INTRODUCTIONA seizure disorder is a condition in which the neurons in the brain function abnormally, resulting in sudden, brief changes in how the brain works. These changes result in seizures, which involve convulsions, muscle spasms, and loss of consciousness. A person needs to have two or more seizures to be classified as having a disorder. Also known as convulsions, epileptic seizures, and if recurrent, epilepsy. It is a sudden alterations in normal brain activity that cause distinct changes in behavior and body function. They are thought to result from abnormal, recurrent, uncontrolled electric discharges of neurons in the brain.Pathophysiology is poorly understood but seems to be related to metabolic and electrochemical factors at the cellular level. Predisposing factors include head or brain trauma, tumors, cranial surgery, metabolic disorders (hypocalcemia, hypoglycemia or hyperglycemia, hyponatremia, anoxia); central nervous system infection; circulating disorders; drug toxicity; drug withdrawal states (alcohol, barbiturates); and congenital neurodegenerative disorders.Seizures happen when your brain cells, which communicate through electrical signals, send out abnormal signals. However, even mild seizures that happen more than once should be treated, because they could cause harm if they happen while you are driving, walking, or swimming, for example. It sometimes do cause brain damage, particularly if they are severe. However, most seizures do not seem to have a detrimental effect on the brain. Any changes that do occur are usually subtle, and it is often unclear whether these changes are caused by the seizures themselves or by the underlying problem that caused the seizures.While epilepsy cannot currently be cured, for some people it does eventually go away. The odds of becoming seizure-free are not as good for adults or for children with severe epilepsy syndromes, but it is nonetheless possible that seizures may decrease or even stop over time.

HISTORYSeizure was one of the first brain disorders to be described. It was mentioned in ancient Babylon more than 3,000 years ago. The strange behavior caused by some seizures has contributed through the ages to many superstitions and prejudices. People once thought that those with seizures were being visited by demons or gods. However, in 400 B.C., the early physician Hippocrates suggested that seizure was a disorder of the brain -- and we now know that he was right.Seizure is a brain disorder in which clusters of nerve cells, or neurons, in the brain sometimes signal abnormally. Neurons normally generate electrochemical impulses that act on other neurons, glands, and muscles to produce human thoughts, feelings, and actions. In seizure, the normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and loss of consciousness. During a seizure, neurons may fire as many as 500 times a second, much faster than normal. In some people, this happens only occasionally; for others, it may happen up to hundreds of times a day.Famous people who are known or rumored to have had epilepsy include the Russian writer Dostoyevsky, the philosopher Socrates, the military general Napoleon, and the inventor of dynamite, Alfred Nobel, who established the Nobel Prize.

STATISTICSMore than 2 million people -- about 1 in 100 -- have experienced an unprovoked seizure or been diagnosed with epilepsy. For about 80 percent of those diagnosed with epilepsy, seizures can be controlled with modern medicines and surgical techniques. However, about 25 to 30 percent of people with epilepsy will continue to experience seizures even with the best available treatment. Doctors call this situation intractable epilepsy. Only when a person has had two or more seizures is he or she considered to have epilepsy.

What Causes It?A seizure disorder can be caused by a variety of factors. Anything that disturbs the normal pattern of neuron activity -- from illness to brain damage to abnormal brain development -- can cause a seizure. The condition may develop as the result of abnormality in brain wiring, an imbalance of nerve signaling chemicals called neurotransmitters, or some combination of these factors. Seizure disorders are not contagious and are not caused by mental illness or mental retardation. Diagnosing a Seizure DisorderExperiencing a single seizure does not necessarily mean that a person has a seizure disorder. Only when a person has had two or more seizures is he or she considered to have a disorder. Brain scans and electroencephalograms (EEGs) are common tests used to make a diagnosis.

