Practical physiology cns

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?
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)
❖ 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.
❖ 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
following picture?
✓ Temperature sensation
✓ 2 test tubes (ONE containing warm water AND the other containing cold water)
4 If the sensation of this picture is lost, which tract is being damaged? OR where do you ecpect to
find the lesion?
✓ Pain – Light touch – 2-point discrimination …….
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.
❖ 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.
❖ 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
following picture?
✓ Light touch sensation
✓ a piece of cotton wool OR fine hair brush
3 What is the tract that transmits this type of sensation?
✓ Dorsal column tract.
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
✓ 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
following picture?
✓ 2-point discrimination
✓ Calipers OR Compass OR Forceps
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
✓ 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).
❖ 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
following picture?
✓ Joint movement and position (Proprioception) (conscious kinesthetic)
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
following picture?
✓ Vibration sense.
✓ 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.
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
✓ 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:
❖ 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
following picture?
✓ Pressure sense.
✓ Metal rings of different weights
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
✓ 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
following picture?
✓ Stereognosis.
✓ 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.
❖ 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.
4. Tap on the patellar tendon with hammer sharply and strongly using
the hammer.
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.
* 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)

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.
❖ 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.
3. Identify the triceps tendon at its insertion on the olecranon above
the elbow.
4. Strike the triceps tendon with hammer sharply and strongly.
❖ 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
* Ask the patient to do *Reinforcement* ‫فوق‬ ‫بالتفصيل‬ ‫شرحناها‬ ‫دي‬ ‫و‬ Test for clonus
* 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.
The observation
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
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

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