Central Nervous System (CNS) Examination

Examination of Nervous SystemExamination of Nervous System
Compiled by: Dr.Ankit SrivastavaCompiled by: Dr.Ankit Srivastava
B.H.M.S. (Gold Medalist)B.H.M.S. (Gold Medalist)
Email: ankitsrivastav183@gmail.comEmail: ankitsrivastav183@gmail.com08/31/15
Dr.Ankit Srivastava Email:
ankitsrivastav183@gmail.com 1

NERVOUS SYSTEMNERVOUS SYSTEM
• CNSCNS
Brain Spinal CordBrain Spinal Cord
• PNSPNS
Somatic AutonomicSomatic Autonomic
12 CN12 CN
31 Spinal31 Spinal
(In pairs)(In pairs)
Parasymp SympParasymp Symp
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BRAINBRAIN
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SPINAL CORDSPINAL CORD
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CNS:- BRAINCNS:- BRAIN
1.FOREBRAIN1.FOREBRAIN CerebrumCerebrum Lateral VentricleLateral Ventricle
ThalamusThalamus
HypothalamusHypothalamus
MetathalamusMetathalamus Third ventricleThird ventricle
EpithalamusEpithalamus
SubthalamusSubthalamus
2.MIDBRAIN2.MIDBRAIN Crus cerebriCrus cerebri
Substantia NigraSubstantia Nigra
TegmentumTectumTegmentumTectum
3.HINDBRAIN3.HINDBRAIN Pons&CerebellumPons&Cerebellum Fourth VentricleFourth Ventricle
MedullaMedulla
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08/31/15 Dr.Ankit Srivastava Email:
ankitsrivastav183@gmail.com
7