PROGNOSISWhile a seizure disorder cannot currently be cured, for some people, it does eventually go away. One study found that children with idiopathic epilepsy, or a seizure disorder with an unknown cause, had a 68 to 92 percent chance of becoming seizure-free by 20 years after their diagnosis. The odds of becoming seizure-free are not as good for adults or for children with severe seizure disorders, but it is nonetheless possible for seizures to decrease or even stop over time. This is more likely if the disorder has been well-controlled by medication or if the person has had surgery. Most seizures do not cause brain damage; however, it is not uncommon for people with a disorder, especially children, to develop behavioral and emotional problems, sometimes the consequence of embarrassment and frustration or bullying, teasing, or avoidance in school and other social settings. For many people with a seizure disorder, the risk of seizures restricts their independence (some states refuse driver's licenses to people with a disorder) and recreational activities. People with a seizure disorder are at special risk for two life-threatening conditions: status epilepticus and sudden unexplained death. Most women with a seizure disorder can become pregnant, but they should discuss their condition and the medications they are taking with their doctors. Women with the condition have a 90 percent or better chance of having a normal, healthy baby.

Epilepsy Seizure Types and SymptomsBased on the type of behavior andbrainactivity,seizuresare divided into two broad categories: generalized and partial (also called local or focal). Classifying the type of seizure helps doctors diagnose whether or not a patient hasepilepsy.Generalized seizuresare produced by electrical impulses from throughout the entirebrain; partial seizures are produced (at least initially) by electrical impulses in a relatively small part of thebrain. The part of thebraingenerating the seizures is sometimes called the focus. The most common types of seizures are listed below:Generalized Seizures(Produced by the entire brain)Symptoms

1. "Grand Mal" or Generalized tonic-clonicUnconsciousness, convulsions, muscle rigidity

2. AbsenceBrief loss of consciousness

3. MyoclonicSporadic (isolated), jerking movements

4. ClonicRepetitive, jerking movements

5. TonicMuscle stiffness, rigidity

6. AtonicLoss of muscle tone

Generalized SeizuresThere are six types ofgeneralized seizures. The most common and dramatic, and therefore the most well known, is the generalized convulsion, also called thegrand-mal seizure. In this type of seizure, the patient loses consciousness and usually collapses. The loss of consciousness is followed by generalized body stiffening (called the "tonic" phase of the seizure) for 30 to 60 seconds, then by violent jerking (the "clonic" phase) for 30 to 60 seconds, after which the patient goes into a deepsleep(the "postictal" or after-seizure phase). During grand-mal seizures, injuries and accidents may occur, such astonguebiting andurinary incontinence.Absence seizurescause a short loss of consciousness (just a few seconds) with few or no symptoms. The patient, most often a child, typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of "losing time."Myoclonic seizuresconsist of sporadic jerks, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result in dropping or involuntarily throwing objects.Clonic seizuresare repetitive, rhythmic jerks that involve both sides of the body at the same time.Tonic seizuresare characterized by stiffening of the muscles.Atonic seizuresconsist of a sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall.Partial Seizures(Produced by a small area of the brain)Symptoms

1. Simple(awareness is retained)a.Simple Motorb.Simple Sensoryc.Simple Psychologicala. Jerking, muscle rigidity, spasms, head-turningb. Unusual sensations affecting either thevision, hearing, smell taste, or touchc. Memory or emotional disturbances

2. Complex(Impairment of awareness)Automatisms such as lip smacking, chewing, fidgeting, walking and other repetitive, involuntary but coordinated movements

3. Partial seizure with secondary generalizationSymptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions.

Partial SeizuresPartial seizuresare divided into simple, complex and those that evolve into secondary generalized seizures. The difference between simple and complex seizures is that during simple partial seizures, patients retain awareness; during complex partial seizures, they lose awareness.Simple partial seizuresare further subdivided into four categories according to the nature of their symptoms: motor, autonomic, sensory, or psychological. Motor symptoms include movements such as jerking and stiffening. Sensory symptoms caused by seizures involve unusual sensations affecting any of the five senses (vision, hearing, smell, taste, or touch). When simple partial seizures cause sensory symptoms only (and not motor symptoms), they are called "auras."Autonomic symptoms affect the autonomicnervous system, which is the group of nerves that control the functions of our organs, like theheart,stomach,bladder,intestines. Therefore autonomic symptoms are things like racing heart beat, stomach upset,diarrhea, loss ofbladdercontrol. The only common autonomic symptom is a peculiar sensation in the stomach that is experienced by some patients with a type ofepilepsycalledtemporal lobe epilepsy. Simple partial seizures with psychological symptoms are characterized by various experiences involving memory (the sensation of deja-vu), emotions (such as fear or pleasure), or other complex psychological phenomena.Complex partial seizures, by definition, include impairment of awareness. Patients seem to be "out of touch," "out of it," or "staring into space" during these seizures. There may also be some "complex" symptoms called automatisms. Automatisms consist of involuntary but coordinated movements that tend to be purposeless and repetitive. Common automatisms include lip smacking, chewing, fidgeting, and walking. The third kind of partial seizure is one that begins as a focal seizure and evolves into a generalized convulsive ("grand-mal") seizure. Most patients with partial seizures have simple partial, complex partial, and secondarily generalized seizures. In about two-thirds of patients with partial epilepsy, seizures can be controlled withmedications. Partial seizures that cannot be treated with drugs can often be treated surgically.

