Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
CNS Examination Practical
• Presented By – 
Prof.Dr.R.R.Deshpande 
(M.D in Ayurvdic 
Medicine & M.D. in 
Ayurvedic Physiol...
Clinical Examination of
Central Nervous System
11/28/2016 Prof.Dr.R.R.Deshpande 2
Centers in Brain
11/28/2016 Prof.Dr.R.R.Deshpande 3
Examination of Nervous System
• (1) Examination for higher functions
• (2) Examination of cranial nerves
• (3) Examination...
Examination of Higher Functions
• (1) Level of consciousness.
• (2) Orientation of time, place and person
• (3) Intelligen...
Asking questions for orientation of
Time,Place & Person
11/28/2016 Prof.Dr.R.R.Deshpande 6
Cranial Nerves
11/28/2016 Prof.Dr.R.R.Deshpande 7
Cranial Nerves
11/28/2016 Prof.Dr.R.R.Deshpande 8
Examination of Cranial Nerves
• (1) First cranial nerve - Olfactory nerve –
• This can be tested by asking patient to smel...
Testing of Olfactory Nerve
11/28/2016 Prof.Dr.R.R.Deshpande 10
2nd Cranial Nerve – Optic Nerve
• This nerve is examined ,under following 
headings
• (A) Acuity of Vision
• (B) Field of ...
Examination of Optic Nerve –
Snellen’s chart
11/28/2016 Prof.Dr.R.R.Deshpande 12
Acuity of vision
• Tested by asking the patient to read "Snellen's
chart" from a distance of 6 m. 
• Suppose, person reads...
Near Vision Testing
• (ii) Near Vision - is tested with the help of 
Jeger's chart .This chart is to be read from a 
dista...
Examination of Optic Nerve –
Near vision – Jeger’s Chart
11/28/2016 Prof.Dr.R.R.Deshpande 15
Colour Vision
• Tested with 'Ishihara chart’
• This chart is to be tested by each eye 
separately  and the person is asked...
Examination of Optic Nerve –
Colour vision – Ishihara Chart
11/28/2016 Prof.Dr.R.R.Deshpande 17
Field of vision – Confrontation
Test
• This is done with the help of Perimeter.
• Principle used in this test is that the ...
Examination of Optic Nerve –
Confrontation Test
11/28/2016 Prof.Dr.R.R.Deshpande 19
Trochlear Nerve – Pupillary Reflex
• (4) Trochlear Nerve - To test pupillary reflex is 
also a part of examination of 3rd ...
Examination of Trochlear Nerve –
Pupillary Reflex
11/28/2016 Prof.Dr.R.R.Deshpande 21
Trochlear Nerve – Pupillary Reflex
• Throwing of light in one eye and constriction of pupil 
of the same eye is direct ref...
Examination of Trochlear Nerve –
Accommodation Reflex
11/28/2016 Prof.Dr.R.R.Deshpande 23
Trigeminal Nerve
• (5) Fifth Cranial Nerve - is Trigeminal Nerve.
• Sensory component - can be tested by testing 
sensatio...
Trigeminal Nerve
• For testing sensory component, wick  of 
cotton wool is used for testing touch
sensation
• Temperature ...
Examination of Trigeminal Nerve –
Touch sensation
11/28/2016 Prof.Dr.R.R.Deshpande 26
Examination of Trigeminal Nerve –
Temperature sensation
11/28/2016 Prof.Dr.R.R.Deshpande 27
Examination of Trigeminal Nerve –
Motor component
11/28/2016 Prof.Dr.R.R.Deshpande 28
Facial Nerve
• (7) 7th Cranial nerve - Facial Nerve
• (i) Basically, this is motor nerve which 
supplies superficial muscl...
Facial Nerve
• (a) Make wrinkling on forehead (To test 
Occipito frontalis)
• (b) Close eyes tightly (To test Orbicularis ...
Examination of Facial Nerve
Wrinking of Forehead Close Eyes tightly
11/28/2016 Prof.Dr.R.R.Deshpande 31
Examination of Facial Nerve
Blow the cheeks Blow whistle
11/28/2016 Prof.Dr.R.R.Deshpande 32
Facial Nerve
• (iii) Conjunctival and corneal reflexes
• Are also the part examination of facial 
nerve which we have alre...
Examination of Facial Nerve
Conjunctival Reflex Corneal Reflex
11/28/2016 Prof.Dr.R.R.Deshpande 34
Vestibulo Cochlear Nerve
• (8) 8th Cranial Nerve - Vestibulo cochlear nerve - 
• Cochlear component is concerned with posi...
Hearing Tests
• (A) Rinne's Test - If BC > AC, It indicates conductive 
deafness
• (Nerve deafness can not be detected by ...
Vibrating Tuning fork for
Hearing Test
11/28/2016 Prof.Dr.R.R.Deshpande 37
Examination of
Vestibulo Cochlear Nerve
Rinne’s Test Rinne’s Test
11/28/2016 Prof.Dr.R.R.Deshpande 38
Examination of
Vestibulo Cochlear Nerve
Schwabach Test Schwabach Test
11/28/2016 Prof.Dr.R.R.Deshpande 39
Hearing Test
• (C) In Weber test - We confirm the deafness ,which
is detected By Rinne's test and schwabach test. - 
Vibra...
Weber Test for Hearing
11/28/2016 Prof.Dr.R.R.Deshpande 41
Examination of 9th, 10th, 11th
cranial nerves
• Glossopharyngeal, Vagus, Accessory
• 9th and 10th cranial nerve carry sens...
Glossopharyngeal Nerve
• Patient is asked to open his mouth and say  Aa , 
(Doctor will observe position of Uvula and arch...
Examination of
Glossopharyngeal Nerve
Say Aa Touch Sensation
11/28/2016 Prof.Dr.R.R.Deshpande 44
Accessory Nerve
• Accessory nerve has 2 components
• Cranial component - Supplying laryngeal 
muscle and another
• Spinal ...
Examination of Accessory Nerve
11/28/2016 Prof.Dr.R.R.Deshpande 46
Accessory Nerve
• Speech is tested by asking the patient to speak out 
few words.(Like asking question –What is your Name ...
Examination of Accessory Nerve
Movement of Trapezium Movement of Trapezium
11/28/2016 Prof.Dr.R.R.Deshpande 48
Examination of Accessory Nerve
•  To test sternomastoid muscle patient is asked to 
turn his neck on one side and patient ...
Examination of Accessory Nerve
11/28/2016 Prof.Dr.R.R.Deshpande 50
9th, 10th, 11th Cranial Nerve examination
• Palatal or pharyngeal wall reflex is also the 
part of 9th, 10th, 11th Cranial...
Hypoglossal Nerve
• 12th Cranial Nerve - Hypoglossal Nerve –
• This is purely motor nerve.
• It supplies all the muscles o...
Examination of Hypoglossal nerve
11/28/2016 Prof.Dr.R.R.Deshpande 53
Hypoglossal Nerve
• The patient is asked as follows ----
• Say Aa, Take Tongue out ,Take tongue in
,Take tongue up ,Take T...
Clinical Examination of Sensory System
• One should remember the following points while 
carrying out examination of senso...
Clinical Examination of Sensory System
Hair Asthesiometer Compass Asthesiometer
11/28/2016 Prof.Dr.R.R.Deshpande 56
Clinical Examination of Sensory System
Compass Asthesiometere Tuning Fork
11/28/2016 Prof.Dr.R.R.Deshpande 57
Clinical Examination of Sensory System
Key & Coin-Steregnosis Cotton wick –Crude Touch
11/28/2016 Prof.Dr.R.R.Deshpande 58
Clinical Examination of Sensory System
Blunt end of Pencil –pressure Hot & Cold water
11/28/2016 Prof.Dr.R.R.Deshpande 59
Clinical Examination of Sensory System
11/28/2016 Prof.Dr.R.R.Deshpande 60
Types of Sensations – Fine Sensation
• (i) Fine touch
• (ii) Tactile localisation
• (iii) Tactile discrimination
• (iv) Vi...
Types of Sensations – Crude Sensation
• (i) Crude touch
• (ii) Pressure
• (iii) Temperature
• (iv) Pain
• Note - Integrity...
Fine sensation & Tactile Localization
• Tested by Warn cruze hair Asthesiometer or even a 
thin wire can be used.
• The pa...
Examination of Sensory System
Touch on right side Touch on Left side
11/28/2016 Prof.Dr.R.R.Deshpande 64
Fine Sensation –
Fixing of Dermatome
Sr.No Area Dermatome
1 Near ankle  L 5
2 Below knee  L 4 
3 Above knee  L 3
4 Thigh L...
Tactile Localization
• The patient will locate the area where he is 
felling fine touch ,by closing eyes 
11/28/2016 Prof....
Tactile Discrimination
• Tested by Compass Asthesiometer
• Tell patient as follows – 
• Now I am touching 2 pointers of th...
Examination of Sensory System
Touch on Right side Touch on Left side
11/28/2016 Prof.Dr.R.R.Deshpande 68
Sense of Steregnosis
• The patient is asked to recognise ----
• familiar objects (pen, pencil, coin, key) given 
in his ha...
Steregnosis
Identifying Pen Identifying Coin
11/28/2016 Prof.Dr.R.R.Deshpande 70
Vibration sense
• (5) Vibration Sense - A vibrating tunning fork having 
frequency 100 Hz is kept on bony prominence such ...
Vibration sense
On right side On Left side
11/28/2016 Prof.Dr.R.R.Deshpande 72
Joint position & Muscle movement sense
• To test joint position sense, we do the 
movements of great toe or thumb and 
sub...
Examination for recognizing
Joint Position
Downward Movement Upward Movement
11/28/2016 Prof.Dr.R.R.Deshpande 74
Examination for recognizing
Joint Position
Downward Movement Upward Movement
11/28/2016 Prof.Dr.R.R.Deshpande 75
Fine sensations –Lost
• All above fine sensations are disturbed, if 
Dorsal Column Tract
• Tract is damaged due to "Tabes ...
Crude Sensations
• (1) Crude touch
• (2) Pressure
• (3) Temperature
• (4) Pain
• (Integrity of Spinothalamic tract is test...
Crude Touch
• Tested by wick of  cotton wool
• Identical Dermatomes are to be compared
• Ask the patient ,to tell ,where h...
Examination for Crude Touch
On Right Side On Left Side
11/28/2016 Prof.Dr.R.R.Deshpande 79
Sense of Pressure
• Blunt end of the pencil is used. It is pressed
on extremities or on face and subject is asked 
to reco...
Examination for sense of Pressure
On Right Side On Left Side
11/28/2016 Prof.Dr.R.R.Deshpande 81
Temperature sense
• Test tubes containing warm or cold water are 
used Subject is asked to recognise these 
sensations wit...
Examination for
Sense of Temperature
On Right Side On Left Side
11/28/2016 Prof.Dr.R.R.Deshpande 83
Pain sensation
• Pin is used. Subject is asked to recognise pain
stimulus, given with pin
• Tell patient that you are now ...
Examination of Pain Sensation
On Right Side On Left Side
11/28/2016 Prof.Dr.R.R.Deshpande 85
Crude sensations
• Thus, by testing crude sensations, we have 
tested integrity of Spinothalamic system
•  These tracts ar...
Examination of Motor System
• Motor system is examined under following headings. 
These points are very useful in examine ...
Examination of Nutrition of
Muscle
• Nutrition is tested by measuring
circumference of muscle, at its bulk and 
comparing ...
Examination of Nutrition of Muscle
