central nervous system examination

Examination
Examination
of
cEntral
nErvous systEm
Dr. Shalu Jain
MD Scholar
Pt. Khushilal Sharma Govt. Auto. Ayurveda College And Institute, Bhopal (M.P.)
Examination
Examination
cEntral
nErvous systEm
Jain
MD Scholar
College And Institute, Bhopal (M.P.)

INTRODUCTION
 The purpose of CNS examination is to determine
the presence or absence of disease in the nervous
system .
system .
 These are involve in examining the neurological
& physical status of the patient as part of the
total physical assessment .
 History taking
 General examination
 General examination
 Systemic examination ( CNS )
Dr. Shalu jain @ Pt. Khushilal Sharma Govt. Auto. Ayurveda College And institute, Bhopal (M.P)
The purpose of CNS examination is to determine
the presence or absence of disease in the nervous
These are involve in examining the neurological
& physical status of the patient as part of the
Systemic examination ( CNS )

Aspects of CNS Examination....
 Higher Functions
 Higher Functions
 Cranial Nerves
 Sensory System
 Motor System
 Reflexes
 Reflexes
Aspects of CNS Examination....

HIGHER FUNCTIONS
HIGHER FUNCTIONS
1. Consciousness
1. Consciousness
2. Orientation
3. Intelligences
4. Memory
5. Language and speech
5. Language and speech
HIGHER FUNCTIONS
HIGHER FUNCTIONS

CONSCIOUSNESS
 Consciousness is a state of awareness of one’s self and
one’s environment.
one’s environment.
Level of consciousness:-
 Sleep
 Catatonia
 Akinetic mutism
 Drowsiness
 Semicoma
 Stupor
 coma
Consciousness is a state of awareness of one’s self and

ASSESSMENT OF LEVEL OF
CONSCIOUSNESS
CONSCIOUSNESS
Glasgow Coma Scale Abbreviated Coma Scale
Glasgow Coma Scale
(GCS)
GCS is useful in assessing level
of consciousness in a patient
with head injury.
Best Total sore - 15
Mild injury - 13 -15
Abbreviated Coma Scale
(AVPU)
A alert
V responds to vocal stimuli
P respond to pain
U unresponsive
Mild injury - 13 -15
Moderate injury 9 – 12
Severe injury 8
(AVPU)
alert
responds to vocal stimuli
respond to pain
unresponsive

ORIENTATION
Questions are put to the patients to test his
orientation to
orientation to
 Time
 Place
 Person
TIME PLACE
Questions are put to the patients to test his
PERSON

Memory
It is the power to retain and recall past experience.
It can be tested by mini mental state examination (MMSE)
Components of
memory
 Reception
 Registration
a. Immediate or short term
memory
 Registration
 Retention
 Recall
b. Recent memory
c. Long term or secondary or
remote memory
It is the power to retain and recall past experience.
Immediate or short term
memory
Types of memory
Recent memory
Long term or secondary or
remote memory

Examination of Cranial nerves
Cranial nerves are a set of twelve nerves that
has a different function for sense or movement
1.
3
11
Examination of Cranial nerves
that originate in the brain. Each
movement.
2
8
4
6
8
12

Olfactory nerve
 Function: Smell
Optic nerve
 Function:
eye to brain
 Examination: Block one nostril.
Get patient to smell strong distinctive
smell (coffee, lemon, cinnamon).
 Normal: If patient can identify
smell with both nostrils – olfactory
nerve intact.
 Examination:
Acuity: Read
2. Visual
(for each
3. Pupillary
 Normal:
both pupillary
light reflex
 Palsy/Lesion: Unilateral
loss of smell – lesion Generally
from trauma, meningitis.
light reflex
 Palsy
one or both
Optic nerve
Function: Visual transmission –
brain
Examination: 1. Visual
Read snellen chart.
Visual fields – finger wiggle
each eye)
Pupillary light reflex
Normal: Consensual response to
pupillary light and swinging
reflex
reflex
Palsy: visual acuity is reduced in
one or both eyes

Oculomotor Nerve
 Function: eye movement.
Trochlear
 Function:
Oblique
 Examination: . Look for
ptosis, eye position and
nystagmus, inspect pupil for
PERRLA
 Examination
Look for
nystagmus
PERRLA
Normal: Consensual pupil
responses No diplopia or
nystagmus
Palsy: Ptosis
PERRLA
 Palsy
Trochlear nerve
Function: Innervates Superior
Oblique
Examination: Examination:
Look for ptosis, eye position and
nystagmus, inspect pupil for
PERRLA
PERRLA
Palsy: Intorsion

