order-Bulk Tone, , power , reflex

CNS EXAMINATION BY SADDRUDEEN

➢ Sensory or motor symptoms which start abruptly and are at their most
marked at or very soon after their onset strongly suggest a vascular
causation (transient ischaemia or ischaemic or haemorrhagic stroke).
➢ In contrast, similar symptoms evolving over a few days, reaching a plateau
in severity and then slowly receding typify inflammatory central nervous
system (CNS) demyelination (a first episode or a relapse of multiple
sclerosis).
➢ Subacute (developing over weeks to months), progressive symptoms can
be caused by many kinds of pathology, but neoplasia is always a prime
concern.
➢ Neurodegenerative conditions always develop insidiously with gradual
progression, but occasionally patients present acutely.
➢ Start with higher functions, head neck and spine, Cranial nerve exam,
cerebellar examination, and finish with the Sensory and Motor
Examination of both limbs.

HIGHER FUNCTION TESTING MNEMONIC - COMIS

C- CONSCIOUSNESS GCS SCORE

GCS-MVE-6 + 3 + 4015 V C
O
M

I
Orientation -
time , place , person
.
O-ORIENTATION
● Is the patient oriented in time, place and person?
● Ask the patient what time or day it is, where he is, (hospital) and what is
the reason for him/her being there.
● Ask about who he’s talking to (the student) - give a brief introduction about
yourself ,before clerking.

MEMORY
● Immediate- the patient can repeat several digits or recall three words after
five minutes
● Short Term -ask about events of the past few days, what happened a
week ago, relatives’ last hospital visit. etc
● Long Term - ask about the current president of Kenya, what month
elections were held, , events of the past few Months, events from
childhood.
INTELLIGENCE
● Is the patient able to read and write? If no then ask his level of education
- -

● Calculations - subtracting serial 7’s , Addition

● Fund of knowledge - Level of knowledge in the Patient’s own culture and
education.
● Abstract Concepts- ability to explain similarities between objects and
understand the meaning of simple proverbs.

SPEECH

~
~ Fi

HEAD, NECK AND SPINE

CRANIAL NERVE EXAMINATIONS

ask
1, Olfactory nerve use
coffee perfume
-
, if
nasal
passag
● Tested using a small number of bottles containing either a fragrant or
is

pungent smelling substance such as lemon.

● Each nostril should be tested separately.
Bilateral anosmia-common cold
Unilateral anosmiae more useful
 lack of smell.
● Anosmia causes:
❖ Subfrontal meningiomas
❖ Lewy body disease (Idiopathic Parkinsonism)
❖ Kallman’s syndrome
I eye as a time
-
Test
2. The optic (II) nerves
a) Acuity and color vision
Acuity-Snellen
● Measured using the Snellen chart Colour-Ishihara
● Ukikosa chart :) - ability to count fingers at 1 meter, ability to perceive
hand movements, perception of light only and no perception of light.

-read nametag
~
(CA)
CHA

● Test color vision using Ishihara charts

RAPD Bedside e Im away

-
 usually 30 am from their hand.

b) Visual fields and visual attention

while it closer to
Accommodation check
-
finger moving
the patient
 visuale field preserved
lateral interior
,
,

-test superior
,

- lookat centre of forehead - point

mnafunga mnaappear
side closed
E
same

Pupil size-2-4mm -
equal size

reactive to light-
c) Pupillary light reflex DIMLY LIT ROOM
1. First, in normal illumination, establish whether the pupils are of equal size.
2. Shine the light into one eye-The normal response being constriction of the pupil
which is sustained until the light is removed. (Direct Reflex)
3. Repeat the test, this time looking at the contralateral pupil, which will normally
constrict (Consensual Reflex) -

efferent
4. Swinging torch test - may be used to detect a relative afferent pupillary defect.- Tell
the patient to keep looking at the wall in front of him and just swing a torch across
both eyes.
5. Accommodation reflex - tell the patient to look at a point in the wall , then focusing on
a pen you put in front of him

Cre
3 S 4 S 6
3. The oculomotor (III), trochlear (IV) and abducens (VI) nerves – eye
movements

defect (RAPD) paradoxic dilation of the

lative afferent pupilary
-

. into it
is shone
affected pupil when light
Observe for Nystagmus
.