• e.g. 6 inches below Tibial tuberosity. Measure
the circumference of right and left ca...
Nutrition of Muscle
Measuring from Fixed
distance Measuring Circumference
11/28/2016 Prof.Dr.R.R.Deshpande 90
Examination of Nutrition of Muscle
• In the same manner, for the upper extremity - 
circumference of forearm and arm muscl...
Nutrition of Muscle
Right side Measuring Circumference
11/28/2016 Prof.Dr.R.R.Deshpande 92
Examination of Nutrition of Muscle
• In right sided person circumference of right 
sided muscle can be slightly more. This...
Tone of Muscle
• Tone of a muscle is a partial state of
contraction. It is maintained by stretch reflex.
• Tone of the mus...
Tone of Muscle
Tone of Leg Muscle Tone of Thigh Muscle
11/28/2016 Prof.Dr.R.R.Deshpande 95
Tone of Muscle
• Doctor can feel muscle at its bulk and he can 
compare the feel on right and left side 
• e.g. doctor can...
Tone of Muscle
Bicep Muscle Tone Tone –Forearm muscle
11/28/2016 Prof.Dr.R.R.Deshpande 97
Tone of Muscle
• Normal feel is Elastic.
• Second method of examination of Tone is to 
see resistance offered to passive M...
Tone of Muscle
• Doctor can do passive movements at knee 
joint to test the tone of flexors and extensors 
of knee
• When ...
Tone of Muscle
Passive movement Passive movement
11/28/2016 Prof.Dr.R.R.Deshpande 100
Tone of Muscle
• For testing upper extremities, same 
movements can be done at elbow
• Doctor can test Tone of biceps and ...
Tone of Muscle
Elbow Flexion Elbow Extension
11/28/2016 Prof.Dr.R.R.Deshpande 102
Tone of Muscle
• In lower and upper extremities, when 
resistance offered is moderate, it indicates 
tone is normal
• Hype...
Power of Muscles
• Power is graded under fine grades as follows
• Grade O - No movements at all.
• Grade 1 - Only flicking...
Power of Muscle
Grade 3 Power Grade 3 Power
11/28/2016 Prof.Dr.R.R.Deshpande 105
Power of Muscles
• Grade 4 - Patient is able to move his 
extremities against resistance
• Grade 5 - Patient is able to li...
Power of Muscle
Grade 4 Power Grade 4 Power
11/28/2016 Prof.Dr.R.R.Deshpande 107
Power of Muscle
Grade 5 Power Grade 5 Power
11/28/2016 Prof.Dr.R.R.Deshpande 108
Power of Muscles
• In the same manner, power of 
extensors of hip, flexors of knee (Ask 
the patient to bend the knee ) 
e...
Power of Muscles
• Even planter flexors, dorsi flexors of foot can 
be compared
• In upper extremity, flexors and extensor...
Power of Muscles
• For testing power in the neck muscle, patient 
is asked to lift his neck up in lying down 
position
• A...
Power of Muscle
Grade 4 Power Grade 4 Power
11/28/2016 Prof.Dr.R.R.Deshpande 112
Power of Muscles
• Complete loss of power is called as 'paralysis'
which is typical feature of LMN lesion like 
polio myel...
Coordination of Muscles
• (A) Coordination of muscles in upper 
extremity is tested by following tests
• (1) Finger - Nose...
Coordination of Muscles
• (B) for lower extremity, following tests
• (1) Knee - heel test
• (2) Walking in straight line
•...
Coordination of Muscles
• Ask the patient ,by closing the eyes ,he should 
try to touch Index finger of the left hand by h...
Coordination of Muscle
Finger- Nose –Finger Test Finger –Nose –Finger Test
11/28/2016 Prof.Dr.R.R.Deshpande 117
Coordination of Muscles
• Ask the patient to perform Pronation & 
Supination activity of both hands ,speedily 
(diadochoki...
Coordination of Muscle
Diadochokinesia Diadochokinesia
11/28/2016 Prof.Dr.R.R.Deshpande 119
Coordination of Muscles
• Kneel Heel Test – Ask the patient to sit on 
table or lie down on bed 
• First keep right heel o...
Coordination of Muscle
Knee-heel Test Knee –heel Test
11/28/2016 Prof.Dr.R.R.Deshpande 121
Coordination of Muscles
• Ask the patient to stand straight ,by keeping both 
feet near to each other – First stand with e...
Rhomberg's sign
11/28/2016 Prof.Dr.R.R.Deshpande 123
Coordination of Muscles
• Straight line walking Test – Ask the patient to 
stand at one end of the 8 feet straight line 
•...
Straight line walking Test
Walk on Straight line Return back –on straight line
11/28/2016 Prof.Dr.R.R.Deshpande 125
Coordination of Muscles
• If patient walks correctly with open eyes, but looses 
balance with closed eyes - It indicates d...
Involuntary Movements
• 3 types
• (1) Fine Tremors – In Thyrotoxicosis
• Tachycardia, weight loss, Intolerance to heat 
at...
Involuntary Movements
• (2) Pin rolling tremors at rest –
• In Parkinsonism – This disease develops due 
to deficiency of ...
Involuntary Movements
Fine Tremors Pin rolling Tremors
11/28/2016 Prof.Dr.R.R.Deshpande 129
Involuntary Movements –Action Tremor
11/28/2016 Prof.Dr.R.R.Deshpande 130
Advantage of
Motor System Examination
• Advantage of motor system examination, over 
sensory system examination is that --...
Advantage of
Motor System Examination
• (2) In sensory system examination, if patient is 
non-co-operative then he can not...
Superficial Reflexes – Root values
Sr.No Reflex Root Value
1 Conjunctival reflex 5th and 7th cranial nerve
2 Corneal refle...
Deep Reflexes – Root values
Sr.No Reflex Root Value
1 Bicep jerk C5, C6
2 Triceps jerk C6, C7, C8
3 Supinator jerk C5, C6
...
Reflexes
• In superficial reflexes --- receptors are in skin 
or mucous membrane
• In deep reflexes ----  receptors are in...
Superficial Reflex – Conjunctival Reflex
• Doctor will touch wisp of the cotton wool to 
the white portion of eye i.e. Bul...
Conjunctival Reflex
For Right Eye For Left Eye
11/28/2016 Prof.Dr.R.R.Deshpande 137
Superficial Reflex –Corneal Reflex
• Doctor will touch the wisp of cotton wool to
black portion of eye i.e. cornea closer ...
Corneal Reflex
For Right Eye For Left Eye
11/28/2016 Prof.Dr.R.R.Deshpande 139
Palatal & Pharyngeal Reflex
• Doctor will touch soft palate or post
pharyngeal wall with tongue depressor
• Doctor will ex...
Palatal & Pharyngeal Reflex
Ready with Tongue Depressor Touch Post Pharyngeal wall
11/28/2016 Prof.Dr.R.R.Deshpande 141
Abdominal Reflexes
• Imp precaution to be carried out is that - 
abdomen should be relaxed, by flexing 
knee
• Ask the pat...
Abdominal Reflexes
Mid abdominal Reflex Away from Umbilicus
11/28/2016 Prof.Dr.R.R.Deshpande 143
Abdominal Reflexes
• Now, blunt end of hammer is moved, 
radiating away from umbilicus in all directions
• While testing t...
Abdominal Reflex – Root value
Sr.No Part Of Abdomen Root Value
1 Upper abdominal reflex T6 to T9
2 Mid abdominal reflex T9...
Abdominal Reflexes
• In obese patients, abdominal reflexes 
may not be elucidated. In such cases, 
unilateral absence of a...
Superficial Reflex – Plantar Reflex
• Root value of the plantar reflex is L5, S1, S2.
• Scratch sole of the foot from heel...
Babinski's sign
Left Plantar Reflex Right Plantar Reflex
11/28/2016 Prof.Dr.R.R.Deshpande 148
Superficial Reflex – Plantar Reflex
• Normal response is plantar flexion of all toes
• If dorsiflexion of great toe and fa...
Deep Reflex – Bicep Jerk
• For testing deep reflexes, special method is 
adopted which is called as the Jendrassik
maneuve...
Deep Reflex – Bicep Jerk
Tap Bicep Tendon Contraction of Bicep muscle
11/28/2016 Prof.Dr.R.R.Deshpande 151
Jendrassik maneuver 
• By this manual, gamma motor neuron
discharge is decreased and reflex is obtained 
properly 
• Bicep...
Deep Reflex – Tricep Reflex
• Doctor will give a tap just above Olecranon
process, which is Tricep tendon
• Do  Jendrassik...
Deep Reflex – Tricep Reflex
Tap above Olecranon Process Contraction of Muscle
11/28/2016 Prof.Dr.R.R.Deshpande 154
Deep Reflex –
Supinator Reflex or wrist Jerk Reflex
• Tap is given just above the head of radius. 
Doctor can see the cont...
Supinator Reflex or
wrist Jerk Reflex
Left Wrist jerk Right wrist jerk
11/28/2016 Prof.Dr.R.R.Deshpande 156
Deep Reflex – Knee Jerk
• For testing this reflex, exposer of Quadriceps muscle 
is important, so that the doctor can see ...
Deep Reflex – Knee Jerk
• Contraction of Quadriceps muscle is 
Important response
• Root value is - L2, L3, L4
11/28/2016 ...
Deep Reflex – Knee Jerk
Right Knee Reflex Left Knee Reflex
11/28/2016 Prof.Dr.R.R.Deshpande 159
Deep Reflex – Ankle Jerk
• For this reflex gastrocnemius muscle should be 
exposed. Tapping of the gastrocnemius
tendon, j...
Deep Reflex – Ankle Jerk
Right Ankle Jerk Left Ankle Jerk
11/28/2016 Prof.Dr.R.R.Deshpande 161
Importance of Testing Reflexes
• Examination of the reflexes is most imp part in 
examination of the nervous system.
• Adv...
Importance of Testing Reflexes
• In UMN lesions - Deep reflexes are
exaggerated 
• (Jerks will be very much prominent)
• E...
Examination of Spine & Cranium
• Spine is to be inspected from cervical to sacral 
region for noticeing abnormality
• With...
Examination of Spine & Cranium
Cervical to Sacral With knuckles
11/28/2016 Prof.Dr.R.R.Deshpande 165
Examination of Spine & Cranium
• For testing cranium deep pressure is to be
given on skull, from all angles and patient is...
Examination of Spine & Cranium
Deep pressure from all angles Deep pressure from all angles
11/28/2016 Prof.Dr.R.R.Deshpand...
Examination of Gait
Sr.No Gait Disease
1 Circumduction gait Hemiplegia
2 Jerky gait Parkinsonism
3 Drunk man's gait Cerebe...
Abnormal Gait
Circumduction gait Drunken Gait
11/28/2016 Prof.Dr.R.R.Deshpande 169
Abnormal Gait
Parkinson’s Gait Polio Gait
11/28/2016 Prof.Dr.R.R.Deshpande 170
Abnormal Gait
11/28/2016 Prof.Dr.R.R.Deshpande 171
Abnormal Gait – Scissor Gait
11/28/2016 Prof.Dr.R.R.Deshpande 172
Examination of Special Signs
• Neck rigidity - in Meningitis
• High Fever, severe Headache, projectile 
vomiting, positive...
Prof.Dr.R.R.Deshpande
• Sharing of Knowledge 
• FOR 
• Propagating Ayurved
11/28/2016 174Prof.Dr.R.R.Deshpande
Upcoming SlideShare
Loading in …5
×