Trigeminal nerve
Function:
 Sensory to the face by ophthalmic,
maxillary, mandibular
 Motor: Muscles of mastication
 Examination: Point touch with cotton wool/
tissue, pain using a sharp point,
 Corneal reflex: rapid blinking of the eye lids
 Motor: Inspect. Palpate temporalis and masseters
clenches the jaw, pterygoids – mouth open against resistance, jaw
 Normal: even feeling of sensation, both eyelids
reflex, able to clench jaw, no jaw jerk
reflex, able to clench jaw, no jaw jerk
 Palsy: wasting of temporalis or masseter, unable
close mouth
lids from a sudden stimulus
masseters as patient
mouth open against resistance, jaw jerk
eyelids respond to corneal
unable to resist pressure to

Facial nerve
Function: Sensory - Taste (Anterior 2/3 of the
of facial expression
 Examination:
 Sensory: Test Taste of distinctive flavours
test of olfactory).
 Motor: 1) raise both eyebrows 2) screw eyes
muscular strength 3) smile 4) bare teeth (show
teeth) 6) puff out cheeks
 Palsy: Bell’s Palsy (central/peripheral)
the tongue); Motor – Muscles
flavours (similar to the smell
eyes up, try to pull to test
(show both upper and lower

Vestibulocochlear nerve
 Function: Hearing
 Function: Hearing
 Examination: 1) Whisper a number into patient’s
time. Ask the patient to repeat the numbers
 2) Rinne Test 3) WeberTest
 Normal: 1. Correct number 2. Air conduction louder than bone 3.
Hear the tuning fork in both ears equally
 Palsy: in middle year disease bone conduction is better then air
conduction
patient’s ears. One at a
Normal: 1. Correct number 2. Air conduction louder than bone 3.
Palsy: in middle year disease bone conduction is better then air

Spinal
 Function
SCM and
Function: Swallowing, Gag
Reflex
Glossopharyngeal ,
Vagus nerve
 Examination:
patient
shrug
(against
 Normal:
Symmetrical
movements
Reflex
Examination: Gag response
Palsy: Abnormal Cough on
swallowing
movements
Able
 Palsy:
unable
SpinalAccessory
Function: Innervation to
SCM and Trapezius.
Examination: Ask
patient to turn head,
shrug shoulders
(against resistance).
Normal:
Symmetrical
movements performed.
movements performed.
Able to resist pressure
Palsy: Muscle wasting,
unable to resist pressure

Hypoglossal Nerve
 Function: movement of tongue
 Function: movement of tongue
 Examination: Inspect for tongue fasciculations
atrophy. Ask patient to poke out their tongue
 Normal: No deviation of the tongue on protrusion
 Palsy: Will deviate ipsilateral to the paralysis and
contralateral to the lesion
contralateral to the lesion
fasciculations, asymmetry or
protrusion
to the paralysis and

Modalities of sensation to be tested :
 Exteroceptive Senstion /Superficial sensation
 Exteroceptive Senstion /Superficial sensation
 Proprioceptive Sensations
 Cortical sensations
Modalities of sensation to be tested :-
/Superficial sensation
/Superficial sensation

Exteroceptive Senstion /Superficial
sensation
Touch
 Fine touch – tested by cotton
Pain
 Superficial pain:
 Fine touch – tested by cotton
wool
 Crude touch – by blunt object
Temperature Two test tubes one
containing hot water and the other
 Superficial pain:
pin prick
 Deep pain :
the calves,
containing hot water and the other
crushed ice is taken and placed on
all the parts of the body
/Superficial
Superficial pain:- tested with a
Superficial pain:- tested with a
pin prick
Deep pain :- tested by pressing
the calves, tendo achilis or testis.

