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 o Consciousness o Orientation ( Person, Place, Time ). o Memory o Handedness 2.Speech o Flow of speech o Comprehension o Repetition

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 important ones ( 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 direct and consensual responses. Assess afferent pupillary defect by moving light in arc from pupil to pupil.

10. The pupils

12. "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].

13. Convergence by moving finger towards bridge of pt's nose. Test accommodation by pt looking into distance, then a hat pin 30cm from nose.

14. Motor Sensory Reflex CN V: Trigeminal

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

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

17. 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].

18. Motor Taste sensation CN VII: Facial

19. 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.

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

22. 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.

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

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

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

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

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

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

30. Coordination Finger to nose test Finger to finger test Dysdiadochokinesis Rebound test

31. 2.Lower limbs Inspect the gait of the patient Expose both thighs and legs. Inspect for muscle wasting – scars – deformity – posture -fasciculation – skin pigmentation.

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

33. Clonus more than 3 ankle and knee clonus Power ( 0 – 5 ) by active movement at the hip, knee, ankle, and tarsal joints

34. 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

35. 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

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

38. Auscultation Auscultate over the carotid arteries looking for bruits.