CNS Examination
Done by
Dr/ Abdullah Mohd. Jan
MBBS,Intern
Aspects of Examination
1. General Ex
2. The Cranial nerves
3. The upper limbs
( Motor + Sensory + coordenation )
4. The lower limbs
( Motor + Sensory + coordenation)
5. The skull and spine for local disease
6. The carotid arteries for bruits
General Examination
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Assessment of the higher centers
Speech
Neck stiffness
Abnormal movements
General Examination
1. Assessment of the higher centers
o
o
o
o
Consciousness
Orientation ( Person , Place , Time ).
Memory
Handedness
2. Speech
o
Flow of speech
o
o
Comprehension
Repetition
3. Neck stiffness
looking for meningism ( meningitis ,SAH)
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 ) .
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
CN III, IV, VI: Oculomotor,
Trochlear, Abducent
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Inspection of pupil
Light reflex
Eye Movement & nystagmus
Convergence & accomodation
• 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.
The pupils
CN V :Trigeminal
• Motor
• Sensory
• Reflex
• 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.
• Sensory
Facial sensation by cotton on forehead,
cheek & jaw.
• 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].
CN VII :Facial
• Motor
• Taste sensation
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 .
• Pt smile :compare nasolabial grooves .
• Pt show teeth, puff out cheeks .
• Taste sensation in the anterior 2/3 of the
tongue.
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.
CN XII: Hypoglossal
• Inspect tongue in mouth for wasting,
fasciculations.
• Protrude tongue: unilateral
deviates to affected side.
Motor system
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don’t forget to compare both limbs
Inspection
Palpation ( muscle bulk + tenderness )
Muscle tone
Muscle power
Reflexes
Motor system
1. Upper limbs (compare)
• Inspect for muscle wasting ( proximal &
Distal ) – scars – deformity –
fasciculation – skin pigmentation.
•
Drift test
• Feel the muscle bulk ( proximally &
Distally ) – muscle tenderness.
• Tone ( normo – hypo – hypertonia )
by passive movement of wrist and elbow
joints.
• Power ( 0 – 5 )
by active movement at the shoulder ,
elbow , wrists and fingers.
• Reflexes ( 0 - ++++ )
Biceps ( C5,C6 ) – Triceps ( C7,C8 ) –
Brachioradialis ( C5,C6 )
• Coordination
Finger to nose test
Finger to finger test
Dysdiadochokinesis
Rebound test
2. Lower limbs
• Inspect the gait of the patient
•
Expose both thighs and legs.
•
Inspect for muscle wasting – scars –
deformity – posture -fasciculation – skin
pigmentation .
• Feel the muscle bulk and muscles for
tenderness.
• Tone ( normo – hypo – hypertonia )
by passive movement of the knee and
ankle joints
• Clonus more than 3
ankle and knee clonus
• Power ( 0 – 5 )
by active movement at the hip , knee ,
ankle , and tarsal joints
• Reflexes ( 0 - ++++ )
Knee jerk ( L3,L4 ) – Ankle jerk (S1,S2 ) –
Plantar reflex ( L5, S1 , S2 )
• Coordination
Heal to shin test
Toe finger test
Tapping test
Foot
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
Back
• Inspect for deformity – scars –
neurofibromas .
• Palpate for tenderness over the vertebral
bodies
• Do the straight leg raising test
Auscultation
• Auscultate over the carotid arteries looking
for bruits.