Nervous system exam

1. NERVOUS SYSTEM
EXAMINATION
Dr. Shahin Akter Nipa
MD (Phase A) Resident , Internal Medicine
Chittagong Medical College & Hospital

2. Nervous System Definition
The nervous system is the part
of body that coordinates its
action and transnmits signals
to and from different parts of
the body.

3. NERVOUS SYSTEM
 CENTRAL NERVOUS SYSTEM
 BRAIN
 SPINAL CORD
 PERIPHERAL NERVOUS SYSTEM
 CRANIAL NERVES---12 pairs
 SPINAL NERVES---31 pairs
• 8 CERVICAL
• 12 THORACIC
• 5 LUMBAR
• 5 SACRAL
• 1 COCCYGEAL
 AUTONOMIC NS
• SYMPATHETIC
• PARASYMPATHETIC

5. SYMPTOMS
(CANDIDATES FOR NS EXAMINATION)
 HEADACHE
 TRANSIENT LOSS OF CONCIOUSNESS (TLOC)
 TIA
 STROKE
 DIZZINESS
 VERTIGO
 FUNCTIONAL SYMTOMS

6. EQUIPMENTS for EXAMINATION
 pin
 Cotton
 Tunning fork
 Reflex hummer
 key
 Flashlight
 Ophthalmoscope
 Vision screeners
 Snellen chart
 Ishihara chart
 ophthalmoscope
 Gloves
 Coffee

8. COMPONENTS
1.Higher Mental function
2.Cranial nerves examination
3.Examination of Motor system
4.Examination of Sensory system
5.Sign of Meningeal Irritation

9. A.HIGHER
MENTAL
FUNCTION

10. 1. Appearnce & Behavior
 General elements- eg:attire,signs of self neglect
 Disturbed / Agitated/ Confused/ Apathetic
 Neat & Tidy/ Untidy
 Silent/ Monosyllabic/ Over Talkative
 Reaction to greeting
 Presence of Facial Tics/ Inappropiate Behavior

11. 2.Emotional state
Happy/ Distressed/Depressed/Irritable
Enjoy life/ Fed-up with life

12. 3. DELUSION AND HALLUCINATION
Dellusion : It is a false belief in
something which is not a fact.
Hallucination: It is a false perception
of some special senses without any
external object or stimulus.

13. 4. ORIENTATION IN PLACE AND TIME

15. 5.LEVEL OF CONSCIOUSNESS

16.  Coma: Coma is state in which the patient makes no
psychological meaninngful response to external
stimulus or to inner need.
 Stupor: Show some response for instance to painful
stimuli
 Dementia: Patient awake and alert but muddled in
time,place,and person and has impaired memory
and mental processing
 Delirium: Patient confused but alertness is
impaired

17. 6. Memory:
1. Recent memory:
 Day of the week
 Date in the month
2. Short term memory
 Memory for events of a few seconds or minutes past
 Test-repeat seven digits backwards
 Spell world backwards
3. Long Term Memory

18. 7. INTELLIGENCE
 General knowledge
 Abstraction
 Judgment
 Insight
 Reasoning

19. 8. SPEECH AND LANGUAGE
Listen to the patient’s spontaneous speech,
noting volume,rhythm and clarity.
Ask the patient to repeat phrases such as
‘yellow lorry’ to test lingual (tongue) sounds
and ‘baby hippopotamus’ for labial (lip)
sounds, then a tongue twister, e.g. ‘the Leith
police dismisseth us’.
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.

20. SPEECH AND LANGUAGE (continued…)
 During spontaneous speech, listen to the fluency and appropriateness of the
content, particularly for paraphasias and neologisms.
 Show the patient a common object, e.g. coin or pen, and ask its name.
 Give a simple three-stage command, e.g. pick up this piece of paper, fold it in
half and place it under the book.
 Ask the patient to repeat a simple sentence, e.g. ‘Today is Tuesday’.
 Ask the patient to read a passage from a newspaper.
 Ask the patient to write a sentence; examine his handwriting.

21. SPEECH AND LANGUAGE (continued…)
 Dysarthria is a motor speech disorder. It results from impaired
movement of the muscles used for speech production, including
the lips, tongue, vocal folds etc.
 Aphasia is an impairment of language, affecting the production or
comprehension of speech and the ability to read or write.
 Dysphasia is loss of or deficiency in the power to use or
understand language as a result of injury to or disease of the
brain.
 Dysphonia is commonly referred to as hoarse voice, refers to
dysfunction in the ability to produce voice due to laryngeal
disorder.

