Central Nervous System examination

NEUROLOGICAL EXAM MENTAL STATUS CRANIAL NERVES MOTOR EXAM REFLEXES STRENGTH GAIT CEREBELLAR REFLEXES SENSATION

Level of Consciousness Awake and alert Agitated Lethargic Arousable with Voice Gentle stimulation Painful/vigorous stimulation Comatose

ORIENTATION PERSON PLACE TIME

LANGUAGE FLUENCY NAMING REPETITION READING WRITING COMPREHENSION Aphasia

MEMORY IMMEDIATE REMOTE - Name 3 OBJECTS and ask to repeat HISTORICAL EVENTS PERSONAL EVENTS

OTHER COGNITIVE FUNCTIONS CALCULATION ABSTRACTION SIMILARITIES/DIFFERENCES JUDGEMENT PERSONALITY/BEHAVIOR

Sensory How and what part of the nervous system are we checking? Light touch Pinprick Temperature Vibration Joint position sense Checking a level Romberg- correct positioning!

SENSORY EXAM VIBRATION JOINT POSITION SENSE PIN PRICK TEMPERATURE 128 hz tuning fork JOINT POSITION SENSE PIN PRICK TEMPERATURE Start distally and move proximally

3+: brisk, without clonus 4+: brisk, with clonus Reflexes Grading system 0: absent 1+: hyporeflexia 2+: normal 3+: brisk, without clonus 4+: brisk, with clonus

BICEPS BRACHIORADIALIS TRICEPS KNEE ANKLE

Plantar reflex Planar reflex(S1) Normal- On stroking the lateral border of the sole there is flexion of the big toe and other toes.

Extensor plantar response Babiniski sign Dorsiflexion of the big toe and ankle joint and fanning of the other toes.

CRANIAL NERVE EXAM I - OLFACTORY II - OPTIC DON’T USE A NOXIOUS STIMULUS COFFEE, LEMON EXTRACT II - OPTIC VISUAL ACUITY VISUAL FIELDS FUNDOSCOPIC EXAM

CRANIAL NERVE EXAM III/IV/VI OCULMOTOR, TROCHLEAR, ABDUCENS PUPILLARY RESPONSE EYE MOVEMENTS 9 CARDINAL POSITIONS OBSERVE LIDS FOR PTOSIS V - TRIGEMINAL MOTOR - JAW STRENGTH SENS - ALL 3 DIVISIONS

CRANIAL NERVES VII - FACIAL VIII - VESTIBULAR OBSERVE FOR FACIAL ASYMMETRY FOREHEAD WRINKLING, EYELID CLOSURE, WHISTLE/PUCKER VIII - VESTIBULAR ACUITY RINNE, WEBER

CRANIAL NERVES IX/X - GLOSSOPHARYNGEAL, VAGUS XI - SPINAL ACCESSORY GAG XI - SPINAL ACCESSORY STERNOCLEIDOMASTOID M. TRAPEZIUS MUSCLE XII - HYPOGLOSSAL TONGUE STRENGTH RIGHT XII THRUSTS TONGUE TO LEFT

MUSCLE OBSERVATION ATROPHY FASCIULATIONS

ABNORMAL MOVEMENTS TREMOR CHOREA ATHETOSIS ABNORMAL POSTURES REST WITH ARMS OUTSTRETCHED INTENTION CHOREA ATHETOSIS ABNORMAL POSTURES

CEREBELLAR FUNCTION RAPID ALTERNATING MOVEMENTS FINGER TO FINGER TO NOSE TESTING HEEL TO SHIN GAIT TANDEM

Romberg Sign Stand with feet together - assure patient stable - have them close eyes Romberg is positive if they do worse with eyes closed Measures Cerebellar function Frequently poor balance with eyes open and closed Proprioception Frequently do worse with eyes closed Vestibular system

Strength: check agonist/antagonist pairs Abnormal movements MOTOR Tone Muscle bulk Strength: check agonist/antagonist pairs Abnormal movements Motor

STRENGTH STRENGTH GRADED 0 - 5 0 - NO MOVEMENT 1 - FLICKER 2 - MOVEMENT WITH GRAVITY REMOVED 3 - MOVEMENT AGAINST GRAVITY 4 - MOVEMENT AGAINST RESISTANCE 5 - NORMAL STRENGTH

STRENGTH EXAM UPPER AND LOWER EXTREMITIES DISTAL AND PROXIMAL MUSCLES GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH SUBTLE WEAKNESS TOE WALK, HEEL WALK OUT OF CHAIR DEEP KNEE BEND

INCREASED, (Hypertonia) COGWHEEL rigidity CLASP KNIFE spasticity TONE INCREASED, (Hypertonia) COGWHEEL rigidity CLASP KNIFE spasticity DECREASED, (Hypotonic)

1. Ask the subject if he/she has a subjective olfactory problem. 􀂄 2. Check for rash, deformity of nose. 􀂄 3. One nostril is occluded while examining the other. Use pleasant odor substances like tea or rose water. Don’t use irritating substances

CN II: OpticNerve 􀂇 There are three main aspects to this nerve: visual acuity, visual fields, and fundi opticus. 􀂄 1. Examine visual acuity: 􀂄 2. Examine visual fields: 􀂄 3. Look into the fundi:

CN III,IV and VI 􀂇 CN III Oculomotor: 􀂄 Eyelid and eyeball movement 􀂇 CN IV Trochlear: 􀂄 Innervates superior oblique 􀂄 Turns eye downward and laterally 􀂇 CN VI Abducens: 􀂄 Turns eye laterally 􀂇 Cranial Nerves III, IV and VI supply the muscles of eye movement and are tested as a unit.

