CNS exam by zerosoul

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									CNS Examination
Common Presenting Symptoms: 1. Headache: When there is a pain, please remember SOCSRATE: ite: Unilateral/Bilateral? Localization/Generalized? nset: When? Quick/Gradual? haracter: Use patient’s own description, sharp/ dull? Throbbing? everity adiation ssociating factor: Lacrimation, rhinorrhoea? iming: Last for how long? xacerbating/relieving factor: e.g. trigger by light? Several typical headache: - Unilateral, throbbing, associated with nausea, Last from 6hr–3days then weeks/months pain-free interval Classic Migraine - Similar to classic migraine, but without other focal symptom, can be cyclical (in women, menstruation can trigger) Common migraine - Unilateral , localized in cheek/temple/around eye, excruciating, with ptosis/lacrimation/rhinorrhoea, last from 30min – 3hr Cluster headache - Bilateral, ‘Like a tight band’, worst to end of day Tension headache Some typical and important diagnosis: - Generalized, with drowsiness, vomiting raise ICP - Generalized, gradual onset, with fever & stiff neck meningitis - Unilateral, knife-like/burning, affect single nerve innervation, last seconds 1 time, and recurr over several min neuralgia (* some neuralgia e.g. CN V&IX trigger by some activity e.g. brush teeth, shaving, eating) - Sudden onset, bilateral locate by patient with snaps of finger, worst in occipital region. With nausea /vomiting/impair conciousness/ meningial irritation sign Subarachnoid heamorrhage - Unilateral, sudden onset, throbbing, with general malaise if patient has recent onset aged > 55yr, consider temporal arteritis 2. Syncope, seizure: Definition: Syncope = loss of consciousness due to recoverable loss of cerebral blood flow - Caridac syncope = syncope due to reduce cardiac output - Vasovagal = syncope due to peripheral vasodilation Seizure(fit) = loss of consciousness due to dysfunction of electric control of brain - Partial seizure = seizure not affect only part/one side body - Complex partial seizure = impair consciousness in seizure - Simple partial seizure = no impair consciousness in seizure IMPORTANT: differentiate syncope with epilepsy (generalized tonic clonic seizure) 3. Dizziness If a patient complain of this, determine what does this mean first syncope? Seizure? Vertigo? Vertigo = Mismatch of visual, proprioceptive, vestibular information to brain * Vertigo can be peripheral (benign poSitioning vertigo, acute labyrinthinitis, vestibular neuronitis) or central (leision affecting vestibular nuclei in brain stem) Some rare cause of vertigo: - Ototoxic drugs e.g. aminglycoside (with deafness/tinnitus) - Acoustic neuroma - Vertibrobasilar transient isvhemic attack (with diploopia, visual loss, ataxia) - Internal auditory artery occulsion 4. Visula disturbance Diplopia?Amblyopia (blurred vision)? Light intolerance (photophobia)? Visual loss? 5. Fall 4 major reasons: - Simple accident - Acute illness cause collapse - Syncope - Multiple risk factor Disease (e.g. cerebrovascular, Alzheimer’s, Parkinson’s disease) Disability (Impair balance – vision/gait disturbance) Drug (side effect) 6. Disturbance of gait, vision, sensation 7. Tremor, involuntory movement Resting tremor Parkinsonism Intention tremor Physiological (anxiety), thyrotoxicosis 8. Speech, metal ststus problem General examination: 1.Consciousness: Use Glasgow coma scale >13 = mild injury, 9-12 = moderate, <8 = severe

2. Neck stiffness: (*any patient with neurologic al symptom and febrile MUST assess for meningitis) Check flexion resistance: hand under occiput, gently flex neck without patient’s assistance Reason for meninge irritate sign: - Meningitis - Blood in subarachnoid space (subarachnoid hemorrhage) - Cervical spondylosis - After cervical fusion - Parkinson’s disease - Raise ICP Suspect meningitis: Check Kernig’s sign: flex hip, then extend knee, if limited spasm of hamstring

