CENTRAL NERVOUS SYSTEM EXAMINATION
TABLE OF CONTACT
- Mental Status
- Cranial Nerves
- Motor
- Coordination and Gait
- Reflexes
- Sensor
- Mental Status
-Orientation in person
- place
- time
- Memory ( past ,present )
- Level of consciousness Intelligence
- mood
- Attention speech
- hallucination and delusions
- Level of education, cooperation with the examiner
2. Cranial Nerves
I – Olfactory - smell
II - Optic - Examine the Optic Fundi Test Visual Acuity
ScreenVisual Fields by Confrontation
Test Pupillary Reactions to Light
III - Oculomotor - Observe for Ptosis (dropping upper eyelid due to paralysis)
- Test Extraocular Movements
- Test Pupillary Reactions to Light
IV - Trochlear
Test Extraocular Movements (Inward and Down Movement )
V – Trigeminal
- Test Temporal and Masseter Muscle
- Test the Three Divisions for Pain Sensation
- Test the Corneal Reflex
VI - Abducens
Test Extraocular Movements (Lateral Movement)
VII - Facial
Observe for Any Facial Droop or Asymmetry
Ask Patient to do the following,
- Raise eyebrows
- Close both eyes to resistance
- Smile
- Frown
- Show teeth
- Puff out cheeks
Note :- any lag, weakness, or asymmetry
VIII - Vestibulocochlear nerve
Screen Hearing
Test for Lateralization
Compare Air and Bone Conduction (Rinne)
IX – Glossopharyngeal & X - Vagus
Listen to the patient's voice, is it hoarse or nasal?
Ask Patient to Swallow
Ask Patient to Say "Ah"
Watch the movements of the soft palate and the pharynx.
Test Gag Reflex (Unconscious/Uncooperative Patient)
Stimulate the back of the throat on each side.
It is normal to gag after each stimulus
4. MOTOR
1. Inspection
Involuntary Movements
Muscle Symmetry, Left to Right
Proximal vs. Distal, Atrophy
Pay particular attention to the hands, shoulders, and thighs
Gait
2. Muscle Tone
Ask the patient to relax
Flex and extend the patient's fingers, wrist, and elbow
Flex and extend patient's ankle and knee.
There is normally a small, continuous resistance to passive movement
Observe for decreased (flaccid) or increased (rigid/spastic) tone
Report
- hypotonic
- Normotonic
- Hyper tonic
3. Muscle power or strength
Grading Motor Strength | |
Grade | Description |
0/5 | No muscle movement |
1/5 | Visible muscle movement, but no movement at the joint |
2/5 | Movement at the joint, but not against gravity |
3/5 | Movement against gravity, but not against added resistance |
4/5 | Movement against resistance, but less than normal |
5/5 | Normal strength |
5. COORDINATION AND GAIT
1.Rapid Alternating Movements
Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible
2. Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible
3. Ask the patient to tap your hand with the ball of each foot as fast as possible
2. Point-to-Point Movements
1. Ask the patient to touch your index finger and their nose alternately several times Move your finger about as the patient performs this task
Hold your finger still so that the patient can touch it with one arm and finger outstretched
2. Ask the patient to move their arm and return to your finger with their eyes closed
3. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe
Repeat with the patient's eyes closed
3. Romberg
Be prepared to catch the patient if they are unstable
1. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support
The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem)
GAIT
Ask the patient to:
Walk across the room, turn and come back
Walk heel-to-toe in a straight line
Walk on their toes in a straight line
Walk on their heels in a straight line
Hop in place on each foot
Do a shallow knee bend
Rise from a sitting position
6. REFLEX
1. Deep Tendon Reflexes
The patient must be relaxed and positioned properly before starting
Reflex response depends on the force of your stimulus. Use no more force than you need to provoke a definite response
Reflexes can be reinforced by having the patient perform isometric contraction of other muscles (clenched teeth)
Reflexes should be graded on a 0 to 4 "plus" scale:
Tendon Reflex Grading Scale | |
Grade | Description |
0 | Absent |
1+ or + | Hypoactive |
2+ or ++ | "Normal" |
3+ or +++ | Hyperactive without clonus |
4+ or ++++ | Hyperactive with clonus |
2. Clonus
If the reflexes seem hyperactive, test for ankle clonus:
Support the knee in a partly flexed position
With the patient relaxed, quickly dorsiflex the foot
Observe for rhythmic oscillations
3. Plantar Response (Babinski)
Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
Note movement of the toes, normally flexion (withdrawal)
Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski
7. SENSORY
General
Explain each test before you do it.
Unless otherwise specified, the patient's eyes should be closed during the actual testing
Compare symmetrical areas on the two sides of the body
Also compare distal and proximal areas of the extremities
When you detect an area of sensory loss map out its boundaries in detail
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