Clinical Examination of Nervous System - PPT

Clinical Examination of Nervous System - PPT -- By Prof. Dr. R. R. Deshpande
• This PPT explains how to perform Central Nervous System Examination systematically & step by step .This includes (1) Examination for higher functions (2) Examination of cranial nerves (3) Examination of sensory system (4) Examination of motor system (5) Examination of reflexes (6) Examination of gait (7) Examination of spine and cranium (8) Examination for special signs (such as cerebellar signs)
• Visit – www.ayurvedicfriend.com
• Phone – 922 68 10 630


Related Books

Free with a 30 day trial from Scribd

See all
  • Be the first to comment

Clinical Examination of Nervous System - PPT

  1. 1. CNS Examination Practical • Presented By –  Prof.Dr.R.R.Deshpande  (M.D in Ayurvdic  Medicine & M.D. in  Ayurvedic Physiology) • www.ayurvedicfriend.c om • Mobile – 922 68 10 630 • professordeshpande@g mail.com 11/28/2016 1Prof.Dr.R.R.Deshpande
  2. 2. Clinical Examination of Central Nervous System 11/28/2016 Prof.Dr.R.R.Deshpande 2
  3. 3. Centers in Brain 11/28/2016 Prof.Dr.R.R.Deshpande 3
  4. 4. Examination of Nervous System • (1) Examination for higher functions • (2) Examination of cranial nerves • (3) Examination of sensory system • (4) Examination of motor system • (5) Examination of reflexes • (6) Examination of gait • (7) Examination of spine and cranium • (8) Examination for special signs (such as  cerebellar signs) 11/28/2016 Prof.Dr.R.R.Deshpande 4
  5. 5. Examination of Higher Functions • (1) Level of consciousness. • (2) Orientation of time, place and person • (3) Intelligence • (4) Memory • (5) Speech • Note :- Special tests are required for  psychiatric patients. 11/28/2016 Prof.Dr.R.R.Deshpande 5
  6. 6. Asking questions for orientation of Time,Place & Person 11/28/2016 Prof.Dr.R.R.Deshpande 6
  7. 7. Cranial Nerves 11/28/2016 Prof.Dr.R.R.Deshpande 7
  8. 8. Cranial Nerves 11/28/2016 Prof.Dr.R.R.Deshpande 8
  9. 9. Examination of Cranial Nerves • (1) First cranial nerve - Olfactory nerve – • This can be tested by asking patient to smell a  known substance with each nostril like  camphor ,Eucalyptus 11/28/2016 Prof.Dr.R.R.Deshpande 9
  10. 10. Testing of Olfactory Nerve 11/28/2016 Prof.Dr.R.R.Deshpande 10
  11. 11. 2nd Cranial Nerve – Optic Nerve • This nerve is examined ,under following  headings • (A) Acuity of Vision • (B) Field of Vision • (C) Colour Vision 11/28/2016 Prof.Dr.R.R.Deshpande 11
  12. 12. Examination of Optic Nerve – Snellen’s chart 11/28/2016 Prof.Dr.R.R.Deshpande 12
  13. 13. Acuity of vision • Tested by asking the patient to read "Snellen's chart" from a distance of 6 m.  • Suppose, person reads only 2nd line, on which  distance mentioned is 36 m, then we express his far  vision as 6/36 (Normal far vision should be 6/6) • In above case - it is understood that what a normal  person can read from 36 m, our patient is reading  from 6 m and so, patient is suffering from Myopia. 11/28/2016 Prof.Dr.R.R.Deshpande 13
  14. 14. Near Vision Testing • (ii) Near Vision - is tested with the help of  Jeger's chart .This chart is to be read from a  distance of 25 cm, which is our near point.  Each eye should be tested separately and then  binocular vision. • Normally the person should read smallest  print on Jeger's chart. • This indicates near vision of patient is normal.  He is not suffering from Hypermetropia. 11/28/2016 Prof.Dr.R.R.Deshpande 14
  15. 15. Examination of Optic Nerve – Near vision – Jeger’s Chart 11/28/2016 Prof.Dr.R.R.Deshpande 15
  16. 16. Colour Vision • Tested with 'Ishihara chart’ • This chart is to be tested by each eye  separately  and the person is asked to  recognize the figure which are printed in different colours in the chart. 11/28/2016 Prof.Dr.R.R.Deshpande 16
  17. 17. Examination of Optic Nerve – Colour vision – Ishihara Chart 11/28/2016 Prof.Dr.R.R.Deshpande 17
  18. 18. Field of vision – Confrontation Test • This is done with the help of Perimeter. • Principle used in this test is that the field of vision of doctor's right eye is same as field of vision of left eye of patient . patient sits at a distance of 1 m. Then  eyeball movements are tested • - Patient is instructed not to move his neck but  patient has to move only eyeballs, as doctor is  moving his finger. (We test the movements, such as -  abduction, adduction, elevation, depression, internal  rotation and external  rotation) 11/28/2016 Prof.Dr.R.R.Deshpande 18
  19. 19. Examination of Optic Nerve – Confrontation Test 11/28/2016 Prof.Dr.R.R.Deshpande 19
  20. 20. Trochlear Nerve – Pupillary Reflex • (4) Trochlear Nerve - To test pupillary reflex is  also a part of examination of 3rd cranial nerve. • For this Light Reflex and accommodation  reflex should be tested • For testing the Light Reflex doctor will throw light on the patients eye and doctor will look for the response i.e. constriction of pupil. 11/28/2016 Prof.Dr.R.R.Deshpande 20
  21. 21. Examination of Trochlear Nerve – Pupillary Reflex 11/28/2016 Prof.Dr.R.R.Deshpande 21
  22. 22. Trochlear Nerve – Pupillary Reflex • Throwing of light in one eye and constriction of pupil  of the same eye is direct reflex and construction of  pupil of another eye is indirect reflex • Accommodation reflex - can be tested by asking the  patient to look at distant object first and suddenly  towards the object, near to eye (as close as 25 cm)  Effect will be constriction of pupil and conversions of  eyes and bulging of lens. 11/28/2016 Prof.Dr.R.R.Deshpande 22
  23. 23. Examination of Trochlear Nerve – Accommodation Reflex 11/28/2016 Prof.Dr.R.R.Deshpande 23
  24. 24. Trigeminal Nerve • (5) Fifth Cranial Nerve - is Trigeminal Nerve. • Sensory component - can be tested by testing  sensations from all parts of face. • Motor component - can be tested by muscle  of mastication (Temporalis, Masseter muscles).  We also test medial and lateral pterygoid  muscle by asking the patient to move his jaw  sidewise. 11/28/2016 Prof.Dr.R.R.Deshpande 24
  25. 25. Trigeminal Nerve • For testing sensory component, wick  of  cotton wool is used for testing touch sensation • Temperature sense can be tested by  taking warm and cold water in test tubes. 11/28/2016 Prof.Dr.R.R.Deshpande 25
  26. 26. Examination of Trigeminal Nerve – Touch sensation 11/28/2016 Prof.Dr.R.R.Deshpande 26
  27. 27. Examination of Trigeminal Nerve – Temperature sensation 11/28/2016 Prof.Dr.R.R.Deshpande 27
  28. 28. Examination of Trigeminal Nerve – Motor component 11/28/2016 Prof.Dr.R.R.Deshpande 28
  29. 29. Facial Nerve • (7) 7th Cranial nerve - Facial Nerve • (i) Basically, this is motor nerve which  supplies superficial muscles of face • (ii) The doctor will test all movements of  face 11/28/2016 Prof.Dr.R.R.Deshpande 29
  30. 30. Facial Nerve • (a) Make wrinkling on forehead (To test  Occipito frontalis) • (b) Close eyes tightly (To test Orbicularis  occuli) • (c) Blow your cheeks (To test Buccinator) • (d) Blow whistle (To test orbicularis oris) 11/28/2016 Prof.Dr.R.R.Deshpande 30
  31. 31. Examination of Facial Nerve Wrinking of Forehead Close Eyes tightly 11/28/2016 Prof.Dr.R.R.Deshpande 31
  32. 32. Examination of Facial Nerve Blow the cheeks Blow whistle 11/28/2016 Prof.Dr.R.R.Deshpande 32
  33. 33. Facial Nerve • (iii) Conjunctival and corneal reflexes • Are also the part examination of facial  nerve which we have already tested in  Trigeminal nerve. 11/28/2016 Prof.Dr.R.R.Deshpande 33
  34. 34. Examination of Facial Nerve Conjunctival Reflex Corneal Reflex 11/28/2016 Prof.Dr.R.R.Deshpande 34
  35. 35. Vestibulo Cochlear Nerve • (8) 8th Cranial Nerve - Vestibulo cochlear nerve -  • Cochlear component is concerned with position of  head and neck (balance of body).  • To test cochlear component we carry out "Test of hearing". • Rinne's test. Scbwabach test, Weber test - Basic  principle in all these tests is AC > BC, Due to  Impedance Matching, brought about by Ossicular  chain. 11/28/2016 Prof.Dr.R.R.Deshpande 35
