Central Nervous System EXAMINATION FORMAT.pptx

How to examine central nervous system

1. CNS EXAMINATION FORMAT MODERTOR – DR. HEMANTH KUMAR PRESENTOR – DR.RESHMA

2. CONTENTS MOTOR SYSTEM SENSORY SYSTEM INVOLUNTARY MOVEMENTS GAIT

3. MOTOR SYSTEM

4. MOTOR SYSTEM BULK TONE POWER REFLEXES ABORMAL MOVEMENTS

5. BULK OF MUSCLE

6. BULK Inspection • Posture • Wasting or atrophy—muscle is small, soft and flabby. The convexity of the muscle is lost. The bones and tendons become prominent • Hypertrophy Palpation. Wasted muscles are flabby

7. Measurement: The circumference of the muscles should be measured and compared with the opposite side. Measurements should be done at identical points on both sides. The circumference of the muscles are measured from sites equidistant from fixed bony prominences

8. ARM CIRCUMFERENCE

9. FOREARM CIRCUMFERENCE

10. THIGH CIRCUMFERECE

11. LEG CIRCUMFERECE

12. TONE The tone of a muscle is the state of continuous partial contraction even at rest. It may be Normal Decreased (hypotonia) Increased (hypertonia)

13. INSPECTION Hypotonia – muscle lax and pendulous at rest Hypertonia – muscle appears more prominent with increased convexity

14. PALAPATION Muscle should be felt between the forefinger and the thumb In Hypotonia – flabby & soft increased range of passive movements decreased resistance to passive movements In hypertonia – firm increased resistance for passive movements at the joints

15. HYPOTONIA

16. POWER It is the force of contraction that can be generated by the contraction of each muscle. It denotes the strength of muscle.

17. MRC GRADING OF MUSCLE WEAKNESS Grade Clinical examination 0 - Complete paralysis total paralysis (no power) 1 - Visible or palpable flicker or trace of contracture 2 - Able to move eliminating the gravity - Able to move against gravity but not against resistance 4 - Able to move against partial resistance 5 - Normal power

18. REFLEXES Superficial Reflexes These are muscle contractions that are evoked by cutaneous stimulation, that is, stroking the skin

19. SUPERFICIAL REFLEXES Reflex Root Value Normal Response Abdominal reflex Spinal segments T6-TI2 Muscles of abdomen contract Plantar reflex L5,S1 Flexion of great toe, flexion of other toes Cremasteric reflex L1,L2 Testicle is pulled up due to contraction of cremasteric muscle

20. PLANTAR REFLEX The lateral border of the sole is stroked from the heel towards the ball of the great toe. Normal response is flexor Abnormal response - extensor

21. DEEP TENDON REFLEXES REFLEXES ROOT VALUE NORMAL RESPONSE Biceps reflex C5, C6 Flexion at the elbow joint with visible contraction of the biceps muscle Supinator reflex C5, C6 Contraction of brachioradialis with flexion of elbow. Slight flexion of fingers and contraction of biceps may also be present Triceps reflex C6,C7,C8 Extension of elbow with visible contraction of the triceps muscle

22. REFLEXES ROOT VALUE NORMAL RESPONSE Knee jerk L2, L3, L4 Extension of the knee due to contraction of quadriceps Ankle jerk S1 Contraction and flexion of toe

23. Grades Findings 0 Absent 1 Sluggish obtainable with reinforcement 2 Readily elicitable 3 Brisk/increased like normal knee jerk 4 Clonus (sustained/ill-sustained)

24. DEEP TENDON REFLEXES

25. ANKLE CLONUS

26. SENSORY SYSTEM Sensations are of two types: primary and cortical. 1) Primary sensations are- touch pain temperature position passive movements vibration

27. 2 ) Cortical sensations are: localization two-point discrimination stereognosis graphesthesia Complete loss of sensation – Anesthesia Impaired sensation perception – Hypoesthesia Increased sensory perception – Hyperasthesia

28. PAIN:

29. CEREBELLAR SIGNS

30. ABNORMAL MOVEMENTS ATHETOSIS: Slow, sinuous, writhing movements more marked in the distal extremities. These occur due to a lesion in putamen . CAUSES: • Infection—encephalitis • Wilson’s disease • Injury • Kernicterus • Cerebral palsy

31. HEMIBALLISMUS: Violent flinging movements or rotational excursion of limbs (usually proximal). Ballismus disappears during sleep associated with structural lesions in the contralateral subthalamic nucleus.

32. CHOREA: Semi-purposive (or quasi-purposive), non-repetitive, jerky, brief, irregular movements caudate nucleus. It is increased by stress Disappears during sleep.

33. SIGNS SEEN IN RHEUMATIC CHOREA: Milkmaid sign Pronator sign Jack in box phenomenon

34. DYSTONIA: TARDIVE DYSKINESIA Due to writhing movements of t tongue and face that occur due to I intake of certain drugs.

35. Epilepsy Fibrillations/ Fasciculations Tremors Tetany Tics

36. GAIT Points to observe and describe Stance/posture Distance between feet Ankle/knee/hip position Pelvis Shoulder and arms Look at ay asymmetries

37. Spastic gait - Scissoring gait slow, spastic, shuffling This occurs in UMN lesions.

38. EQUINUS GAIT seen in spastic cerebral palsy and pseudo-muscular dystrophy

39. Waddling gait seen in achondroplasia , bilateral coxa vara, bilateral slipped epiphysis and cerebellar disease

40. HIGH STEPPING GAIT seen in tabes dorsalis, Friedreich’s ataxia, subacute combined degeneration and syphilitic meningoencephalitis

41. MENINGEAL SIGNS

42. SPINE KYPHOSIS SCOLIOSIS

43. CNS EXAMINATION HIGHER MENTAL FUNCTIONS CRANIAL NERVES MOTOR SYSTEM SENSORY SYSTEM CEREBELLAR SIGNS SIGNS OF MENINGEAL IRRITATIONS GAIT SPINE CRANIUM