Kingdom of Bahrain

Arabian Gulf University

College of Medicine and Medical Sciences

Professional Skills Review

Central Nervous System (CNS)

Prepared by: Ali Jassim Alhashli

Based on: Macleod’s Clinical Examination; 13th Ed
 Physical Examination of CNS
• Start your physical examination by the following system:
– Consciousness.
– Speech.
– Cognition.
– Gait and stance.
– Cranial nerves.
– Sensory system.
– Motor system (+ reflexes).
• Consciousness (level of consciousness): comment if patient is
– Alert.
– Drowsy.
– Stuporous.
– Comatose.
• Speech:
– Dysphasia/aphasia:
• Broca’s: patient understands speech but is not fluent.
• Wernicke’s: patient doesn’t understand speech but he is fluent.
• Conductive (arcuate fasciculus lesion): patient understands speech and is fluent but cannot find his
words.
 Physical Examination of CNS
• Cognitive function:
– Do a rough test before the detailed one (Mini-Mental State Examination MMSE).
– Tell the patient 3 random words and ask him to repeat after you.
– Tell him that you will ask him about those words later. Distract the patient with other questions then
ask him to recall those words:
• 3 out of 3: normal.
• 2 out of 3: ask the patient to draw a clock with the current time → if he can do it → he is normal.
• 1 out of 3: impaired recall → in this case you have to do MMSE.
– MMSE:
• Orientation: to time, place and person.
• Memory:
– Immediate memory: ask the patient to repeat a sentence after you.
– Intermediate memory: ask the patient about what he had for dinner last night.
– Long-term memory: “when were you born?”.
• Calculation: ask patient to count from 100 subtracting 7 or 5 each time; or ask him to pronounce
the word “WORLD” backwards.
• Abstract (reasoning and judgment): ask the patient to explain the meaning of a famous proverb.
Ask the patient to differentiate between 2 different objects.
Physical Examination of CNS
 Physical Examination of CNS
• Gait and stance:
– Left this part for the end of your examination.
– Patient must take off his shoes and socks; expose both legs to mid-calf.
– Ask the patient to stand, walk in the room, turn and come back.
– Then, ask him to walk on a straight line one foot after the other (tandem gait); walk on the tip of his toes, walk
on heels.
– Romberg’s sign:
• Ask the patient to raise his arms to the sides and close his eyes.
• Stand near the patient and be ready to support him if he falls.
• If patient sways or falls → this is considered to be a positive Romberg’s sign indicating the presence of
sensory ataxia (involvement of the dorsal column).
– Gait types:
• Spastic gait (hemiplagia): most commonly seen.
• Scissoring gait: bilateral spastic weakness; seen in patient with cerebral palsy or paraplegia.
• Waddling gait: patient walking on tip-toes; seen in patients with muscular dystrophies.
• High-steppage gait: seen with foot drop due to fibular nerve injury.
• Festinating gait: feet not lifted off the ground with small steps; seen in patients with Parkinson’s disease.
• Ataxic gait: inability to perform tandem gait; seen in patients with cerebellar dysfunction and alcoholics.
Physical Examination of CNS
 Physical Examination of CNS
• Signs of cerebellar dysfunction:
– Head:
• Head titubation: shaking movements of the head.
• Nystagmus:
– Primary: occurring at position.
– 2nd degree: occurring when patient is looking to the left or right sides.
– 3rd degree: occurring at position and when looking to left/right sides.
• Dysarthria: staccato speech.
– Upper limb:
• Intention tremor: finger-nose test.
• Rebound phenomenon: ask the patient to flex his forearm at the elbow while you resist this
movement. Make sure to cover patient’s face with your other hand. Suddenly stop your resistance
for the movement → normally the arm will stop flexion and will not hit patient’s face.
• Dysdiadochokinesis: rapid alternating movement test.
– Lower limb:
• Heel-shin test: patient must raise one leg high up and rub it against the shin of the flat leg starting
from the knee downwards to the foot and repeat.
• Ataxic gait.
• Pendular knee jerk.
Physical Examination of CNS
 Physical Examination of CNS
• Signs of meningeal irritation:
– Neck rigidity: flex patient’s neck
while supine → stretching
irritated meninges → patient will
feel pain and resist flexion.
– Brudzinski’s sign: when flexing
patients neck → patient will feel
pain and flexes his hips and knees
(to relax the stretched meninges).
– Kernig’s sign: flex patients hip
and knee of one side then extend
the leg gradually → meninges will
be stretched and patient will feel
pain.
 Physical Examination of CNS
• Cranial nerves:
– CN-I (olfactory nerve):
• To check for anosmia (inability to smell): most commonly occurs due to Upper Respiratory Tract
Infection (URTI).
• Use non-irritating odors (fruit/ coffee).
• Ask patient to close his eyes and test one nasal opening at a time.
– CN-II (optic nerve):
• Inspection for: ptosis, redness, secretions, squint and nystagmus.
• Test the following for optic nerve:
– Visual acuity:
» Examine each eye separately.
» Use Snelen chart (placed 6 m away from the patient or 3 m when using a mirror).
» A result of 6/6 means: patient see at 6 m what an average person sees at 6 m.
