Download MBBS Neuroanaesthesia PPT 9 Cns Neurological Examination Part 1 Lecture Notes

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Higher mental functions

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Cranial Nerves

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Motor system examination ? bulk, tone, power

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Reflexes.

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Coordination ? fine movements, balance and gait.

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Sensory system examination.
Higher mental functions

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The mental status examination is a structured assessment of the patient's behavioural and

cognitive functioning.

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The specific cognitive functions of alertness, language, memory, constructional ability, and

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abstract reasoning are the most clinically relevant.

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It should be a requisite part of standard neurologic examination ? at least Mini Mental State

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Examination should be performed in neurologic patients.

Appearance and General Behavior

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These variables give the examiner an overall impression of the patient.

The patient's physical appearance (apparent vs. stated age), grooming

(immaculate/unkempt), dress (subdued/riotous), posture (erect/kyphotic), and

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eye contact (direct/furtive) are all pertinent observations aiding the diagnosis.

Certain specific syndromes such as unilateral spatial neglect and the

disinhibited behavior of the frontal lobe syndrome are readily appreciated

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through observation of behaviour alone.
Structured Examination of Cognitive Abilities

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Performing a mini-mental status examination.

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Or a using a Mental status questionnaire.

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These measures only give a snapshot of patients cognition.

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Mini mental state examination

MMSE is a 30 point scoring system and is one of the most widely used brief

screening systems for cognitive state.

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Components include: I. Orientation

ii. Registration

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iii. Attention and Calculation

iv.Recall

V. Language

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1.Orientation ( total 10 points )

What is the orientation to time? time ( 1 point) date ( 1 point)

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day ( 1 point) Month ( 1 point) year( 1 point) ?
A total of 5 points.

What is the name of this: (orientation to place) Ward ( 1 point)

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hospital ( 1 point) district ( 1 point) town ( 1 point) country ( 1 point)
A total of 5 points.

2. Registration ( 3POINTS )

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Name any three objects

Score 1, 2, 3 points according to how many the patient repeats.

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Re-submit the list until the patient is word perfect in order to use this for a

later test of recall

Score only for first attempt 3 points

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3. Attention and calculation

Have the patient subtract 7 from 100 and then from

the result a total of five times.

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Score 1 point for each correct subtraction 5 points

4.Recall ( 3points)

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Ask for three objects used in the registration test.

one point being awarded for each correct answer.

A total of 3 points avoided per correct recall.

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5.Language and Intelligence (9points)

1 point each for two objects correctly named (pencil and watch) 2 points.

1 point for correct repetition (No ifs and buts) 1 point.

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3 points if three-stage commands correctly obeyed

`Take this piece of paper in your right hand, fold it in half, and
place it on the floor'. 3 points.

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1 point for correct response to a written command such as `close your eyes'.

1 point.

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Have the patient write a sentence. Award 1 point if the sentence is

meaningful, has a verb and a subject. 1 point

Test the patient's ability to copy a complex diagram of two intersected

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pentagons. 1 point
Total score is 30. Maximum score of 30 is normal.

Scores between 15 and 22 suggest mild to moderate dementia.

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Scores lower than 21 are associated with severe cognitive impairment
CRANIAL NERVE EXAMINATION

12 pairs of cranial nerves:

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CN1 Olfactory

CN2 Optic

CN3 Oculomotor

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CN4 Trochlear

CN5 Trigeminal

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CN6 Abducens

CN7 Facial

CN8 Vestibulocochlear

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CN9 Glossopharyngeal

CN10 Vagus

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CN11 Spinal Accessory nerve

CN12 Hypoglossal
On broad inspection

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Look for facial asymmetry
Look for ocular deviation , Ptosis or

Unequal pupils ( Anisocoria )

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CN1 ? Olfactory nerve

SENSORY ONLY cranial nerve

Smell sensation

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to test olfactory function, the patient should be asked to distinguish between smells

such as coffee and cinnamon or other mild spices.

Noxious stimulation (such as smelling ammonium salts) that irritate the nasal mucosa

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should be avoided.

Test each nostril separately with familiar smells (e.g. coffee)

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CN2 ? Optic nerve examination

SENSORY only cranial nerve.

Visual acuity

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Visual fields

Reflexes:

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Pupillary light reflex

Accommodation reflex

Colour vision

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Fundoscopy
Visual Acuity- Snellen's chart at 6 metres. (bring
them closer if they cannot read top letter)

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One eye tested at a time

With normal correction establish the smallest

line patient can read

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If acuity too poor for Snellen chart, try:

Finger counting at 20cm
Hand movement

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Perception of light

Visual fields:

Ask patient to look at your eye

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Test one eye at a time

Cover your eye that is opposite the

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patient's covered eye

Ask patient to report finger

movements on both sides, move

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inwards until they are able to see them

Compare with your own visual field
Ocular reflexes

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Pupillary light reflex

Ask patient to fixate on a distant point

Shine light into one eye

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Look for constriction of that pupil (direct

reflex) and the other pupil (consensual

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reflex)
Swinging light test

Swing light between the eyes

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If optic nerve intact, both stay

constricted

If optic nerve damaged, pupils

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appear to dilate when light shone

directly into it

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Relative afferent pupillary defect

Accommodation reflex

Ask patient to fixate on distant object

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Present an object around 6 inches

from their face and ask them to focus
on it

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Look for pupil constriction
Colour vision

Ishihara plates ? ask patient to read

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out the numbers

Not always available (available as an

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iPhone app!)

