Sensory Exam: pain, temp, two point descrimination

4. Reflexes: bicep, tricep, supinator

B. Lumbar radiculopathy tests:

1. Motor exam

2. Sensory

3. Reflex: knee, ankle, babinski reflex

4. Check for posture: pt body leaning towards contralateral to herniation

5. Dorsal column signs

C. Winged Scapula test

D. Tremor/ Asterixis test:

Have pt extend wrist. Wringing like tremors indicate hepatic encephalopathy.

3.Mononeuropathies. E.g. “Winging” of scapula

Have pt stand against the wall in a pushup position. If the scapula is winged, the test is positive. Indicates long thoracic nerve damage.
 Meningeal signs, Radiculopathies, Winging of scapula & Flapping tremor pg.3
4. Examining for low back pain

1. Inspection (pt standing): look for deformities , lack of symmetry, spinal alignment. Pelvic obliquity

2. Palpation (pt standing): sciatic nerve pain, nodes, muscle spasms, trigger zones, compress iliac crests for sacroiliac tenderness

3. Spinal column movements (pt standing): flexion, extension, rotation, side bending

4. Pt kneeling: ankle jerk reflex, test sensation on calf and sole

5. Pt sitting: Knee jerk, measure calf circumference

6. Straight Leg Test (pt lying supine):

lift leg 30-70 degrees and check for pain. Test positive if pain is present. Pain in between 30-70 degrees indicates L4-S1 herniation. Pain below 30 degrees indicates
spondylolisthesis, gluteal abscess, disc protrusion or extrusion, tumor of the buttock, acute dural inflammation, a malingering patient. Pain above 70 degrees indicates tightness of
gluteal muscle, hamstrings, hip capsule, or pathology of hip or sacroiliac joints. To increase test sensitivity, do Bragaads test (while pt leg is lifted, dorsiflex the toes)

7. Aortic aneurysm test (pt supine):

A.flex thigh and extend knee (pts leg should be at 90 degrees) while dorsiflexing toes.
B. Palpate abdomen and listen for bruit (AA indication)
C. Palpate for peripheral pulses and check extremity temperature
D. palpate for lumbar lordosis
E. measure leg lengths (ASIS to medial malleolus)
F. test sensation and motor power in leg
G. look for erector spinae tenderness

8. Renal tenderness (Pt prone): have them extend their spine and palpate for renal tenderness or spasm
5. Flapping tremor
Have pt extend wrist. Wringing like tremors indicate hepatic encephalopathy.
 Dermatomes (Nerves AREAS SUPPLIED
dermatomes C2 Front part of the ear per the picture

C3 (front & back of neck)&C4 Supplies skin over base of neck extending laterally over
(shoulder) shoulder

C6 (thumb) Supplies forearm laterally and the thumb

C8 Supplies little finger and medial aspect of hand and forearm

T4 Nipple line

T10 Umbillicus

L1 Inguinal

L2 Anterior Thigh

L4 Medial Calf/knee

L5 Anterior ankle and foot/lateral calf

S5 Perianal

References: History and Physical Examination, A Common Sense Approach by Mark Kaufmann (2014)
 Spinal segments for motor movements Spinal segments for muscle stretch reflexes
Upper Limb (includes muscle strength), Lower Limb (includes muscle strength) Muscle Stretch Reflexes
Actions of group of muscles Spinal segments in green, Major Nerve Actions of group of muscles Spinal segments in green, Major Nerve Stretch Reflexes Spinal segments
Root/Myotome in Red Root/Myotome in Red
Shoulder abduction (Deltoid) C5, 6 – Axillary n. Hip flexion (Ilio-psoas) L 2, L3, L4 – Femoral n. Biceps reflex (C5, C6)
Elbow flexion (Biceps & C5, 6 – Musculocutaneous Hip extension (Gluteus maximus) S1 - Inferior gluteal n. Triceps reflex (C6, C7)
Brachioradialis)
Elbow extension (Triceps) C6, C7, C8– Radial n. Hip adduction (Adductors) L2, L3, L4 – Obturator n. Brachioradialis reflex (C5, C6)

Wrist flexion (Flexor Carpi C7,C8– Ulnar & Median n. Hip abduction (Gluteus medius, minimus) L4, L5,S1 – Superior gluteal n. Quadriceps (patellar) (L2, L3, L4)
Ulnaris, Flexor Carpi Radialis, reflex
Flexor Digitorum Superficialis,
palmaris longus)

Wrist extension (extensor carpi C6, C7, C8 – Radial n. Knee flexion (Hamstrings) L4,L5, S1,S2 – Sciatic n. Achilles (ankle) reflex (primarily S1)
radialis longus and brevis,
extensor carpi ulnaris)

Thumb extension (Extensor C7– Posterior interosseous n. Knee extension (Quadriceps) L2,L3, 4 – Femoral n.
pollicus longus, Extensor
pollicus brevis)

Thumb opposition (Opponens C8, T1 – Median nerve Dorsiflexion (Tibialis anterior) L4,L5 – Deep peroneal n. Muscle stretch reflex grading
pollicis)

Finger flexion (Flexor C8 – Median & Ulnar nerves Plantar flexion (Gastrocnemius, Soleus) S1– Tibial n. 0 Reflex absent
digitorium superficials)
Finger extension (extensor C7,C8 – Radial nerve Great Toe extension (Extensor Hallucis L5,S1 – Deep peroneal n. +1 Somewhat diminished, or requires reinforcement
digitorum) Longus, Extensor Digitorum Longus)

Finger abduction (dorsal C8, T1 – Ulnar n. Great Toe plantarflexion (flexor hallucus S1,S2,S3 +2 Average; normal
interosseous, abductor digiti longus)
minimi)

abduction of the thumb— C8, T1- median nerve Inversion (Tibialis posterior) L4, 5 – Tibial n. +3 Brisker than average; possibly but not necessarily
abductor pollicis brevis indicative of disease
Test the grip C7, C8, T1 Eversion (Peroneus longus & brevis) L5, S1 – Superficial peroneal n. +4 Very brisk, w/ clonus (rhythmic oscillations btwn
flexion & extension)
Muscle strength is graded on a 0 to 5 scale

5—Active movement against full resistance without evident fatigue. This is normal muscle strength. References: History and Physical Examination, A Common Sense Approach by Mark Kaufmann (2014)
Bates' Guide to Physical Examination and History Taking (2012)
4—Active movement against gravity and some resistance Snell's Clinical Anatomy by Regions (2018)
3—Active movement against gravity
2—Active movement of the body part with gravity eliminated (planar motion)
1—A barely detectable flicker or trace of contraction
0—No muscular contraction detected
So “all normal” subcategory scores would
be-> E4, M6, V5

(E4+ M6 + V5)= 15
Total Coma Score of 15.
16