Read Assigned Chapters, lecture Discussion Notes, Powerpoints, Lab Manual Chapter Activities and Online questions

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Exam 3 Study Guide

Read Assigned Chapters, lecture Discussion Notes, Powerpoints, Lab Manual Chapter Activities and Online questions.


Know the order of the exam

Central Vision—how tested and how scored.

-snellen alphabet chart is the most commonly used and accurate measure of visual acuity

-place Snellen chart in well-lit spot at eye level

-position person exactly 20 feet from the chart

-cover one eye at each time while performing the test

-have them read the chart to the smallest letters possible

-normal score is 20/20

-20/30 is worse vision whereas 20/15 is better vision

Peripheral Vision—how tested and interpreted

-confrontation test it a gross measure of peripheral vision

-position yourself at eye level with person about 2 feet away

-have them cover one eye and look straight at you with the other hand

-cover your own eye on the same side

-hold a finger up midline between you both and slowly advance it in from the periphery

-have the person say now when they can see it in their vision

-estimate angle between the anteroposterior axis of the eye and the peripheral axis where the object is first seen

-normal results are about 50 degrees upward, 90 degrees temporally, 70 degrees down, and 60 degrees nasally

-in older adults this screens for glaucoma

Know the eye anatomy

External Eye:

-Eyes surrounded by orbital cavity, fat & muscles

-Eyelids: movable shades; Upper larger & more mobile

-Eyelashes: short hairs in double or triple rows, curve outward from lid margins

-Palpebral fissure: opening between eyelids

-Canthus: corner of eye

-Tarsal plates: within upper lid, strips of CT; Contain meibomian glands, modified sebaceous glands, secrete oily lubricant onto lids

-Conjunctiva: transparent protective covering

-Palpebral conjunctiva: lines lids, is clear, with many small blood vessels

-Bulbar conjunctiva: overlays eyeball, white sclera shows through; at limbus, conjunctivae merge with cornea

-Cornea: clear, dome-shaped surface

-lacrimal apparatus (see below)


-6 muscles attach sclera to orbit & direct eye

-4 rectus muscles: superior, inferior, lateral & medial

-2 oblique muscles: superior & inferior

-Conjugate movement

-Parallel axes are important because human brain has a binocular, single-image visual system

Internal Eye:

-eye has 3 coats:

1. the outer sclera: tough, protective; continuous with the cornea anteriorly that covers the iris and the pupil; the cornea is part of the refracting media of eye, bending incoming light rays so that they will be focused on the inner retina

2. middle layer choroid: delivers blood to retina

3. inner layer retina: visual receptive layer of eye which light waves are changed into nerve impulses; the structures visible are the optic disc, retinal vessels, general background, and macula

-optic disc: area in retina where fibers from retina converge to form the optic nerve

-retinal vessels: normally include a paired artery and vein extending into each quadrant

-macula: slightly darker pigmented region surrounding the fovea centralis which is the sharpest, keenest vision; the macula receives and transduces the light from the center of the visual field

-pupil: round and regular;

-lens: biconvex disc that is posterior to pupil; serves as a refracting medium keeping the viewed object in continual focus on the retina; it bulges when focusing on near objects and flattens when focusing on far away objects

-anterior and posterior chambers: contains the clear, watery aquaeous humor that is produced continually by the ciliary body; the continuous flow of fluid delivers nutrients and removes waste from surrounding tissues
how tested, what is it tested for, and possible abnormalities

Accommodation: adaptation of eye for near vision

    • Accomplished by increasing curvature of lens

    • Lens cannot be observed, but the components of accommodation that can be observed are:

      • Convergence of the axes of eyeballs

      • Pupillary constriction

Test near vision: For those who report difficulty reading

    • Test with handheld vision screener with various sizes of print, e.g., a Jaeger card

      • Hold card in good light 14 inches from the eye; this distance equals print size on 20-foot Snellen chart

      • Test each eye separately, with glasses on

      • Normal result is “14/14” in each eye, read without hesitancy & without moving card closer or farther away

      • When no vision screening card is available, ask to read from a magazine or newspaper

Corneal light reflex, the Hirschberg test

      • Assess parallel alignment of eye axes

      • Direct patient to stare straight ahead as you hold light about 12 inches away

      • Note reflection of light on corneas; should be in exactly same spot on each eye

cover test

cardinal postion test

      • In addition to parallel movement, note any nystagmus

      • Mild nystagmus at extreme lateral gaze is normal

      • Note that upper eyelid continues to overlap top of iris, even during downward movement

