MENINGEAL SIGN

Dr. Steven, M.Si .Med, Sp.S

 Meningeal sign
1. Neck stiffnes
2. Kernig`s sign
3. Brudzinski I (neck sign)
4. Brudzinski II (contralateral leg sign)
5. Brudzinski III (cheek si gn)
6. Brudzinski IV (symphisis sign)
Neck Stiffnes
+ : resistance

Kernig`s sign
+ : < 135º pain or resistance /
Contralateral leg flexion
 Brudzinski I-IV
+ : leg flexion

Neck sign Contralateral leg sign

Cheek sign : press os zygomaticum

Symphisis sign : press symphisis pubis
CRANIAL NERVES
EXAMINATION

Dr. Steven, M.Si .Med, Sp.S

 Olfactory Nerve (I)

Examination Technique :
• patient should not be able to see
the stimulus
• test one nostril at a time with the
opposite side occluded
• stimulant should be non -irritating
(avoid stimulation of N. V)
• Tobacco, tea, coffee, etc
Normal Response:
· to perceive the scent with either nostril

Abnormal Response:
1. a unilateral loss is more likely to be significant
and may imply a structural brain lesion af fecting
the olfactory bulb or tract, but could also be due
to local causes such as a deviated septum or
blocked nasal passage
2. bilateral loss can occur with rhinitis or damage
to the cribriform plate
• Anosmia
• Hipo / Hiperosmia
• Parosmia
• Kakosmia
• Halusinasi (epilepsy)
• Foster kenedy: Anosmia ipsilateral
Atrofi optic ipsilateral
Papil Oedema contralateral
Optic Nerve (II)

Examination :
1. Visual Acuity
2. Visual fields
3. Color
4. Fundoscopy
 Visual Acuity

Examination Technique :
• each eye is tested separately
• Improvement of vision through a
pinhole indicates that the error is
refractive.
• Using a Snellen chart ( …/6), count
fingers (…/60), hand movements
(1/300), perceive light (1/~)
 Visual Fields
Gross testing by Confrontation
Examination technique :
• the examiner compares the patient’s visual field
to their own and assumes that theirs is normal
• test each eye separately
• the examiner places himself approximately 30 –
40 cm away from the patient
• advises the patient to look directly at the
examiner’s eye
• The test object (either a wiggling finger, one or
two fingers, or a white pin head) is presented
equidistant from the patient’s and examiner’s
eye
• the patient is asked either to state the num ber of
fingers or say "yes" when they first see a moving
target
GOLDMANN Perimeter

Campimeter
 Color

• Use Ishihara chart

• Color woll yarn
 Fundoscopy

• Fundoscopy is the assessment of the fundus using an

ophthalmoscope

Normal papil Edema papil

Oculomotor (III), Trochl ear (IV), Abducens
(VI) nerves
• Observe eyelid
- Palpebra superior retraction
- Ptosis
- Blink
- Open and close the eye
• Observe pupil
- Size and shape pupil
- equality
- Reflex
• Observe eye movement
 Observe eyelid
• Palpebra superior retraction if it`s too much elevated
• Normal retraction if can`t see white sclera and limbus
cornea superior from palpebra superior edge
• Ptosis is present if the eyelid droops over the pupil when
the eyes are fully open
• Frequency blink of eyes : 15x/minute
 Observe pupil

• Size of pupil
measure the Ø of each pupil in mm
• Shape (regular or not)
• Equality
Isocoria or not
• Reflex
- Direct light ref lex and consensual reflex
- Accommodation reflex
 Observe eye movement
• Steady the patient`s head
• ask him to follow an object held at arm`s length.
• Observe the full range of horizontal and vertical eye
movements
• Conjugate movement
Note the ability of the eyes to move together
(conjugately) in horizontal or vertical direction

• Nystagmus
 Trigeminal nerve (V)

