APPROCH TO EXAMINATION

OF THE NERVOUS SYSTEM

BY: DR DIRESS M.

For pharmacy students

The nervous system consists of the central nervous
system and the peripheral nervous system.
The central nervous system is made by the brain and
the spinal cord.
 The peripheral nervous system consists of the
cranial nerves, the spinal nerves and all other nerves
extending from these
 Peripheral nervous system
1- Cranial nerves
2- Spinal nerves
3- Peripheral nerves
4- Neuromuscular junctions
 NEUROLOGIC HISTORY

Common neurologic symptoms are:

o Loss of consciousness
o Seizure ( convulsion )
o Syncope
o Weakness or paralysis of part of the body
o Abnormal body movements like tremor
o Neurologic pain
o Altered or loss of sensation
 NEUROLOGIC EXAMINATION

 Components:-
1. Mental status examination
2. Cranial nerves examination
3. Motor examination including deep tendonreflexes
4. Sensory examination
5. Examination for signs of meningeal irritation
 MENTAL STATE EXAMINATION

• Level of Consciousness
• Orientation
• Memory
• Attention
• Arithmetic Calculations
• Constructional Tasks
• Speech & Language
• Insight & Judgement
• Emotional State
LEVEL OF CONSCIOUSNESS
 Conscious = fully alert having a clear
sensorium
 Drowsy = light sleep, easily arousable & alert
for a brief period
 Stupor = only a brief & incomplete arousal
even by vigrous stimuli
 Comatose = pt cannot be aroused
 ORIENTATION
 to time = time, day, date, week, month, year
 to place = where now, address, town / city, zone,
region….
 to person = his name, name of relatives, friends,
known persons
 MEMORY
 Immediate memory = to repeat a list of 3 items e.g.
pencil, car, bird
 Recent memory = ask to recall the 3 items 5, 15min
later
 Remote Memory = ask schools, jobs held, known past
events
 THE CRANIAL NERVES EXAMINATION

CN I: (Olfactory nerve)
Smelling
Test each nostril: soap, coffee, lemon, etc.
- Abolished sense = anosmia.
- Perversion of sense = parosmia
CN II: (Optic nerve)
Visual acuity:
-Rough test - reading book
-Formal test- Snellen’s chart
Visual field-confrontation test
Color vision- Ishihara chart - Color blindness –
red/green, blue/yellow
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 CN III: (Oculomotor), IV: (Trochlear), & VI:
(Abducent

CN IV: Superior oblique muscle

CN VI: Lateral rectus muscle
CN III:
- Medial rectus
- Inferior rectus
- Superior rectus
- Inferior oblique
- Levator palpebrae
- Parasymapathetic suppply to Ciliary muscles,iris.
The third, fourth and sixth cranial nerves are
checked together
The first thing to do is inspect carefully to see if there
is
 Ptosis: - drooping of the eyelid which is found in 3rd
nerve palsy.
 Abnormal eye position (strabismus), such patient
may complain of double vision
 Then test the movement of the eye balls in all
directions
 Examine the pupils for: -
• Size, Symmetry,
• Pupilary light reflex
-In dimly lighted room ask patient to look into the
distance.
-Shine a bright light obliquely into in to each pupil in
turn.
-Record pupil size in millimetres and any asymmetry
or irregularity
 Accommodation
Hold a finger at 10 cm from the patient nose.
 Ask patient to look alternatively at your finger and
into the distance.
 Observe the pupillary response in each eye and
converging movement of the eyeballs.
 CN V: (Trigeminal nerve)

