CNS EXAMINATION

1. HIGHER FUNCTIONS

● Level Of Consciousness (GCS)

- Eye Response
- Verbal Response
- Motor Response
● Orientation – Time, place , person
(<1 yr - behavior with mother & doc)
● General Intelligence - Abstract thinking, Reasoning,
Judgement.
(To recite poems, ABCD…, Additions, tables)
● Memory -
- Short term (repeat random colors, numbers…)
- Long term (years)
- Recent memory (last day)
● Speech- Spontaneous speech, Naming objects,
Comprehension of spoken commands.
- Slurring (muffling)
- Scanning (drag 1st alphabet)
- Stammering (unable to complete sentence)
- Stockton/Hot potato ( 1st word loud & then muffles)
● Mental & Emotion {not for peds}
2. EXAMINATION OF THE CRANIAL
NERVES

● First Cranial Nerve (Olfactory Nerve) -

- Close eyes.
- Ask to close 1 nostril & identify by the smell of coffee,
peppermint oil, clove oil, soap, etc.
- Alternate nostril also….
- DDs - ANOSMIA ; PAROSMIA

● Second Cranial Nerve (Optic Nerve)

1. Visual acuity - Snellen’s chart, Finger counting, hand
movement and perception of light.
2. Visual fields – Perimetry , Confrontation test (finger
moves from behind to front, opposite to each other
@ 1 metre distance, same eye level)
3. Colour vision – Ishihara chart or Colour of dress.
4. Ophthalmoscopy - Fundus examination (Atropine/
tropicamide drops for dilation -- Circular Optic disc,
random blood vessels-follow vessels to reach Optic
disc, tortuosity of vessels, Optic disc colour, Any
spots, Retinal hemorrhages...)
● The Oculomotor (Third), Trochlear (Fourth), and Abducent
(Sixth) Cranial Nerves
1. Eye movements - 6 Cardinal Direction of Gaze – SO4,
LR6 & Rest by 3rd nerve.
2. Direct (1 Eye closed & other eye checked for dilation)
& Indirect/ Consensual pupillary reflex (hand of pt in
middle, light on 1 eye & look for other eye)
3. Size of Palpebral Fissures - Ptosis

● Fifth Cranial Nerve (Trigeminal Nerve)

1. Sensory System - Pain, Temperature, Light Touch are
examined (with pin, hot water & cotton)
✔ Ophthalmic division (forehead and upper part of
the side of the nose)
✔ Maxillary division (the malar region and upper lip)
✔ Mandibular division (chin)
2. Motor System (clench teeth)
✔ Masseter and Temporalis Muscles
✔ Pterygoid Muscle
3. Reflexes
✔ Corneal reflex
✔ Jaw jerk

● Seventh Cranial Nerve (Facial Nerve)

A. Motor Function
 ✔ Rraise the eyebrows
✔ Wrinkle the forehead
✔ Close eyes tightly
✔ Smile
B. Sensory Functions
✔ Taste on 2 sides (ant 2/3rd tongue)

● The Eighth Cranial Nerve (Vestibulocochlear Nerve)

▪︎Tuning Fork Tests
i. Rinne’s Test (AC>>BC = SNL) (First
near ear & when it stops, on
mastodon process)
ii. Weber’s test (Lateralized to diseased
ear) (TF on glabella)

● The Ninth and Tenth Cranial Nerves (Glossopharyngeal and

Vagus Nerves
i. Oral and taste sensation, Salivation (Post. 1/3rd
tongue)
ii. Palatal reflex (palatal rise to phonation &coordinated
swallowing)
iii. Gag reflex (Contraction of the back of the throat
triggered by an object touching the roof of your
mouth, the back of your tongue, the area around
your tonsils, or the back of your throat.
 ● Eleventh Cranial Nerve (Accessory Nerve)
i. Testing of Sternocleidomastoid Muscle ( head
turning)
ii. Testing of the Trapezius Muscle (shrugging/elevation
of shoulder)

● The Twelfth Cranial Nerve (Hypoglossal Nerve)

⮚ Look for any deviation of the protruded tongue
& position of uvula.
⮚ Look for any abnormal movement of the tongue

3. MOTOR SYSTEM
(1) Nutrition: ( inspectory finding)
Inspect for gross wasting -in Quadriplegic CP (OR)
Hypertrophy of muscles.