      • You should not see white rim of sclera between lid & iris

      • If noted, this is termed lid lag


Know the order of the internal eye exam

-Inspect external ocular structures:

-General: begin with external points, work inward

-Ability to move around room

-Note facial expression


-Look for symmetry

-Present bilaterally, move symmetrically as expression changes, no scaling or lesions

-Eyelids & lashes:

-Upper lids overlap superior part of iris & approximate completely with lower lids when closed; no ptosis

-Lower lids hugs limbus; no ectropion or entropion

-Skin intact without redness, swelling, discharge or lesions

-Palpebral fissures horizontal in non-Asians; Asians normally have an upward slant

-Eyelashes are evenly distributed along lid margins, curve out

-Eyeballs aligned in sockets: no exophthalmos or enopthalmos

-African Americans may have slight protrusion.

-Conjunctiva & sclera:

-Ask to look up; using thumbs, slide lower lids down along orbital rim

-Inspect exposed area; eyeball should look moist & glossy

-Numerous small blood vessels visible through conjunctiva

-Conjunctivae clear, pink over lower lids & white over sclera

-Note any color change, swelling or lesions

-Sclera is china white, African Americans may have gray-blue or “muddy” color

-In dark-skinned people, may see small brown macules on sclera

-Lacrimal apparatus - ask to look down; with thumbs, slide outer part of upper lid up along bony orbit to expose under lid; inspect for redness or swelling

-Inspect anterior eyeball structures:

-Cornea & lens:

-Shine light from side across cornea & check for smoothness & clarity

-There should be no opacities in cornea, anterior chamber or lens; Do not confuse an arcus senilis with an opacity; arcus senilis is normal finding in aging persons

-Iris & pupil:

-Note size, shape & equality of pupils; normally pupils appear round, regular & equal

-To test pupillary light reflex, darken room, ask person to gaze into distance; this dilates pupils; advance a light in from side & note respons; -Normally you will see a direct & a consensual light reflex

-Test for accommodation by asking to focus on a distant object; This dilates pupils; then have person shift gaze to near object, such as your finger held about 12 inches from nose

-Normal response includes

-Pupillary constriction

-Convergence of axes of eyes

-Record normal response to these maneuvers as PERRLA, or Pupils Equal, Round, React to Light & Accommodation

-Inspect ocular fundus:

-Ophthalmoscope - inspect: anterior chamber & retinal background

-Ophthalmoscope contains lenses strength of each lens is diopter

-Black numbers indicate positive diopter; use to focus on near objects

-Red numbers show negative diopter, focus on objects farther away

-Systematically inspect structures in ocular fundus:

-General background of fundus

-Color normally varies from light red to dark brown-red; view of fundus should be clear; no lesions should obstruct retinal structures

-Retinal vessels

-Follow a paired artery & vein to periphery in 4 quadrants note:

-Number: paired artery & vein pass in each quadrant; vessels look straighter at nasal side

-Color: arteries brighter red than veins; have arterial light reflex

-A:V ratio: ratio comparing artery-to-vein width is 2:3 or 4:5

-Caliber: arteries & veins show a decrease in caliber as they extend to periphery

-Optic disc

-Most prominent landmark, located on nasal side of retina; explore these characteristics:

-Color: creamy yellow-orange to pink

-Shape: round or oval

-Margins: distinct & sharply demarcated, nasal edge may be slightly fuzzy


-Located temporal to disc

-Inspect last in funduscopic exam; bright light may cause tearing, discomfort, pupillary constriction

-Normal even & color darker than rest of fundus

-Clumped pigment may occur with aging

What cranial nerves are associated with eye exam—and how tested

-Extraocular muscles movement is stimulated by:

-CN VI: abducens nerve, innervates lateral rectus muscle, which abducts eye

-CN IV: trochlear nerve, innervates superior oblique muscle, moves eye down & medially

-CN III: oculomotor nerve, innervates the superior, inferior & medial rectus & the inferior oblique muscles
Constriction and dilation of pupil----what situations cause these to occur

-stimulation of the parasympathetic branch through cranial nerve III causes constriction of the pupil

-stimulation of sympathetic branch causes dilation of pupil and raising of eyelid

-pupils dilate when in a dark room or at night

-pupillary light reflex is normal constriction of pupils when a bright light shines on the retina

-when one pupil is exposed to a bright light, the other pupil will constrict with it (consensual light reflex)

-accomodation test will also cause the pupils to constrict

What is the red glow noted with the oto-ophthalmoscope on the patient’s pupil?

