CNS Examination

Question 1

4 main aspects of the examination

Answer 1

limbs and gait
cranial nerves
fundoscopy
level of consciousness and higher functions

Question 2

parts of the limbs examination x7

Answer 2

observation

tone

power

coordination

reflexes

sensation

observation of gate

Question 3

limbs and gait examination : upper limb
1. observation

Answer 3

SWIFT

• Scars and Skeletal
  deformity
• Muscle wasting/
  atrophy
• Involuntary
  movements
• Fasciculation
• Tremor

Question 4

limbs and gait examination : upper limb
2. tone x5

Answer 4

1. ask if patient is in any pain
2. ask patient to relax arms
3. hold hand and elbow and bend elbow
4. hold hand and turn hand at wrist
5. hold hand and bend wrist

repeat on the other side
“no sign of hyper or hypotonia

Question 5

types of hypertonia: name for increased tone during fast movements

Answer 5

spasicity

Question 6

types of hypertonia: name for increased tone on slow muscle movements

Answer 6

rigidity

Question 7

limbs and gait examination : upper limb
3. power x8

Answer 7

1. shoulders: put elbows in the air “don’t let me push them down”
2. elbows: flex in front of chest “don’t let me push or pull”
3. wrists: make a fist and flex “don’t let me stop” flexion of extension
4. hands: hold fingers out straight, put my hand across “don’t let me stop” moving fingers up
5. intrinsic hands: spread fingers out “don’t let me push them in”
6. thumbs- push both sides
7. grip-squeeze my fingers
8. pronator drift- arms out, palms up close eyes 15s

test both sides

Question 8

Medical Research Council (MRC) Scale for power

Answer 8

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

Question 9

limbs and gait examination : upper limb
4. coordination x3

Answer 9

1. hold arms out- postural tremor or dystonia
2. 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

Question 10

limbs and gait examination : upper limb
4. reflexes x3

Answer 10

• 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

Question 11

limbs and gait examination : upper limb
5. sensation x3

Answer 11

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

2. pronator drift: hold hands out palms up. close eyes and wait

Question 12

limbs and gait examination: lower limbs
1. observation

Answer 12

same as before
SWIFT

• Scars and Skeletal
  deformity
• Muscle wasting/
  atrophy
• Involuntary
  movements
• Fasciculation
• Tremor

Question 13

limbs and gait examination: lower limbs
2. tone x3

Answer 13

ask if in any pain
relax legs

1. hip rotation- roll leg about
2. hip and knee flexion- pick knee up quickly, if heel stays on tone is normal
3. clonus- sharply flex the ankle up and see if theres any repeated beats

repeat on other side

Question 14

limbs and gait examination: lower limbs
3. power x4

Answer 14

• 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)

Question 15

limbs and gait examination: lower limbs
4. coordination

Answer 15

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

Question 16

limbs and gait examination: lower limbs
5. reflexes x3

Answer 16

• 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

Question 17

limbs and gait examination: lower limbs
6. sensation

Answer 17

1. pin prick and cotton swab:
   top of foot
   inner and outer calf
   inner and outer thigh
2. vibration- large tuning fork
   on big toe
   on sticky out bone of ankle
3. proprioception
   move toe up and down and ask patient
   large the small movements
4. proprioception 2- Romberg’s test
   patient to stand feet close together
   one arm in front and behind
   ask to close eyes

Question 18

limbs and gait examination: lower limbs
7. gait x4

Answer 18

1. normal walking- walk along side
   get patient to walk up a hallway, turn on the spot and come back
2. balance - walk along side
   as before but heel to toe
3. proximal lower limb power
   rise from a chair without using their arms
4. distal limb power you can ask the patient
   to walk on their heels and to stand on tip toes.

Question 19

Rinnes results meaning

Answer 19

air should be better than bone- positive test

if bone is better than air- conductive loss- negative test

Question 20

Webers result meaning

Answer 20

• sound should be equal
• louder in problem ear = conductive
  *louder in good ear = sensorineural

Question 21

causes of issues with tones

Answer 21

spasticity/hypertonia = upper motor neuron lesion

rigidity = parkinsonism or extra pyrimidal condition

hypotonia = lower motor neuron lesion

Question 22

upper limb:
nerves to remember for myotomes (power) and dermatomes (sensation)
(same as where pinpricking should happen)

Answer 22

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)

Question 23

nerves for arm reflexes

Answer 23

• Biceps- C5/6
• Supinator- C6
• Triceps- C7

Question 24

lower limb:
nerves to remember for myotomes (power) and dermatomes (sensation)
(same as where pinpricking should happen)

Answer 24

L2- upper thigh
L3- middle leg- over knee
L4- backs of calves
L5- shins and top of foot
S1- heel and smallest 2 toes

Question 25

nerves for leg reflexes

Answer 25

* Knee- L3, L4 * Ankle- S1

Question 26

tip for when testing power

Answer 26

always support joint just above joint being testes

Question 27

power on hand: what nerves are tested for each bit x5

Answer 27

straight fingers- extension = radial nerve flexion = C8 intrinsic (spread fingers)- ulnar thumb- median grip- median and ulnar pronator drift- hemisphere problem

Question 28

cranial nerve overview

Answer 28

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

Question 29

what cranial nerves are tested together

Answer 29

3, 4, 6 - eye movement 9 and 10- throat

Question 30

Testing cranial nerves: CN I

Answer 30

easy- just ask if any loss

Question 31

Testing cranial nerves: CN II x6

Answer 31

1. visual acuity: -Ask about any problems with sight -can use eye chart or book 2. 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 3. 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 4. 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 5. 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. 6. fundoscopy- see other

Question 32

fundoscopy x2

Answer 32

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 1. red reflex set to 0 at about 30cm look to see red no red = cataracts 2. positioning Right- right of patient Left- left of patient -"look at distant object" - set dial to 0 - knuckled to cheek

Question 33

findings on fundoscopy x4

Answer 33

* 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

Question 34

testing cranial nerves: CN III, IV, VI x2

Answer 34

1. inspection - ptosis - abnormal gaze 2. keep head still and follow fingers in an H pattern - "any double vision" - look for nystagmus

Question 35

testing cranial nerves: CN V x3

Answer 35

1. sensation - eyes closed - cotton wool then neurotip - forehead, cheek,jaw "saw when u feel something" 2. motor Palpate the masseter ask patient to clench their teeth open jaw against resistance to test pterygoid muscles. 3. 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

Question 36

testing cranial nerves CN VII x2

Answer 36

1. inspection facial symmetry 2. face movements -wrinkle their forehead -screw up their eyes -smile/show their teeth. -puff out their cheeks, then press gently

Question 37

testing cranial nerves CN VIII x2

Answer 37

1. nystagmus and balanced normally already tested 2. hearing - rinnes and webers -whisper

Question 38

whisper voice test

Answer 38

- 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.

Question 39

testing cranial nerves CN IX, X x3

Answer 39

1. inspection get patient to open mouth and say "ahh" palate should move symmetrically and uvula should stay central 2. cough get patient to cough and listen to see if it sounds normal 3. gag reflex touch the side of the throat on each side, one at a time look for reflex contraction of the pharyngeal muscles

Question 40

testing cranial nerves: CN XI x2

Answer 40

1. trapezius feel shrugging shoulders- feel for contraction of trapezius 2. 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.

Question 41

testing cranial nerves: CN XII x3

Answer 41

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