Proprioceptive sensation/ Deep
sensation
Position sense
 A part of limb / arm is placed in
Joint sense
 Fixing
 A part of limb / arm is placed in
definite position and then he is
asked to denote the position or
place the other limb in similar
position.
 Fixing
moved
joint
holding
 Patient
either
Vibration
Assessment of vibration sense by tuning fork(128 Hz) is
applied on bony prominences .
sensation/ Deep
Joint sense
Fixing the joint, the finger/ toe is
Fixing the joint, the finger/ toe is
moved at terminal interphalangeal
, either up or down by
holding the sides of digits.
Patient to tell the direction i.e.
either up or down.
by tuning fork(128 Hz) is
College And institute, Bhopal (M.P)

Cortical Sensory Functions
Localzation Test
 Touch a part of patient body with
his eyes closed
 Ask him to open the eyes and
Two Point Discrimination Test
 Ability to distinguish the
contact of two separate points
applied simultaneously to the
 Ask him to open the eyes and
place his finger of that part
skin
Tactile Extinction Test
Tactile Extinction Test
When two stimuli are applied simultaneously
to two symmetrical portion of the body, the
patient neglect the one on the opposite side
the lesion,.
Though individually he appriciates the
stimulus on both side.
Cortical Sensory Functions
Two Point Discrimination Test
Ability to distinguish the
contact of two separate points
simultaneously
the
of
the

Cont.
Graphasthesia
 The ability to recognize a
number or letter written in the
Stereognosis
 The
suitable object after careful
number or letter written in the
palm with closed eyes.
 This ability is lost in sensory
cortex lesion
palpation.
 This ability is lost in sensory
cortex lesion
Stereognosis
The abilty to identify a
palpation.
This ability is lost in sensory
cortex lesion

Examination of Motor System
Motor system is examined under following headings. These
points are very useful in examine the
points are very useful in examine the
Hemiplegia
 Nutrition
 Tone
 Power
 Co-ordination
 Co-ordination
 Involuntary movements
System
system is examined under following headings. These
the patient of
the patient of

Nutrition
 Nutrition is tested by measuring circumference of muscles, at bulk
and comparing circumference of left and right
 Circumference of muscle can be measured
distance from bony prominence.
 For upper limb (arm & forearm) -10 cm above and below the
olecronon process.
 For lower limb (thigh & calf region) -16 cm above
 10 cm below the tibial tuberosity (knees)
by measuring circumference of muscles, at bulk
right side.
measured by fixing the
10 cm above and below the
16 cm above patela

Cont.
 When circumference of both right and left
indicates nutrition of these muscles is normal.
 When it abnormal it may
 Atrophy or wasting of muscle is seen in LMN
myelitis
 Hypertrophy of muscle is seen in UMN lesion
When circumference of both right and left sides is normal it
normal.
LMN lesion like polio
lesion

Tone
 Its resistance offered by noramal muscle to passive
movements.
 It is greatest in those muscles that maintain the body in
 It is greatest in those muscles that maintain the body in
position.
 Tone of the muscle is tested by 2 ways
 By examining feel of the muscle
 Tone can be seen by Resistance offered
Movements.
 Normal feel is Elastic.
 Hypertonia is seen in UMN lesion
 Hypotonia is seen in LMN lesion
muscle to passive
It is greatest in those muscles that maintain the body in
It is greatest in those muscles that maintain the body in
ways
offered to passive

Power of Muscles
The power of all muscles should be tested at each joint in both the
upper and lower limb.
MRC (Medical Research Council) Scale for strength is a commonly
used scale for assessing muscle strength.
used scale for assessing muscle strength.
 Grade 0 - No movements at all.
 Grade 1 - Only flickering movement are visible but no movements
possible
 Grade 2 - If movement is occurring horizontally but not
against gravity.
 Grade 3 - If subject is able to lift up leg or hand,
gravity (compare the right and left side)
gravity (compare the right and left side)
 Grade 4 - Patient is able to move his extremities
against resistance
 Grade 5 - Patient is able to lift the extremities
against the good resistance applied by the
The power of all muscles should be tested at each joint in both the
for strength is a commonly
visible but no movements
If movement is occurring horizontally but not able to lift
to lift up leg or hand, against
his extremities
extremities
the doctor.

Cont.
 Complete loss of power is called as
 Complete loss of power is called as
typical feature of LMN lesion like
 Partial loss of power is called as "paresis" which
typically seen in Hemiplegia or Paraplegia
as 'paralysis' which is
as 'paralysis' which is
lesion like polio myelitis
"paresis" which is
Paraplegia.

