CNS PROFORMA-DR S V PRASHANTHI RAJU MD (AIMSR)

Taking a detailed history and performing a careful examination can help

the doctor to determine the site of a specifc neurological lesion and reach
a diagnosis, or at least diferential diagnoses.
A systematic approach is required.
Observation of the patient when they walk in --
Gait
Look at the patient's gait as they walk in to the room.
Note if there evidence of, for example, hemiparesis, footdrop, ataxic gait,
a typical Parkinsonian gait.
Speech
Is there a problem with articulation (dysarthria)? Here comprehension is
retained and speech construction is normal. There is usually weakness or
inco-ordination of the orolingual muscles.
Is there a problem with phonation (dysphonia)? This is usually due to
laryngeal problems which can cause voice hoarseness. There may be
reduced speech volume. Is there a problem with language function
(dysphasia)? This is due to a lesion in the language areas of the dominant
hemisphere.

Involuntary movements
Is there evidence of, for example, tremor, tics, chorea, hemiballismus,
orofacial dyskinesias?
History
Specifc emphasis should be placed on the following:
Presenting complaint-
Elaborate about these symptoms: When was patient normal or
asymptomatic Before this illness started. When did problem start? What
are they?
Which part of the body do they afect? Are they localised or more
widespread?
When did they start sudden or progressive or static?
How long do they last for duration?
Were they sudden, rapid or gradual in onset? Is there a history of trauma?
Are the symptoms static or deteriorating, or are there exacerbations and
remissions? For example, worsening of symptoms with hot environments -
eg, sauna, hot bath or hot weather in demyelinating disorders (called
Uhthof's sign).
Does anything trigger the symptoms - eg, exercise( myasthenia gravis),
sleep( loss of sleep triggers Migraine), posture or external stimuli such as
light or smell(triggers Migraine)

Ask about symptoms (features of neurological disease):in order –

Ask history about and altered consciousness, speech disturbances, memory loss,
history of each cranial nerve involvement, loss of power in limbs , sensory loss,
incoordination, gait changes, bladder and bowel changes. Then

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Headache,Seizures,Photophobia.
Numbness, pins and needles, cold or warmth.
Weakness, unsteadiness, stifness or clumsiness.
Nausea or vomiting.
Visual disturbance.
Altered consciousness.
Psychological changes - eg, agitation, tearfulness, depression or elation,
sleep disturbance.
Bladder and Bowel History – ability to feel fullness and empty or hold till
they reach rest room. Any Incontinence and relation of incontinence to
coughing sneezing.
A collateral history maybe useful.
Try to understand how the symptoms may afect the patient's life - ask
about activities of daily living.

Elaboration Of History:

Headache : site, onset, character, aggravating and relieving factors, radiation, associated
features (vomiting, photophobia), timing, severity.
Transient loss of consciousness: a.duration of loss of consciousness b.Presence of
prodrome c. what was the patient doing then – at rest or working ? d. any triggers?

e. Was it associated with a episode of seizure? Was there any self injury or tongue bite? f.
Drug history – of antihypertensives g. History of chest pain or cardiac illness in past

3.Stroke and transient ischaemic attack : onset, duration, progression, time of day it has
occurred, what was the patient doing then – at rest or doing daily work, has there been any
improvement in the symptoms? (Suggestive of TIA), history suggesting motor, sensory or
cranial nerve involvement. Bladder and Bowel involvement. H/O Seizures after insult.

4.Dizziness and vertigo : description of the attack, whether associated with change in
posture, Neck Pain, history of cerebrovascular disease, whether patient was having anxiety
or was panic, history of drug usage, recent URTI (if any)

Motor system history

a. Is there any thinning of muscles (in case of chronic cases)

b. Presence of any abnormal movements
c. Upper limbs:Is patient able to mix food and feed and dress herself, raise arm above
shoulder, coomb hair .
d. Lower limbs:Is patient able to squat, sit from lying down position without using hands,
walk upstairs and climb downstairs, hold slippers, stand on toes.

Sensory system history

a. Is patient able to appreciate clothes on body

b. Feel the temperature of water as hot or cold while bathing
c. Is patient feeling dizzy while washing face
d. Is patient able to feel floor while walking, does patient have any feeling of walking on
cotton wool or on pebbles/thorns or has burning feet.

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Cerebellum history

a. Is patient able to reach for objects correctly?

b. Is patient able to walk straight (on bunds)?
c. Is patient able to sit from a lying down position without swaying on either sides?