Complications of EpilepsyComplications of complex partial seizures are easily triggered by emotional stress. The limbic structures (i.e., hypothalamus, hippocampus, amygdala) of the brain may be damaged by seizure activity. The limbic system is concerned with emotion and motivation.These patients may develop cognitive and behavioral difficulties, such as the following: Interictal personality: humorlessness, dependence, obsessions, anger, hypo- or hypersexuality, emotionality Memory loss: short-term memory loss attributable to dysfunction in the hippocampus, anomia (inability to recall words or names of objects) Poriomania: prolonged aimless wandering followed by amnesia Violent behavior: aggression and defensiveness when subjected to restraint during a seizureComplications associated with tonic-clonic seizures may involve injury, such as the following: Aspiration (inhalation into the lungs) of secretions or vomited stomach contents Skull or vertebral fractures, shoulder dislocation Tongue, lip, or cheek injuries caused by biting Status epilepticusStatus epilepticusis a medical emergency in which seizures recur without the patient regaining consciousness between events. This condition can develop in any type of seizure but is most common in tonic-clonic seizures. Status epilepticus may cause brain damage or cognitive dysfunction and may be fatal.Subsequent seizures become briefer, more localized, and may be reduced to myoclonic activity. Complications may include: Aspiration Cardiac arrhythmias Dehydration Fractures Myocardial infarction (heart attack) Oral and head trauma Pulmonary edema (fluid build-up in the lungs)COMMON COMPLICATIONS: Hypoxia or anoxia from airway occlusion Traumatic injury Brain damage Depression and anxiety

Risk factors for epilepsy include:Any injury to the brain, either from external (environmental) or internal (medical/metabolic) sources can increase your risk of epilepsy.Brain injury can be caused by: Head injury Stroke Alzheimers disease Tumors(primary or metastatic) Heart failure Kidney failure Liver failure Any condition that deprives the brain of oxygen, such asnear-drowning Sleep deprivation Infectious diseases, such as: Meningitis AIDS Viral encephalitis Hydrocephalus(excess fluid in the brain) Celiac disease(intolerance to wheat gluten) Metabolic conditions, such aslow blood sugar, high or low salt, low magnesium or calciumIn some cases, epilepsy can result from genetic abnormalities inherited at birth.Different causes and types of seizures are more or less likely depending on your age.In children, risk factors include: High fever Poor nutritionOther factors that can increase your risk of epilepsy include: Exposure to: Lead Carbon monoxide Other environmental toxins Certain illegaldrugs Overdose or withdrawal of antidepressants and other medications Medication interactions Alcoholism Cysticercosisan infection caused by a porktapeworm

NORMAL ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEMIntroductionThe human nervous system is made up of two main components: the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS is composed of the brain, the cranial nerves, and the spinal cord. The PNS is made up of the nerves that exit from the spinal cord at various levels of the spinal column as well as their tributaries. The autonomic nervous system (divided into the sympathetic and parasympathetic nervous system) is also considered to be a part of the PNS and it controlls the body's many vegetative (non-voluntary) functions.BrainThe human brain serves many important functions ranging from imagination, memory, speech, and limb movements to secretion hormones and control of various organs within the body. These functions are controlled by many distinct parts that serve specific and important tasks. These components and their functins are listed below.Brain Cells: The brain is made up of two types of cells: neurons (yellow cells in the image below) and glial cells (pink and purple cells in the image below). Neurons are responsible for all of the functions that are attributed to the brain while the glial cells are non-neuronal cells that provide support for neurons. In an adult brain, the predominant cell type is glial cells, which outnumber neurons by about 50 to 1. Neurons communicate with one another through connections called synapses.

