THE NEUROLOGICAL EXAMINATION

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THE NEUROLOGICAL EXAMINATION

• Prof Mohammad Abduljabbar

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Resources

• Neuroanatomy through Clinical Cases by Hal
  Blumenfeld
• http//www.neuroexam.com/
• http//www.utoronto.ca/neuronotes/NeuroExam/main.h
  tm
• The Technique of the Neurologic Examination by
  William DeMyer
• DeJongs Neurologic Examination by William W.
  Campbell

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You must do a minimum basic examination on every
patient but you dont need to do every test
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Tools of the trade
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NEUROLOGICAL EXAM

• MENTAL STATUS
• CRANIAL NERVES
• MOTOR EXAM
• STRENGTH
• GAIT
• CEREBELLAR
• REFLEXES
• SENSATION

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MENTAL STATUS
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Level of Consciousness

• Awake and alert
• Agitated
• Lethargic
• Arousable with
• Voice
• Gentle stimulation
• Painful/vigorous stimulation
• Comatose

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Mental Status Exam

• 1. Level of alertness,attention and cooperation
• We can test attention by seeing if the patient
  can remain focused on a simple task, such as
  spelling a short word forward and backward
  (W-O-R-L-D / D-L-R-O-W is a standard), repeating
  a string of integers forward and backward (digit
  span), or naming the months forward and then
  backward. Normal digit span is 6 or more forward,
  and 4 or more backward, depending slightly on age
  and education. Degree of cooperation should be
  noted, especially if it is abnormal, since this
  will influence many aspects of the exam.

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LANGUAGE

• FLUENCY
• NAMING
• REPETITION
• READING
• WRITING
• COMPREHENSION
• Aphasia vs. dysarthria

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Mental Status Exam

• 3. Speech and language
• Spontaneous speech Note the patient's fluency,
  including phrase length, rate, and abundance of
  spontaneous speech. Also note tonal modulation
  and whether paraphasic errors (inappropriately
  substituted words or syllables), neologisms
  (nonexistent words), or errors in grammar are
  present.
• Comprehension Can the patient understand simple
  questions and commands? Comprehension of
  grammatical structure should be tested as well
• Naming Ask the patient to name some easy (pen,
  watch, tie, etc.) and some more difficult
  (fingernail, belt buckle, stethoscope, etc.)
  objects
• Repetition Can the patient repeat single words
  and sentences (a standard is "no ifs ands or
  buts")?
• Reading Ask the patient to read single words, a
  brief passage, and the front page of the
  newspaper aloud and test for comprehension.
• Writing Ask the patient to write their name and
  write a sentence.

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MEMORY

• IMMEDIATE
• REALLY A MEASURE OF ATTENTION RATHER THAN MEMORY
• REMOTE
• 3 OBJECTS AT 0/3/5 MINUTES
• HISTORICAL EVENTS
• PERSONAL EVENTS

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Mental Status Exam

• 4. Memory for recent and remote events
• Recent memory Ask the patient to recall three
  items or a brief story after a delay of 3 to 5
  minutes. Be sure the information has been
  registered by asking the patient to repeat it
  immediately before initiating the delay. Provide
  distracters during the delay to prevent the
  patient from rehearsing the items repeatedly.
• Remote memory Ask the patient about historical
  or verifiable personal events.
• Memory can be impaired on many different
  timescales. Impaired ability to register and
  recall something within a few seconds after it
  was said is an abnormality that blends into the
  category of impaired attention. If immediate
  recall is intact, then difficulty with recall
  after about 1 to 5 minutes usually signifies
  damage to the limbic memory structures located in
  the medial temporal lobes and medial diencephalon

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ORIENTATION

• PERSON
• NOT WHO THEY ARE BUT WHO YOU ARE
• PLACE
• TIME

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OTHER COGNITIVE FUNCTIONS

• CALCULATION
• ABSTRACTION
• SIMILARITIES/DIFFERENCES
• JUDGEMENT
• PERSONALITY/BEHAVIOR

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Mental Status Exam

• 6. Apraxia
• The term apraxia will be used here to mean
  inability to follow a motor command that is not
  due to a primary motor deficit or a language
  impairment. It is apparently caused by a deficit
  in higher-order planning or conceptualization of
  the motor task. You can test for apraxia by
  asking the patient to do complex tasks, using
  commands such as "Pretend to comb your hair" or
  "Pretend to strike a match and blow it out" and
  so on. Patients with apraxia perform awkward
  movements that only minimally resemble those
  requested, despite having intact comprehension
  and an otherwise normal motor exam. This kind of
  apraxia is sometimes called ideomotor apraxia. In
  some patients, rather than affecting the distal
  extremities, apraxia can involve primarily the
  mouth and face, or movements of the whole body,
  such as walking or turning around.