Bladder and bowel incontinence : Urinary urgency, frequency and nocturia are
associated with an ‘upper motor neurone (UMN)’ bladder and characteristic of spinal
cord disease, especially demyelination.
History of Fever, Headache , Photophobia and altered conscious state.-
Meningitis

Past medical history--- similar complaints in past.

Some neurological problems can present years after a causative event.
Enquire about other medical problems, past and present. These may give
clues to the diagnosis. For example:
A person in atrial fbrillation may be producing multiple tiny emboli.
There may be vascular problems or recurrent miscarriage to suggest
antiphospholipid syndrome and CVA or CVT in young people.
Diabetes mellitus. Hypertension, Contact with TB.
Rabies Vaccination.

Systematic enquiry
The systematic enquiry is very important here. For example: Fever
Loss of weight and appetite may suggest malignancy and this may be a
paraneoplastic syndrome.
Gain in weight may have precipitated diabetes mellitus.
Polyuria may suggest diabetes mellitus. Difculty with micturition or
constipation may be part of the neurological problem but was not
volunteered in the general history. In men, enquire about erectile
dysfunction.

Social history
Note smoking and drinking habits. Alcohol is a signifcant neurotoxin, both
centrally and peripherally.
Ask about drugs including prescribed, over-the-counter and illicit. This
includes complementary and alternative medicines.
Ask about occupation and what it involves. There may be exposure to
toxins. Is repetitive strain injury likely? Is there prolonged visual work
which may predispose to tension headache or migraine? The job may
involve driving but the patient has admitted to convulsions. He may work
at heights or in a dangerous environment.
Ask about marital status. Has there been recent bereavement or divorce
which may have afected symptoms?
Ask about sexual orientation and consider the likelihood of sexually
transmitted infection - eg, syphilis, HIV

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Family history- Anyone in family has same disease.
Consider if there may be a genetic basis or predisposition. For example:
A cousin with Duchenne muscular dystrophy or Becker's muscular
dystrophy would be very important for a boy who cannot run like his
peers.
Huntington's chorea is unusual in that it is a familial disease that does not
present until well into adult life.
A family history of, for example, type 2 diabetes mellitus, cerebral
aneurysm, neuropathies, epilepsy,migraine or vascular disease may be
important.
General Examination CNS:
Consious state, oriented to time place and person,
pallor/icterus/clubbing/ vital signs
Pulse- regular or irregular BP- high BP indicates risk of stroke

Then look for neurocutaneous markers-

Examine the neck movements:

Is there evidence of degenerative disease( cervical Spondylosis/ PIVD)
which may be producing radicular symptoms in the upper limbs? Examine
flexion, extension and rotation.

Look for Lhermitte's sign. This is when neck flexion causes an electric
shock-like feeling on the limbs. It is due to disease in cervical spinal cord

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sensory tracts (seen in, for example, multiple sclerosis, syringomyelia,
tumours).

-Palpate the supraclavicular fossae:

-Look for enlarged lymph nodes or cervical ribs.
-Listen for any bruits: -Listen at the carotid bifurcation at the angle of the
jaw for carotid bruits. -Listen over the supraclavicular fossa for vertebral
or subclavian bruits.
-A common carotid bruit may be heard by listening between these two
sites.Listen with the bell of the stethoscope over a closed eyelid for bruits
due to cerebral
arteriovenous malformations.
-Listen for cardiac murmurs to ensure that any bruit heard is not just due
to transmission of these. Note that just because a bruit is not heard, it
does not mean that there is no signifcant stenosis present.

Examination of higher mental functions:

1. Consciousness – Glasgow coma scale if altered consciousness is present

2. Appearance
3. Orientation to time, place and person
4. Handedness
5. Intelligence
6. Memory – check for immediate, recent, and remote memory. Ask for number
of kids, patient’s address, date etc.
7. Speech
8. Perceptions – delusions, hallucinations or illusions

Examination of speech
Look for spontaneous speech, fluency and use of appropriate words during
conversation.
Ask the patient to name objects.
Ask the patient to carry out some commands to assess their
comprehension.
Ask the patient to read aloud. This can show evidence of any dyslexia.
Ask the patient to repeat a simple sentence. Inability to do this suggests a
conduction dysphasia.
In some cases -Look at the patient's handwriting. There may be problems
with form, grammar or syntax which may suggest a more global language
problem and not just a speech disorder.

