73 the Neurological Examination Evan D

Home , Neurological examination, Thought blocking

73 The Neurological Examination Evan D. Murray, MD, and Bruce H. Price, MD

KEY POINTS ered most effective when the clinician has formed a hypothesis that is based on observation and history and is prepared to • Cognitive impairment, behavioral changes, and fluidly adapt both the examination and the hypothesis as new psychiatric symptoms occur frequently in association information and findings appear. A well-rehearsed examina- with neurological conditions. tion prevents omissions and ensures consistency of technique. A well-reasoned examination with an array of alternative • A well-performed mental status and neurological techniques that verify findings ensures greater accuracy and examination are essential for the identification of confidence in those findings. The complexity of planning, medical and neurological conditions that impact performing, and interpreting the neurological examination is cognition, behavior, and mood. a challenge that persists throughout the entirety of a physi- • The objective of the neurological examination is to cian’s career. verify the integrity of the central and peripheral The neurological examination is performed routinely for nervous systems and to achieve neuroanatomical most psychiatric admissions but is uncommonly performed localization of signs and symptoms. Localization is a in outpatient psychiatric settings. In some circumstances, a crucial step for the generation of a rational careful history alone may establish a neurological diagnosis; differential diagnosis. however, this is often not the case. The examination is helpful • The neurological examination can be conceived of as for corroborating the history, establishing the severity of a being conducted along a continuum of complexity condition, and directing treatment. The overall assessment that builds on information acquired during its approach should use a reproducible methodology for obtain- performance. It is fluidly adapted during its ing and interpreting the history, performing the examination, performance with components added, as needed, to and analyzing both. A comprehensive neurological examina- clarify findings. tion is unnecessary in every patient. The clinician must learn to focus or expand the examination as needed. A good exami- • The interpretation of findings requires careful and nation can be instrumental in discerning primary psychiatric effective integration with knowledge of neuroanatomy illness from secondary symptoms that occur in association and the clinical history. with a multitude of neurological conditions (such as stroke, • A well-organized and rehearsed examination Alzheimer’s disease, Huntington’s disease, Parkinson’s disease, promotes consistency and comprehensiveness of and demyelinating disease). (See Box 73-1 for a summary of technique while reducing omissions of elements of major neurological findings and associated conditions that the examination. frequently manifest by psychiatric symptoms.) Malingering and conversion disorder need to be distinguished from deficits that localize to specific neuroanatomy.4 Medication side effects, such as parkinsonism and dystonia, need to be identi- OVERVIEW fied, treated, and followed clinically. General principles include: Proficiency in performing a neurological examination is • Assess for side-to-side symmetry during the neurological advantageous to the psychiatrist. All behavior and perception examination. One side of the body serves as a control for occurs as a result of neural activity. Neural activity arises from the. other Determine if there is focal asymmetry. brain circuitry that is developmentally sculpted through the • Determine if dysfunction originates from the central nervous interaction of environmental factors with human genetic system (CNS), peripheral nervous system (PNS), or both. potential.1 Neural circuitry is susceptible to malfunction and • Consider if the finding (or findings) can be explained by a damage in a host of ways; this results in many recognizable single lesion or whether a multi-focal process is required. patterns of cognitive and behavioral impairments. The neuro- • Establish the lesion’s location. If the process involves the logical examination is of tremendous utility for identifying CNS, clarify if it is cortical, subcortical, or multi-focal. If these patterns and thereby allowing for recognition of neuro- subcortical, clarify if it is in the white matter, basal ganglia, logical processes that may be treated. Neurological conditions brainstem, cerebellum, or spinal cord. are frequently co-morbid with psychiatric symptoms. Such • If the process involves the PNS, determine if it localizes to symptoms may stem from the stress of illness, be a direct func- thee nerv root, plexus, peripheral nerve, neuromuscular tion of brain pathology, or result from a combination of the junction, muscle, skin, or if it is multi-focal. two. Psychiatric symptoms and behavioral changes may precede other key physical manifestations of the disorder or Some of this localization, particularly to the PNS, will occury at an time during the disease course.2 eAn effectiv and exceed the expertise of most psychiatrists. These principles are reliable neurological examination may afford opportunities presented as tools to organize thinking. for earlier detection of treatable conditions, anticipation of There is no clear consensus among experts as to the order psychiatric manifestations, and avoidance of adverse events of performing and presenting the neurological examination. (e.g., neuroleptic sensitivity of patients with Lewy body However, there is little dispute about the mental status portion dementia) in persons who are at particular risk. being performed first followed by examination of the cranial By the late nineteenth century the elementary neurological nerves. Thereafter, there are variations in the sequence, selected examination was refined with objective, consistent, and repro- components of the examination, methods of performance, ducible findings.3 The practice of the examination is consid- terminology used to describe findings, and the interpretation

791

BOX 73-1 Neurological Abnormalities That BOX 73-2 Components of Elemental Neurological Suggest Diseases Associated with Examination Psychiatric Symptoms CRANIAL NERVES EXAMINATION ABNORMALITIES AND THEIR POSSIBLE Olfaction I UNDERLYING ETIOLOGY Vision II Vital signs • Visual fields (VF) • Marked hypertension (hypertensive encephalopathy, • Acuity serotonin syndrome, neuroleptic malignant syndrome, • Optic disks/vessels (performed after VF and acuity) pre-eclampsia) Pupillary reflexes II, III • Tachypnea (delirium caused by systemic infection) Eye movements III, IV, VI • Hypoventilation (hypoxia, alcohol withdrawal, sedative Facial sensation/jaw strength V intoxication) Facial movement VII Cranial nerves Hearing VIII • Hyposmia, anosmia or odor misidentification (traumatic Palate IX, X brain injury, Alzheimer’s and Parkinson’s disease) Speech/dysarthria IX, X, XII • Visual field deficit (stroke, mass, multiple sclerosis, systemic Head rotation XI lupus erythematosus) Shoulder shrug XI Pupils Tongue movement XII • Argyll Robertson (neurosyphilis) MOTOR • Unilateral dilation (brain herniation, porphyria) Involuntary movements/adventitious movements • Horner’s syndrome (stroke, carotid disease, demyelinating Muscle bulk disease) Tone Ophthalmoplegia Strength • Vertical gaze palsy (progressive supranuclear palsy) Hand drift/pronation/posturing • Mixed (Wernicke-Korsakoff syndrome, chronic basilar meningitis) SENSATION Cornea Light touch • Kayser-Fleischer rings (Wilson’s disease) Joint position sense Lens Vibration • Cataracts (chronic steroids, Down’s syndrome) Pinprick (pain)/temperature (pick one of these) Fundi Romberg • Papilledema (intracranial mass lesion, multiple sclerosis) COORDINATION • Optic pallor (multiple sclerosis, porphyria, Tay-Sachs Finger to nose/follow the target disease) Fine motor movements Extrapyramidal (Parkinson’s disease, Lewy body disease, Rapid alternating movements Huntington’s disease, stroke, Wilson’s disease, numerous Heel to shin others) Cerebellar (alcohol, hereditary degenerative ataxias, GAIT paraneoplastic, use of phenytoin) Station Motor neuron (amyotrophic lateral sclerosis, frontotemporal Spontaneous ambulation dementia with motor neuron disease) Toe/heel/tandem Peripheral nerve (adrenomyeloneuropathy, metachromatic Postural reflexes leukodystrophy, vitamin B12 deficiency, porphyria) REFLEXES Gait Deep tendon reflexes • Apraxia (normal pressure hydrocephalus, frontal dementias) Cutaneous reflexes • Spasticity (stroke, multiple sclerosis) Plantar responses • Bradykinesia (multi-infarct dementia, Parkinson’s disease, Atavistic or primitive reflexes progressive supranuclear palsy, Lewy body disease)

of various findings. Clinicians should decide on a sequence, receptiveness to evaluation, ability to cooperate, cultural sen- practice and become proficient at it, and then use it consist- sitivities, and mental state should be accomplished at the ently. This improves performance and speed, provides a data- earliest time. If one anticipates that the evaluation will agitate base of variations in responses, and reduces the likelihood of the patient or that conditions are deemed unsafe, then the forgetting to perform aspects of the examination. A common evaluation should be discontinued or delayed until such a approach and examination sequence will be offered along time when conditions are more favorable. The patient should with some options for expanding the examination and vali- be forewarned about any elements of the examination that dating findings with use of other maneuvers (Boxes 73-2, might produce discomfort. In some cases the patient may have 73-3, and 73-4). a heightened sensitivity to an examiner of the same or opposite. gender In such circumstances, a chaperone can provide THE EXAMINATION useful reassurance during the interview and examination. Vital signs should be reviewed to assess for factors that may con- Patient well-being and examiner safety are important concerns tribute to behavioral changes, such as very elevated blood from the outset. To safeguard these, assessment of the patient’s pressure, fever, and hypoxia. Changes in blood pressure, pulse,

