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CNS PE

CNS PE

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Published by: jslum on Jul 06, 2011
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11/07/2012

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- ysca xamnaonCranial NervesI (Olfactory)
Can you smell?Anosmia = cannot smell
II (Optic)
Visual acuity (Snellen chart)
y
 
Eg.
6/6
y
 
W
ith spectaclesVisual field (Red pin)
y
 
Remove spectacles
y
 
Ask patient to stare into your eyes (close another eye)
y
 
4
Directions to test for each eyeInside-to-outside (from center of eye until cannot see the pin)
y
 
B
lind spot (temporal portion of visual field)Colour vision
y
 
3
Colours
y
 
Can you see the colours
 
F
undoscopy
III (Oculomotor), IV (Trochlear), VI (Abducent) -
(LR
6
SO
4
)
3
 Inspection (shine pen torch below eye)
y
 
Size, shape of pupils are equal/ unequal on both sides
y
 
P
tosis (eyelid droppin
g
)
y
 
N
ysta
g
mus (conju
g
ate eye movement)
E
ye movements
y
 
Ask patient to focus on your fin
g
er  H pattern
y
 
Double vision?
o
 
B
oth eyes  vision axis not parallel
o
 
Close 1 eye  lens displace
y
 
T
o check for muscles (C
N
III, IV, VI)Saccadic movements (frontal lobe)
y
 
Ask patient to follow the sound when examiner snaps the fin
g
ers
P
ursuit movements
y
 
Ask patient to follow the examiners fin
g
ersLi
g
ht reflex
D
irect Light Reflex Consensual Light Reflex
Shine li
g
ht on same eyeSame eye constrict (pupil)Shine li
g
ht on 1 eye
T
he other eye constrict (pupil)Accommodation reflex
y
 
Ask patient to look at a distance (far)
 
y
 
Ask to focus on fin
g
er about
30
cm in front of nose (near)
 
y
 
See normal constriction of both pupils
 V (Trigeminal)
Corneal reflex (V
1
  Ophthalmic & VII)
y
 
U
se cotton wool
y
 
T
ouch cornea (not conjunctiva)Ask whether the patient can feel (C
N
V
1
)
y
 
If blinkin
g
of both eyes (C
N
VII) (
N
ormal response)Sensory (
P
ain & Li
g
ht touch) (Sharp object, Cotton wool) (
E
yes closed)
y
 
T
est
3
divisions of nerve (V
1
, V
2
, V
3
)Motor (C
N
V
3
)
y
 
Muscles of Mastication (M
TPP
 empty pee)Masseter,
T
emporalis,
P
tery
g
oid (medial, lateral)
y
 
Observe wastin
g
& thinnin
g
of temporalis muscle
y
 
Ask patient to clamp jaws to
g
ether
F
eel for temporalis & messeter muscles
y
 
Attempt to open patients jaw by applyin
g
pressure to chin
y
 
Ask to open mouth (assess jaw deviation  ptery
g
oid muscles)Jaw Jerk
y
 
Relax jaw
y
 
P
lace fin
g
er on chin & tap with hammer
Slight Jerk Increased Jerk
N
ormal
B
ilateral
U
M
N
lesion
Cranial Nerves
(cont
.
)
 VII (Facial)
Inspection
y
 
Symmetry
y
 
P
uff cheeks (symmetry)Motor
y
 
W
rinkle forehead (frontalis)
y
 
Close eyes while examiner attempts to open them (orbicularis oculi)
y
 
P
urse lips while examiner presses cheeks (buccinators)
y
 
Show teeth (orbicularis oris)Stapedius muscle (both ears)
y
 
E
xaminer rub fin
g
ers
y
 
Any loud/ soft sound?
T
aste (anterior 2/
3
of ton
g
ue)
VIII (Vestibulochochlear)
Otoscopy (inspect external auditory meatus, eardrum)Rinnes test
W
ebers test
IX & X (Glossopharyngeal & Vagus)
Speak (if short case) (assess hoarseness)Ask patient to cou
g
h, swallowInspect palate (for palatal weakness)Inspect uvula
y
 
Ask patient to say Ah
y
 
Inspect symmetricalGa
g
reflex
XI (Accessory)
Sternomastoid
y
 
Ask patient to rotate head a
g
ainst resistance
T
rapezius
y
 
Shru
g
the shoulders
XII (Hypoglossal)
Inspect ton
g
ue (atrophy, fasciculation)
y
 
