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CNS Examination

CNS Examination. Done By Abdullah Mohd . Jan 6 th year medical student-2007. Aspects of Examination. General The cranial nerves The upper limbs ( Motor + Sensory + coordenation ) The lower limbs ( Motor + Sensory + coordenation)

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CNS Examination

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  1. CNS Examination Done By Abdullah Mohd. Jan 6thyear medical student-2007

  2. Aspects of Examination • General • The cranial nerves • The upper limbs ( Motor + Sensory + coordenation ) • The lower limbs ( Motor + Sensory + coordenation) • The skull and spine for local disease • The carotid arteries for bruits

  3. General Examination • Assessment of the higher centers • Speech ( reception & production ) • Neck stiffness • Abnormal movements

  4. General Examination • Assessment of the higher centers • Consciousness • Orientation ( Person , Place , Time ) • Cognetion • Memory asses both short & long term memory

  5. Handedness to determine the dominant hemisphere • Speech ( reception & production ) • Flow of speech • Comprehension (yes – No)

  6. Repetition • Neck stiffness looking for meningism ( meningitis – sub arachnoid haemorrhage

  7. Abnormal movements

  8. Cranial Nerves Examination • you have to know how to examine all cranial nerves in detail but we will focus on the most important ones ( 3rd , 4th , 5th , 6th , 7th , 11th & 12th ) . • You have to know the location of the nuclei of the cranial nerve as it gives you a hint about the site of the lesion.

  9. 3rd & 4th cranial nerves are located in the mid brain • 5th , 6th , 7th & 8th cranial nerves are located in the pons • 9th , 10th , 11th & 12th cranial nerves are located in the medulla oblongata

  10. CN III, IV, VI: Oculomotor, Trochlear, Abducent • Inspection of pupil • Light reflex • Eye Movement & nystagmus • Convergence & accomodation

  11. Look at pupils: shape, relative size, • ptosis. • Shine light in from the side to look for pupil's light reaction.• Assess both direct and consensual responses.• Assess afferent pupillary defect by moving light in arc from pupil to pupil. 

  12. "Follow finger with eyes without moving head": test the 6 cardinal points in an H pattern.• Look for failure of movement, nystagmus [pause to check it during upward/ lateral gaze].

  13. Convergence by moving finger towards bridge of pt's nose. • Test accommodation by pt looking into distance, then a hat pin 30cm from nose.

  14. CN V: Trigeminal • Sensory • Motor • Reflex (deep + superficial)

  15. Facial sensation: sterile sharp item on forehead, cheek, jaw.• Repeat with cotton at the same parts.

  16. Motor: pt opens mouth, clenches teeth (pterygoids).• Palpate temporal, masseter muscles as they clench. • Test jaw jerk: • Dr's finger on tip of jaw. • Grip patellar hammer halfway up shaft and tap Dr's finger lightly.

  17. Usually nothing happens, or just a slight closure. • If increased closure, think UMNL, esp  pseudobulbar palsy.

  18. Corneal reflex: patient looks up and away.• Touch cotton wool to other side.• Look for blink in both eyes, ask if can sense it.• Repeat other side [tests V sensory, VII motor].

  19. CN VII: Facial • Inspection • Motor • Taste sensation

  20. CN VII: Facial • Inspect for facial droop or asymmetry. • Facial expression muscles: pt looks up and wrinkles forehead.• looking for wrinkling loss. • Pt shuts eyes tightly: compare each side.

  21. Pt smile: compare nasolabial grooves. • Pt show teeth, puff out cheeks. • Taste sensation in the anterior 2/3 of the tongue.

  22. CN XI: Accessory • Inspection From behind, examine for trapezius atrophy, asymmetry. • Pt. shrugs shoulders (trapezius). • Pt. turns head against resistance: watch, palpate SCM on opposite side.

  23. CN XII: Hypoglossal • Listen to articulation. • Inspect tongue in mouth for wasting, fasciculations. • Protrude tongue: unilateral deviates to affected side.

  24. Motor system don’t forget to compare both limbs • Inspection • Palpation ( muscle bulk + tenderness ) • Muscle tone • Muscle power • Reflexes :. ( superficial + deep )

  25. Motor system • Upper limbs (compare) • Inspect for muscle wasting ( proximal & Distal ) – scars – deformity – fasciculation – skin pigmentation. • Drift test

  26. Feel the muscle bulk ( proximally & Distally ) – muscle tenderness. • Tone ( normo – hypo – hypertonia ) by passive movement of wrist and elbow joints.

  27. Power ( 0 – 5 ) by active movement at the shoulder , elbow , wrists and fingers.

  28. Reflexes ( 0 - ++++ ) Biceps ( C5,C6 ) – Triceps ( C7,C8 ) – Brachioradialis ( C5,C6 )

  29. Coordination Finger to nose test – Finger to finger test – Dysdiadochokinesis – Rebound test

  30. Lower limbs • Inspect the gait of the patient • Expose both thighs and legs. • Inspect for muscle wasting – scars – deformity – posture -fasciculation – skin pigmentation .

  31. Feel the muscle bulk and muscles for tenderness. • Tone ( normo – hypo – hypertonia ) by passive movement of the knee and ankle joints

  32. Clonus more than 3 ankle and knee clonus • Power ( 0 – 5 ) by active movement at the hip , knee , ankle , and tarsal joints

  33. Reflexes ( 0 - ++++ ) Knee jerk ( L3,L4 ) – Ankle jerk (S1,S2 ) – Plantar reflex ( L5, S1 , S2 ) • Coordination Heal to shin test – Toe finger test – Foot tapping test

  34. Sensory system • Spinothalamic pathway Pain and Temperature ( usually temperature is not tested ) • Posterior column pathway Vibration and Proprioception Romberg Sign • Light touch with cotton wool

  35. Back • Inspect for deformity – scars – neurofibromas . • Palpate for tenderness over the vertebral bodies • Do the straight leg raising test

  36. Auscultation • Auscultate over the carotid arteries looking for bruits.

  37. Thank You Happy New Year

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