CNS EXAMINATION

⚫ General look of patient: Facial expression, General demeanor, Posture, Gait, Speech, Involuntary
movements

⚫ Vital signs

⚫ Level of consciousness

Speech and language exam:

⚫ Listen to the patient’s spontaneous speech, noting volume, rhythm and clarity.

⚫ Ask the patient to make sounds like:

‫ببببببب‬
‫تتتتتتتت‬
‫كككككككككك‬

⚫ Ask the patient to count steadily to 30 to assess fatigue.

 ⚫ Ask the patient to cough and to say ‘Ah’; observe the soft palate rising bilaterally.

⚫ listen to the fluency and appropriateness of the content during speech.

⚫ Ask the patient to name a common object

⚫ Give a simple three-stage command

⚫ Ask the patient to repeat a simple sentence

⚫ Ask the patient to read a passage from a newspaper.

⚫ Ask the patient to write a sentence; examine his handwriting.

⚫ Comment: No dysarthria, No dysphonia, no dysphasia

Stance and Gait:

⚫ Stance:

⚫ Examine stance on narrow base while eyes are open and closed (feet together)

⚫ Gait:

⚫ Note the gait: Look at shoes for abnormal wear pattern

⚫ Preform a time get-up-and-go test

⚫ Listen for the slapping sound of a foot drop gait.

⚫ Ask the patient to walk first on tip toes, then on the heels

⚫ Tandem gait (if presented check other cerebellar signs)

MOTOR SYSTEM
1-Inspection

a) Asymmetry
b) Deformity
c) Abnormal movement (Fasciculation, tremors and myoclonic jerks…)
d) Muscle Wasting or Hypertrophy
 ● After inspection you can palpate for bulk, hypertrophy, wasting, tenderness and masses

2-Tone + Clonus
a) patient is relaxed and in supine position (ask the Pt to go floppy)
b) warm your hands
c) Passively move the joint through full range of motion both slowly and quickly, be unpredictable.

• upper limb: (Bilateral)

1) Hold as if shaking hand & support the elbow with the other hand
2) Flex and extend the hand, forearm, and the shoulder, and rotate the forearm
(pronation/supination)
3) Ask the Pt to draw circles in the air in one hand while assessing the other

• lower limb: (Bilateral)

Rolling the leg from one side to the other rolling then briskly lift the knee in flexed position

● Ankle clonus repeated dorsiflexion of the ankle in response to brisk dorsiflexion and eversion of the
foot (with both knee and ankle resting on 90 degrees flexion)

Comments:
No hypertonia or hypotonia, No
spasticity, No rigidity No Ankle clonus
3-Power
a) Ask about pain
b) Ask the Pt to get up from a chair and walk
c) Ask the Pt to sit up from a lying position (for truncal strength)
d) First assess power against gravity
e) Then apply resistance
f) compare both sides

• Upper limb: Pt sitting on the end of the coach

• Ask the Pt to their arms above their head
• Ask them to play the piano
• Pronator drift: Patient holds hands outstretched forward, palms up and fingers straight,
Eyes closed, wait 10+ seconds to rule out drift.

Shoulder--> abduction
 Elbow--> flexion & extension
Wrist-->extension
Fingers--> flexion and extension Thumb
--> abduction
• Lower limb: Pt reclining
Hip--> flexion & extension
Knee--> flexion & extension
Ankle-> dorsiflexion & plantar flexion &eversion & inversion Great
toe--> extension
Comments:
Power is 5/5 all over four
limbs, No pronator drift

4-Reflexes
a) deep tendon reflexes
1. keep patient as relaxed as possible (supine) and ask about pain before
2. Compare each reflex with the other side, check for symmetry of response
3. use reinforcement
4. Record as: increased, normal, diminished, present only with reinforcement, or absent

⚫ Flex your wrist and allow the weight of the tendon hammer head to determine the strength of the blow.
Strike the tendon, not the muscle or bone.