CEREBRUM-BROADMANN’S AREACEREBRUM-BROADMANN’S AREA
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CEREBRUM FRONTAL LOBECEREBRUM FRONTAL LOBE
S/S/
NN
AREAAREA FUNCTIONFUNCTION EFFECT OFEFFECT OF
LESIONLESION
11 MOTORMOTOR
AREA-4AREA-4
voluntary activities ofvoluntary activities of
opposite half of bodyopposite half of body
Contralateral paralysisContralateral paralysis
22 PREMOTORPREMOTOR
66
extrapyramidal systemextrapyramidal system
33 FRONTALFRONTAL
EYEFIELDEYEFIELD
6,86,8
Hz movements of eyeHz movements of eye Movements are lostMovements are lost
44 Motor speechMotor speech
44,4544,45
Spoken speechSpoken speech AphasiaAphasia
55 PrefrontalPrefrontal Emotion, concentrationEmotion, concentration
attention & judgementattention & judgement
Loss of orientationLoss of orientation
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PARIETAL LOBEPARIETAL LOBE
S/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OFEFFECT OF
LESIONLESION
11 Sensory areaSensory area
3,1,23,1,2
Perception ofPerception of
touch, pain,touch, pain,
temperaturetemperature
Loss ofLoss of
appreciation ofappreciation of
impulsesimpulses
receivedreceived
22 Parietal areaParietal area Stereognosis &Stereognosis &
sensory speechsensory speech
Astereognosis &Astereognosis &
aphasiaaphasia
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OCCIPITAL LOBEOCCIPITAL LOBE
LESIONLESION
11 VISUO-VISUO-
SENSORYSENSORY
AREA 17AREA 17
visual impressionvisual impression
of color sizeof color size
motionmotion
HomonymousHomonymous
hemianopiahemianopia
22 VISUO-VISUO-
PSYCHICPSYCHIC
18,1918,19
Correlation ofCorrelation of
visual impulsesvisual impulses
with past memorywith past memory
& recognition of& recognition of
object seenobject seen
Visual agnosiaVisual agnosia
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TEMPORAL LOBETEMPORAL LOBE
LESIONLESION
11 AUDITO-AUDITO-
SENSORYSENSORY
AREA 41 42AREA 41 42
auditory impressionauditory impression
of loudness, qualityof loudness, quality
& pitch& pitch
ImpairedImpaired
hearinghearing
22 AUDITO-AUDITO-
PSYCHICPSYCHIC
AREA 22AREA 22
Correlation ofCorrelation of
auditory impressionauditory impression
with past memorywith past memory
and identification ofand identification of
sound heardsound heard
AuditoryAuditory
agnosiaagnosia
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THALAMUSTHALAMUS
 FUNCTIONSFUNCTIONS
It is a major station where all specific sensory impulses (exceptingIt is a major station where all specific sensory impulses (excepting
smell) relay before finally terminating in the cerebral cortex likesmell) relay before finally terminating in the cerebral cortex like
hippocampal, visceral, straital, cerebellar, extroception & tastehippocampal, visceral, straital, cerebellar, extroception & taste
impulseimpulse
 LESIONLESION
Lesion of thalamus cause impairement of all type of sensibillitiesLesion of thalamus cause impairement of all type of sensibillities
joint sense being the most affected.joint sense being the most affected.
 THALAMIC SYNDROMETHALAMIC SYNDROME
It is characterized by disturbance of sensation, hemiplegia emotionalIt is characterized by disturbance of sensation, hemiplegia emotional
disturbance ,weakness and tremor.disturbance ,weakness and tremor.
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THALAMUSTHALAMUS
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HYPOTHALAMUSHYPOTHALAMUS
• FUNCTIONSFUNCTIONS
1.ENDOCRINECONTROL- It regulates secretion of TSH, ACTH,1.ENDOCRINECONTROL- It regulates secretion of TSH, ACTH,
LH, FSH, Somatotropin, prolactin.LH, FSH, Somatotropin, prolactin.
2.NEUROSECRETION- Oxytocin, vasopressin(ADH)2.NEUROSECRETION- Oxytocin, vasopressin(ADH)
3.GENERALAUTONOMIC EFFECT- It controls cvs,respiratory &3.GENERALAUTONOMIC EFFECT- It controls cvs,respiratory &
Elementry function.Elementry function.
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4.TEMPERATURE REGULATION-It maintains a balance4.TEMPERATURE REGULATION-It maintains a balance
between heat production & heat lossbetween heat production & heat loss
5.REGULATION OF FOOD & WATER INTAKE5.REGULATION OF FOOD & WATER INTAKE
6.SEXUAL BEHAVIOUR & REPRODUCTION-Through6.SEXUAL BEHAVIOUR & REPRODUCTION-Through
control of ant pituitary it controls gametogenesis, uterine,control of ant pituitary it controls gametogenesis, uterine,
ovarian cycle, maturation & maintenance of secondary sexualovarian cycle, maturation & maintenance of secondary sexual
characterstics.characterstics.
7.BIOLOGICAL CLOCKS- Wakefulness & sleep is maintained7.BIOLOGICAL CLOCKS- Wakefulness & sleep is maintained
by it.by it.
8. EMOTIONS.,FEAR, RAGE, AVERSION, PLEASURE &8. EMOTIONS.,FEAR, RAGE, AVERSION, PLEASURE &
REWARD all these controlled by hypothalamusREWARD all these controlled by hypothalamus
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LESION OFLESION OF
HYPOTHALAMUSHYPOTHALAMUS
• ObesityObesity
• Hyperglycaemia & glycosureaHyperglycaemia & glycosurea
• Autonomic epilepsy which is characterized by flushing,Autonomic epilepsy which is characterized by flushing,
sweating, salivation, lachrimation, tachycardia,sweating, salivation, lachrimation, tachycardia,
retardation of respiratory rate, unconsciousness.retardation of respiratory rate, unconsciousness.
• Sexual disturbance- precocity or impotenceSexual disturbance- precocity or impotence
• Disturbance of sleep-somnolence(persistent sleep) orDisturbance of sleep-somnolence(persistent sleep) or
narcolepsy (paroxysmal sleep)narcolepsy (paroxysmal sleep)
• Acute ulceration in the upper part of gastrointestinalAcute ulceration in the upper part of gastrointestinal
tracttract
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BASAL GANGLIABASAL GANGLIA
 FUNCTIONFUNCTION
 It regulates muscle tone, posture & helps inIt regulates muscle tone, posture & helps in
smoothering voluntary movements.smoothering voluntary movements.
 It controls automatic associated movements, likeIt controls automatic associated movements, like
the swinging of arms during walking. Itthe swinging of arms during walking. It
coordinated movements of different parts of thecoordinated movements of different parts of the
bodybody
 It is required to initiate voluntary movements.It is required to initiate voluntary movements.