16

 Sensory + motor
• Motor branch supplies the masseter, temporalis and
lateral pterigoid muscles
• Sensory branch supplies the skin of the face and
anterior part of the scalp.
 It also supplies the mucous membrane of the mouth
and cornea
 It has three sub- branches
• Ophthalmic
• Maxillary and
• Mandibular divisions
 Examination of the fifth cranial nerve includes:
- Motor examination of jaw movement -Patient is
asked to extend the jaw, move it from side to side,
and bite strongly.
-Palpate the masseter and temporalis muscles as the
patient clenches his teeth.
Sensory examination of the three divisions of the
trigeminal nerve-the examiner tests light-touch
sensibility with a cotton and pain by pricking with a
pin the patient’s forehead, the area of the mandible
and the maxilla.
 Corneal reflex- The patient is asked to look upward
while the examiner uses the wisp of cotton carefully
and to briefly stroke the cornea from the side and
from below.
 The normal response is blinking.
 CN VII: (Facial nerve)
21

- All muscles of the face & scalp except the levator

palpebrae superioris
- Anterior two-third of the tongue for taste
Test:
 Inspect the face both at rest and during
conservation .
• Note any asymmetry
affected side droop & pulled towards stronger side.
• Look for flattening of creases of forehead & naso-
labial angle
 Note any weakness & facial asymmetry asking the pt to:
 Raise both eyebrows
 Frowning
 Show both upper and lower teeth
 Smile
 Close both eyes tightly while you are trying to open it.
 Puff out both cheeks
 Blowing the cheek against resistance of your hand
 Test taste on the anterior 2/3 of tongue- for sweat, salt,
sour, and bitter
 23

Upper (supranuclear) facial palsy forehead is

spared
Lower (infranuclear) facial palsy all of one-half
of face affected
 CN VIII: (Vestibulo--cochlear nerve)

 Testing for hearing

1. By the use of sounds of : - fingers rubbed together,
- ticking of a watch or
- human voice
2. By the use of tuning fork
a. Rinne test:- air vs bone conduction
- In normal ear = air > bone conduction = Rinne positive.
- Also, in sensori-neural deafness = Rinne is positive.
- In conductive deafness = bone > air conduction =Rinne is
negative
b. Weber test - lateralization
- Normally –sound is heard equally in each ear.
- In conductive deafness – deafer ear perceives it
more.
- In sensori-neural loss – better hearing ear hears it
more =Weber test is lateralized
 CN IX: (glossopharyngeal nerve) and X: (Vagus
nerve) , CN XI:(Spinal Acessory nerve):

 CN IX and X
- the taste of posterior third of tongue
- sensation of mucous membrane of pharynx
- gag reflex
- Look the position of the uvula
- Watch movement of soft palate & uvula during pt says ‘ah’
 CN XI: (Spinal Acessory nerve):
- Shrugging the shoulder ----- Trapezius muscle:
- Turning the head ------ Sternocleidomastoid muscle (the
opposite side)
 CN XII: (Hypoglossal nerve)

• look the tongue for - asymmetry, atrophy,

fasciculation, tremor
• symmetry of movement – on moving from side to
side.
• The tongue is pushed over to the paralyzed side in
hypoglossal paralysis.
 MOTOR EXAMINATION

o position
Muscle bulk
 Muscle Tone
 Power of muscles
 Reflxes
 Fasciculation of muscles
 Coordinations
 Gait
 Muscle Bulk

 Inspection - compare on both sides

normal & symmetrical, or
 hypertrophy or
atrophy (flat or concave)
 Palpation-wasted muscles - softer & flabby than
normal.
Measuring
-with a tape meter - on the two sides
-Atrophy LMNL or disuse atrophy in UMNL
 Muscles Tone

 the resistance of a relaxed limb to passive movement at a

joints
 Normal tone
 Hypotonia - LMNL
 Hypertonia - UMNL
-Spasticity (clasp knife type) = tone with rapidly flexed or
extended limb -cortico-spinal tract lesions
-Cog wheel rigidity = ­resistance throughout passive mov’t with
jerky-interruptions parkinsonism.
-Lead pipe (plastic) type = ­tone with uniform resistance
throughout-passive mov’t extrapyramidal tract lesion
 Power of muscles