Upper limb:
-Reinforcement: ask the Pt to make a fist with the other hand

● Biceps jerk C5. Tap With your finger on tendon

● Supinator C6. Tap With your finger on tendon

● Triceps jerk C7. Tap directly on triceps tendon

● Hoffmann’s jerk: your index finger under the DIP of the middle finger then flick the Pt’s finger with
you index and Look for thumb flexion (abnormal, positive Hoffman’s)

● Finger jerk C8.: Place your middle and index fingers across the palmar surface of the patient’s
proximal phalanges, Tap your own fingers with the hammer, Watch for flexion of the patient’s fingers
-Lower limb: Reinforcement: reflexes, ask the patient to interlock the fingers and pull one hand against the
other
 ● Knee jerk L3, 4 (Tap directly on patellar tendon)

● Ankle jerk S1 (Tap directly on Achilles tendon)

● Planter response: blunt object from the heel laterally towards the little finger. The normal response is
plantar flexion of the great toe (downward movement).
Just mention:
● Abdominal reflexes T8-T12

● Cremasteric reflex (only in males) L1,L2

● Primitive reflexes: Snout, Grasp, Palm omental, Glabellar tap

⚫ Comment: No hyperreflexia or hyperreflexia, Negative plantar response or if present positive Babinski

sign, Positive or Negative Hoffmann’s and finger jerks

Sensory examination

1. Light touch
• Patient should look away or close his eyes
• Use a touch pen/ cotton wool
• Dabbing rather than stroking irregularly, compare
• Distal to proximal
2. Superficial pain:

o Patient should look away or close his eyes, explain and demonstrate on the sternum first.
▪ Use special sharp neurologic pen

▪ Move from reduced to higher sensibility

3. Temperature
• Use tuning fork for cold sensation. Ideally it should be examined using cold tubes and hot tubes.
4. Vibration
• first demonstrate on sternum
Upper limb:
• DIP Joint of forefinger, If impaired progress proximally to PIP,MCP, wrist , elbow, shoulder, clavicle
Lower limb:
 • Start at tip of great toe, If impaired progress proximally to the medial malleolus, patella , ASIS, lower
chest wall

5. Joint position sensation

Demonstrate on great toe or middle finger with eyes opened then ask the patient to close eyes
• start examination with the big toe, DIP of the middle finger and proceed proximally if impaired
6. Stereognosis and graphesthesia
• Ask the patient to close his eyes
• Stereognosis
•Place a familiar object in his hand and ask him to identify it.(Coin)
• Graphaesthesia:
• Use the blunt end of a pencil trace letters or digits on the patient's palm and ask him to identify its
7. Point localization and sensory inattention( only if sensory pathways are otherwise intact)
• Ask the patient to close his eyes
• point localization
• Touch his arms/legs in turn and ask which side has been touched.
• Touch different fingers and ask the patient which is touched
• sensory inattention
• Touch both sides simultaneously and ask whether the left, right or both sides were touched.

Coordination

1- Speech and language: dysarthria

2-Stance: check if cerebellar ataxia or sensory ataxia
Ask the patient to stand up, feet together (preferably bare) and putting your hands around him
with eyes open for 30 seconds (cerebellar ataxia), Then with closed eyes
Romberg test; outstretched hands with eye closing to 30 seconds (sensory
ataxia)
Rebound

⚫ Ask the patient to stretch his arms out and maintain this position.

⚫ Push the patient’s wrist quickly downward and observe the returning movement.

3- Gait
Ask the Pt to walk heel to toe (tandem gate)
4) Eye movements

Ask the Pt to follow an object in all directions (H) to assess for nystagmus.
5) Finger-to-nose test:
 ⚫ Ask the patient to touch his nose with the tip of his index finger and then touch your finger tip.

⚫ Hold your finger just within the patient’s arm’s reach

⚫ Ask him to repeat the movement between nose and target finger as quickly as possible.

⚫ Make the test more sensitive by changing the position of your target finger.

⚫ Move your finger just as the patient’s finger is about to leave his nose, otherwise you will induce a false-
positive finger-to-nose ataxia.

⚫ Some patients are so ataxic that they may injure their eye/face with this test. If so, use your two hands as
the targets and ask patients to touch their chin instead of nose.

6) Rapid alternating movements test:

⚫ Demonstrate repeatedly patting the palm of your hand with the palm and back of your opposite
hand as quickly and regularly as possible.

⚫ Ask the patient to copy your actions.

⚫ Repeat with the opposite hand.

7) Heel-to-shin test:

⚫ With the patient lying supine, ask him to place his heel on his opposite knee, and then slide his heel up and
down the shin between knee and ankle

Comment: No dysarthria, No cerebellar or sensory ataxia, No nystagmus, Negative cerebellar signs

Apraxia:
Asking patients to do or Imitate common learned tasks (drinking a cup of tea, making a V sign , copy a geometric
figure, ask them to dress up with one sleeve of the shirt inside out and to perform a cycling movements with their
legs
 CRANIAL NERVES

1) Olfactory nerve
Check the nasal passage
Ask the patient to close their eyes
Close one nostril at a time
Use “scratch and sniff” test cards, such as the University of Pennsylvania Smell Identification Test
(UPSIT)