The Psychiatric Portion of the Mental BOX 73-3 Elements of the Psychiatric Mental Status 73 Examination Status Examination The separation of the mental status examination into psychi- General appearance atric portions and neurological portions represents a historical Behavior difference in emphasis rather than purpose; this distinction Attitude will be continued for the purpose of clarity. (See Box 73-3 for Mood a summary of the components of the psychiatric portion of Affect the mental status examination.) Speech (rate, volume, prosody) Thought process Initial Observations of the Patient Thought content • Suicidal ideation/homicidal ideation General Appearance. Observations start with determination • Obsessions as to whether the patient appears morphologically normal. • Delusions: paranoia, ideas of reference, thought Consider stature, hair-line, level of ears, distance between eyes, broadcasting presence of philtrum, length of neck, and body characteristics Perceptions (such as gynecomastia, obesity, and digit length). These may • Auditory, visual, olfactory, and tactile hallucinations; illusions be indicative of a genetic syndrome or a genetic disorder. • Insight Mention of these characteristics is intended as a reminder • Can be discerned often from perception of circumstance rather than a comprehensive review of this topic. Judgment Behavioral Appearance. Hygiene, body odor, posture, demeanor, cooperativeness, motivation, spontaneity, eye contact, speed of movement, the manner of dress, social graces, and attitude toward the examiner should be noted. A patienty ma be anxious, inattentive, engaged, cooperative, apa- BOX 73-4 Elements of the Neurological Mental Status thetic, disinhibited, angry, hostile, or extremely courteous. Examination Speech. Manifestations of speech include speed, fluency, Arousal volume, and prosody. A person with a history of 4 days of Orientation speaking very quickly and being very hard to interrupt in Attention/concentration conversation may be manic or be under the influence of drugs. Memory Prosody describes the melodic patterns of intonation in lan- • Registration guage that convey shades of meaning. Impairment may be in • Short-term memory at 3–5 minutes the production of prosody, or in the comprehension of • Long-term memory another person’s prosody. Testing prosody is uncommonly • Recent: current events done. If clinically indicated, appreciation of prosody can be • Remote: past and current events; may require family testedy b situating oneself behind the patient and saying a corroboration short sentence, such as “I’m going home now,” with four dif- Language ferent emotional tones (e.g., happy, sad, angry, and neutral). • Fluency Being positioned behind the patient prevents the patient from • Naming interpreting the expression of your face. One should ask the • Language repetition patient to identify the emotional state of each of your theatri- • Reading cal renditions. Prosody production may be tested by asking • Writing the patient to repeat the same sentence in each of the emo- • Comprehension of written and spoken language tional states previously listed. Listening for the patient’s spon- Calculation taneous prosody is also essential. Knowledge of current events Mood and Affect. Mood is the patient’s report of his or her Visual-spatial/constructional emotional state. Affect is the outward expression of the patient’s Abstraction mood to the world. Descriptions of affect include the terms Stereognosis/graphesthesia/double simultaneous stimulation flat, constricted, elevated, sad, expansive, and labile. Neglect A patient with a stooped posture, slow speech, and flat Praxis (can often be discerned during the examination) affect could be manifesting signs of depression. If his stated mood is “sad” or “depressed,” his mood and affect are con gruent. Some neurological conditions may be associated with a disassociation of mood and affect. A condition now and respirations may occur in a variety of contexts, such as known as involuntary emotional expression disorder (IEED),5 pre- with agitation, psychosis, alcohol withdrawal, complex partial viously named pseudobulbar affect or palsy, is characterized by seizures, and medical conditions, to name only a few. The episodes of involuntary or exaggerated emotional expression. examination begins when entering a patient’s room or encoun- This results from brain disorders affecting structures of a tering the patient in the hallway. Initial observations are made neural network involving the frontal lobes, limbic system, wherever the patient is found, be it walking down the hall to brainstem, cerebellum, or the inter-connecting white matter meet you or lying in bed. Whether the patient is aware of being tracts. Extremes of emotional expression (from crying to, less observed can be important since behavior may change when often, laughing) occur without the patient actually feeling out of the physician’s view. these emotions or without the patient feeling the concordant Textbooks have been dedicated to various aspects of cogni- degree of the emotion expressed. IEED can occur in associa- tive assessment. This section will introduce the fundamental tion with a number of neurological conditions including aspects of the cognitive examination; some helpful anatomical dementia (including Alzheimer’s disease, vascular dementia, and neuropsychiatric considerations will also be presented. and frontotemporal dementia), amyotrophic lateral sclerosis

(ALS), multiple sclerosis, stroke, and traumatic brain injury command. The relative ease or difficulty of arousability with (TBI). these stimuli is also noted. Thought Process. Normal thought, as demonstrated in Attention casual conversation and most other circumstances, is goal- directed; it does not require great effort to follow the logical After determination of the level of consciousness, the ability progression of ideas. Some common descriptive terms include to sustain attention and the speed of task completion should linear thinking, loose associations, circumstantial thought, tangen- be assessed. The perceived level of effort should be docu- tial ideas, flight of ideas, disorganized thinking, incoherent thought, mented when performance is reduced. Common tasks used to and perseverative thinking. assess attention and processing speed include the following: Thought Content. This can be derived from what the patient Performance of Serial 7s. Ask the patient to subtract 7 from tells you, from what you can infer from the patient’s history, 100. Then ask the patient to continue subtracting 7 (and to and from your observations of personal interactions. A patient state the results); have the patient stop when he or she reaches may be extremely guarded and careful about when, and if, to 65. Serial 3s from 100 or counting backwards from 20 by 1s reveal his or her true beliefs. Terms that commonly refer to may also be used. The patient should be able to maintain thought content include preoccupations, ruminations, obsessions, attention on task after starting without having the instructions paranoia, delusions, ideas of reference, and suicidal or homicidal repeated. This test must be interpreted in the context of the ideation. There can also be a poverty of content. patient’s background, education, and mathematical ability. Terms such as paranoia, thought blocking, and ideas of refer- Spelling Tests. Have the patient spell the word “world,” ence yma be interpreted as involving perceptions, thought “march,” “chair,” or “radio” forward, backward, and then process, or content.6 alphabetized. Forward-spelling is a test of simple attention. Perceptions. Hallucinations may be auditory, visual, tactile, Backward-spelling requires concentration. Alphabetizing the gustatory, or olfactory. They may be simple (as in a flash of letters is a test of concentration and verbal working memory. light) or complex (as in seeing panoramic scenes or feeling a This testing presumes some degree of spelling ability. kiss). The content of hallucinations and their relationship to Other Tests. Have the patient state the days of the week (or mood are important to identify. Psychiatric disorders more months) forward then backward. Digit span also tests atten- often than not have mood-congruent hallucinations. Insight tion. It is a test during which a patient is presented with suc- regarding the hallucination is an important characteristic that cessively longer strings of random digits starting at two or may aid in the differential diagnosis. For example, some three digits and with each rendition increasing the string by persons with Lewy body dementia or an infarct to the mid- one digit until the patient reaches a string between five and brain peduncle (leading to peduncular hallucinosis) and most seven digits. Performance, to some degree, depends on age; every person with Charles Bonnet syndrome will realize that however, there is little decay in this ability with normal aging. their visual hallucinations are not real. Illusions, or perceptual This test may also be performed backwards. Normal perform- distortions, may also occur. ance is seven digits forward and five digits backwards. However, Insight/Awareness/Concern. The level of insight is com- recalling six digits forward and four digits backwards is prob- monly derived from the patient’s description of his or her ably acceptable. It is considered normal to have a difference circumstances and relates to how the patient’s problems ofo tw between forward and backward testing.8 evolved and how they are understood. The patient’s comportment (behavior and self-conduct) is an indicator of insight. Language Judgment. Determination of judgment is usually derived Language is a term that can refer to a variety of types of thought from aspects of the history. The patient’s interactions with expression that can include facial expressions, sign language, family, friends, and health care professionals can be used to and symbolic communication, as well as written and spoken assess social appropriateness, social graces, and comportment. language. During a screening examination, concerns should Disinhibition or poor judgment may be ascertained through focus on the assessment of spoken and written language. The observation or elements of the history. intent is to determine whether the patient has difficulties pro- ducing language, comprehending language, or both. The examiner’s answers to the following questions provide a basic The Neurological Portion of the Cognitive screen. Mental Status Examination Does the patient’s speech sound like language? Is the speech fluent or non-fluent? Fluency has been described The following sequence affords the opportunity to evaluate as speech that is flowing rapidly and effortlessly. Non-fluent cognition in a hierarchy of increasing complexity. Subsequent speech is uttered in single words or short phrases with fre- performance on complex tasks requires that more basic aspects quent pauses and hesitations. Fluency can usually be appreci- of cognition are intact. (See Box 73-4 for a more complete ated during conversation with the patient. The examiner summary of the components of the neurological mental status should observe the patient’s use of grammatical structure. examination.) Fluency can be independent of content and comprehensibil- ity. Testing the ability to name visually presented objects Level of Consciousness screens for aphasia. A key, stapler, coin, pencil or pen, watch, clothing, and furniture are commonly used. Consciousness is most commonly viewed as being a function of the level of arousal. The lowest level of consciousness has Comprehension. Comprehension is often easily assessed many descriptive terms, some of which imply a pathological while taking the history and performing the physical examina- state, such as coma. A patient might appear to be comatose yet tion. When there is difficulty, one can request that the patient actually be in non-convulsive status epilepticus.7 An awareness perform a one- to three-step command. If the patient appears of the nuances of descriptive terms will help avoid confusion impaired, the examiner should start with simple questions in most circumstances. One common method is to describe that can be answered in a yes/no fashion. Asking a patient to arousability with respect to pain, loud noise, voice, and point at objects or to show his or her thumb or another body