 Presence of healthy basal ganglia inhibits thePresence of healthy basal ganglia inhibits the
appearance of tremorappearance of tremor
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LESION OF BASAL GANGLIALESION OF BASAL GANGLIA
• Damage of basal ganglia is cause PARKINSONISMDamage of basal ganglia is cause PARKINSONISM
• +VE SIGN-+VE SIGN-
• Rigidity- hypertonia of flexors & extensors of limb. It is a lead pipeRigidity- hypertonia of flexors & extensors of limb. It is a lead pipe
rigidity.rigidity.
• Tremor- Involuntary rhythmic alternating contraction of agonist &Tremor- Involuntary rhythmic alternating contraction of agonist &
antagonist muscles of joints.Drum beating tremor.antagonist muscles of joints.Drum beating tremor.
Static tremor-tremor at rest but disappear while attempts to doStatic tremor-tremor at rest but disappear while attempts to do
something -VE SIGNsomething -VE SIGN
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 Patient is not inclined to initiate voluntary movements.Patient is not inclined to initiate voluntary movements.
 Associated movements are reduced like-facial expressions withAssociated movements are reduced like-facial expressions with
changing emotions(masked facies) ,movements hand whilechanging emotions(masked facies) ,movements hand while
walkingwalking
 Posture – universally flexed attitude while standingPosture – universally flexed attitude while standing
 Gait – festinating gait-great tendency to falling forward “as ifGait – festinating gait-great tendency to falling forward “as if
catch his elusive centre of gravity”catch his elusive centre of gravity”
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CEREBELLUMCEREBELLUM
• FUNCTIONSFUNCTIONS
It controls same side of body ie its influence isIt controls same side of body ie its influence is
ipsilateral.ipsilateral.
It coordinates voluntary movements so thatIt coordinates voluntary movements so that
they r smooth, balanced & accurate.they r smooth, balanced & accurate.
It mainly controls tone, posture, equilibrium.It mainly controls tone, posture, equilibrium.
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LESION OF CEREBELLUMLESION OF CEREBELLUM
• Cerebellar damage causes cerebellar syndrome. It may be due toCerebellar damage causes cerebellar syndrome. It may be due to
thrombosis ,injury, tumor. Sign & symptoms divided into 2 groupsthrombosis ,injury, tumor. Sign & symptoms divided into 2 groups
• A. Voluntary motor activity signsA. Voluntary motor activity signs
DYSMETRIA-Patient fails to gauge exact degree of contraction ofDYSMETRIA-Patient fails to gauge exact degree of contraction of
the muscles needed.the muscles needed.
INTENTION TREMOR- no tremor at rest but on attempting to doINTENTION TREMOR- no tremor at rest but on attempting to do
something tremor appearssomething tremor appears
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 DYSARTHRIA-Defects in articulation while patient is talking.DYSARTHRIA-Defects in articulation while patient is talking.
 NYSTAGMUS-Hz rhythmic oscillation of eyes.NYSTAGMUS-Hz rhythmic oscillation of eyes.
 DYSDIADOCHOKINESIA-Patient fail to perform rapidDYSDIADOCHOKINESIA-Patient fail to perform rapid
alternative movements like pronation & supination of forearm.alternative movements like pronation & supination of forearm.
 B.TONE POSTURE EQUILIBRIUM SIGNB.TONE POSTURE EQUILIBRIUM SIGN
 HYPOTONIAHYPOTONIA
 Ability to balance is severely weakened.Ability to balance is severely weakened.
 Tilting the head towards the side of lesion.Tilting the head towards the side of lesion.
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CNS EXAMINATIONCNS EXAMINATION
1.1. HIGHER FUNCTIONHIGHER FUNCTION
2.2. CRANIAL NERVESCRANIAL NERVES
3.3. MOTOR SYSTEMMOTOR SYSTEM
4.4. SENSORY SYSTEMSENSORY SYSTEM
5.5. REFLEXESREFLEXES
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1. HIGHER FUNCTIONS1. HIGHER FUNCTIONS
• CONSCIOUSNESSCONSCIOUSNESS
• BEHAVIORBEHAVIOR
• INTELLIGENCEINTELLIGENCE
• MEMORYMEMORY
• EMOTIONSEMOTIONS
• ORIENTATION IN TIME,PLACE,PERSONORIENTATION IN TIME,PLACE,PERSON
• HALLUCINATION,DELUSIONHALLUCINATION,DELUSION
• LANGUAGE, SPEECHLANGUAGE, SPEECH
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CONSCIOUSNESSCONSCIOUSNESS
• It is a state of awareness of one’s self & one’sIt is a state of awareness of one’s self & one’s
environment.environment.
 SLEEPSLEEP
 CATATONIA- Psychosis,Frontal lobe lesion,CATATONIA- Psychosis,Frontal lobe lesion,
hypothalamic lesionhypothalamic lesion
 AKINETIC MUTISM-Diencephalon & BrainstemAKINETIC MUTISM-Diencephalon & Brainstem
lesionlesion
 DROWSINESSDROWSINESS
 SEMICOMASEMICOMA
 COMACOMA
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MEMORYMEMORY
DEFECT INDEFECT IN
Registration-Toxic stateRegistration-Toxic state
DementiaDementia
ManiaMania
Retention- Dementia,Retention- Dementia,
Frontal lobe lesionFrontal lobe lesion
Recall- Epilepsy,Recall- Epilepsy,
Korskoff psychosis,Korskoff psychosis,
HysteriaHysteria
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EMOTIONAL STATEEMOTIONAL STATE
• DEPRESSEDDEPRESSED
• EUPHORIAEUPHORIA
Incontinence of Emotions presents inIncontinence of Emotions presents in
 Pseodobulbar palsyPseodobulbar palsy
 Multiple sclerosisMultiple sclerosis
 DementiaDementia
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ORIENTATION OFORIENTATION OF
TIME,PLACE,PERSONTIME,PLACE,PERSON
• Ask about the day,date,month, year, time,timeAsk about the day,date,month, year, time,time
of day like morning,evening etcof day like morning,evening etc
• Ask about where he is-name the place, cityAsk about where he is-name the place, city
where he liveswhere he lives
• Ask about himself or other person in room,Ask about himself or other person in room,
about relativesabout relatives
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HALLUCINATION &HALLUCINATION &
DELUSIONDELUSION
• Hallucination is perception of sensation in the absenceHallucination is perception of sensation in the absence
of any sensory stimulus. It may be auditory, visual,of any sensory stimulus. It may be auditory, visual,
olfactory, taste, tactile.olfactory, taste, tactile.