-called the red reflex

-reflection of the ophthalmoscope light off inner retina

-keep sight of red reflex and move closer

-if you lose the red reflex, the light has wandered off the pupil and onto the iris or the sclera, adjust your angle to find it again

Review eye abnormalities in lecture notes: highlighted ones are the ones mentioned in the lecture slides

-extraocular muscle dysfunction (p. 311)

-strabismus: true disparity of the eye axes; this constant malignment is also termed tropia and is likely to cause amblyopia

-esotropia and exotropia:


-abnormalities of eyelids (p. 312-313):

-periorbital edema: lids are swollen and puffy; lid tissues are loosely connected so excess fluid is easily apparent; occurs w/ local infections, crying, systemic conditions such as CHF, renal failure, allergies, and myxedema

-exophthalmos: forward displacement of the eyeballs and widened palpebral fissures

-enophthalmos: sunken eyes; caused by loss of fat in the orbits and occurs w/ dehydration and chronic wasting illnesses

-ptosis: occurs from neuromuscular weakness, occulomotor cranial nerve III damage, or sympathetic nerve damage, or it can be congenital

-upward palpebral slant: normal in many children however when combined with the epicanthal folds, hypertelorism (large spacing between the eyes), and brushfield spots indicates Down syndrome

-ectropion: lower lid is loose and rolling out, does not approximate to eyeball; eyes feel dry and itchy because tears do not drain correctly over the corner and toward the medial canthus; increased risk for inflammation; occurs in aging as a result of atrophy of elastic and fibrous tissues but may result from trauma

-entropion: lower lid rolls in because of spasm of lids or scar tissue contracting; constant rubbing of lashes may irritate cornea; person feels foreign body sensation

-lesions on the eyelids (p. 314):

-blepharitis: red, scaly, greasy falkes and thickened, crusted lid margins occur w/ staph infection or sebhorric dermatitis of the lid edge; symptoms include burning, itching, tearing, foreign body sensation, and some pain

-chalazion: beady nodule protruding on the eyelid, is an infection or retention cyst of a meibomian gland; it is nontender, firm, discrete swelling with freely movable skin overlying the nodule

-hordeolum (stye): localized staph infection of the hair follicles at the lid margin; it is painful, red, swollen, pustule at the lid margin

-dacryocystitis: infection and blockage of sac and duct; pain, warmth, redness, and swelling occur below the inner canthus toward the nose; tearing is present; pressure on sac yields prurulent discharge from puncta

-basal cell carcinoma: carcinoma is rare but itoccurs most often on the lower lid and medial canthus; looks like a papule w/ an ulcerated center; rolled out pearly edges, metastatsis is rare but should be referred for removal

-abnormalities in the pupil (p. 315):

-anisocoria: unequal pupil size; although this exists normally in 5% of the population, consider central nervous system

-monocular blindness: when light is directed to blind eye, no response occurs in either eye; when light is directed to the normal eye, both pupils constrict as long as the ocular nerve is intact

-dilated and fixed pupils (mydriasis): enlarged pupils occur w/ stimulation of sympathetic nervous system, reaction to sympathomimetic drugs, use of dilating drops, acute glaucoma, or past or recent trauma

-constricted and fixed pupils (miosis): occurs with the use of pilocarpine drops for glaucoma treatment, use of narcotics, with iritis, and with brain damage of pons

-argyll Robertson pupil: no reaction to light, pupil does not constrict w/ accommodation; small irregular bilaterally; occurs with CNS syphilis, brain tumor, meningitis, and chronic alcoholism

-tonic pupil (Adies pupil): sluggish reaction to light and accommodation; usually unilateral, a large regular pupil that does not react but sluggishly after long latent time

-Horner’s syndrome: unilateral, small, regular pupil does not react to light and accommodation; occurs in Horner’s syndrome (a leasion of the sympathetic nerve); also note ptosis and absence of sweat on same side

-cranial nerve III damage: unilateral dilated pupil with no reaction to light or accommodation, occurs with oculomotor damage; may also have ptosis with eye deviating down and laterally

-vascular disorders of the external eye (p. 317):

