CNS Examination ppt for mbbs ug students

Cns examination

1. CNS examination - higher mental function,Sensorium,speech By Gauri Chikhalkar

2. Higher Mental Function

3. CONSCIOUSNESS Consciousness Level of consciousness is the patient’s relative state of awareness of the self and the environment, and ranges from fully awake to comatose. Sleep is a state of physical and mental inactivity from which patient can be aroused to normal consciousness Catatonia is a state during which rigid plastic postures of limbs for long hours are assumed . Akinetic Mutism- state during which patient remains immobile , making no sound , follows movement slowly with his eyes and allow himself to be fed and nursed. Drowsiness is a pathological state that resembles normal sleep. Patient can be aroused with an external stimulus , but reverts back to drowsy state on withdrawal of the stimulus

4. Semicom a a pathological state , which requires stronger stimulation to arouse the patient , though his reflexes are normal Stupor considered synonymous to semicoma , whereas some doctors regard it as a state between drowsiness and semicoma Coma deepest level of unconsciousness. Patient is immobile , all reflexes are absent and plantar response is extensor

5. GLASGOW COMA SCALE(GCS)

6. ORIENTATION Time - What time of the day is it? (Do not ask - is it day or night -leading question) Place - where are you presently? Person - who am I or who is the attendee with you? In the given order , do not ask leading questions

7. DELIRIUM defined as a relatively acute decline in cognition that fluctuates over hours or days 2 subtypes- hypoactive and hyperactive Reversibility of dementia Assess mental status , fluctuation “sundowning”

8. DEMENTIA defined as an acquired deterioration in cognitive abilities that impairs the successful performance of activities of daily living. Episodic memory, the ability to recall events specific in time and place, is the cognitive function most commonly lost.

9. MMSE - MINI MENTAL STATE EXAMINATION Score<21 in educated person=severe dementia for screening and progress of dementia Total score= 30 Score<21 in educated person=severe dementia.

10. MEMORY analyzed according to three main time scales: (1) immediate memory is assessed by saying a list of three items and having the patient repeat the list immediately (2) short-term memory is tested by asking the patient to recall the same three items 5 and15 mins later (3) long-term memory is evaluated by determining how well the patient is able to provide a coherent chronologic history of his or her illness or personal events.

11. INTELLIGENCE Abnormalities of insight and judgment detected during the patient interview; a more detailed assessment can be elicited by asking the patient to describe how he or she would respond to situations having a variety of potential outcomes (e.g., “What would you do if you found a wallet on the sidewalk?”). Abstract thought can be tested by asking the patient to describe similarities between various objects or concepts (e.g. apple and orange) or to list items having the same attributes (e.g. a list of four-legged animals). Calculation ability is assessed by having the patient carry out a computation that is appropriate to the patient’s age and education (e.g., serial subtraction of 7 from 100 or 3 from 20; or word problems involving simple arithmetic).

12. NEURO-PSYCHIATRIC EXAMINATION Delusion Emotional status

13. Speech APHASIA - is an impairment,affecting production or comprehension of speech and the ability to read and write

14. Testing for Aphasia Establish if the patient is right or left handed Discover the patients first language

15. COMPREHENSION ASSESS UNDERSTANDING Ask the patient a simple question - What is your name/address? What is your job? Where do you come from?

16. UNDERSTANDING Ask questions with yes /no answers Give a simple command If successful try more complicated command

17. NAMING Show an object to patient, ask him to name it. NAMING DEFICITS TWO WAY(semantic)-cannot name even on clues ONE WAY(Retrieval based)- can point to the right object Circumlution - Patient fails to come up with the appropriate word ,may provide a circumlutious description of the object(eg - tells the function of the object - pen shown to patient and asked to name it - patient says it is used for writing )

18. PARAPHASIA - patient offers incorrect but related word 2 types: Semantic- pt knows function of the object , tells a related word eg- pencil shown-pt calls it “pen” Phonemic - pt is phonetically incorrect eg-pencil shown -PT calls it “pentil”

19. REPETITION Asking PT to repeat single words ,short sentences,or string of words such as ‘No ifs,ands,or buts’ Test of repetition with tongue twisters such as “hippopotamus” provides a better assessment of dysarthria.

20. FLUENCY Talk with the patient about a familiar topic preferably in patient’s first language For spontaneous speech: Fluent -if it maintains appropriate output volume,phrase length Non-fluent -if it is sparse and halting and average utterance length is below four words The examiner also should note the integrity of grammar as manifested by word order (syntax), tenses, suffixes, prefixes, plurals, and possessives

21. Other important higher mental functions APRAXIA - inability to do skilled motor activity. Eg- ask or to uncap and again cap the pen and keep it back . Ideational Constructive Dressing Ideomotor Speech

22. AGNOSIA- inability to recognise an object in spite of normal sensory ,motor and cerebellar function Auditory Tactile Visual

23. PROFORMA Higher functions are normal with MMSE Score of ___/30, well oriented to time, place , person, normal behavior, memory, intelligence, unaffected speech, and no perceptual or emotional abnormality .