1. Appearance of eyes: 􀂇 2. Eyeball movement: 􀂇 3. Look at pupils: 􀂇 4. Test pupillary light reaction: 􀂇 5. Pupillary reaction to convergence and accommodation reflex:

CN V: Trigeminal Functions: 􀂄 Chewing 􀂄 Face & mouth touch & pain 􀂇 1. Facial sensation: 1) Use sterile sharp item on forehead, cheek and jaw. 2) If abnormal, then test temperature [water-heated/cooled tuning fork], light touch [cotton].

2. Motor: Subject opens mouth, clenches teeth. 1) Palpate temporal, masseter muscles as they clench. 2) Subject opens mouth; assess the symmetry of the mouth.

3. Corneal reflex: Ask the patient looks up and straight. 1) Touch cotton wool to the sclera on the other side. 2) Look for blink in both eyes, ask if subject can sense it. 3) Repeat on the other side.

􀂇 4. Test jaw jerk: 1) Examiner places finger on tip of jaw. 2) Grip patellar hammer halfway up shaft and tap examiner’s finger lightly. 3) Usually nothing happens, or just a slight closure

CN VII: Facial Functions: controls most facial expressions, secretion of tears & saliva, taste 􀂇 1. Muscles of facial expression: 􀂇 2. Check the sense of taste:

CN VIII: Vestibulocochlear 􀂇 Functions: hearing; equilibrium sensation 􀂇 Auditory acuity 􀂄 1. Rinne test: 􀂄 2. Weber test: 􀂇 Vestibular function:

CN IX Glossopharyngeal: 􀂄 taste 􀂄 senses carotid blood pressure 􀂇 CN X Vagus: 􀂄 senses aortic blood pressure 􀂄 slows heart rate 􀂄 stimulates digestive organs

CN XI: Accessory 􀂇 1. Sternocleidomastoid Press a hand against the patient's jaw and have the patient rotate the head against resistance. Pressing against the right jaw tests the left sternocleidomastoid and vice versa. 􀂇 2. Trapezius Have the patient shrug shoulders against resistance and assess weakness.

CN XII: Hypoglossal 1. Listen to articulation. 􀂇 2. Inspect tongue in mouth for wasting, fasciculations. 􀂇 3. Protrude tongue: deviates to affected side.

INVOLUNTARY MOVEMENTS TREMORS They are regular rhythmic movements. STATIC TREMOR 1.parkinsonism 2.senile POSTRUAL TREMORS Anxiety Familial Hyperthyroidsm

Some useful tests for detection of deficiencies in motor function of the palate, pharynx, and larynx are described below. Sensory function needs to be checked if one suspects cranial neuropathy or a brain stem lesion. 1. Palatal Elevation 2. Gag reflex (afferent IX, efferent X) 3. Sensory function 4. Voice Quality 5. Taste test see CN VII

INTENTION TREMORS Cerebellar Severe parkinsonism HYSTERICAL TREMORS

CHOREA Quick jerky irregular brief movements. Causes Infections Hereditary Endocrine Collagen disorders Liver disease like Wilson disease Myoclonus Muscular contractions

Evaluation of severity of Coma Grading of level of coma Grade -0 Fully conscious Grade1-Drowsy,but responds to verbal commands Grade 2-Unconscious but responds to minimal pain Grade3-unconscious but responds to deep pain Grade4- Unconscious with no response to pain

The sum of these values is calculated. The minimum GCS is 3 (deep coma) The maximum is 15 GCS 11-15 good prognosis GCS 5-10 intermediate GCS 3-4 poor prognosis

CEREBELLAR FUNCTION RAPID ALTERNATING MOVEMENTS FINGER TO FINGER TO NOSE TESTING HEEL TO SHIN GAIT TANDEM

Romberg Sign Stand with feet together - assure patient stable - have them close eyes Romberg is positive if they do worse with eyes closed Measures Cerebellar function Frequently poor balance with eyes open and closed Proprioception Frequently do worse with eyes closed Vestibular system

MENENGITIS Meningeal signs Neck stiffness- Causes Meningitis Subarchonoid hemorrhage Cervical spondylosis

Kernig’s sign With the hip flexed the knee is extended. Normally it can be done upto 135 degree. In meningitis it is restricted due to spasm of the hamstrings.

Brudzinski’s sign Neck sign Leg sign