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3. Higher center & speech A. Handedness (L/R handed)? B. Orientation (Person: ask patient his/her name, Place: Ask present location, Time: Ask patient date) Disorientation acute, reversible = delirium, chronic, irreversible = dementia C. Speech (disorder in using symbol of communication dysphasia, diff. with articulation dysarthria, altered quality of voice dysphonia) Dysphasia: Receptive cannot understand spoken/written word, lesion in Wernicke’s area. Expressive understand other’s say, cannot answer appropriate, lesion in Broca’s area Nominal diff. naming things, lesion in temporal parietal area Conductive Repeat statements, can follow commands, name objects poorly, lesion in arcuate faciculus Dysarthria: Bilateral upper motor neuron lesion (Pseudobulbar palsy) smal, spasctic tone, like squeeze out words from mouth Lower motor neuron lesion (Bulbar palsy) toNe depeNd on which gp. Of nerve affected e.g. weakness in tongue cause diff. in lingual pronounce, palatal weakness cause nasal speech Extrapirimidal monotonous speech Cerebellar disease loss of coordination, slow, slurred, explosive speech Dysphonia: Recurrent laryngeal nerve palsy, laryngeal disease

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Cerebral hemisphere signs

MINI-MENTAL STATE EXAMINATION (MMSE) A) ORIENTATION What is the (year) (month) (date) (day) (month)? Max:5 Where are we: (state) (county) (town or city) (hospital) (floor)? Max:5 1pt. For each () B) REGISTRATION Max:3 -Name 3 common objects (eg., "apple, table, penny"): - Take 1 second to say each. Then ask the patient to repeat all 3 after you have said them. Give 1 point for each correct answer. - Then repeat them until he/she learns all 3. Count trials and record. Trials up to 6 C) ATTENTION AND CALCULATION Max:5 Serial 7’s backwards. Count 100 backward by seven Give 1 point for each corrEct answer. Stop after 5 answers (100,93,86,79,65). Alternatively, spell "WORLD" backwards. One point for each correct letter. D) LANGUAGE Name 2 objects shown e.g. "pencil," and "watch." 1pt. For each correct ans, Max:2 Repeat the following: "No ifs, ands, or buts." Max:1 Follow a 3-stage command, 1pt. For each correct step E.g."Take a paper in your right hand, fold it in half, and put it on the floor." Read and obey the following, 1pt. Each, Max:3: Close your eyes. Write a sentence. Score if it is sensible and has a subject and a verb Copy the following design: intersecting pentagons, all 10angle present, 2 shape intersect Total:30, 21-29 mild cognitive impair, <20 severe cognitive impair (dementia)

Cranial Nerve Exam
Inspection: - Scar - Skin leision - Lumps e.g. lymph node - Dysmorphism - Asymmetry in eyelid, skin crease, facial muscle

CN I: Olfactory nerve 1. Ensure nasal passage clear 2. Ask patient close eye, use finger to shut 1 nostril. 3. Present common available odour e.g. coffee, DO NOT use irritant e.g. ammonia Loss sense of smell anismia parosmia Altered sense of smell *olfactory hallucination is feature of complex partial seizure

CN II: Optic nerve Inspection ptosis, pupil size, symmetry, regularity Visual Acuity: Ask patient if he/she can see, or need glasses, use Snellan chart, test each et separate If can’t see number count finger move finger light Rapid onset bilateral reduce visual acuity bilateral occiputal lobe infarct/trauma, methanol damage Gradual onset bilateral reduce visual acuity cataract, acute glaucoma, macular degeneration, diabetic retinopathy

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CN II: Optic nerve (cont’) Visual field confrontation test