# .
2
vision does pen appear or
Check for double
->
 -cheating neve

● Ask the patient if he has any double vision before doing the tests
● Patient’s head should be perfectly still
● Check for any ptosis, restriction of eye movement, nystagmus, the eyes
should ideally follow the finger in smooth pursuit.

letter
Draw the
Hat I
↓
-
&
·
M
↓
 Use toothpick
mastication face
4. The trigeminal (V) nerve

● The trigeminal nerve is a mixed motor and sensory nerve.

-
-

● Three divisions of theTrigeminal Nerve - ophthalmic (V1), maxillary (V2)

and mandibular (V3).
● These nerves also mediate general sensation inside the mouth and nose
and proprioception.

Can you feel it ? Is their a difference ?

 ● Motor component of the trigeminal nerve -They supply the muscles of
mastication: masseter, temporalis and the lateral pterygoids.
don't forget both glabellar tap
- -

the edge of the

from
1. The corneal reflex come
sides eye abnormal-continuous

I
① ② ● A sensory stimulus applied to the cornea causes a reflex blink which blinking
- cannot be suppressed; its absence on one side establishes
unequivocally the presence of a trigeminal lesion.
● Remember that if there is ipsilateral facial paralysis (e.g. Bell’s
palsy), the reflex will be absent on the affected side, but will be
readily seen on the other side. ~ sensory
tri minal .

● Use a piece of cotton wool/neural tip to examine sensation all over

! the face on both sides with the patient’s eyes closed.

-

2. Testing the motor component of the trigeminal nerve

● Look for wasting of the temporalis and masseter muscles.
-
V
● Feel for contraction of the masseter muscles when the patient
clenches his jaw
● Ask the patient to open his mouth; the lateral pterygoid muscles on
each side draw the mandible forward, such that a severe lesion of
the trigeminal nerve will lead to deviation of the jaw towards the side
-

of the lesion due to weakness of the pterygoid muscles on the

-

affected side
● The pterygoid muscles may be further tested by asking the patient to

UlaLeod's
push his open jaw sideways against your hand.
3. Jaw jerk reflex primitive reflex
-

under the lip then hit with a patella

hamme
.

Place finger
-
5. The facial (VII) nerve
● The facial nerve is principally a motor nerve, supplying facial muscles on
one side, but it also has small general somatic sensory and major
gustatory sensory components, as well as important parasympathetic
functions. ~ Frontalis -Buccinator
I
● Testing the facial nerve is as follows: ~
obicularis auris ,
1. Look for asymmetry of the face.

S
2. Ask the patient to raise his eyebrows (to look astonished), to blink and then
to screw both eyes up, firmly closed. On the weak side, the eyelashes will
be less buried by the eyelids.
~ Forehead wrinkles. nose
fold
~ Nasolabial folds (Wtnasolabial
~
Angles of the mouth
 others -
Raise eyebrows -
smile
them
close eyes-try and open purse lips
to stapedia
-
-

↑ -

Blow out checks -

hyperacusis
-

e
nere noise
3. Attempt to raise the patient’s eyebrows while his eyes are closed and
screwed up; mild weakness may be detected.
★ To differentiate UMN from LMN
● When there is severe lower motor neuron facial weakness, the
patient will not be able to close the affected eye.
● Attempted eye closure will be accompanied by elevation of the eyes
(Bell’s phenomenon).

Both
affected can
raise
eyebrow

y
Affected

4. Ask the patient to blow his cheeks out and try closing them against
resistance. (Buccinator Muscle)
5. Never forget to test the muscles of facial expression.
6. Innervates the anterior ⅔ of the tongue with special sensation (sweet,
salty, and sour)
7. Hyperacusis (if the stapedius is paralyzed)
checkside loss of nasolabial fold
Raise eyebrows Can't raise
-

* summary
- ipsilateral) fold
.

LMN-same side [
but loss of nasolabial
-

can raise

UMN- contralateral-
 cortex
-motor contralateral and
upper part-both
ipsilateral nerve fibres

upper part
of
lower part-only contralateral nerve
nucleus
↑
fibres

Pons upper part-supplies region (a)

lower part-supplies region (b)

Yower part it intra or supranuclei ?

-
* Is
of nucleus
(a)

(b)

stillworking affected
Manifestation
↑ ↑ -
to smile
Unable
-affected
~

~ Unable to
whistle
old
~ loss of nasolabial
both eyebrows
* can raise
 UMN

~ Can't close eyelid.

10 LMN-L 30 LMN-R
20 UMN-L 40 UMN-R
 8. Crocodile tears’ (i.e. inappropriate tear production when salivary glands
should be activated), attributed to aberrant reinnervation of salivary and
lacrimal glands.
9. Clinical tip : Herpes zoster affecting the facial nerve - leading to Ramsay
Hunt Syndrome, similar presentation to facial nerve palsy.Check for herpes
zoster lesions in the auditory meatus.

