This presentation deals with clinical examination of Central Nervous System.

1. CENTRAL NERVOUS SYSTEM
EXAMINATION
Dr Akshay Shetty
Asst.Professor
Dept of Panchakarma
SSRAMCH Inchal

2. Contents
• Objectives
• Higher mental functions examination
• Motor system examination
• Cranial nerve examination
• Sensory system examination
• Reflexes
• Summary
• References
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3. Objectives
By the end of the presentation the learners
must be able
• To understand Higher mental functions
examination
• To demonstrate Motor system examination
• To demonstrate Cranial nerve examination
• To demonstrate Sensory system examination
• To demonstrate Reflexes
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4. Higher mental function examination
Consciousness : is a state of awareness of ones self and ones
environment.
Sleep
Akinetic
mutism
Catatonic
Semico
ma
Drowsiness Stupor
Coma
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5. Contd.…
• Delirium is a state of confusion with
excitement and hyperactivity
• Causes
oInfective : Septicaemia, Typhoid,
Cerebral malaria
oWithdrawal state
oToxic: Overdose of aspirin,
amphetamine, atropine etc
oDeficiency of thiamine and nicotinic
acid
oMetabolic : Renal failure,porphyria
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6. Contd…
Delusions are false beliefs which cannot
be corrected in spite of evidence to the
contrary, these have to be distinguished
from superstitions.
Causes
• Holistic
• Delusion of guilt
• Delusions of grandeur
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7. Contd…
• Hallucinations this is a perception of
sensations in the absence of any
sensory stimulus e.g. humming in
the ears or seeing somebody who
does not exist
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8. Contd…
Memory
• Deficient in registration :toxic delirium,
maniac states, senile dementia
• Deficient in retention : senile dementia ,GPI,
Frontal lobe lesion
• Deficient in recall: post traumatic states
,epilepsy ,hysteria.
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9. Contd…
Language & speech
• Dysphasia/Aphasia :is difficulty with
language function.
• Types
• Sensory (Wernicke’s ) dysphasia
• Motor (Broca’s ) dysphasia
• Central dysphasia
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10. Contd…
Dysarthria is indistinct speech due to
weakness or impaired coordination of the
orolingual muscles concerned with the
production of consonants. However grammar
is normal and comprehension of spoken and
written language is retained.
• Types
• Spastic
• Monotonous
• Ataxic
• Lower motor neurone
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11. Motor system examination
Nutrition Tone Power
Ataxia
Involuntary
movements
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12. Contd…
Nutrition
• Hypertrophy of muscles
• Wasting of muscles
• Measurements
For U/L: 4 inches above and below olecranon
For L/L: 6 inches above and below tibial
tuberosity
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13. Contd…
Causes
• Parietal lobe lesions
• Vertebral lesions
• Spinal cord lesions
• Anterior horn cell lesions : Poliomyelitis, Peroneal muscular atrophy
• Root lesions : Cervical spondylitis, cervical cord tumour
• Peripheral nerve lesions :leprosy ,carpal tunnel syndrome
• Systemic wasting : tuberculosis, malignancy, HIV, AIDS, thyrotoxicosis
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14. Contd..
Tone is the resistance offered by the normal muscles to
passive movements .it is greater in those muscles that
maintain the body in position .these are antigravity
muscles .
Hypotonia(Flaccidity)
It is characterised by flabby muscles which offer less
resistance to passive movements.
Causes :
LMND :Poliomyelitis, peripheral neuritis
Rheumatic chorea
Cerebellar disease
This Photo by Unknown Author is licensed under CC BY-SA
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15. Contd..
• Hypertonia is increased resistance to passive
movements
Causes
i. Pyramidal disorders
ii. Extrapyramidal disorders
iii. Tetany
iv. Hysteria
v. Strychnine poisoning
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16. Contd …
Types of hypertonia
Clasp knife rigidity :Pyramidal lesions
Lead pipe rigidity :Extra pyramidal lesions
Cog wheel rigidity :Parkinson disease
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17. Contd..
Spasticity
1. Pyramidal
2. Involves only antigravity
muscles viz extensor of upper
limbs & flexors of lower limbs
Rigidity
1. Extra pyramidal
2. Involves all groups
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18. Contd…
• Power should be tested at each joint in both upper and the lower
limbs both against the gravity and against resistance.
