CNS Examination

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CNS Examination

• Done by
• Dr/ Abdullah Mohd. Jan
• MBBS,Intern

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Aspects of Examination

• General Ex
• The Cranial nerves
• The upper limbs
• ( Motor Sensory coordenation )
• The lower limbs
• ( Motor Sensory coordenation)
• The skull and spine for local disease
• The carotid arteries for bruits

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General Examination

• Assessment of the higher centers
• Speech
• Neck stiffness
• Abnormal movements

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General Examination

• Assessment of the higher centers
• Consciousness
• Orientation ( Person , Place , Time ).
• Memory
• Handedness
• Speech
• Flow of speech
• Comprehension
• Repetition

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• Neck stiffness
• looking for meningism ( meningitis ,SAH)

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Cranial Nerves Examination

• you have to know how to examine all cranial
  nerves in detail but we will focus on the most
  important ones ( 3rd , 4th , 5th , 6th , 7th ,
  11th 12th ) .

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Where CN Come From?

• 3rd 4th cranial nerves are located in the mid
  brain
• 5th , 6th , 7th 8th cranial nerves are located
  in the pons
• 9th , 10th , 11th 12th cranial nerves are
  located in the medulla oblongata

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CN III, IV, VI Oculomotor, Trochlear, Abducent

• Inspection of pupil
• Light reflex
• Eye Movement nystagmus
• Convergence accomodation

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• Look at pupils shape, relative size,
• Ptosis.
• Shine light in from the side to look for pupil's
  light reaction. Assess both direct and
  consensual responses. Assess afferent
  pupillary defect by moving light in arc from
  pupil to pupil. 

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The pupils
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• "Follow finger with eyes without moving head"
  test the 6 cardinal points in an H pattern.
• Look for failure of movement, nystagmus pause
  to check it during upward/ lateral gaze.

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• Convergence by moving finger towards bridge of
  pt's nose.
• Test accommodation by pt looking into distance,
  then a hat pin 30cm from nose.

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CN V Trigeminal

• Motor
• Sensory
• Reflex

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• Motor pt opens mouth, clenches teeth
  )pterygoids). Palpate temporal, masseter
  muscles as they clench.
• Jaw jerk
• Dr's finger on tip of jaw.
• Grip patellar hammer halfway up shaft and tap
  Dr's finger lightly.

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• Sensory
• Facial sensation by cotton on forehead, cheek
  jaw.

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• Corneal reflex patient looks up and away.
  Touch cotton wool to other side. Look for blink
  in both eyes, ask if can sense it. Repeat other
  side tests V sensory, VII motor.

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CN VII Facial

• Motor
• Taste sensation

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CN VII Facial

• Inspect for facial droop or asymmetry.
• Facial expression muscles pt
  looks up and wrinkles forehead. looking for
  wrinkling loss.
• Pt shuts eyes tightly compare each
  side.

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• Pt smile compare nasolabial grooves.
• Pt show teeth, puff out cheeks.
• Taste sensation in the anterior 2/3 of the
  tongue.

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CN XI Accessory

• Inspection From behind, examine for trapezius
  atrophy, asymmetry.
• Pt. shrugs shoulders (trapezius).
• Pt. turns head against resistance watch, palpate
  SCM on opposite side.

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CN XII Hypoglossal

• Inspect tongue in mouth for wasting,
  fasciculations.
• Protrude tongue unilateral
  deviates to affected side.

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Motor system

• dont forget to compare both limbs
• Inspection
• Palpation ( muscle bulk tenderness )
• Muscle tone
• Muscle power
• Reflexes

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Motor system

• Upper limbs (compare)
• Inspect for muscle wasting ( proximal Distal )
  scars deformity fasciculation skin
  pigmentation.
• Drift test

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• Feel the muscle bulk ( proximally Distally )
  muscle tenderness.
• Tone ( normo hypo hypertonia )
• by passive movement of wrist and elbow
  joints.

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• Power ( 0 5 )
• by active movement at the shoulder , elbow ,
  wrists and fingers.

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• Reflexes ( 0 - )
• Biceps ( C5,C6 ) Triceps ( C7,C8 )
  Brachioradialis ( C5,C6 )

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• Coordination
• Finger to nose test
• Finger to finger test
• Dysdiadochokinesis
• Rebound test

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• Lower limbs
• Inspect the gait of the patient
• Expose both thighs and legs.
• Inspect for muscle wasting scars deformity
  posture -fasciculation skin pigmentation .

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• Feel the muscle bulk and muscles for tenderness.
• Tone ( normo hypo hypertonia )
• by passive movement of the knee and ankle
  joints

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• Clonus more than 3
• ankle and knee clonus
• Power ( 0 5 )
• by active movement at the hip , knee , ankle ,
  and tarsal joints

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• Reflexes ( 0 - )
• Knee jerk ( L3,L4 ) Ankle jerk (S1,S2 )
  Plantar reflex ( L5, S1 , S2 )
• Coordination
• Heal to shin test
  Toe finger test
  Foot Tapping test

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Sensory system

• Spinothalamic pathway
• Pain and Temperature ( usually temperature is
  not tested )
• Posterior column pathway
• Vibration and Proprioception
• Romberg Sign
• Light touch with cotton wool

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Back

• Inspect for deformity scars neurofibromas .
• Palpate for tenderness over the vertebral bodies
• Do the straight leg raising test

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Auscultation

• Auscultate over the carotid arteries looking for
  bruits.

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Thank You