central nervous system (cns) examination

Examination of Nervous Examination of Nervous SystemSystem

Compiled by: Dr.Ankit Srivastava Compiled by: Dr.Ankit Srivastava B.H.M.S. (Gold Medalist)B.H.M.S. (Gold Medalist)

Email: [email protected]: [email protected]/02/23Dr.Ankit Srivastava Email:

[email protected] 1

NERVOUS SYSTEMNERVOUS SYSTEM• CNSCNS

Brain Spinal Brain Spinal CordCord

• PNSPNS

Somatic Somatic AutonomicAutonomic

12 CN12 CN 31 Spinal31 Spinal(In pairs)(In pairs)

Parasymp Parasymp Symp Symp

05/02/23Dr.Ankit Srivastava Email:

[email protected] 2

BRAINBRAIN


[email protected] 3

SPINAL CORDSPINAL CORD


[email protected] 4

CNS:- BRAINCNS:- BRAIN1.FOREBRAIN1.FOREBRAIN CerebrumCerebrum Lateral Lateral

VentricleVentricleThalamusThalamusHypothalamusHypothalamusMetathalamusMetathalamus Third ventricle Third ventricle EpithalamusEpithalamusSubthalamusSubthalamus

2.MIDBRAIN2.MIDBRAIN Crus cerebriCrus cerebriSubstantia NigraSubstantia NigraTegmentumTectTegmentumTectumum

3.HINDBRAIN3.HINDBRAIN Pons&CerebelluPons&Cerebellumm

Fourth VentricleFourth Ventricle

MedullaMedulla05/02/23Dr.Ankit Srivastava Email:

[email protected] 5


[email protected] 6

05/02/23 Dr.Ankit Srivastava Email: [email protected]

7

CEREBRUM-BROADMANN’S AREACEREBRUM-BROADMANN’S AREA


[email protected] 8

CEREBRUM FRONTAL LOBECEREBRUM FRONTAL LOBE

S/S/NN

AREAAREA FUNCTIONFUNCTION EFFECT OF EFFECT OF LESIONLESION

11 MOTOR MOTOR AREA-4AREA-4

voluntary voluntary activities of activities of opposite half of opposite half of bodybody

Contralateral Contralateral paralysisparalysis

22 PREMOTOPREMOTOR 6R 6

extrapyramidal extrapyramidal systemsystem

33 FRONTAL FRONTAL EYEFIELD EYEFIELD 6,86,8

Hz movements of Hz movements of eyeeye

Movements are Movements are lostlost

44 Motor Motor speech speech 44,4544,45

Spoken speechSpoken speech Aphasia Aphasia

55 Prefrontal Prefrontal Emotion, Emotion, concentration concentration attention & attention & judgementjudgement

Loss of orientationLoss of orientation05/02/23Dr.Ankit Srivastava Email:

[email protected] 9

PARIETAL LOBEPARIETAL LOBES/S/NN


11 Sensory Sensory area area 3,1,23,1,2

Perception Perception of touch, of touch, pain, pain, temperaturtemperature e

Loss of Loss of appreciatioappreciation of n of impulses impulses receivedreceived

22 Parietal Parietal areaarea

StereognosiStereognosis & sensory s & sensory speechspeech

AstereognosAstereognosis & aphasiais & aphasia


[email protected] 10

OCCIPITAL LOBEOCCIPITAL LOBES/S/NN


11 VISUO-VISUO-SENSORY SENSORY AREA 17AREA 17

Perception of Perception of visual visual impression of impression of color size color size motionmotion

Homonymous Homonymous hemianopiahemianopia

22 VISUO-VISUO-PSYCHIC PSYCHIC 18,1918,19

Correlation of Correlation of visual visual impulses with impulses with past memory past memory & recognition & recognition of object seenof object seen

Visual Visual agnosiaagnosia



TEMPORAL LOBETEMPORAL LOBES/NS/N AREAAREA FUNCTIONFUNCTION EFFECT OF EFFECT OF

LESIONLESION11 AUDITO-AUDITO-

SENSORY SENSORY AREA 41 AREA 41 4242

Perception of Perception of auditory auditory impression of impression of loudness, loudness, quality & pitchquality & pitch

Impaired Impaired hearinghearing

22 AUDITO-AUDITO-PSYCHIC PSYCHIC AREA 22AREA 22

Correlation of Correlation of auditory auditory impression impression with past with past memory and memory and identification identification of sound heardof sound heard

Auditory Auditory agnosiaagnosia



THALAMUSTHALAMUS FUNCTIONSFUNCTIONSIt is a major station where all specific sensory impulses It is a major station where all specific sensory impulses

(excepting smell) relay before finally terminating in (excepting smell) relay before finally terminating in the cerebral cortex like hippocampal, visceral, the cerebral cortex like hippocampal, visceral, straital, cerebellar, extroception & taste impulsestraital, cerebellar, extroception & taste impulse

LESIONLESION Lesion of thalamus cause impairement of all type of Lesion of thalamus cause impairement of all type of

sensibillities sensibillities joint sense being the most affected.joint sense being the most affected.