• N. V à sensory V1, V2, V3

motor component V3
• Examination: sensory
motor
reflex
• Sensation is tested to light touch
with a cotton wisp
• Temperature with a cold tuning
fork
• Pain with a disposable pin
• Compare side to side
• Motor à muscle of mastication (m. temporalis, m.
masseter, m. pterigoideus)
• Ask patient to clamp jaws together and palpate the
temporalis and masseter muscle
• Ask the patient to open their mouth and repeat this
against resistance. Obeserve f or any deviation of the jaw
to one side
• With open mouth, ask the patient to protrude their jaw to
either side against resistance
 Reflex

Corneal ref lex

Afferent à opthalmicus nerve (N. V1)

Efferent à Facial nerve (N. VII)

Examination Technique:
1. Explain to the patient what you will be doing
2. Avoid a visual threat
3. Stimulate the limbus cornea by touching with a wisp of
cotton
4. Observe the direct (same) eye and consensual
(opposite eye) blink in response to corneal stimulation
5. Repeat the opposite side
Jaw jerk

Afferent à sensory N. V3
Efferent à motor N. V3

Examination Technique:
1. Ask patient to rwelax jaw
2. Place our index f inger over the middle of patient`s chin
with mouth slightly open
3. Tapped with a reflex hammer
4. Slight jerk à normal
Increased jerk à bilateral upper neuron lesion
 Facial nerve (N. VII)

• The anterior two-thirds of the tongue

• Tested using salty, bitter, sour or sweet solutions.

Examination Technique
1. the tongue is protruded and held gently by the examiner
2. a small sample of solution is applied to one side of the
anterior two-thirds of the tongue using a cotton tipped
applicator
3. with the tongue still protruded, asked to point to a sign
displaying one of the four possible tastes
4. then given a small sip of water and the test is repeated
with the others
N. VII à the muscles of facial expression

Examination Technique :
1. observe for asymmetry – widening of the palpebral
fissure or flattening of the nasolabial f old
2. observe for involuntary facial movements
3. ask the patient to wrinkle their forehead, close their eyes
tightly, show their teeth, puff out their cheeks and appose
their lips

Normal : symetric
Abnormal :
Infranuclear / perifer à weakness of entire side
of the face
Supranuclear / central à weakness of lower muscles
of facial expression
 Vestibulocochlear Nerve (n. VIII)
Hearing and vestibular function

Examination Technique:
1. Hearing (n. cochlear)
- mask the opposite ear and whisper numbers. The
patient should not be able to read your lips. Ask the
patient to repeat the numbers
- compare air versus bone conduction using the Rinne
test
 - test for lateralization using the W eber test

2. Vestibular function (n. vestibular)

- Observe nystagmus
- Caloric test
 Glossophariyngeal nerve (N. IX)
Vagus Nerve (N. X)
• Tested together
• Swallowing, phonation, guttural, &
palatal articulation
• N. IX à 1/3 posterior tongue

Examination Technique:
• check palatial elevation by having
the patient sustain an " ah." When
observing palatal movement, look
at the palate rather than the uvula
• assess the gag reflex by gentling stroking the sof t palate
on each side
• swallowing can be assessed by giving the patient a sip
of water and observing them swallow
• listen to the patient ’s speech

Normal response : the palate should elevate symmetrically,

Gag reflex +
Abnormal response: with unilateral palatal weakness, the
palate fails to elevate on the weak side and the gag
reflex will be absent on that side
 Accessory Nerve (N. XI)
The trapezius and sternocleidomastoid muscle

Examination Technique:
1. observe for atrophy or asymmetry of the muscles
2. observe for quickness of shoulder shrug and ask the
patient to shrug their shoulders against resistance
3. ask the patient to turn their head to the opposite side
against resistance, both watch and palpate the
sternocleidomastoid muscle
 Hypoglossal Nerve (N. XII)

Motor to the tongue

Examination Technigue:
• observe for tongue atrophy or
enlargement
• There is fasciculation or not
• ask the patient to protrude the tongue
• ask the patient to push the tongue into
each cheek
Normal response:
the tongue should be able to protrude relatively straight.
Minimal degrees of deviation (i.e. only millimeters)
affecting only the tip are insignif icant.
Abnormal response:
the tongue deviates towards the weak side
Infranuclear lesion à atrophy / fasciculation