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Mental Status Exam

• Folstein Mini-mental status exam
• This is a screening tool used to follow the
  cognitive decline associated with dementia. It
  has been in wide use since 1975 and takes 5-10
  minutes to administer. It is a limited test
  instrument. This examination is not suitable for
  making a diagnosis but can be used to indicate
  the presence of cognitive impairment, such as
  when dementia or head injury are suspected.
  People from different cultural groups or low
  intelligence or education may score poorly on
  this examination in the absence of cognitive
  impairment and well educated people may score
  well despite having cognitive impairment

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Mental Status Exam

• 9. Sequencing tasks and frontal release signs
• Frontal lobe lesions in adults can cause the
  reemergence of certain primitive reflexes that
  are normally present in infants. These so-called
  frontal release signs include the grasp, snout,
  root, and suck reflexes. Of these reflexes, the
  grasp reflex is the most useful in evaluating
  frontal lobe dysfunction.
• Patients with frontal lobe dysfunction may have
  particular difficulty in changing from one action
  to the next when asked to perform a repeated
  sequence of actions.This phenomenon is called
  perseveration

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Mental Status Exam

• 10. Delusions and Hallucinations
• Does the patient have any delusional thought
  processes? Does he have auditory or visual
  hallucinations? Ask questions such as, "Do you
  ever hear things that other people don't hear or
  see things that other people don't see?" "Do you
  feel that someone is watching you or trying to
  hurt you?" "Do you have any special abilities or
  powers?"
• These abnormalities can be seen in toxic or
  metabolic abnormalities and other causes of
  diffuse brain dysfunction, and in primary
  psychiatric disorders. In addition, abnormal
  sensory phenomena can be caused by focal lesions
  or seizures in visual, somatosensory, or auditory
  cortex, and thought disorders can be caused by
  lesions in the association cortex and limbic
  system

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Mental Status Exam

• 11. Mood
• Signs of major depression include depressed mood,
  changes in eating and sleeping patterns, loss of
  energy and initiative, low self-esteem, poor
  concentration, lack of enjoyment of previously
  pleasurable activities, and self-destructive or
  suicidal thoughts and behavior. Anxiety disorders
  are characterized by preoccupation with worrisome
  thoughts. Mania causes patients to be abnormally
  active and cognitively disorganized.

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CRANIAL NERVES
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CRANIAL NERVE EXAM

• I - OLFACTORY
• DONT USE A NOXIOUS STIMULUS
• COFFEE, LEMON EXTRACT
• II - OPTIC
• VISUAL ACUITY
• VISUAL FIELDS
• FUNDOSCOPIC EXAM

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Cranial Nerve1Olfaction

• Not tested much unless a frontal lobe tumor is
  suspected
• May be damaged in patients with closed head
  injuries,nasal obstruction,viral infections, and
  can be abnormal in Parkinsons disease,
  Alzheimers,and Multiple Sclerosis
• Test by asking if patients can smell,coffee,vanill
  a, or cinnamon in each nostril. Avoid noxious
  odors ( ie NH3)

http//www.neuroexam.com/
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Cranial Nerve 2Optic Nerve

• Visual Acuity (test with hand card)
• Color Vision (loss of color vision especially red
  is an important symptom of optic neuritis)
• Visual Fields (can be tested at the bedside by
  counting fingers in each quadrant)
• Visual Extinction (to detect visual neglect)
• Funduscopic Examination

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Cranial Nerve 2 and 3Pupillary responses

• The size and shape of the pupil should be
  recorded at rest. Under normal conditions, the
  pupil constricts in response to light. Note the
  direct response, meaning constriction of the
  illuminated pupil, as well as the consensual
  response, meaning constriction of the opposite
  pupil.
• Test the pupillary response to accommodation.
  Normally, the pupils constrict while fixating on
  an object being moved from far away to near the
  eyes.
• Direct response (pupil illuminated). The direct
  response is impaired in lesions of the
  ipsilateral optic nerve, the pretectal area, the
  ipsilateral parasympathetics traveling in CN III,
  or the pupillary constrictor muscle of the iris.
• Consensual response (contralateral pupil
  illuminated). The consensual response is impaired
  in lesions of the contralateral optic nerve, the
  pretectal area, the ipsilateral parasympathetics
  traveling in CN III, or the pupillary constrictor
  muscle.
• Accommodation (response to looking at something
  moving toward the eye). Accommodation is impaired
  in lesions of the ipsilateral optic nerve, the
  ipsilateral parasympathetics traveling in CN III,
  or the pupillary constrictor muscle, or in
  bilateral lesions of the pathways from the optic
  tracts to the visual cortex. Accommodation is
  spared in lesions of the pretectal area.