THALAMIC SYNDROMETHALAMIC SYNDROMEIt is characterized by disturbance of sensation, It is characterized by disturbance of sensation,

hemiplegia emotional disturbance ,weakness and hemiplegia emotional disturbance ,weakness and tremor. tremor.



THALAMUSTHALAMUS



HYPOTHALAMUSHYPOTHALAMUS

• FUNCTIONSFUNCTIONS

1.ENDOCRINE CONTROL- It regulates secretion of 1.ENDOCRINE CONTROL- It regulates secretion of TSH, ACTH, LH, FSH, Somatotropin, prolactin.TSH, ACTH, LH, FSH, Somatotropin, prolactin.

2.NEUROSECRETION- Oxytocin, 2.NEUROSECRETION- Oxytocin, vasopressin(ADH)vasopressin(ADH)

3.GENERAL AUTONOMIC EFFECT- It controls 3.GENERAL AUTONOMIC EFFECT- It controls cvs,respiratory & Elementry function.cvs,respiratory & Elementry function.



4.TEMPERATURE REGULATION-It maintains a balance 4.TEMPERATURE REGULATION-It maintains a balance between heat production & heat loss between heat production & heat loss

5.REGULATION OF FOOD & WATER INTAKE5.REGULATION OF FOOD & WATER INTAKE

6.SEXUAL BEHAVIOUR & REPRODUCTION-Through 6.SEXUAL BEHAVIOUR & REPRODUCTION-Through control of ant pituitary it controls gametogenesis, control of ant pituitary it controls gametogenesis, uterine, ovarian cycle, maturation & maintenance of uterine, ovarian cycle, maturation & maintenance of secondary sexual characterstics.secondary sexual characterstics.

7.BIOLOGICAL CLOCKS- Wakefulness & sleep is 7.BIOLOGICAL CLOCKS- Wakefulness & sleep is maintained by it.maintained by it.

8. EMOTIONS.,FEAR, RAGE, AVERSION, PLEASURE & 8. EMOTIONS.,FEAR, RAGE, AVERSION, PLEASURE & REWARD all these controlled by hypothalamusREWARD all these controlled by hypothalamus



LESION OF LESION OF HYPOTHALAMUSHYPOTHALAMUS

• ObesityObesity• Hyperglycaemia & glycosureaHyperglycaemia & glycosurea• Autonomic epilepsy which is characterized Autonomic epilepsy which is characterized

by flushing, sweating, salivation, by flushing, sweating, salivation, lachrimation, tachycardia, retardation of lachrimation, tachycardia, retardation of respiratory rate, unconsciousness.respiratory rate, unconsciousness.

• Sexual disturbance- precocity or impotenceSexual disturbance- precocity or impotence• Disturbance of sleep-somnolence(persistent Disturbance of sleep-somnolence(persistent

sleep) or narcolepsy (paroxysmal sleep)sleep) or narcolepsy (paroxysmal sleep)• Acute ulceration in the upper part of Acute ulceration in the upper part of

gastrointestinal tractgastrointestinal tract05/02/23Dr.Ankit Srivastava Email:


BASAL GANGLIABASAL GANGLIA FUNCTIONFUNCTION It regulates muscle tone, posture & helps It regulates muscle tone, posture & helps

in smoothering voluntary movements.in smoothering voluntary movements. It controls automatic associated It controls automatic associated

movements, like the swinging of arms movements, like the swinging of arms during walking. It coordinated during walking. It coordinated movements of different parts of the bodymovements of different parts of the body

It is required to initiate voluntary It is required to initiate voluntary movements.movements.

Presence of healthy basal ganglia Presence of healthy basal ganglia inhibits the appearance of tremorinhibits the appearance of tremor



LESION OF BASAL LESION OF BASAL GANGLIA GANGLIA

• Damage of basal ganglia is cause Damage of basal ganglia is cause PARKINSONISMPARKINSONISM

• +VE SIGN-+VE SIGN-

• Rigidity- hypertonia of flexors & extensors of Rigidity- hypertonia of flexors & extensors of limb. It is a lead pipe rigidity.limb. It is a lead pipe rigidity.

• Tremor- Involuntary rhythmic alternating Tremor- Involuntary rhythmic alternating contraction of agonist & antagonist muscles of contraction of agonist & antagonist muscles of joints.Drum beating tremor.joints.Drum beating tremor.

Static tremor-tremor at rest but disappear while Static tremor-tremor at rest but disappear while attempts to do something -VE SIGN attempts to do something -VE SIGN



Patient is not inclined to initiate voluntary Patient is not inclined to initiate voluntary movements.movements.

Associated movements are reduced like-facial Associated movements are reduced like-facial expressions with changing emotions(masked expressions with changing emotions(masked facies) ,movements hand while walkingfacies) ,movements hand while walking

Posture – universally flexed attitude while Posture – universally flexed attitude while standingstanding

Gait – festinating gait-great tendency to falling Gait – festinating gait-great tendency to falling forward “as if catch his elusive centre of forward “as if catch his elusive centre of gravity” gravity” 05/02/23

Dr.Ankit Srivastava Email: [email protected] 22

CEREBELLUMCEREBELLUM• FUNCTIONSFUNCTIONSIt controls same side of body ie its It controls same side of body ie its

influence is ipsilateral. influence is ipsilateral. It coordinates voluntary movements It coordinates voluntary movements

so that they r smooth, balanced & so that they r smooth, balanced & accurate.accurate.