• Delusion is false beliefs which cannot be corrected inDelusion is false beliefs which cannot be corrected in
spite of evidence.It may bespite of evidence.It may be
 of grandeur,of grandeur,
 of poverty,of poverty,
 of nihilistic,of nihilistic,
 of love,of love,
 of infedility,of infedility,
 of influenceof influence
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LANGUAGE & SPEECHLANGUAGE & SPEECH
• DYSPHAGIA-Difficulty in languageDYSPHAGIA-Difficulty in language
function.It is due to lesion in Broca’s area ,function.It is due to lesion in Broca’s area ,
Wernicke’s area.Wernicke’s area.
• DYSARTHRIA-Indistinct speech due toDYSARTHRIA-Indistinct speech due to
weakness of orolingual muscle concern withweakness of orolingual muscle concern with
production of consonant.production of consonant.
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B. CRANIAL NERVESB. CRANIAL NERVES
S.NS.N NAME OF NERVENAME OF NERVE TYPETYPE PLACE OF NUCLEIPLACE OF NUCLEI
11 OLFACTORYOLFACTORY SENSORYSENSORY FOREBRAINFOREBRAIN
22 OPTICOPTIC SENSORYSENSORY FOREBRAINFOREBRAIN
33 OCULOMOTOROCULOMOTOR MOTOR+P.SMOTOR+P.S MIDBRAINMIDBRAIN
44 TROCHLEARTROCHLEAR MOTORMOTOR MIDBRAINMIDBRAIN
55 TRIGEMINALTRIGEMINAL MIXEDMIXED PONSPONS
66 ABDUCENTABDUCENT MOTORMOTOR PONSPONS
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S.N.S.N. NAME OF NERVENAME OF NERVE TYPETYPE NUCLEINUCLEI
77 FACIALFACIAL MIXED+P.SMIXED+P.S PONSPONS
88 VESTIBULOCOCHLEAVESTIBULOCOCHLEA
RR
SENSORYSENSORY PONSPONS
99 GLOSSOPHARANGEALGLOSSOPHARANGEAL MIXED+PSMIXED+PS MEDULLAMEDULLA
1010 VAGUSVAGUS MIXED+PSMIXED+PS MEDULLAMEDULLA
1111 ACCESSORYACCESSORY MOTORMOTOR MEDULLAMEDULLA
1212 HYPOGLOSSALHYPOGLOSSAL MOTORMOTOR MEDULLAMEDULLA
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1.OLFACTORY NERVE1.OLFACTORY NERVE
• Sense of smell from nasalSense of smell from nasal
mucosa to brainmucosa to brain
• Tested by asking the patient toTested by asking the patient to
sniff various non irritatingsniff various non irritating
substance each nostrilsubstance each nostril
seperatelyseperately
• Lesion of nerve may causeLesion of nerve may cause
 anosmia,anosmia,
 parosmia,parosmia,
 cacosmiacacosmia
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2.OPTIC NERVE2.OPTIC NERVE
• Bringing visual senseBringing visual sense
from retina to brainfrom retina to brain
• 3 tests3 tests
 Visual acquity,Visual acquity,
 Visual field,Visual field,
 Color visionColor vision
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6060
3636
2424
1818
1212
99
66
55
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PSEUDOISOCHROMATICPSEUDOISOCHROMATIC
ISHIHARA PLATEISHIHARA PLATE
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3.OCULOMOTOR 4.TROCHLEAR3.OCULOMOTOR 4.TROCHLEAR
6.ABDUCENT6.ABDUCENT
• All 3 nerves controlAll 3 nerves control
extraocular as well asextraocular as well as
intraocular muscles.intraocular muscles.
• SO4SO4
• LR6LR6
SNSN MUSCLE NAMEMUSCLE NAME NERVENERVE
SUPPLYSUPPLY
11 Lateral RectusLateral Rectus AbducentAbducent
22 Medial RectusMedial Rectus OculomotorOculomotor
33 Superior RectusSuperior Rectus OculomotorOculomotor
44 Inferior RectusInferior Rectus OculomotorOculomotor
55 Superior ObliqueSuperior Oblique TrochlearTrochlear
66 Inferior ObliqueInferior Oblique OculomotorOculomotor
77 Levator PalpabraeLevator Palpabrae
SuperiorisSuperioris
OculomotorOculomotor
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EXTA OCULAR MUSCLESEXTA OCULAR MUSCLES
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3.OCULOMOTOR3.OCULOMOTOR
• Somatic –external muscles of eyeSomatic –external muscles of eye
• P S- smooth muscles of pupil ,ciliary body of eyeP S- smooth muscles of pupil ,ciliary body of eye
Complete paralysis of 3Complete paralysis of 3rdrd
nervenerve
 Ptosis,Ptosis,
 Diplopia,Diplopia,
 Lateral squint,Lateral squint,
 Downward deviation,Downward deviation,
 Dilatation of pupil,Dilatation of pupil,
 Slight proptosis,Slight proptosis,
 Loss of accomodationLoss of accomodation
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PTOSISPTOSIS
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4.TROCHLEAR4.TROCHLEAR
• Supplies superior oblique. It cause downwardSupplies superior oblique. It cause downward
movement,lateral movement, & intorsion.movement,lateral movement, & intorsion.
Complete paralysis of 4Complete paralysis of 4thth
nerve causesnerve causes
 Medial squint,Medial squint,
Upward deviation of eyeball,Upward deviation of eyeball,
Diplopia-only below hz planeDiplopia-only below hz plane
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6.ABDUCENT6.ABDUCENT
• Supplies Lateral Rectus. It cause onlySupplies Lateral Rectus. It cause only
abduction of eye.abduction of eye.
Complete paralysis of 6Complete paralysis of 6thth
nerve causenerve cause
 Medial squintMedial squint
DiplopiaDiplopia
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5.TRIGEMINAL5.TRIGEMINAL
• Motor-Muscle ofMotor-Muscle of
masticationmastication
• Sensory-From face, mouthSensory-From face, mouth
cavity,cavity,
conjunctivaconjunctiva
• 3 Branches-3 Branches-
Ophthalmic,Maxillary,Ophthalmic,Maxillary,
MandibularMandibular
• Test-By clench the teethTest-By clench the teeth
By open mouthBy open mouth
By cornealBy corneal
reflexssssssssreflexssssssss
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7.FACIAL7.FACIAL
• Motor-Muscle of facial expressionMotor-Muscle of facial expression
• Sensory-Taste sensation of ant 2/3 of tongueSensory-Taste sensation of ant 2/3 of tongue
• P S-Submandible,Sublingual,LachrimationP S-Submandible,Sublingual,Lachrimation
glandsglands
• TestTest
 Motor function can be tested by inspection ofMotor function can be tested by inspection of
facial expression & facial mobilityfacial expression & facial mobility
 Sensory function can be tested by asking theSensory function can be tested by asking the
different taste of ant 2/3 of the tongue.different taste of ant 2/3 of the tongue.
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Motor function test of facial nerveMotor function test of facial nerve
S/S/
NN
TESTTEST MUSCLEMUSCLE
USEDUSED
RESULT DUERESULT DUE
TO LESIONTO LESION
11 Ask to raiseAsk to raise
eyebroweyebrow
OccipitalisOccipitalis Wrinkling is lostWrinkling is lost