Co-ordination of Muscles
 Co-ordination means the smooth recruitment interaction and co
operation of separate muscle or group of muscles in order to
accomplish a definite motor act.
 If it is imperfect it is called ataxia that means the motor action
becomes difficult and impossible.
 Causes of ataxia
 cerebellar
 Sensory
 Labyrinthine
 Labyrinthine
 Central
 How to test- all test of co-ordination performs first with eyes open
and then with eyes close.
Muscles
ordination means the smooth recruitment interaction and co-
If it is imperfect it is called ataxia that means the motor action
ordination performs first with eyes open

Co-ordination Tests
Romberg’s test Finger nose test
Tandem walking Knee heel test
Finger nose test
Postural holding
Postural holding

Cont.
 If patient walks correctly with open eyes, but looses balance with
 If patient walks correctly with open eyes, but looses balance with
closed eyes - It indicates damage lies in dorsal column tract (which
is called as sensory ataxia)
 If patient is not able to walk with open or closed
cerebellum (it is cerebellar or Motor ataxia)
If patient walks correctly with open eyes, but looses balance with
If patient walks correctly with open eyes, but looses balance with
It indicates damage lies in dorsal column tract (which
to walk with open or closed eyes damage is in
ataxia)

Involuntary Movements
 An involuntary movements occur when you move your body in an
uncontrollable and intended way.
uncontrollable and intended way.
 These movements can be anything :-
 Tremors
 Chorea
 Athetosis
 Hemibellismus
 Dystonia
 Dystonia
 Fasciculation
 fibrillation
Movements
An involuntary movements occur when you move your body in an

Tremors
These are unintentional rhythmic muscle contraction movement.
It is most common in all involuntary movements and can affect the
hands, arms, head , face, voice, trunk and leg.
• Fine Tremors – In
Thyrotoxicosis, Tachycardia,
weight loss, Intolerance to heat
atmosphere ,Feeling excessive
heat all the time.
• Pin rolling tremors at rest
In Parkinsonism
• Action
• Action
diseases
These are unintentional rhythmic muscle contraction movement.
It is most common in all involuntary movements and can affect the
hands, arms, head , face, voice, trunk and leg.
Pin rolling tremors at rest –
In Parkinsonism
Action tremor - In cerebellar
Action tremor - In cerebellar
diseases

Reflexes
 It is an involuntary and nearly instantaneous movement in response
 It is an involuntary and nearly instantaneous movement in response
to stimuli
 In Superficial Reflexes - receptors are in skin or
 In Deep Reflexes -receptors are in muscles
 By convention the deep tendon reflexes are graded as follows:
 0 = No Response (Absent)
 1+ =Hypoactive
 1+ =Hypoactive
 2+ = A Brisk Response (Normal)
 3+ = Hyperactive Without Clonus
 4+ = Hyperactive Without Clonus
It is an involuntary and nearly instantaneous movement in response
It is an involuntary and nearly instantaneous movement in response
skin or mucous membrane
muscles or tendons
By convention the deep tendon reflexes are graded as follows:

Superficial Reflexes

Plantar Reflex
 The normal plantar
 The normal plantar
reflex consists of flexion of
the great toe or no response.
 With dysfunction of the
corticospinal tract, there is a
positive Babinski sign, which
consists of dorsiflexion of the
great toe with an associated
fanning of the other toes.
fanning of the other toes.

Deep Tendon Reflexes

Cont.

Gait
 Circumduction gait –paralysis
Gait is a person’s pattern of walking. Walking involves
muscles that the body is propalled forward in arhythm
There are numerous possibilities that may cause
 Circumduction gait –paralysis
 Diplegic gait /scissor gait –
cerebral palsy
 Neuroplegic gait- peroneal
nerve palsy
 Fascinating gait –
parkinsonism
 Cerebellar gait/ ataxic gait
involves balance and co-ordination of
arhythm is called stride.
an abnormal gait.

Sign of Meningeal Irritation
Irritation

Summary & Conclusion
Central Nervous System Examination
Higher Function
Cranial Nerves
Motor System
Consciousness
Orientation
Memory
Nutrition
Tone
Power
Co-ordination
Involuntary
Movement
Central Nervous System Examination
Motor System
Sensory System
Reflexes
ordination Touch
Pain
Temperature
Jointsense
Superficial
Deep
Jointsense
Position Sense
Vibration
Tactile L

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