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Examination of Nervous SystemExamination of Nervous System
Compiled by: Dr.Ankit SrivastavaCompiled by: Dr.Ankit Srivastav...
NERVOUS SYSTEMNERVOUS SYSTEM
• CNSCNS
Brain Spinal CordBrain Spinal Cord
• PNSPNS
Somatic AutonomicSomatic Autonomic
12 CN...
BRAINBRAIN
08/31/15
Dr.Ankit Srivastava Email:
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SPINAL CORDSPINAL CORD
08/31/15
Dr.Ankit Srivastava Email:
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CNS:- BRAINCNS:- BRAIN
1.FOREBRAIN1.FOREBRAIN CerebrumCerebrum Lateral VentricleLateral Ventricle
ThalamusThalamus
Hypotha...
08/31/15
Dr.Ankit Srivastava Email:
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08/31/15 Dr.Ankit Srivastava Email:
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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...
PARIETAL LOBEPARIETAL LOBE
S/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OFEFFECT OF
LESIONLESION
11 Sensory areaSensory area
3,...
OCCIPITAL LOBEOCCIPITAL LOBE
S/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OFEFFECT OF
LESIONLESION
11 VISUO-VISUO-
SENSORYSENSO...
TEMPORAL LOBETEMPORAL LOBE
S/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OFEFFECT OF
LESIONLESION
11 AUDITO-AUDITO-
SENSORYSENSO...
THALAMUSTHALAMUS
 FUNCTIONSFUNCTIONS
It is a major station where all specific sensory impulses (exceptingIt is a major st...
THALAMUSTHALAMUS
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HYPOTHALAMUSHYPOTHALAMUS
• FUNCTIONSFUNCTIONS
1.ENDOCRINECONTROL- It regulates secretion of TSH, ACTH,1.ENDOCRINECONTROL- ...
4.TEMPERATURE REGULATION-It maintains a balance4.TEMPERATURE REGULATION-It maintains a balance
between heat production & h...
08/31/15
Dr.Ankit Srivastava Email:
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LESION OFLESION OF
HYPOTHALAMUSHYPOTHALAMUS
• ObesityObesity
• Hyperglycaemia & glycosureaHyperglycaemia & glycosurea
• Au...
BASAL GANGLIABASAL GANGLIA
 FUNCTIONFUNCTION
 It regulates muscle tone, posture & helps inIt regulates muscle tone, post...
08/31/15
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LESION OF BASAL GANGLIALESION OF BASAL GANGLIA
• Damage of basal ganglia is cause PARKINSONISMDamage of basal ganglia is c...
 Patient is not inclined to initiate voluntary movements.Patient is not inclined to initiate voluntary movements.
 Assoc...
CEREBELLUMCEREBELLUM
• FUNCTIONSFUNCTIONS
It controls same side of body ie its influence isIt controls same side of body i...
08/31/15
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LESION OF CEREBELLUMLESION OF CEREBELLUM
• Cerebellar damage causes cerebellar syndrome. It may be due toCerebellar damage...
 DYSARTHRIA-Defects in articulation while patient is talking.DYSARTHRIA-Defects in articulation while patient is talking....
CNS EXAMINATIONCNS EXAMINATION
1.1. HIGHER FUNCTIONHIGHER FUNCTION
2.2. CRANIAL NERVESCRANIAL NERVES
3.3. MOTOR SYSTEMMOTO...
1. HIGHER FUNCTIONS1. HIGHER FUNCTIONS
• CONSCIOUSNESSCONSCIOUSNESS
• BEHAVIORBEHAVIOR
• INTELLIGENCEINTELLIGENCE
• MEMORY...
CONSCIOUSNESSCONSCIOUSNESS
• It is a state of awareness of one’s self & one’sIt is a state of awareness of one’s self & on...
MEMORYMEMORY
DEFECT INDEFECT IN
Registration-Toxic stateRegistration-Toxic state
DementiaDementia
ManiaMania
Retention- De...
EMOTIONAL STATEEMOTIONAL STATE
• DEPRESSEDDEPRESSED
• EUPHORIAEUPHORIA
Incontinence of Emotions presents inIncontinence of...
