Detailed and clinically oriented checklist of Central Nervous System (CNS) Examination, structured exactly as a doctor or medical student would perform and document it during bedside assessment.
🧠 Central Nervous System Examination
1. Higher Mental Functions (HMF)
Assessed when the patient is conscious and cooperative.
A. Consciousness & Orientation
- Consciousness: Alert / Drowsy / Stuporous / Comatose
- Orientation:
- Time – Day/date/month/year
- Place – Current location
- Person – Own name, relatives
B. Memory
- Immediate: Repeat 3 digits or words
- Recent: Events from the same day (e.g., breakfast)
- Remote: Historical/personal past events
C. Attention & Concentration
- Serial 7s / Spelling ‘WORLD’ backward
D. Language and Speech
- Spontaneous speech – fluent/non-fluent
- Comprehension – follow commands
- Naming – common objects
- Repetition – phrases
- Reading & Writing – comprehension & output
E. Intellect, Judgment & Abstract Thinking
- Simple proverbs, similarities (e.g., apple vs orange)
F. Mood & Affect
- Euthymic / Depressed / Elevated / Anxious
- Appropriateness to context
2. Cranial Nerve Examination (CN I–XII)
CN I – Olfactory
- Test each nostril separately with non-irritant smells (e.g., coffee)
CN II – Optic
- Visual Acuity – Snellen’s chart
- Visual Fields – Confrontation method
- Color Vision – Ishihara plates
- Fundus Examination – Papilledema, atrophy, hemorrhages
- Pupillary Light Reflex (afferent limb)
CN III, IV, VI – Oculomotor, Trochlear, Abducens
- Extraocular Movements – H test
- Nystagmus – Direction, type
- Ptosis – CN III lesion
- Pupils – Size, shape, reactivity (direct/consensual), accommodation
CN V – Trigeminal
- Sensory (V1, V2, V3): Light touch, pinprick, temperature
- Motor: Clench jaw (masseter, temporalis)
- Corneal Reflex: (afferent limb – V1)
CN VII – Facial
- Motor: Raise eyebrows, close eyes tightly, smile, puff cheeks
- Taste: Anterior 2/3 tongue (if needed)
- Bell's phenomenon, asymmetry, flattening of nasolabial fold
CN VIII – Vestibulocochlear
- Hearing: Whisper test / Rinne’s (AC>BC) / Weber’s (lateralization)
- Balance: Romberg’s test, past-pointing, nystagmus (vestibular)
CN IX & X – Glossopharyngeal & Vagus
- Uvula Movement: Say "ah" – deviation
- Gag Reflex: Present/Absent
- Voice: Hoarseness/nasal quality
- Swallowing: Observe or ask
CN XI – Accessory
- Trapezius: Shrug shoulders against resistance
- SCM: Turn head against resistance
CN XII – Hypoglossal
- Tongue: Protrusion (deviation, atrophy, fasciculations), side-to-side movement
3. Motor System Examination
A. Inspection
- Muscle bulk: Wasting or hypertrophy
- Fasciculations / Tremors
- Posture and involuntary movements
B. Tone
- Compare both sides: Upper & lower limbs
- Spasticity: Velocity-dependent ↑ tone (UMN)
- Rigidity: Uniform ↑ tone (Lead-pipe or Cogwheel – Extrapyramidal)
- Hypotonia: LMN or cerebellar lesion
C. Power (MRC Grading 0–5)
Test against resistance in:
- Upper limb: Shoulder abduction, elbow flexion/extension, wrist movements
- Lower limb: Hip flexion/extension, knee movements, ankle dorsiflexion/plantarflexion
D. Involuntary Movements
- Resting tremor, action tremor, chorea, athetosis, dystonia, myoclonus, tics
E. Coordination
- Upper limbs: Finger-nose test, rapid alternating movements (RAM)
- Lower limbs: Heel-shin test
- Dysdiadochokinesia, intention tremor, past-pointing
4. Reflexes
A. Superficial Reflexes
- Abdominal (T7–T12)
- Cremasteric (L1–L2)
- Plantar (L5–S1): Flexor (normal) / Extensor (Babinski – UMN lesion)
B. Deep Tendon Reflexes (DTRs)
- Biceps (C5–C6)
- Triceps (C7–C8)
- Supinator (C5–C6)
- Knee jerk (L3–L4)
- Ankle jerk (S1–S2)
- Grading: 0 (absent) to 4+ (clonus)
C. Pathological Reflexes
- Babinski sign
- Hoffman’s sign
- Ankle clonus (sustained – UMN)
5. Sensory System Examination
A. Primary Sensations
- Light Touch – Cotton
- Pain – Pinprick
- Temperature – Warm/cold test tubes
- Position Sense (Proprioception) – Move finger/toe up/down with eyes closed
- Vibration – 128 Hz tuning fork over bony prominences
B. Cortical Sensations
- Stereognosis – Identify object in hand
- Graphesthesia – Number traced on palm
- Two-point discrimination
- Tactile localization
- Double simultaneous stimulation (Extinction)
6. Gait & Station
- Normal Gait – Observe arm swing, step length, heel-toe pattern
- Tandem Walking – Heel-to-toe in a straight line
- Types of Abnormal Gait:
- Spastic Hemiplegic – Swinging leg in semicircle
- Parkinsonian – Short shuffling steps, stooped posture
- Cerebellar Ataxia – Wide-based, unsteady
- Sensory Ataxia – High-stepping, positive Romberg
- Waddling (Myopathic)
- Steppage Gait (Foot drop)
7. Cerebellar Signs
- Ataxia – Gait & limb
- Dysmetria
- Dysdiadochokinesia
- Intention tremor
- Rebound phenomenon
- Nystagmus
- Hypotonia
8. Extrapyramidal Signs
- Tremors – Resting (pill-rolling), postural, kinetic
- Rigidity – Cogwheel or lead pipe
- Bradykinesia
- Mask-like facies, stooped posture
- Postural instability
9. Meningeal Irritation Signs
- Neck stiffness
- Kernig’s Sign – Pain/resistance on knee extension with hip flexed
- Brudzinski’s Sign – Involuntary hip/knee flexion on neck flexion
- Photophobia
10. Signs of Raised Intracranial Pressure (ICP)
- Headache, vomiting (projectile)
- Papilledema (fundoscopy)
- Altered consciousness
- Cushing’s Triad: Hypertension, bradycardia, irregular respiration
