CNS Examination

1. Introduce yourself to the patient.
2. Confirm patient’s name and dob.
3. Explain the procedure and reassure the patient.
4. Get patient’s consent.
5. Wash hands.
6. Ask the patient to sit on a chair, approximately one
arm’s length away.
7. Ask the patient if they have any pain before
proceeding with the clinical examination.
Good morning I’m ...(your name)... I’m a second
year medical student. Can you tell me your name
and give me your ID please ?.Okay ...(patient
name)... today I’m here to examine your cranial
nerves “that may include .........“ , is that okay
with you4 ? Before I start I should wash my
hands5 and prepare the materials see the materials
I just want you to sit to begin the examination

General Inspection

 Speech abnormalities: may indicate glossopharyngeal or vagus nerve pathology.

 Facial asymmetry: suggestive of facial nerve palsy.
 Eyelid abnormalities: ptosis may indicate oculomotor nerve pathology.
 Pupillary abnormalities: mydriasis occurs in oculomotor nerve palsy.
 Strabismus: may indicate oculomotor, trochlear or abducens nerve palsy.
 Limbs: pay attention to the patient’s arms and legs as they enter the room and take a seat noting any
abnormalities (e.g. spasticity, weakness, wasting, tremor, fasciculation) which may suggest the presence of
a neurological syndrome).

Examination

1) Olfactory nerve (CN I)

 Ask the patient if she/he has noticed a change in his sense of smell or taste. (If yes, perform an
olfactory examination: test each nostril separately)
 (Ask the patient to close his/her eyes and block one nostril.)
 (Take one of the scent stimuli and ask patient to sniff and describe the scent.) lemon, peppermint and
coffee, vanilla
(Do you notice any change in your sense of smell or taste.? “If it YES” .Okay i will perform an
olfactory examination, I will test each nostril separately. Can you please close your eyes and block
one of your nostril ?Then I will take one of scent stimuli can you smell it and describe the scent please
[repeat the same test with the other nostril])
2) Optic nerve (CN II)
 Test visual acuity on a Snellen chart or using a near vision card (or a page in a book).
i. Stand the patient at 6 metres from the Snellen chart.
ii. Ask the patient to cover one eye and read the lowest line they are able to.
iii. Record the lowest line the patient was able to read (e.g. 6/6 (metric) which is equivalent to
20/20 (imperial)).
iv. You can have the patient read through a pinhole to see if this improves vision (if vision is
improved with a pinhole, it suggests there is a refractive component to the patient’s poor
vision).
v. Repeat the above steps with the other eye
 Pupillary Reflexes
i. Assess the direct pupillary reflex:
 Shine the light from your pen torch into the patient’s pupil and observe for pupillary
restriction in the ipsilateral eye.
 A normal direct pupillary reflex involves constriction of the pupil that the light is
being shone into.
ii. Swinging light test
 Move the pen torch rapidly between the two pupils to check for a relative afferent
pupillary defect
iii. Assess the consensual pupillary reflex:
 Once again shine the light from your pen torch into the same pupil, but this time
observe for pupillary restriction in the contralateral eye.
 A normal consensual pupillary reflex involves the contralateral pupil constricting as a
response to light entering the eye being tested.
 iv. Accommodation reflex
 Ask the patient to focus on a distant object (clock on the wall/light switch).
 Place your finger approximately 20-30cm in front of their eyes (alternatively, use the
patient’s own thumb).
 Ask the patient to switch from looking at the distant object to the nearby
finger/thumb.
 Observe the pupils, you should see constriction and convergence bilaterally.
 Visual Inattention
i. Position yourself sitting opposite the patient approximately 1 metre away.
ii. Ask the patient to remain focused on a fixed point on your face (e.g. nose) and to state if they
see your left, right or both hands moving
iii. Hold your hands out laterally with each occupying one side of the patient’s visual field (i.e.
left and right).
iv. Take turns wiggling a finger on each hand to see if the patient is able to correctly identify
which hand has moved
v. Finally wiggle both fingers simultaneously to see if the patient is able to correctly identify this
(often patients with visual neglect will only report the hand moving in the unaffected visual
field – i.e. ipsilateral to the primary brain lesion).
 Assessment for visual fields
i. Sit directly opposite the patient, at a distance of around 1 metre.
ii. Ask the patient to cover one eye with their hand.
iii. If the patient covers their right eye, you should cover your left eye (mirroring the patient).
iv. Ask the patient to focus on part of your face (e.g. nose) and not move their head or eyes
during the assessment. You should do the same and focus your gaze on the patient’s face.
v. As a screen for central visual field loss or distortion, ask the patient if any part of your face is
missing or distorted. A formal assessment can be completed with an Amsler chart.
vi. Position the hatpin (or another visual target such as your finger) at an equal distance between
you and the patient (this is essential for the assessment to work).
vii. Assess the patient’s peripheral visual field by comparing to your own and using the target.
Start from the periphery and slowly move the target towards the centre, asking the patient to
report when they first see it. If you are able to see the target but the patient cannot, this would
suggest the patient has a reduced visual field.
viii. Repeat this process for each visual field quadrant, then repeat the entire process for the other
eye.
 Examine the retina and optic nerve by direct fundoscopy.
(Now I’ll examine your visual acuity by using “ say what you will use “ , then I’ll test your visual
fields by using confrontation ,the last thing I’ll examine the retina and optic nerves by direct
fundoscopy.)
3) Oculomotor, trochlear, and abducens nerves (CN III, IV, and VI)
 Examine eye movements:
i. Ask the patient to keep his/her head still and to follow your finger with his/her eyes and to tell
you if he sees double at any point (move your fingers in a ‘H’ pattern)
ii. Look for nystagmus at the extremes of gaze.
(Now I will test your accommodation, can you please focus on my finger
Now I will examine your eye movements please don’t move your head keep it still and follow my
finger with your eyes and tell me if you see double vision or pain at any point)