Cranial nerves
Examination of the cranial nerves takes practice. The cranial nerves and
their function is summarised below.
I (olfactory nerve): smell.
II (optic nerve): visual acuity, visual felds and ocular fundi.
II, III (optic nerve and oculomotor nerve): pupillary reactions.

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III, IV, VI (oculomotor, trochlear and abducent nerves): extra-ocular
movements, including opening of the eyes.
V (trigeminal nerve): facial sensation, movements of the jaw, and corneal
reflexes.
VII (facial nerve): facial movements and gustation.
VIII (vestibulocochlear nerve): hearing and balance.
IX, X (glossopharyngeal and vagus nerves): swallowing, elevation of the
palate, gag reflex and gustation.
V, VII, X, XII (trigeminal, facial, vagus and hypoglossal nerves): voice and
speech.
XI (accessory nerve): shrugging the shoulders and turning the head.
XII (hypoglossal nerve): movement and protrusion of tongue.

Cranial nerve examination

Olfactory nerve
Tested using bottles containing characteristic substances such as
peppermint, cofee or vanilla. Ask
the patient to identify each in turn.
Test each nostril separately and occlude the other.
The patient's eyes should be closed.
If such bottles are not available, simply ask the patient if he or she has
any problems with smell or taste.
Remember that most of what we call taste is really smell.

Optic nerve
Usually done bedside by finger counting
Visual acuity can easily be tested with a Snellen chart. If the patient
normally wears spectacles, they should wear these.

Test the visual felds by confrontation. Sit about 40 cm away from the
patient and ask them to keep their eyes fxed on your nose. Ask them to
cover one eye. Hold your fnger half way between you and the patient
with your arm extended. Test each quadrant of their visual feld in that
eye by moving your fnger laterally to medially along the diagonal. Move
inwards from the periphery at a number of points in
the upper and lower, nasal and temporal quadrants. Ask the patient when
your fnger appears into view.
If you also fx on their nose, you can compare their response with yours,
taking your own as normal.Repeat for the other eye.
Take the ophthalmoscope and ask the patient to fx their gaze on
something in the distance. First shine the light on each eye and then
remove it. The pupil should be brisk in its response. Check direct and
consensual reflexes (the reaction of the pupil on the side that you shine
the light in is called the direct light reflexx the constriction of the other
pupil is the consensual light reflex).

Test accommodation by asking the patient to look in the distance and

then at an object close up. Look for any change in pupil size.

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Then use the ophthalmoscope to examine the back of each eye. Check
that the optic disc is clear and that there is no papilloedema. Note the
vessels of the retina and try to see the periphery
Oculomotor, trochlear and abducent nerves
Hold the patient's head still with your left hand on their forehead.
With your arm extended, hold out your right index fnger about 40 cm in
front of the patient. Ask them to follow your fnger with their eyes.
Move your fnger up and down and left and right. There should be a full
range of movements of both eyes.
Then move the fnger to the left and hold it there for several seconds
whilst the eyes are observed for nystagmus. Repeat to the right and up
and down. False positive tests for nystagmus can result from holding the
fnger too close and by moving it too far to the extreme of vision.
Test convergence by bringing in your fnger from a distance towards the
tip of the patient's nose and asking them to focus on it.

Trigeminal and facial nerves

Lightly touch each side of the face in the three sensory regions (forehead,
cheek/side of nose and chin) and ask if it feels normal and symmetrical.
Ask the patient to clench their teeth. Both masseters should feel frm and
strong. Ask the patient to open their jaw against resistance. In this brief
assessment it is fair to omit the corneal reflex.
Ask the patient to give a smile, demonstrating what you want. Is it full and
symmetrical? Ask them to screw up their eyes. Gently try to prise them
open. You should fail. If there is any facial weakness, ask them to raise
their eyebrows. The upper motor neurone innervation of the muscles of
the forehead is bilateral. Hence a lower motor neurone lesion will cause
asymmetry but an upper motor neurone
lesion will not.

Vestibulocochlear nerve
Either whispering into each ear or using a high-frequency tuning fork can
give a very crude assessment of hearing.
.
Glossopharyngeal, vagus nerves
Ask the patient to open their mouth wide and to say, "Arhh". Phonation
should be clear and the uvula should not move to one side.Elicit the gag
reflex by touching the tonsil or the pharynx. There should be elevation of
the pharynx and
the palate. Test each side.Ask the patient to puf out the cheeks.