  36. 36. Hearing Tests • (A) Rinne's Test - If BC > AC, It indicates conductive  deafness • (Nerve deafness can not be detected by Rinne's test) • (B) Schwabach Test - AC of patient is compared with  AC of doctor, BC of patient is compared with BC of  doctor. (If AC < BC  -- conductive deafness)  • If AC &  BC ,both are reduced , It indicates nerve  deafness. 11/28/2016 Prof.Dr.R.R.Deshpande 36
  37. 37. Vibrating Tuning fork for Hearing Test 11/28/2016 Prof.Dr.R.R.Deshpande 37
  38. 38. Examination of Vestibulo Cochlear Nerve Rinne’s Test Rinne’s Test 11/28/2016 Prof.Dr.R.R.Deshpande 38
  39. 39. Examination of Vestibulo Cochlear Nerve Schwabach Test Schwabach Test 11/28/2016 Prof.Dr.R.R.Deshpande 39
  40. 40. Hearing Test • (C) In Weber test - We confirm the deafness ,which is detected By Rinne's test and schwabach test. -  Vibrating tunning fork is kept on vertex and patient is  asked on which side he hears better. - Normally, he  should hear equal on both sides. If it is better on  Right side it means conductive deafness on Rt side or  nerve deafness of opposite side • All tests are done with Tunning fork, having  frequency 256 and 512. Because our ear is maximum  sensitive for these frequencies. 11/28/2016 Prof.Dr.R.R.Deshpande 40
  41. 41. Weber Test for Hearing 11/28/2016 Prof.Dr.R.R.Deshpande 41
  42. 42. Examination of 9th, 10th, 11th cranial nerves • Glossopharyngeal, Vagus, Accessory • 9th and 10th cranial nerve carry sensation from post. part of tongue as well as pharynx. • 10th cranial nerve also supplies palate,  laryngeal muscle. 11/28/2016 Prof.Dr.R.R.Deshpande 42
  43. 43. Glossopharyngeal Nerve • Patient is asked to open his mouth and say  Aa ,  (Doctor will observe position of Uvula and arches of  soft palate) • Post 1/3rd of tongue can be tested by for general  sensation  touch, as well as special sensations like  Taste.( Hold the cotton in forcep & touch on  posterior 1/3rd of  tongue & ask whether the person  feels touch ) • - Then patient is asked to drink water while  swallowing movement of larynx is to be tested. 11/28/2016 Prof.Dr.R.R.Deshpande 43
  44. 44. Examination of Glossopharyngeal Nerve Say Aa Touch Sensation 11/28/2016 Prof.Dr.R.R.Deshpande 44
  45. 45. Accessory Nerve • Accessory nerve has 2 components • Cranial component - Supplying laryngeal  muscle and another • Spinal component - Supplying sternomastoid  and trapezium 11/28/2016 Prof.Dr.R.R.Deshpande 45
  46. 46. Examination of Accessory Nerve 11/28/2016 Prof.Dr.R.R.Deshpande 46
  47. 47. Accessory Nerve • Speech is tested by asking the patient to speak out  few words.(Like asking question –What is your Name  ?) • To test palatal and pharyngeal reflex stick with  cotton is to be touched to palate or pharyngeal wall  and reflex is elicited • Spinal accessory supplies - Trapezium and Sternomastoid • Trapezium is tested by asking the patient to elevate  his shoulder, against resistance. 11/28/2016 Prof.Dr.R.R.Deshpande 47
  48. 48. Examination of Accessory Nerve Movement of Trapezium Movement of Trapezium 11/28/2016 Prof.Dr.R.R.Deshpande 48
  49. 49. Examination of Accessory Nerve •  To test sternomastoid muscle patient is asked to  turn his neck on one side and patient is asked to  press his chin on the hands of the doctor. • In this process doctor can see prominence of Sternomastoid muscle • Palatal or pharyngeal wall reflex is also the part of  9th, 10th, 11th Cranial Nerve examination. • Soft palate or post pharyngeal wall is touched with  tongue depressor or cotton stick. - patient gets  coughing sensations. 11/28/2016 Prof.Dr.R.R.Deshpande 49
  50. 50. Examination of Accessory Nerve 11/28/2016 Prof.Dr.R.R.Deshpande 50
  51. 51. 9th, 10th, 11th Cranial Nerve examination • Palatal or pharyngeal wall reflex is also the  part of 9th, 10th, 11th Cranial Nerve  examination • Soft palate or post pharyngeal wall is touched with tongue depressor or cotton stick. Patient  gets coughing sensations 11/28/2016 Prof.Dr.R.R.Deshpande 51
  52. 52. Hypoglossal Nerve • 12th Cranial Nerve - Hypoglossal Nerve – • This is purely motor nerve. • It supplies all the muscles of tongue, these  muscles bring out the movement such as  elevation, depression, protrusion, retraction  and rolling of tongue. 11/28/2016 Prof.Dr.R.R.Deshpande 52
  53. 53. Examination of Hypoglossal nerve 11/28/2016 Prof.Dr.R.R.Deshpande 53
  54. 54. Hypoglossal Nerve • The patient is asked as follows ---- • Say Aa, Take Tongue out ,Take tongue in ,Take tongue up ,Take Tongue out & down  • This is the end of the cranial nerve  examination. 11/28/2016 Prof.Dr.R.R.Deshpande 54
  55. 55. Clinical Examination of Sensory System • One should remember the following points while  carrying out examination of sensory system. • (1) Subject (patient) should be blind folded (this means, patient's eyes should be closed) and patient  has to answer with closed eyes. • (2) Identical dermatomes are to be compared for  sensation and usually we go from below upwards (i.e.  from lower extremities trunk, upper extremities and  then face) 11/28/2016 Prof.Dr.R.R.Deshpande 55
  56. 56. Clinical Examination of Sensory System Hair Asthesiometer Compass Asthesiometer 11/28/2016 Prof.Dr.R.R.Deshpande 56
  57. 57. Clinical Examination of Sensory System Compass Asthesiometere Tuning Fork 11/28/2016 Prof.Dr.R.R.Deshpande 57
  58. 58. Clinical Examination of Sensory System Key & Coin-Steregnosis Cotton wick –Crude Touch 11/28/2016 Prof.Dr.R.R.Deshpande 58
  59. 59. Clinical Examination of Sensory System Blunt end of Pencil –pressure Hot & Cold water 11/28/2016 Prof.Dr.R.R.Deshpande 59
  60. 60. Clinical Examination of Sensory System 11/28/2016 Prof.Dr.R.R.Deshpande 60
  61. 61. Types of Sensations – Fine Sensation • (i) Fine touch • (ii) Tactile localisation • (iii) Tactile discrimination • (iv) Vibration sense • (v) Joint position and muscle movement sense • Note - By testing fine sensations integrity of dorsal  column tract is tested. 11/28/2016 Prof.Dr.R.R.Deshpande 61
  62. 62. Types of Sensations – Crude Sensation • (i) Crude touch • (ii) Pressure • (iii) Temperature • (iv) Pain • Note - Integrity of spinothalamic tract is tested 11/28/2016 Prof.Dr.R.R.Deshpande 62
  63. 63. Fine sensation & Tactile Localization • Tested by Warn cruze hair Asthesiometer or even a  thin wire can be used. • The patient is suggested as follows • Ask the patient – Now I am touching this wire to  different parts of your body • By closing your eyes ,you can tell ,whether you feel the touch ? On which part of your body ,you are  feeling the touch ? On which side you are feeling the  touch – Right or Left ?  11/28/2016 Prof.Dr.R.R.Deshpande 63
  64. 64. Examination of Sensory System Touch on right side Touch on Left side 11/28/2016 Prof.Dr.R.R.Deshpande 64
  65. 65. Fine Sensation – Fixing of Dermatome Sr.No Area Dermatome 1 Near ankle  L 5 2 Below knee  L 4  3 Above knee  L 3 4 Thigh L 2  5 Above wrist  L 7  6 Below elbow  L 6  11/28/2016 Prof.Dr.R.R.Deshpande 65
  66. 66. Tactile Localization • The patient will locate the area where he is  felling fine touch ,by closing eyes  11/28/2016 Prof.Dr.R.R.Deshpande 66
  67. 67. Tactile Discrimination • Tested by Compass Asthesiometer • Tell patient as follows –  • Now I am touching 2 pointers of this  Instruments – By closing your eyes , you tell  me ,whether you are feeling touch with 1 pointer or 2 pointers ? 11/28/2016 Prof.Dr.R.R.Deshpande 67
  68. 68. Examination of Sensory System Touch on Right side Touch on Left side 11/28/2016 Prof.Dr.R.R.Deshpande 68
  69. 69. Sense of Steregnosis • The patient is asked to recognise ---- • familiar objects (pen, pencil, coin, key) given  in his hand (by shape, size and texture )  with  closed eyes 11/28/2016 Prof.Dr.R.R.Deshpande 69