It mainly controls tone, posture, It mainly controls tone, posture, equilibrium.equilibrium.

05/02/23


LESION OF LESION OF CEREBELLUMCEREBELLUM

• Cerebellar damage causes cerebellar syndrome. It Cerebellar damage causes cerebellar syndrome. It may be due to thrombosis ,injury, tumor. Sign & may be due to thrombosis ,injury, tumor. Sign & symptoms divided into 2 groupssymptoms divided into 2 groups

• A. Voluntary motor activity signsA. Voluntary motor activity signs

DYSMETRIA-Patient fails to gauge exact degree of DYSMETRIA-Patient fails to gauge exact degree of contraction of the muscles needed.contraction of the muscles needed.

INTENTION TREMOR- no tremor at rest but on INTENTION TREMOR- no tremor at rest but on attempting to do something tremor appearsattempting to do something tremor appears



DYSARTHRIA-Defects in articulation while patient is DYSARTHRIA-Defects in articulation while patient is talking.talking.

NYSTAGMUS-Hz rhythmic oscillation of eyes.NYSTAGMUS-Hz rhythmic oscillation of eyes. DYSDIADOCHOKINESIA-Patient fail to perform rapid DYSDIADOCHOKINESIA-Patient fail to perform rapid

alternative movements like pronation & supination of alternative movements like pronation & supination of forearm.forearm.

B.TONE POSTURE EQUILIBRIUM SIGNB.TONE POSTURE EQUILIBRIUM SIGN HYPOTONIAHYPOTONIA Ability to balance is severely weakened. Ability to balance is severely weakened. Tilting the head towards the side of lesion. Tilting the head towards the side of lesion.



CNS EXAMINATIONCNS EXAMINATION

1.1. HIGHER FUNCTIONHIGHER FUNCTION2.2. CRANIAL NERVESCRANIAL NERVES3.3. MOTOR SYSTEMMOTOR SYSTEM4.4. SENSORY SYSTEMSENSORY SYSTEM5.5. REFLEXESREFLEXES



1. HIGHER FUNCTIONS1. HIGHER FUNCTIONS

• CONSCIOUSNESSCONSCIOUSNESS• BEHAVIORBEHAVIOR• INTELLIGENCEINTELLIGENCE• MEMORYMEMORY• EMOTIONSEMOTIONS• ORIENTATION IN ORIENTATION IN

TIME,PLACE,PERSONTIME,PLACE,PERSON• HALLUCINATION,DELUSIONHALLUCINATION,DELUSION• LANGUAGE, SPEECHLANGUAGE, SPEECH



CONSCIOUSNESSCONSCIOUSNESS• It is a state of awareness of one’s self & It is a state of awareness of one’s self &

one’s environment.one’s environment. SLEEPSLEEP CATATONIA- Psychosis,Frontal lobe CATATONIA- Psychosis,Frontal lobe

lesion, lesion, hypothalamic lesionhypothalamic lesion AKINETIC MUTISM-Diencephalon & AKINETIC MUTISM-Diencephalon &

Brainstem lesionBrainstem lesion DROWSINESSDROWSINESS SEMICOMASEMICOMA COMACOMA



MEMORYMEMORYDEFECT INDEFECT INRegistration-Toxic state Registration-Toxic state DementiaDementia ManiaManiaRetention- Dementia,Retention- Dementia, Frontal lobe lesionFrontal lobe lesionRecall- Epilepsy,Recall- Epilepsy, Korskoff psychosis,Korskoff psychosis, HysteriaHysteria



EMOTIONAL STATEEMOTIONAL STATE• DEPRESSEDDEPRESSED• EUPHORIAEUPHORIA Incontinence of Emotions Incontinence of Emotions

presents inpresents in Pseodobulbar palsy Pseodobulbar palsy Multiple sclerosisMultiple sclerosis Dementia Dementia



ORIENTATION OF ORIENTATION OF TIME,PLACE,PERSONTIME,PLACE,PERSON

• Ask about the day,date,month, Ask about the day,date,month, year, time,time of day like year, time,time of day like morning,evening etcmorning,evening etc

• Ask about where he is-name the Ask about where he is-name the place, city where he livesplace, city where he lives

• Ask about himself or other person Ask about himself or other person in room, about relativesin room, about relatives



HALLUCINATION & HALLUCINATION & DELUSIONDELUSION

• Hallucination is perception of sensation in Hallucination is perception of sensation in the absence of any sensory stimulus. It may the absence of any sensory stimulus. It may be auditory, visual, olfactory, taste, tactile.be auditory, visual, olfactory, taste, tactile.

• Delusion is false beliefs which cannot be Delusion is false beliefs which cannot be corrected in spite of evidence.It may be corrected in spite of evidence.It may be

of grandeur,of grandeur, of poverty, of poverty, of nihilistic,of nihilistic, of love,of love, of infedility,of infedility, of influenceof influence



LANGUAGE & SPEECHLANGUAGE & SPEECH

• DYSPHAGIA-Difficulty in DYSPHAGIA-Difficulty in language function.It is due to language function.It is due to lesion in Broca’s area , lesion in Broca’s area , Wernicke’s area.Wernicke’s area.

