1. JOSE S. SANTIAGO M.D.

2. Glasgow Coma Scale

4. Cranial Nerves  12 pairs of nerves that mostly serve the head and neck  Numbered in order, front to back  Most are mixed nerves, but three are sensory only

5. Distribution of Cranial Nerves Figure 7.21

6. Cranial Nerves I Olfactory nerve – sensory for smell II Optic nerve – sensory for vision III Oculomotor nerve – motor fibers to eye muscles IV Trochlear nerve – motor fiber to eye muscles (superior oblique m.)

7. Cranial Nerves V Trigeminal nerve – sensory for the face; motor fibers to chewing muscles VI Abducens nerve – motor fibers to eye muscles (lateral rectus m.) VII Facial nerve – sensory for taste; motor fibers to the face VIII Vestibulocochlear nerve – sensory for balance and hearing

8. Cranial Nerves IX Glossopharyngeal nerve – sensory for taste; motor fibers to the pharynx X Vagus nerve – sensory and motor fibers for pharynx, larynx, and viscera XI Accessory nerve – motor fibers to neck and upper back (Trapezius and Sternocleidomastoid) XII Hypoglossal nerve – motor fibers to tongue

9. Examination of the cranial nerves 1.Cover one nostril and smell the substance. Tell me what it smells like. 2.I would like to check your vision. Read the chart in front of you please. 3.I am going to assess what you can see out of the corner of your eye. Look at the middle of my face and point at my finger when I wiggle it.

10. Examination of the cranial nerves 4.Now I need to shine a light in your eyes to look at the reaction of the pupils. Keep looking straight ahead. 5.Now I’m going to assess the movement of your eyes. Hold your head still and follow my finger just by moving your eyes.

11. Examination of the cranial nerves 1.Now I’m going to assess the feeling on your face. I’m going to touch the skin on your face very lightly with some cotton wool. Say “yes” when I touch your face and keep your eyes closed. 2.Now I want to examine the strength in the muscles of your face. Close your eyes very tightly. Don't let me open them. Now purse your lips together very tightly. Stop me from opening them.

12. Examination of the cranial nerves 3.Now I’m going to test your hearing. Tell me if you can hear what I’m whispering into each ear in turn. “17”, “hello” 4.Now I want to examine the muscles at the back of your mouth. Open your mouth wide and “Aahhh”. 5.I’m going to test the feeling at the back of your mouth. Tell me if you feel a gentle touch of the wooden stick.

13. Examination of the cranial nerves 6.Open your mouth wide again and stick your tongue out. Wiggle your tongue quickly from side to side. 7.Shrug your shoulders against me and turn your head to one side, then turn it to the other side so that I can see the strength of the muscles in your neck.

14. Typical symptoms I have a bad headache. I have a throbbing headache. I feel dead-tired. I have poor balance. My memory is going. I have a terrible memory. I have difficulty concentrating.

15. Typical symptoms I have double vision. I have difficulty focusing. My vision seems blurred. I have zigzag lines in front of my eyes. My eyes hurt in bright light. I have difficulty speaking. I cannot get the words out clearly.

16. Typical symptoms I have difficulty swallowing. Food seems to stick in my throat. My neck feels stiff. My neck clicks. My hands are shaky. I have no strength in my fingers. I can’t pick up a cup anymore.

17. Typical symptoms My coordination is poor especially in my arms. My arms feel weak. I feel pins and needles in my hands. My leg drags. I tend to catch my foot when I walk. My foot is numb.

18. Typical symptoms My leg feels stiff. Both my legs feel stiff. I cannot feel my feet. My toes feel numb. I have difficulty passing water. I find it difficult going to the toilet. I have sudden blackouts.

19. Typical symptoms I lose consciousness without warning. Someone said that I had a convulsion. Someone said that I had a fit. Someone said that I had a seizure. My arm twitches for no reason. My hand jerks without warning. I seem to go vacant for short period of time.

20. Typical symptoms My muscles feel stiff. My muscles are sore. My muscles are painful. I’m losing weight. My muscles are getting thin. I’m aching all over. My face is twisted to one side.