• MRC grading of Power
Grade 0 No power
Grade I Flicker of contraction only
Grade II Movement with gravity eliminated
Grade III Movement against gravity
Grade IV Movement against gravity and some resistance
Grade V Normal power
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19. Contd…
1) Deltoid—abduction (elevation) of upper arm – (C5-6, axillary nerve)
2) Biceps—flexion of forearm at elbow – (C5-6, musculocutaneous nerve)
3) Triceps—extension of forearm at elbow – (C6-8, radial nerve)
4) Extensor carpi radialis—dorsiflexion of hand at wrist – (C5-6, radial
nerve)
5) Abductor pollicus brevis—palmar abduction of thumb – (C8-T1, median
nerve) w/ thumb at right angle to palm
6) Interrosei—finger abduction (dorsal) & adduction (palmar) – (C8-T1,
ulnar nerve)
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20. Contd…
• Iliopsoas—hip flexion –(L1-3, femoral nerve)
• Quadriceps—knee extension – (L2-4, femoral nerve)
• Hamstrings—knee flexion – (L5-S2, sciatic nerve)
• Tibialis anterior—ankle dorsiflexion – (L4-5, deep peroneal nerve)
• Gastrocnemius/soleus—ankle plantar flexion – (S1-2, tibial nerve)
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21. Contd…
Ataxia
Causes
Cerebellar
• Cerebellar tumour or abscess
• Vascular lesions
• Cerebellar degeneration
• Encephalitis
• Drugs: Alcohol ,eptoin, piperazine citrate,streptomycin
• Labyrinthitis
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22. Contd…
Sensory
• Peripheral neuritis
• Tabes dorsalis
• Parietal lobe
Labyrinthine
• Acute labyrinthitis
• Meniere's disease
• Drugs: streptomycin
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23. Contd…
Tests
1. Romberg's test
2. Tandem walking
3. Finger nose test
4. Finger to finger test
5. Knee-heel test
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24. Tests
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25. Contd….
Involuntary movements
Tremors are regular rhythmic contraction of agonist and antagonist
Classification
Type : simple,
compound
Site: unilateral,
bilateral
Rhythm: regular,
irregular
Amplitude :fine,
moderate,
coarse
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26. Cranial nerve examination
CNI: Olfactory nerve
• Cannot evaluate if nasal passages obstructed by rhinitis, polyps, etc.
• Eyes closed
• Occlude one nostril and test other
• Compare 2 sides
• Use non irritating substances – Avoid those that stimulate trigeminal
nerve endings or taste buds (e.g., peppermint, menthol, ammonia)
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27. CNII: Optic nerve
• Visual acuity
• Visual fields
• Fundoscopy
• Afferent limb of pupillary function
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28. CNII: Visual acuity
• Hold Snellen chart at comfortable reading distance
• Cover 1 eye
• Glasses on
(looking for optic nerve lesion, not refractive error)
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30. CNII: Fundoscopic exam
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31. CNII & III: Pupillary function
• Normal pupils are equal in size and shape and are situated in center
of iris
• Pupillary size varies with intensity of ambient light, but at average
intensity is 3-4 mm
• – Miosis < 2 mm
• – Mydriasis > 5 mm
• – Anisocoria = pupillary asymmetry
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33. CNII & III: Light reflex
• Dim lights
• Fix gaze on opposite wall to eliminate effects of accommodation
• Shine bright light obliquely into each pupil
• Look for both direct (same eye) and consensual (opposite eye)
reaction
• Record pupil size and shape
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34. CNII & III: Accommodation
• Hold finger 10 cm from patient’s nose
• Alternate looking into distance and at finger
• Observe pupillary response
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35. CNIII, IV, VI: Ocular nerves
• CNIII Oculomotor nerve
• CNIV Trochlear nerve
• CNVI Abducens nerve
 Visual inspection: ocular alignment, lids
 Convergence
Smooth pursuits
Saccades
 Nystagmus
 6 cardinal directions of gaze
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41. CNVIII: Auditory nerve
• Hearing (cochlear nerve)
• Test with finger rubbing at arm’s length
• If can’t hear strong rubbing impaired
• If can hear faint rubbing normal
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43. CNIX & X: Glossopharyngeal & vagus nerves
Testing centres on motor function –
• Palate elevation
• Swallowing
• Voice
• Cough
• Gag reflex
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44. CNXI: Spinal accessory nerve
Trapezius –
• Push head back against resistance
• Shrug shoulders
Sternocleidomastoid –
• Place hand on lower face and have patient rotate head toward that
side
• Observe contraction of opposite SCM
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45. CNXII: Hypoglossal nerve
• Note tongue position at rest and on protrusion
• Does tongue deviate in either position?
• Note strength and rapidity of movements
• Have patient push tongue into each cheek
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46. Sensory system examination
• Touch :is tested with cotton wool or the head of the pin on all parts of
the body
• Pain :superficial pain is tested with a pin prick ,deep pain is tested by
pressing calves, tendo Achilles or testes.
• Temperature : two test tubes one containing hot water and other
crushed ice is taken and placed on all the parts of the body.
• Position :the patient is explained the procedure, with his eyes closed
a part of his limb is placed in definite position and then he is asked to
denote the position.
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47. Contd…
• Vibrations : a tuning fork of 128 vibrations per second is vibrated and
placed on some bony prominence, and is asked to indicate vibrations.
• Cortical sense: Tactile localisation ,tactile discrimination,tactile
extinction are tested.
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49. Reflexes
• Deep tendon reflex
• Superficial reflex
• 0: absent reflex
• 1+: trace, or seen only with reinforcement
• 2+: normal
• 3+: brisk
• 4+: non sustained clonus (i.e., repetitive vibratory movements)
• 5+: sustained clonus
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50. Deep tendon reflex
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51. Superficial reflex
• Plantar reflex(S1)
• Abdominal reflex (T6-T12)
• Cremasteric reflex (L1)
• Bulbocavernous reflex (S2-S4)
• Anal reflex (S4-S5)
• Hoffmann's sign
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52. Summary
Higher mental
functions
examination
Motor system
examination
Cranial nerve
examination
Sensory
system
examination
Reflexes
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53. THANK
YOU
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