CNS Examination Flashcards
4 main aspects of the examination
limbs and gait
cranial nerves
fundoscopy
level of consciousness and higher functions
parts of the limbs examination x7
observation
tone
power
coordination
reflexes
sensation
observation of gate
limbs and gait examination : upper limb
1. observation
SWIFT
- Scars and Skeletal
deformity - Muscle wasting/
atrophy - Involuntary
movements - Fasciculation
- Tremor
limbs and gait examination : upper limb
2. tone x5
- ask if patient is in any pain
- ask patient to relax arms
- hold hand and elbow and bend elbow
- hold hand and turn hand at wrist
- hold hand and bend wrist
repeat on the other side
“no sign of hyper or hypotonia
types of hypertonia: name for increased tone during fast movements
spasicity
types of hypertonia: name for increased tone on slow muscle movements
rigidity
limbs and gait examination : upper limb
3. power x8
- shoulders: put elbows in the air “don’t let me push them down”
- elbows: flex in front of chest “don’t let me push or pull”
- wrists: make a fist and flex “don’t let me stop” flexion of extension
- hands: hold fingers out straight, put my hand across “don’t let me stop” moving fingers up
- intrinsic hands: spread fingers out “don’t let me push them in”
- thumbs- push both sides
- grip-squeeze my fingers
- pronator drift- arms out, palms up close eyes 15s
test both sides
Medical Research Council (MRC) Scale for power
0- No muscle contraction visible
1- Flicker of contraction but no movement
2- Joint movement when effect of gravity eliminated
3- Movement against gravity but not against examiner’s resistance
4- Movement against resistance but weaker than normal
5- Normal power
limbs and gait examination : upper limb
4. coordination x3
- hold arms out- postural tremor or dystonia
- finger nose- “ fast as you can” and move your finger side to side. repeat with other finger
3.Rapid alternating hand movements- hold left hand still and tap fast with right. then alternating flip right hand over. repeat on other side
limbs and gait examination : upper limb
4. reflexes x3
- Biceps: place your thumb or index finger over
the biceps tendon- in bend of arm strike finger - Supinator: place your thumb or index finger
over a point 3-4 cm above the wrist patents hand should be on side
and then strike finger. - Triceps: strike the tendon directly about 2cm above the elbow whilst supporting the weight of the arm
repeat on both sides
limbs and gait examination : upper limb
5. sensation x3
pin prick and cotton will on:
2 down the inner side
3 on the hands
2 on the outer side
vibration sense:
large tuning fork on end of finger
say “as there’s no loss I won’t continue up but if I did I would ensure to place it on bony landmarks such as the radius and olecranon (elbow)”
proprioception:
1. move finger up and down with eye closed. explain and show before
- pronator drift: hold hands out palms up. close eyes and wait
limbs and gait examination: lower limbs
1. observation
same as before
SWIFT
- Scars and Skeletal
deformity - Muscle wasting/
atrophy - Involuntary
movements - Fasciculation
- Tremor
limbs and gait examination: lower limbs
2. tone x3
ask if in any pain
relax legs
- hip rotation- roll leg about
- hip and knee flexion- pick knee up quickly, if heel stays on tone is normal
- clonus- sharply flex the ankle up and see if theres any repeated beats
repeat on other side
limbs and gait examination: lower limbs
3. power x4
- Hip: straight leg raise pushing thigh up against
your hand “keep it there do not let me push it
down”(flexion) and then pushing down against
your hand(extension) - Knee: bend one knee “pull heel towards your
bottom” (flexion) and then to straighten the
knee (extension) “push me away”. - Ankle: pull foot back towards them keeping
their knee straight (dorsiflexion) against your
hand and then push their foot down against
your hand (plantarflexion). -
Extensor Hallux Longus: pull big toe towards
them (keeping leg straight)
limbs and gait examination: lower limbs
4. coordination
heel shin test
take the heel of one leg and put it on the knee of the other leg,
then run the heel down their shin towards the ankle
lifting off at the ankle and back to the knee again, and repeat
the movement.
repeat on both legs
limbs and gait examination: lower limbs
5. reflexes x3
- Knee reflex: place your left forearm under
one knee and gently lift the leg off the bed
Strike the patellar tendon, just below the lowest point of
the patella. - Ankle reflex: put foot on other foot
hold foot and strike achilles tendon
plantar response:
small, reasonably hard but blunt object (such as the blunt end of a Neurotip).
Stroke the lateral side of the sole of the foot firmly
starting near the heel and working up towards toes
and across the ball of the foot towards the base of
the big toe. toe should curl inwards
limbs and gait examination: lower limbs
6. sensation
- pin prick and cotton swab:
top of foot
inner and outer calf
inner and outer thigh - vibration- large tuning fork
on big toe
on sticky out bone of ankle - proprioception
move toe up and down and ask patient
large the small movements - proprioception 2- Romberg’s test
patient to stand feet close together
one arm in front and behind
ask to close eyes
limbs and gait examination: lower limbs
7. gait x4
- normal walking- walk along side
get patient to walk up a hallway, turn on the spot and come back - balance - walk along side
as before but heel to toe - proximal lower limb power
rise from a chair without using their arms - distal limb power you can ask the patient
to walk on their heels and to stand on tip toes.