ORIENTATION OFORIENTATION OF
TIME,PLACE,PERSONTIME,PLACE,PERSON
• Ask about the day,date,month, year, time,timeAsk about t...
HALLUCINATION &HALLUCINATION &
DELUSIONDELUSION
• Hallucination is perception of sensation in the absenceHallucination is ...
LANGUAGE & SPEECHLANGUAGE & SPEECH
• DYSPHAGIA-Difficulty in languageDYSPHAGIA-Difficulty in language
function.It is due t...
B. CRANIAL NERVESB. CRANIAL NERVES
S.NS.N NAME OF NERVENAME OF NERVE TYPETYPE PLACE OF NUCLEIPLACE OF NUCLEI
11 OLFACTORYO...
S.N.S.N. NAME OF NERVENAME OF NERVE TYPETYPE NUCLEINUCLEI
77 FACIALFACIAL MIXED+P.SMIXED+P.S PONSPONS
88 VESTIBULOCOCHLEAV...
08/31/15
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1.OLFACTORY NERVE1.OLFACTORY NERVE
• Sense of smell from nasalSense of smell from nasal
mucosa to brainmucosa to brain
• T...
2.OPTIC NERVE2.OPTIC NERVE
• Bringing visual senseBringing visual sense
from retina to brainfrom retina to brain
• 3 tests...
6060
3636
2424
1818
1212
99
66
55
08/31/15
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08/31/15
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08/31/15
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PSEUDOISOCHROMATICPSEUDOISOCHROMATIC
ISHIHARA PLATEISHIHARA PLATE
08/31/15
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3.OCULOMOTOR 4.TROCHLEAR3.OCULOMOTOR 4.TROCHLEAR
6.ABDUCENT6.ABDUCENT
• All 3 nerves controlAll 3 nerves control
extraocul...
EXTA OCULAR MUSCLESEXTA OCULAR MUSCLES
08/31/15
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08/31/15
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3.OCULOMOTOR3.OCULOMOTOR
• Somatic –external muscles of eyeSomatic –external muscles of eye
• P S- smooth muscles of pupil...
PTOSISPTOSIS
08/31/15
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4.TROCHLEAR4.TROCHLEAR
• Supplies superior oblique. It cause downwardSupplies superior oblique. It cause downward
movement...
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6.ABDUCENT6.ABDUCENT
• Supplies Lateral Rectus. It cause onlySupplies Lateral Rectus. It cause only
abduction of eye.abduc...
5.TRIGEMINAL5.TRIGEMINAL
• Motor-Muscle ofMotor-Muscle of
masticationmastication
• Sensory-From face, mouthSensory-From fa...
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7.FACIAL7.FACIAL
• Motor-Muscle of facial expressionMotor-Muscle of facial expression
• Sensory-Taste sensation of ant 2/3...
08/31/15
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08/31/15
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Motor function test of facial nerveMotor function test of facial nerve
S/S/
NN
TESTTEST MUSCLEMUSCLE
USEDUSED
RESULT DUERE...
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FACIAL PALSY(BELL’S PALSY)FACIAL PALSY(BELL’S PALSY)
• Infranuclear lesion of facial nerve known as Bell’sInfranuclear les...
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8.VESTIBULOCOCHLEAR8.VESTIBULOCOCHLEAR
1.Cochlear-Hearing1.Cochlear-Hearing
2.Vestibular-Equilibrium2.Vestibular-Equilibri...
RINNE’S TESTRINNE’S TEST
• Vibrating tuning fork is placed in front ofVibrating tuning fork is placed in front of
ear & th...
WEBER’S TESTWEBER’S TEST
• Vibrating tuning fork is placed on forehead.Vibrating tuning fork is placed on forehead.
• Norm...
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9 GLOSSOPHARYNGEAL9 GLOSSOPHARYNGEAL
• MIXED NERVE+ PS FIBERSMIXED NERVE+ PS FIBERS
• SENSORY-Taste over the posterior one...
10 VAGUS10 VAGUS
• MIXED+PSMIXED+PS
• MOTOR-Soft palate, pharynx and larynxMOTOR-Soft palate, pharynx and larynx
• Sensory...