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Pupillary Size is determined by the light input,
sympathetic and parasympathetic tone
Text
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CRANIAL NERVE EXAM

• III/IV/VI OCULMOTOR, TROCHLEAR, ABDUCENS
• PUPILLARY RESPONSE
• EYE MOVEMENTS
• OBSERVE LIDS FOR PTOSIS
• V - TRIGEMINAL
• MOTOR - JAW STRENGTH
• SENS - ALL 3 DIVISIONS

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Cranial Nerve 3,4,6Extraocular Movements

• Observe the eyes at rest to see if there are any
  abnormalities such as spontaneous nystagmus (see
  below)or dysconjugate gaze (eyes not both fixated
  on the same point) resulting in diplopia (double
  vision)
• Test smooth pursuit by having the patient follow
  an object moved across their full range of
  horizontal and vertical eye movements. Test
  convergence movements by having the patient
  fixate on an object as it is moved slowly towards
  a point right between the patient's eyes
• In comatose or severely lethargic patients, the
  vestibulo-ocular reflex can be used to test
  whether brainstem eye movement pathways are
  intact. The oculocephalic reflex, a form of the
  vestibulo-ocular reflex, is tested by holding the
  eyes open and rotating the head from side to side
  or up and down

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Cranial Nerve 5Facial Sensation and Muscles of
Mastication

• Test facial sensation using a cotton wisp and a
  sharp object. Also test for tactile extinction
  using double simultaneous stimulation.
• The corneal reflex, which involves both CN 5 and
  CN 7, is tested by touching each cornea gently
  with a cotton wisp and observing any asymmetries
  in the blink response.
• Feel the masseter muscles during jaw clench. Test
  for a jaw jerk reflex by gently tapping on the
  jaw with the mouth slightly open.

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CRANIAL NERVES

• VII - FACIAL
• OBSERVE FOR FACIAL ASYMMETRY
• FOREHEAD WRINKLING, EYELID CLOSURE,
  WHISTLE/PUCKER
• VIII - VESTIBULAR
• ACUITY
• RINNE, WEBER

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Cranial Nerve 7Muscles of Facial Expression and
Taste

• Look for asymmetry in facial shape or in depth of
  furrows such as the nasolabial fold. Also look
  for asymmetries in spontaneous facial expressions
  and blinking. Ask patient to smile, puff out
  their cheeks, clench their eyes tight, wrinkle
  their brow, and so on. Old photographs of the
  patient can often aid your recognition of subtle
  changes
• Check taste with sugar, salt, or lemon juice on
  cotton swabs applied to the lateral aspect of
  each side of the tongue. Like olfaction, taste is
  often tested only when specific pathology is
  suspected, such as in lesions of the facial
  nerve, or in lesions of the gustatory nucleus
• The upper motor neurons for the upper face
  project to the facial nuclei bilaterally.
  Therefore, upper motor neuron lesions, such as a
  stroke, cause contralateral face weakness sparing
  the forehead, while lower motor neuron lesions,
  such as a facial nerve injury, typically cause
  weakness involving the whole ipsilateral face.

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Cranial Nerve 8 Hearing and Balance

• Test to see can the patient hear fingers rubbed
  together or words whispered just outside of the
  auditory canal and identify which ear hears the
  sound? A tuning fork can be used to perform the
  Weber and Rinne test to evaluate sensorineural
  and conductive hearing loss respectively
• Hearing loss can be caused by lesions in the
  acoustic and mechanical elements of the ear, the
  neural elements of the cochlea, or the acoustic
  nerve (CN VIII). After the hearing pathways enter
  the brainstem, they cross over at multiple levels
  and ascend bilaterally to the thalamus and
  auditory cortex. Therefore, clinically
  significant unilateral hearing loss is invariably
  caused by peripheral neural or mechanical
  lesions.
• Vestibular testing is not done routinely.