-conjunctivitits: infection of the conjunctiva (pink eye), has red beefy looking vessels at peripherary but usually clearer around iris; common from bacterial or viral infection, allergy, or chemical irritation

-subconjunctival hemorrhage: red patch on the sclera, subconjunctival hemorrhage looks alarming but is usually not serious; red patch has sharp edges like a spot of paint; occurs from increased intraocular pressure from coughing, vomiting, weight lifting, labor during childbirth, straining from stool, or trauma

-iritis (circumcorneal redness): deep dull red halo around the iris and cornea; pupil shape may be irregular from swelling of iris; person also has marked photophobia, constricted pupil, blurred vision, and throbbing pain

-acute glaucoma: circumcorneal redness around the iris w/ a dilated pupil; it is oval, dilated, cornea looks steamy; occurs with sudden increase in intraocular pressure from blocked outflow from anterior chamber; person experiences a sudden clouding of vision, sudden eye pain, and halos around lights

-abnormalities on cornea and iris (p. 318-319):

-pterygium: a triangle opaque wing of bulbar conjunctiva overgrows toward the center of the cornea; looks membranous, translucent, and yellow to white, usually invades from nasal side and may obstruct vision as it covers pupil; occurs usually from chronic exposure to hot, dry, sandy climate which stimulates growth of a pinguecula into a pterygium

-corneal abrasion: most common result of a blunt eye injury, top layer of cornea removed from scratches or poorly fitting or overworn contact lenses; area is rich in nerve endings so person feels intense pain, foreign body sensation, and lacrimation, redness and photophobia

-shallow anterior chamber: iris is pushed anteriorly due to increased intraocular pressure; may be a sign of acute angle-closure glaucoma; iris looks bulging because aqueous humor cannot circulate

-hyphema: blood in anterior chamber is a serious result of herpes zoster infection, also occurs with blunt trauma

-hypopyon: prurulent matter ub abterior chamber occurs with iritis and w/ inflamm. in the anterior chamber

-opacities in the lens (p. 319):

-semile cataracts: nuclear cataract shows an opaque gray surrounded by black background as it forms in the center of lens nucleus; begins after 40 years and develops slowly, gradually obstructing vision

-star-shaped opacity (cortical cataract): asymmetric, radical, white spokes w/ black center; this forms in outercortex of lens, progressing faster than nuclear cataract

-abnormalities in optic disc (p. 320):

-optic atrophy: white or grey color of the disc as a result of partial or complete death of the optic nerve; results in decreased visual acuity, decreased color vision, and decreased contrast sensitivity

-papiledema (choked disc): increasedintracranial pressure causes venous stasis in the globe showing redness, congestion, elevation of the disc, blurred margins, hemorrhages, and absent venous pulsations; serious sign of increased intracranial pressure usually caused by a space-occupying mass; visual acuity is not affected

-excessive cup disc ratio: w/ primary open angle glaucoma, the increased intraocular pressure decreases blood supply to retinal structures; physiologic cup enlarges to more than half of the disc diameter, vessels appear to plunge over edge of cup, and vessels are displaced nasally; this is asymptomatic although person may have decreased vision or visual field defects in the late stages of glaucoma

-abnormalities in retinal vessels and background (p. 320-321):

-arteriovenous crossing: when vessel is occluded, it dilates distal to crossing; person also has disc edema and hard exudates in a macular star pattern that occur with acutely elevated hypertension; with hypertension the arteriole wall thickens and becomes opaque so that no blood is seen inside it

-narrowed (attenuated) arteries: generalized decrease in arteriole diameter; light reflex also narrows; occurs w/ severe hypertension and with occlusion of the central retinal artery and retinitis pigmentosa

-diabetic retinopathy:

-microaneurysms: round punctate dots that are localized dilations of a small vessel; edges are smooth and discrete; occurs in diabetes

-intraretinal hemorrhages: dot shaped hemorrhages are deep intraretinal hemorrhages that look splattered on; may be distinguished from microaneurysms by blurred irregular edges; flame shaped hemorrhages are superficial retinal hemorrhages that look linear and spindle shaped; occur in hypertension

-exudates: soft exudates or cotton wool areas look like fluffy gray white cumulus clouds; they are arteriolar microinfarctions that envelop and obscure the vessels; occurs with diabetes, hypertension, subacute bacterial endocarditis, lupus, and papilledema of any cause; hard exudates are numerous small yellow-white spots, having disctinct edges and a smooth, solid looking surface; often form a circular pattern clustered around a venous microinfarction; may also form a linear or star pattern

