CNS examination.......................ppt

Dr

1. CNS Examination
Done by
Dr/ Abdullah Mohd. Jan
MBBS,Intern

2. Aspects of Examination
1.General Ex
2.The Cranial nerves
3.The upper limbs
( Motor + Sensory + coordenation )
4.The lower limbs
( Motor + Sensory + coordenation)
5.The skull and spine for local disease
6.The carotid arteries for bruits

3. General Examination
•Assessment of the higher centers
•Speech
•Neck stiffness
•Abnormal movements

4. General Examination
1.Assessment of the higher centers
oConsciousness
oOrientation ( Person , Place , Time ).
oMemory
oHandedness
2.Speech
oFlow of speech
oComprehension
oRepetition

5. 3.Neck stiffness
looking for meningism( meningitis ,SAH)

6. Cranial Nerves Examination
•you have to know how to examine all
cranial nerves in detail but we will focus on
the most importantones ( 3
rd
, 4
th
, 5
th
, 6
th
, 7
th
, 11
th
& 12
th
).

7. Where CN Come From?
•3
rd
& 4
th
cranial nerves are located in the
mid brain
•5
th
, 6
th
, 7
th
& 8
th
cranial nerves are
located in the pons
•9
th
, 10
th
, 11
th
& 12
th
cranial nerves are
located in the medulla oblongata

8. •Inspection of pupil
•Light reflex
•Eye Movement & nystagmus
•Convergence & accomodation
CN III, IV, VI: Oculomotor,
Trochlear, Abducent

9. •Look at pupils: shape, relative size,
•Ptosis.
•Shine light in from the side to look for
pupil's light reaction.
• Assess both directand consensual
responses.
• Assess afferent pupillary defectby
moving light in arc from pupil to pupil.

10. The pupils

12. •Motor
•Sensory
•Reflex
CN V :Trigeminal

13. •Motor:pt opens mouth, clenches teeth
)pterygoids).
• Palpate temporal, masseter musclesas
they clench .
•Jaw jerk :
–Dr's finger on tip of jaw .
–Grip patellar hammer halfway up shaft and
tap Dr's finger lightly.

14. •Sensory
Facial sensation by cotton on forehead,
cheek & jaw.

15. •Corneal reflex :patient looks up and away.
• Touch cotton wool to other side.
• Look for blink in both eyes, ask if can
sense it.
• Repeat other side [ tests V sensory, VII
motor].

16. •Motor
•Taste sensation
CN VII :Facial

17. CN VII :Facial
•Inspectfor facial droop or asymmetry .
•Facial expression muscles:pt
looks up and wrinkles forehead.
• looking for wrinkling loss.
•Pt shuts eyes tightly :compare
each side .

18. •Pt smile :compare nasolabial grooves .
•Pt show teeth, puff out cheeks.
•Taste sensation in the anterior 2/3 of the
tongue.

20. CN XI: Accessory
•InspectionFrom behind, examine for
trapezius atrophy, asymmetry.
•Pt. shrugs shoulders (trapezius).
•Pt. turns head against resistance: watch,
palpate SCM on opposite side.

21. CN XII: Hypoglossal
•Inspect tongue in mouth for wasting,
fasciculations.
•Protrude tongue: unilateral
deviates to affected side.

23. Motor system
don’t forget to compare both limbs
•Inspection
•Palpation ( muscle bulk + tenderness )
•Muscle tone
•Muscle power
•Reflexes

24. Motor system
1.Upper limbs (compare)
•Inspect for muscle wasting( proximal &
Distal ) –scars–deformity–
fasciculation–skin pigmentation.
•Drift test

25. •Feel the muscle bulk( proximally &
Distally ) –muscle tenderness.
•Tone ( normo –hypo –hypertonia )
by passive movement of wrist and elbow
joints.

26. •Power( 0 –5 )
by active movement at the shoulder ,
elbow , wrists and fingers.

27. •Reflexes ( 0 -++++ )
Biceps ( C5,C6 ) –Triceps ( C7,C8 ) –
Brachioradialis ( C5,C6 )

28. •Coordination
Finger to nose test
Finger to finger test
Dysdiadochokinesis
Rebound test

29. 2.Lower limbs
•Inspect the gaitof the patient
•Expose both thighs and legs.
•Inspect for muscle wasting–scars–
deformity–posture-fasciculation–skin
pigmentation.

30. •Feel the muscle bulkand muscles for
tenderness.
•Tone ( normo –hypo –hypertonia )
by passive movement of the knee and
ankle joints

31. •Clonusmore than 3
ankle and knee clonus
•Power( 0 –5 )
by active movement at the hip , knee ,
ankle , and tarsal joints

32. •Reflexes( 0 -++++ )
Knee jerk ( L3,L4 ) –Ankle jerk (S1,S2 ) –
Plantar reflex ( L5, S1 , S2 )
•Coordination
Heal to shin test
Toe finger test Foot
Tapping test

33. Sensory system
•Spinothalamic pathway
Painand Temperature( usually temperature is
not tested )
•Posterior column pathway
Vibrationand Proprioception
Romberg Sign
•Light touch with cotton wool

34. Back
•Inspect for deformity–scars–
neurofibromas.
•Palpate for tenderness over the vertebral
bodies
•Do the straight leg raising test

36. Auscultation
•Auscultate over the carotid arteries looking
for bruits.