Meninges: The bony covering around the brain is called the cranium, which combines with the facial bones to create the skull. The brain and spinal cord are covered by a tissue known as the meninges, which is made up of three layers: dura mater, arachnoid layer, and pia mater. The dura mater is a whitish and nonelastic membrane which, on its outer surface, is attached to the inside of the cranium. This layer completely covers the brain and the spinal cord and has two major folds in the brain, that are called the falx and thetentorium. The falx separates the right and left halves of the brain while the tentorium separates the upper and lower parts of the brain. The arachnoid layer is a thin membrane that covers the entire brain and is positioned between the dura mater and the pia mater, and for the most part does not follow the folds of the brain. The pia mater, which is attached to the surface of the entire brain, follows the folds of the brain and has many blood vessels that reach deep into the brain. The space between the arachnoid layer and the pia mater is called the subarachnoid space and it contains thecerebrospinal fluid.

Cerebrospinal Fluid(CSF): CSF is a clear fluid that surrounds the brain and spinal cord, and helps to cushion these structures from injury. This fluid is constantly made by structures deep within the brain called the choroid plexus which is housed inside spaces within the brain calledventricles, after which it circulates through channels around the spinal cord and brain where is it finally reabsorbed. If the delicate balance between production and absorption of CSF is disrupted, then backup of this fluid within the system of ventricles can causehydrocephalus.Ventricles: Brain ventricles are a system of four cavities, which are connected by a series of tubes and holes and direct the flow ofCSFwithin the brain. These cavities are the lateral ventricles (right and left), which communicate with the third ventricle in the center of the brain through an opening called the interventricular foramen. This ventricle is connected to the fourth ventricle through a long tube called the Cerebral Aqueduct.CSFthen exits the ventricular system through several holes in the wall of the fourth ventricle (median and lateral apertures) after which it flow around the brain and spinal cord.

Brainstem: The brainstem is the lower extension of the brain which connects the brain to the spinal cord, and acts mainly as a relay station between the body and the brain. It also controls various other functions, such as wakefulness, sleep patterns, and attention; and is the source for ten of the twelvecranial nerves. It is made up of three structures: the midbrain, pons and medulla oblongata. The midbrain is inovolved in eye motion while the pons coordinates eye and facial movements, facial sensation, hearing, and balance. The medulla oblongata controls vegetative functions such as breathing, blood pressure, and heart rate as well as swallowing.

Thalamus: The thalamus is a structure that is located above the brainstem and it serves as a relay station for nearly all messages that travel from the cerebral cortex to the rest of the body/brain and vice versa. As such, problems within the thalamus can cause significant symptoms with regard to a variety of functions, including movement, sensation, and coordination. The thalamus also functions as an important component of the pathways within the brain that control pain sensation, attention, and wakefulness.Cerebellum: The cerebellum is located at the lower back of the brain beneath theoccipital lobesand is separated from them by thetentorium. This part of the brain is responsible for maintaining balance and coordinating movements. Abnormalities in either side of the cerebellum produce symptoms on the same side of the body.

Cerebrum: The cerebrum forms the major portion of the brain, and is divided into the right and left cerebral hemispheres. These hemispheres are separated by a groove called the great longitudinal fissure and are joined at the bottom of this fissure by a struture called the corpus callosum which allows communication between the two sides of the brain. The surface of the cerebrum contains billions ofneuronsandgliathat together form the cerebral cortex (brain surface), also known as "gray matter." The surface of the cerebral cortex appears wrinkled with small grooves that are called sulci and bulges between the grooves that are called gyri. Beneath the cerebral cortex are connecting fibers that interconnect the neurons and form a white-colored area called the "white matter."