– Visual field:
» Examine each eye separately.
» This test is best performed using perimetry but as a student you have to know the
confronational method: you have to be at the same level with your patient; 1 m away; you
and the patient cover same eyes which are facing each other; ask the patient to look at
your eye with his opened one; move your finger midway starting from 2, 4, 8 and 10
o’clock to the center.
 Physical Examination of CNS
• Cranial nerves (continued):
– CN-II (optic nerve)… continued:
• Test the following for optic nerve
– Visual reflexes:
» Light reflex: dim the lights; ask the patient to focus on a far object; shine a
light source from sides and look for direct and indirect pupillary constriction.
Notice that afferent nerve is CN-II and efferent nerve is CN-III.
» Accommodation and convergence: ask the patient to focus on a far object;
place your index finger or a pen closely between his eyes; ask him to look to
focus on your finger → you must expect the following: medial convergence
of both eyes, pupillary constriction and increased lens convexity.
– Ophthalmoscopy:
» Ask the patient to focus on a far object; when examining patient’s right eye
hold the ophthalmoscope with your right hand and use the right eye of
yours; start 1 ft away from the patient and move from a lateral position;
check for the red reflex; then start moving medially to find the optic disc; to
check the macula ask the patient to look at the scope.
– Color vision: it is checked by using Ishihara cards.
Physical Examination of CNS
 Physical Examination of CNS
• Cranial nerves (continued):
– CN-III (oculomotor nerve), CN-IV (trochlear nerve), CN-VI (abducens nerve):
• Inspection: ptosis, squint, nystagmus, redness/secretions and pupils.
• How to test for them: examiner’s finger placed at the same level of the patient between his two eyes
and moved in the pattern of a capital (H) latter.
– Make sure patients doesn’t have double vision with each movement.
– Frontal eye filed lesion caused by a stroke in frontal lobe → eyes looking TOWARDS the lesion.
– Frontal eye field lesion caused by a seizure in frontal lobe → eyes looking AWAY from the
lesion.
– CN-V (trigeminal nerve):
• Inspection and palpation:
– Atrophy of muscles of mastication.
– Palpate muscles by asking the patient to clench his teeth → checking temporalis and masseter.
– Pterygoid muscle:
» Ask patient to open his mouth and look for deviation of the jaw → notice that in LMNL
the jaw will be deviated towards the side of the lesion.
» Ask the patient to open his mouth against resistance.
Physical Examination of CNS
 Physical Examination of CNS
• Cranial nerves (continued):
– CN-V (trigeminal nerve)… continued:
• Sensation:
– Use a cotton (to check for light touch), pin (to check for pain) and tuning fork (to
check for temperature).
– Ask the patient to close his eyes; start your examination by checking for sensation in
a central area (if patient has sensation in the central area → proceed with your
examination); check the sensation of the 3 division of trigeminal nerve (V1:
ophthalmic, V2: maxillary and V3: madibular) on both sides of the face.
• Reflexes:
– Corneal reflex (afferent: V1, efferent: facial nerve): by a tip of a tissue, gently touch
the cornea of the patient and watch for blinking of both eyes (normal reflex).
– Jaw reflex (afferent and efferent: V3): place your index finger above patient’s open
mouthed chin; tap with a reflex hammer on your index finger → normally no reflex is
present.
– Glabellar reflex (afferent: V1, efferent: facial nerve): tap the center of patient’s
forehead several times; normally there is habituation (if there is no habituation →
this is called Myerson’s sign → and seen in patients with Parkinson’s disease).
Physical Examination of CNS
 Physical Examination of CNS
• Cranial nerves (continued):
– CN-VII (facial nerve):
• LMNL: half of the face will be affected on the same side of
the lesion. Affected side (Bell’s palsy):
– Inability to close the eye.
– Wrinkles of forehead are less prominent.
– Absence of nasolabial fold.
– Dropping of mouth angle.
• UMNL: lower half of the face will be affected on the
opposite side of the lesion.
• Check for the following muscles:
– Frontalis: ask the patient to wrinkle his forehead
against resistance.
– Orbicularis oculi: ask the patient to close his eyes
tightly against resistance.
– Buccinator: ask the patient to full his mouth with
air and you press against it.
– Orbicularis ori: ask the patient to purse his lips (as if
he is kissing).
– Levator angularis: ask the patient to smile.
• Check for taste in anterior 2/3 of the tongue while
patient’s eyes are closed; test for salt, sugar, sour and
bitter.
 Physical Examination of CNS
• Cranial nerves (continued):
– CN-IX (glossopharyngeal nerve) and CN-X (vagus nerve):
• Check for:
– Swallowing (ask patient to drink a glass of water).
– Ask patient to say “Aaaah” and check for uvula and soft palate (when there is
a LMNL of the vagus nerve → there will be deviation of uvula to opposite side
of the lesion and depression of soft palate at the same side of the lesion).
– Ask the patient to cough.