• DYSARTHRIA-Indistinct speech DYSARTHRIA-Indistinct speech due to weakness of orolingual due to weakness of orolingual muscle concern with production muscle concern with production of consonant.of consonant.



B. CRANIAL NERVESB. CRANIAL NERVESS.S.NN

NAME OF NAME OF NERVENERVE

TYPETYPE PLACE OF PLACE OF NUCLEI NUCLEI

11 OLFACTORYOLFACTORY SENSORYSENSORY FOREBRAINFOREBRAIN

22 OPTICOPTIC SENSORYSENSORY FOREBRAINFOREBRAIN

33 OCULOMOTOROCULOMOTOR MOTOR+P.MOTOR+P.SS

MIDBRAINMIDBRAIN

44 TROCHLEARTROCHLEAR MOTORMOTOR MIDBRAINMIDBRAIN

55 TRIGEMINALTRIGEMINAL MIXEDMIXED PONSPONS

66 ABDUCENTABDUCENT MOTORMOTOR PONSPONS05/02/23


S.N.S.N. NAME OF NERVENAME OF NERVE TYPETYPE NUCLEINUCLEI

77 FACIALFACIAL MIXED+P.SMIXED+P.S PONSPONS

88 VESTIBULOCOCHLVESTIBULOCOCHLEAREAR

SENSORYSENSORY PONSPONS

99 GLOSSOPHARANGGLOSSOPHARANGEALEAL

MIXED+PSMIXED+PS MEDULLAMEDULLA

1010 VAGUSVAGUS MIXED+PSMIXED+PS MEDULLAMEDULLA

1111 ACCESSORYACCESSORY MOTORMOTOR MEDULLAMEDULLA

1212 HYPOGLOSSALHYPOGLOSSAL MOTORMOTOR MEDULLAMEDULLA05/02/23


1.OLFACTORY NERVE1.OLFACTORY NERVE

• Sense of smell from Sense of smell from nasal mucosa to brainnasal mucosa to brain

• Tested by asking the Tested by asking the patient to sniff various patient to sniff various non irritating substance non irritating substance each nostril seperatelyeach nostril seperately

• Lesion of nerve may Lesion of nerve may cause cause

anosmia, anosmia, parosmia, parosmia, cacosmiacacosmia



2.OPTIC NERVE2.OPTIC NERVE

• Bringing visual Bringing visual sense from retina sense from retina to brainto brain

• 3 tests 3 tests Visual acquity,Visual acquity, Visual field,Visual field, Color visionColor vision



6060 36 36 24 24 18 1812 12

996655



PSEUDOISOCHROMATIC PSEUDOISOCHROMATIC ISHIHARA PLATEISHIHARA PLATE



3.OCULOMOTOR 3.OCULOMOTOR 4.TROCHLEAR4.TROCHLEAR6.ABDUCENT6.ABDUCENT

• All 3 nerves All 3 nerves control control extraocular as extraocular as well as well as intraocular intraocular muscles.muscles.

• SO4SO4• LR6LR6

SNSN MUSCLE NAMEMUSCLE NAME NERVE NERVE SUPPLYSUPPLY

11 Lateral RectusLateral Rectus AbducentAbducent22 Medial RectusMedial Rectus OculomotOculomot

oror33 Superior RectusSuperior Rectus OculomotOculomot

oror

44 Inferior RectusInferior Rectus OculomotOculomotoror

55 Superior Superior ObliqueOblique

TrochlearTrochlear

66 Inferior ObliqueInferior Oblique OculomotOculomotoror

77 Levator Levator Palpabrae Palpabrae SuperiorisSuperioris

OculomotOculomotoror



EXTA OCULAR MUSCLESEXTA OCULAR MUSCLES



3.OCULOMOTOR3.OCULOMOTOR• Somatic –external muscles of eyeSomatic –external muscles of eye• P S- smooth muscles of pupil ,ciliary P S- smooth muscles of pupil ,ciliary

body of eyebody of eyeComplete paralysis of 3Complete paralysis of 3rdrd nerve nerve Ptosis,Ptosis, Diplopia,Diplopia, Lateral squint,Lateral squint, Downward deviation,Downward deviation, Dilatation of pupil,Dilatation of pupil, Slight proptosis,Slight proptosis, Loss of accomodation Loss of accomodation 05/02/23


PTOSISPTOSIS



4.TROCHLEAR4.TROCHLEAR

• Supplies superior oblique. It cause Supplies superior oblique. It cause downward movement,lateral downward movement,lateral movement, & intorsion.movement, & intorsion.

Complete paralysis of 4Complete paralysis of 4thth nerve nerve causescauses

Medial squint,Medial squint,Upward deviation of eyeball,Upward deviation of eyeball,Diplopia-only below hz planeDiplopia-only below hz plane



6.ABDUCENT6.ABDUCENT

• Supplies Lateral Rectus. It cause Supplies Lateral Rectus. It cause only abduction of eye.only abduction of eye.