22 Wrinkle the browWrinkle the brow CorrugatorCorrugator
supercillisupercilli
Frowning ofFrowning of
forehead is lostforehead is lost
33 Close the eyesClose the eyes OrbicularisOrbicularis
oculioculi
InvoluntaryInvoluntary
blinking is lostblinking is lost
44 Showing teeth &Showing teeth &
whistlingwhistling
OrbicularisOrbicularis
orisoris
Whistling is lostWhistling is lost
55 Blow out cheeksBlow out cheeks BuccinatorBuccinator Cheeks puffs outCheeks puffs out
66 Retract the chinRetract the chin PlatysmaPlatysma Retraction lostRetraction lost
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FACIAL PALSY(BELL’S PALSY)FACIAL PALSY(BELL’S PALSY)
• Infranuclear lesion of facial nerve known as Bell’sInfranuclear lesion of facial nerve known as Bell’s
Palsy,the whole of the face of the same side getsPalsy,the whole of the face of the same side gets
paralysed.paralysed.
 Assymetry of face,Assymetry of face,
 Affected side is motionless,Affected side is motionless,
 Wrinkles is lost,Wrinkles is lost,
 Flattening of nasolabial fold,Flattening of nasolabial fold,
 Any attempt to smile draws the mouth to the normal side,Any attempt to smile draws the mouth to the normal side,
 During mastication food accumulates between the teethDuring mastication food accumulates between the teeth
& cheek,& cheek,
 Dribbling of saliva through angle of mouthDribbling of saliva through angle of mouth
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8.VESTIBULOCOCHLEAR8.VESTIBULOCOCHLEAR
1.Cochlear-Hearing1.Cochlear-Hearing
2.Vestibular-Equilibrium2.Vestibular-Equilibrium
Test for Cochlear functionTest for Cochlear function
By TICK-TICK of watch at each ear.If impairment ofBy TICK-TICK of watch at each ear.If impairment of
hearing than following test r done to determinehearing than following test r done to determine
whether the disease is of vestibulocochlear systemwhether the disease is of vestibulocochlear system
or from middle ear disease.or from middle ear disease.
RINNE’S TESTRINNE’S TEST
WEBER TESTWEBER TEST
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RINNE’S TESTRINNE’S TEST
• Vibrating tuning fork is placed in front ofVibrating tuning fork is placed in front of
ear & than mastoid boneear & than mastoid bone
• Normal- AC>BCNormal- AC>BC
• Conductive Deafness- BC>ACConductive Deafness- BC>AC
• Nerve Deafness- AC>BC but both rNerve Deafness- AC>BC but both r
depresseddepressed
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WEBER’S TESTWEBER’S TEST
• Vibrating tuning fork is placed on forehead.Vibrating tuning fork is placed on forehead.
• Normally vibration r equally both side.Normally vibration r equally both side.
• Conductive Deafness-better diseased sideConductive Deafness-better diseased side
because external sound interfering with thebecause external sound interfering with the
vibration is less on affected side.vibration is less on affected side.
• Sensorineural deafness-better on healthy side.Sensorineural deafness-better on healthy side.
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9 GLOSSOPHARYNGEAL9 GLOSSOPHARYNGEAL
• MIXED NERVE+ PS FIBERSMIXED NERVE+ PS FIBERS
• SENSORY-Taste over the posterior one third of the tongue.SENSORY-Taste over the posterior one third of the tongue.
• MOTOR-Middle constrictor of pharynx andMOTOR-Middle constrictor of pharynx and
stylopharyngeus muscle-responsible for gag responsestylopharyngeus muscle-responsible for gag response
• Test-GAG REFLEXTest-GAG REFLEX
stimulation of posterior pharyngeal wall by cotton applicatorstimulation of posterior pharyngeal wall by cotton applicator
results in elevation and constriction of pharyngealresults in elevation and constriction of pharyngeal
musculature and retraction of tongue.musculature and retraction of tongue.
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10 VAGUS10 VAGUS
• MIXED+PSMIXED+PS
• MOTOR-Soft palate, pharynx and larynxMOTOR-Soft palate, pharynx and larynx
• Sensory & motor-viscera of thorax & upperSensory & motor-viscera of thorax & upper
abdomenabdomen
• TEST-TEST-
• Ask to open the mouth & say ‘ah’& palatalAsk to open the mouth & say ‘ah’& palatal
movement & uvula is notedmovement & uvula is noted
• If paralysis then uvula is deviated to normalIf paralysis then uvula is deviated to normal
sideside
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11 ACCESSORY11 ACCESSORY
• MOTOR- Pharynx & larynx, trapezius,MOTOR- Pharynx & larynx, trapezius,
sternomastoidsternomastoid
• TESTTEST
Trapezius-Ask the patient to shrug hisTrapezius-Ask the patient to shrug his
shoulder against downward resistanceshoulder against downward resistance
Sternomastoid- Ask the patient to rotate hisSternomastoid- Ask the patient to rotate his
chin to the opposite sidechin to the opposite side
-If paralysis chin is deviated to the opposite side-If paralysis chin is deviated to the opposite side
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12 HYPOGLOSSAL12 HYPOGLOSSAL
• MOTOR-Muscle of tongueMOTOR-Muscle of tongue
• TestTest
Tongue should be observe at rest & onTongue should be observe at rest & on
protrusion, various movement r notedprotrusion, various movement r noted
If paralysis tongue is deviated to affected sideIf paralysis tongue is deviated to affected side
If bilateral than dysphagia, dyspnea &If bilateral than dysphagia, dyspnea &
dysarthriadysarthria
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C. MOTOR SYSTEMC. MOTOR SYSTEM
• BULK OF MUSCLESBULK OF MUSCLES
• STRENGTH OF MUSCLESSTRENGTH OF MUSCLES
• TONE OF MUSCLESTONE OF MUSCLES
• GAITGAIT
• INVOLUNTARY MOVEMENTSINVOLUNTARY MOVEMENTS
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1. BULK OF MUSCLES1. BULK OF MUSCLES
• HYPERTROPHY-Muscles r enlarge from theirHYPERTROPHY-Muscles r enlarge from their
normal sizenormal size
In muscular dystrophy-large muscles mayIn muscular dystrophy-large muscles may
develop esp calves, buttocksdevelop esp calves, buttocks
HYPOTROPHY-Wasting of musclesHYPOTROPHY-Wasting of muscles
Wasted muscles r small, soft, flabbyWasted muscles r small, soft, flabby
If wasting is associated with fibrosis musclesIf wasting is associated with fibrosis muscles
feel hard, inelastic & shortenedfeel hard, inelastic & shortened
08/31/15