  70. 70. Steregnosis Identifying Pen Identifying Coin 11/28/2016 Prof.Dr.R.R.Deshpande 70
  71. 71. Vibration sense • (5) Vibration Sense - A vibrating tunning fork having  frequency 100 Hz is kept on bony prominence such  as Tibial Tuberosity or Olecranon and subject is  asked to recognise vibration sense • Ask the patient --- Tell ,closing your eyes , whether you feel vibrations created by this Instrument ,  Tunning fork  ? 11/28/2016 Prof.Dr.R.R.Deshpande 71
  72. 72. Vibration sense On right side On Left side 11/28/2016 Prof.Dr.R.R.Deshpande 72
  73. 73. Joint position & Muscle movement sense • To test joint position sense, we do the  movements of great toe or thumb and  subject is asked to recognise that movement  with closed eyes • Tell patient – That now I am moving your  thumb up or down .Then by closing your eyes  ,you can tell me ,whether I am moving your  thumb up or down ?  11/28/2016 Prof.Dr.R.R.Deshpande 73
  74. 74. Examination for recognizing Joint Position Downward Movement Upward Movement 11/28/2016 Prof.Dr.R.R.Deshpande 74
  75. 75. Examination for recognizing Joint Position Downward Movement Upward Movement 11/28/2016 Prof.Dr.R.R.Deshpande 75
  76. 76. Fine sensations –Lost • All above fine sensations are disturbed, if  Dorsal Column Tract • Tract is damaged due to "Tabes Dorsalis (Neuro syphilis) or Tumour 11/28/2016 Prof.Dr.R.R.Deshpande 76
  77. 77. Crude Sensations • (1) Crude touch • (2) Pressure • (3) Temperature • (4) Pain • (Integrity of Spinothalamic tract is tested) 11/28/2016 Prof.Dr.R.R.Deshpande 77
  78. 78. Crude Touch • Tested by wick of  cotton wool • Identical Dermatomes are to be compared • Ask the patient ,to tell ,where he is feeling the  touch of cotton, by closing eyes ?  11/28/2016 Prof.Dr.R.R.Deshpande 78
  79. 79. Examination for Crude Touch On Right Side On Left Side 11/28/2016 Prof.Dr.R.R.Deshpande 79
  80. 80. Sense of Pressure • Blunt end of the pencil is used. It is pressed on extremities or on face and subject is asked  to recognise it • Tell patient – that I am pressing this Pencil  surface on your body .By closing eyes ,you tell  me whether you are feeling pressure & on  which part & on which side ,right or left ?  11/28/2016 Prof.Dr.R.R.Deshpande 80
  81. 81. Examination for sense of Pressure On Right Side On Left Side 11/28/2016 Prof.Dr.R.R.Deshpande 81
  82. 82. Temperature sense • Test tubes containing warm or cold water are  used Subject is asked to recognise these  sensations with his feelings • Tell patient that now you touching 2 test tubes  of hot & cold water to his body .Ask him to tell  ,by closing eyes ,which temperature touch ,he  feels –Hot or Cold ?  11/28/2016 Prof.Dr.R.R.Deshpande 82
  83. 83. Examination for Sense of Temperature On Right Side On Left Side 11/28/2016 Prof.Dr.R.R.Deshpande 83
  84. 84. Pain sensation • Pin is used. Subject is asked to recognise pain stimulus, given with pin • Tell patient that you are now touching his  body with pin prick .Ask the patient to tell ,by  closing his eyes ,whether he feels pin prick or  not ,on which part & on which side ?  • Identical Dermatomes are tested. 11/28/2016 Prof.Dr.R.R.Deshpande 84
  85. 85. Examination of Pain Sensation On Right Side On Left Side 11/28/2016 Prof.Dr.R.R.Deshpande 85
  86. 86. Crude sensations • Thus, by testing crude sensations, we have  tested integrity of Spinothalamic system •  These tracts are damaged, if there is a tumour pressing on spinal cord or if there is a disease like "Transverse Myelitis," involving spinal cord. 11/28/2016 Prof.Dr.R.R.Deshpande 86
  87. 87. Examination of Motor System • Motor system is examined under following headings.  These points are very useful in examine the patient  of Hemiplegia • (1) Nutrition • (2) Tone • (3) Power • (4) coordination • (5) Involuntary movements 11/28/2016 Prof.Dr.R.R.Deshpande 87
  88. 88. Examination of Nutrition of Muscle • Nutrition is tested by measuring circumference of muscle, at its bulk and  comparing circumference of left and right side • e.g. Circumference of calf muscle can be  measured by fixing the distance from bony  prominence. 11/28/2016 Prof.Dr.R.R.Deshpande 88
  89. 89. Examination of Nutrition of Muscle • e.g. 6 inches below Tibial tuberosity. Measure the circumference of right and left calf muscle at a same distance. • Similarly circumference of thigh muscle, from  a fixed bony prominence like Tibial Tuberosity  or ASIS (Anterior Superior Iliac Spine) can be  compared 11/28/2016 Prof.Dr.R.R.Deshpande 89
  90. 90. Nutrition of Muscle Measuring from Fixed distance Measuring Circumference 11/28/2016 Prof.Dr.R.R.Deshpande 90
  91. 91. Examination of Nutrition of Muscle • In the same manner, for the upper extremity -  circumference of forearm and arm muscles  can be compared from a fixed bony  prominence like olecranon process • When circumference of both right and left sides is normal it indicates nutrition of these muscles is normal 11/28/2016 Prof.Dr.R.R.Deshpande 91
  92. 92. Nutrition of Muscle Right side Measuring Circumference 11/28/2016 Prof.Dr.R.R.Deshpande 92
  93. 93. Examination of Nutrition of Muscle • In right sided person circumference of right  sided muscle can be slightly more. This is  physiological • Atrophy of muscle is seen in LMN lesion like polio myelitis 11/28/2016 Prof.Dr.R.R.Deshpande 93
  94. 94. Tone of Muscle • Tone of a muscle is a partial state of contraction. It is maintained by stretch reflex. • Tone of the muscle is tested by 2 ways • (a) By examining feel of the muscle • (b) Tone can be seen by Resistance offered to  passive Movements. 11/28/2016 Prof.Dr.R.R.Deshpande 94
  95. 95. Tone of Muscle Tone of Leg Muscle Tone of Thigh Muscle 11/28/2016 Prof.Dr.R.R.Deshpande 95
  96. 96. Tone of Muscle • Doctor can feel muscle at its bulk and he can  compare the feel on right and left side  • e.g. doctor can observe the feel of calf muscles, thigh and muscles of bicep and triceps 11/28/2016 Prof.Dr.R.R.Deshpande 96
  97. 97. Tone of Muscle Bicep Muscle Tone Tone –Forearm muscle 11/28/2016 Prof.Dr.R.R.Deshpande 97
  98. 98. Tone of Muscle • Normal feel is Elastic. • Second method of examination of Tone is to  see resistance offered to passive Movements • Patient is not moving his extremities but the  doctor is carrying out passive movements 11/28/2016 Prof.Dr.R.R.Deshpande 98
  99. 99. Tone of Muscle • Doctor can do passive movements at knee  joint to test the tone of flexors and extensors  of knee • When doctor is doing flexion of knee, he is testing tone in extensors. When doctor is doing extension at knee he is testing Tone of flexors 11/28/2016 Prof.Dr.R.R.Deshpande 99
  100. 100. Tone of Muscle Passive movement Passive movement 11/28/2016 Prof.Dr.R.R.Deshpande 100
  101. 101. Tone of Muscle • For testing upper extremities, same  movements can be done at elbow • Doctor can test Tone of biceps and triceps and  he can compare the Tone at other side. When doctor is carrying flexion at elbow he is testing Tone in triceps. When doctor is carrying extension in elbow he is testing tone in biceps 11/28/2016 Prof.Dr.R.R.Deshpande 101
  102. 102. Tone of Muscle Elbow Flexion Elbow Extension 11/28/2016 Prof.Dr.R.R.Deshpande 102
  103. 103. Tone of Muscle • In lower and upper extremities, when  resistance offered is moderate, it indicates  tone is normal • Hypertonia is seen in UMN lesion • Hypotonia is seen in LMN lesion 11/28/2016 Prof.Dr.R.R.Deshpande 103
  104. 104. Power of Muscles • Power is graded under fine grades as follows • Grade O - No movements at all. • Grade 1 - Only flicking movement are visible but no  movements possible • Grade 2 - If movement is occurring horizontally but  not able to lift against gravity. • Grade 3 - If subject is able to lift up leg or hand,  against gravity • (compare the right and left side) 11/28/2016 Prof.Dr.R.R.Deshpande 104
  105. 105. Power of Muscle Grade 3 Power Grade 3 Power 11/28/2016 Prof.Dr.R.R.Deshpande 105