Complete paralysis of 6Complete paralysis of 6thth nerve nerve causecause

Medial squintMedial squintDiplopia Diplopia



5.TRIGEMINA5.TRIGEMINALL

• Motor-Muscle of Motor-Muscle of masticationmastication

• Sensory-From face, Sensory-From face, mouth cavity, mouth cavity, conjunctiva conjunctiva

• 3 Branches-3 Branches-Ophthalmic,Maxillary, Ophthalmic,Maxillary, MandibularMandibular

• Test-By clench the Test-By clench the teethteeth

By open mouthBy open mouth By corneal By corneal reflexssssssssreflexssssssss



7.FACIAL7.FACIAL• Motor-Muscle of facial expressionMotor-Muscle of facial expression• Sensory-Taste sensation of ant 2/3 of Sensory-Taste sensation of ant 2/3 of

tonguetongue• P S-Submandible,Sublingual,Lachrimation P S-Submandible,Sublingual,Lachrimation

glands glands• TestTest Motor function can be tested by Motor function can be tested by

inspection of facial expression & facial inspection of facial expression & facial mobilitymobility

Sensory function can be tested by asking Sensory function can be tested by asking the different taste of ant 2/3 of the tongue. the different taste of ant 2/3 of the tongue.



Motor function test of facial nerveMotor function test of facial nerveS/S/NN

TESTTEST MUSCLE MUSCLE USEDUSED

RESULT DUE RESULT DUE TO LESIONTO LESION

11 Ask to raise Ask to raise eyebroweyebrow

OccipitaliOccipitaliss

Wrinkling is Wrinkling is lostlost

22 Wrinkle the Wrinkle the browbrow

CorrugatoCorrugator r supercillisupercilli

Frowning of Frowning of forehead is forehead is lostlost

33 Close the eyesClose the eyes OrbiculariOrbicularis oculis oculi

Involuntary Involuntary blinking is blinking is lostlost

44 Showing teeth Showing teeth & whistling& whistling

OrbiculariOrbicularis oriss oris

Whistling is Whistling is lostlost

55 Blow out Blow out cheekscheeks

BuccinatoBuccinatorr

Cheeks puffs Cheeks puffs out out

66 Retract the Retract the chinchin

PlatysmaPlatysma Retraction Retraction lostlost



FACIAL PALSY(BELL’S PALSY)FACIAL PALSY(BELL’S PALSY)• Infranuclear lesion of facial nerve known Infranuclear lesion of facial nerve known

as Bell’s Palsy,the whole of the face of the as Bell’s Palsy,the whole of the face of the same side gets paralysed.same side gets paralysed.

Assymetry of face,Assymetry of face, Affected side is motionless,Affected side is motionless, Wrinkles is lost,Wrinkles is lost, Flattening of nasolabial fold,Flattening of nasolabial fold, Any attempt to smile draws the mouth to Any attempt to smile draws the mouth to

the normal side,the normal side, During mastication food accumulates During mastication food accumulates

between the teeth & cheek,between the teeth & cheek, Dribbling of saliva through angle of mouthDribbling of saliva through angle of mouth05/02/23


8.VESTIBULOCOCHLEAR8.VESTIBULOCOCHLEAR1.Cochlear-Hearing1.Cochlear-Hearing2.Vestibular-Equilibrium2.Vestibular-EquilibriumTest for Cochlear functionTest for Cochlear functionBy TICK-TICK of watch at each ear.If By TICK-TICK of watch at each ear.If

impairment of hearing than following impairment of hearing than following test r done to determine whether the test r done to determine whether the disease is of vestibulocochlear system or disease is of vestibulocochlear system or from middle ear disease.from middle ear disease.

RINNE’S TESTRINNE’S TESTWEBER TESTWEBER TEST



RINNE’S TESTRINNE’S TEST

• Vibrating tuning fork is placed in Vibrating tuning fork is placed in front of ear & than mastoid bonefront of ear & than mastoid bone

• Normal- AC>BCNormal- AC>BC• Conductive Deafness- BC>ACConductive Deafness- BC>AC• Nerve Deafness- AC>BC but both Nerve Deafness- AC>BC but both

r r depressed depressed



WEBER’S TESTWEBER’S TEST• Vibrating tuning fork is placed on Vibrating tuning fork is placed on

forehead.forehead.• Normally vibration r equally both side.Normally vibration r equally both side.• Conductive Deafness-better diseased Conductive Deafness-better diseased

side because external sound side because external sound interfering with the vibration is less interfering with the vibration is less on affected side.on affected side.

• Sensorineural deafness-better on Sensorineural deafness-better on healthy side. healthy side.



9 GLOSSOPHARYNGEAL9 GLOSSOPHARYNGEAL• MIXED NERVE+ PS FIBERSMIXED NERVE+ PS FIBERS• SENSORY-Taste over the posterior one third SENSORY-Taste over the posterior one third

of the tongue.of the tongue.• MOTOR-Middle constrictor of pharynx andMOTOR-Middle constrictor of pharynx and stylopharyngeus muscle-responsible for gag stylopharyngeus muscle-responsible for gag

responseresponse• Test-GAG REFLEX Test-GAG REFLEX stimulation of posterior pharyngeal wall by stimulation of posterior pharyngeal wall by

cotton applicator results in elevation and cotton applicator results in elevation and constriction of pharyngeal musculature and constriction of pharyngeal musculature and retraction of tongue.retraction of tongue.