HYPERTROPHY OF MUSCLESHYPERTROPHY OF MUSCLES
08/31/15

2.STRENGTH OF MUSCLES2.STRENGTH OF MUSCLES
• UPPER LIMBUPPER LIMB
 Abductors of fingersAbductors of fingers
 Adductors of fingersAdductors of fingers
 Flexors of fingersFlexors of fingers
 Flexors of wristFlexors of wrist
 Extensors of wristExtensors of wrist
 BrachioradialisBrachioradialis
 BicepsBiceps
 DeltoidDeltoid
 InfraspinatusInfraspinatus
 PectoralsPectorals
 Serratus anteriorSerratus anterior
 Latassimus dorsiLatassimus dorsi
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ABDUCTORS OF FINGERSABDUCTORS OF FINGERS
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ADDUCTORS OF FINGERSADDUCTORS OF FINGERS
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FLEXORS OF WRISTFLEXORS OF WRIST
08/31/15

EXTENSORS OF WRISTEXTENSORS OF WRIST
08/31/15

SERRATUS ANTERIORSERRATUS ANTERIOR
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LATASSIMUS DORSILATASSIMUS DORSI
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08/31/15

• LOWER LIMBLOWER LIMB
Dorsiflexion & planter flexion of feet & toesDorsiflexion & planter flexion of feet & toes
Flexors of kneeFlexors of knee
Extensors of kneeExtensors of knee
Flexors of hipFlexors of hip
Extensors of hipExtensors of hip
Abductors of thighAbductors of thigh
Adductors of thighAdductors of thigh
Rotators of thighRotators of thigh
08/31/15

DORSIFLEXION OF FOOTDORSIFLEXION OF FOOT
08/31/15

PLANTERFLEXION OF FOOTPLANTERFLEXION OF FOOT
08/31/15

FLEXORS OF KNEEFLEXORS OF KNEE
08/31/15

EXTENSORS OF KNEEEXTENSORS OF KNEE
08/31/15

ADDUCTORS OF THIGHADDUCTORS OF THIGH
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ABDUCTORS OF THIGHABDUCTORS OF THIGH
08/31/15

FLEXORS OF HIPFLEXORS OF HIP
08/31/15

EXTENSORS OF HIPEXTENSORS OF HIP
08/31/15

Medical Research Council Scale forMedical Research Council Scale for
grading muscle functiongrading muscle function
• GRADEGRADE
• 0 - Complete paralysis0 - Complete paralysis
• 1 - A flicker of contraction only1 - A flicker of contraction only
• 2 - Power detectable only when gravity is2 - Power detectable only when gravity is excludedexcluded
by appropriate postural adjustmentby appropriate postural adjustment
• 3 - The limb can be held against the force of gravity,3 - The limb can be held against the force of gravity,
but not against the examiner’s resistancebut not against the examiner’s resistance
• 4 - There is some degree of weakness, usually4 - There is some degree of weakness, usually
described as poor, fair, or moderate strengthdescribed as poor, fair, or moderate strength
• 5 - Normal power is present5 - Normal power is present
08/31/15