 Muscle Strength Testing

- pt flex, extend, adduct, & abduct at each joint actively against your
resistance
 Grading of power:
Grade 5 = Full (normal) power/ strength
Grade 4 = Active movement against gravity and some resistance
Grade 3 = Movement against the force of gravity but not against
resistance of the examiner
Grade 2 = movement detectable only when gravity is eliminated
Grade 1 = a visible or palpable flicker of contraction only but no
associated movement at a joint
Grade 0 = no movement
• UMNL - Proximal + distal weakness
• Proximal weakness alone myopathy (NMJ or
muscle)
• Distal weakness alone peripheral neuropathy
 Deep tendon reflexes (DTR)

 Upper limb reflexes

 Lower limb reflexes
 Biceps reflex (C5, C6 nerves)
 Triceps reflex (C6, C7, C8 nerves)
 Brachioradialis reflex (C5, C6 nerves)
 Knee (patellar or quadriceps) reflex (L2,L3, L4
nerves)
 Ankle (Achilles, gastrocnemuis–soleus ) reflex (S1,
S2 nerves)
Clonus (ankle, patellar)
Grading reflexes
Grade 4-hyperactive with Clonus (often indicative of
disease)
Grade 3 - Exaggerated, very brisk (hyperactive)
(possibly but not necessary indicative of disease
Grade 2 - Brisk, averagely normal (normoactive)
Grade 1 - Diminished (hypoactive)
Grade 0- Absent
 Cutaneous (Superficial) reflexes

Corneal reflex (CN V, VII)

 Pharyngeal reflex (gagging) reflex (CN IX, X)
 Abdominal reflex =epigastric (T6-9), midabdomen
(T9-10), hypogastrium ((T11--L1))
 Cremasteric reflex (L1,2)
 Anal reflex (S2,3,4)
o Plantar reflex (L5, S1,2)
 Fasciculation of muscles

-flicker of mov’ts under skin – sponataneously / induced by

light percussion
 signs of UMNL:
 Weakness
 Spasticity
 increased DTR
 Extensor plantar responses
 signs of LMNL:
 Weakness
 Fasciculation
 Muscle wasting
 Loss of DTR and
 Hypotonia (flaccidity)
 CO-ORDINATION EXAMINATION
(Cerebellar Function Test)

 In the upper limbs:

 Finger to nose test
o Rapid alternating supination and pronation
movements of forearm
 In the lower limbs:
 Rapid taping with foot
o Heel-knee-shin test
 Sensory Exam

 peripheral sensation
-Light touch = wisp of cotton or examiner’s finger.
- Pain = blunt & sharp end of new pin
- Temperature
- Position sense
- Vibration sense
 Centeral(cortical sensation)
• Two point discrimination
- on finger tips = normally 2mm separation can be recognized
- on pulps of toes = ~1cm separation recognized normally
• Recognition of size, shape, weight & form- (Stereognosis)
• Identification of number or letter written on palm- (Graphesthesia)
• Romberg’s sign = test for loss of position sense- (sensory ataxia) in legs.
 SIGNS OF MENINGEAL IRRITATIONS (
meningism)

Nucheal rigidity (neck stiffness) = the

pathognomonic sign
 Kernig’s sign = classic sign
 Brudzinki’s sign = also a classic sign
1. Neck stiffness- involuntary rigidity of the neck due
to pain arising from meningeal irritation.
2. . Kerning’s sign- the thigh is first flexed and then
the leg is extended at the knee while patient is lying
on his back. This will stretch the nerve root and
pain will be elicited at the inflamed meanings.
3. . Brudzinsky’s sign-when trying to flex the neck of
patient with meningeal irritation the knees will
automatically flex to prevent stretching of the
meanings
 Musculoskeletal AND
INTEGUMENTARY system
examination
 Musculoskeletal system examination

Musculoskeletal system Provides stability and mobility

necessary for physical activity
Musculoskeletal system examination include:
- joints
- connecting bony structure
- muscle
Common symptoms of musculoskeletal system
Low back pain
Neck pain
Mono articular ,pauci articular or poly articular joint pain
Joint pain with sytemic symptoms such as;fever
chills,rash,anorexia and weight loss
Joint pain with symptoms from other organ symptoms
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 Cont…

