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CNS Examination. Done By Abdullah Mohd . Jan 6 th year medical student-2007. Aspects of Examination. General The cranial nerves The upper limbs ( Motor + Sensory + coordenation ) The lower limbs ( Motor + Sensory + coordenation)

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cns examination

CNS Examination

Done By

Abdullah Mohd. Jan

6thyear medical student-2007

aspects of examination
Aspects of Examination
  • General
  • The cranial nerves
  • The upper limbs

( Motor + Sensory + coordenation )

  • The lower limbs

( Motor + Sensory + coordenation)

  • The skull and spine for local disease
  • The carotid arteries for bruits
general examination
General Examination
  • Assessment of the higher centers
  • Speech ( reception & production )
  • Neck stiffness
  • Abnormal movements
general examination1
General Examination
  • Assessment of the higher centers
  • Consciousness
  • Orientation ( Person , Place , Time )
  • Cognetion
  • Memory

asses both short & long term memory

slide6
Handedness

to determine the dominant hemisphere

  • Speech ( reception & production )
  • Flow of speech
  • Comprehension (yes – No)
slide7
Repetition
  • Neck stiffness

looking for meningism ( meningitis – sub arachnoid haemorrhage

cranial nerves examination
Cranial Nerves Examination
  • you have to know how to examine all cranial nerves in detail but we will focus on the most important ones ( 3rd , 4th , 5th , 6th , 7th , 11th & 12th ) .
  • You have to know the location of the nuclei of the cranial nerve as it gives you a hint about the site of the lesion.
slide10
3rd & 4th cranial nerves are located in the mid brain
  • 5th , 6th , 7th & 8th cranial nerves are located in the pons
  • 9th , 10th , 11th & 12th cranial nerves are located in the medulla oblongata
cn iii iv vi oculomotor trochlear abducent
CN III, IV, VI: Oculomotor, Trochlear, Abducent
  • Inspection of pupil
  • Light reflex
  • Eye Movement & nystagmus
  • Convergence & accomodation
slide12
Look at pupils: shape, relative size,
  • ptosis.
  • Shine light in from the side to look for pupil's light reaction.• Assess both direct and consensual responses.• Assess afferent pupillary defect by moving light in arc from pupil to pupil. 
slide14
"Follow finger with eyes without moving head": test the 6 cardinal points in an H pattern.• Look for failure of movement, nystagmus [pause to check it during upward/ lateral gaze].
slide15
Convergence by moving finger towards bridge of pt's nose.
  • Test accommodation by pt looking into distance, then a hat pin 30cm from nose.
cn v trigeminal
CN V: Trigeminal
  • Sensory
  • Motor
  • Reflex (deep + superficial)
slide17
Facial sensation: sterile sharp item on forehead, cheek, jaw.• Repeat with cotton at the same parts.
slide18
Motor: pt opens mouth, clenches teeth (pterygoids).• Palpate temporal, masseter muscles as they clench.
  • Test jaw jerk:
    • Dr's finger on tip of jaw.
    • Grip patellar hammer halfway up shaft and tap Dr's finger lightly.
slide19
Usually nothing happens, or just a slight closure.
  • If increased closure, think UMNL, esp  pseudobulbar palsy.
slide20
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].
cn vii facial
CN VII: Facial
  • Inspection
  • Motor
  • Taste sensation
cn vii facial1
CN VII: Facial
  • Inspect for facial droop or asymmetry.
  • Facial expression muscles: pt looks up and wrinkles forehead.• looking for wrinkling loss.
  • Pt shuts eyes tightly: compare each side.
slide23
Pt smile: compare nasolabial grooves.
  • Pt show teeth, puff out cheeks.
  • Taste sensation in the anterior 2/3 of the tongue.
cn xi accessory
CN XI: Accessory
  • Inspection From behind, examine for trapezius atrophy, asymmetry.
  • Pt. shrugs shoulders (trapezius).
  • Pt. turns head against resistance: watch, palpate SCM on opposite side.
cn xii hypoglossal
CN XII: Hypoglossal
  • Listen to articulation.
  • Inspect tongue in mouth for wasting, fasciculations.
  • Protrude tongue: unilateral deviates to affected side.
motor system
Motor system

don’t forget to compare both limbs

  • Inspection
  • Palpation ( muscle bulk + tenderness )
  • Muscle tone
  • Muscle power
  • Reflexes :.

( superficial + deep )

motor system1
Motor system
  • Upper limbs (compare)
  • Inspect for muscle wasting ( proximal & Distal ) – scars – deformity – fasciculation – skin pigmentation.
  • Drift test
slide29
Feel the muscle bulk ( proximally & Distally ) – muscle tenderness.
  • Tone ( normo – hypo – hypertonia )

by passive movement of wrist and elbow joints.

slide30
Power ( 0 – 5 )

by active movement at the shoulder , elbow , wrists and fingers.

slide31
Reflexes ( 0 - ++++ )

Biceps ( C5,C6 ) – Triceps ( C7,C8 ) – Brachioradialis ( C5,C6 )

slide32
Coordination

Finger to nose test – Finger to finger test – Dysdiadochokinesis – Rebound test

slide33
Lower limbs
  • Inspect the gait of the patient
  • Expose both thighs and legs.
  • Inspect for muscle wasting – scars – deformity – posture -fasciculation – skin pigmentation .
slide34
Feel the muscle bulk and muscles for tenderness.
  • Tone ( normo – hypo – hypertonia )

by passive movement of the knee and ankle joints

slide35
Clonus more than 3

ankle and knee clonus

  • Power ( 0 – 5 )

by active movement at the hip , knee , ankle , and tarsal joints

slide36
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

sensory system
Sensory system
  • Spinothalamic pathway

Pain and Temperature ( usually temperature is not tested )

  • Posterior column pathway

Vibration and Proprioception

Romberg Sign

  • Light touch with cotton wool
slide38
Back
  • Inspect for deformity – scars – neurofibromas .
  • Palpate for tenderness over the vertebral bodies
  • Do the straight leg raising test
auscultation
Auscultation
  • Auscultate over the carotid arteries looking for bruits.
slide41

Thank You

Happy New Year