4) Trigeminal nerve (CN V)

 Sensory Part (Ask patient to close his/her eyes).
i. Test light touch ( use cotton ball), neuro-tip (sharp pin) senses in the three branches of the
trigeminal nerve. Compare both sides.
 Motor Part - Test the muscles of mastication by asking the patient to:
i. Clench his/her teeth (palpate his temporal and masseter muscles bilaterally).
ii. Open and close his/her mouth against resistance (place your fist under his chin).((Inform
patient that you would hold his/her chin and test the jaw jerk).
iii. Ask the patient to let his mouth fall open slightly.
iv. Place your index finger on his/her chin and hold chin with your middle finger
v. Gently tap on your index finger with a tendon hammer and observe jaw jerk.
(Can you please clench your teeth and relax? “Palpate his temporal and masseter in both sides” I’ll
hold your chin to test the jaw jerk so can you please open and close your mouth against resistance?
 (While you’re doing this place your fist under his chin) then place your index finger on his/her chin
and hold chin with your middle finger. Now tap on your index finger with a tendon hammer and
observe jaw jerk. Tell the doctor that his motor part of his trigeminal nerve is normal.)

5) Facial nerve (CN VII) - Look for facial asymmetry. (Note that the nasolabial folds and the angle of the
mouth are especially indicative of facial asymmetry)
 Motor Part - Test the muscles of facial expression by asking the patient to:
i. Lift his/her eyebrows as far as they will go.
ii. Close his/her eyes as tightly as possible. (Don’t let me open.)
iii. Blowout his/her cheeks. (Don’t let me push them in)
iv. Purse his/her lips or whistle.
v. Show his/her teeth.
vi. (I’ll examine your facial nerve, look for any facial asymmetry focus on the nasolabial folds
and the angle of the mouth because they are specially indicative of facial asymmetry “tell the
doctor that there’s no facial asymmetry”. Apply either salty, bitter sour or sweet solutions on
the tongue to test the anterior two thirds of the tongue “tell the doctor that the sensory part of
his facial nerve is normal” in the exam you will not feed the patient but you have to mention
it. Okay can you please lift your eyebrows as far as you can? ”after doing this” can you please
close your eyes as tightly as possible? Try to open them ”after doing this” can you please
blowout your cheeks? “After doing this” Can you please purse your lips? “After doing this”
can you please show me your teeth? or can you please smile? Tell the doctor that his motor
part of his facial nerve is normal.)
 Sensory part –
i. Have you been experiencing change of taste (ant 2/3 of the tongue)
ii. Have you been hearing sounds that are louder than usual.(stapedius paralysis)