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CRANIAL NERVES

• IX/X - GLOSSOPHARYNGEAL, VAGUS
• GAG
• XI - SPINAL ACCESSORY
• STERNOCLEIDOMASTOID M.
• TRAPEZIUS MUSCLE
• XII - HYPOGLOSSAL
• TONGUE STRENGTH
• RIGHT XII THRUSTS TONGUE TO LEFT

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Cranial Nerve 9 and 10Palatal Elevation and Gag
Reflex

• Does the palate elevate symmetrically when the
  patient says, "Aah"? Does the patient gag when
  the posterior pharynx is brushed? The gag reflex
  needs to be tested only in patients with
  suspected brainstem pathology, impaired
  consciousness, or impaired swallowing.
• Palate elevation and the gag reflex are impaired
  in lesions involving CN 9, CN 10, the
  neuromuscular junction, or the pharyngeal muscles.

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Cranial Nerve11Sternocleidomastoid and Trapezius
Muscles

• Ask the patient to shrug their shoulders, turn
  their head in both directions, and raise their
  head from the bed, flexing forward against the
  force of your hands.
• Weakness in the sternocleidomastoid or trapezius
  muscles can be caused by lesions in the muscles,
  neuromuscular junction, or lower motor neurons of
  the accessory spinal nerve (CN XI). Unilateral
  upper motor neuron lesions in the cortex or
  descending pathways cause contralateral weakness
  of the trapezius, with relative sparing of
  sternocleidomastoid strength

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Cranial Nerve12

• Note any atrophy or fasciculations (spontaneous
  quivering movements caused by firing of muscle
  motor units) of the tongue while it is resting on
  the floor of the mouth. Ask the patient to stick
  their tongue straight out and note whether it
  curves to one side or the other. Ask the patient
  to move their tongue from side to side and push
  it forcefully against the inside of each cheek
• Fasciculations and atrophy are signs of lower
  motor neuron lesions. Unilateral tongue weakness
  causes the tongue to deviate toward the weak
  side. Tongue weakness can result from lesions of
  the tongue muscles, the neuromuscular junction,
  the lower motor neurons of the hypoglossal nerve
  (CN XII), or the upper motor neurons originating
  in the motor cortex. Lesions of the motor cortex
  cause contralateral tongue weakness.

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Hypoglossal Nerve Injury
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MOTOR EXAMINATION
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Motor Examination
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Motor Examination

• Observe Look for any twitches, tremors, abnormal
  movements or postures. Look carefully for
  hypokinesia,decreased eye blinking or staring
  which could be indicative or an extrapyramidal
  disorder such as Parkinsons disease
• In suspected lower motor neuron disorders,look
  for muscle wasting or fasiculations
• Palpate muscles in cases of suspected myopathy to
  check for muscle tenderness
• Passively move each limb to check muscle tone.
  Ask the patient to relax before beginning

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MUSCLE OBSERVATION

• ATROPHY
• FASCIULATIONS

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ABNORMAL MOVEMENTS

• TREMOR
• REST
• WITH ARMS OUTSTRETCHED
• INTENTION
• CHOREA
• ATHETOSIS
• ABNORMAL POSTURES

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TONE

• INCREASED, DECREASED, NORMAL
• COGWHEELING
• CLASP KNIFE

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Motor Examination

• Test for subtle weakness first by checking
  pronator drift, finger tapping,
  pronation/supination movements and toe tapping.
• Then check individual muscles for strength using
  the MRC scale to rate strength

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STRENGTH

• STRENGTH
• GRADED 0 - 5
• 0 - NO MOVEMENT
• 1 - FLICKER
• 2 - MOVEMENT WITH GRAVITY REMOVED
• 3 - MOVEMENT AGAINST GRAVITY
• 4 - MOVEMENT AGAINST RESISTANCE
• 5 - NORMAL STRENGTH

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STRENGTH EXAM

• UPPER AND LOWER EXTREMITIES
• DISTAL AND PROXIMAL MUSCLES
• GRIP STRENGTH IS A POOR SCREENING TOOL FOR
  STRENGTH
• SUBTLE WEAKNESS
• TOE WALK, HEEL WALK
• OUT OF CHAIR
• DEEP KNEE BEND

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REFLEXES
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MUSCLE STRETCH REFLEXES (DEEP TENDON REFLEXES)

• GRADED 0 - 5
• 0 - ABSENT
• 1 - PRESENT WITH REINFORCEMENT
• 2 - NORMAL
• 3 - ENHANCED
• 4 - UNSUSTAINED CLONUS
• 5 - SUSTAINED CLONUS

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MSR / DTR

• BICEPS
• BRACHIORADIALIS
• TRICEPS
• KNEE
• ANKLE

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OTHER REFLEXES

• Upper motor neuron dysfunction
• BABINSKI
• present or absent
• toes downgoing/ flexor plantar response
• HOFMANS
• JAW JERK
• Frontal release signs
• GRASP
• SNOUT
• SUCK
• PALMOMENTAL

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Plantar Response

• Test the plantar response by scraping an object
  across the sole of the foot beginning from the
  heel, moving forward toward the small toe, and
  then arcing medially toward the big toe. The
  normal response is downward contraction of the
  toes. The abnormal response, called Babinski's
  sign, is characterized by an upgoing big toe and
  fanning outward of the other toes.The presence of
  Babinski's sign is always abnormal in adults, but
  it is often present in infants, up to the age of
  about 1 year.

