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1. CNS EXAMINATION

2. Examination of Higher Mental Functions

3. Examination of Higher Mental Function Level of Consciousness : Give a Verbal command Give a Superficial painful stimulus Give a Deep painful stimulus Orientation to Time, Place and Person

4. Hallucinations and Delusions: Hallucinations – False sensory perception without stimuli (visual, auditory, olfactory) Delusions – False sensory perception even in the presence of contrary Mood of the Patient: Normal, Depressed, Irritable, Ferocious, Angry

5. Examination of Higher Mental Functiona Mood of the Patient Normal, Depressed, Irritable, Ferocious, Angry Memory: Past Memory – Tested by asking a question which is relevant to at least One-year back Present Memory – A memory earlier that day Recent Memory: Give and object Take it back Ask what it was sometime later Tell the patient a number ask 30 seconds later what number it was

6. Speech – Speech is the process of producing specific sounds that convey meaning to the listener . [ Articulation of communication]. A speech disorder refers to any condition that affects a person’s ability to produce sounds that create words . Two types – Central or Peripheral Central speech affected – Aphasia (Tested by giving verbal and visual command) Peripheral speench affected – Dysarthria Broca’s Area affected - Expression Lost, Wernicke’s Area affected - Comprehension Lost

7. Right or Left Handed: Right Handed Individuals – 100% are Left Dominant Left Handed Individuals – 85% are Left Dominant If Right side paralysis - Left Brain affected - Loss of Speech – leads to APHASIA Aphasia is  a condition that affects your ability to communicate . It can affect your speech, as well as the way you write and understand both spoken and written language. Aphasia typically occurs suddenly after a stroke or a head injury .

8. Inspection Head to toe examination – look for any neuro-cutaneous markers

9. Examination of Cranial Nerves

10. Olfactory Steps to examine smell 1. Close the eyes and one nostril of the patient 2. Test the Patency of the nostril to be tested 3. Ask the patient to smell the substance 4. Ask the patient to tell what substance it was

11. Optic Nerve Visual Acuity 1. Snellen’s Chart 2. Finger Counting/Movement 3. PL

12. Field of Vision Finger Confrontation Test, Assumes Examiner’s Field of vision is normal Perimetry Preferred: Patient’s and Examiner’s eyes should be at the same level Ask the Patient to close the eye on the same side of the examiners (RL, L-R) Examiner should bring their finger inwards from the periphery Patient should tell the examiner when they see the examiner’s finger The examiner should judge whether the finger is seen at the same time or later

13. Color Vision Test: Ischihara’s Color Vision Chart Colored Thread or Marbles, COLOUR BLOCKS Light Reflex Direct Light Reflex tests the 2nd and 3rd CN nucleus on the same side, and the 3rd CN on the opposite side. Indirect Light Reflex tests the 3rd CN nucleus on the same side

14. Occulomotor, Trochlear, Abducens Ptosis – Upper 1/3rd of corneo-scleral junction covered by the eyelid Position of the eyeball Medial Rectus palsy – Lateral squint (exotropia) Lateral Rectus palsy – Medial squint ( esotropia ) – more common

15. Movement of Eyeball Tested simultaneously or Individually in an H-shaped pattern Accommodation – Adjust of optic apparatus by converging and constriction of pupil for near vision, and dilation and divergence for far vision Note - BRING THE OBJECT FROM FAR TO NEAR , AND NOT TO BRING HANDS SUDDENLY IN FRONT OF CHILDREN.