21. Typical symptoms My face seems to get weak on one side. My mouth is drooping.

22. Examination of the arms (Motor) 1.Stretch your arms out on both sides to show me the strength of your shoulder muscles. 2.Pull your elbows down toward both of your sides. 3.Test each of your arms in turn by making a fist and pull the fist up towards your shoulder while I try to stop you.

23. Examination of the arms (Motor) 4.Straighten your arm out of the elbow while I try to stop you. Do that again on the other side. 5.Holding both arms in front of you, make two fists and pull your wrists backwards. Stop me from moving the wrists. 6.Bend your wrists downwards and upwards while I try to stop you.

24. Examination of the arms (Motor) 7.Stretch all your fingers out straight and stop me from bending your fingers. 8.Curl your fingers up tightly into my fingers and make a strong grip. Keep the fingers tightly curled up. 9.Squeeze my fingers as tight as you can in both hands. 10.Spread your fingers wide apart while I test the small muscles in the hand. Stop me from pushing the small fingers together.

25. Examining skin sensation (arms) Keep your patient’s eyes closed during the examination. 1.I’m going to touch the skin of your arms lightly in different places using a cotton wool. Say “yes” every time I touch your skin. 2.Now I’m going to test the same feeling using the tip of a pin instead of a cotton wool. Say “yes” every time you feel the touch of the pin.

26. Examining skin sensation (arms) Keep your patient’s eyes closed during the examination. 3.Tell me if you can feel the vibration of the tuning fork. 4.I’m going to assess whether you can feel your finger being moved up and down. I’m going to hold your little finger and move it down and up slowly. Say “up” or “down”.

27. Examination of the Legs (Motor) 1.I’d like to assess your walking. Let me see you walk around. Just slowly. 2.Relax your legs while I move them around slowly. Lift your leg up straight while I try to hold it downward. 3.Bend the knee and keep it bent. Stop me from straightening it. Now, kick the leg straight against me!

28. Examination of the Legs (Motor) 4.Flex your foot up towards your face and stop me from pulling it down. 5.Turn the foot so that the sole of the foot is facing the other foot and keep it there. 6.Turn the sole of the foot outwards and keep it there. Stop me from straightening the ankle.

29. Examination of the Legs(Sensory) 1.I am going to touch your legs with a cotton wool. Tell me if the touch feels the same on the left leg as it does on the right. 2.I am going to test your sensation using a pinprick. Tell me if there is a clear difference between the touch of the pin and the cotton wool.

30. Examination of the Legs(Sensory) 3.Can you feel the vibration of the tuning fork when I touch it on to the bones of your ankle? 4.I am going to wiggle your big toe up and down. Close your eyes and say “up” when you feel I move your toe up.

31. Deep Tendon Reflexes Biceps Reflex- The biceps reflex is elicited by placing your thumb on the biceps tendon and striking your thumb with the reflex hammer and observing the arm movement.

32. Deep Tendon Reflexes Triceps Reflex- The triceps reflex is measured by striking the triceps tendon directly with the hammer while holding the patient's arm with your other hand.

33. Deep Tendon Reflexes Patellar Reflex- With the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer.

34. Deep Tendon Reflexes Ankle Reflex- The ankle reflex is elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion

35. Deep Tendon Reflexes Plantar Reflex- The plantar reflex (Babinski) is tested by coarsely running a key or the end of the reflex hammer up the lateral aspect of the foot from heel to big toe

36. Traumatic Brain Injuries Concussion  Slight brain injury  No permanent brain damage Contusion  Nervous tissue destruction occurs  Nervous tissue does not regenerate Cerebral edema  Swelling from the inflammatory response  May compress and kill brain tissue

37. Hematoma- accumulation of blood in a space Epidural hematoma- blood in the epidural space 37

38. Subdural hematoma- blood in the subdural space 38

39. Types of Brain Hematoma

40. Cerebrovascular Accident (CVA)  Commonly called a stroke  The result of a ruptured blood vessel supplying a region of the brain  Brain tissue supplied with oxygen from that blood source dies  Loss of some functions or death may result