22. TYPES OF DYSPHAISIA:
1.EXPRESSIVE (MOTOR) DYSPHASIA:
Damage to broca’s area(inferior frontal region)
Decrease verbal output
Non fluent speech
Errors of grammer and syntax
Comprehension is intact

23. 2. RECEPTIVE (SENSORY) DYSPHASIA:
 Dysfunction in Wernicke’s area
 Poor comprehension
 Speech is fluent
 Meaningless
 Paraphasias(incorrect word)
 Neologisms(nonsense new words)

24. PARIETAL LOBE LESION:
Dyslexia:difficulty comprehending written language
Dysgraphia:impairement of writing
Apraxia: inability to carry out complex task despite having an
intact sensory and motor system
Agnosia:inability to interpret sensation
NONDOMINANT PARIETAL LOBE DYSFUNCTION:
Constructional apraxia:
Inability to copy accurately drawing of 3 dimensional
construction

25. Cranial Nerve Examination
 CN 1: Olfactory
 CN 2: Optic
 Visual acuity
 Visual fields
 Fundus
 CN 3: Oculomotor
 Pupil reactivity to light (direct and
consensual) and accomadation
 Extraocular eye movements (superior, medial
and inferior recti; inferior oblique)

26. Cranial Nerves (continued)
 CN 4: Trochlear
 Extraocular eye movements (superior
oblique)
 CN 5: Trigeminal
 Muscles of mastication
 Facial sensation (V1, 2, 3 divisions)
 CN 6: Abducens
 Extraocular eye movements (lateral rectus)

27. Cranial Nerves (continued)
 CN 7: Facial
Facial muscles
Taste (anterior 2/3)
 CN 8: Vestibulocochlear
Hearing
Vestibular function
 CN 9: Glossopharyngeal
Taste (posterior 1/3)
Uvula

28. Cranial Nerves (continued)
 CN 10: Vagus
Phonation
Palate elevation
 CN 11: Spinal accessory
Head turn
Shoulder shrug
 CN 12: Hypoglossal
Tongue protrusion

30. Cranial Nerve I
The Olfactory Nerve
 Each nostril should first be evaluated for
potency by compressing one nostril and
having the patient breath through the
opposite.
 Each nostril should then be tested
separately with a volatile, non-irritating
substance such as cloves, coffee or vanilla.
The patient should close his eyes, occlude
one nostril and identify the substance
placed under the open nostril.

31.  Causes of anosmia:
-upper RTI
-smoking,increasing age
- ethmoid tumor
-basal skull fracture,frontal fracture
- congenital-Kallmann’s syndrome
-meningioma
-following meningitis

32. Cranial nerve II
Visual Acuity
 Position yourself in front of the patient.
 Each eye separately covering one at a time .
 Snellen's chart is used

35. Cranial nerve II (continued)

37. Cranial nerve II (continued)
Colour Vision Test

38. Cranial nerve II (continued)
OPTHALMOSCOPIC EXAMINATION

40. Retinal abnormalities.
(A) Left optic atrophy. Note the lack of a pink
neuroretinal rim.
(B) Preretinal haemorrhage.
(C) Pale white swollen disc. This is highly suggestive of
giant cell arteritis, particularly if associated with visual
loss.
(D) Arteriolar occlusion of the horizontal nerve fibre
layer.
Multiple cotton-wool spots in human immunodeficiency
virus (HIV) retinopathy.
(E) Cytomegalovirus retinitis. Note the large superficial
retinal infiltrate associated with flame haemorrhage.
(F) Central retinal artery occlusion. Note the milky-white
pale infarcted retina surrounding healthy pink fovea
(‘cherry-red spot’).
(G) Central retinal vein occlusion. Note the widespread
retinal haemorrhages and swollen optic disc.
(H) Diabetic retinopathy with multiple dot and blot
haemorrhages, indicating widespread capillary
occlusion, a precursor of new vessel formation.

41. Cranial nerves II , III
Pupils: Reaction to Light
 Have the patient look at a distant object
 Look at size, shape and symmetry of
pupils.
 Shine a light into each eye and observe
constriction of pupil .
 Flash a light on one pupil and watch it
contract briskly .
 Flash the light again and watch the opposite
pupil constriction (consensual reflex)
 Repeat this procedure on the opposite eye.