10 VAGUS10 VAGUS• MIXED+PSMIXED+PS• MOTOR-Soft palate, pharynx and MOTOR-Soft palate, pharynx and

larynxlarynx• Sensory & motor-viscera of thorax & Sensory & motor-viscera of thorax &

upper abdomenupper abdomen• TEST-TEST-• Ask to open the mouth & say ‘ah’& Ask to open the mouth & say ‘ah’&

palatal movement & uvula is noted palatal movement & uvula is noted • If paralysis then uvula is deviated to If paralysis then uvula is deviated to

normal sidenormal side



11 ACCESSORY11 ACCESSORY• MOTOR- Pharynx & larynx, trapezius, MOTOR- Pharynx & larynx, trapezius,

sternomastoidsternomastoid• TESTTEST Trapezius-Ask the patient to shrug Trapezius-Ask the patient to shrug

his shoulder against downward his shoulder against downward resistanceresistance

Sternomastoid- Ask the patient to Sternomastoid- Ask the patient to rotate his chin to the opposite siderotate his chin to the opposite side

-If paralysis chin is deviated to the -If paralysis chin is deviated to the opposite sideopposite side



12 HYPOGLOSSAL 12 HYPOGLOSSAL • MOTOR-Muscle of tongueMOTOR-Muscle of tongue• Test Test Tongue should be observe at rest & Tongue should be observe at rest &

on protrusion, various movement r on protrusion, various movement r notednoted

If paralysis tongue is deviated to If paralysis tongue is deviated to affected sideaffected side

If bilateral than dysphagia, dyspnea & If bilateral than dysphagia, dyspnea & dysarthriadysarthria



C. MOTOR SYSTEMC. MOTOR SYSTEM• BULK OF MUSCLESBULK OF MUSCLES• STRENGTH OF MUSCLESSTRENGTH OF MUSCLES• TONE OF MUSCLESTONE OF MUSCLES• GAITGAIT• INVOLUNTARY MOVEMENTSINVOLUNTARY MOVEMENTS



1. BULK OF MUSCLES1. BULK OF MUSCLES• HYPERTROPHY-Muscles r enlarge from HYPERTROPHY-Muscles r enlarge from

their normal sizetheir normal size In muscular dystrophy-large muscles In muscular dystrophy-large muscles

may develop esp calves, buttocksmay develop esp calves, buttocks HYPOTROPHY-Wasting of musclesHYPOTROPHY-Wasting of muscles Wasted muscles r small, soft, flabbyWasted muscles r small, soft, flabby If wasting is associated with fibrosis If wasting is associated with fibrosis

muscles feel hard, inelastic & muscles feel hard, inelastic & shortenedshortened



HYPERTROPHY OF HYPERTROPHY OF MUSCLESMUSCLES



2.STRENGTH OF 2.STRENGTH OF MUSCLESMUSCLES

• UPPER LIMBUPPER LIMB Abductors of Abductors of

fingersfingers Adductors of Adductors of

fingers fingers Flexors of fingersFlexors of fingers Flexors of wrist Flexors of wrist Extensors of wristExtensors of wrist BrachioradialisBrachioradialis

BicepsBiceps DeltoidDeltoid InfraspinatusInfraspinatus PectoralsPectorals Serratus anteriorSerratus anterior Latassimus dorsiLatassimus dorsi



ABDUCTORS OF ABDUCTORS OF FINGERSFINGERS



ADDUCTORS OF ADDUCTORS OF FINGERSFINGERS



FLEXORS OF WRISTFLEXORS OF WRIST



EXTENSORS OF WRISTEXTENSORS OF WRIST



SERRATUS ANTERIORSERRATUS ANTERIOR



LATASSIMUS DORSILATASSIMUS DORSI



• LOWER LIMBLOWER LIMB

Dorsiflexion & planter flexion of feet & Dorsiflexion & planter flexion of feet & toes toes

Flexors of kneeFlexors of kneeExtensors of knee Extensors of knee Flexors of hipFlexors of hipExtensors of hipExtensors of hipAbductors of thighAbductors of thighAdductors of thighAdductors of thighRotators of thighRotators of thigh



DORSIFLEXION OF FOOTDORSIFLEXION OF FOOT



PLANTERFLEXION OF FOOTPLANTERFLEXION OF FOOT



FLEXORS OF KNEEFLEXORS OF KNEE



EXTENSORS OF KNEEEXTENSORS OF KNEE



ADDUCTORS OF THIGHADDUCTORS OF THIGH



ABDUCTORS OF THIGHABDUCTORS OF THIGH



FLEXORS OF HIPFLEXORS OF HIP



EXTENSORS OF HIPEXTENSORS OF HIP



Medical Research Council Medical Research Council Scale for grading muscle Scale for grading muscle

functionfunction• GRADEGRADE• 0 - Complete paralysis0 - Complete paralysis• 1 - A flicker of contraction only1 - A flicker of contraction only• 2 - Power detectable only when gravity is 2 - Power detectable only when gravity is

excluded excluded by appropriate postural adjustment by appropriate postural adjustment• 3 - The limb can be held against the force of 3 - The limb can be held against the force of

gravity, gravity, but not against the examiner’s but not against the examiner’s resistanceresistance