16. Trigeminal Sensory Part – Test Touch, Temperature, and Pain Ophthalmic(a), Maxillary(b), Mandibular(c) Motor Part Muscles of Mastication : Masseter – By clenching Temporal – By clenching Lateral Pterygoid – Ask patient to move jaw laterally against resistance Medial Pterygoid – Open mouth, Cannot exam individually *Tongue and Jaw goes to the same side of the lesion Jaw Jerk Afferent and Efferent is the Trigeminal Nerve Normally present but not obvious If exaggerated Lesion is Bilateral above the pons Example: Pseudobulbar Palsy (Primary Motor System Disease)

17. Facial Motor Part – Muscles of Facial Expression: Frontal Belly of Occipitofrontalis – Look up, forehead wrinkles (Frowning) Orbicularis Oculil – Ask the patient to close their eyes, try to open physically Levator Angularis – Check for naso-labial fold Orbicularis Oris – Whistling, puckering, and blowing action of the mouth Buccinator – Blow against a closed mouth Platysma – Clench teeth, look at the patient neck

18. Tests for facial nerve

19. Facial Sensory Part – Test of Taste (Anterior 2/3rd of Tongue ) Patient should not talk throughout the test Make solution of three substances, Patient does not know the substances o Protrude the tongue and dry with cotton Place a drop of solution on the lateral part of the tip of tongue Ask the patient to point at the solution used Wipe it, take a different solution and test the opposite side

20. Vestibulocochlear Watch Test Weber’s Test Rinne’s Test

21. Rinne’s test

22. Glossopharyngeal, Vagus Gag Reflex, do if palatal reflex is absent, if uvula constricts palate goes up and motor is intact Instruments – swab, tongue depressor, torch Depress the tongue, check position of the uvula Touch palate with swab – contraction (palate goes upward) Touch the posterior pharyngeal wall – pharynx comes forward

23. Spinal Accessory Nerve Sternocleidomastoid – Push chin, ask patient to push against resistance Trapezius – Ask patient to shrug against resistance

24. Hypoglossal Examined with tongue on the floor of the mouth Examine the size of the tongue o Macroglossia – LMN Tongue, Flaccid Microglossia – UMN Tongue, Spastic Fasciculation Chorea – Explained as a ‘bag of worms’ in the mouth Protrusion of the Tongue – check the position Movement of the Tongue – Side to side Power – checked by pushing tongue against cheek *Power of Tongue and Small muscles of hand cannot be graded

25. Examination of Motor System

26. Components : Muscle bulk Tone Power DTR Superficial reflexes Gait Abnormal movements

27. MUSCLE BULK Muscle Bulk – Measurement is from a fixed bony prominence, because the tape should not cross the joint where there is max muscle bulk Look for atrophy or hypertrophy – look for shoulder , pelvic girdle, thenar , hypothenar eminence. Arm – Lateral Epicondyle Forearm – Olecranon Process Thigh – Either Condyle Calf – Tibial Tuberosity P eripheral muscles – in neuropathies, there early atrohy of the extensor digitorum brevis.

28. Tone – DESCRIBE Resistance offered by the muscle during passive movement A ssessment : P osture F eel the muscle R esistance to passive stretching F lappability Tested on the group of muscles acting on the joint of concern Hypotonia – LMN Lesions Normal Tone Hypertonia – UMN Lesions, SPASTICITY, RIGIDITY

29. HYPERTONIA : Spasticity – velocity dependent. Clasp Knife Spasticity (initial increased resistance followed by a catch) – Pyramidal Lesion (corticospinal pathway) Rigidity – diffuse increase in resistance – Extrapyramidal Lesion (Agonist and Antagonist both Hypertonic) . Increased tone is constant from beginning to end of movement and does not vary with speed of movement. 1. Cogwheel – Rigidity + Tremors (stepwise) 2. Lead Pipe – Rigidity without Tremors (uniform)

30. HYPOTONIA – 180 degree flip test

31. Power Active movement against resistance . LIMB IS COMPLETELY EXPOSED START WITH AGAINST THE GRAVITY MOVEMENTS. THEN OFFER RESISTANCE . Tested on the group of muscles acting on the joint of concern Grading 1 – Flickering 2 – Eliminating Gravity 3 – Against Gravity. 4 – Mild Examiners Resistance 5 – Normal

32. Reflexes Superficial Reflexes: Corneal – 5th CN (Afferent), 7th CN (Efferent) Abdominal – T7-T10 (Upper Abdomen), T10-T12 (Lower Abdomen) Scratch in a diamond shape away from the umbilicus Cremasteric (L1) Scratch the medial aspect of the Thigh (L1)

