CNS Examination C N S Symptoms 1 Symptoms

CNS Examination

C N S Symptoms 1 -Symptoms of increased ICT (hedeache, vomiting and blurring of vision) 2 -Symptoms of paroxysmal disorder (convlusion, syncope and vertigo) 3 - Symptoms of cranial nerves affection 4 -Symptoms of motor system affection 5 -Symptoms of sensory system affection 6 -Symptoms of sphincteric troubles 7 -Symptoms of A N S affection

Aspects of Examination 1 -Mental function 2 -Speech 3 -Cranial nerves 4 -Motor system 5 -Reflexes 6 -Sensory system 7 -Coordination 8 -Back and Spine 9 -Neck 10 -Gait

Examinationof Mental function 1 -State of Consciousness 2 -Orientation for place , time and persons 3 -Intelligence 4 -Behaviour 5 -Handedness

Examination of Speech 1 -Aphasia—Inability to formulate speech 2 -Dysarthria—Difficulty to articulate speech • Staccato speech • Slurred speech • Monotonous speech

Examination of Cranial Nerves • 3 rd & 4 th cranial nerves are located in the mid brain • 5 th , 6 th , 7 th cranial nerves are located in the pons • 9 th , 10 th , 11 th & 12 th cranial nerves are located in the medulla oblongata

Olfactory nerve • Non irritant substance • Each nostril is tested separately with both eyes closed • Anosmia—loss of sense of smell

Optic nerve • 1 -Acuity of vision—Snellens chart, counting fingers and light perception • 2 -Field of vision • 3 -Ophthalmoscopic examination

Opthalmoscopy: young child Return to examples Photo credit: Tom Shulz 9

CN III, IV, VI: Oculomotor, Trochlear, Abducent 1 -Ptosis (Partial or Complete) 2 - pupil • Light reflex (RRR) • Convergence & accomodation reflex 3 - Extra ocular movement 4 -Nystagmus

Light reflex • Look at pupils: shape, relative size, • Shine light in from the side to look for pupil's light reaction. Assess both direct and consensual responses.

The pupils

Eye movements Return to examples Photo credit: Tom Shulz 13

Squint 14

Trigeminal nerve 1 -Motor(muscles of mastication) patient opens mouth, clenches teeth Palpate temporal, masseter muscles 2 -Sensory • Ophthalmaic • Maxillary • Mandibular • 3 -Reflexs Corneal reflex

V Trigeminal nerve examination Return to examples 16 Photo credit: Tom Solomon

• 1 -Corneal reflex(A 5 -E 7): (patient looks up and away. ) • Touch cotton wool to other side. • Look for blink in both eyes. • Repeat other side • 2 -Jaw reflex

V Trigeminal nerve- jaw jerk normal(A 5 -E 5) Return to examples 18 Photo credit: Tom Solomon

Facial nerve (VII) 1 -Motor (muscles of expression of the face) • Upper part (Frontalis and Orbicularis oculi) • Lower part(Orbicularis oris, buccinator and retractor anguli) • UMNL--LMNL 2 -Sensory • Chorda Tympani(taste sensation from anterior two- third of tongue) 3 -Rflex ---Glabellar reflex

CN VII : Facial

Cochleo-Vestibular nerve 1 -Cochlear part • Rinnes test • Weber tes 2 -Vestibular part • Caloric test

VIII nerve examination: Hearing Return to examples 23

Glossopharyngeal and Vagus nerves • Platal reflex (A 5 -E 10) Stimulation of soft palate--elevation • Pharyngeal reflex(A 9 -E 10) Stimulation of pharynx---gag reflex

CN XI: Accessory • Inspection From behind, examine for trapezius atrophy, asymmetry. • Patient elevate shoulders against resistance (trapezius). • Patient turns head against resistance(sternomastiod muscle)

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

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

Inspection(state of the muscles) Inspect for muscle wasting ( proximal & Distal ) – scars – deformity – fasciculation – skin pigmentation – muscle tenderness

Muscle Tone 1 -Passive flexion and extension of all joints 2 -Shaking method for wrist and ankle 3 -Gower method • Tone(normal-hypo or hypertonia) • Hypertonia(spasticity or rigidity)

Increased leg tone Return to examples 31

Muscle power • The muscles tested against resistance • Upper limbs , lower limbs and abdominal muscles • Grades of muscle power 0 -no movement at all 1 -Trace of contraction or flickering 2 -Movement with gravity 3 -Movement against gravity 4 -Movement against resistance 5 -Full strength of the muscles

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

Power upper limbs: normal 34

Reflexes (deep reflexes) • Upper limb Biceps ( C 5, C 6 ) – Triceps ( C 7, C 8 ) – Brachioradialis ( C 5, C 6 )

Reflexes: Upper limb Right and left abnormal (brisk) Return to examples 36

Reflexes • Lower limb Knee jerk ( L 3, L 4 ) – Ankle jerk (S 1, S 2 )

Clonus 1 -Ankle clonus 2 -Wirst clonus 3 -Patellar clonus

Clonus (abnormal) Return to examples 39

Superficial reflexes 1 -Abdominal reflex (T 6 -T 12) 2 -Cremasteric reflex (L 1) 3 -Gluteal reflex (L 4, 5) 4 -Anal reflex (S 3, 4, 5) 5 -Plantar reflex (S 1, 2)

Abdominal reflexes normal Return to examples 41

Plantar reflex normal Return to examples 42

Sensory System A-Superficial sensation • (pain, temperature, touch) B-Deep sensation • (position, movement , vibration) C-Cortical sensation 1 -Tactile localisation 2 -Two-pionts discrimination 3 -Stereognosis 4 -Graphosthesia

Examination of Coordination Upper limb 1 -Finger to nose test 2 -Finger to finger test 3 -Finger to finger doctor test 4 -Rebound test 5 -Buttoning and unbuttoning Lower limb 1 -Heel to knee test 2 -Walking test 2 -Romberg test

Cerebellar tests: finger-nose test normal Return to examples Photo credit: Tom Shulz 45

Examination of Back and Spine • Tenderness • Swelling • Deformity • Hair tuft Examination of neck • Sign of meningeal irritation(neck stiffnes)

Neck stiffness: normal Return to examples 47

Examination of Gait • • • 1 -Circumduction 2 -Scissoring 3 -High steppage 4 -Waddling 5 -Stamping (5 -Drunken(Zigzag