Central nervous system

examination

1
 Learning Objectives
By the end of this session, students are expected to
be able to:
•Identify patient common complaints related to
central nervous system (CNS) conditions
•Explain the guidelines of examining nervous
system
•Describe the techniques used to examine the CNS
(inspection, palpation, percussion auscultation)
•Demonstrate skills in examining the CNS
 Common complaints Related to CNS
The following are common complaints related to
neurological disorders:
•Headache
•Dizziness or vertigo
•Generalized, proximal, or distal weakness
•Numbness, abnormal or loss of sensations
•Loss of consciousness, syncope, or near syncope
•Seizures
•Tremors or involuntary movements
 Guidelines for CNS Examination
• Try to always conduct your examination in a logical
sequence
• The following is a brief but comprehensive
guideline for neurological assessment:
Mental status examination
Cranial nerves examination
Motor system examination
Sensory examination
Gait and coordination
MENTAL STATUS
 Level of Consciousness

• Awake and alert

• Agitated
• Lethargic
– Arousable with
• Voice
• Gentle stimulation
• Painful/vigorous stimulation
• Comatose
 LANGUAGE
• FLUENCY
• NAMING
• REPETITION
• READING
• WRITING
• COMPREHENSION
Aphasia vs. dysarthria
 MEMORY
• IMMEDIATE
– REALLY A MEASURE OF ATTENTION RATHER
THAN MEMORY
• REMOTE
• 3 OBJECTS AT 0/3/5 MINUTES
• HISTORICAL EVENTS
• PERSONAL EVENTS
 ORIENTATION
• PERSON
– NOT WHO THEY ARE BUT WHO YOU ARE
• PLACE
• TIME
 OTHER COGNITIVE FUNCTIONS
• CALCULATION
• ABSTRACTION
• SIMILARITIES/DIFFERENCES
• JUDGEMENT
• PERSONALITY/BEHAVIOR
CRANIAL NERVES
 CRANIAL NERVE EXAM
• I - OLFACTORY
– DON’T USE A NOXIOUS STIMULUS
– COFFEE, LEMON EXTRACT
• II - OPTIC
– VISUAL ACUITY - Distant vision with Snellen’s chart
– VISUAL FIELDS
• Testing of the visual field is important for localisation of a
lesion.
• The visual fields are divided vertically through the point
of fixation into the temporal and nasal fields on each eye

– FUNDOSCOPIC EXAM
 CRANIAL NERVE EXAM
• III/IV/VI OCULMOTOR, TROCHLEAR, ABDUCENS
• -Look at pupils: shape, relative size, ptosis
• -Pursuit eye movements test
– PUPILLARY RESPONSE
– EYE MOVEMENTS
• 9 CARDINAL POSITIONS
– OBSERVE LIDS FOR PTOSIS
• V - TRIGEMINAL
– MOTOR - Jaw-jerk
– Pterygoid muscle
– Masseter and Temporalis muscles

– SENSORY – Corneal reflex, facial sensation

CN III/IV/VI
 CRANIAL NERVES
• VII - FACIAL
– OBSERVE FOR SYMMETRY NASOLABIAL FOLD
– FOREHEAD WRINKLING,
– EYELID CLOSURE,
– WHISTLE/PUFF THE CHEEKS
• VIII - VESTIBULOCOCHLEAR
– Test each ear separately by whispering numbers or by
holding a ticking watch close to each ear
– If the hearing in one ear is reduced or lost, perform
Rinne’s and Weber’s tests.
– RINNE,
– WEBER
CN VII
 CRANIAL NERVES
• IX,X,XII - GLOSSOPHARYNGEAL, VAGUS, HYPOGLOSSAL
• Examine Gum and tongue, larynx, pharynx and gag
reflex
• Ask him to put out his tongue
• Assess the weakness of the tongue
• Gag reflex by touching the pharyngeal wall with
spatula and then observe uvula
• Test for speech