Optic Nerve
Optic nerve:
1. Observe the head position, Face and orbit for asymmetry, swelling, erythema, any
abnormalities
2. Lids: Look for the lids position (ptosis vs lid retraction), and
3. Lid lag: Examine the seated patient from the right. Hold your finger from a point
45° above the horizontal to point below this plane. Watch how the upper eyelid
moves with the downward movement of the eye. In lid lag the sclera can be seen
above the iris
4. Eyeball: proptosis; examine from the back by looking from above
5. Palpate around the orbital rim and orbit and look for any masses.
6. Visual acuity: (Just mention, but they have to know the theory part)
Use a backlit Snellen chart positioned at 6 meter and dim the room lighting. Cover one
eye and ask the patient to read the chart from the top down until they cannot read any
further. Repeat for the other eye.
If the patient cannot see the largest font, reduce the test distance to 3 meter, then to 1
meter if necessary.
If they still cannot see the largest font, document instead whether they can count fingers,
see hand movement or just perceive the difference between light and dark. If the patient
cannot read down to line (6/6), place a pinhole directly in front of the eye (with the
patient keeping their usual spectacles on, if they wear them) to correct any residual
refractive error.
Assess near vision with a similar test using text of reducing font size held at a comfortable
reading distance.
7. Pupils (points 7-10): start with inspection looking for shape and asymmetry (anisocoria)
8. Direct and consensual light reflex
With the patient fixating on a point in the distance and in ambient lighting, shine a bright
light from the temporal side into one eye and look for constriction of the ipsilateral pupil.
 To test the consensual reflex, assess the pupil response in the contralateral pupil when light
is directed towards the ipsilateral pupil. Repeat for the other pupil.
9. Relative-afferent pupillary defect
Use a bright light source.
Move the light briskly from one eye to the other but place it on each eye for a
minimum of 3 seconds.
10. Accommodation
Ask the patient to look at a close fixation target (do not use a light source) after fixating
on a distant target. Look for pupillary constriction and convergence.
11. Visual field:
Check visual acuity and ensure that the patient has at least enough vision to count fingers.
Sit directly facing the patient, about 1 meter away.

With your eyes and the patient’s eyes open, ask the patient to look at your face and
comment on whether they have any difficulty seeing parts of your face.
*** Start while both eyes are opened to examine homonymous defects and sensory
inattention
Homonymous defects: Ask the patient to keep looking straight at your face with both eyes.
Hold your hands out and bring an extended finger in from the periphery towards the center
of the visual field. For an accurate assessment of the patient’s fields, it is vital that the testing
finger is always kept in the plane exactly halfway between yourself and the patient. Wiggle
your fingertip and ask the patient to point to it when they first see it. Test all four quadrants
separately.
Sensory inattention

▪ Test both eyes together. Both you and the patient should keep your eyes open.

▪ Test both left and right fields at the same time.

▪ Note whether the patient reports seeing only one side move and which quadrant or side
is affected

***Then for the next tests, each eye will be tested separately:
Peripheral visual field
Ask the patient to close or cover one eye and look directly across to your opposite eye; you
should also close your other eye. Ask the patient to keep looking straight at your face. Test
each eye separately.
 Same as homonymous defect exam, Hold your hands out and bring an extended finger in
from the periphery towards the center of the visual field. Wiggle your fingertip and ask the
patient to point to it when they first see it. If the patient fails to notice your finger when it is
clearly visible to you, their field is reduced in that area. Test all four quadrants separately.
Then use a small white hatpin or a white Neurotip.

Central visual field: Repeat the same test using a red hatpin

Color desaturation

▪ It is important to show the patient the red target and ask them to report what colour they
see.

▪ A dull or pale red suggests colour desaturation, which may indicate optic nerve
dysfunction

12. Examine for blind spot:

Place a red-tipped target between the patient and yourself at the visual fixation point
Move the target temporally until it disappears
Then move the target slowly up and down, as well as from side to side

13. ophthalmoscopy: to look for optic disc swelling from compression. (Just mention)
14. Color vision (just mention): Assess red-green color vision using Ishihara test plates

Ocular movements (CN III, IV, XI)

● sit facing the Pt, 1 meter away(both eyes open), ask the patient to look at a target or pen-
torch light about 50 cm away.

● -Ask them to say if they experience diplopia.

● -Starting from the primary position, move the target in the six positions of gaze and up
and down.

● -If diplopia is present, ask whether this is horizontal, vertical or a combination of the
two. -Determine where the image separation is most pronounced.