– Check for gag reflex by touching posterior pharyngeal wall (afferent:
glossopharyngeal nerve, efferent: vagus nerve).
– CN-XI (accessory nerve):
• Supplies SCM and trapezius muscles.
– SCM muscle: ask the patient to rotate his head against resistance to the
opposite side of the muscle.
– Trapezius muscle: ask the patient to raise his shoulders against resistance.
 Physical Examination of CNS
• Cranial nerves (continued):
– CN-XII (hypoglossal nerve):
• Inspect patient’s mouth in resting position for atrophy and fasciculations.
• Ask the patient to push his tongue against the side of his mouth and you apply
external resistance to it.
• Ask the patient to stick his tongue out and check for deviation (LMNL shows
deviation of the tongue towards the affected side).
 Physical Examination of CNS
• Motor system:
– Inspection:
• Inspect for muscle atrophy and fasciculations (indicating the presence of a LMNL), hypertrophy
or any other abnormal movements.
• Always remember to compare both sides.
• Don’t forget to check for muscle tone, muscle power and reflexes.
• Muscle tone:
– Definition: resistance of a muscle when moved passively against a fixed joint.
– Hypotonia → flaccidity.
– Hypertonia:
» Spasticity: there is an injury in pyramidal tract; ↑deep tendon reflex, presence of
clonus and Babinski’s sign; clasp knife: resistance only at the beginning of a passive
movement.
» Rigidity: injury to extra-pyramidal tract; lead-pipe: resistance throughout stretching
seen with Parkinson’s disease; cog-wheel: lead-pipe rigidity + tremors.
• Muscle power (do it against resistance):
– Grading:
» Grade-0: no movement.
» Grade-1: flicker movements.
» Grade-2: movement with gravity.
» Grade-3: movement against gravity but not against resistance.
» Grade-4: movement against resistance.
» Grade-5: normal power.
 Physical Examination of CNS
• Motor system (continued):
– Inspection… continued:
• Reflexes:
– Deep tendon reflexes (limb which will be examined must be relaxed; muscles of the limb
are exposed; if there is no clear reflex → distract the patient by asking him to clench his
teeth):
» Biceps: C5, C6.
» Triceps: C7, C8.
» Brachioradialis: C6.
» Knee jerk: L3, L4.
» Ankle: S1, S2.
– Superficial reflexes:
» Abdominal: starting from each corner, stroke patient’s abdomen until reaching the
umbilicus.
» Cremasteric: stroking medial aspect of patient’s thigh normally results in contraction
and ipsilateral rise of testicle.
» Plantar (testing for Babinski’s sign): normal → down-going (don’t say negativ
Babinski’s sign); Babinski’s sign → dorsiflexion of big toe and fanning of other toes.
Physical Examination of CNS
 Physical Examination of CNS
• Sensory system:
– Check for the following:
• Dorsal column-medial lemniscus (eventually reaching post-central gyrus; if there is a lesion →
there will be an ipsilateral loss of sensation): light touch, vibration and proprioception.
• Lateral spinothalamic tract (if there is a lesion → there will be a contralateral loss of sensation):
pain and temperature.
– Example (1)… light touch: same concept when checking for pain sensation
• Ask patient to close his eyes.
• Test sensation on a central area → sternum → if patient can feel → proceed with your physical
examination.
• Start by examining upper limbs and then lower limbs, knowing the dermatomes and comparing
both sides to each other.
– Example (2)… vibration:
• Ask the patient to close his eyes, use a 128 Hz tuning fork and don’t forget to check for
sensation on a central area (sternum).
• Place the vibrating tuning fork on bony prominence starting distally and moving proximally.
• If there is loss of sensation → continue your examination to know the extension.
 Physical Examination of CNS
• Sensory system (continued):
– Example (3)… conscious proprioception (sense of joint position):
• Hold the sides of patient’s index finger (for example) at the middle phalanx and with your other hand hold the sides of
distal phalanx of the same finger.
• Show patient (up and down) movements of his finger.
• Ask the patient to close his eyes and move his finger randomly (up or down) → normally he should be able to tell you the
movement you are doing.
– Cortical sensation → check for the following:
• Tactile localization:
– Ask patient to close his eyes.
– Touch them in different parts of their body.
– Normally, they should be able to tell you exactly where they felt each touch.
• Two-point discrimination:
– Ask patient to close his eyes.
– Use a paper clip and make it with two ends.
– Check on fingertips.
– Normally, patient has the ability to feel two points as two separate points.
• Stereognosis:
– Ask the patient to close his eyes.
– Place a key or a coin in his hand.
– Normally, he has the ability to tell you what is the object by feeling it.
• Graphesthesia:
– Ask the patient to close his eyes.
– Write a number on the palm of their hands (but you have to show them the line you will write on first).
– Normally, he has the ability to identify numbers when traced on the skin.
• Extinction:
– Patient has the ability to feel two types of stimuli (light touch and pain) on two different body parts at the same
time.
Don’t forget to thank your patient.