CNS Examination Hadeel Khadawardi, teaching assistant at Internal Medicine Department, Faculty of Medicine, Umm Al-Qura University

CNS examination consists of: High Cortical Function Cranial Nerves Motor Coordination Sensory

High Cortical Functions Handedness Consciousness Orientation Memory Speech

Handedness Shake patient hand and ask if he or she Rt. or Lt. handed to assess for the likely dominant hemisphere. 94% of people are Rt. handed.

2. Consciousness Levels of consciousness Alertness Lethargy Obtundation Stupor Coma

3. Orientation Time Place Person

4. Memory Remote (long) memory: Birthdays,… Recent (short) memory: event of the day, …

5. Speech Dysphasia: dominant higher center disorder in the use of symbols for communication. Dysarthria: difficulty with articulation. Dysphonia: altered quality of the voice. Types od dysphasia; Expressive Receptive

Cranial Nerves

I. Olfactory Nerve

II. Optic Nerve Visual acuity: Is checked by using Snellen Chart. b) Visual field: c) Visual color: Is checked by using Ishihara Charts. d) Fundoscopy: e) Light reflex: The afferent of light reflex is by optic nerve and the efferent is by oculomotor nerve.

III, IV, VI. Oculomotor, trochlear & abducent Nerves Inspect the eyes for ptosis, shape and size of pupils. Eye movement; ask the patient to follow your finger in H shape comment on: Failure of eye movement Diplopia Nystagmus c) Light reflex d) Accommodation

V. Trigeminal Nerve Motor; (Muscle of mastication) Temporalis Masseter Pterygoids b) Sensory; Access for fine touch and pin break in the 3 divisions ( ophthalmic, maxillary, mandibular). c) Corneal reflex; The afferent of corneal reflex is by trigeminal nerve and the efferent is by facial nerve. d) Jaw reflex;

How would differentiate b/w UMNL & LMNL of VII nerve? VII. Facial Nerve Inspection Forehead wrinkles Angle of the eye Corner of the mouth Loss of nasolabial fold Dropping of saliva Motor Frontalis muscle Orbicularis oculi Buccinator muscle Orbicularis oris Sensory Anterior 2/3 of the tongue. Corneal reflex How would differentiate b/w UMNL & LMNL of VII nerve?

VIII. Vestibulocochlear Nerve Whispering Rinnes test Webers test IX, X. Glossopharyngeal & Vagus Nerves Inspection of uvula. Difficulty of swallowing Ask the patient to say ‘Ah’ Gag reflex

XI. Accessory Nerve XII. Hypoglossal Nerve Trapezius muscle Sternomastoid muscle XII. Hypoglossal Nerve Inspect the tongue Ask the patient to protrude his/her tongue

Motor Motor Exposure & Inspection Tone Power Reflex

Drift (For Upper Limb Only) Inspection Skin (rash, scar, ulcer,…) Muscle (wasting, fasciculation) Deformity Abnormal movement Drift (For Upper Limb Only)

What are the types of hypertonia? Tone For upper & lower limbs Examine each joint Start from distal to proximal Always compare both sides What are the types of hypertonia?

What are the grading of power? For upper & lower limbs Examine each joint Always compare both sides What are the grading of power?

What are the grading of reflex? Patient should be comfortable and relaxed Expose the tested muscle Strike the tendon, not the muscle belly Observe the muscle contraction Reflex of upper limb: Brachioradialis reflex (C5,C6) Biceps reflex (C5,C6) Triceps reflex (C7,C8) Reflex of lower limb: Ankle reflex (S1,S2) Knee reflex (L3,L4) Planter reflex (S1,S2) Clonus: Ankle clonus Knee clonus What are the grading of reflex? What is reinforcement?

Coordination Finger nose test Rapidly alternative movement Heel to shin test Rebound

Gait Expose both legs Ask the patient to: walk heel to toe How to differentiate b/w UMNL &LMNL ? Expose both legs Ask the patient to: walk heel to toe walk on toes walk on heels squat to stand Romberg test What are the types of abnormal gait?

Thank You