What happens to eye with aging process

-external eye structures become droopy and wrinkly

-lacrimal glands involute causing decreased tear production and a feeling of dryness and burning

-cornea may show infiltration of degenerative lipid material around the limbus

-pupil size decreases

-lens loses elasticity, becoming hard and glass like decreasing its ability to change shape to accommodate for near vision (termed presbyopia)

-normally transparent fibers of the lens begin to thicken and yellow; beginning of senile cataract

-floaters appear in the vitreous as a result of debris that accumulates because vitreous is not renewed as often as aqueous

-Cornea may look cloudy with age

-Arcus senilis: commonly seen around cornea

-Xanthelasma: soft, raised yellow plaques occurring on lids at inner canthus

-3 most common causes of decreased visual functioning:

1. cataract formation: from clumping of proteins in the lens

2. glaucoma: increased intraocular pressure; chronic open angle glaucoma is the most common type and involves gradual loss of peripheral vision

3. macula degeneration: breakdown of cells in the macula of the retina resulting in loss of central vision leading to blindness; person is unable to read fine print, sew, or do fine work and may have difficulty distinguishing faces

Know sections of the mental status exam: Appearance, Behavior, Cognitive Functions, and Thought Processes and Perception—what goes in each section

Know lobes and major functions

-frontal: areas concerned with personality, behavior, emotions, and intellectual function

-precentral gyrus: initiates voluntary movement

-parietal lobe: postcentral gyrus tha is the main center for sensation

-occipital lobe: primary visual receptor center

-temporal lobe: primary auditory reception center w/ functions of hearing, taste, and smell

-wernicke’s area: associated w/ language comprehension; when damaged, receptive aphasia results

-broca’s area: mediates motor speech; when damaged, expressive aphasia results

Know neurological system anatomy and major functions.

  • Divided in two parts: central and peripheral. CNS includes the brain and spinal cord. PNS includes all the nerve fibers outside the brain and spinal cord: the 12 pairs of cranial nerves, the 31 pairs of spinal nerves and all branches. PNS carries sensory messages to the CNS, motor messages from the CNS out to muscles and glands and autonomic messages that govern the internal organs and blood vessels

  • Cerebral Cortex is the cerebrum’s outer layer of nerve cell bodies and looks like gray matter because it lacks myelin. Myelin is the white insulation on the axon that increases the conduction velocity of nerve impulses. Cerebral cortex is the center for the human’s highest functions, governing thought, memory, reasoning, sensation and voluntary movement.

  • Each hemisphere is divided into 4 lobes: frontal, parietal, temporal and occipital. Frontal lobe is concerned with personality, behavior, emotions and intellectual function. The precentral gyrus of the frontal lobe initiates voluntary movement. The parietal lobe’s postcentral gyrus is the primary center for sensation. The occipital lobe is the primary visual receptor center. The temporal lobe behind the ear has the primary auditory reception center for hearing, taste and smell. Wernicke’s area in the temporal lobe is associated with language comprehension. Broca’s area in the frontal lobe mediates motor speech.

  • Basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system. They help to initiate and coordinate movement and control automatic associated movements of the body.

  • The thalamus is the main relay station where the sensory pathways of the spinal cord, cerebellum and brainstem form synapses on their way to the cerebral cortex.

  • The hypothalamus is the major respiratory center with basic functions of temperature, appetite, sex drive, HR, and BP. Also is the sleep center and coordinator of ANS activity and stress response

  • The cerebellum is a coiled structure located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium and muscle tone. Smoothes and coordinates movement.

  • The brainstem is the central core of the brain and consists mostly of nerve fibers. Has the midbrain, pons and medulla. The midbrain is the most anterior part and contains many motor neurons and tracts. The pons is the enlarged area and has two respiratory centers. The medulla is the continuation of the spinal cord in the brain that has respiration, heart, GI functions

What is central nervous system and what structures does it include

  • Central nervous system : includes the brain & spinal cord

  • Cerebral cortex

    • Cerebral cortex is the cerebrum’s outer layer of nerve cells

*looks like gray matter- lacks myelin

    • Governs: thought, memory, reasoning, sensation, voluntary movement

    • Each half of cerebrum is hemisphere

    • Left is dominant in 95% of humans

    • Each hemisphere has 4 lobes: frontal, parietal, temporal & occipital

What is peripheral nervous system and what structures does in include

  • PNS is a bundle of fibers outside the CNS. The peripheral nerves carry input to the CNS via their sensory afferent fibers and deliver output from the CNS via the efferent fibers.