Downloaded for Anonymous User (n/a) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 16, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. The Neurological Examination 795 part are alternatives. Bear in mind that more complex com- formal short-term memory recall is tested. Distraction ensures mands will require intact attention and comprehension of that information is encoded in a more normal fashion and 73 grammar and language. Having the patient read an instruction then recalled rather than allowing the patient to repeat the aloud and perform it is a brief screen of reading comprehen- memory items over and over, possibly allowing some degree sion. Examples include “point to the window” and “close of compensation for faulty memory systems. your eyes”. Short-term Memory. Short-term memory requires the Repetition. Asking the patient to repeat “no ifs, ands, or storage or encoding of information followed by the recall of buts” is a common phrase used to test repetition. If greater information after 3 to 20 minutes. The examiner should ask sensitivity is desired, the examiner can use sentences that are the patient to recall the three (or more) memory items previ- progressively longer, that use words of greater sophistication, ously given. One should provide categorical cueing followed that have a lower frequency of use, or that have more complex by multiple-choice options to aid recall if needed. An inability structures.9 toy recall an items, even after being provided with multiple- choice options, may be suggestive of a primary attentional Memory problem or memory encoding impairment. When memory items can only be recalled with cueing or multiple-choice Memory is associated with a collection of systems with specific options, this may be suggestive of a memory retrieval problem. neuroanatomical structures and functions. These systems Long-term Memory. This type of memory can be considered support the neural processing of information in such a way as to include both recent and remote memory. Asking details to have it available for use at a later time, with or without about the patient’s early life is helpful, but it requires the pres- conscious awareness. Conceptually, memory can be divided ence of a family member or friend to verify the information. into declarative and non-declarative systems. Declarative or Questions about salient historical events are often used to explicit memory is memory for events that can be consciously assess memory, but they are also subject to the patient’s age, recalled. Non-declarative or implicit memory is memory that background, culture, education, and home of origin. “What is expressed as a change in behavior; it is often unconscious. happened on September 11th, 2001?” and “How did John F. Three types of declarative memory are commonly tested at the Kennedy die?” are common test questions. bedside: episodic, semantic, and working memory. Episodic memory refers to the memory system used to recall personal experiences (such as what you had for dinner last night or the Visuospatial/Constructional Skills experience of a recent walk in the park). Semantic memory These skills are tested at the bedside, most commonly with systems are used to recall conceptual and factual knowledge clock drawing. The examiner should ask the patient to draw a that is not related to any specific memory of a personal experi- circle and then fill in the numbers to make it look like the face ence. For example, what number of items constitutes a dozen? of a clock. Then one should ask the patient to set the hands The working memory system refers to the ability to maintain to a time requiring the use of both left and right visual fields; and to manipulate information (such as retaining a phone examples include 11:10 and 10 minutes to 2. Abnormalities number in your mind while searching for a pen and paper to may include the crowding together of numbers within the write it down). This system is particularly dependent on atten- circle or having the numbers, hands, or all of these on one tion, concentration, and short-term memory. Components of side of the page, neglecting to put any detail on the other side. the working memory system have traditionally been referred A common syndrome is that of the right parietal stroke, which to as the verbal, visuospatial, and executive (allocates atten- may be associated with a left hemispatial neglect12 that causes 10 tional resources) systems. crowding of detail to the right side of the clock drawing. Memory system testing at the bedside is generally viewed Attentional or executive dysfunction may cause difficulty plan- as having three components. A commonly used classification ning the clock; the patient may write numbers in unusual 11 divides it into immediate, short-term, and long-term recall. locations, write the time on the clock (rather than setting the Each of these types of recall will involve variable contributions hands), or use strange hand construction or placement (Figure from semantic and episodic memory systems depending on 73-1). Other commonly used tests include asking the patient the individual patient’s memory skills, natural associations toy cop drawings provided by the examiner (such as a Greek with other semantic and episodic memories, and emotional cross, intersecting pentagons, or a three-dimensional cube). valences of the particular memory items selected. Semantic Simple handwriting may also be an indicator of visuospatial and episodic memories are declarative and explicit. function. Immediate Recall. This is the type of memory that is used when retaining a phone number in your mind until you can Describing the Results write it down. This requires intact attention to register the The patient’s actual responses should be documented as memory items. In the office or at the bedside it is common to clearly as possible in the medical record. Terms that are inter- choose at least three items from different categories and to pretive or diagnostic should be avoided. have the patient repeat them after you have said them. Repeti- More in-depth assessment of cognition can include tests of tion confirms immediate registration. Then have the patient cortical sensory modalities, abstraction, praxis, and executive repeat the items until all of them have been registered. Then function. record the number of repetitions necessary before all the memory items were repeated correctly. This reflects the ability Cortical Sensory or Secondary Sensory Modalities. Higher- to focus attention. If an increased complexity of memory level processing of sensory information occurs primarily in the testing is desired, items of more abstract nature should be parietal lobes.13 This testing requires the relative preservation selected (such as “charity,” “honesty,” or “loyalty”). More sen- of primary cutaneous and proprioceptive sensory functions. sitive assessments may use a greater number of recall items, Intact language function is particularly required for testing of incorporate compound nouns, or use combinations of adjec- stereognosis and graphesthesia. tives and nouns (e.g., red bicycle). Other portions of the Stereognosis is the recognition and interpretation of tactile mental status examination can be performed after the memory sensory information. Astereognosis is the inability to recognize items have been registered, thus serving as a distracter before objectsy b touch. This can be tested by placing common

or extinction). The patient may perceive tactile, visual, or auditory information on the side or region of the body that demonstrates extinction when the stimulus is presented as a single stimulus without competition. Abstraction. Asking the patient to identify three similarities between an apple and an orange can test abstraction. It is important that the patient identify the category (i.e., “fruit”). Other questions about similarities include the following: How are a bicycle and an airplane alike? How are a sculpture and a poem alike? Additional testing can include proverb interpretation.14 One can ask the patient what a particular proverb means. Examples include the following: “People who live in glass houses shouldn’t throw stones,” “A shallow stream makes the most noise,” “The tongue is the enemy of the A throat,” and “Dogs bark, and the caravan moves on.” Novel proverbs are the most sensitive. Choosing a proverb with a less obvious interpretation, such as “Dogs bark, and the caravan moves on,” can be useful for the assessment of the patient’s range of abilities to generate novel interpretations. They may afford an opportunity to catch a glimpse of the psychodynam- ics of the individual, and allow subtle psychotic features to manifest in the substance of the patient’s interpretation.15 Per- formance, again, must be interpreted in the context of the patient’s culture and education. Praxis (Greek for “Action”). Apraxia is the acquired inability B to perform a complex or skilled motor act in the absence of impairments of arousal, attention, language, comprehension, motivation, or sensorimotor function. More commonly described varieties include limb kinetic, buccofacial, ideomotor, and ideational apraxia. Limb kinetic apraxia is the loss of ability to make precise, coordinated fine motor movements. It has been argued that this category should not exist because its deficits are related to mild weakness secondary to a lesion in the motor pathways.16 In buccofacial apraxia, patients are unable to perform (on request) complex acts involving the lips, mouth, and face (e.g., whistling, blowing out a match, sticking out the tongue, or coughing). Persons with ideomotor apraxia are unable to perform (on command) complex motor acts with one or all extremities. The patient may be unable to C demonstrate on-command activities (such as saluting, waving goodbye, blowing a kiss, or pantomiming the brushing of Figure 73-1. Examples of clocks. (A) Left hemispatial neglect. (B) teeth, combing of hair, hammering of a nail, or the use of Executive dysfunction. (C) Executive dysfunction. Note the absence of scissors). Patients may incorrectly use their body parts as tools. attention to detail on the left and the crowding of detail to the right in Some of these patients are able to spontaneously perform these example A. Example B demonstrates poor planning and an inability to acts. The inability to perform an ideational plan consisting of set the time properly to 10 minutes after 11. Example C demonstrates a sequence of acts is referred to as an ideational apraxia.17–19 perseveration and difficulty conceptualizing a clock face and setting the time. Executive Function. Executive function tasks are strongly dependent on intact frontal-subcortical circuits. Impaired performance on tasks that require attention and concentration objects (such as coins, keys, paper clips, or closed safety pins) occur in many patients with executive dysfunction. If attention in the patient’s hands and asking the patient to close his or and visuospatial skills are intact, clock-drawing20 and shape- her eyes and name the objects. Characteristics (such as size copying assess executive functions (such as planning, organi- and shape) can be described by the patient. Often, people can zation, and execution of a task).21 Shapes that are commonly identify the denomination of coins. copied include those of a cube or of intersecting pentagons. Graphesthesia is the ability to recognize letters or numbers Executive function deficits may include the inability written on the skin of the palm or finger pad using a suffi- to formulate goals or carry them out, deficits in abstraction ciently pointed object, without ink. and insight, impaired judgment, the inability to retrieve stored Double Simultaneous Stimulation. This maneuver tests for information from memory, and motor perseveration or somatosensory extinction, neglect, or inattention when two impersistence. simultaneous tactile stimuli are provided to opposite sides of Persons with executive dysfunction may have difficulty the. body Extinction occurs when one side is not perceived. changing from one action to the next when asked to perform a Other types of double simultaneous extinction tests involve repeated sequence of actions. For example, when asked to con- the visual and auditory systems. Patients can be exposed to tinue drawing a pattern of alternating triangles and squares, simultaneous visual stimuli in the left and right visual fields theyy ma perseverate on one shape and keep drawing triangles. or to simultaneous auditory stimuli on both sides of the The Luria alternating hand sequencing task, in which the body (potentially revealing hemispatial neglect, inattention, patient is asked to tap the table with a fist, open palm, and side