3. TONE OF MUSCLES3. TONE OF MUSCLES
• TONE is the resistance offered byTONE is the resistance offered by
normal muscles to passivenormal muscles to passive
movements. It is greatest inmovements. It is greatest in
muscles which maintain posture iemuscles which maintain posture ie
antigravity muscles-flexors in upperantigravity muscles-flexors in upper
limb & extensors of lower limblimb & extensors of lower limb
08/31/15

• HYPOTONIA-HYPOTONIA-
• It is characterized by flabby muscles which offerIt is characterized by flabby muscles which offer
less resistance to passive movements, leading toless resistance to passive movements, leading to
an increased range of passive movements & limban increased range of passive movements & limb
is unable to maintain postureis unable to maintain posture
CAUSESCAUSES
1 . Lower motor neuron disease-Poliomyelitis,1 . Lower motor neuron disease-Poliomyelitis,
peripheral neuritis, tabes dorsalisperipheral neuritis, tabes dorsalis
2 . Cerebeller disease2 . Cerebeller disease
3 . Rheumatic chorea3 . Rheumatic chorea
08/31/15

• HYPERTONIA-HYPERTONIA-
• It is characterized byIt is characterized by
increased resistance toincreased resistance to
passive movements &passive movements &
increased firmness onincreased firmness on
palpationpalpation
• CAUSESCAUSES
 Pyramidal disorderPyramidal disorder
 Extrapyramidal disorderExtrapyramidal disorder
 TetanusTetanus
 Strychnine poisoningStrychnine poisoning
• TYPESTYPES
• Clasp knife spasticityClasp knife spasticity
• Lead pipe rigidityLead pipe rigidity
• Cog wheel rigidityCog wheel rigidity
• HystericalHysterical
• Reflex rigidityReflex rigidity
• MyotoniaMyotonia
08/31/15

4.GAIT4.GAIT
• CAUSESCAUSES
• UPPER MOTORUPPER MOTOR
NEURON DISEASENEURON DISEASE
• LOWER MOTORLOWER MOTOR
NEURONE DISEASENEURONE DISEASE
• CEREBELLARCEREBELLAR
SYNDROMESYNDROME
• EXTRAPYRAMIDALEXTRAPYRAMIDAL
SYNDROMESYNDROME
• TYPESTYPES
• SPASTIC GAITSPASTIC GAIT
• STAMPING GAITSTAMPING GAIT
• REELING GAITREELING GAIT
• FESTINANT GAITFESTINANT GAIT
• WADDLING GAITWADDLING GAIT
08/31/15

5 CORDINATION OF5 CORDINATION OF
MUSCLESMUSCLES
• 1. ROMBERG’S TEST1. ROMBERG’S TEST
• 2. TANDEM WALKING2. TANDEM WALKING
• 3. FINGER NOSE TEST3. FINGER NOSE TEST
• 4. FINGER TO FINGER TEST4. FINGER TO FINGER TEST
• 5. FOR DYSDIADOCHOKINESIA5. FOR DYSDIADOCHOKINESIA
• 6. POSTURAL HOLDING IN UPPERLIMB6. POSTURAL HOLDING IN UPPERLIMB
• 7. KNEE-HEEL TEST7. KNEE-HEEL TEST
08/31/15

6.INVOLUNTARY MOVEMENTS6.INVOLUNTARY MOVEMENTS
• A.TREMOR-A.TREMOR-
StaticStatic-tremor at rest & not at voluntary-tremor at rest & not at voluntary
movement eg. Parkinsonismmovement eg. Parkinsonism
PosturalPostural-when limb is actively maintained in a-when limb is actively maintained in a
certain position eg. Hyperthyroidismcertain position eg. Hyperthyroidism
IntentionIntention-It is on willed movement esp desired-It is on willed movement esp desired
object is approached eg Cerebellarobject is approached eg Cerebellar
syndromesyndrome
HystericalHysterical-tremor in any limb and examiner-tremor in any limb and examiner
restrained on that limb it may move torestrained on that limb it may move to
another part of bodyanother part of body
08/31/15

4.REFLEXES4.REFLEXES
A.A. SUPERFICIALSUPERFICIAL
B.B. DEEPDEEP
C.C. VISCERALVISCERAL
D.D. PATHOLOGICALPATHOLOGICAL
08/31/15

A.A. SUPERFICIALSUPERFICIAL
SNSN NAME OFNAME OF
REFLEXREFLEX
HOW TO ELICITHOW TO ELICIT RESPONSERESPONSE
11 PLANTERPLANTER Scratching the soleScratching the sole
of footof foot
Planter flexion ofPlanter flexion of
great toe & fingergreat toe & finger
22 ABDOMINALABDOMINAL Scratch quadrant ofScratch quadrant of
abdomenabdomen
Contraction ofContraction of
abdominal musclesabdominal muscles
33 CONJUNCTIVACONJUNCTIVA
LL
Light touching ofLight touching of
conjunctivaconjunctiva
Blinking of eyeBlinking of eye
44 CREMESTERICCREMESTERIC Scratching at insideScratching at inside
of thighof thigh
Elevation testicle ofElevation testicle of
that sidethat side
08/31/15

