Cns Exam 3rd

Anthony P. Toledo, MD ,RN, MAN, DPAFPCHAIRMAN, MS2Professor/Lecturer/Reviewer/Doctor On Call, College of NursingOur Lady of Fatima University

LEARNING OBJECTIVES

By the end of this session, you will know: By the end of this session, you will know: 1. How to test the cranial nerves, and common

reasons for abnormalities 2. How some cranial nerve abnormalities look 3. How to test touch, sharp, position and

vibration sensation 4. How to grade a patient's strength 5. How to grade reflexes, and how some

abnormal reflexes look 6. Which nerve roots you are testing when you

check reflexes 7. Several abnormal gaits 8. How to test coordination, how abnormal tests

look and what they mean.

Neurologic Exam

EXAM SECTIONS

The Neurologic Examination has six The Neurologic Examination has six sections:sections:

1. Mental Status Examination 2. Testing Cranial Nerves 3. Sensation Examination 4. Testing Strength 5. Deep Tendon Reflexes Examination 6. Coordination Examination

MENTAL STATUS EXAMINATION Alertness:Alertness: ranges from alert to

comatose. "Alert and oriented""Alert and oriented" means that the

patient, at least: opens eyes spontaneously converses appropriately follows verbal "commands"(requests) is oriented to person (self and others),

place (state, town, building) and time (month, day and year).

MENTAL STATUS EXAMINATION

Intellectual FunctionIntellectual Function – abstract reasoning 100 – 7 = 93 – 7 = 86 – 7 = 79 . . . .

Thought ContentThought Content – spontaneous, natural, clear, relevant and coherent.

Emotional StatusEmotional Status – affect Natural, even, irritable, angry, flat,

anxious, apathetic, or euphoric.

MENTAL STATUS EXAMINATION PerceptionPerception – agnosia (inability of client to

recognize object seen through special senses)

Motor AbilityMotor Ability Throw a ball

Language AbilityLanguage Ability – aphasia Broca’s aphasia / expressive aphasia

(Broken) Wernecke’s aphasia / receptive aphasia

(Wordy) Impact on LifestyleImpact on Lifestyle – patient’s role in

society, including family and community.

MENTAL STATUS EXAMINATION Level of Consciousness (LOC)Level of Consciousness (LOC) –

arousal; awareness of self or environment AlertAlert – fully awake; appropriate

responses to external and internal stimuli; oriented to person, place and time

LethargicLethargic – somnolent, drowsy, listless, indifferent to surroundings, very sleepy, can be aroused from sleep but when stimulation ceases, falls back to sleep; may be oriented or confused


StuporousStuporous – unconscious most of the time but makes spontaneous movements and response is evoked only by a strong, continuous, noxious stimuli; loud noises or sounds, bright light, pressure to sternum, response is usually a purposeful attempt to remove the stimulus

ComatoseComatose – absence of voluntary response to stimuli including painful stimuli; no response, no eye opening – score of 7 or less on GCS

Glascow Coma ScaleEYE OPENING EYE OPENING RESPONSERESPONSE

SPONTANEOUSSPONTANEOUS

TO VOICETO VOICE

TO PAINTO PAIN

NONENONE

44

33

22

11

BEST VERBAL BEST VERBAL RESPONSERESPONSE

ORIENTEDORIENTED

CONFUSEDCONFUSED

INAPPROPRIATE WORDSINAPPROPRIATE WORDS

INAPPROPRIATE SOUNDSINAPPROPRIATE SOUNDS

NONENONE

55

44

33

22

11

BEST MOTOR BEST MOTOR RESPONSERESPONSE

OBEYS COMMANDSOBEYS COMMANDS

LOCALIZES PAINLOCALIZES PAIN

WITHDRAWS (PAIN)WITHDRAWS (PAIN)

FLEXION (PAIN)FLEXION (PAIN)

EXTENSION (PAIN)EXTENSION (PAIN)

NONENONE

66

55

44

33

22

11

TOTALTOTAL 1515


Client with Abnormal Mental Status Exam Oriented Good short term

memory Remote memory

impairment

CRANIAL NERVES

Cranial Nerve I - THE OLFACTORY Cranial Nerve I - THE OLFACTORY NERVESNERVES

Test this with odorous things, one nostril at a time. As most physicians don't carry odorants, the screening exam usually omits the first cranial nerve.