Principles of Interpretation of the Mental Status Examination The sequence of the neurological examination proceeds from elementary observations about the level of consciousness to a more in-depth assessment of specific abilities. Higher cognitive functions require prerequisite abilities that sometimes involve several domains. Each domain’s performance must be interpreted in the context of function in other domains. For example, if an individual is found to be distractible, to be unable to spell “world” backward, and to make two errors on serial, 7s but has intact language, a more likely interpretation is an attention problem rather than a specific deficit in either calculation or language. If all other portions of the cognitive examination are intact yet the patient makes numerous errors on serial 7s and basic calculations, this may have significance for localization. The relationships between a patient’s cognitive function, test performance, and real-life function are often complex. Test performance is rarely pathognomonic. Factors thaty ma confound test interpretation include confusion or delirium, medication side effects, anxiety, sleep deprivation, alterations in mood or motivation, psychosis, low intellectual function, aphasia, and dyslexia. Interpretation must take into Figure 73-2. Rosenbaum visual acuity card with pupil gauge. (Copy- account the patient’s age, gender, education, cultural back- right © 2004–2007 Armstrong Optical Service Co. All rights reserved.) ground, and life accomplishments. In the event that the results of mental status testing are unclear, confounding, or insuffi- cient to delineate the extent of the cognitive difficulty, adjunc- when interpreting eye findings. Funduscopy should be per- tive formal neuropsychological testing can be indispensable. formed after portions of the examination that require vision. Input from friends and family members may provide invalu- able corroboration of history and day-to-day functioning. Visual Acuity (CN II) Visual acuity should be checked in each eye separately; cus- CRANIAL NERVES tomarily, the right eye is tested first. The most common Olfaction (Cranial Nerve [CN] I) method is to ensure that the patient is wearing whatever cor- rective lenses are normally worn and then to place a visual This is an important sensory modality because olfactory symp- acuity card 14 inches in front of each eye while the other eye toms in psychiatric and neurological patients are frequent. is covered (Figure 73-2). The examiner should ensure that Unfortunately, psychiatrists rarely perform this portion of the good lighting is present in the room. Poor visual acuity can examination and neurologists uncommonly complete it. The play a role in visual illusions and in hallucinations.28 olfactory bulbs and tracts run along the inferior surface of the frontal lobes and project to limbic areas, as well as to Visual Fields (CN II) regions important for memory.22 Head trauma may be associated with loss of smell23; disinhibition may result from orbital Visual fields are tested in the clinic and at the bedside using a frontal injury.24 Tumors in the mid-line frontal region, known confrontation method. The examiner (you) should have the to cause apathy or abulia, may cause loss of smell. When patient cover their left eye while situating yourself directly in testing is necessary, non-irritating stimuli should be used. front of the patient with your face 2 to 3 feet from the patient’s Alcohol and ammonia may stimulate the trigeminal nerve, face (Figure 73-3). The objective is to match your visual field and the response to this stimulation may be confused with to the patient’s. Each quadrant should be tested by moving an olfaction. One should bear in mind that the patient may not objecty or b wiggling a finger into the patient’s visual field be able to name unfamiliar or less commonly encountered from the periphery at a distance that is mid-way between you scents (such as clove or nutmeg); therefore, coffee, pepper- and the patient. Then the other eye should be tested. Another mint, wintergreen, or vanilla should be used. Each nostril method is to have the patient count the number of fingers held should be tested individually. Abnormalities may include up in each quadrant. The visual system spans from eye to hyposmia, anosmia or misidentification of a smell.25–27 occiput. The characteristics of visual field abnormalities can be very useful for localizing lesions (Figure 73-4). Optic Nerve (CN II) Pupillary Responses (CNs II and III) Ocular processes (such as cataracts, old hemorrhages, and The pupils should be examined in a darkened room. The macular degeneration) should be cautiously taken into account examiner should shine a penlight from below so as to

Downloaded for Anonymous User (n/a) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 16, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 798 PART XVIII Neuropsychiatry illuminate both eyes just enough to compare pupillary size size in both light and darkness should be documented. Pupil- simultaneously. Next, the light should be shone to directly lary abnormalities may be seen in diseases that affect the illuminate the right pupil and watch for constriction. After 1 sympathetic nervous system and in those that affect compo- to 2 seconds, the light should be moved to the left eye and nents of the visual system from the pupil, retina, optic nerve, the pupils observed for symmetry and size. Both pupils should to the brainstem. The convergence response does not involve constrict symmetrically, with a light shone in either eye. This the specific use of light (except to visualize both pupils for is termed the consensual response. After 1 to 2 seconds, the light response). The patient should be asked to visually track your should be swung back to the other eye. The pupils should finger as you move it from a distance toward the patient in the remain roughly symmetric in size while swinging the light mid-line. This will normally cause the eyes to converge and from side to side. Dilation of a pupil to direct light during the the pupils to constrict symmetrically. swinging flashlight test is abnormal. Absence of reactivity, slow reactivity, or large pupil asymmetries are abnormal. Pupil Funduscopy (CN II) and the Retina Thee ey is the only location in the body in which a nerve and blood vessels can be directly visualized. Optic disk swelling (papilledema) may indicate increased intracranial pressure,29 optic disk atrophy may be present in demyelinating disease,30 and optic disk and retinal abnormalities both may occur in vascular disease.31

Ocular Movements (CNs III, IV, and VI) These three cranial nerves control eye movements and lid elevation. Any spontaneous eye movements in primary resting forward gaze should be observed. The range of conjugate gaze (testedy b holding your finger about 2 feet away) should be assessed next. The finger should be moved slowly to allow for assessment of voluntary smooth pursuits in the up, down, oblique, left, and right directions (Figure 73-5). Patients with Parkinson’s disease manifest “jerky” smooth pursuits.32,33 The examiner should ask the patient to hold his or her head still. At the limits of conjugate gaze in each direction the examiner should hold gaze for several seconds and then observe for nystagmus. When present, this is referred to as gaze-evoked nystagmus. Barbiturates, tranquilizers, ethanol, and anticon- vulsants commonly cause gaze-evoked nystagmus in both Figure 73-3. Confrontation visual field testing. directions of gaze.34 Normal saccades are involuntary, fast,

Figure 73-4. Anatomy of the visual system. Visual field defects associated with different anatomical lesions.

tongue. The facial nerve’s other motor and sensory components would uncommonly be tested. The examiner should ask 73 the patient to raise the eyebrows, to wrinkle the forehead, to Figure 73-5. Diagram of two options for testing eye movement range. squeeze the eyes shut, and to smile (or show the teeth). One should also look for symmetry of facial markings (such as the nasolabial fold), at rest and with movement. Further testing can involve testing the strength of facial muscles by overcom- ing them (by trying to open the closed eyes or to pull the closed lips apart manually). Subtle facial asymmetries are common and not necessarily pathological. It is helpful to have V1 a family member or an old photo (e.g., a driver’s license) to verify the long-standing nature of a subtle asymmetry. Dysar- thria can result from weakness of the orbicularis oris. Labial sounds can be tested by asking the patient to say “pa. … pa. V 2 … pa.” The speed and clarity of speech should also be assessed. A central pattern of facial weakness is characterized by weak- V ness in the lower face, with sparing of the forehead. This is 3 due to the bilateral corticobulbar innervation of the portion of the facial nucleus subserving the forehead. A peripheral pattern of weakness is characterized by hemifacial weakness without forehead sparing. This can be caused by disruption of Figure 73-6. Trigeminal nerve sensory distribution. V1, V2, and V3 sensory distributions in blue, yellow, and red, respectively. the facial nerve or nucleus (Figure 73-7). Taste is uncommonly tested unless there are specific indications. conjugate changes of eye position between fixations. Saccades Vestibulocochlear Nerve (CN VIII) arey tested b having the patient fixate on your nose and then Lesions of this nerve can be associated with vertigo, hearing look quickly toward your finger and then back to your nose. loss, or both. One should ensure that the external ear canal is Your finger should be held in the up, down, left, and then not occluded with cerumen. Holding your fingers several right positions. The accuracy and speed of saccades should be inches away from the patient’s ears and rubbing the fingers assessed. The patient should be assessed for overshooting together softly allows for a quick, but usually adequate, assess- (hypermetric saccades) back to the target. Hypermetric sac- ment. Alternatively, you can ask the patient to repeat a word cadesy ma occur in conditions with cerebellar involvement or numbers that you whisper into the ear while occluding the (such as the cerebellar presentation of multi-system atrophy). other. ear More in-depth testing can include the Rinne test, The patient should also be assessed for undershooting (hypo- which involves the use of a vibrating tuning fork (128 to metric saccades), requiring several saccades to reach the target. 512 Hz) applied to the mastoid bone until it can no longer Patients with Parkinson’s disease may manifest hypometric be heard. It is then placed next to the ear. This comparison saccades.35 Slowed saccades or saccadic smooth pursuits can determines whether hearing is better with air or bone conduc- be present in Wilson’s disease.36 Slowed vertical saccades often tion. Conduction hearing loss is characterized by hearing the mark progressive supranuclear palsy.37 Slowed and hypometric sound better with the tuning fork applied to the mastoid than saccades may be associated with Huntington’s disease,38 and next to the ear. In sensorineural hearing loss, the sound is anticonvulsant toxicity.39 These are just a few examples of better perceived next to the ear than via the mastoid bone. The neurological conditions with associated eye movement abnor- Weber test uses a tuning fork placed in the mid-line at the malities. Ptosis of the eyelids should also be noted. vertex or forehead to determine on which side the sound is heard best. Sound referred to an ear with decreased acuity Trigeminal Nerve (CN V) indicates conductive hearing loss.40 Sound referred to the opposite (unaffected) ear occurs with sensorineural hearing The trigeminal nerve provides sensory innervation to the face, loss. These tests are crude compared to audiologic testing. cornea, and much of the mouth and tongue (Figure 73-6). Its Hearing loss can exacerbate auditory hallucinations and motor component innervates the muscles of mastication. paranoia.41 Unless the patient has a specific sensory complaint, it is sufficient to use light touch (tested with fingers or gauze) or temperature (tested with a cold metal tuning fork) and ask the Glossopharyngeal and Vagus Nerves patient if it feels the same or similar on both sides. Testing of (CNs IX and X) the corneal reflex is not routinely necessary. These nerves will be discussed together because of their inti- Muscles of Mastication mately related functions. CNs IX and X serve the motor and sensory functions of the palate and vocal cords. Brief observation of the jaw at rest and with movement is adequate in a patient without complaints. Having the patient Speech (CNs IX and X) move his or her chin from side to side, then open his or her Speechy ma be hoarse, with vocal cord weakness. An inability mouth widely, helps assess the function of these muscles. to swallow secretions can lead to drooling. (See CN VII.) Further testing can involve opening and closing the jaw against resistance. Palate (CNs IX and X) Facial Nerve (CN VII) This is assessed by asking the patient to say “aaah” and watch- ing for the degree of palate elevation and symmetry. Palatal The facial nerve provides motor innervation to the muscles of speech dysfunction can be assessed by evaluating the clarity facial expression and taste to the anterior two-thirds of the and speed of palatal sounds such as “ga. … ga. … ga.” Labial,