CN III: Oculomotor nerve Inspect pupil size & symmetry Pupil movEMent (light reflex): Direct reflex, Consensual reflex, Accommodation reflex (REMEMBER reflex pathway is afferent: II, efferent: III) CN III, IV, VI (eye move) Inspect any deviation and ask any diplopia. Move finger in H shape, ask the patient to tell you when they see 2 fingers Find diplopia, nystagmus, lid lag (show exophthalmic goitre or CN III abnormal) CN V: Sensory: - Test light touch & superficial pain in V1, V2, V3 region - Test touch sensation in anterior 2/3 tongue with orange stick Motor: - Look for muscle wasting - Ask patient to clench teeth, feel the bulk of mastication muscle Corneal reflex (afferent: V1, efferent: VII) Jaw Jerk: Brisk jerk bilateral upper motor neuron lesion above pons CN VII: Facial Nerve Motor: Upper face: Wrinkle forehead/look upward, Screw eyes tightly Lower face: Blow out cheek with mouth close optic atrophy Facial weakness: Only lower face face lower motor neuron lesion CN IX: Glossophayngeal and Vagus nerve Ask patient to speak Push down tongue, ask patient say aaah, check any uvula deviation, asymmetry, atrophy (if move to right, left side is paralysed) Gag reflex (afferent IX, efferent: X) Test taste CN VIII: Whisper test Rinne’s and Weber’s test Check conduction deafness & sensorineural deafness upper motr neuron lesion, Both up amd low

Fundoscopy: 1. Clarity of optic disc edge, blurred papilloedema 2. Optic disc color: normal should be rich yellow, if white 3. 4 Quadrants of retina for diabetic, hypertensive change CN XI: - Inspect any asymmetry/ wasting of SCM & trapezius - Test the muscle power of SCM & trapezius CN XII: Ask patient protrude tongue slightly, inspect any deviation, wasting, fasciculation, involuntary movement.

Upper Limb Examination
Principle sequence, always remember the following procedure: 1. Motor system - Gen. inspection (Posture, Muscle bulk, Abnormal movement) - Fasciculation - Tone - Power - Reflex - Co-ordination 2. Sensory System - Pain, Temp. - Light tough - Proprioception Upper Limb: Inspection: Muscle Bulk wasting Lower motor neuron lesion Prolonged upper motor neuron lesion disuse wasting Rheumatoid arthritis small hand muscle wasting Cachexia widespread wasting Fasciculation If cannot observe any fasciculation, slightly tap muscle Fasciculation lower motor neuron lesion, with wasting Myoclonic jerk: sudden shock-like contraction May associate with epilepsy, diffuse brain damage, dementia Tremor: Physiological hyperthyroidism, alcohol, caffee Intention cerebellar sign Resting Parkinsonism Other involuntary movement (Dyskinesia) drug side effect e.g. neuroleptics, anti-parkinsonian agent) Dystonia gradual develop abnormal posture Chorea/athetosis

Tone: Elbow joint: flexion/extension Wrist joint: flexion/ extension/ circumduction, pronation/supination Muscle tone abnormality: Hypotonia lower motor neuron lesion (*can indicate cerebeller leision as loss of facilitatory influence on spinal motor neuron) Hypertonia: 2 main type a)spasticity b)rigidity Spasticity: velocity-dependent resistance to passive movement upper motor neuron lesion Rigidity: sustain resistance throughtout range of movement A)‘Cog-wheel’ rigidity Parkinsonism B) Clasp-knife rigidity: tone resist passive movement initially, then give-away Lesion in the corticospinal tract C) Decerebrate rigidity: Involuntary extension of the upper extremities in response to external stimuli brain stem damage, specifically damage below the level of the red nucleus Muscle Power: Present with MRC grade: 5: normal power 4: Moderate against resistance 3: cannot against resistance, but against gravity 2: can move when exclude gravity 1: can flicker of contraction 0: complete prarlysis Shoulder: Abduction: deltoid, supraspinatus (C5) Adduction: Pec. Major, latissimus dorsi (C6,7,8) Elbow: Flexion: bicep brachialis (C5,6) Extension: tricep (C7,8) Wrist: Flexion: Flexor carpi radialis/ulnaris (C6,7) Extension: Extensor carpi gp. (C6,7) Finger: Flexion: Flexor digitorum superficialis/profundus (C7,8) Abduction: Interossei (T1)