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CEREBELLAR FUNCTION

• RAPID ALTERNATING MOVEMENTS
• FINGER TO FINGER TO NOSE TESTING
• HEEL TO SHIN
• GAIT
• TANDEM

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Coordination

• Normal performance of these motor tasks depends
  on the integrated functioning of multiple sensory
  and motor subsystems. These include position
  sense pathways, lower motor neurons, upper motor
  neurons, the basal ganglia, and the cerebellum.
  Thus, in order to convincingly demonstrate that
  abnormalities are due to a cerebellar lesion, one
  must first test for normal joint position sense,
  strength, and reflexes and confirm the absence of
  involuntary movements caused by basal ganglia
  lesions. As already mentioned, limb ataxia is
  usually caused by lesions of the cerebellar
  hemispheres and associated pathways, while
  truncal ataxia is often caused by damage to the
  midline cerebellar vermis and associated pathway
• Tests for Limb Ataxia include Rapid alternating
  movements, Finger Nose Finger test, and Heel Knee
  Shin test

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Gait evaluation

• Include walking and turning
• Examples of abnormal gait
• High steppage
• Waddling
• Hemiparetic
• Shuffling
• Turns en bloc

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Gait

• Gait involves multiple sensory and motor systems.
  These include vision, proprioception, lower motor
  neurons, upper motor neurons, basal ganglia, the
  cerebellum, and higher-order motor planning
  systems in the association cortex
• Observe
• Stance, how far apart are the feet, posture,
  stability, how high the feet are raised off the
  floor, trajectory of leg swing and whether there
  is circumduction (an arced trajectory in the
  medial to lateral direction), leg stiffness and
  degree of knee bending, arm swing, tendency to
  fall or swerve in any particular direction, rate
  and speed, difficulty initiating or stopping
  gait, and any involuntary movements that are
  brought out by walking. Turns should also be
  observed closely. The patient's ability to rise
  from a chair with or without assistance should
  also be recorded.
• To bring out abnormalities in gait and balance,
  ask the patient to do more difficult maneuvers
  ie Tandem Gait

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Romberg Sign

• Stand with feet together - assure patient stable
  - have them close eyes
• Romberg is positive if they do worse with eyes
  closed
• Measures
• Cerebellar function
• Frequently poor balance with eyes open and
  closed
• Proprioception
• Frequently do worse with eyes closed
• Vestibular system

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SENSORY EXAM
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Sensory Exam

• The sensory exam relies to a large extent on the
  ability or willingness of the patient to report
  what he is feeling. It can therefore often be the
  most difficult and unreliable part of the
  neurologic exam

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Primary Sensation

• Light Touch
• Pinprick
• Vibration
• Joint Position
• Temperature
• Two point discrimination
• The pattern of sensory loss can provide important
  information that helps localize lesions to
  particular nerves, nerve roots, and regions of
  the spinal cord, brainstem, thalamus, or cortex

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SENSORY EXAM

• VIBRATION
• 128 hz tuning fork
• JOINT POSITION SENSE
• PIN PRICK
• TEMPERATURE
• Start distally and move proximally

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HIGHER CORTICAL SENSATIONS

• GRAPHESTHESIA
• STEREOGNOSIS
• DOUBLE SIMULTANEOUS STIMULATION
• BAROSTHESIA
• TEXTURES

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Cortical sensation

• Graphesthesia
• Sterognosis
• Double Simultaneous Stimulation
• Intact primary sensation with deficits in
  cortical sensation such as agraphesthesia or
  astereognosis suggests a lesion in the
  contralateral sensory cortex. Note, however, that
  severe cortical lesions can cause deficits in
  primary sensation as well. Extinction with intact
  primary sensation is a form of hemineglect that
  is most commonly associated with lesions of the
  right parietal lobe. Extinction can also be seen
  in right frontal or subcortical lesions, or
  sometimes in left hemisphere lesions causing mild
  right hemineglect

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