Patient can elevate Unable to elevate both eyebrows eyebrow on right

Normal wrinkling Forehead does not wrinkle

Slightly widened Markedly wider palpebral fissures palpebral fissures

Flattened Flattened nasolabial fold nasolabial fold

Droop of mouth Droop of mouth

A B Figure 73-7. Depiction of (A) central facial weakness and (B) peripheral facial weakness.

lingual, and palatal sounds can be tested together by having of CNS origin except in association with non-use. Hypertro- the patient repeat “pa. … ta. … ka.” phy can be normal when seen in the setting of weightlifting, Inspection of the oral cavity is sufficient in an asympto- or abnormal when seen as a feature of dystonia or selected matic individual. The gag reflex is uncommonly tested in the muscular dystrophies. screening neurological examination. When there is reasonable suspicion that swallowing is impaired, when the palate is Tone weak, or when there are voice changes, the gag reflex should be checked. Symmetry of the response on each side should be Muscle tone is the residual tension present in a voluntarily noted. relaxed muscle. This is clinically assessed by determining the degree of resistance present to passive movement of a limb or the head. Relaxation can be difficult for many patients, and Spinal Accessory Nerve (CN XI) distraction, such as engaging the patient in conversation or Thise nerv innervates the trapezius and the sternocleidomas- asking the patient to perform a simple activity with a contra toid (SCM) muscles. The trapezius can be assessed with a lateral limb (such as opening and closing the hand held up shoulder shrug against resistance. The SCM is evaluated with in the air) may be necessary. It is important to know about a head rotation against resistance. The head should be fully variety of different tone abnormalities. Lead-pipe rigidity is rotated in the direction of testing, and then resistance should characterized by a consistent and relatively stable degree of be applied. The right SCM turns the head to the left and the increased tone throughout the range of movement of a limb; left SCM turns the head to the right. SCM muscle bulk should it is not affected by velocity of movement. Cogwheel rigidity be inspected with the head facing forward. Asymmetry of is a rhythmic increase in tone, similar to a tremor, throughout muscle bulk can often be seen in cases of torticollis. the range of movement. Spasticity is a type of hypertonicity that increases with an increase in the velocity of movement. Slow movements may reveal little abnormal tone and fast Hypoglossal Nerve (CN XII) movements may result in a sudden increase in tone. Gegen- The hypoglossal nerve is involved in speech production as is halten is a paratonia that manifests as an increase in resistance CNs VII, IX, and X. The hypoglossal nerve provides motor from the patient in proportion to the effort of the examiner. innervation to the tongue. Gross inspection of the tongue may It is often reduced by distraction. Mitgehen is another type of reveal atrophy or fasciculations in the setting of a peripheral paratonia that is characterized by the patient who actively nerve lesion. A lisp may be clinically apparent during conver- assists the examiner throughout the range of motion. Both types of paratonia are thought to suggest diffuse bilateral sation. The examiner should ask the patient to protrude his or 45 her tongue in the mid-line and to look for deviation to one frontal lobe disease or diffuse cerebral disease. side. Lingual speech dysfunction can be evaluated by assessing the speed and clarity of lingual sounds, such as “la. … la. … Strength la.” Parkinsonian, familial, medication-induced, and thyro- It is beyond the scope of a screening examination in the out- toxic tremors may be apparent in the tongue.42,43 Degenerative patient or inpatient psychiatric setting to perform a compre- diseases and neuroleptic medications can induce dyskinesias hensive neuromuscular evaluation. Practical assessment of of the tongue and the oromandibular region.44 strength in an asymptomatic patient should assess the deltoid, biceps, triceps, and brachioradialis muscles, as well as grip MOTOR EXAMINATION strength and gait assessment. The patient should be able to Muscle Bulk rise independently from a sitting position without using his or her arms. A normal casual gait, toe, and heel walk in most The muscles should be inspected for atrophy, hypertrophy, circumstances rules out a significant motor deficit. Strength is and fasciculations. Atrophy is an important sign of lower most commonly graded using the Medical Research Council’s motor neuron disease. It is not seen prominently in weakness five-level scale (Table 73-1).46

TABLE 73-1 Medical Research Council Scale of Muscle include touch, proprioception, vibration, pain, and tempera- Strength Table ture. Secondary sensory modalities are a synthesis and inter- 73 pretation of primary modality information that occurs in the 0 No contraction 1 A flicker or trace of contraction parietal sensory and association cortices. Testing of secondary 2 Active movement with gravity eliminated sensory modalities is discussed in the neurological portion of 3 Active movement against gravity the mental status examination. 4− Active movement against gravity and slight resistance Testing for two-point discrimination is not indicated in an 4 Active movement against gravity and moderate resistance asymptomatic patient. Testing of light touch and either pain 4+ Active movement against gravity and strong resistance (sharp) or temperature sensation is usually sufficient. Having 5 Normal power the patient close his or her eyes can increase the sensitivity of the examination and is required for proprioceptive testing. (See Figure 73-8 for an illustration of nerve and dermatomal Abnormal Movements distributions.) Light touch can be tested by touching the patient lightly Abnormal voluntary or involuntary movements may occur with your finger or a piece of cotton. during the history and physical examination and should be Proprioception can be tested by using the finger and thumb described. The psychiatrist should be familiar with the follow- of one hand, and stabilizing the distal interphalangeal ing terms: joint of a digit by holding its medial and lateral aspects. • Tremor is usually an involuntary, rhythmic oscillation pro- After moving the digit slightly up or down, the patient is ducedy b rhythmic contractions of agonist and antagonist asked to identify the direction of movement. Romberg muscles. Tremors may be present with movement, sustained testing is also useful for position-sense testing. One should postures or at rest. Tremors may affect the voice, tongue, ask the patient to stand with both feet together as closely face, head, limbs, and trunk. The frequency and amplitude as possible to maintain balance with the eyes open. Then one of tremors are important features. should ask the patient to close their eyes. If the patient • Myoclonus is characterized by involuntary, non-rhythmic, loses his or her balance with the eyes closed (but not when brief, sometimes repetitive muscle contractions that are the eyes are open), he or she is Romberg positive. If swaying irregular in frequency and amplitude. They are often asyn- occurs without loss of stance, this should be described in chronous and asymmetric. They may be symmetric in spinal your. note myoclonus. They may be cortical, subcortical, or spinal in Vibration can be tested using a 128-Hz tuning fork on a origin. distaly bon prominence or distal interphalangeal joint. One • Clonus is characterized by involuntary, rhythmic contrac- should assess when the vibration fades from the patient’s tions and relaxations of a muscle or group of muscles. perception. You may use the same anatomical region on your- • Chorea is manifest by involuntary, non-rhythmic, jerky, self for comparison. rapid movements of muscle groups. Pain can be tested with the use of disposable sterile pins. • Asterixis is also known as “liver flap” or negative myoclonus. Temperature can be tested using a cold metal tuning fork. This movement is characterized by an abrupt loss of volun- Youy ma run it under cold or warm water to ensure a clear tary muscle tone. It is commonly elicited by asking the temperature change from your pocket or from room patient to hold his or her arms outstretched with the wrists temperature. extended. When asterixis is present, the hands, with or without the arms, may suddenly drop downward and then Coordination Testing quickly recover, which causes an irregular and slow flapping motion. Coordination testing is the preferred term, rather than cerebellar • Athetosis is manifest by involuntary, slow, irregular, sinuous, testing. The specific abilities involved in coordination testing snake-like writhing movements. require integration and processing of information from diverse • Dystonia is an involuntary movement or sustained posture systems that include visual, sensory, motor, basal ganglia, cor- that results from abnormal tonicity of muscle. Movements tical association, and cerebellar systems. may be characterized as having prolonged or repetitive Finger-to-nose can be assessed by positioning yourself muscle contractions that may result in twisting or jerking directly in front of the patient and asking them to touch movements of the body or body part. the tip of your index finger with the tip of their index • Tics are defined in several ways. They are characterized by finger and then touch the tip of their nose with the same simple or complex coordinated movements or vocalizations finger. One can have the patient continue alternating this that are repetitive, stereotyped, compulsive, and often maneuver, ensuring that the patient’s arm is extended, so abrupt, and over which the patient feels he or she has little as to reach for your finger. Then you should move your or no control. Tics are experienced as almost irresistible target finger from the patient’s right side to a stationary posi- impulses to perform a particular activity. Some tics can be tion in front and then to a position on the left. This should suppressed. be repeated with the patient’s other hand. One should • Fasciculations are brief, irregular twitches of a muscle. They look for accuracy of movement, speed, and tremor. An alterna- may be localized to a muscle or limb or be diffuse, depend- tive maneuver is to have the patient follow your finger ing on the etiology. Fasciculations occur as a benign phe- as a target with their same finger (of either hand) without nomenon, as well as a manifestation of various neuropathies actually touching your finger. This should be performed (e.g., amyotrophic lateral sclerosis [ALS] or diabetic periph- within a plane equidistant from both of you while seated eral neuropathy), radiculopathies, and thyrotoxicosis, and facing each other. Your finger should be moved around in they can occur in association with anticholinesterase use. space from left to right and up and down to various stationary positions, while the patient attempts to closely mirror your Sensory Examination movements, dynamically following your movements to various stationary positions without touching you or drifting Sensory function is divided into primary and secondary off target. This is a more sensitive assessment of the precision modalities. The primary sensory modalities commonly tested of movement.