What are the autonomic nervous system, sympathetic and parasympathetic nervous systems.

  • The autonomic nervous system consists of fibers that innervate smooth (involuntary ) muscles, cardiac muscles and glands. The autonomic system mediates unconscious activity. The overall function of the ANS is to maintain homeostasis of the body.

  • Parasympathetic nervous system aka rest and digest: Performs 7 regulatory functions:

  • *Focusing the eye for near vision
    *Constricting the pupil
    *Slowing of the heart rate
    *Contracting bronchial smooth muscle
    *Increased gastric secretion
    *Emptying of the bladder
    *Emptying of the bowel

  • Sympathetic nervous system aka fight or flight and performs the below functions:

    • *Increasing heart rate and blood pressure
      *Shunting blood away from the skin & viscera & into skeletal muscles
      *Dilating the bronchi to improve oxygenation
      *Dilating the pupils (perhaps to enhance visual acuity)
      *Mobilizing stored energy, thereby providing glucose for the brain and fatty acids for muscles

What is the difference between vertigo, dizziness and tinnitus

  • Vertigo is rotational spinning caused by neurologic disease in the vestibular apparatus in the ear or in the vestibular nuclei in the brainstem. Dizziness is more light-headed and faint feeling but does not usually contain the rotational spinning component. Tinnitus is a noise or ringing in the ears.

Know the 12 cranial nerves—sensory, motor or both; how tested and expected findings—abnormalities







Sensory:  smell reception/interpretation

Test familiar aromatic odors, one at time with eyes closed



Sensory:  visual acuity and visual fields

Snellen Chart/Rosenbaum near vision chart.  Test visual fields by confrontation



Motor:  Raise eyelids, most extraocular movements.  Parasympathic: constrict pupils, change lens shape

Inspect pupils’ size for equality and their direct & consensual response to light & accommodation.  Inspect eyelids for drooping.  Assess the six cardinal fields of gaze



Motor:  downward, inward eye movements

Accessed with CNIII



Motor:  jaw opening and clenching, chewing and mastication

Sensory:  Sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and oral mucosa, teeth, tongue, ear, facial skin

Inspect face for muscle atrophy/tremors.  Palpate jaw muscles for tone/strength with clenched teeth  Test superficial pain/touch sensation in each branch.  Test temp sensation if there are unexpected findings to pain or touch.  Test corneal reflex.



Motor:  lateral eye movement

Assessed with CN III & IV



Motor:  Movement of facial expression muscles except jaw, close eyes, close eyes

Sensory:  taste, anterior two thirds of tongue, sensation to pharynx

Paraympathetic:  secretion of saliva/tears

Inspect symmetry of facial features with various expressions (smile frown puffed cheeks, wrinkled forehead)



Sensory:  hearing and equilibrium

Test sense of hearing with whispered screening tests or audiometry.  Test for lateralization of sound (Weber & Rhine tests)



Motor: Voluntary muscles for swallowing & phonation

Sensory:  sensation of nasopharynx, gag reflex, taste of posterior third of tongue

Parasympathetic:  secretion of salivary glands

Test gag reflex and ability to swallow.  Test ability to identify sour and bitter tastes



Motor:  Voluntary muscles of phonation and swallowing.

Sensory:  sensation behind ear and part of external ear canal

Parasympathetic:  secretion of digestive enzymes, peristalsis; involuntary action of heart, lungs and digestive tract, carotid reflex

Inspect palate/uvula for symmetry with speech sounds and gag reflex.  Observe for swallowing difficulty.  Evaluate quality of speech sounds ( presence of nasal or hoarse quality to voice)  Tested with CN IX


Spinal Accessory

Motor:  Turn head, shrug shoulders, some actions for phonation

Test trapezius muscle strength (Shrug shoulders against resistance)  Test sternocleidomastoid muscle strength (turn head to each side against resistance)



Motor:  tongue movement for speech sound articulation and swallowing

Inspect tongue in mouth/protruded for symmetry, tremors and atrophy.  Inspect tongue movement toward nose & chin.  Test tongue strength with index finger when tongue is pressed against cheek.  Evaluate quality of lingual speech sounds (L, T, D, N)
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