  106. 106. Power of Muscles • Grade 4 - Patient is able to move his  extremities against resistance • Grade 5 - Patient is able to lift the extremities  against the good resistance applied by the  doctor. 11/28/2016 Prof.Dr.R.R.Deshpande 106
  107. 107. Power of Muscle Grade 4 Power Grade 4 Power 11/28/2016 Prof.Dr.R.R.Deshpande 107
  108. 108. Power of Muscle Grade 5 Power Grade 5 Power 11/28/2016 Prof.Dr.R.R.Deshpande 108
  109. 109. Power of Muscles • In the same manner, power of  extensors of hip, flexors of knee (Ask  the patient to bend the knee )  extensors of knee (Extend leg by  making knee straight ) can be  compared. 11/28/2016 Prof.Dr.R.R.Deshpande 109
  110. 110. Power of Muscles • Even planter flexors, dorsi flexors of foot can  be compared • In upper extremity, flexors and extensors of  elbow can be compared, flexors and extensors  of wrist can be compared • Movements at shoulder such as flexion, extension, abduction, adduction can be tested for power 11/28/2016 Prof.Dr.R.R.Deshpande 110
  111. 111. Power of Muscles • For testing power in the neck muscle, patient  is asked to lift his neck up in lying down  position • Ask the patient to lift the neck ,put down the  head .Then ask patient to lift the neck ,when  doctor is pressing on forehead  11/28/2016 Prof.Dr.R.R.Deshpande 111
  112. 112. Power of Muscle Grade 4 Power Grade 4 Power 11/28/2016 Prof.Dr.R.R.Deshpande 112
  113. 113. Power of Muscles • Complete loss of power is called as 'paralysis' which is typical feature of LMN lesion like  polio myelitis • Partial loss of power is called as "paresis"  which is typically seen in Hemiplegia or  Paraplegia. 11/28/2016 Prof.Dr.R.R.Deshpande 113
  114. 114. Coordination of Muscles • (A) Coordination of muscles in upper  extremity is tested by following tests • (1) Finger - Nose - finger test • (2) Rapid pronation and supination of palm (Dysdiadochokinesia) 11/28/2016 Prof.Dr.R.R.Deshpande 114
  115. 115. Coordination of Muscles • (B) for lower extremity, following tests • (1) Knee - heel test • (2) Walking in straight line • All tests of co-ordination should be done with  open eyes first and then with closed eyes, to  differentiate between sensory Ataxia and  cerebellar Ataxia (Motor ataxia) 11/28/2016 Prof.Dr.R.R.Deshpande 115
  116. 116. Coordination of Muscles • Ask the patient ,by closing the eyes ,he should  try to touch Index finger of the left hand by his  index finger of right hand & then same right  hand finger should touch to his nose tip  • Same procedure is repeated with Left hand  Index finger •   • This is Finger – Nose – Finger Test 11/28/2016 Prof.Dr.R.R.Deshpande 116
  117. 117. Coordination of Muscle Finger- Nose –Finger Test Finger –Nose –Finger Test 11/28/2016 Prof.Dr.R.R.Deshpande 117
  118. 118. Coordination of Muscles • Ask the patient to perform Pronation &  Supination activity of both hands ,speedily  (diadochokinesia) --- • Check ,whether patient can do it for both the  hands  11/28/2016 Prof.Dr.R.R.Deshpande 118
  119. 119. Coordination of Muscle Diadochokinesia Diadochokinesia 11/28/2016 Prof.Dr.R.R.Deshpande 119
  120. 120. Coordination of Muscles • Kneel Heel Test – Ask the patient to sit on  table or lie down on bed  • First keep right heel on left knee & take the  heel down along with shin of tibia ,till left foot  • Perform Same procedure by keeping left heel  on right knee & taking down heel along with  the shin of tibia ,up to right foot  11/28/2016 Prof.Dr.R.R.Deshpande 120
  121. 121. Coordination of Muscle Knee-heel Test Knee –heel Test 11/28/2016 Prof.Dr.R.R.Deshpande 121
  122. 122. Coordination of Muscles • Ask the patient to stand straight ,by keeping both  feet near to each other – First stand with eyes open  & then stand with close eyes  • Doctor has to see ,whether patient can maintain  balance of his body  • If patient cannot stand straight, and he swings with  closed eyes - It is called as, "positive Rhomberg's sign", which is typical sign of Dorsal column tract damage. 11/28/2016 Prof.Dr.R.R.Deshpande 122
  123. 123. Rhomberg's sign 11/28/2016 Prof.Dr.R.R.Deshpande 123
  124. 124. Coordination of Muscles • Straight line walking Test – Ask the patient to  stand at one end of the 8 feet straight line  • Then ask him to walk on this line to & fro – First with open eyes & then with close eyes   11/28/2016 Prof.Dr.R.R.Deshpande 124
  125. 125. Straight line walking Test Walk on Straight line Return back –on straight line 11/28/2016 Prof.Dr.R.R.Deshpande 125
  126. 126. Coordination of Muscles • If patient walks correctly with open eyes, but looses  balance with closed eyes - It indicates damage lies in  dorsal column tract (which is called as sensory ataxia) • If patient is not able to walk with open or closed eyes  – damage is in cerebellum (it is cerebellar or Motor ataxia) 11/28/2016 Prof.Dr.R.R.Deshpande 126
  127. 127. Involuntary Movements • 3 types • (1) Fine Tremors – In Thyrotoxicosis • Tachycardia, weight loss, Intolerance to heat  atmosphere ,Feeling excessive heat all the  time 11/28/2016 Prof.Dr.R.R.Deshpande 127
  128. 128. Involuntary Movements • (2) Pin rolling tremors at rest – • In Parkinsonism – This disease develops due  to deficiency of Dopamin neutrotransmitter in  Basal Ganglia   • Tab Carbidopa is used to compensate this  deficiency • (3) Action tremor - In cerebellar diseases 11/28/2016 Prof.Dr.R.R.Deshpande 128
  129. 129. Involuntary Movements Fine Tremors Pin rolling Tremors 11/28/2016 Prof.Dr.R.R.Deshpande 129
  130. 130. Involuntary Movements –Action Tremor 11/28/2016 Prof.Dr.R.R.Deshpande 130
  131. 131. Advantage of Motor System Examination • Advantage of motor system examination, over  sensory system examination is that ---  • (1) Even if patients cooperation is not there we can draw few conclusions like - UMN  lesion, LMN lesion, Parkinsonism, Cerebellar • ataxia ,Sensory ataxia. 11/28/2016 Prof.Dr.R.R.Deshpande 131
  132. 132. Advantage of Motor System Examination • (2) In sensory system examination, if patient is  non-co-operative then he can not answer the  doctor's questions and then examination is of  no value • However, sensory system examination is important to detect the level of damage in spinal cord. 11/28/2016 Prof.Dr.R.R.Deshpande 132
  133. 133. Superficial Reflexes – Root values Sr.No Reflex Root Value 1 Conjunctival reflex 5th and 7th cranial nerve 2 Corneal reflex 5th and 7th cr. N 3 Pharyngeal reflex 9th, 10th, 11th cr. N 4 Abdominal reflex T6 to L1 5 Plantar reflex L5, Si, S2 11/28/2016 Prof.Dr.R.R.Deshpande 133
  134. 134. Deep Reflexes – Root values Sr.No Reflex Root Value 1 Bicep jerk C5, C6 2 Triceps jerk C6, C7, C8 3 Supinator jerk C5, C6 4 Knee jerk L2, L3, L4 5 Ankle jerk L5, S1, S2 11/28/2016 Prof.Dr.R.R.Deshpande 134
  135. 135. Reflexes • In superficial reflexes --- receptors are in skin  or mucous membrane • In deep reflexes ----  receptors are in muscles  or tendons. 11/28/2016 Prof.Dr.R.R.Deshpande 135
  136. 136. Superficial Reflex – Conjunctival Reflex • Doctor will touch wisp of the cotton wool to  the white portion of eye i.e. Bulbar   conjunctiva • Response is closer of both eyes 11/28/2016 Prof.Dr.R.R.Deshpande 136
  137. 137. Conjunctival Reflex For Right Eye For Left Eye 11/28/2016 Prof.Dr.R.R.Deshpande 137
  138. 138. Superficial Reflex –Corneal Reflex • Doctor will touch the wisp of cotton wool to black portion of eye i.e. cornea closer of both  eyes is normal response • NOTE : Conjunctival and corneal reflexes have  already been tested in examination of  trigeminal and facial nerve. If these nerves are  damaged reflexes are lost 11/28/2016 Prof.Dr.R.R.Deshpande 138
  139. 139. Corneal Reflex For Right Eye For Left Eye 11/28/2016 Prof.Dr.R.R.Deshpande 139