Common causes of cranial nerve I dysfunction include: trauma to the cribriform plate frontal lobe mass or stroke nasal problems (e.g. allergic or viral).

CRANIAL NERVES

Cranial Nerve I - Cranial Nerve I - THE OLFACTORY THE OLFACTORY NERVESNERVES

Sensory

CRANIAL NERVES

Cranial Nerve II - THE OPTIC NERVECranial Nerve II - THE OPTIC NERVE Test this with field of vision and visual

acuity. Many MDs carry a pocket visual screening card. To screen field of vision, test by confrontation (patient looks at your nose while you move fingers).

CRANIAL NERVES

Cranial Nerve II - THE OPTIC NERVE Cranial Nerve II - THE OPTIC NERVE Common causes of optic nerve

abnormalities: Eye disease or injury. Diabetic retinopathy

and glaucoma are major causes. Occipital lobe mass or stroke. This causes

loss of visual field in both eyes. Patients can lose ½ or ¼ of a visual field

Optic chiasm mass, such as pituitary tumors. These cause loss of the temporal visual fields bilaterally - bitemporal hemianopsia.

CRANIAL NERVES

Cranial Nerve II - Cranial Nerve II - THE OPTIC THE OPTIC NERVENERVE

Sensory Visual Acuity

CRANIAL NERVES


Sensory Visual Field

CRANIAL NERVES


Fundoscopy

CRANIAL NERVES

Cranial Nerve II Cranial Nerve II and III - THE and III - THE OPTIC NERVE OPTIC NERVE and and OCULOMOTOR OCULOMOTOR NERVENERVE

Sensory + Motor Pupillary light

reflex

CRANIAL NERVES

Cranial Nerve III, IV and VI - THE Cranial Nerve III, IV and VI - THE OCULOMOTOR, TROCHLEAR and OCULOMOTOR, TROCHLEAR and ABDUCENS NERVESABDUCENS NERVES

Test these three nerves with extraocular movements and pupil function (cranial nerve III). To detect subtle abnormalities, ask patient whether they have double vision (diplopia) during extraocular movements.

CRANIAL NERVES

Cranial Nerve III, IV and VI - THE Cranial Nerve III, IV and VI - THE OCULOMOTOR, TROCHLEAR and OCULOMOTOR, TROCHLEAR and ABDUCENS NERVESABDUCENS NERVES

One mnemonic to remember these three nerves is LR6SO4 : all the muscles are innervated by CN III except for the lateral rectus (6) and superior oblique (4).

Some common causes for cranial nerve palsies are: brainstem injury or compression (e.g. tumor,

stroke, intracranial bleeding diabetic neuropathy (can cause temporary

palsies).

CRANIAL NERVES

Cranial Nerve III, Cranial Nerve III, IV and VI - THE IV and VI - THE OCULOMOTOR, OCULOMOTOR, TROCHLEAR and TROCHLEAR and ABDUCENS ABDUCENS NERVESNERVES

Ocular inspection

CRANIAL NERVES

Cranial Nerve III, Cranial Nerve III, IV and VI - THE IV and VI - THE OCULOMOTOR, OCULOMOTOR, TROCHLEAR and TROCHLEAR and ABDUCENS ABDUCENS NERVESNERVES

Motor EOM

CRANIAL NERVES

Cranial Nerve V - THE TRIGEMINAL Cranial Nerve V - THE TRIGEMINAL NERVENERVE

Screen this nerve with facial sensation (to light touch, e.g. q-tip) and strength of the masseter muscles.

Common cause for CN V abnormality is stroke in the contralateral sensory cortex.

CRANIAL NERVES

Cranial Nerve V - Cranial Nerve V - THE TRIGEMINAL THE TRIGEMINAL NERVENERVE

Sensory

CRANIAL NERVES

Cranial Nerve V - Cranial Nerve V - THE TRIGEMINAL THE TRIGEMINAL NERVENERVE

Motor

CRANIAL NERVES

Cranial Nerve VII - THE FACIAL Cranial Nerve VII - THE FACIAL NERVENERVE

Test this with facial movements: ask the patient to raise eyebrows, show teeth, smile, puff out cheeks, whistle.

Injuries to facial strength central to the nucleus (in the cortex or corticospinal tracts) - often caused by a stroke - cause weakness of the lower face, with sparing of the forehead, due to cross-innervation of the forehead. We call this a central facial palsy.