Lobes: Several large grooves (fissures) separate each side of the brain into four distinct regions called lobes: frontal, temporal, parietal, and occipital. Each hemisphere has one of each of these lobes, which generally control function on the opposite side of the body. The different portions of each lobe and the four different lobes communicate and function together through very complex relationships, but each one also has its own unique characteristics. The frontal lobes are responsible for voluntary movement, speech, intellectual and behavioral functions, memory, intelligence, concentration, temper and personality. The parietal lobe processes signals received from other areas of the brain (such as vision, hearing, motor, sensory and memory) and uses it to give meaning to objects. The occipital lobe is responsible for processing visual information. The temporal lobe is involved in visual memory and allows for recognition of objects and peoples' faces, as well as verbal memory which allows for remembering and understanding language.Hypothalamus: The hypothalamus is a structure that communicates with the pituitary gland in order to manage hormone secretions as well as controlling functions such as eating, drinking, sexual behavior, sleep, body temperature, and emotions.

Pituitary Gland: The pituitary gland is a small structure that is attached to the base of the brain in an area called the sella turcica. This gland controls the secretion of several hormones which regulate growth and development, function of various organs (kidneys, breasts, and uterus), and the function of other glands (thyroid gland, gonads, and the adrenal glands).Basal Ganglia: The basal ganglia are clusters of nerve cells around the thalamus which are heavily connected to the cells of the cerebral cortex. The basal ganglia are associated with a variety of functions, including voluntary movement, procedural learning, eye movements, and cognitive/emotional functions. The various components of the basal ganglia include caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nucleus. Diseases affecting these parts can cause a number of neurological conditions, including Parkinson's disease and Huntington's disease.

Cranial Nerves: There are 12 pairs of nerves that originate from the brain itself, as compared to spinal nerves that initiate in the spinal cord. These nerves are responsible for specific activities and are named and numbered as follows:Cranial nerve I (Olfactory nerve): SmellCranial nerve II (Optic nerve): VisionCranial nerve III (Oculomotor nerve): Eye movements and opening of the eyelidCranial nerve IV (Trochlear nerve): Eye movementsCranial nerve V (Trigeminal nerve): Facial sensation and jaw movementCranial nerve VI (Abducens nerve): Eye movementsCranial nerve VII (Facial nerve): Eyelid closing, facial expression and taste sensationCranial nerve VIII (Vestibulocochlear nerve): Hearing and sense of balanceCranial nerve IX (Glossopharyngeal nerve): Taste sensation and swallowingCranial nerve X (Vagus nerve): Heart rate, swallowing, and taste sensationCranial nerve XI (Spinal accessory nerve): Control of neck and shoulder musclesCranial nerve XII (Hypoglossal nerve): Tongue movement

Pineal Gland: The pineal gland is an outgrowth from the back portion of thethird ventricle, and has some role in sexual maturation, although the exact function of the pineal gland in humans is unclear.

Spinal CordThe spinal cord is a long, thin, tubular bundle of neurons and support cells that extends from the bottom of the brain down to the space between the first and second lumbar vertebrae, and is housed and protected by the bony vertebral column. The spinal cord functions primarily in the transmission of signals between the brain and the rest of the body, allowing movement and sensation, but it also contains neural circuits that can control numerous reflexes independent of the brain.General Structure: The length of the spinal cord is much shorter than the length of the bony spinal column, extending about 45 cm (18 inches). It is ovoid in shape and is enlarged in the cervical (neck) and lumbar (lower back) regions. Similar to the brain, the spinal cord is protected by three layers of tissue, called spinal meninges. The dura mater is the outermost layer, and it forms a tough protective coating. Between the dura mater and the surrounding bone of the vertebrae is a space called the epidural space, which is filled with fatty tissue and a network of blood vessels. The arachnoid mater is the middle protective layer. The space between the arachnoid and the underlyng pia mater is called the subarachnoid space which containscerebrospinal fluid(CSF). The medical procedure known as alumbar puncture(or spinal tap) involves use of a needle to withdraw cerebrospinal fluid from the subarachnoid space, usually from the lumbar (lower back) region of the spine. The pia mater is the innermost protective layer. It is very delicate and it is tightly associated with the surface of the spinal cord.In the upper part of the vertebral column, spinal nerves exit directly from the spinal cord, whereas in the lower part of the vertebral column nerves pass further down the column before exiting. The terminal portion of the spinal cord is called the conus medullaris. A collection of nerves, called the cauda equina, continues to travel in the spinal column below the level of the conus medullaris. The cauda equina forms as a result of the fact that the spinal cord stops growing in length at about age four, even though the vertebral column continues to lengthen until adulthood.Three arteries provide blood supply to the spinal cord by running along its length. These are the two Posterior Spinal Arteries and the one Anterior Spinal Artery. These travel in the subarachnoid space and send branches into the spinal cord that communicate with branches from arteries on the other side.Function: The spinal cord is divided into 33 different segments. At every segment, a pair of spinal nerves (right and left) exit the spinal cord and carry motor (movement) and sensory information. There are 8 pairs of cervical (neck) nerves named C1 through C8, 12 pairs of thoracic (upper back) nerves termed T1 through T12, 5 pairs of lumbar (lower back) nerves named L1 through L5, 5 pairs of sacral (pelvis) nerves numbered S1 through S5, and 3-4 pairs of coccygeal (tailbone) nerves. These nerves combine to supply strength to various muscles throughout the body as follows:C1-C6: Neck flexionC1-T1: Neck extensionC3-C5: DiaphragmC5-C6: Shoulder movement and elbow flexionC6-C8: Elbow and wrist extensionC7-T1: Wrist flexionC8-T1: Hand movementT1-T6: Trunk muscles above the waisteT7-L1: Abdominal musclesL1-L4: Thigh flexionL2-L4: Thigh adduction (movement toward the body)L4-S1: Thigh abduction (movement away from the body)L2-L4: Leg extension at the kneeL5-S2: Leg extension at the hipL4-S2: Leg flexion at the kneeL4-S1: Foot dorsiflexion (move upward) and toe extensionL5-S2: Foot plantarflexion (move downward) and toe flexionThe spinal nerves also provide sensation to the skin in an organized manner as depicted below.