● -Look for nystagmus and determine whether the eye movement is smooth

- Examine direct and consensual light reflex

Trigeminal nerve:
Sensory exam:

Ask the patient to close their eyes and say ‘yes’ each time they feel a light touch (you use
a cotton-wool tip for this test). Do this in the areas of V1, V2 and V3. Repeat using a fresh
neurological pin, such as a Neurotip, to test superficial pain. Compare both sides.
Normal sensation in anterior two thirds of the tongue
Nasal tickle test: not done routinely
Motor:

Inspect for wasting of the muscles of mastication

Ask the patient to clench their teeth; feel the masseters estimating their bulk. Ask
the patient to open their jaw and note any deviation
Corneal reflex (not done routinely)

Gently depress the lower eyelid while the patient looks up.

Lightly touch the lateral edge of the cornea with a wisp of damp cotton wool Look
for both direct and consensual

Jaw jerk

Ask the patient to let their mouth half opened.

Place your forefinger in the midline between lower lip and chin.

Percuss your finger gently with the tendon hammer in a downward direction,
noting any reflex closing of the jaw.
An absent, or just slightly present reflex is normal. If reflex is pronounced this indicates
UMNL
Facial nerve:
Motor function

Inspect the face for asymmetry or differences in blinking or eye closure on one side.
Watch for spontaneous or involuntary movement. Ask
the patient to:

- raise their eyebrows and observe symmetrical wrinkling of the forehead

(frontalis muscle).
- screw their eyes tightly shut and resist you opening them (orbicularis oculi).
- bare their teeth (orbicularis oris).
- blow out their cheeks with their mouth closed (buccinators and orbicularis
oris).
-Taste sensation over the anterior two thirds of the tongue
Corneal reflex
Vestibulocochlear (VIII) nerve

1- Whispered voice test

a. Stand behind the patient.

b. Start testing with your mouth about 15 cm from the ear you are assessing.
Mask hearing in the patient’s other ear by rubbing the tragus (‘masking’).
c. Ask the patient to repeat a combination of multisyllable numbers and words. Start
with a normal speaking voice to confirm that the patient understands the test.
d. Lower your voice to a clear whisper.

e. Repeat the test but this time at arm’s length from the patient’s ear. People with
normal hearing can repeat words whispered at 60 cm.
2- Weber’s test

a. Strike the prongs of the tuning fork against a hard surface to make it vibrate.
Place the base of the vibrating tuning fork in the middle of the patient’s
forehead Ask the patient, ‘Where do you hear the sound?’
3- Rinne’s test
a. Strike the prongs of the tuning fork against a hard surface to make it vibrate.
Place the vibrating tuning fork on the mastoid process
b. Now place the still-vibrating base at the external auditory meatus and ask, ‘Is it
louder in front of your ear or behind?’
Glossopharyngeal (IX) and vagus (X) nerves
-Assess the patient’s speech for dysarthria or dysphonia

-Ask them to say ‘Ah’. Look at the movements of the palate and uvula using a torch
(comment: symmetrical palate elevation, no uvular deviation)
-Ask the patient to puff out their cheeks with their lips tightly closed. Listen for air
escaping from the nose.
-Ask the patient to cough; assess the strength of the cough.

-Testing pharyngeal sensation and the gag reflex is unpleasant. Instead, and in fully conscious
patients only, use the swallow test. Administer 3 teaspoons of water and observe for absent
swallow, cough or delayed cough, or change in voice quality after each teaspoon. If there are
no problems, observe again while the patient swallows a glass of water.

Accessory (XI) nerve

-Face the patient and inspect the sternomastoid muscles for wasting or hypertrophy;
palpate them to assess their bulk.
-Stand behind the patient to inspect the trapezius muscle for wasting or asymmetry.

-Ask the patient to shrug their shoulders, then apply downward pressure with your hands to
assess the power.
-Test power in the left sternomastoid by asking the patient to turn their head to the right while
you provide resistance with your hand placed on the right side of the patient’s chin. -Reverse the
procedure to check the right sternomastoid.
-Test both sternocleidomastoid muscles simultaneously by asking the patient to flex their neck.
Apply your palm to the forehead as resistance.

Hypoglossal (XII) nerve

-Ask the patient to open their mouth. Look at the tongue at rest for wasting, fasciculation or
involuntary movement.
-Ask the patient to put out their tongue. Look for deviation or involuntary movement. -Ask
the patient to move their tongue quickly from side to side.
-Test power by asking the patient to press their tongue against the inside of each cheek in turn
while you press from the outside with your finger.
-Assess speech by asking the patient to say ‘yellow lorry’.
-Assess swallowing with a water swallow test