33. Plantar Reflex ( L5- S1) Blunt object used to scratch along the lateral aspect of the sole of the foot, and then against the base of the toes up till the 3rd toe Pyramidal Lesion will show Babinski’s Sign Babinski’s Sign 5 Components: 1. Up going Great Toe 2. Fanning of Other Toes 3. Dorsiflexion at the ankle joint 4. Flexion of knee and hip 5. Lateral rotation of hip due to contracture of tensor fascia lata Minimal Babinski’s – Only the Tensor Fascia Lata contracts – Lateral Flexion

34. Deep Reflexes Motor response to a sensory stimulus Biceps: C5-C6 Supinator: C5-C6 Triceps: C6-C7 Knee: L2-L3 Ankle: L5-S1 Clonus – Indicates UMN, Patellar and Plantar both tested

35. Clonus

36. Coordination Finger-Nose Test – Tested with eyes closed Finger-Nose-Finger Test – Tested with eyes open Heel-Shin Test

37. Abnormal Movements Tremors Chorea – movement disorder of peripheral joints, dancing like Hemiballismus – movement disorder of proximal joints Tonic Clonic Twitching Fasciculation

38. Gait Hemiplegic Gait (Seizure Gait) Short Shuffling Gait (Parkinson’s) – patient’s arms to their sides, small steps High Stepping Gait – Foot Drop seen, Patient is seen to take high steps Stamping Gait – Foot drop with pyramidal involvement Waddling Gait – Proximal muscle weakness, in pregnancy, hip fracture, myopathies, dislocation Hysterical Gait – Haphazard Ataxic Gait – Falls to same side

39. Examination of sensory system

40. Examination of Sensory System 5 Points to be kept in mind 1. All tests should be done with eyes closed 2. Explain to the patient about the test in detail 3. Every segment C2 (Behind the Ear) to S5 (Perineal Area) 4. Compare sensation of Upper ½ and lower ½ 5. Compare sensation of Right and Left side *Touch, Temperature and Pain are Primary modalities of sensation

41. Touch Superficial (Cotton) Deep (Pen or Blunt Object) Temperature – Cannot be tested accurately bedside Use two tubes with water 5c more and 5c less than room temperature Pain Sharp Object (End of a Knee Hammer) Vibration Test: Tuning Fork of 128 Hz or bony prominence (Condyles, Spine, Ribes, etc.)

42. Joint Sensation: Fix the joint to be tested, Thumb and Greater Toe to be checked. Move the joint side to side, flex and extend. Ask the patient which direction it was moved. Mistake more than 3 times is significant Position Sensation: Examiner puts a joint in a certain position. Patient should mimic the position in the other limb

43. Tactile Localization: examiner touches a certain point. Patient should touch the same point with their finger Two Point Discrimination: Assessed with Calipers Stereognosis: An object in the patient’s hands should be guessed by the physical characteristics felt by the patient Graphesthesia: On the back or thigh, the examiner should draw a number or letter, ask the patient to guess what was drawn

44. Examination of Cerebellar Function

45. Examine – Equilibrium, Coordination and Tone Titubation – Nodding of the head, unable to keep head straight Eye – Horizontal Nystagmus, Vertical Brainstem Lesion Dysarthria – Staccato or Broken Speech, Ask the patient to say “British Constituency” Dysmetria: Draw two lines, ask the patient to start at one line and end at the other, passing the 2nd line may be due to hypotonia. Draw a circle, ask the patient to place dots within the circle Dysdiadokinesia – Repeated movements of hands on palms

46. Finger-Nose-Finger Test Rebound Phenomenon: two arms outstretched – give a tap on each arm hypotonia makes arms drop Pendular Knee Jerk: Sit the patient against a bed, knees should be parallel. On knee reflex, the lower leg oscillates more than 3 times with the same intensity Heel-Shin Test Cerebellar Gait – Cannot walk in a straight line (Heel-Toe)

47. Romberg test

48. Thank you