1. Central Nervous System examination

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

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

4. ORIENTATION
PERSON
PLACE
TIME

5. LANGUAGE FLUENCY NAMING REPETITION READING WRITING COMPREHENSION
Aphasia

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

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

8. 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!

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

13. 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

14. BICEPS
BRACHIORADIALIS
TRICEPS
KNEE
ANKLE

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

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

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

18. 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

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

20. 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

21. MUSCLE OBSERVATION
ATROPHY
FASCIULATIONS

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

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

24. 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

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

27. 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

28. 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

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

31. 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

32. 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:

33. 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.

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

35. 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].

36. 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.

37. 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.

38. 􀂇 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

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

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

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

45. 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.

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

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

48. 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

49. INTENTION TREMORS
Cerebellar
Severe parkinsonism
HYSTERICAL TREMORS

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

51. 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

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

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

56. 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

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

58. 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.

59. Brudzinski’s sign
Neck sign
Leg sign