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11 ACCESSORY11 ACCESSORY
• MOTOR- Pharynx & larynx, trapezius,MOTOR- Pharynx & larynx, trapezius,
sternomastoidsternomasto...
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08/31/15
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12 HYPOGLOSSAL12 HYPOGLOSSAL
• MOTOR-Muscle of tongueMOTOR-Muscle of tongue
• TestTest
Tongue should be observe at rest & ...
08/31/15
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C. MOTOR SYSTEMC. MOTOR SYSTEM
• BULK OF MUSCLESBULK OF MUSCLES
• STRENGTH OF MUSCLESSTRENGTH OF MUSCLES
• TONE OF MUSCLES...
1. BULK OF MUSCLES1. BULK OF MUSCLES
• HYPERTROPHY-Muscles r enlarge from theirHYPERTROPHY-Muscles r enlarge from their
no...
HYPERTROPHY OF MUSCLESHYPERTROPHY OF MUSCLES
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2.STRENGTH OF MUSCLES2.STRENGTH OF MUSCLES
• UPPER LIMBUPPER LIMB
 Abductors of fingersAbductors of fingers
 Adductors o...
ABDUCTORS OF FINGERSABDUCTORS OF FINGERS
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ADDUCTORS OF FINGERSADDUCTORS OF FINGERS
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FLEXORS OF WRISTFLEXORS OF WRIST
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EXTENSORS OF WRISTEXTENSORS OF WRIST
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SERRATUS ANTERIORSERRATUS ANTERIOR
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LATASSIMUS DORSILATASSIMUS DORSI
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• LOWER LIMBLOWER LIMB
Dorsiflexion & planter flexion of feet & toesDorsiflexion & planter flexion of feet & toes
Flexor...
DORSIFLEXION OF FOOTDORSIFLEXION OF FOOT
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PLANTERFLEXION OF FOOTPLANTERFLEXION OF FOOT
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FLEXORS OF KNEEFLEXORS OF KNEE
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EXTENSORS OF KNEEEXTENSORS OF KNEE
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ADDUCTORS OF THIGHADDUCTORS OF THIGH
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ABDUCTORS OF THIGHABDUCTORS OF THIGH
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FLEXORS OF HIPFLEXORS OF HIP
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EXTENSORS OF HIPEXTENSORS OF HIP
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Medical Research Council Scale forMedical Research Council Scale for
grading muscle functiongrading muscle function
• GRAD...
3. TONE OF MUSCLES3. TONE OF MUSCLES
• TONE is the resistance offered byTONE is the resistance offered by
normal muscles t...
• HYPOTONIA-HYPOTONIA-
• It is characterized by flabby muscles which offerIt is characterized by flabby muscles which offe...
• HYPERTONIA-HYPERTONIA-
• It is characterized byIt is characterized by
increased resistance toincreased resistance to
pas...
4.GAIT4.GAIT
• CAUSESCAUSES
• UPPER MOTORUPPER MOTOR
NEURON DISEASENEURON DISEASE
• LOWER MOTORLOWER MOTOR
NEURONE DISEASE...
5 CORDINATION OF5 CORDINATION OF
MUSCLESMUSCLES
• 1. ROMBERG’S TEST1. ROMBERG’S TEST
• 2. TANDEM WALKING2. TANDEM WALKING
...
6.INVOLUNTARY MOVEMENTS6.INVOLUNTARY MOVEMENTS
• A.TREMOR-A.TREMOR-
StaticStatic-tremor at rest & not at voluntary-tremor ...
4.REFLEXES4.REFLEXES
A.A. SUPERFICIALSUPERFICIAL
B.B. DEEPDEEP
C.C. VISCERALVISCERAL
D.D. PATHOLOGICALPATHOLOGICAL
08/31/1...
A.A. SUPERFICIALSUPERFICIAL
SNSN NAME OFNAME OF
REFLEXREFLEX
HOW TO ELICITHOW TO ELICIT RESPONSERESPONSE
11 PLANTERPLANTER...
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DEEP REFLEXESDEEP REFLEXES
SNSN NAME OFNAME OF
REFLEXREFLEX
HOW TO ELICITHOW TO ELICIT RESPONSERESPONSE
11 Knee jerkKnee j...
KNEE JERKKNEE JERK
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ANKLE JERKANKLE JERK
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TRICEPS REFLEXTRICEPS REFLEX
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BICEPS REFLEXBICEPS REFLEX
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VISCERAL REFLEXVISCERAL REFLEX
• Pupillary relexPupillary relex
Shining light on eyeShining light on eye
Constriction of t...
