This document provides an overview of how to examine the central nervous system. It describes how patients may present with neurological issues and lists the areas to examine, including higher functions, cranial nerves, motor system, reflexes, and sensory systems. The examination involves assessing consciousness, orientation, memory, attention, intelligence, speech, and gait. It also details how to test individual cranial nerves and provides examples of involuntary movements, signs of meningeal irritation, and cerebellar signs. The goal of the examination is to thoroughly evaluate neurological function.

1. CNS EXAMINATION
by
Dr. Gobinda Prasad Pradhan

2. How they present
• Altered sensorium
• Loss of consciousness
• Loss of attained milestones
• Seizure
• Abnormal movements
• Dev. Delay
• Aspiration of feeds
• Weakness
• Ataxia, nystagmus
• Disturbance of speech, vision, hearing
• Loss of bladder & bowel movement………& many more
©Dr. Gobinda Pr. Pradhan

3. EXAMINATION
• Higher function
• Cranial nerve
• Motor
• Involuntary movements
• Reflex
• Sensory system
• Autonomic function
• Cerebellar signs
• Signs of meningeal irritation
• Skull & spine
• PNS
• Locomotor system
©Dr. Gobinda Pr. Pradhan

4. ©Dr. Gobinda Pr. Pradhan

5. HIGHER FUNCTION
COMA IS G
C : Consciousness
O : Orientation
M : Memory
A : Attention
I : Intelligence
S : Speech
G : Gait
©Dr. Gobinda Pr. Pradhan

6. Consciousness : ability to relate to both self & surroundings
Level of Consciousness
• Drowsy
• Obtundation
• Stupor
• Delirium
• Light coma
• Deep coma
• Falccid coma
©Dr. Gobinda Pr. Pradhan

7. Consciousness
©Dr. Gobinda Pr. Pradhan

8. Orientation
• Time
• Place
• Person
©Dr. Gobinda Pr. Pradhan

9. MEMORY
• Immediate
• Short term
• Long term
©Dr. Gobinda Pr. Pradhan

10. Attention
Digit repetition test
• The digit span test consists of telling the person that you are going to give
him a short test. The person is then told to listen carefully because you will
say a series of numbers and ask him to repeat them back to you in the
same order you say them.
• The first series is three numbers, such as "3, 9, 2." Each number is said in
a monotone voice, one second apart. The person repeats those numbers
back to you.
• The next step is to speak a series of four numbers, such as, "4, 7, 3, 1."
Again, the individual repeats those back to you.
• Continue in the same manner by increasing the series of numbers to five
and ask the person to repeat the numbers back to you. Some test versions
stop after a series of five numbers, while other versions continue
increasing the series of numbers by one each time until the answers are
incorrect.
©Dr. Gobinda Pr. Pradhan

11. Intelligence
• Calculation & abstract thinking
©Dr. Gobinda Pr. Pradhan

12. Speech
• Is a function of dominant hemisphere
• Involves Higher cortical function, muscle articulation, voice
production
• Delayed speech
• no word up to 18 m.
• Or no sentence up to 3yrs.
• Slurred speech……………………(pyramidal lesion).
• Monotonus speech …………….(extrapyramidal lesion).
• Staccato speech…………………(cerebeller lesion)
©Dr. Gobinda Pr. Pradhan

13. GAIT
• Stance : is the way a person stands
• Gait : is the way a person walks
 Hemiparetic gait
 Ataxic gait
 Shuffling gait
 High stepping gait
 Spastic or scissoring gait
 Waddling gait
©Dr. Gobinda Pr. Pradhan

14. Can u recognise ?
©Dr. Gobinda Pr. Pradhan

15. Can u recognise ?
©Dr. Gobinda Pr. Pradhan

16. Can u recognise ?
©Dr. Gobinda Pr. Pradhan

17. Can u recognise ?
©Dr. Gobinda Pr. Pradhan

18. Can u recognise ?
©Dr. Gobinda Pr. Pradhan

19. CRANIAL NERVE
• I
• II
• III
• IV
• V
• VI
• VII
• VIII
• IX
• X
• XI
• XII
©Dr. Gobinda Pr. Pradhan
 Olfactory
 Optic
 Occulomotor
 Trochlear
 Trigeminal
 Abducens
 Facial
 Vestibulocochlear
 Glossopharyngeal
 Vagus
 Spinal accessory
 hypoglossal

20. OLFACTORY
• Difficult to examine in children
• m/c/c for poor smell perception in children ?
• Tested from 5 yr onwards
©Dr. Gobinda Pr. Pradhan

21. ??
GOA
Hypogonadism
Obesity
Anosmia
Kallman
syndrome
©Dr. Gobinda Pr. Pradhan

22. OPTIC NERVE
• Visual aquity (snellens, Jaegers,Menace)
• FOV (perimetry, confrontation method, menace)
• Colour vision (Isihara)
• Fundus
©Dr. Gobinda Pr. Pradhan

23. 346
• Ptosis
• Pupil(Pupil size,LR)
• Squint
• Nystagmus
• Diplopia
©Dr. Gobinda Pr. Pradhan