Accessory nerve
This nerve supplies the trapezius and sternomastoid muscles.
Ask the patient to shrug their shoulders up. Try to push them down. Then
ask them to rotate their head to the right against resistance on the right
side of the chin from your hand. Repeat for the left side. Both these
movements should be very difcult to resist.

Hypoglossal nerve
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Ask the patient to protrude their tongue. Note any deviation or wasting.
Assess tongue movement from side to side.

Examination of the motor system

There are separate articles that describe motor examination in detail:
Both upper and lower limbs should be examined. The following gives a
brief outline of the examination.
Inspection of muscles-Start by looking at the patient.
Note the resting posture. Is there unusual rotation or posture of a joint? Is
the patient
symmetrical?
Look for muscle bulk if there is wasting or hypertrophy. Is it focal or
difuse? An upper motor neurone lesion will produce disuse atrophy but a
lower motor neurone lesion or myopathy will produce much more marked
wasting.
Look for muscle fasciculation (a sign of lower motor neurone disease
process). These are subcutaneous twitches over a muscle belly at rest.
Tapping the belly may stimulate fasciculation.

Tone:
Hypertonia is found in upper motor neurone lesionsx hypotonia is found in
lower motor neurone lesions and cerebellar disorders.
IN THE UPPER LIMBS:
Ask the patient to let their shoulders and arms 'go floppy'.
Flex and extend their shoulder passively and feel for abnormality of tone.
Repeat for the elbow and w9rist.
In the lower limbs:
Ask the patient to let their legs 'go floppy'.
Internally and externally rotate the 'floppy' leg. Assess for any increased
or
reduced tone.
Then lift the knee of the bed with one of your hands. Does the ankle raise
of the
bed as well, signifying increased tone?

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Power:
As with sensation, test each group of muscles in a systematic order.
The Medical Research Council (MRC) has a recommended grading system for
power :MRC scale for muscle power
0 No muscle contraction is visible.
1 Muscle contraction is visible but there is no movement of the joint.
2 Active joint movement is possible with gravity eliminated.
3 Movement can overcome gravity but not resistance from the examiner.
4 The muscle group can overcome gravity and move against some resistance from
the examiner.
5 Full and normal power against resistance.

Upper extremity muscles •Deltoid—abduction (elevation) of upper arm

–(C5-6, axillary nerve)
•Biceps—flexion of forearm at elbow
–(C5-6, musculocutaneous nerve)
•Triceps—extension of forearm at elbow
–(C6-8, radial nerve)
•Extensor carpi radialis—dorsiflexion of hand at wrist
–(C5-6, radial nerve)
•Abductor pollicus brevis—palmar abduction of thumb
–(C8-T1, median nerve) w/ thumb at right angle to palm
•Interrosei—finger abduction (dorsal) & adduction (palmar)
–(C8-T1, ulnar nerve)
Lower extremity muscles how to test
•Iliopsoas—hip flexion
–(L1-3, femoral nerve)
•Quadriceps—knee extension

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–(L2-4, femoral nerve)
•Hamstrings—knee flexion
–(L5-S2, sciatic nerve)
•Tibialis anterior—ankle dorsiflexion
–(L4-5, deep peroneal nerve)
•Gastrocnemius/soleus—ankle plantar flexion
–(S1-2, tibial nerve)

Deep tendon refexes:

Eliciting deep tendon reflexes requires good technique and an appropriate
tendon hammer is required.
Tendon reflexes tend to be brisk when there is an upper motor neurone
lesion and
depressed in a lower motor neurone lesion. Isolated loss of a reflex can
point to a
radiculopathy afecting that segment.
Reflexes can either hyperactive (ccc), normal (cc) sluggish (c) or
absent (-). ± is used when the reflex is only present on reinforcement //Or
use

Reflex grading :

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Reflexes areeauepictreuaic ardea tres alickeearapictrteicrlaues teicpit afteaers y an uees rr uic f

Reflexes: Reinforcement when u r unable to elicit in a tensed patient :

• Isometric contraction of other muscles (Jendrassik maneuver, teeth clenching)

• Distraction -ask the patient something related to kids, job ect so that they relax.

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Superficial tendon refexes:

Plantar (L4-S2, esp S1; tibial nerve)

To elicit this, the patient should be lying down with their legs extended.

Use a blunted point and run this along the lateral border of the foot,
starting at the heel and moving towards the big toe. Stop on the frst
movement of the big toe.