5.SENSORY SYSTEM5.SENSORY SYSTEM
• Following sensation should be testedFollowing sensation should be tested
 TouchTouch
...
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MENINGEAL SIGNMENINGEAL SIGN
• NECK STIFFNESSNECK STIFFNESS
• KERNIG’S SIGNKERNIG’S SIGN
• BRUDZINSKI’S SIGNBRUDZINSKI’S S...
Kernig’s sign-severe stiffness of hamstrings causes anKernig’s sign-severe stiffness of hamstrings causes an
inability to ...
Brudzinski’s neck sign-severe neck stiffnessBrudzinski’s neck sign-severe neck stiffness
causes patient’s hip & knee to fl...
INVESTIGATIONSINVESTIGATIONS
• LUMBAR PUNCTURELUMBAR PUNCTURE
• ELECTROENCEPHALOGRAMELECTROENCEPHALOGRAM
• ELECTROMYOGRAME...
LUMBAR PUNCTURELUMBAR PUNCTURE
• It is used for obtainingIt is used for obtaining
sample of CSFsample of CSF
• Puncture ma...
EEGEEG
• It is used in investigation of epilepsy,It is used in investigation of epilepsy,
diagnosis of encephalitis, demen...
EMGEMG
• Electrical activity occurring in muscleElectrical activity occurring in muscle
during voluntary contraction, dene...
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Central Nervous System (CNS) Examination

  1. 1. 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
  2. 2. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 2
  3. 3. BRAINBRAIN 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 3
  4. 4. SPINAL CORDSPINAL CORD 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 4
  5. 5. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 5
  6. 6. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 6
  7. 7. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 7
  8. 8. CEREBRUM-BROADMANN’S AREACEREBRUM-BROADMANN’S AREA 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 8
  9. 9. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 9
  10. 10. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 10
  11. 11. OCCIPITAL LOBEOCCIPITAL LOBE S/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OFEFFECT OF LESIONLESION 11 VISUO-VISUO- SENSORYSENSORY AREA 17AREA 17 Perception ofPerception of 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 11
  12. 12. TEMPORAL LOBETEMPORAL LOBE S/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OFEFFECT OF LESIONLESION 11 AUDITO-AUDITO- SENSORYSENSORY AREA 41 42AREA 41 42 Perception ofPerception of 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 12
  13. 13. 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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 13
  14. 14. THALAMUSTHALAMUS 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 14
  15. 15. 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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 15
  16. 16. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 16
  17. 17. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 17
  18. 18. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 18
  19. 19. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 19
  20. 20. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 20
  21. 21. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 21
  22. 22.  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” 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 22
  23. 23. 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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 23
  24. 24. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 24
  25. 25. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 25
  26. 26.  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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 26
  27. 27. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 27
  28. 28. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 28
  29. 29. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 29
  30. 30. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 30
  31. 31. EMOTIONAL STATEEMOTIONAL STATE • DEPRESSEDDEPRESSED • EUPHORIAEUPHORIA Incontinence of Emotions presents inIncontinence of Emotions presents in  Pseodobulbar palsyPseodobulbar palsy  Multiple sclerosisMultiple sclerosis  DementiaDementia 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 31
  32. 32. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 32
  33. 33. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 33
  34. 34. 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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 34
  35. 35. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 35
  36. 36. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 36
  37. 37. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 37
  38. 38. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 38
  39. 39. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 39
  40. 40. 6060 3636 2424 1818 1212 99 66 55 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 40
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  42. 42. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 42
  43. 43. PSEUDOISOCHROMATICPSEUDOISOCHROMATIC ISHIHARA PLATEISHIHARA PLATE 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 43
  44. 44. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 44
  45. 45. EXTA OCULAR MUSCLESEXTA OCULAR MUSCLES 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 45
  46. 46. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 46
  47. 47. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 47
  48. 48. PTOSISPTOSIS 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 48
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  50. 50. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 50
  51. 51. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 51
  52. 52. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 52
  53. 53. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 53
  54. 54. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 54
  55. 55. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 55
  56. 56. 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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 56