6) Vestibulocochlear nerve (CN VIII)

 Test hearing sensitivity :
i. Position yourself approximately 60cm from the ear and then whisper a number or word.
ii. Mask the ear not being tested by rubbing the tragus. Do not place your arm across the face of
the patient when rubbing the tragus, it is far nicer to occlude the ear from behind the head. If
possible shield the patient’s eyes to prevent any visual stimulus.
iii. Ask the patient to repeat the number or word back to you. If they get two-thirds or more
correct then their hearing level is 12db or better. If there is no response use a conversational
voice (48db or worse) or loud voice (76db or worse).
iv. If there is no response you can move closer and repeat the test at 15cm. Here the thresholds
are 34db for a whisper and 56db for a conversational voice.
 Apply Rinne and Weber tests and examine the ears by auroscopy.
(I’ll examine your acoustic nerve (while you’re doing the examination ask the patient about her/his
hearing sensitivity) for example you can ask “do you hear well? or are there any problems while
you’re hearing? Do you feel pain?” After this examination tell the doctor that he’s hearing well and
there’s no tenderness so his acoustic nerve is normal (if their answers to the previous questions are all
normal).
7) Glossopharyngeal nerve (CN IX) AND Vagus nerve (CN X)
 Gag reflex- Ask the patient to phonate (say aaah~) and look for deviation of the uvula with a pen
light.
 Swallow Assessment - ask the patient to take a small sip of water (approximately 3 teaspoons) and
observe the patient swallow. The presence of a cough or a change to the quality of their voice suggests
an ineffective swallow which can be caused by both glossopharyngeal (afferent) and vagus (efferent)
nerve pathology.
(I’ll examine your vagus nerve, can you please say aaah (phonation) (while your doing the examination look
for the deviation of the uvula with you penlight) tell the doctor that his vagus nerve is normal.In abnormal
conditions the uvula will be on the right/left side.)
8) Accessory nerve (CN XI)
 Look for wasting of the sternocleidomastoid and trapezius muscles.
 Ask the patient to:
i. raise their shoulders and resist you pushing them downwards: this assesses the trapezius
muscle (accessory nerve palsy will result in weakness).
 ii. turn their head left whilst you resist the movement and then repeat with the patient turning
their head to the right: this assesses the sternocleidomastoid muscle (accessory nerve palsy
will result in weakness).
(I’ll examine your accessory nerve, can you please raise your shoulders against resistance?
the doctor that his accessory nerve is normal and there’s no wasting of the sternocleidomastoid and
trapezius muscles)
9) Hypoglossal nerve (CN XII)
 Ask the patient to open their mouth and inspect the tongue for wasting and fasciculations at rest
(minor fasciculations can be normal).
 Ask the patient to protrude their tongue and observe for any deviation (which occurs towards the side
of a hypoglossal lesion).
 Place your finger on the patient’s cheek and ask them to push their tongue against it. Repeat this on
each cheek to assess and compare power (weakness would be present on the side of the lesion)
(Tell the doctor that his hypoglossal nerve is normal and there’s no wasting and fasciculation.)
Closing
1. Ensure that the patient is comfortable.
2. Make explanations to the patient, answer his/her questions and discuss management plan.
3. Dispose of sharps and waste material according to infection control standards.
4. Wash hands.
(After finishing the examination,
Okay are you comfortable?
Do you have any questions?
“Dispose the wastes” (or just mention it “I should dispose the wastes “)
I’ll wash my hands.)
Today I examined Mr…., a age and gender. On general inspection, the patient appeared comfortable at rest, with
normal speech and no other stigmata of neurological disease. There were no objects or medical equipment around the
bed of relevance.”

“Examination of all twelve cranial nerves was unremarkable.”

“In summary, these findings are consistent with a normal cranial nerve examination.”