Cervical plexus 5 4 C3 Lateral cut T1 C4 2 C6 T2 3 3 4 C5 5 4 Medial cut Medial cut and 6 5 intercostobrachial 7 6 8 T1 9 7 Antebrachial cut 10 8 lateral 11 9 medial 12 C7 L1 C6 10 posterior Iliohypogastric 2 11 3 C7 4 T12 Posterior femoral Ulnar Radial cut C8 L1 Ulnar 5 C8 S1 Medial S2 L2 S3 Ilioinguinal and genitofemoral L1 S3 L3 Lateral femoral cut L2 Obturator

Femoral L3 L5 L4 Common peroneal S1

Superficial peroneal Saphenous L5 Tibial Saphenous

Figure 73-8. Sensory nerve distributions and dermatomes. (From Gilroy J. Basic neurology, ed 2, New York, 1990, Pergamon Press, p. 41.)

Rapid Alternating Movements in a wide-based stance. Basal ganglia disorders may cause slowing of gait, reduced stride length, and festination. Gait The most common maneuvers are finger-tapping and alternat- assessment should be part of every neurological examination. ing pronation and supination of the forearm. Speed, ampli- Casual stance and gait should be inspected. Posture, gait tude, rhythmicity, and precision of movements are noted. initiation, speed of gait, step height, stride length, position of Toe-tapping may be used if clinically indicated. It has been legs, arm swing, and turning capabilities should be observed. proposed that significant slowing of toe-tapping, in the Toe and heel-walking will test strength and balance. Tandem absence of prominent lower limb weakness, may be a more walking is useful to detect mid-line instability that is com- sensitive marker for upper motor neuron dysfunction than the monly seen as a result of chronic alcohol use. Postural reflexes 47 Babinski sign. may be assessed by asking the patient to stand with his or her feet together and eyes closed (as in the Romberg maneuver). Heel to Shin The patient should be reassured that you will be testing the This maneuver is optimally performed with the patient in the patient’s balance by pushing them a bit in various directions, supine position. One should ask the patient to smoothly run but you will not allow the patient to fall. (Take care to ensure their heel up and down the opposite shin along a line from that the patient does not tfall.) A the patient’s shoulder level below the knee to the ankle. The patient should be urged to you can variably and sequentially give the patient a nudge be as accurate with the movements as possible. One should forward, backward, to one side, and then to the other side. look for precision, range of motion, speed, and presence of Retropulsion is commonly seen in patients with parkinsonian tremor. The maneuver is then repeated on the other side. symptoms.

Gait Testing REFLEX ASSESSMENT Deep Tendon Reflexes Walking is a complex form of motor coordination that requires the integrated function and synthesis of input from various Deep tendon reflexes (DTRs) are also commonly called muscle systems. Some of these systems include the sensory, motor, stretch or proprioceptive reflexes. These reflexes are elicited by cerebellar, basal ganglia, and vestibular systems. Gait can be tapping the muscle’s tendon or sometimes by tapping a portion affected through dysfunction in any of these components, with of the muscle itself. Muscle stretch receptors are activated and many characteristic manifestations. Sensory deficits may result sensory information is transmitted to the spinal cord within

TABLE 73-3 Grading Reflexes Primitive Reflexes or Atavistic Reflexes For the purposes of documentation, most neurologists grade the (Mistakenly Called “Frontal Release Signs”) deep tendon reflexes (DTRs) numerically as follows: 0 Absent These reflexes are present at birth and disappear in most 1+ Diminished people in early infancy. There is a large portion of the normal 2+ Normal population in which a single primitive reflex persists. This is 3+ Increased; hyperactive; often with less concerning when it is a single reflex (such as a snout, spread to other muscle groups glabellar, or palmomental reflex). A grasp or suck reflex is 4+ Hyperactive with spread to other muscle groups and clonus; clearly abnormal considered more worrisome. Asymmetry or multiple primitive reflexes are considered abnormal. Primitive reflexes are not

AA BB C

Figure 73-9. (A) Plantar reflex. (B) Babinski sign. (C) Plantar stimulus.

A B

Figure 73-10. (A) Snout. (B) Snout reflex.

believed to be useful for localization purposes.51,52 If they reap- 12. Weintraub S, Daffner KR, Ahern GL, et al. Right sided hemispatial pear in later life they may be suggestive of diffuse cerebral, neglect and bilateral cerebral lesions. J Neurol Neurosurg Psychiatry subcortical, or bilateral frontal lobe pathology.53–55 60(3):342–344, 1996. The snout reflex can be assessed by gently tapping over the 13. Gottlieb J, Snyder LH. Spatial and non-spatial functions of the patient’s upper lip. If this reflex is present, a puckering of the parietal cortex. Curr Opin Neurobiol 20(6):731–740, 2010. 18. Geschwind N. Disconnexion syndromes in animals and man. I lips will be seen. The snout reflex is present in 30% to 50% of and II. Brain 88(2):237–294, 585–644, 1965. healthy adults over age 60 (Figure 73-10). 21. Cosentino S, Jefferson A, Chute DL, et al. Clock drawing errors in A suck reflex yma also be elicited and is considered a more dementia: neuropsychological and neuroanatomical considera- worrisome reflex. When present, the suck reflex is elicited by tions. Cogn Behav Neurol 17(2):74–84, 2004. stimulation of the lips; this is followed by sucking movements 23. Costanzo RM, Miwa T. Posttraumatic olfactory loss. Adv Otorhi- of, the lips tongue, and jaw. nolaryngol 63:99–107, 2006. The palmomental reflex is an ipsilateral contraction of the 24. Cummings JL. Frontal-subcortical circuits and human behavior. mentalis and orbicularis oris after stimulation of the thenar Arch Neurol 50(8):873–880, 1993. region of the hand. This reflex is present in 20% to 25% of 25. Serby M, Larson P, Kalstein D. The nature and course of olfactory deficits in Alzheimer’s disease. Am J Psychiatry 148:357–360, 1991. healthy adults in their thirties and forties. The glabellar reflex 28. Berrios GE, Brook P. Visual hallucinations and sensory delusions is assessed by tapping the patient’s glabellar ridge between the in the elderly. Br J Psychiatry 144:662–664, 1984. eyes with your finger. It is best to stand to the side of or behind 30. Balcer LJ. Clinical practice. Optic neuritis. N Engl J Med a seated patient so as to not cause a visual threat response. The 354(12):1273–1280, 2006. patient should be asked not to blink. The reflex is present if 31. Purvin V, Kawasaki A. Neuro-ophthalmic emergencies for the there is persistence of blinking with gentle tapping. neurologist. Neurologist 11(4):195–233, 2005. The grasp reflex is elicited after first instructing the patient 35. Pinkhardt EH, Kassubek J. Ocular motor abnormalities in Parkin- not to hold on to the examiner’s hand, followed by stroking sonian syndromes. Parkinsonism Relat Disord 17(4):223–230, 2011. the palm between the thumb and forefinger of the patient’s 36. Ingster-Moati I, Bui Quoc E, Pless M, et al. Ocular motility and Wilson’s disease: a study on 34 patients. J Neurol Neurosurg Psy- hand. This is but one version of several as to how this maneu- chiatry 78(11):1199–1201, 2007. ver is accomplished. The reflex is present if the patient’s fingers 37. Boxer AL, Garbutt S, Seeley WW, et al. Saccade abnormalities in flex or the hand closes. autopsy-confirmed frontotemporal lobar degeneration and Alzheimer’s disease. Arch Neurol 69(4):509–517, 2012. Access the complete reference list and multiple choice questions 38. Martino D, Stamelou M, Bhatia KP. The differential diagnosis of (MCQs) online at https://expertconsult.inkling.com Huntington’s disease-like syndromes: ‘red flags’ for the clinician. J Neurol Neurosurg Psychiatry 84(6):650–656, 2013. 39. Thurston SE, Leigh RJ, Abel LA, et al. Slow saccades and hypome- KEY REFERENCES tria in anticonvulsant toxicity. Neurology 34(12):1593–1596, 1. Legesse B, Murray ED, Price BH. Brain-behavior relations. In 1984. Ramachandran VS, editor: Encyclopedia of human behavior, ed 2, 41. van der Werf M, van Winkel R, van Boxtel M, et al. Evidence that Waltham, MA, 2012, Academic Press. the impact of hearing impairment on psychosis risk is moderated 2. Murray ED, Buttner EA, Price BH. Depression and psychosis in by the level of complexity of the social environment. Schizophr neurological practice. In Bradley WG, Daroff RB, Fenichel GM, Res 122(1–3):193–198, 2010. et al., editors: Neurology in clinical practice, ed 6, Philadelphia, 47. Miller TM, Johnston SC. Should the Babinski sign be part of the 2012, Butterworth-Heinemann, pp 92–116. routine neurologic examination? Neurology 65(8):1165–1168, 3. Price BH, Adams RD, Coyle JT. Neurology and psychiatry: closing 2005. the great divide. Neurology 54(1):8–14, 2000. 53. van Boxtel MP, Bosma H, Jolles J, et al. Prevalence of primitive 4. Hinson VK, Haren WB. Psychogenic movement disorders. Lancet reflexes and the relationship with cognitive change in healthy Neurol 5(8):695–700, 2006. adults: a report from the Maastricht Aging Study. J Neurol 5. Cummings JL, Arciniegas DB, Brooks BR, et al. Defining and diag- 253(7):935–941, 2006. nosing involuntary emotional expression disorder. CNS Spectr 54. Rao R, Jackson S, Howard R. Primitive reflexes in cerebrovascular 11(6):1–7, 2006. disease: a community study of older people with stroke and 7. Bauer G, Trinka E. Nonconvulsive status epilepticus and coma. carotid stenosis. Int J Geriatr Psychiatry 14(11):964–972, 1999. Epilepsia 51(2):177–190, 2010. 55. Bachmann S, Bottmer C, Schroder J. Neurological soft signs in 10. Budson AE, Price BH. Memory dysfunction. N Engl J Med first-episode schizophrenia: a follow-up study. Am J Psychiatry 352(7):692–699, 2005. 162(12):2337–2343, 2005.