Vertebral ColumnGeneral Structure: The vertebral column is made up of 33 vertebrae that fit together to form a flexible, yet extraordinarily tough, column that serves to support the back through a full range of motion. There are seven cervical vertebrae (C1-C7), 12 thoracic vertebrae (T1-T12), five lumbar vertebrae (L1-L5), five fused sacral vertebrae (S1- S5),and four coccygeal vertebrae in this column, each separated by intervertebral disks.The first two cervical vertebrae have very distinct anatomy as compared to the ramaining vertebrae. The first cervical vertebra, known as the atlas, supports the head; and pivots on the second cervical vertebra, the axis. The seventh cervical vertebra joins the first thoracic vertebra. The thoracic vertebrae provide an attachment site for the ribs, and make up part of the back of the chest (thorax). The thoracic vertebrae join the lumbar vertebrae, which are particularly study and large, as they support the entire upper body weight. At the top of the pelvis, the lumbar vertebrae join the sacral vertebrae. By adulthood these five bones have usually fused to form a triangular bone called the sacrum. At the tip of the sacrum, the final part of the vertebral column projects slightly outward. This is the coccyx, better known as the tailbone. It is made up of three to five coccygeal vertebrae.A typical vertebra consists of two essential parts: the vertebral body in front and the vertebral arch in the back. The vertebral arch consists of a pair of pedicles, a pair of lamina, a spinous process, and four articular processes (joints) that connect the vertebra to one another, as depicted below.The vertebral bodies, stacked on top of eachother, form a strong pillar for the support of the head and trunk. Between each two vertebral bodies exists a hole, called the intervertebral foramina, which allows for the transmission of the spinal nerves on either side.

