CNS Examination

Anatomy and PhysiologyCentral Nervous SystemBrain, spinal cord, motor and sensory pathwaysPeripheral Nervous SystemSpinal nerves, cranial nerves, autonomic nervous system

Focused Health AssessmentPresent Health/Illness Statusnumbness, difficulty with speech, vision, hearing, medications, changes in behavior, lifestyleFamily Historyheadaches, mental illness, depression

Continued:Past Health Historyseizures, headacheshead injurysurgeriesstroke

Equipment Needed:Cotton ball, safety pin, snellen chartTongue bladeTuning forkReflex hammerpen lightpencil and papersweet/sour substancesFamiliar aromatic substance (coffee, vanilla)

Neurological exam Mental status Cranial nerves Motor system Reflexes Sensory system Coordination Station and gait

Mental status exam

Level of consciousness Attention Orientation Language fluency, comprehension, repetition, naming, reading, writing Memory immediate recall, recent, remote Higher intellectual functiongeneral knowledge, abstraction, judgment, insight, reasoning Mood and affect

General ExaminationAssessment of the higher centers Consciousness Orientation ( Person , Place , Time ).MemoryHandedness

SpeechFlow of speechComprehensionRepetition

Neck stiffness looking for meningism ( meningitis ,SAH)

Cranial Nerves Exam

12 pairs of cranial nerves.

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

Functions of cranial nervesSome of these nerves bring information from the sense organs to the brain;Others control muscles;Others are connected to glands or internalorgans such as the heart and lungs.

The innervation areas of the cranial nerves

CN I: Olfactory: smell1. Ask the subject if he/she has a subjective olfactory problem.2. Check for rash, deformity of nose.3. One nostril is occluded while the subject sniffs anunknown substance. Test one nostril with soap, cigaretteand toothpaste; ask the subject to point to the correct nameon the paper.4. Test the other nostril, repeat step 3.

CN II: Optic: visionThere are three main aspects to this nerve: visual acuity, visual fields, and fundi opticus.1. Examine visual acuity:2. Examine visual fields:3. Look into the fundi:

Inspection of pupilLight reflexEye Movement & nystagmusConvergence & accomodationCN III, IV, VI: Oculomotor, Trochlear, Abducent

CN III Oculomotor:Eyelid and eyeball movementCN IV Trochlear:Innervates superior obliqueTurns eye downward and laterallyCN VI Abducens:Turns eye laterallyCranial Nerves III, IV and VI supply the muscles of eye movement and are tested as a unit.

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

"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].

Convergence by moving finger towards bridge of pt's nose.

Test accommodation by pt looking into distance, then a hat pin 30cm from nose.

Functions: Chewing Face & mouth touch & painMotorSensory Reflex CN V: Trigeminal

1. Facial sensation:1) Use sterile sharp item on forehead, cheek and jaw.2) If abnormal, then test temperature [water-heated/cooledtuning fork], light touch [cotton].Sensory Facial sensation by cotton on forehead, cheek & jaw.

2. Motor: Subject opens mouth, clenches teeth.1) Palpate temporal, masseter muscles as they clench.2) Subject opens mouth; assess the symmetry of the mouth.

3. Corneal reflex: patient looks up and away.1) Touch cotton wool to the sclera on the other side.2) Look for blink in both eyes, ask if subject can sense it.3) Repeat on the other side.

4. Test jaw jerk:1) Examiner places finger on tip of jaw.2) Grip patellar hammer halfway up shaft and tap examinersfinger lightly.3) Usually nothing happens, or just a slight closure.

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: FacialFunctions: controls most facial expressions,secretion of tears & saliva, taste1. Muscles of facial expression:2. Check the sense of taste:

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 VIII: Vestibulocochlear Functions: hearing; equilibrium sensation Auditory acuity 1. Rinne test: 2. Weber test: Vestibular function:

CN IX, X: Glossopharyngeal, Vagus Some useful tests for detection of deficiencies in motorfunction of the palate, pharynx, and larynx are described below.Sensory function needs to be checked if one suspects cranialneuropathy or a brain stem lesion.1. Palatal Elevation2. Gag reflex (afferent IX, efferent X)3. Sensory function4. Voice Quality5. Taste test see CN VII.

CN XI: AccessoryFunctions: Controls trapezius & sternocleidomastoid Controls swallowing movements

1. SternocleidomastoidPress a hand against the patient's jaw and have the patientrotate the head against resistance. Pressing against the rightjaw tests the left sternocleidomastoid and vice versa. 2. TrapeziusHave the patient shrug shoulders against resistance and assessweakness.

CN XII: HypoglossalFunction: controls tongue movements 1. Listen to articulation. 2. Inspect tongue in mouth for wasting, fasciculations. 3. Protrude tongue: deviates to affected side.

Motor system dont forget to compare both limbs InspectionPalpation ( muscle bulk + tenderness )Muscle tone Muscle powerReflexes

Motor systemUpper 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 Dysdiadochokinesia

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 Foot Tapping test

Sensory systemSpinothalamic pathway Pain and Temperature ( usually temperature is not tested )

Posterior column pathway Vibration and Proprioception

Light touch with cotton wool

BackInspect for deformity scars neurofibromas .

Palpate for tenderness over the vertebral bodies

Do the straight leg raising test

****************Dysdiadochokinesis is the medical term for an impaired ability to perform rapid, alternating movements *******