· Nerve
10 to
stapedius
( nearing)

hearing -balance .

6. The cochlear and vestibular (VIII) nerves

● These two nerves convey afferents from the cochlea and the vestibular
apparatus, respectively.
 F -

central

start with ear

Conductive outer/middle ear-eg

-

wax ,
block ear.

sensorineural-innear (cochlear
Ask which side is louder - when rubbing your ears
.
 ~

● Testing the cochlear- Assessment of hearing can be achieved by rubbing

- -
-

your index finger and thumb together close to the patient’s ear or by
whispering numbers close to his ear, with the contralateral ear occluded.
● Rinne’s test is good for distinguishing between conduction and
sensorineural deafness, as long as you use the appropriate tuning fork (
512 Hz) or 256H2)
● Unilateral sensorineural deafness is an important feature of
‘cerebellopontine angle lesions’, such as acoustic neuroma or meningioma
● Bilateral sensorineural deafness may be a feature of certain multisystem
neurological disorders, particularly mitochondrial disorders.

(check)
cows
cold-opposite
warm-same

● Vestibular function - tell the patient to close their eyes and match on the
same spot Turning/unterberger test
● A normal patient remains in the same spot while a pathological patient
turns towards the side of the lesion PATHOLOGY -towards Leison
unconscious-dolls eye-
7. The glossopharyngeal (IX) nerve posterior pharyngeal wall.
● Responsible for the gag reflex: tested by lightly touching the uvula with a
spatula do it incase you sense thereis a pathology
● CN IX innervates the posterior ⅓ of the tongue with general and special
-

sensations. wula curtain -> when one

usual low check opens
of taste
~
~ sense

says "aaah"
*
8. The vagus (X) nerve *
sour

● Tested by evaluating the uvula:

Patho : Vvula deviates away from leison

.
 -
Autonomic

○ Normal finding: centrally located

○ Abnormal finding: deviation toward the normal side
● Hoarseness or an impaired cough reflex indicates damage to CN
X.(Bovine cough)
● Tell the patient to have a glass of water, check for any odynophagia,
-

delayed swallow or cough.

> tested stroke ->
already affected
- -

9. The accessory (XI) nerve not in .

● The spinal accessory nerve consists of motor nerve fibers from the cervical
spinal cord (C2-6)
● The spinal accessory nerve supplies the sternocleidomastoid muscle and
the upper part of the trapezius muscle.
● Testing the accessory nerve
○ The left sternocleidomastoid muscle contributes to rotation of the
head to the right and vice versa. Weakness of the left
sternocleidomastoid is therefore assessed by asking the patient to
turn his head to the right with force, while the examiner opposes the
rotation with the left hand, pushing carefully against the right side of
the face
○ Scapular winging due to trapezius weakness is most commonly
caused by a lesion of the accessory nerve in the posterior triangle of

inside b
the neck, often iatrogenic related to surgical excision of a lymph
node.

asSess of deviates to the lesion

10. The hypoglossal (XII) nerve Tongue
.

outside
-

mouth ● Attempted protrusion of the tongue results in deviation of the tongue

towards the weak side
-
-

● A chronic lesion will be associated with visible muscle atrophy of the

affected side of the tongue.
● Innervates the tongue muscles: Ask the subject to press against their
cheek from the inside, while the examiner tests the strength from the
outside.
- twitching
● Bilateral wasting and weakness of the tongue with fasciculation are usually
due to the progressive bulbar atrophy of motor neuron disease

ropen mouth then

inspect-symmetry
-no fasiculations
the floor of mouth
.
-resting on

weakness of torguer
fasiculation >
-

UMN
.
 Reporting CN exam
.

On cranial nerves ;
-

did not assess offactory

Pupils-2-3 mm
equally reactive to light preserved
,
visual

acuity and
Full range of eye movement with no mystagmus
symetrical appearance of face
 tongue cait touch roof - tongue tie

check localizing loisons of these nerves

.

CEREBELLAR TESTS
● Cerebellar examination frequently appears in OSCEs and you’ll be
expected to identify the relevant clinical signs using your examination
skills. This cerebellar examination OSCE guide provides a clear
step-by-step approach to examining the cerebellum

VANISHED

V-Vertigo
A-Ataxia
N-Nystagmus
I
- Intention Tremor
S- Scanning speech
H-Hypotonia Dysmetric
broad based gait
E-Exaggerated +
movement
Preliminaries D- Dysdiadokinesia and legs rapid finger
1. Gain consent to proceed with the examination. to nose
2. Ask the patient to sit on a chair, approximately one arm’s length away.
3. Ask the patient if they have any pain before proceeding with the clinical
examination.