• XI - SPINAL ACCESSORY
– STERNOCLEIDOMASTOID M.
– TRAPEZIUS MUSCLE
HYPOGLOSAL
MOTOR EXAMINATION
 Inspection
• Posture
• Wasting
• Involuntary movement eg tremors, ticks,
fasciculation, chorea, akathisia
 Palpation
• Muscle bulk Feel for the muscle bulkiness on the
biceps, triceps, hamstring and gastrocnemius
• Muscle tone Hold the forearm and the elbow
and move the arm through the full range of
flexion and extension at the elbow. Also test tone
at the knees, and ankle
The result of muscle tone is reported as
• Normal
• Decreased tone i.e. flaccidity
• Increased tone i.e. spasticity
• Muscle strength Hold both hands (the left
hand of the patient with your left hand and
the right hand of the patient with your right
hand as if greeting). Then ask the patient to
hold firmly. The weaker side can directly be
noticed from the differences in the strength of
the grip
• Muscle power -power should be graded
• Ask the patient to move the limb laterally, if
he can do it, ask to lift the limb straight and if
he can do it apply resistance.
No movement Grade 0

Flickering of muscles Grade 1

Moves with gravity eliminated i.e. Grade 2

laterally
Moves against the gravity but Grade 3
without resistance
Slight movement against resistance Grade 4

Normal muscle power Grade 5

REFLEXES
 Deep tendon reflexes
• Deep tendon reflexes result from stimulation
of the stretch-sensitive afferent nerve from
the neuromuscular spindle which, via a single
synapse stimulates a motor nerve leading to
muscular contraction
 Tendon to be examined
• Biceps reflex: C5
• Triceps reflex: C7
• Supinator reflex: C6
• Ankle reflex: S1 and S2
• Knee reflex: L3 and L4
BICEPS, TRICEPS, BRACHIORADIALIS
KNEE REFLEX
 Superficial reflexes
• Babinski’s sign
• Abdominal reflex
• Cremasteric reflex
• Anal reflex
SENSORY EXAM
• In all parts of sensory testing, it is essential:
• First to teach the patient about the test
• Perform the test
• Start distally and proceed proximally. If
sensation is normal distally there is no point in
proceeding proximally
• Compare right with the left
 SENSORY EXAM
• There are five sensory modality to be
examined in CNS examination
• VIBRATION-Ask the patient to close the eyes,
then strike the tuning fork (128 Hz) and place
it on the bone prominence. Ask if he can feel
the vibration
• JOINT POSITION SENSE – Romberg’s test
• Ask the patient to stand with his feet together
with eyes open.
• Allow him to stand like this for a few seconds.
• If the patient falls with his eyes open do not
proceed with the test.
• But if he does not fall, ask the patient to close
the eyes
• PIN PRICK Show the patient what you are going
to do. Explain that you want him to tell you if
the pin is sharp or blunt. Touch an unaffected
area with the pin and then touch the same
areas with the opposite blunt end of the pin.
• Ask the patient to close the eyes then apply
randomly sharp and blunt stimuli and note the
patient’s response. Use a disposable safety pin
or tooth pick stick
• LIGHT TOUCH With the patient’s eyes open
show him that you will be touching an area of
skin. Ask him to say ‘yes’ every time he is
touched.
• Ask the patient to close his eyes; use a piece
of cotton wool or fingertip to test the areas as
for pin-prick. Apply the stimulus at random
intervals.
• TEMPERATURE Fill two dry tubes with water:
One with warm water and another with cold
water. With patients eyes open illustrate to
the patient what you are going to do by
touching area of unaffected skin with the hot
tube or with the cold tube randomly.
 Reflection
• What is examined in the motor system?
• Mention the common reflexes which are
examined.
• What are the routine sensory tests which can
be tested at bedside?
 Key points
• Perform neurological examination in a logical
way planning it in relation to the patient’s
history.
• Gait should always be observed in patient
while entering examination room as they
walk.
• Test recent and distant memories.
 References
• Bickley, L.S. (2008) Bates’ Guide to Physical
Examination and History Taking. (10th ed.)
Philadelphia, USA: Lippincott Williams & Wilkins.
• DK Images. Health and Beauty: Medical Examination.
Retrieved March 14, 2010 from:
www.dkimages.com/.../Medical-Examination-04.html
• Swash. M. & Glynn, M. (2007). Hutchison’s Clinical
Methods. (22nd ed.) London: Saunders.
• Swash, M. (2002). Hutchison’s Clinical Methods (21st
ed.) London: Saunders.