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Dr Tim Coughlin and Dr Karan Wadhwa

Overview basic neuroanatomy Outline CNS and PNS examination Common neurolological deficits and
their causes

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1 - Olfactory 2 - Optic 3 - Oculomotor 4 - Trochlear 5 - Trigeminal 6 - Abducens 7 - Facial 8 - Vestibulocochlea 9 - Glossopharyngea 10 - Vagus 11 - Accessory 12 - Hypoglossal

1-12 in order (visual movements

incorporating nerves 3-6 are assessed together) throughout

Clinical Examination of Cranial Nervous System

Aim is to be smooth and observant

Have you had any change in your
sense of smell recently? if correctly identified. practice.

Can use coffee/orange smells to see Not routinely examined in clinical

Optic acuity. Assess visual Can you read my badge? Does

Snellen chart would be ideal, but
not routinely done in clinical practice.

my face look whole to you, are any parts missing?

Visual fields by confrontation.

use Amslers grid for greater accuracy).


To complete my examination I

Oculomotor, Abducens and Trochlear

Keeping you head perfectly still,
follow my finger with your eyes.

Make a H pattern with your finger. Do you see double anywhere? Look for nystagmus.

Trigeminal Nerve
Two parts: - Sensory to face - Motor to muscles of mastication Assess sensation to face Determine if patient can open

Clench your teeth - feel for

muscle bulk at Masseters

V1 - Opthalmic V2 - Maxillary V3 - Mandibular

Facial Nerve
Must assess at least 3 muscle

Raise your eyebrows Show me your teeth Puff out your cheeks

Grossly assess by rustling fingers at
one ear and whispering in opposite. Rhines tests

Can confirm using Webers and

Glossopharyngeal and Vagus

Open your mouth. Say arrgh Look at palatal movement. Deviates
AWAY from affected side. done

Assess gag reflex - not routinely

Put hand on one cheek, push me
away, and feel sternocleidomastoid bulk on opposite side.

Stick out your tongue Look for deviation TOWARDS
affected side.

Can assess power, but only if deficit

found on gross examination.

Peripheral Nervous System Examination

Aim is to be systematic Ensure you have permission,
adequate exposure and tendon hammer to hand.

Same system for upper and lower limb

Inspection Tone Power Reflexes Sensation Coordination

Look for muscle wasting, scars,
abnormal movements, fasciculations.

Assess tone in upper limb by
holding hand and moving wrist. by rolling leg and looking at ankle movement, or lifting up leg by knee and dropping onto bed.

Tone in lower limb can be assessed

Best assessed by moving joint into
neutral and moving all power groups in turn against your resistance. compare like with like. strong as you!

Needs to be systematic and Remember old people are not as

Elicit biceps, triceps and supinator
in upper limb. response.

Elicit knee , ankle and plantar


Coordination Upper limb:

Touch the index finger of your right
hand to your nose, now using the same finger, touch my finger.

Place finger at a stretch from theirs. Look for intention tremor and pass

Repeat for left hand side. Can also assess coordination by

looking for dysdiadokinesis.

Lower limb:

Place the heel of your right foot on Repeat for left hand side.

left knee and run foot down left shin and back to knee as fast as possible.

Patterns of disease
Upper motor neurone pathlogy

- Spastic paralysis - Hypertonic - Reduced power - Hyper-reflexia - Impaired coordination

Lower motor neurone pathology

(multiple sclerosis)

- Flaccid paralysis - Hypotonia - Reduced power - Hyporeflexia - Impaired coordination

Cerebellar Disease
Trauma, alcohol, SOL, old age


ysdiadokinesis taxia ystagmus ntenion tremor tacatto speech ypotonia endular reflexes

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Outlined basic neuroanatomy Highlighted key aspects of

Described major pathology and Using iTunes to review lectures

explained reasoning behind signs