Rinnes results meaning
air should be better than bone- positive test
if bone is better than air- conductive loss- negative test
Webers result meaning
- sound should be equal
- louder in problem ear = conductive
*louder in good ear = sensorineural
causes of issues with tones
spasticity/hypertonia = upper motor neuron lesion
rigidity = parkinsonism or extra pyrimidal condition
hypotonia = lower motor neuron lesion
upper limb:
nerves to remember for myotomes (power) and dermatomes (sensation)
(same as where pinpricking should happen)
C5- upper, outer arm
C6- lower outer arm, thumb and index finger
C7- middle finger
C8- ring finger and pinky
T1- inner forearm
(T2- small portion of upper inner arm and armpit)
nerves for arm reflexes
- Biceps- C5/6
- Supinator- C6
- Triceps- C7
lower limb:
nerves to remember for myotomes (power) and dermatomes (sensation)
(same as where pinpricking should happen)
L2- upper thigh
L3- middle leg- over knee
L4- backs of calves
L5- shins and top of foot
S1- heel and smallest 2 toes
nerves for leg reflexes
- Knee- L3, L4
- Ankle- S1
tip for when testing power
always support joint just above joint being testes
power on hand: what nerves are tested for each bit x5
straight fingers-
extension = radial nerve
flexion = C8
intrinsic (spread fingers)- ulnar
thumb- median
grip- median and ulnar
pronator drift- hemisphere problem
cranial nerve overview
CN I- ask about smell
CN II-
a) ask about sight or snellen chart
b) pupil response
c)fields
d)fields no movement
e) pen to nose)
f) fundoscopy
CN III, CN IV, CN VI-
a)inspection
b) finger H shape
CN V-
a) cotton wool and prick on forehead, cheek and lower jaw
b) palpate masseter and open jaw against resistance
c) touch cornea with cotton wool
CN VII-
a) inspection- asymmetry
b) face movements
CN VIII-
rinnes/webbers and whisper test
CN IX, CN X-
a) “ahh”
b) cough
c) gag
CN XI-
a) shrug
b) turn face and push
CN XII-
a) inspection
b) tongue into each cheek
c) days of the week
what cranial nerves are tested together
3, 4, 6 - eye movement
9 and 10- throat
Testing cranial nerves: CN I
easy- just ask if any loss
Testing cranial nerves: CN II x6
- visual acuity:
-Ask about any problems with sight
-can use eye chart or book - pupil responses:
-get patient to look at a fixed point
shine light in the eye- direct response
-look at other (non shine) eye- indirect or consensual response
- fields
-sit at same level
-get patient to cover their right eye
-cover your left eye
-bring hand from edge of your periphery to theres on 4 corners
-get them to tell you when they can see it
- inattention:
-hold both hands out within fields
-ask patient to say which hand is moving
-once both sides done wiggle both
-repeat for upper and lower
- accommodation:
-ask to look at tip of pen or finger
-hold pen of finger away and move towards nose
-pupils should constrict as the eyes converge. - fundoscopy- see other
fundoscopy x2
Use your right eye and right hand to examine patient’s right eye and
your left eye and left hand for patient’s left eye
- red reflex
set to 0
at about 30cm look to see red
no red = cataracts - positioning
Right- right of patient
Left- left of patient
-“look at distant object”
- set dial to 0
- knuckled to cheek
findings on fundoscopy x4
- Optic Disc
-shape
-colour
-definition of edges/rim - Vessels
-twisty
-congested,
-arteriovenous nipping- arteries constrict veins at crossings - Retina Observe
colour
haemorrhages
exudates
detachment
tears. - Macula Ask patient to look directly at the beam of light just before finishing looking
at that eye
testing cranial nerves: CN III, IV, VI x2
- inspection
- ptosis
- abnormal gaze - keep head still and follow fingers in an H pattern
- “any double vision”
- look for nystagmus
testing cranial nerves: CN V x3
- sensation
- eyes closed
- cotton wool then neurotip
- forehead, cheek,jaw “saw when u feel something” - motor
Palpate the masseter
ask patient to clench their teeth
open jaw against resistance to test pterygoid muscles.
- corneal reflex
look up to the LEFT and touch the cornea of the RIGHT eye on the lateral side with a wisp of cotton wool.
repeat
blink should be on both sides
testing cranial nerves CN VII x2
- inspection
facial symmetry - face movements
-wrinkle their forehead
-screw up their eyes
-smile/show their teeth.
-puff out their cheeks, then press gently
testing cranial nerves CN VIII x2
- nystagmus and balanced normally already tested
- hearing
- rinnes and webers
-whisper
whisper voice test
- Stand 60 cm behind from the ear being tested
while masking the other ear by gently rubbing the tragus.
in a normal voice say a series of sounds (letters + numbers) and ask the patient to repeat
-repeat using a whispered voice at 60 cm
-If not heard repeat at a distance of 15 cm using a normal voice
-and if this is not heard then escalate to a loud voice at same distance.
testing cranial nerves CN IX, X x3
- inspection
get patient to open mouth and say “ahh”
palate should move symmetrically and uvula should stay central
- cough
get patient to cough and listen to see if it sounds normal - gag reflex
touch the side of the throat
on each side, one at a time
look for reflex contraction of the pharyngeal muscles
testing cranial nerves: CN XI x2
- trapezius
feel shrugging shoulders- feel for contraction of trapezius - sternocleidomastoid
-turn their head to one side
watch for contralateral muscle contract.
The patient should then
push against the side of your fist with their face.
testing cranial nerves: CN XII x3
Inspection:
-open mouth
- look for fasciculation, wasting or deviation
motor:
-get patient to push tongue in each cheek
-and move side to side
speech:
- say days of the week