Fundoscopy

This involves looking into the back of

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the patient's eye with an

ophthalmoscope to visualise the

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retina and optic disc.
CN3 (OCULOMOTOR)
CN4 (TROCHLEAR)
CN6 (ABDUCENS)

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MOTOR ONLY cranial nerves.

Eye movements:

CN3 ? Superior rectus, Inferior rectus,

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Medial Oblique, Inferior oblique

CN4 ? Superior Oblique

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CN6 ? Lateral Rectus
On inspection:

Eye moves towards the muscles that still work

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Third nerve palsy:

Down and outward deviation

= Tramps Pupil

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Fourth nerve palsy:

Subtle ? Head tilted away from lesion

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Sixth nerve palsy:

Inward deviation

Inability to look out

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Ocular movements

Ask patient to keep their head still and follow

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your finger with their eyes

Ask patient to report any double vision in

neutral position or during test

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Move your finger slowly through a large double

letter HH

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Observe for full eye movements
CN5 ? Trigeminal nerve

SENSORY & MOTOR (mixed) cranial nerve

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Sensory ? 3 divisions:

Ophthalmic

Maxillary

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Mandibular

Motor:

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Muscles of mastication:

Jaw jerk reflex

Sensory testing

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Test light touch sensation in each of the areas

shown

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Demonstrate on sternum for reference.

Ask patient to close their eyes and report when

they feel it and if it feels normal

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Corneal reflex ? touch cornea lightly with cotton

wool and look for blink in both eyes
Motor testing

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Muscles of mastication:

Inspect for wasting

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Palpate on jaw clenching

Resisted mouth opening

Jaw jerk reflex

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Mouth slightly open, jaw relaxed

Place finger on chin and tap with tendon hammer

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Normally absent or small

Brisk in UMN lesions

CN7 ? Facial nerve

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SENSORY & MOTOR cranial nerve.

Sensory

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Taste sensation to anterior 2/3 of

tongue

Motor

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Muscles of facial expression
Sensory:
Not routinely tested
Motor

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Muscles of facial expression ? ask patient
to:
Raise eyebrows

Close their eyes and don't let you open

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them

Smile

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Puff out their cheeks

CN8 ? Vestibulocochlear nerve

SENSORY only cranial nerve.

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Carries hearing and balance input from ear

Crudely test hearing

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Whisper a number into each ear whilst making a

distracting sound in the other ear

Ask patient to repeat the number

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If concerned, perform Weber's and Rinne's tests
Weber's test:

? Tuning fork in centre of forehead ? in

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which ear does it sound louder?

? Normally equal in both ears.

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? Conductive hearing loss:

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Lateralises to affected side

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? Sensorineural hearing loss:

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Lateralises to non-affected side

Rinne's test

? Tuning fork on Mastoid

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? When sound stops move next to ear

? Ask if can now hear it?

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Yes = Normal

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or Equally affected = Sensorineural

Deafness

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No = Conductive deficit
CN9 & 10 ? GLOSSOPHARYNGEAL & VAGUS NERVE

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SENSORY & MOTOR

CN9 Sensory

Nasopharynx

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Posterior 1/3 Tongue

Middle + Inner Ear

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CN10 Sensory

Pharynx + Larynx

CN10 Motor

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Pharynx + Larynx

Palate

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Observe for any dysphonia

Ask patient to open mouth wide and say "aah"

Observe for any deviation of the uvula

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Deviation would be AWAY from the side of the
lesion

Gag reflex Not routinely done

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CN11 ? Spinal accessory nerve

MOTOR only cranial nerve

Trapezius muscle

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Sternocleidomastoid muscle
Trapezius muscle

Ask patient to shrug their shoulders

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against resistance

Sternocleidomastoid muscle

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Ask patient to turn their head to each

side against resistance

CN 12 ? Hypoglossal Nerve

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MOTOR only

Muscles of the tongue
Muscles of the tongue : Observe for

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fasciculations

Ask patient to stick out their tongue

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Observe for deviation

Deviation would be TOWARDS the side of the

lesion

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Check power of muscles by asking patient to

push their tongue into the side of their cheek
and pressing on it from the outside

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Videos uploaded after sorting permission from "The University of Utah "

neurology center.