(2) Bulk of muscle (palpatory finding)

▪ Mid-arm circumference
▪ Mid-forearm circumference
▪ Mid-thigh circumference
▪ mid-leg circumference
 Interference: called wasting when
In UL: difference >1 cm in both UL
In LL: difference >2 cm

(3) Tone (inspectory and palpation finding)

• Hypertonia : extension at knee and dorsiflexion of
foot at rest

• Hypotonia : Pith-Frog posture.

External rotation at hip & flexion at knee.
Also can move wrist and ankle freely to see hypotonia

• Passive movements of joints -

Stabilize distal joints and move the limb.
Interference:
- If resistance felt/Restricted mvt. =
hypertonia
- If movements are too free : hypotonia
Hypertonia :-
(1) SPASTICITY :
Clasp knife spasticity (Resistance in initial mvt.,
smooth later, resistance again at late stage)
(2) RIGIDITY:
a. Lead pipe: resistance throughout the
movement.
b. Cog wheel: Intermittent resistance.
4. REFLEXES

(a) Superficial reflex

1. Conjunctival reflex
2. Corneal reflex
3. Abdominal reflex (Stroke from medial to lateral
diagonally -- Umbilicus moves towards stroked side)
4. Cremasteric reflex ( Stroke medial surface of thigh ---
Upward reflex of testicles)
5. Anal reflex (Stroke Perianally -- Upward reflex of anal)
6. Plantar reflex ( Lateral lower to medial to wall of big toe
-- Dorsiflexion & abduction)

(b) Deep reflexes

1. Biceps ( strike on finger with narrow end of hammer --

contacting of muscle)
2. Triceps (broad end of hammer with hand crossed to
other shoulder)
3. Knee jerk (just above medial tuberose- narrow end
hammer - Contraction at medial thigh muscle)
4. Ankle ( Abduction at hip, flexion at knee, Dorsiflexion at
ankle - broad end hammer- back end of ankle - Contraction
at back muscles of leg)
5. SENSORY TRACT

Lateral Posterior Cortical

Column Column Sensory Tract

Pain Fine touch 2 point

discrimination
Crude touch Joint Tactile
sensation localization
Temperature Pressure Stereognosis
Vibration Graphesthesia

Crude Touch - with blunt end hammer, close eyes & identify the
location.
Pain - black of hammer, ask where did you feel?
Temperature - 2 test tubes- warm & normal - which Temp felt ?
Joint sensation - Ask to close the eyes, and ask to move the
joint as per doctor.
Vibration - Keep TF on bony prominence - What are you
feeling?
Stereognosis - Sense of shape. Identify objects with closed eyes.
Graphaestgesia - Write/Draw/Stroke on back/forearm. Ask
what was written/Drawn ?

6. CEREBELLAR SIGNS :-

• Head – titubation (involuntary movements of head)

• Eye – nystagmus (involuntary eye mvt.)
(flocculonodular lesion)
• Extremities –
▪ Intention tremors
▪ Dysmetria (overshooting) & Dyssynergia
(deviation in path) --- Finger-Finger test &
Finger-Nose test .
▪ Rebound phenomenon
▪ Dysdiadochokinesis (rapid alternating
movements of hands)
• Trunk – truncal ataxia (move side to side
involuntarily) • Lower extremities –
▪ Tandem gait (ask to walk in straight line)
▪ Pendular knee jerk (mvt >3 times)
▪ Heel to shin test

7. MENINGEAL SIGNS –
● Neck stiffness- (Touch chin to chest)
● Kernig's sign (when the patient is lying with the hip
flexed on the abdomen, the leg cannot completely
extended)
● Brudzinski's sign (when the neck is flexed, flexion of
the knees and hips is produced; when the lower
extremities of one side is passively flexed similar
movements seen in the opposite side)