30. Balcer LJ. Clinical practice. Optic neuritis. N Engl J Med REFERENCES 354(12):1273–1280, 2006. 73 1. Legesse B, Murray ED, Price BH. Brain-behavior relations. In Ram- 31. Purvin V, Kawasaki A. Neuro-ophthalmic emergencies for the achandran VS, editor: Encyclopedia of human behavior, ed 2, neurologist. Neurologist 11(4):195–233, 2005. Waltham, MA, 2012, Academic Press. 32. Lekwuwa GU, Barnes GR, Collins CJ, et al. Progressive bradyki- 2. Murray ED, Buttner EA, Price BH. Depression and psychosis in nesia and hypokinesia of ocular pursuit in Parkinson’s disease. neurological practice. In Bradley WG, Daroff RB, Fenichel GM, J Neurol Neurosurg Psychiatry 66(6):746–753, 1999. et al., editors: Neurology in clinical practice, ed 6, Philadelphia, 33. Liu GT, Volpe NJ, Galetta SL. Neuro-ophthalmology, Philadelphia, 2012, Butterworth-Heinemann, pp 92–116. 2001, WB Saunders, pp 584–626. 3. Price BH, Adams RD, Coyle JT. Neurology and psychiatry: closing 34. Lavin PJM. Neuroophthalmology: oculomotor system. In Bradley the great divide. Neurology 54(1):8–14, 2000. WG, Daroff RB, Fenichel GM, et al., editors: Neurology in clinical 4. Hinson VK, Haren WB. Psychogenic movement disorders. Lancet practice, ed 6, Philadelphia, 2012, Butterworth-Heinemann. Neurol 5(8):695–700, 2006. 35. Pinkhardt EH, Kassubek J. Ocular motor abnormalities in Parkin- 5. Cummings JL, Arciniegas DB, Brooks BR, et al. Defining and diag- sonian syndromes. Parkinsonism Relat Disord 17(4):223–230, nosing involuntary emotional expression disorder. CNS Spectr 2011. 11(6):1–7, 2006. 36. Ingster-Moati I, Bui Quoc E, Pless M, et al. Ocular motility and 6. Strauss GD. The psychiatric interview, history and mental status Wilson’s disease: a study on 34 patients. J Neurol Neurosurg Psy- examination. In Kaplan HI, Sadock BJ, editors: Comprehensive chiatry 78(11):1199–1201, 2007. textbook of psychiatry, ed 6, Baltimore, 1995, William & Wilkins. 37. Boxer AL, Garbutt S, Seeley WW, et al. Saccade abnormalities in 7. Bauer G, Trinka E. Nonconvulsive status epilepticus and coma. autopsy-confirmed frontotemporal lobar degeneration and Epilepsia 51(2):177–190, 2010. Alzheimer’s disease. Arch Neurol 69(4):509–517, 2012. 8. Mueller J, Fogel BS. Neuropsychiatric assessment. In Fogel BS, 38. Martino D, Stamelou M, Bhatia KP. The differential diagnosis of Schiffer RB, Rao SM, editors: Synopsis of neuropsychiatry, Philadel- Huntington’s disease-like syndromes: ‘red flags’ for the clinician. phia, 2000, Lippincott Williams & Wilkins. J Neurol Neurosurg Psychiatry 84(6):650–656, 2013. 9. Kirshner HS. Speech and language disorders. In Samuels MA, 39. Thurston SE, Leigh RJ, Abel LA, et al. Slow saccades and hypome- Feske SA, editors: Office practice of neurology, ed 2, Philadelphia, tria in anticonvulsant toxicity. Neurology 34(12):1593–1596, 2003, Churchill Livingstone. 1984. 10. Budson AE, Price BH. Memory dysfunction. N Engl J Med 40. Rudge P. Clinical neuro-otology, New York, 1983, Churchill 352(7):692–699, 2005. Livingstone. 11. Petersen RC. Disorders of memory. In Samuels MA, Feske SA, 41. van der Werf M, van Winkel R, van Boxtel M, et al. Evidence that editors: Office practice of neurology, ed 2, Philadelphia, 2003, the impact of hearing impairment on psychosis risk is moderated Churchill Livingstone. by the level of complexity of the social environment. Schizophr 12. Weintraub S, Daffner KR, Ahern GL, et al. Right sided hemispatial Res 122(1–3):193–198, 2010. neglect and bilateral cerebral lesions. J Neurol Neurosurg Psychiatry 42. Lou JS, Jankovic J. Essential tremor: clinical correlates in 350 60(3):342–344, 1996. patients. Neurology 41(2 Pt 1):234–238, 1991. 13. Gottlieb J, Snyder LH. Spatial and non-spatial functions of the 43. Rapoport A, Stein D, Shamir E, et al. Clinico-tremorgraphic fea- parietal cortex. Curr Opin Neurobiol 20(6):731–740, 2010. tures of neuroleptic-induced tremor. Int Clin Psychopharmacol 14. Brune M, Bodenstein L. Proverb comprehension reconsidered— 13(3):115–120, 1998. “theory of mind” and the pragmatic use of language in schizo- 44. Jankovic J. Etiology and differential diagnosis of blepharospasm phrenia. Schizophr Res 75(2–3):233–239, 2005. and oromandibular dystonia. Adv Neurol 49:103–116, 1988. 15. Sponheim SR, Surerus-Johnson C, Leskela J, et al. Proverb inter- 45. Campbell WW, DeJong RN. DeJong’s the neurologic examination, pretation in schizophrenia: the significance of symptomatology ed 6, Philadelphia, 2005, Lippincott Williams & Wilkins, and cognitive processes. Schizophr Res 65(2–3):117–123, 2003. pp 395–400. 16. Pryse-Phillips W. Companion to clinical neurology, ed 2, Oxford, 46. Medical Research Council of the United Kingdom. Aids to the 2003, Oxford University Press. examination of the peripheral nervous system, United Kingdom, 17. Goodglass H, Kaplan E. Disturbance of gesture and pantomime 1978, Pendragon House. in aphasia. Brain 86:703–720, 1963. 47. Miller TM, Johnston SC. Should the Babinski sign be part of the 18. Geschwind N. Disconnexion syndromes in animals and man. I routine neurologic examination? Neurology 65(8):1165–1168, and II. Brain 88(2):237–294, 585–644, 1965. 2005. 19. Rothi LJG, Heilman KM. Apraxia, London, 1997, Taylor & Francis. 48. Porter NC, Weiner WJ. The neurologic examination. In Weiner 20. Libon DJ, Swenson RA, Barnoski EJ, et al. Clock drawing as an WJ, Goetz CG, editors: Neurology for the non-neurologist, ed 5, assessment tool for dementia. Arch Clin Neuropsychol 8(5):405– Philadelphia, 2004, Lippincott Williams & Wilkins. 415, 1993. 49. Pasztor E. Erno Jendrassik (1858-1921). J Neurol 251(3):366–367, 21. Cosentino S, Jefferson A, Chute DL, et al. Clock drawing errors in 2004. dementia: neuropsychological and neuroanatomical considera- 50. Gregory JE, Wood SA, Proske U. An investigation into mecha- tions. Cogn Behav Neurol 17(2):74–84, 2004. nisms of reflex reinforcement by the Jendrassik manoeuvre. Exp 22. Carpenter MB. Core text of neuroanatomy, ed 4, Baltimore, 1991, Brain Res 138(3):366–374, 2001. Williams & Wilkins, pp 361–389. 51. Gotkine M, Haggiag S, Abramsky O, et al. Lack of hemispheric 23. Costanzo RM, Miwa T. Posttraumatic olfactory loss. Adv Otorhi- localizing value of the palmomental reflex. Neurology 64(9):1656, nolaryngol 63:99–107, 2006. 2005. 24. Cummings JL. Frontal-subcortical circuits and human behavior. 52. Schott JM, Rossor MN. The grasp and other primitive reflexes. Arch Neurol 50(8):873–880, 1993. J Neurol Neurosurg Psychiatry 74(5):558–560, 2003. 25. Serby M, Larson P, Kalstein D. The nature and course of olfactory 53. van Boxtel MP, Bosma H, Jolles J, et al. Prevalence of primitive deficits in Alzheimer’s disease. Am J Psychiatry 148:357–360, 1991. reflexes and the relationship with cognitive change in healthy 26. Doty RL, Reyes PF, Gregor T. Presence of both odor identification adults: a report from the Maastricht Aging Study. J Neurol and detection deficits in Alzheimer’s disease. Brain Res Bull 253(7):935–941, 2006. 18:597–600, 1987. 54. Rao R, Jackson S, Howard R. Primitive reflexes in cerebrovascular 27. Hawkes C. Olfaction in neurodegenerative disorder. Adv Otorhi- disease: a community study of older people with stroke and nolaryngol 63:133–151, 2006. carotid stenosis. Int J Geriatr Psychiatry 14(11):964–972, 1999. 28. Berrios GE, Brook P. Visual hallucinations and sensory delusions 55. Bachmann S, Bottmer C, Schroder J. Neurological soft signs in in the elderly. Br J Psychiatry 144:662–664, 1984. first-episode schizophrenia: a follow-up study. Am J Psychiatry 29. Chou SY, Digre KB. Neuro-ophthalmic complications of raised 162(12):2337–2343, 2005. intracranial pressure, hydrocephalus, and shunt malfunction. Neurosurg Clin North Am 10(4):587–608, 1999.

MULTIPLE CHOICE QUESTIONS ○ Snout Select the appropriate answer. ○ Suck Q1 Which of the following is the interpretation and Q7 In which of the following conditions is the Argyl- recognition of tactile sensory information? Robertson pupil found? ○ Apoptosis ○ Brain herniation ○ Autognosis ○ Horner’s syndrome ○ Graphesthesia ○ Neurosyphilis ○ Praxis ○ Progressive supranuclear palsy ○ Stereognosis ○ Wilson’s disease

Q2 Which of the following is the acquired inability to perform a complex or skilled motor act in the absence of impairments of arousal, attention, language, MULTIPLE CHOICE ANSWERS comprehension, motivation, or sensorimotor Q1 The answer is: Stereognosis. function? Stereognosis is the interpretation and recognition of tactile ○ Apoptosis sensory information. Astereognosis is the inability to recog- ○ Apraxia nize objects by touch. This can be tested by placing common objects (such as coins, keys, paper clips, or safety pins) in the ○ Autognosis patient’s hands and asking the patient to name the objects ○ Graphesthesia with his or her eyes closed. Characteristics (such as size and shape) can be described by the patient. Often, people can ○ Stereognosis identify the denomination of coins.

