- The bare minimum: Check the fundi, visual fields (VFs), pupil size and reactivity, extraocular movements, and facial movements.
Occlude each nostril sequentially and ask pt to gently sniff and identify a mild test stimulus, such as toothpaste or coffee.
Check visual acuity with eyeglasses or contact lens correction using a Snellen chart or similar tool. Map VFs by confrontation testing in each quadrant of VF for each eye individually. The best method is to sit facing pt (2-3 ft apart) and then have pt cover one eye gently and fix uncovered eye on examiner's nose. A small white object (e.g., a cotton-tipped applicator) is then moved slowly from periphery of field toward center until seen. Pt's VF should be mapped against examiner's for comparison. Formal perimetry and tangent screen examination are essential to identify small defects. Optic fundi should be examined with an ophthalmoscope, and the color, size, and degree of swelling or elevation of the optic disc recorded. The retinal vessels should be checked for size, regularity, arteriovenous (AV) nicking at crossing points, hemorrhage, exudates, and aneurysms. The retina, including the macula, should be examined for abnormal pigmentation and other lesions.
Describe size, regularity, and shape of pupils; reaction (direct and consensual) to light; and convergence (pt follows an object as it moves closer). Check for lid drooping, lag, or retraction. Ask pt to follow your finger (and report any double vision) as you move it horizontally to left and right and vertically with each eye first fully adducted then fully abducted. Check for failure to move fully in particular directions and for presence of regular, rhythmic, involuntary oscillations of eyes (nystagmus). Test quick voluntary eye movements (saccades) as well as pursuit (e.g., follow the finger).
Feel the masseter and temporalis muscles as pt bites down and test jaw opening, protrusion, and lateral motion against resistance. Examine sensation over entire face. Testing of the corneal reflex is indicated when suggested by the history.
Look for asymmetry of face at rest and with spontaneous movements. Test eyebrow elevation, forehead wrinkling, eye closure, smiling, frowning; check puff, whistle, lip pursing, and chin muscle contraction. Observe for differences in strength of lower and upper facial muscles. Taste on the anterior two-thirds of tongue can be affected by lesions of the seventh CN proximal to the chorda tympani.
Check ability to hear tuning fork, finger rub, watch tick, and whispered voice at specified distances with each ear. Check for air versus mastoid bone conduction (Rinne) and lateralization of a tuning fork placed on center of forehead (Weber). Accurate, quantitative testing of hearing requires formal audiometry. Remember to examine tympanic membranes.
Check for symmetric elevation of palate-uvula with phonation (“ahh”), as well as position of uvula and palatal arch at rest. Sensation in region of tonsils, posterior pharynx, and tongue may also require testing. Pharyngeal (“gag”) reflex is evaluated by stimulating posterior pharyngeal wall on each side with a blunt object (e.g., tongue blade). Direct examination of vocal cords by laryngoscopy is necessary in some situations.
Check shoulder shrug (trapezius muscle) and head rotation to each side (sternocleidomastoid muscle) against resistance.
Examine bulk and power of tongue. Look for atrophy, deviation from midline with protrusion, tremor, and small flickering or twitching movements (fasciculations).
- The bare minimum: Look for muscle atrophy and check extremity tone. Assess upper limb strength by checking for pronator drift and strength of wrist or finger extensors. Test for lower limb strength by asking pt to walk normally and on heels and toes and testing power of the toe extensors.
Power should be systematically tested for major movements at each joint (Table 183-1 Muscles That Move Joints). Strength should be recorded using a reproducible scale (e.g., 0 = no movement, 1 = flicker or trace of contraction with no associated movement at a joint, 2 = movement present but cannot be sustained against gravity, 3 = movement against gravity but not against applied resistance, 4 = movement against some degree of resistance, and 5 = full power; 4 values can be supplemented with + and - signs to provide additional gradations). Speed of movement, ability to relax contractions promptly, and fatigue with repetition should all be noted. Loss in bulk and size of muscle (atrophy) should be noted, as well as the presence of irregular involuntary contraction (twitching) of groups of muscle fibers (fasciculations). Any involuntary movements should be noted at rest, during maintained posture, and with voluntary action.