CNS Examination

Anatomy and Physiology

Central Nervous System
Brain, spinal cord, motor and sensory
pathways

Peripheral Nervous System

Spinal nerves, cranial nerves, autonomic
nervous system

Focused Health Assessment

Present Health/Illness Status
numbness, difficulty with speech, vision,
hearing, medications, changes in
behavior, lifestyle

Family History
headaches, mental illness, depression

Continued:
Past Health History
seizures, headaches
head injury
surgeries
stroke

Equipment Needed:

Cotton ball, safety pin, snellen chart

Tongue blade
Tuning fork
Reflex hammer
pen light
pencil and paper
sweet/sour substances
Familiar aromatic substance (coffee,
vanilla)

Neurological exam

Mental status
Cranial nerves
Motor system
Reflexes
Sensory system
Coordination
Station and gait

Mental status exam

Level of consciousness
Attention
Orientation
Language fluency, comprehension,
repetition, naming, reading, writing
Memory immediate recall, recent, remote
Higher intellectual functiongeneral
knowledge, abstraction, judgment, insight,
reasoning
Mood and affect

General Examination
1. Assessment of the higher centers
o
o
o
o

Consciousness
Orientation ( Person , Place , Time ).
Memory
Handedness

2. Speech
o

Flow of speech

o
o

Comprehension
Repetition

3. Neck stiffness
looking for meningism
( meningitis ,SAH)

Cranial Nerves Exam

12 pairs of cranial
nerves.

Where CN Come From?

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

Functions of cranial
nerves
Some of these nerves bring
information from the sense organs to
the brain;
Others control muscles;
Others are connected to glands or
internal
organs such as the heart and lungs.

The innervation areas of the cranial nerves

CN I: Olfactory: smell
1. Ask the subject if he/she has a subjective
olfactory problem.
2. Check for rash, deformity of nose.
3. One nostril is occluded while the subject sniffs an
unknown substance. Test one nostril with soap,
cigarette
and toothpaste; ask the subject to point to the
correct name
on the paper.
4. Test the other nostril, repeat step 3.

CN II: Optic: vision

There are three main aspects to this
nerve: visual acuity, visual fields, and
fundi opticus.
1. Examine visual acuity:
2. Examine visual fields:
3. Look into the fundi:

CN III, IV, VI: Oculomotor,

Trochlear, Abducent

Inspection of pupil
Light reflex
Eye Movement & nystagmus
Convergence & accomodation

CN III Oculomotor:
Eyelid and eyeball movement
CN IV Trochlear:
Innervates superior oblique
Turns eye downward and laterally
CN VI Abducens:
Turns eye laterally
Cranial Nerves III, IV and VI supply the
muscles of eye movement and are
tested as a unit.

 Look at pupils: shape, relative size,

Ptosis.
Shine light in from the side to look for
pupil's light reaction.
Assess both direct and consensual
responses.
Assess afferent pupillary defect by
moving light in arc from pupil to pupil.

The pupils

CN V: Trigeminal
Functions:
Chewing
Face & mouth touch & pain
Motor
Sensory
Reflex

 1. Facial
sensation:
1) Use sterile sharp
item on forehead,
cheek and jaw.
2) If abnormal, then
test temperature
[waterheated/cooled
tuning fork], light
touch [cotton].

Sensory

Facial sensation by cotton on

forehead, cheek & jaw.

 2. Motor: Subject opens mouth,

clenches teeth.
1) Palpate temporal, masseter muscles
as they clench.
2) Subject opens mouth; assess the
symmetry of the mouth.

 3. Corneal reflex: patient looks up and away.

1) Touch cotton wool to the sclera on the other
side.
2) Look for blink in both eyes, ask if subject can
sense it.
3) Repeat on the other side.
4. Test jaw jerk:
1) Examiner places finger on tip of jaw.
2) Grip patellar hammer halfway up shaft and
tap examiners
finger lightly.
3) Usually nothing happens, or just a slight
closure.

 Corneal reflex: patient looks up and

away.
Touch cotton wool to other side.
Look for blink in both eyes, ask if
can sense it.
Repeat other side [ tests V sensory,
VII motor].

CN VII: Facial
Functions: controls most facial
expressions,
secretion of tears & saliva, taste
1. Muscles of facial expression:
2. Check the sense of taste:
Inspect for facial droop or
asymmetry.
Facial expression muscles: pt
looks up and wrinkles forehead.
looking for wrinkling loss.
Pt shuts eyes tightly: compare
each side.

 Pt smile: compare nasolabial

grooves.
Pt show teeth, puff out cheeks.
Taste sensation in the anterior 2/3 of
the tongue.

CN VIII:
Vestibulocochlear
Functions: hearing; equilibrium
sensation
Auditory acuity
1. Rinne test:
2. Weber test:
Vestibular function:

CN IX, X: Glossopharyngeal, Vagus

Some useful tests for detection of deficiencies in
motor
function of the palate, pharynx, and larynx are
described below.
Sensory function needs to be checked if one
suspects cranial
neuropathy or a brain stem lesion.
1. Palatal Elevation
2. Gag reflex (afferent IX, efferent X)
3. Sensory function
4. Voice Quality
5. Taste test see CN VII.

CN XI: Accessory
Functions:
Controls
trapezius &
sternocleidomast
oid
Controls
swallowing
movements

 1. Sternocleidomastoid
Press a hand against the patient's jaw and have the
patient
rotate the head against resistance. Pressing against
the right
jaw tests the left sternocleidomastoid and vice
versa.
2. Trapezius
Have the patient shrug shoulders against resistance
and assess
weakness.

CN XII: Hypoglossal
Function: controls
tongue movements
1. Listen to articulation.
2. Inspect tongue in
mouth for wasting,
fasciculations.
3. Protrude tongue:
deviates to affected side.

Motor system

dont forget to compare both limbs

Inspection
Palpation ( muscle bulk + tenderness
)
Muscle tone
Muscle power
Reflexes

Motor system
1. Upper limbs (compare)
Inspect for muscle wasting
( proximal & Distal ) scars
deformity fasciculation skin
pigmentation.

Drift test

 Feel the muscle bulk ( proximally &

Distally ) muscle tenderness.
Tone ( normo hypo hypertonia )
by passive movement of wrist and
elbow joints.

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

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

 Coordination
Finger to nose test
Finger to finger test
Dysdiadochokinesia

2. Lower limbs
Inspect the gait of the patient

Expose both thighs and legs.

Inspect for muscle wasting scars

deformity posture -fasciculation
skin pigmentation .

 Feel the muscle bulk and muscles for

tenderness.
Tone ( normo hypo hypertonia )
by passive movement of the knee
and ankle joints

 Clonus more than 3

ankle and knee clonus
Power ( 0 5 )
by active movement at the hip ,
knee , ankle , and tarsal joints

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

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

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