CENTRAL NERVOUS SYSTEM 

EXAMINATION 
Lesson Plan for 4TH YEAR,  
Prepared by Dr. Mahrung Jamali 

OVERVIEW & PURPOSE 

Central Nervous System examination is divided into two main parts - Sensory 
Examination and reflexes , second is Cranial nerves examination. 

ESSENTIALS OF CNS EXAMINATION 

● Higher Mental functions - Consciousness , memory, posture of the patient and 

behaviour and emotion of the patient. 
● Speech - aphasia, dysphasia and dysphonia 
● Gait - ​Ataxic​ or ​broad-based gait​ (due to a cerebellar lesion, or alcohol) ; ​Shuffling​ or
festinating gait​ (“gait apraxia”) ; ​Tilted gait ; High-stepping gait.
● Coordination - ​coordination in the upper limbs: the ​finger-nose test​ and
dysdiadochokinesis ; ​coordination in the lower limbs ​heel-shin test.

OBJECTIVES FOR SENSORY SYSTEM 

1. Assess pain, temperature, light touch, and vibratory response. 

2. Assess position sense and discriminative sensation. 
3. Elicit deep tendon reflexes of biceps, triceps, brachioradialis, knee and ankle. 
4. Properly test the plantar response or Babinski’s sign. 

EXAMINATION : 

1. INSPECTION - careful handshake, and overall inspection of patient on the bed.   

2. SENSATION UPPER AND LOWER LIMBS - use symmetric pattern on both sides. 

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 a. First light touch with hand to assess any lesions, then test pain sensation (a 
blunt end and pointed end, tell patient to close eyes), then temperature (hot 
and cold tubes), and then light touch test with a cotton wisp (when felt 
reply). Vibratory response checked with a tuning fork.  
b. Positional sense performed on toes and fingers and the wrist (patient’s eyes 
closed) identify the movement. Discriminative sensation - place an object in 
the palm while patient’s eyes are closed and let them identify. Blunt object 
to draw a number on the palm. Two-point discrimination (touched with 
two points or one point). Point localization - touch a point on the skin and 
they should point where they were touched. Extinction - touch one or two 
areas simultaneously and patient needs to be able to identify one side or 
two sides.  
3. REFLEXES   

Deep tendon Reflex response - Grading scale  

0  Complete absence of movement  

1+  Diminished reflex, movement with 

reinforcement 

2+  Average, normal response 

3+  Brisker than average response 

4+  Very brisk, hyperactive response with 

clonus 

4. Biceps Reflex (C5/C6), Triceps reflex (C6/C7), Brachioradialis reflex (C5/C6) 

5. Knee Reflex (L2/L3/L4), Ankle Reflex (S1/L5) - Test for ankle clonus if Knee and 
Ankle reflex are hyperactive.​ Tip : ​Never use the sharp end of hammer on the 
tendon 
6. Cutaneous Stimulation Reflexes - Above T8-10 and below T10-12 using pointed end 
of the broken q-tip.   
7. Plantar Response - end of the hammer. Lightest stimulus. Normal is downgoing 
toe. 
8. Meningeal Sign : test Brudzinski’s sign. Make sure there is no injury to the cervical 
vertebrae or cervical cord. 
9. Kernig’s Sign : pain and resistance to knee extension 
10. Straight-leg raise test  

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 MATERIALS NEEDED 

1. Q-tip 
2. Paper clip 
3. Hammer 

ACTIVITY 

Sensory Examination and reflexes ​https://www.youtube.com/watch?v=v0Bz2TF8FCg 

Cranial Nerves examination ​https://www.youtube.com/watch?v=AZu_Jb81V1k 

CRANIAL  SENSORY  FUNCTION  TEST 

NERVE  / MOTOR 

I - Olfactory  Sensory  Sense of smell  ● Ask patient to occlude one nostril 

and close their eyes. 
● Present a stimulus, such as coffee, 
and ask the patient to identify the 
smell. 

II - Optic  Sensory  Vision  ● Visual Acuity 

● Colour Vision 
● Visual Field 
● Pupillary response to light to test 
for an afferent pupillary defect 

III -  Motor  ● Ocular motility (superior,  ● Routinely tested during 

Oculomotor    inferior and medial recti,  examination with extraocular 
  inferior oblique)  motility 
  ● Lid elevation (levator  ● Supraduction 
  palpebrae superioris)  ● Infraduction 
  ● Pupillary constriction  ● Adduction 
  (efferent limb of light 
  pathway) 
 

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 Sensory 

IV - Trochlear  Motor  Ocular Motility (Superior oblique  ● Routinely tested during 

muscle)  examination with extraocular 
motility. Infraduction upon 
adduction. 
● Intorsion 

V - Trigeminal  Motor   Muscles of mastication  ● Assess the motor function V by 

    feeling either side of the jaw just 
    inferior and anterior to the ear 
    for muscle contraction while 
    asking the patient to clench their 
    teeth.  
     
     
     
Sensory  Face, Anterior part of head and  ● Test distributions of V1, V2 and 
inside the mouth  V3 separately with a light torch 
with a cotton wisp to the 
forehead, upper cheek and jaw, 
respectively, with the patient’s 
eyes closed. Ask the patient to 
compare the sensation from right 
to left, looking for any 
asymmetry. 
● If indicated, test the corneal 
reflex (afferent limb: ophthalmic, 
V1 and efferent limb, V2) with a 
cotton wisp. 

VI - Abducens   Motor  Ocular motility (abduction linear  ● Routinely tested during 

rectus)  examination with extraocular 
motility  
● Abduction 

VII - Facial  Motor  Muscles of facial expressions,  Ask the patient to smile, raise their 
  stapedius muscle  eyebrows, frown, puff out their cheeks 
    and squeeze their eyelids tightly 
    together while looking for any 
    asymmetry or weakness. 
Sensory  Taste to anterior ⅔ of tongue 
Part of external ear 
Parasympathetic ( lacrimal, 
submandibular and sublingual 
glands) 

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VIII -  Sensory  Auditory and vestibular system  Hearing can grossly be checked by 
Vestibulocochl (balance and hearing)  rubbing your fingers together near a 
ear  patient’s ear and asking if they can 
identify which ear can hear the sound 
and if they notice any asymmetry in the 
volume of the sound. 

IX -  Motor  Stylopharyngeus  Ask the patient to open his mouth and 

Glossopharyng     say “Ahh” and look for any asymmetry 
eal  Sensory   Pharynx and soft palate  in palate or deviation of the uvula. 
Taste (posterior ⅓ of tongue) 
Parasympathetic (parotid gland) 

X - Vagus  Motor   Muscles of soft palate, pharynx  CN IX and X T ​ hese are not examined
  and larynx  separately; their close anatomic relationship
    rarely results in isolated lesions. 
Sensory  Parasympathetic (thorax and 
abdomen) 

XI - Accessory   Motor  Sternocleidomastoid and  Ask the patient to turn the head from 
trapezius muscle  side-to-side and shrug their shoulders 
looking for any asymmetry or weakness. 

XII-  Motor  Muscle action of tongue  Ask the patient to stick their tongue out 
Hypoglossal  and note if it deviates to one side. 

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