Normal response = flexion (toes go down) Abnormal response = extension

(dorsiflexion of great toe as the extensor hallucis longus is recruited) Babinski sign

Sign of hyperexcitability associated with corticospinal dysfunction. An extensor

plantar response (upgoing big toe) is pathological and signifies an upper motor
neurone lesion.

Abdominal refex – patient should be lying on bed with abdomen

exposed and with a blunt object strokes are made from periphery towards
umbilicus and contraction of abdominal muscles are noticed. Absence of

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contractions denotes UMN lesion or fat belly or lax abdomen in Women.

Cremastric refex: ( Males) and Anal refexes are done sometimes to

localize dermatomes or segments involved.

Co-ordination:
The cerebellum helps in the co-ordination of voluntary, automatic and
reflex movement.
Neurological examination of the upper limbs include:
The fnger-nose test ,Rapid alternating movement
Tests of cerebellar function in the lower limbs examination of the lower
limbs include:
The heel-shin test, The heel-toe test
Romberg's test: examines lower limb cerebellar function but also tests
balance
mechanisms that rely on the cerebellar, vestibular and proprioceptive
systems.
Ask the patient to keep their eyes open and stand with their feet together,
arms
by their sides. Then ask them to maintain this position when they close
their eyes.
Patients who have cerebellar lesions often cannot stand in this position,
even
with their eyes open. If balance is only lost when the eyes are closed, this
signifes a proprioceptive or vestibular lesion.
Be ready to catch the patient by standing behind.

Examination of the sensory system

See the separate articles that describe sensory examination in detail: .
Both the upper and lower limbs should be examined. Work in a methodical
way. A logical progression is required when examining each sensory
modality.
With the lower limbs, you may want to start testing over the groin and
move down the front of the leg and up the posterior side, as this moves
progressively from L1 to S3 dermatomes.

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With the upper limbs, you may want to start testing over the shoulder and
to move along the lateral aspect of the arm and up the medial side, as
this moves progressively from C4 to T3 dermatomes.

The following sensory modalities should be tested:

Light touch and pinprick (sharp touch):

Both light touch and pinprick are conducted along the same pathways.
Light touch can be tested by using a light touch of the fnger, a piece of
cotton wool or a small brush. It is important to touch and not to stroke, as
moving sensations, such as rubbing and scratching are conducted along
pain pathways.
Test sharp touch using a dedicated disposable pin. Test light touch using
the light touch of a fnger, a piece of cotton wool or a piece of tissue
paper.

Temperature:
One approach is to touch the patient with a tuning fork, as the metal feels
cold.
Containers of warm and cool water may be used for more accurate
assessment. Ask the patient to distinguish between warm and cool on
diferent areas of the skin with their eyes closed.
Proprioception (joint position sense):
This can be tested at the distal interphalangeal joint of the index fnger
and at the
interphalangeal joint of the big toe.
The examination technique is described in the articles on neurological
examination of the upper and lower limbs.
Vibration sense:
This can be examined using a vibrating 128 Hz tuning fork.
Refer to the above-mentioned articles for examination technique.
Two-point discrimination
This is usually just performed on the pulp of the fngers, using a two-point
discriminator.

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DiscriminativeSensations:
Stereognosis, graphesthesia, two-point discrimination
Tests ability of sensory cortex to correlate, analyze, & interpret sensations
Dependent on touch & position sense
Screen first with stereognosis - proceed to other methods if indicated

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Cerebellar examination :

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Signs of meningeal irritation: Is there any neck stifness (can be a sign
of meningeal irritation)? The chin can normally touch the chest when the
neck is flexed but this is not possible if neck stifness is present.
In Meningitis main feature is neck stifness, or increased resistance to
passive flexion of the neck. It should be tested whenever there is a clinical
possibility of meningeal irritation. It is a more sensitive test than Kernig's
sign. These signs are nearly always due to meningitis or to subarachnoid
haemorrhage.

Kernig's sign is elicited with the patient supine on the bed. Passively
extend the patient's knee on either side when the hip is fully flexed. In
patients with meningeal irritation afecting the lower part of the spinal
subarachnoid space this movement causes pain and spasm of the
hamstrings.
(a) Kernig's sign- Extension of the knee on a flexed hip at 90° causes restriction and pain
Beyond 135° ,
(b) Brudzinski contralateral leg sign- Reflex flexion of a lower extremity on passive flexion
of the opposite extremity.

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