PRINCIPLES OF

CENTRAL NERVOUS
SYSTEM
EXAMINATION

PRESENTER: DR IRENE KARAMAGA

FACILITATOR: DR EDWARD KIJA
OBJECTIVES

• TO OUTLINE THE KEY COMPONENTS OF NERVOUS SYSTEM

EXAMINATION
• TO BE ABLE TO EXAMINE THE NERVOUS SYSTEM WITH ACCURACY
HISTORY TAKING-NEUROLOGICAL
HISTORY
• The objectives of taking a clinical
history are to establish rapport
and trust with the child and
family,
• Understand the nature of their
health concerns regardless of
whether or not they pertain to
the nervous system
• Anatomically localize the
neurologic symptoms
NEUROLOGICAL HISTORY-key points
• Presenting symptom • Mental status
• Onset: sudden/ insidious • Feeding history, family history
• Evolution: improving/ slow • Etiological history- perinatal
progression/ rapid progression events, history of trauma,
• Development before onset of history of drug intoxication if any
symptoms
PREREQUISITES TO NEUROLOGICAL
ASSESSMENT
• TOOLS/EQUIPMENTS
• ENVIROMENT/SETTING- well lit
room, quiet and comfortable
GENERAL EXAMINATION
• General appearance
• Dysmorphic features
• Posture
• Build and nutrition
• Skull shape and size
• Fontanelles-ant, post
• Spine shape/deformities
• Skin- color, lesions etc
anthropometry
• Weight
• Length
• Muac
• Head circumference
Components of neurological examination
1. Higher centers
2. Cranial nerve examination
3. Motor examination
4. Sensory examination
HIGHER CENTERS
• Observations of infants and toddlers during play (eg, while stacking
blocks or playing with an age-appropriate toy) can provide valuable
information on:
o attention span,
o gross and fine motor coordination
o problem-solving abilities.
• It allows the clinician to evaluate the higher cortical functions, and it
provides clues to specific learning difficulties, attention deficit
hyperactivity disorder, and mild developmental delays
 Higher centers
• Level of consciousness
• Emotional status
• Memory and orientation
• speech
CRANIAL NERVE EXAMINATION
• Each cranial nerve (CN) is tested
by performance of a specific
motor or sensory test.
• Testing in infants is often by
observation for specific
movements and responses
Cranial nerves examination
CN I-OLFACTORY CN II- OPTIC
• Sense of smell • Visual acuity and color
• Use pungent smelling • Visual fields
substances-oranges/lemon • Pupillary light response
• Each nostril tested separately • fundoscopy
CRANIAL NERVE EXAMINATION
III (oculomotor), IV (trochlear), V (trigeminal) — 
and VI (abducens) — CN III, IV, and • The sensory function of CN V can
VI for : be tested by the response to light
• extraocular movements in the touch over the face (use a tissue)
horizontal, vertical, and oblique and by sensation on the cornea
planes and can be tested by and conjunctiva
assessing the child's ability to • Motor function of CN V is tested
track a brightly colored toy or by assessing masseter muscle
soft light. strength (asking the child to clench
their jaw while palpating for
muscle contraction).
CRANIAL NERVE EXAMINATION
VII (facial) VIII (vestibulocochlear) — 
•  observing for symmetry of the • In infants, hearing is tested by
nasolabial folds, making a soft sound close to one
ear, such as from rustling of paper.
• assessing eyelid muscle strength,
• By the age of five to six months, the
• and assessing the ability to infant may also be able to localize
wrinkle the forehead the sound to a specific quadrant.
symmetrically.
• The traditional Rinne and Weber
• Also mediates taste sensation tests can be used as well in older
over the anterior two-thirds of children
the tongue
CRANIAL NERVE EXAMINATION
IX (glossopharyngeal) and X XI (spinal accessory) —  its
(vagus) —  function is usually assessed by
• swallowing function and elevation of the shoulders and
movement of the soft palate and turning of the neck against
are often tested by eliciting a gag resistance.
reflex.
• Salivary drooling or pooling of XII (hypoglossal) — tested by
saliva also suggest dysfunction asking the patient to stick out
• Hoarseness of the voice can be their tongue; normally, the tongue
caused by CN X dysfunction. should remain in the midline
MOTOR EXAMINATION
1. POSTURE AND ABNORMAL MOVEMENTS 2. BULKNESS
• Asymmetry at rest in infants (may suggest
hemiparesis
• Opisthotonus (ie, persistent arching of the neck
and trunk due to bilateral cerebral cortical .
dysfunction
• Abducted hips or "frog-legged" posture that
accompanies hypotonia
• Fisting of the hand or holding the thumb adducted
across the palm during quiet wakefulness
• Tremor (rhythmic, fine-amplitude flexion-
extension movements of the distal extremity).
• Myoclonus (quick, nonstereotyped jerks around a
segment of the body).
MOTOR EXAMINATION
3. TONE AND STRENGTH — 4. POWER
•  Muscle tone is the resistance • Grade 0/5 – No muscle movement at all
felt upon passive movement of a • Grade 1/5 – Presence of a flicker of
movement
part of the body
• Grade 2/5 – Movement with gravity
eliminated (eg, across the bedsheet)
• Grade 3/5 – Movement against gravity
• Grade 4/5 – Movement against gravity
and some externally applied resistance
• Grade 5/5 – Movement against gravity
and good external resistance (normal)
MOTOR EXAMINATION
• GAIT
Observe the child walking (if •Ataxic gait: .
able): pay attention to their •High-stepping gait: 
posture, arm swing, stride length, •Waddling gait: 
speed, symmetry, balance and any •Spastic paraparesis:
abnormal movements.
MOTOR EXAMINATION
• Coordination — Patients with
cerebellar dysfunction have
difficulty in regulating the rate
and range of muscle contraction
(known as dysmetria), which
may manifest as nystagmus,
intention tremor, scanning
speech, truncal or gait ataxia, or
rebound phenomenon.
MOTOR EXAMINATION
REFLEXES
Tendon reflexes — The jaw,
biceps, triceps, brachioradialis,
patellar, and ankle are commonly
tested tendon reflexes, and all of
these can usually be tested in
infants and children.
The joint under consideration
should be at approximately 90°
and fully relaxed.
MOTOR EXAMINATION
PRIMITIVE REFLEXES
• Developmental reflexes (also
known as primitive reflexes)
appear at a certain time during
the course of brain development
and normally disappear with
progressive maturation of
cortical inhibitory functions.
They are mediated at subcortical
levels
SENSORY EXAMINATION
• Sensory system — A sensory examination in young children is
often imprecise, and only gross deficits can be detected.
Information obtained from sensory testing in a child below five
to six years of age can be unreliable and may need confirmation
during a second examination session.
• In children older than five to six years, sensory function is
evaluated in the same manner as in an adult,