• 4 - There is some degree of weakness, usually 4 - There is some degree of weakness, usually described as poor, fair, or moderate described as poor, fair, or moderate strengthstrength

• 5 - Normal power is present5 - Normal power is present05/02/23


3. TONE OF MUSCLES3. TONE OF MUSCLES•TONE is the resistance TONE is the resistance

offered by normal muscles offered by normal muscles to passive movements. It to passive movements. It is greatest in muscles is greatest in muscles which maintain posture ie which maintain posture ie antigravity muscles-flexors antigravity muscles-flexors in upper limb & extensors in upper limb & extensors of lower limbof lower limb



• HYPOTONIA-HYPOTONIA-• It is characterized by flabby muscles It is characterized by flabby muscles

which offer less resistance to passive which offer less resistance to passive movements, leading to an increased movements, leading to an increased range of passive movements & limb range of passive movements & limb is unable to maintain posture is unable to maintain posture

CAUSESCAUSES 1 . Lower motor neuron disease-1 . Lower motor neuron disease-

Poliomyelitis, Poliomyelitis, peripheral peripheral neuritis, tabes dorsalisneuritis, tabes dorsalis

2 . Cerebeller disease2 . Cerebeller disease 3 . Rheumatic chorea3 . Rheumatic chorea05/02/23


• HYPERTONIA-HYPERTONIA-• It is characterized by It is characterized by

increased resistance increased resistance to passive to passive movements & movements & increased firmness increased firmness on palpationon palpation

• CAUSESCAUSES Pyramidal disorderPyramidal disorder Extrapyramidal Extrapyramidal

disorderdisorder TetanusTetanus Strychnine poisoningStrychnine poisoning

• TYPESTYPES• Clasp knife Clasp knife

spasticityspasticity• Lead pipe Lead pipe

rigidityrigidity• Cog wheel Cog wheel

rigidityrigidity• HystericalHysterical• Reflex rigidityReflex rigidity• Myotonia Myotonia



4.GAIT4.GAIT• CAUSESCAUSES• UPPER MOTOR UPPER MOTOR

NEURON DISEASENEURON DISEASE• LOWER MOTOR LOWER MOTOR

NEURONE NEURONE DISEASEDISEASE

• CEREBELLAR CEREBELLAR SYNDROMESYNDROME

• EXTRAPYRAMIDAEXTRAPYRAMIDAL SYNDROMEL SYNDROME

• TYPESTYPES• SPASTIC GAITSPASTIC GAIT• STAMPING GAITSTAMPING GAIT• REELING GAITREELING GAIT• FESTINANT FESTINANT

GAITGAIT• WADDLING GAITWADDLING GAIT



5 CORDINATION OF 5 CORDINATION OF MUSCLESMUSCLES

• 1. ROMBERG’S TEST1. ROMBERG’S TEST• 2. TANDEM WALKING2. TANDEM WALKING• 3. FINGER NOSE TEST3. FINGER NOSE TEST• 4. FINGER TO FINGER TEST4. FINGER TO FINGER TEST• 5. FOR DYSDIADOCHOKINESIA5. FOR DYSDIADOCHOKINESIA• 6. POSTURAL HOLDING IN 6. POSTURAL HOLDING IN

UPPERLIMBUPPERLIMB• 7. KNEE-HEEL TEST7. KNEE-HEEL TEST05/02/23


6.INVOLUNTARY 6.INVOLUNTARY MOVEMENTSMOVEMENTS

• A.TREMOR-A.TREMOR- StaticStatic-tremor at rest & not at voluntary -tremor at rest & not at voluntary

movement eg. Parkinsonism movement eg. Parkinsonism PosturalPostural-when limb is actively maintained in a -when limb is actively maintained in a

certain position eg. certain position eg. HyperthyroidismHyperthyroidism

IntentionIntention-It is on willed movement esp -It is on willed movement esp desired desired object is approached object is approached eg Cerebellar eg Cerebellar syndrome syndrome

HystericalHysterical-tremor in any limb and examiner -tremor in any limb and examiner restrained on that limb it may restrained on that limb it may move to move to another part of body another part of body