08/31/15

DEEP REFLEXESDEEP REFLEXES
SNSN NAME OFNAME OF
REFLEXREFLEX
HOW TO ELICITHOW TO ELICIT RESPONSERESPONSE
11 Knee jerkKnee jerk Stroking theStroking the
ligamentumligamentum
patellaepatellae
Sharp extensionSharp extension
of knee jointof knee joint
22 Ankle jerkAnkle jerk Stroking tendoStroking tendo
achillesachilles
Planter flexionPlanter flexion
33 Biceps jerkBiceps jerk Stroking theStroking the
biceps tendonbiceps tendon
Flexion ofFlexion of
elbow jointelbow joint
44 Triceps jerkTriceps jerk Stroking tricepsStroking triceps
tendontendon
Extension ofExtension of
the elbow jointthe elbow joint
08/31/15

KNEE JERKKNEE JERK
08/31/15

ANKLE JERKANKLE JERK
08/31/15

TRICEPS REFLEXTRICEPS REFLEX
08/31/15

BICEPS REFLEXBICEPS REFLEX
08/31/15

VISCERAL REFLEXVISCERAL REFLEX
• Pupillary relexPupillary relex
Shining light on eyeShining light on eye
Constriction of the pupilConstriction of the pupil
Absence may indicateAbsence may indicate
-edema of the brain-edema of the brain
-head injury-head injury
-advance brain tumor-advance brain tumor
-loss of optic nerve-loss of optic nerve
08/31/15

5.SENSORY SYSTEM5.SENSORY SYSTEM
• Following sensation should be testedFollowing sensation should be tested
 TouchTouch
 PainPain
 TemperatureTemperature
 PositionPosition
 VibrationVibration
 Cortical sense-tactile localization,Cortical sense-tactile localization,
tactile discriminationtactile discrimination
tactile extinctiontactile extinction
stereognosisstereognosis
08/31/15

08/31/15

MENINGEAL SIGNMENINGEAL SIGN
• NECK STIFFNESSNECK STIFFNESS
• KERNIG’S SIGNKERNIG’S SIGN
• BRUDZINSKI’S SIGNBRUDZINSKI’S SIGN
1.Neck sign1.Neck sign
2.Leg sign2.Leg sign
3.Symphysis sign3.Symphysis sign
4.Cheek sign4.Cheek sign
08/31/15

Kernig’s sign-severe stiffness of hamstrings causes anKernig’s sign-severe stiffness of hamstrings causes an
inability to straighten the leg when the hip is flexed to 90inability to straighten the leg when the hip is flexed to 90
degreedegree
08/31/15

Brudzinski’s neck sign-severe neck stiffnessBrudzinski’s neck sign-severe neck stiffness
causes patient’s hip & knee to flex when neckcauses patient’s hip & knee to flex when neck
is flexedis flexed
08/31/15

INVESTIGATIONSINVESTIGATIONS
• LUMBAR PUNCTURELUMBAR PUNCTURE
• ELECTROENCEPHALOGRAMELECTROENCEPHALOGRAM
• ELECTROMYOGRAMELECTROMYOGRAM
• NEUROIMAGINGNEUROIMAGING
 Computed tomography scanningComputed tomography scanning
 Magnetic resonance imagingMagnetic resonance imaging
 AngiographyAngiography
08/31/15

LUMBAR PUNCTURELUMBAR PUNCTURE
• It is used for obtainingIt is used for obtaining
sample of CSFsample of CSF
• Puncture may madePuncture may made
through L3/4 or L4/5through L3/4 or L4/5
Composition of CSFComposition of CSF
• Color-clear as waterColor-clear as water
• Cells-nil-5/cmmCells-nil-5/cmm
• Glucose-50-80mg/100mlGlucose-50-80mg/100ml
• Chloride-720-Chloride-720-
750mg/100ml750mg/100ml
• Protein-20-90mg/100mlProtein-20-90mg/100ml
• Abnormality of CSFAbnormality of CSF
• Yellow color-old haemorrhageYellow color-old haemorrhage
jaundicejaundice
excess proteinexcess protein
• Turbidity- +nce of WBC due toTurbidity- +nce of WBC due to
infection subarachnoidinfection subarachnoid
haemorrhagehaemorrhage
Blood- injury,subarachnoid haemBlood- injury,subarachnoid haem
Cells-inc in viral,tub,fungal meninCells-inc in viral,tub,fungal menin
Glucose- tub,fungal,carcinomatusGlucose- tub,fungal,carcinomatus
meningitis- sugar decmeningitis- sugar dec
08/31/15

EEGEEG
• It is used in investigation of epilepsy,It is used in investigation of epilepsy,
diagnosis of encephalitis, dementia.diagnosis of encephalitis, dementia.
• Electrodes applied to the patient’s scalpElectrodes applied to the patient’s scalp
pick up small changes of electrical potential,pick up small changes of electrical potential,
which after amplification are recorded onwhich after amplification are recorded on
paper or displayed on a video monitor andpaper or displayed on a video monitor and
recorded electronically.recorded electronically.
08/31/15

EMGEMG
• Electrical activity occurring in muscleElectrical activity occurring in muscle
during voluntary contraction, denervated atduring voluntary contraction, denervated at
rest can be recorded with needle electrodesrest can be recorded with needle electrodes
inserted percutaneously into the belly of theinserted percutaneously into the belly of the
muscle.muscle.
• It is useful in desease of muscle –It is useful in desease of muscle –
myopathies and dystrophies, LMN lesionmyopathies and dystrophies, LMN lesion
08/31/15

Central Nervous System (CNS) Examination

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