CRANIAL NERVES

Cranial Nerve VII - THE FACIAL Cranial Nerve VII - THE FACIAL NERVENERVE

Injuries to the facial nerve itself (peripheral facial palsy) cause weakness of the entire side of the face, including the forehead. Common causes of peripheral facial palsy are Bell's palsy (idiopathic - cause is unknown) and Lyme disease (which may cause bilateral peripheral facial palsy).

CRANIAL NERVES

Cranial Nerve VII Cranial Nerve VII - THE FACIAL - THE FACIAL NERVENERVE

Motor

CRANIAL NERVES

Cranial Nerve VII Cranial Nerve VII - THE FACIAL - THE FACIAL NERVENERVE

Sensory

CRANIAL NERVES

Cranial Nerve VIII - THE ACOUSTIC Cranial Nerve VIII - THE ACOUSTIC NERVENERVE

Test the acoustic nerve with hearing test (rub fingers by each ear, or whisper into ear, or use your tuning fork). We do this as part of the ear examination. In patients with vertigo or dizziness, you may test also with positional maneuvers, trying to reproduce vertigo by moving the patient.

CRANIAL NERVES

Cranial Nerve VIII - THE ACOUSTIC Cranial Nerve VIII - THE ACOUSTIC NERVENERVE

Common causes of acoustic nerve abnormalities: sensorineural hearing loss due to age

or noise exposure tumors at cerebellopontine angle acoustic neuroma earwax or middle ear disease can

cause temporary hearing loss.

CRANIAL NERVES

Cranial Nerve Cranial Nerve VIII - THE VIII - THE ACOUSTIC ACOUSTIC NERVENERVE

Sensory Auditory Acuity Rinne Weber

CRANIAL NERVES

Cranial Nerve IX and X - THE Cranial Nerve IX and X - THE GLOSSOPHARINGEAL and VAGUS GLOSSOPHARINGEAL and VAGUS NERVESNERVES

Test this with the gag reflex - put tongue blade on the posterior third of patient's tongue and press down. Many clinicians prefer to have alert patient phonate (say aaah) instead, watching for uvula movement.

A common cause of CN IX and X abnormality is a large stroke. The uvula retracts to the normal side.

CRANIAL NERVES

Cranial Nerve IX Cranial Nerve IX and X - THE and X - THE GLOSSOPHARINGLOSSOPHARINGEAL and VAGUS GEAL and VAGUS NERVESNERVES

Sensory + Motor Gag reflex

CRANIAL NERVES

Cranial Nerve XI - THE ACCESSORY Cranial Nerve XI - THE ACCESSORY NERVENERVE

Test this nerve by asking patient to shrug shoulders or turn head against resistance.

A common cause of CN XI abnormality is neck injury.

CRANIAL NERVES

Cranial Nerve XI Cranial Nerve XI - THE - THE ACCESSORY ACCESSORY NERVENERVE

Motor

CRANIAL NERVES

Cranial Nerve XII - THE Cranial Nerve XII - THE HYPOGLOSSAL NERVEHYPOGLOSSAL NERVE

Test this nerve by asking patient to protrude tongue and move it from side to side.

CN XII function abnormalities are often caused by stroke. The tongue points toward its weak side.

CRANIAL NERVES

Cranial Nerve XII Cranial Nerve XII - THE - THE HYPOGLOSSAL HYPOGLOSSAL NERVENERVE

Motor

SENSORY EXAMINATION

Touch:Touch: Test light touch with a cotton swab or microfilament. Subtle abnormality in touch sensation may manifest as

extinction : with eyes closed, the patient touched on both sides only feels touch on the normal side.

Sharp:Sharp: Break off the wooden part of a cotton swab to make a sharp object. Ask the patient with eyes closed to distinguish sharp from dull.

Vibration:Vibration: test with low-frequency (128) tuning fork.

Proprioception:Proprioception: with eyes closed, patient distinguishes whether finger and toe are moved up or down. This tests posterior column function.

SENSORY EXAMINATION

SensorySensory Paresthesia – abnormal sensation;

distortion of sensory stimuli; numbness, tingling sensation

Anesthesia – absence of sensation or touch

Hyperesthesia – pathologic over-perception of touch

Hypoesthesia – reduced sense of touch Analgesic – absence of pain

MOTOR EXAMINATION

Test this with resisted motionsTest this with resisted motions.. We do this during the extremity examination.