1. Dysdiadochokinesia

Dysdiadochokinesia is a term that describes the inability to perform rapid,

-

alternating movements, which is a feature of ipsilateral cerebellar pathology.

-
 DO NOT CLOSE EES

2. Ataxia (gait and posture)

3 . Nystagmus
4. Intention Tremors -covered with finger to nose test
5. Slurred and staccato speech
6. Hypotonia / Heel shin test
 Don't forget hand. Do both sides !

UPPER LIMB
1. SWIFT MNEMONIC others Posture Mobility
-
,
aids , Medications

holding tray ;
POWER imagine your
a

2. PRONATOR DRIFT lift arms up

with palms up then close eyes
If the forearm pronates, with or without downward movement, the patient is
considered to have pronator drift on that side. The presence of pronator drift
indicates a contralateral pyramidal tract lesion. Pronation occurs because, in the
context of an UMN lesion, the supinator muscles of the forearm are typically
weaker than the pronator muscles. +ve > Contralateral corticospinal tract
-

3. TONE at joints leison

6
-

● Spasticity is associated with pyramidal tract lesions (e.g. stroke) and

-
-

rigidity is associated with extrapyramidal tract lesions (e.g. Parkinson’s

-
-

disease). Spasticity and rigidity both involve increased tone, so it’s

important to understand how to differentiate them clinically. Spasticity is
wrist finger joints
elbow
~
shoulder , ,
,
 ~
“velocity-dependent”, meaning the faster you move the limb, the worse it is.
There is typically increased tone in the initial part of the movement which
then suddenly reduces past a certain point (known as “clasp knife
spasticity”). Spasticity is also typically accompanied by weakness.

● Rigidity is “velocity independent” meaning it feels the same if you move

the limb rapidly or slowly. There are two main sub-types of rigidity:
Cogwheel rigidity involves a tremor superimposed on the hypertonia,
resulting in intermittent increases in tone during movement of the limb. This
subtype of rigidity is associated with Parkinson’s disease. Lead pipe rigidity
involves uniformly increased tone throughout the movement of the muscle.
This subtype of rigidity is typically associated with neuroleptic malignant
syndrome.
-

Decreased Hone
~ Lower motor neuron leison(s)
4. POWER
~ cerebellar dx
at muscle groups

(plegial

S
Paresis
-
-

againsunity
not

not resistance
subgrade
.

(E)
C Gresistance
4 less resistance
wrist extension
=

CG
Shoulder abduction C5
-

47-more
Wrist flexion- C617
shoulder adduction C6fC
resistance -

CT
extension
Elbow flexion-C51C6 Finger
-

Elbow extension CT - Finger abduction - T

,
 Thumb to roof
give ideas on
what is
Deepfendow reflexes)
-

5. REFLEXES the myotes

going on
1. Biceps reflex (C5/6)
2. Supinator (brachioradialis) reflex (C5/6) 4 am from
-
thumb
3. Triceps reflex (C7)
(grade 2 +. ) normal. -

+ clonus
~ nerve root , muscle dy-
- -

Hand on stomach elbow on the bed

.

6. SENSATION

Dorsal column and spinothalamic tract

Light touch sensation -

Dorsal column-vibration
 Ca-shoulder

both sides
!!
Always ask if its the same on

they have
7. Proprioception
make sure
More thumb up
and down;

closed their eyes

.

both sides !!
test
*
Always
 LOWER LIMB
1. SWIFT MNEMONIC

&

2.GAIT AND PROXIMAL MUSCLE WEAKNESS

● Proximal muscle weakness

● Normal walking
● Tandem walking
● Walking on heels - testing dorsiflexion
● Walking tiptoeing - testing plantarflexion
● Rhomberg test

3. TONE joint
hip , knee , ankle , toes

roll"justlift
I

just
4. POWER
5. REFLEXES Present and normal

6. SENSATION
 or down-
-up
instructions
atjoint give
Proprioception Stabilize toe
,
,
-

it up down.
close more
Dorsal
column
- eyes ,

horizontal position
Hold it in the
.

have with the toe go

,
proximal
If they an issue

ankle joint ,
knee joint , hip joint .