42. PUPIL Abnormalities:
 DM:small pupil,responds poorly,due to
autonomic neuropathy
 Argyll Robertson pupil:
-in syphilis
-pinpoint,irregular pupil
-constrict only on convergence

43.  Holmes adie pupil:
mid dilated,bilateral
responds poorly to convergence
 Macus gunn pupil:
optic nerve damage result in afferent pupillary defect
both pupil contsrict to light

44. Cranial nerves III, IV and VI
Extraocular Muscles

45. Cranial nerves III, IV and VI (continued..)
Extraocular Muscles

46.  3rd nerve palsy
-unilateral ptosis(complete)
-pupil:large(loss of parasympathetic )
-eye look inferolaterally
cause:posterior communicating
artery aneurysm

47.  Horner’s syndrome:
-partial ptosis
-pupil:small(sympathetic loss)
-drooping eyelid
-decrease sweating

48.  Myasthenia Gravis:
bilateral ptosis

49. NYSTAGMUS:
1.Peripheral vestibular nystagmus:
-horizontal
-vertical
-rotatory

50. 2.CENTRAL VESTIBULAR NYSTAGMUS:
unidirectional
cause:-multiple sclerosis
-CVD

51. 3.VERTICAL NYSTAGMUS:
brain stem lesion
Upbeat :
upper brain stem lesion
multiple sclerosis
infarction
Wernicke’s encephalopathy

52.  Down beat:
Arnold chiari malformation
phenytoin /lithium intoxication

53. 4.PERIODIC ALTERNATING NYSTAGMUS:
Congenital
Drug intoxication
5.ATAXIC NYSTAGMUS:
Marked in abduction
Demyelination of medial longitudinal bundle
within brainstem

54. 6.CONGENITAL NYSTAGMUS
horizontal/pendular
7.ACQUIRED PENDULAR NYSTAGMUS
cerebellar/brainstem disease
multiple sclerosis
spinocerebellar degeneration
brainstem ischaemia

55. DIPLOPIA:
Pure horizontal: 6th CN palsy
Vertical diplopia: 4th CN palsy, Thyroid eye
disease

56. Cranial Nerve V

57. Cranial Nerve V (continued)
Sensory Examination

58. Cranial Nerve V (continued)

59. Cranial Nerve V (continued)

60. Cranial Nerve V (continued)
Jaw Jerk
 The mandible or lower jaw—is
tapped at a downward angle just
below the lips at the chin while the
mouth is held slightly open.
 In response, the masseter muscles
will jerk the mandible upwards.
 Normally this reflex is absent or
very slight.
 However in individuals with upper
motor neuron lesions the jaw jerk
reflex can be quite pronounced.

61. TRIGEMINAL NERVE EXAMINATION

62.  Unilateral loss of 5th nerve:
direct injury
facial fracture
local invasion by cancer

63.  Lesion in cavernous sinus:
loss of corneal reflex
V1 ,V2 sensory loss
3,4 ,6 CN also affected

64.  Trigeminal neuralgia
- due to neurovascular compression
-sevre lancinating pain in V2,V3
 Reactivation of VZV
affect any sensory nerve
 Brisk jaw jerk:
pseudobulbur palsy

65. Cranial Nerve VII
Facial Nerve

66. Cranial Nerve VII
Facial Nerve (continued)

67. Cranial Nerve VII
Facial Nerve (continued)
Sensory Function

68. Cause of LMN facial palsy
 cerebellopontine angle tumor
 Acoustic angle tumor
 Trauma
 Parotid tumour

69. Bilateral facial palsy:
 GBS
 Sarcoidosis
 Lyme disease
 HIV

70. Cranial Nerve VIII
Vestibulocochlear Nerve

71. Cranial Nerve IX and X
Glossopharyngeal & Vagus Nerve

72. Unilateral X nerve palsy(recurrent laryngeal)
 lung cancer
 post thyroid surgery
 mediastinal lymphoma
 aortic arch aneurysm

73. Bilateral X nerve lesion:
 Progressive bulbar palsy(MND)
 Bilateral supranuclear lesion(Pseudobulbur
palsy)
 CVD
 Multiple sclerosis

74. Unilateral IX and X lesion:
 Skull base tumor
 Skull base fracture
 Stroke(lateral medullary syndrome)

75. Cranial Nerve XI
Accessory Nerve
•Have patient shrug shoulder against resistance and evaluate strength
of Trapezius muscle.
•Have patient turn head to one side against resistance and evaluate
strength and observe contracting sternomastoid muscle

76. Cranial Nerve XII
Hypoglossal Nerve
 Ask the patient to move the tongue side to side in the mouth and feel the strength
 Ask the patient to open mouth and observe the tongue whether any atrophy or fasciculation
present or not.
 Ask the patient to protrude the tongue. Protruded tongue deviates to the side of lesion of 12th
nerve.