Becca Poore and James Wight

Examination of the Central Nervous System I – Olfactory Ask patient if they have noticed a change in their sense of smell Ask patient to sniff though both nostrils and then one at a time Identify common odours (coffee, peppermint) II – Optic Acuity - Test near and far vision (with glasses on – chart 6m away) – test each eye separately Fields – Test by confrontation – patient looks at your nose – you waggle your fingers (move towards centre) – one eye at a time (both you and pt). Check for neglect (one or both fingers waggling – both eyes open) Blind spot – close one eye – compare yours to theirs Pupils – PERLA 1) Size equal 2) Light reflexes - hand on forehead – shine light in from side (otherwise get accommodation) – look for direct light reflex – consensual light reflex – do in other eye 3) Swinging light test – shine light in one eye (get normal consensual reflex in other eye) – shine light in other eye – dilates and then constricts = RAPD 4) Accommodation – follow finger in – pupils should constrict Pupils not equal: Horner’s syndrome – loss of the sympathetic supply leads to miosis (pupil constriction), sunken eye, ptosis (partial) & anhydrosis (loss of sweating) DM – paraS III lost – Edinger Westphall nucleus ∴ptosis????? Holmes-Adie syndrome – usually unilateral dilated pupil, slow light reflex but accommodation is normal. Associated with absent knee jerks, and completely benign. Marcus Gunn pupil – there is a relative afferent pupillary defect (RAPD). The swinging light test is performed, showing a normal consensual reflex but abnormal direct light reflex due to problems with optic N, such as in MS and DM. Argyll Robertson –the pupil is small and irregular, and doesn’t react to light (although accommodation is normal). Seen in tertiary syphilis. Fundus – fundoscope / opthalmoscope – disc, macula, vessels – in 4 quadrants Blindness: Optic disc probs – pappilitis / papilloedema Nerve – demyelination A: Monocular blindness B: Chiasm – compression by pituitary (sits underneath and expands up and out with tumour) → bitemporal hemianopia (lose upper outer quadrant 1st – later whole of outer halves) C: Homonymous hemianopia (lose all L side or all R side). Due to ischaemic events – from chiasm backwards D: Scotoma = infarct in occipital lobe (lose blob in middle of visual field)

III, IV & VI – Occulomotor, trochlear & abducent Look for ptosis (droopy eyelid) – partial = sympathetic loss, total = III palsy and asymmetry in pupil diameters (<3mm=miosis, >5mm=mydriasis) Assess eye movements - keep head still with hand near head - follow your finger (which is >50cm away) in an H pattern. Ask about any double vision (diploplia). Look for internuclear ophthalmoplegia (failure of adduction, seen in MS when the medial longitudinal fasciculus is damaged). Assess nystagmus - Ask patient to follow rapidly moving finger - 2-3 beats is normal, more is indicative of cerebellar or vestibular pathology. V – Trigeminal (Sensory to face, scalp, tongue + buccal mucosa, motor for mastication, sensory limb of corneal reflex, jaw jerk) Test touch + pain in 3 sensory divisions (ophthalmic, maxillary, mandibular) – close eyes – cotton wool on area – can you feel it? – same area other side – can you feel it? – do they feel the same? – next area Assess corneal reflex - Touch edge of cornea with wisp of cotton wool and watch for blinking. The corneal reflex can be obliterated if pt wear contacts Assess muscles of mastication - Clench teeth and palpate masseter & temporalis. Open jaw against resistance. Assess jaw jerk - Open mouth (let it hang open), put your thumb on the patient’s chin, and strike thumb with tendon hammer. Closing of the jaw is abnormal (eg in MND). VII – Facial (Motor – face & taste ant 2/3 tongue via chorda tympani – Temporal, zygomatic, buccal, mandibular, cervical) Look for facial paralysis (no wrinkles / droop) Frown and look up (should wrinkle forehead). Temporalis has bilateral innervation. Raise eyebrows Shut eyes tight against R Grimace, smile Show teeth, blow out cheeks, whistle Test taste – sugar (sweet) – salt – quinine (bitter) – vinegar (sour) VIII – Vestibulocochlear Test hearing in each ear – rub fingers next to ear – can you hear that? - repeat whispered no.s or words or (occlude opposite ear) Rinne’s test - hit tuning fork – hold on mastoid bone till they can’t hear it then hold it over meatus (opening) – should then hear it again - air should be better than bone (bone better in conduction deafness) Weger’s test - tuning fork on vertex of skull – sound heard equally in both ears? Inspect ear passages if problem IX – Glossopharyngeal (nasty tests therefore don’t do unless need to) Test taste on post 2/3 tongue – as before Feel swallow Gag reflex - Touch post, pharyngeal wall (sensory limb IX, motor limb X). X – Vagus (Muscles of vocal cords + soft palate) Ask patient to cough (bovine?) Say ‘a, e, i, o, u’ Say agh – soft palate and uvula central or deviated? (uvula pulled to strong side) Gag reflex as above. XI – Spinal accessory Examine bulk & power of sternomastoid and trapezius muscles Shrug shoulders against resistance Turn head against R XII – Hypoglossal Inspect tongue – wasting / fasciculation?

Stick tongue out – deviation? (deviates away from strong side – pushed out) Ask patient to push tongue against each cheek whilst you apply resistance outside