24. Which manoeuvre is this ?
DOLL’S EYE / OCCULO-CEPHALIOC REFLEX
©Dr. Gobinda Pr. Pradhan

25. LIGHT REFLEX
• Afferent….. Optic nerve.
• Center……..midbrain.(3rd nerve nuclei )
• Efferent……3rd cr. N. to both eyes
• Direct/Consensual
©Dr. Gobinda Pr. Pradhan

26. TRIGEMINAL
Sensory :
• Ophthalmic
• Maxillary
• Mandibular
Motor:
• Masseter
• Temporalis
• Pterygoid
Reflexes:
• Corneal reflex
• Conjunctival reflex
• Jaw reflex
Clench the teeth
Side to side movement against resistance
©Dr. Gobinda Pr. Pradhan

27. FACIAL
• Sensory : Ant 2/3rd of tongue
• Motor :
• Asymm. of forehead m/s
• NL fold obliteration
• Deviation of mouth with drooling
• Able to close his eyes
• Prominence of platysma
©Dr. Gobinda Pr. Pradhan

28. SCARY??
©Dr. Gobinda Pr. Pradhan
Bell’s phenomenon

29. VESTIBULOCOCHLEAR
• Difficult to examine
• Cochlear
• Watch test/Rinne/Weber
• Vestibular
• Calorie test
• Unterberger’s test
• Tandem walking
©Dr. Gobinda Pr. Pradhan

30. IX & X tested together
Gag reflex…absent in bulber palsy UMN
exaggarated in pseudo bulber palsy LMN
Uvula ….normally central & mobile.
• In unilateral lesion….uvula deviate to healthy side
• In bilateral lesion…uvula is central but immobile
©Dr. Gobinda Pr. Pradhan

31. ©Dr. Gobinda Pr. Pradhan

32. GLOSSOPHARYNGEAL
• Sensory : post 1/3rd of tongue(can’t be done)
• Motor : Stylopharyngeus
• Reflex :
• Gag reflex
• Palatal reflex
©Dr. Gobinda Pr. Pradhan

33. VAGUS
• Sensory : touch the palate & pharynx
• Motor : Uvula position(say aaahh)
• Reflex :
• Gag reflex
• Palatal reflex
©Dr. Gobinda Pr. Pradhan

34. SPINAL ACCESSORY
• SCM
• Trapezius : shoulder shrugging
©Dr. Gobinda Pr. Pradhan

35. HYPOGLOSSAL
• Bulk : wasting/Atrophy
• Power : Spastic/ Flaccid
©Dr. Gobinda Pr. Pradhan

36. MOTOR SYSTEM
• Bulk (Size, Shape, Symmetry)
• Tone
• Power
©Dr. Gobinda Pr. Pradhan

37. Tone (resistance offered by m/s to passive stretch)
• Inspection
• Position at rest : frog-leg posture
• Hold them in axilla : slips/scissoring
• Palpation
• Firm
• Loose
• Hard
• Rubbery
• Limbs are moved passively at each joint to assess the tone
©Dr. Gobinda Pr. Pradhan

38. Power (Force that can be voluntarily generated)
• Fix the proximal joint
©Dr. Gobinda Pr. Pradhan

39. Involuntary movements
• Tremor
• Chorea
• Athetosis
• Ballismus
• Dystonia
• Myoclonus
• Fasciculation
• Tics
©Dr. Gobinda Pr. Pradhan

40. REFLEXES
• Superficial
• Corneal/conjunctiva
• Palatal
• Abdominal
• Cremasteric
• Anal
• Plantar
• Deep
• Jaw
• Biceps
• Supinator
• Triceps
• Knee
• Ankle
©Dr. Gobinda Pr. Pradhan

41. Sensory system
• Lateral column sensation (Light touch, Pain, temp.)
• Posterior column sensation (Vibration, Propriosensation, Romberg’s
test, Pressure)
• Cortical sensation
• Position sense
• Tactile localization
• 2 point discrimation
• Sensory inattention
• Stereognosis
• Agraphasthesia
©Dr. Gobinda Pr. Pradhan

42. Autonomic system
• BP
• Sweating
• Bladder
• Bowel
©Dr. Gobinda Pr. Pradhan

43. Signs of meningeal irritation
• Neck rigidity
• Tripod sign
• Head drop
• Kernig’s sign
• Brudzinski sign
©Dr. Gobinda Pr. Pradhan

44. ©Dr. Gobinda Pr. Pradhan

45. ©Dr. Gobinda Pr. Pradhan

46. Cerebellar signs
• Upper limb
• Finger-nose test
• Dysdiadochokinesia
• Rebound phenomenon
• Lower limb
• Tandem walking
• Heel knee test
©Dr. Gobinda Pr. Pradhan

47. Skull & spine
• Macewan/Cracked pot sign
• Transillumination
©Dr. Gobinda Pr. Pradhan

48. ©Dr. Gobinda Pr. Pradhan

49. STILL CONFUSED !!
©Dr. Gobinda Pr. Pradhan