  140. 140. Palatal & Pharyngeal Reflex • Doctor will touch soft palate or post pharyngeal wall with tongue depressor • Doctor will expect a response in the form of  coughing • If the patient is getting coughing sensation - It  means 9th, 10th, 11th cranial nerves involving  in this reflex are normal 11/28/2016 Prof.Dr.R.R.Deshpande 140
  141. 141. Palatal & Pharyngeal Reflex Ready with Tongue Depressor Touch Post Pharyngeal wall 11/28/2016 Prof.Dr.R.R.Deshpande 141
  142. 142. Abdominal Reflexes • Imp precaution to be carried out is that -  abdomen should be relaxed, by flexing  knee • Ask the patient to lie down his back &  flex the knees & relax abdominal muscles 11/28/2016 Prof.Dr.R.R.Deshpande 142
  143. 143. Abdominal Reflexes Mid abdominal Reflex Away from Umbilicus 11/28/2016 Prof.Dr.R.R.Deshpande 143
  144. 144. Abdominal Reflexes • Now, blunt end of hammer is moved,  radiating away from umbilicus in all directions • While testing this reflex abdominal muscle will  show a movement, in the form of the  response • Abdominal reflexes are classified into upper  abdominal, mid abdominal and lower  abdominal reflexes 11/28/2016 Prof.Dr.R.R.Deshpande 144
  145. 145. Abdominal Reflex – Root value Sr.No Part Of Abdomen Root Value 1 Upper abdominal reflex T6 to T9 2 Mid abdominal reflex T9 to T11 3 Lower abdominal reflex T11 to L1 11/28/2016 Prof.Dr.R.R.Deshpande 145
  146. 146. Abdominal Reflexes • In obese patients, abdominal reflexes  may not be elucidated. In such cases,  unilateral absence of abdominal reflex is  important finding • Abdominal reflexes are lost in UMN lesion like hemiplegia or paraplegia. 11/28/2016 Prof.Dr.R.R.Deshpande 146
  147. 147. Superficial Reflex – Plantar Reflex • Root value of the plantar reflex is L5, S1, S2. • Scratch sole of the foot from heel to toes,  along lateral border and then medially. This  scratching is done with blunt portion of  hammer • Perform it on both sides & compare  11/28/2016 Prof.Dr.R.R.Deshpande 147
  148. 148. Babinski's sign Left Plantar Reflex Right Plantar Reflex 11/28/2016 Prof.Dr.R.R.Deshpande 148
  149. 149. Superficial Reflex – Plantar Reflex • Normal response is plantar flexion of all toes • If dorsiflexion of great toe and fanning of other toes is seen then diagnosis is positive  Plantar reflex or positive Babinski's sign • This will be seen UMN lesion like hemiplegia or in meningeal irritation (Meningitis) 11/28/2016 Prof.Dr.R.R.Deshpande 149
  150. 150. Deep Reflex – Bicep Jerk • For testing deep reflexes, special method is  adopted which is called as the Jendrassik maneuver   ----  • which is a medical  maneuver wherein the  patient clenches the teeth, flexes both sets of  fingers into a hook-like form and interlocks  those sets of fingers together 11/28/2016 Prof.Dr.R.R.Deshpande 150
  151. 151. Deep Reflex – Bicep Jerk Tap Bicep Tendon Contraction of Bicep muscle 11/28/2016 Prof.Dr.R.R.Deshpande 151
  152. 152. Jendrassik maneuver  • By this manual, gamma motor neuron discharge is decreased and reflex is obtained  properly  • Bicep jerk - Doctor will tap bicep tendon -  contraction of biceps muscle is important,  rather than flexion of forearm.  • We compare the reflex on both sides. Root  value of this reflex is C5, C6. 11/28/2016 Prof.Dr.R.R.Deshpande 152
  153. 153. Deep Reflex – Tricep Reflex • Doctor will give a tap just above Olecranon process, which is Tricep tendon • Do  Jendrassik maneuver • Contraction of the muscle is more important  than extension of forearm  • Compare the reflex on other side. Root value  of this reflex is C 7, C 8. 11/28/2016 Prof.Dr.R.R.Deshpande 153
  154. 154. Deep Reflex – Tricep Reflex Tap above Olecranon Process Contraction of Muscle 11/28/2016 Prof.Dr.R.R.Deshpande 154
  155. 155. Deep Reflex – Supinator Reflex or wrist Jerk Reflex • Tap is given just above the head of radius.  Doctor can see the contraction of  brachioradialis muscle  • Compare the reflex on another side • Root value is C5, C6. 11/28/2016 Prof.Dr.R.R.Deshpande 155
  156. 156. Supinator Reflex or wrist Jerk Reflex Left Wrist jerk Right wrist jerk 11/28/2016 Prof.Dr.R.R.Deshpande 156
  157. 157. Deep Reflex – Knee Jerk • For testing this reflex, exposer of Quadriceps muscle  is important, so that the doctor can see the  contraction of this muscle • Doctor keeps his hand below the knee, patient is  asked to relax. Divert the patients attention by   Jendrassik maneuver •  Ask the patient to clench the teeth  • Give a tap on patellar tendon i.e. between patella  and Tibial Tuberosity. 11/28/2016 Prof.Dr.R.R.Deshpande 157
  158. 158. Deep Reflex – Knee Jerk • Contraction of Quadriceps muscle is  Important response • Root value is - L2, L3, L4 11/28/2016 Prof.Dr.R.R.Deshpande 158
  159. 159. Deep Reflex – Knee Jerk Right Knee Reflex Left Knee Reflex 11/28/2016 Prof.Dr.R.R.Deshpande 159
  160. 160. Deep Reflex – Ankle Jerk • For this reflex gastrocnemius muscle should be  exposed. Tapping of the gastrocnemius tendon, just above the heel is stimulus  • Doctor will make forceful dorsiflexion of foot  and give a tap on tendon. Contraction of  gastrocnemius is the response. Compare the  reflex on other side • Root value is L5, S1, S2 11/28/2016 Prof.Dr.R.R.Deshpande 160
  161. 161. Deep Reflex – Ankle Jerk Right Ankle Jerk Left Ankle Jerk 11/28/2016 Prof.Dr.R.R.Deshpande 161
  162. 162. Importance of Testing Reflexes • Examination of the reflexes is most imp part in  examination of the nervous system. • Advantage of this examination than motor and  sensory examination is that - "It does not require  patient's co-operation." • Various diseases, specially UMN lesion and LMN lesion can be differentiated by examination of deep reflexes • Even if patient is unconscious, non-cooperative - These reflexes will give important clues. 11/28/2016 Prof.Dr.R.R.Deshpande 162
  163. 163. Importance of Testing Reflexes • In UMN lesions - Deep reflexes are exaggerated  • (Jerks will be very much prominent) • Even clonus can be seen at knee and ankle  (where muscle jerk oscillates for longer time) • Clonus is always pathological. It is seen in UMN lesion 11/28/2016 Prof.Dr.R.R.Deshpande 163
  164. 164. Examination of Spine & Cranium • Spine is to be inspected from cervical to sacral  region for noticeing abnormality • With knuckles of fingers ,doctor can give deep pressure on spine and ask the patient whether he gets pain sensation. 11/28/2016 Prof.Dr.R.R.Deshpande 164
  165. 165. Examination of Spine & Cranium Cervical to Sacral With knuckles 11/28/2016 Prof.Dr.R.R.Deshpande 165
  166. 166. Examination of Spine & Cranium • For testing cranium deep pressure is to be given on skull, from all angles and patient is  asked, "Whether he gets pain sensation" ? • If there are abnormalities of the spine, if  there are conditions like hydrocephalus. This  test will give intense pain. 11/28/2016 Prof.Dr.R.R.Deshpande 166
  167. 167. Examination of Spine & Cranium Deep pressure from all angles Deep pressure from all angles 11/28/2016 Prof.Dr.R.R.Deshpande 167
  168. 168. Examination of Gait Sr.No Gait Disease 1 Circumduction gait Hemiplegia 2 Jerky gait Parkinsonism 3 Drunk man's gait Cerebellar disease 4 Spastic gait Paraplegia 5 Flaccid gait Polio-myelitis. 6 Scissors gait Diplegia 11/28/2016 Prof.Dr.R.R.Deshpande 168
  169. 169. Abnormal Gait Circumduction gait Drunken Gait 11/28/2016 Prof.Dr.R.R.Deshpande 169
  170. 170. Abnormal Gait Parkinson’s Gait Polio Gait 11/28/2016 Prof.Dr.R.R.Deshpande 170
  171. 171. Abnormal Gait 11/28/2016 Prof.Dr.R.R.Deshpande 171
  172. 172. Abnormal Gait – Scissor Gait 11/28/2016 Prof.Dr.R.R.Deshpande 172
  173. 173. Examination of Special Signs • Neck rigidity - in Meningitis • High Fever, severe Headache, projectile  vomiting, positive Babinskis sign & positive  Kerning's sign - usually present in  Meningococcal Meningitis 11/28/2016 Prof.Dr.R.R.Deshpande 173
  174. 174. Prof.Dr.R.R.Deshpande • Sharing of Knowledge  • FOR  • Propagating Ayurved 11/28/2016 174Prof.Dr.R.R.Deshpande