  57. 57. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 57
  58. 58. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 58
  59. 59. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 59
  60. 60. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 60
  61. 61. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 61
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  65. 65. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 65
  66. 66. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 66
  67. 67. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 67
  68. 68. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 68
  69. 69. 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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 69
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  75. 75. 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. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 75
  76. 76. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 76
  77. 77. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 77
  78. 78. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 78
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  81. 81. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 81
  82. 82. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 82
  83. 83. C. MOTOR SYSTEMC. MOTOR SYSTEM • BULK OF MUSCLESBULK OF MUSCLES • STRENGTH OF MUSCLESSTRENGTH OF MUSCLES • TONE OF MUSCLESTONE OF MUSCLES • GAITGAIT • INVOLUNTARY MOVEMENTSINVOLUNTARY MOVEMENTS 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 83
  84. 84. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 84
  85. 85. HYPERTROPHY OF MUSCLESHYPERTROPHY OF MUSCLES 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 85
  86. 86. 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 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 86
  87. 87. ABDUCTORS OF FINGERSABDUCTORS OF FINGERS 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 87
  88. 88. ADDUCTORS OF FINGERSADDUCTORS OF FINGERS 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 88
  89. 89. FLEXORS OF WRISTFLEXORS OF WRIST 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 89
  90. 90. EXTENSORS OF WRISTEXTENSORS OF WRIST 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 90
  91. 91. SERRATUS ANTERIORSERRATUS ANTERIOR 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 91
  92. 92. LATASSIMUS DORSILATASSIMUS DORSI 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 92
  93. 93. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 93
  94. 94. • 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 94
  95. 95. DORSIFLEXION OF FOOTDORSIFLEXION OF FOOT 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 95
  96. 96. PLANTERFLEXION OF FOOTPLANTERFLEXION OF FOOT 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 96
  97. 97. FLEXORS OF KNEEFLEXORS OF KNEE 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 97
  98. 98. EXTENSORS OF KNEEEXTENSORS OF KNEE 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 98
  99. 99. ADDUCTORS OF THIGHADDUCTORS OF THIGH 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 99
  100. 100. ABDUCTORS OF THIGHABDUCTORS OF THIGH 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 100
  101. 101. FLEXORS OF HIPFLEXORS OF HIP 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 101
  102. 102. EXTENSORS OF HIPEXTENSORS OF HIP 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 102
  103. 103. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 103
  104. 104. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 104
  105. 105. • 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 105
  106. 106. • 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 106
  107. 107. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 107
  108. 108. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 108
  109. 109. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 109
  110. 110. 4.REFLEXES4.REFLEXES A.A. SUPERFICIALSUPERFICIAL B.B. DEEPDEEP C.C. VISCERALVISCERAL D.D. PATHOLOGICALPATHOLOGICAL 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 110
  111. 111. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 111
  112. 112. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 112
  113. 113. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 113
  114. 114. KNEE JERKKNEE JERK 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 114
  115. 115. ANKLE JERKANKLE JERK 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 115
  116. 116. TRICEPS REFLEXTRICEPS REFLEX 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 116
  117. 117. BICEPS REFLEXBICEPS REFLEX 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 117
  118. 118. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 118
  119. 119. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 119
  120. 120. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 120
  121. 121. 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 121
  122. 122. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 122
  123. 123. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 123
  124. 124. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 124
  125. 125. INVESTIGATIONSINVESTIGATIONS • LUMBAR PUNCTURELUMBAR PUNCTURE • ELECTROENCEPHALOGRAMELECTROENCEPHALOGRAM • ELECTROMYOGRAMELECTROMYOGRAM • NEUROIMAGINGNEUROIMAGING  Computed tomography scanningComputed tomography scanning  Magnetic resonance imagingMagnetic resonance imaging  AngiographyAngiography 08/31/15 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 125
  126. 126. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 126
  127. 127. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 127
  128. 128. 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 Dr.Ankit Srivastava Email: ankitsrivastav183@gmail.com 128
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Central Nervous System (CNS) Examination

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