Sensory: Spinathalamic pathway: Pain and temp - Pain: don’t use metal pin - Temp: use tuning fork PCML: Vibration, proprioception, light touch - Vibration: 128Hz fork place on distal joint, Move to proximal if cannot feel - Proprioception: Test distal joint first, Move to proximal if fail - Light touch: cotton wool, compare 2 side

Reflex: Bicep jerk (C5,6) Tricep jerk (C7,8) Brachioradialis jerk (C5,6) Cerebellum f(x) (coordination): Rebounding Finger-nose test Rapid alternating movement (pronate and supinate quickly, dysdiadochokinesia) if movement is slow and clumsy

Lower Limb Examination
Principle sequence, always remember the following procedure: 1. Motor system - Gen. inspection (Posture, Muscle bulk, Abnormal movement) - Fasciculation - Tone - Power - Reflex - Co-ordination 2. Sensory System - Pain, Temp. - Light tough - Proprioception Lower Limb: Inspection: Muscle Bulk Lower motor neuron lesion wasting Prolonged upper motor neuron lesion disuse wasting Cachexia widespread wasting Fasciculation If cannot observe any fasciculation, slightly tap muscle Fasciculation lower motor neuron lesion, with wasting Myoclonic jerk: sudden shock-like contraction May associate with epilepsy, diffuse brain damage, dementia Tremor: Physiological hyperthyroidism, alcohol, caffee Intention cerebellar sign Resting Parkinsonism Other involuntary movement (Dyskinesia) drug side effect e.g. neuroleptics, anti-parkinsonian agent) Dystonia gradual develop abnormal posture Chorea/athetosis

Tone: Rock the leg to and fro Check full range movement of knee Ankle clonus: bend knee & ankle to 90 degree, then dorsiflex ankle brisky, normal should vibrate<5 time Knee clonus: sharply push patella toward foot Muscle tone abnormality: Hypotonia lower motor neuron lesion (*can indicate cerebeller leision as loss of facilitatory influence on spinal motor neuron) Hypertonia: 2 main type a)spasticity b)rigidity Spasticity: velocity-dependent resistance to passive movement upper motor neuron lesion Rigidity: sustain resistance throughtout range of movement A) Lead-pipe/plastic rigidity Parkinsonism B) Clasp-knife rigidity: tone resist passive movement initially, then give-away Lesion in the corticospinal tract

Muscle Power: Present with MRC grade(see upper limb exam): Hip: Flexion: psoas, iliacus (L2,3) Adduction: Adductor longus, brevis, magus (L2,3) Extension: gluteus maximus (L4,5) Abduction: gluteus medius, minimus, sartorius, tensor fascia lata (L4,5) Knee: Flexion: Hamstrings (L3,4) Extension: Quadricep (L5,S1) Ankle: Dorsiflexion: tibialis anteriorm extensor digitorum longus, extensor hallucis longus (L4,5) Plantar flexion: Gastrocnemius, plantaris, soleus (S1,2) Tarsal: Invertion: Tibialis posterior, gastrocnemius, hallucis longus (L4,5) Eversion: Peroneus longus, breis, extensor digitorum longus (L5, S1)

Sensory: Spinathalamic pathway: Pain and temp - Pain: don’t use metal pin - Temp: use tuning fork PCML: Vibration, proprioception, light touch - Vibration: 128Hz fork place on distal joint, Move to proximal if cannot feel - Proprioception: Test distal joint first, Move to proximal if fail - Light touch: cotton wool, compare 2 side

Reflex: Knee jerk (L3,4) Ankle jerk (S1,2) Planter reflex (L5,S1,2): Babinski sign neuron lesion Cerebellum f(x) (coordination): Heel-shin test Finger-nose test Rhomberg’s test: - Ask patient to stand up straight, feet close together, eyes open Swaying.kurching with eyes open cerebeller sign (ataxia) Loss balance when close eye proprioceptive deficit

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