Becca Poore and James Wight

Examination of the Central Nervous System

I – Olfactory
Ask patient if they have noticed a change in their sense of smell
Ask patient to sniff though both nostrils and then one at a time
Identify common odours (coffee, peppermint)

II – Optic
Acuity - Test near and far vision (with glasses on – chart 6m away) – test each eye separately
Fields – Test by confrontation – patient looks at your nose – you waggle your fingers (move
towards centre) – one eye at a time (both you and pt). Check for neglect (one or both fingers
waggling – both eyes open)
Blind spot – close one eye – compare yours to theirs
Pupils – PERLA
1) Size equal
2) Light reflexes - hand on forehead – shine light in from side (otherwise get
accommodation) – look for direct light reflex – consensual light reflex – do in other eye
3) Swinging light test – shine light in one eye (get normal consensual reflex in other eye) –
shine light in other eye – dilates and then constricts = RAPD
4) Accommodation – follow finger in – pupils should constrict

Pupils not equal:

Horner’s syndrome – loss of the sympathetic supply leads to miosis (pupil constriction),
sunken eye, ptosis (partial) & anhydrosis (loss of sweating)
DM – paraS III lost – Edinger Westphall nucleus ∴ptosis?????
Holmes-Adie syndrome – usually unilateral dilated pupil, slow light reflex but accommodation
is normal. Associated with absent knee jerks, and completely benign.
Marcus Gunn pupil – there is a relative afferent pupillary defect (RAPD). The swinging light
test is performed, showing a normal consensual reflex but abnormal direct light reflex due to
problems with optic N, such as in MS and DM.
Argyll Robertson –the pupil is small and irregular, and doesn’t react to light (although
accommodation is normal). Seen in tertiary syphilis.

Fundus – fundoscope / opthalmoscope – disc, macula, vessels – in 4 quadrants

Blindness:
Optic disc probs – pappilitis / papilloedema
Nerve – demyelination

A: Monocular blindness
B: Chiasm – compression by pituitary (sits
underneath and expands up and out with
tumour) → bitemporal hemianopia (lose
upper outer quadrant 1st – later whole of
outer halves)
C: Homonymous hemianopia (lose all L
side or all R side). Due to ischaemic
events – from chiasm backwards
D: Scotoma = infarct in occipital lobe (lose
blob in middle of visual field)
III, IV & VI – Occulomotor, trochlear & abducent
Look for ptosis (droopy eyelid) – partial = sympathetic loss, total = III palsy
and asymmetry in pupil diameters (<3mm=miosis, >5mm=mydriasis)
Assess eye movements - keep head still with hand near head - follow your finger (which is
>50cm away) in an H pattern. Ask about any double vision (diploplia).
Look for internuclear ophthalmoplegia (failure of adduction, seen in MS when the medial
longitudinal fasciculus is damaged).
Assess nystagmus - Ask patient to follow rapidly moving finger - 2-3 beats is normal, more is
indicative of cerebellar or vestibular pathology.

V – Trigeminal (Sensory to face, scalp, tongue + buccal mucosa, motor for mastication,
sensory limb of corneal reflex, jaw jerk)
Test touch + pain in 3 sensory divisions (ophthalmic, maxillary, mandibular) – close eyes –
cotton wool on area – can you feel it? – same area other side – can you feel it? – do they feel
the same? – next area
Assess corneal reflex - Touch edge of cornea with wisp of cotton wool and watch for blinking.
The corneal reflex can be obliterated if pt wear contacts
Assess muscles of mastication - Clench teeth and palpate masseter & temporalis. Open jaw
against resistance.
Assess jaw jerk - Open mouth (let it hang open), put your thumb on the patient’s chin, and
strike thumb with tendon hammer. Closing of the jaw is abnormal (eg in MND).

VII – Facial (Motor – face & taste ant 2/3 tongue via chorda tympani – Temporal, zygomatic,
buccal, mandibular, cervical)
Look for facial paralysis (no wrinkles / droop)
Frown and look up (should wrinkle forehead). Temporalis has bilateral innervation.
Raise eyebrows
Shut eyes tight against R
Grimace, smile
Show teeth, blow out cheeks, whistle
Test taste – sugar (sweet) – salt – quinine (bitter) – vinegar (sour)

VIII – Vestibulocochlear
Test hearing in each ear – rub fingers next to ear – can you hear that? - repeat whispered
no.s or words or (occlude opposite ear)
Rinne’s test - hit tuning fork – hold on mastoid bone till they can’t hear it then hold it over
meatus (opening) – should then hear it again - air should be better than bone (bone better in
conduction deafness)
Weger’s test - tuning fork on vertex of skull – sound heard equally in both ears?
Inspect ear passages if problem

IX – Glossopharyngeal (nasty tests therefore don’t do unless need to)

Test taste on post 2/3 tongue – as before
Feel swallow
Gag reflex - Touch post, pharyngeal wall (sensory limb IX, motor limb X).

X – Vagus (Muscles of vocal cords + soft palate)

Ask patient to cough (bovine?)
Say ‘a, e, i, o, u’
Say agh – soft palate and uvula central or deviated? (uvula pulled to strong side)
Gag reflex as above.

XI – Spinal accessory
Examine bulk & power of sternomastoid and trapezius muscles
Shrug shoulders against resistance
Turn head against R

XII – Hypoglossal
Inspect tongue – wasting / fasciculation?
Stick tongue out – deviation? (deviates away from strong side – pushed out)
Ask patient to push tongue against each cheek whilst you apply resistance outside