4.REFLEXES4.REFLEXESA.A. SUPERFICIALSUPERFICIALB.B.DEEPDEEPC.C.VISCERALVISCERALD.D.PATHOLOGICALPATHOLOGICAL



A.A. SUPERFICIAL SUPERFICIAL SNSN NAME OF NAME OF

REFLEXREFLEXHOW TO HOW TO ELICITELICIT

RESPONSERESPONSE

11 PLANTERPLANTER Scratching the Scratching the sole of footsole of foot

Planter flexion Planter flexion of great toe & of great toe & fingerfinger

22 ABDOMINALABDOMINAL Scratch Scratch quadrant of quadrant of abdomen abdomen

Contraction of Contraction of abdominal abdominal musclesmuscles

33 CONJUNCTIVCONJUNCTIVALAL

Light touching Light touching of conjunctivaof conjunctiva

Blinking of eyeBlinking of eye

44 CREMESTERICREMESTERICC

Scratching at Scratching at inside of thighinside of thigh

Elevation Elevation testicle of that testicle of that side side 05/02/23


DEEP REFLEXESDEEP REFLEXESSNSN NAME OF NAME OF

REFLEXREFLEXHOW TO HOW TO ELICITELICIT

RESPONSERESPONSE

11 Knee jerkKnee jerk Stroking the Stroking the ligamentum ligamentum patellaepatellae

Sharp Sharp extension of extension of knee jointknee joint

22 Ankle jerkAnkle jerk Stroking Stroking tendo tendo achillesachilles

Planter Planter flexionflexion

33 Biceps jerkBiceps jerk Stroking the Stroking the biceps biceps tendontendon

Flexion of Flexion of elbow jointelbow joint

44 Triceps jerkTriceps jerk Stroking Stroking triceps triceps tendontendon

Extension Extension of the elbow of the elbow

jointjoint



KNEE JERKKNEE JERK



ANKLE JERKANKLE JERK



TRICEPS REFLEXTRICEPS REFLEX



BICEPS REFLEXBICEPS REFLEX



VISCERAL REFLEXVISCERAL REFLEX• Pupillary relexPupillary relex Shining light on eye Shining light on eye Constriction of the pupilConstriction of the pupilAbsence may indicate Absence may indicate -edema of the brain-edema of the brain-head injury-head injury-advance brain tumor-advance brain tumor-loss of optic nerve -loss of optic nerve



5.SENSORY SYSTEM5.SENSORY SYSTEM• Following sensation should be testedFollowing sensation should be tested TouchTouch PainPain TemperatureTemperature Position Position VibrationVibration Cortical sense-tactile localization,Cortical sense-tactile localization, tactile discriminationtactile discrimination tactile extinctiontactile extinction stereognosisstereognosis05/02/23


MENINGEAL SIGNMENINGEAL SIGN

• NECK STIFFNESSNECK STIFFNESS• KERNIG’S SIGNKERNIG’S SIGN• BRUDZINSKI’S SIGNBRUDZINSKI’S SIGN 1.Neck sign1.Neck sign 2.Leg sign2.Leg sign 3.Symphysis sign3.Symphysis sign 4.Cheek sign 4.Cheek sign



Kernig’s sign-severe stiffness of hamstrings Kernig’s sign-severe stiffness of hamstrings causes an inability to straighten the leg causes an inability to straighten the leg

when the hip is flexed to 90 degreewhen the hip is flexed to 90 degree



Brudzinski’s neck sign-severe Brudzinski’s neck sign-severe neck stiffness causes patient’s hip neck stiffness causes patient’s hip & knee to flex when neck is flexed& knee to flex when neck is flexed



INVESTIGATIONSINVESTIGATIONS• LUMBAR PUNCTURELUMBAR PUNCTURE• ELECTROENCEPHALOGRAMELECTROENCEPHALOGRAM• ELECTROMYOGRAMELECTROMYOGRAM• NEUROIMAGINGNEUROIMAGING Computed tomography Computed tomography

scanningscanning Magnetic resonance imagingMagnetic resonance imaging AngiographyAngiography05/02/23


LUMBAR PUNCTURELUMBAR PUNCTURE• It is used for It is used for

obtaining sample of obtaining sample of CSFCSF

• Puncture may made Puncture may made through L3/4 or L4/5through L3/4 or L4/5

Composition of CSFComposition of CSF• Color-clear as waterColor-clear as water• Cells-nil-5/cmmCells-nil-5/cmm• Glucose-50-80mg/Glucose-50-80mg/

100ml100ml• Chloride-720-750mg/Chloride-720-750mg/

100ml100ml• Protein-20-90mg/Protein-20-90mg/

100ml100ml

• Abnormality of CSFAbnormality of CSF• Yellow color-old Yellow color-old

haemorrhagehaemorrhage jaundicejaundice excess proteinexcess protein• Turbidity- +nce of WBC Turbidity- +nce of WBC

due to infection due to infection subarachnoid haemorrhagesubarachnoid haemorrhage

Blood- injury,subarachnoid Blood- injury,subarachnoid haemhaem

Cells-inc in viral,tub,fungal Cells-inc in viral,tub,fungal meninmenin

Glucose- Glucose- tub,fungal,carcinomatus tub,fungal,carcinomatus meningitis- sugar dec meningitis- sugar dec 05/02/23


EEGEEG• It is used in investigation of It is used in investigation of

epilepsy, diagnosis of encephalitis, epilepsy, diagnosis of encephalitis, dementia.dementia.

• Electrodes applied to the patient’s Electrodes applied to the patient’s scalp pick up small changes of scalp pick up small changes of electrical potential, which after electrical potential, which after amplification are recorded on paper amplification are recorded on paper or displayed on a video monitor or displayed on a video monitor and recorded electronically.and recorded electronically.



EMGEMG• Electrical activity occurring in Electrical activity occurring in

muscle during voluntary muscle during voluntary contraction, denervated at rest can contraction, denervated at rest can be recorded with needle electrodes be recorded with needle electrodes inserted percutaneously into the inserted percutaneously into the belly of the muscle.belly of the muscle.

• It is useful in desease of muscle – It is useful in desease of muscle – myopathies and dystrophies, LMN myopathies and dystrophies, LMN lesion lesion



central nervous system (cns) examination

Health & Medicine