ASSESSMENTCranial NervesObservation Ptosis (III) Facial Droop or Asymmetry (VII) Hoarse Voice (X) Articulation of Words (V, VII, X, XII) Abnormal Eye Position (III, IV, VI) Abnormal or Asymmetrical Pupils (II, III)I - OlfactoryNot Normally TestedII - Optic Examine the Optic FundiCovered elsewhere.. Test Visual Acuity1. Allow the patient to use his glasses or contact lens if available. You are interested in the patient's best-corrected vision.2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance).3. Have the patient cover one eye at a time with a card.4. Ask the patient to read progressively smaller letters until he can go no further.5. Record the smallest line the patient read successfully (20/20, 20/30, etc.) [2]6. Repeat with the other eye. Screen Visual Fields by Confrontation0.Stand two feet in front of the patient and have him look into your eyes.1. Hold your hands about one foot away from the patient's ears, and wiggle a finger on one hand.2. Ask the patient to indicate on which side he sees the finger move.3. Repeat two or three times to test both temporal fields.4. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card. Test Pupillary Reactions to Light0. Dim the room lights as necessary.1. Ask the patient to look into the distance.2. Shine a bright light obliquely into each pupil in turn.3. Look for both the direct (same eye) and consensual (other eye) reactions.4. Record pupil size in mm and any asymmetry or irregularity.5. If abnormal, proceed with the test for accommodation. Test Pupillary Reactions to Accommodation0. Hold your finger about 10cm from the patient's nose.1. Ask him to alternate looking into the distance and at your finger.2. Observe the pupillary response in each eye.III - Oculomotor Observe for Ptosis Test Extraocular Movements1. Stand or sit 3 to 6 feet in front of the patient.2. Ask the patient to follow your finger with his eyes without moving his head.3. Check gaze in the six cardinal directions using a cross or "H" pattern.4. Pause during upward and lateral gaze to check for nystagmus.5. Check convergence by moving your finger toward the bridge of the patient's nose. Test Pupillary Reactions to Light (See Above)IV - TrochlearTest Extraocular Movements (Inward and Down Movement, See Above)V - Trigeminal Test Temporal and Masseter Muscle Strength1. Ask patient to both open his mouth and clench his teeth.2. Palpate the temporal and masseter muscles as he does this. Test the Three Divisions for Pain Sensation1. Explain what you intend to do.2. Use a suitable sharp object to test the forehead, cheeks, and jaw on both sides.3. Substitute a blunt object occasionally and ask the patient to report "sharp" or "dull." If you find an abnormality then:1. Test the three divisions for temperature sensation with a tuning fork heated or cooled by water.2. Test the three divisions for sensation to light touch using a wisp of cotton. Test the Corneal Reflex1. Ask the patient to look up and away.2. From the other side, touch the cornea lightly with a fine wisp of cotton.3. Look for the normal blink reaction of both eyes.4. Repeat on the other side.5. Use of contact lens may decrease this response.VI - AbducensTest Extraocular Movements (Lateral Movement, See Above)VII - Facial Observe for Any Facial Droop or Asymmetry Ask Patient to do the following. Note any lag, weakness, or asymmetry:1. Raise eyebrows2. Close both eyes to resistance3. Smile4. Frown5. Show teeth6. Puff out cheeks Test the Corneal Reflex (See Above)VIII - Acoustic Screen Hearing1. Face the patient and hold out your arms with your fingers near each ear.2. Rub your fingers together on one side while moving the fingers noiselessly on the other.3. Ask the patient to tell you when and on which side he hears the rubbing.4. Increase intensity as needed and note any asymmetry.5. If abnormal, proceed with the Weber and Rinne tests. Test for Lateralization (Weber)1. Use a 512 Hz or 1024 Hz tuning fork.2. Start the fork vibrating by tapping it on your opposite hand.3. Place the base of the tuning fork firmly on top of the patient's head.4. Ask the patient where the sound appears to be coming from (normally in the midline). Compare Air and Bone Conduction (Rinne)1. Use a 512 Hz or 1024 Hz tuning fork.2. Start the fork vibrating by tapping it on your opposite hand.3. Place the base of the tuning fork against the mastoid bone behind the ear.4. When the patient no longer hears the sound, hold the end of the fork near the patient's ear (air conduction is normally greater than bone conduction). Vestibular Function is Not Normally TestedIX - GlossopharyngealSee Vagus NerveX - Vagus Listen to the patient's voice. Is it hoarse or nasal? Ask Patient to Swallow Ask Patient to Say "Ah"o Watch the movements of the soft palate and the pharynx. Test Gag Reflex (Unconscious/Uncooperative Patient)1. Stimulate the back of the throat on each side.2. It is normal to gag after each stimulus.XI - Accessory From behind, look for atrophy or asymmetry of the trapezius muscles. Ask patient to shrug shoulders against resistance. Ask patient to turn his head against resistance. Watch and palpate the sternomastoid muscle on the opposite side.XII - Hypoglossal Listen to the articulation of the patient's words. Observe the tongue as it lies in the mouth Ask patient to:1. Protrude tongue2. Move tongue from side to side