    Be the first to comment

    Login to see the comments

  • KapilKumar532

    Apr. 20, 2021
  • Elaquaking

    Apr. 25, 2021
  • Navamichandran1

    Apr. 30, 2021
  • anandanu10

    May. 7, 2021
  • MohammadTausif13

    May. 8, 2021
  • UsaidSulaiman

    May. 9, 2021
  • TarannumNisha3

    May. 17, 2021
  • AneeshRaveendran4

    May. 21, 2021
  • VaibhaviPatel55

    May. 25, 2021
  • Anthonywanyama2

    Jun. 1, 2021
  • STEPHENBAMAI

    Jun. 7, 2021
  • sanamehmood17

    Jun. 16, 2021
  • HemaPriyankaAnnamraju

    Jun. 22, 2021
  • VarshithaRamisetty

    Jun. 25, 2021
  • SurajRawat7

    Jun. 26, 2021
  • NaveenBharathy

    Jun. 28, 2021
  • DhruvrajsinhChavda

    Jul. 3, 2021
  • EvaRajbhandari1

    Jul. 19, 2021
  • SudarshanaRaoGD1

    Jul. 28, 2021
  • HonMikaye1

    Jul. 29, 2021

Clinical Examination of Nervous System - PPT -- By Prof. Dr. R. R. Deshpande • This PPT explains how to perform Central Nervous System Examination systematically & step by step .This includes (1) Examination for higher functions (2) Examination of cranial nerves (3) Examination of sensory system (4) Examination of motor system (5) Examination of reflexes (6) Examination of gait (7) Examination of spine and cranium (8) Examination for special signs (such as cerebellar signs) • Visit – www.ayurvedicfriend.com • Phone – 922 68 10 630

Views

Total views

29,470

On Slideshare

0

From embeds

0

Number of embeds

11

Actions

Downloads

1,660

Shares

0

Comments

0

Likes

424

×