Strength is rated from 0 to 5: 0/5: no motion 1/5: slight muscle motion, but no movement at joint 2/5: full motion parallel to ground, but can't move

against gravity 3/5: can move against gravity, but no more 4/5: full strength against some resistance 5/5: full strength against full resistance - normal.

Subtle central weakness (such as with early CNS malignancy) can be tested via pronator drift. Ask your patient to hold arms forward with palms up. In mild cortical weakness, patient's hand on the weak side pronates and drifts down.

MOTOR EXAMINATION

MotorMotor Decerebrate rigidity – arms stiffly

extended and abducted with hyperpronation of arms

Decorticate rigidity – arms, wrisht and fingers are flexed; arms are adducted; in both, legs fully extended and internally rotated with plantar flexion of feet

MOTOR EXAMINATION

Paresis – impaired strength or power Paralysis – loss of strength Hemiplegia – paralysis of lateral half Paraplegia – paralysis of the legs Apraxia – inability to carry out a learned

movement on command without weakness paralysis

DEEP TENDON REFLEXES EXAMINATION Biceps reflexBiceps reflex tests C5-6. Place your

thumb on biceps tendon and strike your thumb with the reflex hammer.

Brachioradialis reflexBrachioradialis reflex also tests C5-6. Strike tendon with flat side of hammer.

Triceps reflexTriceps reflex tests C7-8. Tap proximal to olecranon.

Quadriceps reflex Quadriceps reflex (knee jerk)(knee jerk) tests L2-L4

Achilles reflex Achilles reflex (ankle jerk)(ankle jerk) tests L5-S2.

DEEP TENDON REFLEXES EXAMINATION GRADING REFLEXESGRADING REFLEXES

0: nothing happens 1+: some movement, less than normal 2+: normal 3+: more brisk than normal 4+: brisk, with clonus (several beats/

repeated motion; sometimes motion in the other extremity, too.)

DEEP TENDON REFLEXES EXAMINATION BABINSKI's SIGNBABINSKI's SIGN Stroke the sole of the foot with the back

of your reflex hammer (Babinski used a key), from lateral heel to lateral ball of foot, then medially to medial ball of foot.

Normal response: great toe goes down (unless patient is ticklish)

Abnormal response: great toe goes up, other toes fan up, ankle may dorsiflex.

Abnormal Babinski is a sign of pyramidal tract / upper motor neuron disease.

ABNORMAL GAITS

Spastic hemiplegia Parkinsonian Gait Antalgic Gait Ataxic Gait

ABNORMAL GAITS

Spastic hemiplegiaSpastic hemiplegia Foot is held inverted, leg too straight

and swung out, arm flexed and held close to chest - a sign of old stroke or other cortical injury.

ABNORMAL GAITS

Parkinsonian Parkinsonian GaitGait Shuffling gait, rapid

small steps, little arm swing, turning "en bloc".

ABNORMAL GAITS

Antalgic GaitAntalgic Gait AntalgicAntalgic (pain-avoiding) gait is not due

to neurologic illness. In this gait, patient spends minimal time on the painful leg or side.

You can also test coordination with tandem gait: the patient walks heel to toe (the drunk test). It's abnormal in cerebellar or posterior column disease.

ABNORMAL GAITS

Ataxic GaitAtaxic Gait Ataxic gaitAtaxic gait is

wide-based, irregular gait, a sign of cerebellar disease

OTHER TESTS of COORDINATION Finger to nose Heel to shin Rapid alternating movements Fine motor Romberg's sign

OTHER TESTS of COORDINATION Finger to nose

Patient touches nose, then examiner's finger, then goes back and forth rapidly. It's abnormal in cerebellar disease.

OTHER TESTS of COORDINATION Heel to shin

Patient moves one heel down the other shin. Abnormal jerky motion in cerebellar disease.

OTHER TESTS of COORDINATION Rapid

alternating movements Ask patient to

rapidly pronate and supinate hands. Abnormal (dysdiadochokinesia) in patients with cerebellar disease.

OTHER TESTS of COORDINATION Fine motor

Patient rapidly touches thumb to each finger of same hand. Abnormal with cortical lesions (tumor or stroke).

OTHER TESTS of COORDINATION Romberg's sign

Patient stands with feet together and closes eyes. Patient sways and can't hold position with eyes closed. This is abnormal in posterior column disease (with cerebellar disease, patient can't stand with feet together even with eyes open).

Cns Exam 3rd

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