P
rotrude ton
g
ue (check for deviation)
y
 
Move around the ton
g
ue
 
 
U
pper LimbsGeneral
Shake hand (if cannot relax - myotonia)Appearance
y
 
Asymmetry/ deformity
y
 
W
astin
g
 
y
 
Hypertrophy
y
 
F
asciculation
y
 
MyokimiaArm driftin
g
 
y
 
P
atient hold out both hands,
P
alms upward,
P
alm extended,
E
yes closed
y
 
W
atch for evidence of driftin
g
 
y
 
Causes
o
 
U
M
N
lesion
o
 
Cerebellar disease
o
 
Loss of proprioception
F
asciculation
y
 
Arms relaxed on lap
y
 
Inspect for fasciculation
Normal (Benign) Abnormal
F
asciculation present
N
o wastin
g
/ weakness
F
asciculation present
W
astin
g
/ weakness
Tone
Ask patient to relaxAssess by alternatin
g
flexin
g
/ extendin
g
the elbow/ wrist
Tone Tone
U
M
N
lesion
E
xtrapyramidal lesionClasp-knifeLead-pipeCo
g
-wheel (assoc
.
w
.
tremor)
Power
Gradin
g
 
y
 
0
 Complete paralysis
y
 
3
P
ossible a
g
ainst
g
ravity
y
 
5
N
ormal(If reduced) Symmetrical/ asymmetrical on both sides
1.
ShoulderAbduction
Stop me pushin
g
your arm downDeltoid, supraspinatus (C
5
, C6)
Adduction
Dont let me separate your armfrom your body
P
ectoralis major, Latissimus dorsi(C6, C7, C8)
2
.
ElbowFlexion
Stop me from strai
g
htenin
g
yourelbow
B
iceps,
B
rachialis (C
5
, C6)
Extension
Stop me from bendin
g
your elbow
T
riceps brachii (C7, C8)
3
.
WristFlexion
P
atient bend wrist
E
xaminer tryin
g
to strai
g
hten
F
lexor carpi ulnaris, radialis(C6, C7)
Extension
Stop me from bendin
g
your wrist
E
xtensor carpi
g
roup (C7, C8)
U
pper Limbs
(cont
.
)
4
.
FingersFlexion
Squeeze my fin
g
ers hard
F
lexor di
g
itorum profundus,sublimis (C7, C8)
Extension
P
atient extends fin
g
ers a
g
ainstresistance
E
xtensor di
g
itorum (C7, C8)
Abduction
Abduct (open) fin
g
ers, and resistDorsal interossei (C8,
T
1)
Adduction
Dont let me separate your fin
g
ers
P
almar interossei (C8,
T
1)
ReflexesBiceps Jerk
P
lace 1 fin
g
er on biceps tendon, tap(C
5
, C6)
Triceps Jerk
Strike elbow few inches aboveolecranon processLook for elbow extension(triceps contraction)(C7, C8)
Supinator Jerk
(
B
rachioradialis)Strike lower end of radius
W
atch for elbow, fin
g
er flexion
B
rachioradialis(C
5
, C6)
Finger JerkCoordination
(Cerebellum)
Finger-Nose Test
Intention tremor
P
ast-pointin
g
 
Rapidly Alternating Movements
(Dysdiadochokinesis)
T
urn hand over, backwards,forwards on the other one(quickly, smoothly)
Rebound
P
henomenon
F
lex elbow a
g
ainst resistanceSuddenly hand will strike face(delay in triceps contraction)
Rebound
(Arm bounce)Downward pressure & suddenrelease of patients outstretchedarm causes excessive swin
g
in
g
 
 
 
U
pper Limbs
(cont
.
)
Sensation
T
est for each dermatome
T4
N
ipple
T
1
0
U
mbilicus
T
12  In
g
uinal li
g
ament
Pain
(Spinothalamic pathway)
P
in-prick test
Temperature
(Spinothalamic pathway)Hot/ cold
Vibration
(DCML)
P
lace vibratin
g
tunin
g
fork on bony prominence (e
g.
radius)Ask patient to feel until vibration ceasesIf impaired, move more proximally & repeat
Proprioception Testing
(Joint position sense)Open eyes, move DI
P
joint up & down a few timesClose the eyes, ask patient whether it is up/ down
Light Touch
Cotton wool
Peripheral Nerves of 
U
pper LimbsRadial Nerve
(C
5
, C6, C7, C8)(
T
riceps,
B
rachialradialis,
E
xtensor ms
.
of hand)Inspect for wrist dropInstruct to pronate, extend fin
g
ers & wristSensation -
U
se pin to test anatomical snuff-box
Median Nerve
(C6, C7, C8,
T
1)(All ms
.
in forearm except 1 ½ supplied by
U
lnar)(Also supply LOA
F
in hand)Ask patient to touch the pen
T
est for abductor pollicis brevis
Ochsners Clasping Test Oshsners Clasping Test
F
lexor di
g
itorum abnormalityCheck for sensory
U
lnar Nerve
(C8,
T
1)(All ms
.
in hand & 1 ½ ms
.
in forearm)Inspect clawin
g
 
F
roments Si
g
n (check for abductor of thumb)
y
 
Hold paper with forefin
g
er & thumb
y
 
Resist when paper is bein
g
pulledCheck for sensory
Brachial Plexus
(C
5
, C6, C7, C8,
T
1)
P
ain & weakness of shoulder/ arm
E
xclude orthopaedic cause(assoc
.
w
.
movement, inflammation, joint deformity)
E
xamine arm & shoulder
g
ridle (
T
alley  p
g
 
3
67)Ask patient to push the wall (check for win
g
in
g
of the scapulae)

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