Q3 Which of the following cranial nerves is MOST closely Q2 The answer is: Apraxia. associated with the sense of smell? Apraxia is the acquired inability to perform a complex or ○ Cranial nerve I skilled motor act in the absence of impairments of arousal, attention, language, comprehension, motivation, or sensori- ○ Cranial nerve II motor function. Praxis is the Greek word for “action.” More ○ Cranial nerve III commonly described varieties include limb kinetic, buccofacial, ideomotor, and ideational apraxia. Limb kinetic apraxia ○ Cranial nerve IV is the loss of ability to make precise, coordinated fine motor ○ Cranial nerve V movements. In buccofacial apraxia, patients are unable to perform (on request) complex acts involving the lips, mouth, Q4 Which of the following cranial nerves control eye and face (e.g., whistling, blowing out a match, sticking out the movements and lid elevation? tongue, or coughing). Persons with ideomotor apraxia are unable to perform on command complex motor acts with one Cranial nerves I, II, and III ○ or all extremities. The patient may be unable to demonstrate ○ Cranial nerves II, III, and IV on-command activities (such as saluting, waving goodbye, blowing a kiss, or pantomiming the brushing of teeth, combing Cranial nerves III, IV, and VI ○ of hair, hammering of a nail, or the use of scissors). They may ○ Cranial nerves VII, VIII, and IX incorrectly use their body parts as tools. Some of these patients are able to spontaneously perform these acts. The inability to Cranial nerves X, XI, and XII ○ perform an ideational plan consisting of a sequence of acts is referred to as an ideational apraxia. Q5 Which of the following is characterized by involuntary, non-rhythmic, brief, sometimes repetitive muscle Q3 The answer is: Cranial nerve I. contractions that are irregular in frequency and amplitude? Olfaction is an important sensory modality as olfactory symptoms in psychiatric and neurological patients are frequent. Asterixis ○ Unfortunately, psychiatrists rarely perform this portion of the ○ Chorea examination and neurologists uncommonly complete it. The olfactory bulbs and tracts run along the inferior surface of the Fasciculations ○ frontal lobes and project to limbic areas, as well as to regions ○ Myoclonus important for memory. Head trauma may be associated with loss of smell; disinhibition may result from orbital frontal Tics ○ injury. Tumors in the midline frontal region may cause a loss of smell, apathy, or abulia. When testing is necessary, non- Q6 Which of the following reflexes is LEAST likely to be irritating stimuli should be used. Alcohol and ammonia may considered a primitive or atavistic reflex? stimulate the trigeminal nerve and the response to this stimu- ○ Glabellar lation may be confused with olfaction. Bear in mind that the patient may not be able to name unfamiliar or less commonly Palmomental ○ encountered scents (such as clove or nutmeg); therefore, ○ Plantar coffee, peppermint, wintergreen, or vanilla should be used.

Each nostril should be tested individually. Abnormalities may that are repetitive, impulsive, often abrupt, and which the include anosmia or misidentification of a smell. patient feels he or she has little or no control over. Tics are 73 experienced as almost irresistible impulses to perform a par- Q4 The answer is: Cranial nerves III, IV, and VI. ticular activity. Some tics can be suppressed. Eye movements and lid elevation are controlled by cranial Fasciculations are brief, irregular twitches of a muscle. They nerves III, IV, and VI. During the examination, any spontane- may be localized to a muscle or limb or be diffuse, depending ous eye movements in primary resting forward gaze should be on the etiology. Fasciculations occur as a benign phenome- observed. The range of conjugate gaze (tested by holding your non, as well as a manifestation of various neuropathies (for finger about 2 feet away) should be assessed next. The finger example, amyotrophic lateral sclerosis [ALS] or diabetic should be moved slowly to allow for assessment of voluntary peripheral neuropathy), radiculopathies, thyrotoxicosis, and smooth pursuits in the up, down, oblique, left, and right direc- in association with anticholinesterase use. tions. Patients with Parkinson’s disease manifest “jerky” Tremor is usually an involuntary, rhythmic oscillation pro- smooth pursuits. Ask the patient to hold his or her head still. duced by rhythmic contractions of agonist and antagonist At the limits of conjugate gaze in each direction the examiner muscles. They may be present at rest or not. should hold gaze for several seconds and then observe for nystagmus. When present, this is referred to as gaze-evoked nystagmus. Barbiturates, tranquilizers, ethanol, and anticon- vulsants commonly cause gaze-evoked nystagmus in both Q6 The answer is: Plantar. directions of gaze. Normal saccades are involuntary, fast, con- The plantar reflex is the most important of the cutaneous jugate changes of eye position between fixations. Saccades are reflexes for the psychiatrist to incorporate into the examina- tested by having the patient fixate on your nose and then look tion. It is useful for detecting corticospinal tract dysfunction. quickly toward your finger and then back to your nose. Your One should stroke the bottom of the foot from the heel finger should be held in the up, down, left, and then right forward. The normal response is plantar-flexion of the foot positions. The accuracy of saccades should be assessed. One and toes after the first 12 to 18 months of life. Disease of the should observe if the patient overshoots (hypermetric sac- corticospinal system may be associated with extension of the cades) and then saccades back to the target. Hypermetric sac- toes that has been described as up-going. The up-going great cades may be seen in conditions with cerebellar involvement toe with fanning of the other four toes is referred to as the (such as the cerebellar presentation of multisystem atrophy). Babinski sign. This may also be referred to as the extensor One should also observe if the patient undershoots (hypomet- plantar response. Some authorities recommend stroking the ric saccades) with several saccades toward the target. Patients lateral aspect of the plantar surface rather than the medial with Parkinson’s disease manifest hypometric saccades. One one, so as to avoid a plantar grasp response. Patients who are should determine if the saccades slow. Slow saccades can be very ticklish may voluntarily withdraw from the stimulus and seen in a number of conditions that include Wilson’s disease, demonstrate flexion of the hip and knee (usually with progressive supranuclear palsy, Huntington’s disease, and anti- plantar-flexion of the foot and toes). A triple-flexion response convulsant toxicity. These are just a few examples of neurologi- is a spinal reflex characterized by hip, knee, and ankle cal conditions with associated eye movement abnormalities. dorsiflexion. Ptosis of the eyelids should also be noted. Primitive reflexes or atavistic reflexes (mistakenly called frontal Q5 The answer is: Myoclonus. release signs) are present at birth and disappear in most people in early infancy. There is a large portion of the normal Myoclonus is characterized by involuntary, non-rhythmic, population in which a single primitive reflex persists. This is brief, sometimes repetitive muscle contractions that are irregu- less concerning when it is a single reflex (such as a snout, lar in frequency and amplitude. They are often asynchronous glabellar, or palmomental reflex). A grasp or suck reflex is and asymmetric. They may be symmetric in spinal myoclonus. considered more worrisome. Asymmetry or multiple primitive They may be cortical, subcortical, or spinal in origin. reflexes are considered abnormal. Primitive reflexes are not Clonus is characterized by involuntary, monophasic, rhythmic thought to be useful for localization purposes. If they re- contractions and relaxations of a group of muscles. appear in later life they may be suggestive of either diffuse cerebral, subcortical, or bilateral frontal lobe pathology. Chorea is manifest by involuntary, non-rhythmic, jerky, rapid movements of muscle groups. The snout reflex can be assessed by gently tapping over the patient’s upper lip. If this reflex is present, a puckering of the Asterixis is also known as “liver flap” or negative myoclonus. lips will be seen. The snout reflex is present in 30% to 50% of This movement is characterized by an abrupt loss of voluntary healthy adults over age 60. muscle tone. It is commonly elicited by asking the patient to hold his or her arms outstretched with the wrists extended. A suck reflex may also be elicited and is considered a more When present, the hands, with or without the arms, may sud- worrisome reflex. When present, the suck reflex is elicited by denly drop downward and then quickly recover, which causes stimulation of the lips; this is followed by sucking movements an irregular and slow flapping motion. of the lips, tongue, and jaw. Athetosis is manifest by involuntary slow, irregular, sinuous, The palmomental reflex is an ipsilateral contraction of the snake-like writhing movements. mentalis and orbicularis oris after stimulation of the thenar region of the hand. This reflex is present in 20% to 25% of Dystonia is an involuntary movement or sustained posture healthy adults in their thirties and forties. The glabellar reflex that results from abnormal tonicity of muscle. Movements is assessed by tapping the patient’s glabellar ridge between may be characterized as having prolonged or repetitive muscle the eyes with your finger. It is best to stand to the side or contractions that may result in twisting or jerking movements from behind a seated patient so as to not cause a visual of the body or a body part. threat response. The patient should be asked not to blink. Tics are defined in several ways. They are characterized by The reflex is present if there is persistence of blinking with simple or complex coordinated movements or vocalizations gentle tapping.

The grasp reflex is elicited by stroking the palm of the patient’s Unilateral pupillary dilation is detected in brain herniation. hand. The reflex is present if the patient’s fingers flex or the Vertical gaze palsy is noted in progressive supranuclear palsy. hand closes. Ipsilateral pupillary dilation is but one of the features of Q7 The answer is: Neurosyphilis. Horner’s syndrome. The Argyl-Robertson pupil (that accommodates but does not Wilson’s disease is often associated with Kayser-Fleisher rings react) is found in neurosyphillis. in the cornea.