If answers to the following questions are

negative musculoskeletal disorder is unlikely:
 1. Do you have any pain or stiffness in your muscels,
joints or back?
 2. have you ever had gout or arthiritis?
3 .can you dress yourself completely with out
difficulty?
4 can you walk up and down stairs with out
difficulty?
 Physical examination
(GALS) screen is a rapid and sensitive screening method
for detecting MSS disorders:
G gait
A arms
L legs
S spine “…
GALS provide a valuable screening test for use in general
practice”
“the procedure can be viewed as a general functional
(disability), as well as a basic musculoskeletal
assessment”
“..be useful in selective situations as a rapid test of
functional performance and to screen out regional
locomotory abnormalities that merit closer scrutiny
 General Approach

Inspection=LOOK
Palpation =FEEL
Movement=MOVE
Stability=MOVE
Compare with opposite side
 General Inspection
48

Observe how the patient moves as they go into the

room or move from chair to table
Body proportions
 Look for asymmetry between sides
Swelling
Deformities
Atrophy
Erythema
Nodules
 Range of Motion
49

Active ROM or passive ROM for each joint note;

 decreased or increased movement of the joint compared
to the other side
 pain with movement
 Listen for crepitus or “popping”
 abnormal movements
 Active Range of Motion
Chin to chest (flexion)
“look at ceiling” (extension)
Chin to each shoulder (lateral rotation)
Ear to each shoulder (lateral flexion, i.e., head tilt)
 Integumentary system..
Integumentary system include: skin , nails and hairs.
Skin:largest organ of our body,accounts for about 15%.
What are functions of skin? Covers the internal structures
of body
 Protects body from trauma and bacteria.
 Prevents the loss of water and electrolytes
 Senses temperature, pain, touch, pressure
 Regulates body temperature throught sweat production and
evaporation
 Synthesizes vitamin D, Identity,Sexual arousal
.Promotes wound repair-cell replacement

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 Integumentary system......
Common symptoms:itching, burning,rash
pigmentation disorder ( hypo/hyper),
ulceration ,hair loss
. Duration of lesion
Type of lesion :rash or ulceration
Distribution of lesion
Bleeding or drainiage from the area?
If there is itching or not?
Sun exposure history and duration?
How do you protect from the UV rays?
 Nail problems ?
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 Skin
Inspect: Palpate
 Color: pallor, cyanosis  Moisture: dry/oiliness
 Integrity  Temperature:warmth/

 Lesions cold,localized/
 Primary generalized
 Texture;
 Secondary
 Turgor/elasticity-
 Vascular
decrease in turgor shows
 Odor
dehydration
 Edema:
 Describing a Lesion
Size Shape
Color Texture
Exudate Tenderness
Surface relationship Blanching or pulsation
• border of vascular lesion
Pattern, configuration,
distribution.
 Cont..

Surface relation ship:

Primary lesion;
 1-macule-flat normal surface size<1cm
 2 patch- similar to macule but size > 1cm
 3-papule-raised size <1cm
 4-plaque-raised size >1cm and thickness<diameter
 5-nodule-raised size > 1cm and thickness=diameter
 6- vesicle-fluid filled lesion size <1cm
 7-blister –fluid filled lesion size >1cm
 8-pustule-a vesicle filled with pus
 Cont..

Secondary lesion
erosion:
ulcer:
fissure:
erythematous
atrophy
Surface related:
smooth,scaly,exudate,friable,crust,lichenification
etc
 Hair
Palpate
Inspect
 Texture
 Color
 Scalp
 Quantity
 Distribution
 Condition of scalp
 Lesions or pediculosis
 Nails

Inspect Palpate
 Color  Texture
 Condition  Consistency

 Angle of attachment  Thickness

 Abnormalities  Adherence to nail bed

 Clubbing
Thank you
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