Appendix: Neurological Examination Instruments

All kinds of instruments are available. They vary in price, and some are associated with the great ancient heroes of European and British neurology.

Figure 18-1. Neurological examination Instruments. {Continued)

210 APPENDIX: NEUROLOGICAL EXAMINATION INSTRUMENTS / 211

Figure 18-1 (continued). Neurological examination instruments.

The cheapest hammer works exactly the same as the most expensive; the cheapest 128 tuning fork is all you need for examining one aspect of pos­ terior column function. Do not buy an instrument for testing pain sensation. A package of sterile pins is all you need. Each patient is examined with his own pin fliat is then discarded. The instruments in Figure 18^1 can be bought from Kennex Medical Inc., PO Box 870009, Stone Mountain, GA 30087. Index

NOTE: Page numbers in bold face type indicate a major discussion. A t following a page number indicates tabular material and an f following a page number indicates a figure.

Abdominal muscles, weakness of, gait of eye, 46 abnormalities and, 161 defects in, convergence and, 67 Abdominal reflexes, 173, 174f medial rectus muscle in, 50 corticospinal system lesions affecting, superior and inferior rectus muscles 193 in, 53Ð54 Abducens nerve (cranial nerve VI) Adductor muscles (magnus, longus, lateral rectus muscle and, 49 brevis), 150 lesions of, 57Ð59 Adie’s syndrome (tonic pupil), 65 Abduction Afferent pupil defect, 64 of arm, 136Ð138 Aging. See Elderly of eye, 45 Alcohol use and abuse, nystagmus caused lateral rectus muscle in, 49Ð50 by, 71 superior and inferior oblique muscles Alternating movements in, 54 lower limb coordination tested with, of fingers, 130 145Ð147, 146f of thigh, 150 upper limb coordination tested with, of thumb, 130 123Ð125, 124f, 125f Abductor pollicis brevis muscle, 130 Altitudinal field defect, 17f Abductor pollicis longus muscle, 130 Amblyopia, 10 Abetalipoproteinemia, CPEO in, 69 American Medical Association test card, Accommodation, 66Ð67 for near vision testing, 13 in Adie’s syndrome, 65 Amsler grid, in macular degeneration diag- ACG. See Acute angle-closure glaucoma nosis, 28 Acoustic nerve (cranial nerve VIII), Amyotrophic lateral sclerosis, jaw weak- 107Ð111. See also Cochlear nerve; ness in, 96 Vestibular nerve Analgesia cochlear nerve, 107Ð109 definition of, 179 diseases of, 110Ð111 facial, trigeminal nerve disorders caus- tinnitus and, 111 ing, 96 vestibular nerve, 109Ð110 Anesthesia, definition of, 179 Acoustic neuroma, tinnitus caused by, 111 Angiography, fluorescein, in macular de- Acuity, visual, 19 generation diagnosis, 28 distance vision, 11, 12 Angle-closure glaucoma, acute (ACG), 26 in latent nystagmus, 12, 73 Angular gyrus, 205 in papilledema, 39 Anisocoria, 62, 65 Acute angle-closure glaucoma (ACG), 26 Ankle clonus, in corticospinal system dis- Adduction ease, 194 of arm, 138, 139f Ankle reflex, 169–170, 170–171f

213 214 / INDEX

Anomic aphasia, 208 Brodmann’s 39 (angular gyrus), 205 Anosmia, 87Ð88 Brodmann’s 40 (supramarginal gyrus), central, 88 205 unilateral, 87 Brodmann’s 41 and 42 (Wernicke’s Anterior chiasmal lesions, visual field de- area), 205 fects caused by, 29Ð30, 29Ð30f Brodmann’s 44 (Broca’s area), 205 Anterior fossa tumors, anosmia caused by, centralis. See Posterior pole 88 Argyll-Robertson pupils, 64 Anterior (saccadic) gaze center, 80Ð81 Arm, 121. See also Upper limb Anterior interosseous nerve abduction of, 136Ð138 flexor digitorum profundus and, 131 adduction of, 138, 139f flexor pollicis longus and, 133 circumference measurement of, 127, Anterior ischemic optic neuropathy, 25 129f Anterior tibial muscle, 148, 151, 151f, 153, Arm drift, 122Ð123, 122f 154 Arnold-Chiari malformation, downbeat Aphakia, 10 nystagmus in, 73 Aphasia, 205Ð211 Arteriovenous “nicking,” retinal, in hyper- anomic, 208 tension, 43 Broca’s, 206, 207 Arteritis, giant cell, of central retinal comprehension, 206Ð207 artery, 25 conduction, 208 Artery definition of, 205 carotid, occlusion of, pupils and, 66 examination of patient with, 206Ð207 retinal fluent speech in, 206 branch, occlusion of, 27 global, 208Ð209 central naming in, 207 giant cell arteritis of, 25 reading in, 207 occlusion of, 27 repetition in, 206 in hypertension, 43 spontaneous speech in, 206 occlusion of, 27 types of, 207Ð209 ophthalmoscopic examination of, 6, Wernicke’s, 208 7f writing in, 207 temporal, giant cell arteritis of, 25 Aphonia, 205 Aspirin, tinnitus and, 111 Apraxia, gait, 157, 161 Astigmatism, 10 Arcuate fasciculus, 205 examiner’s, eyeglass use during oph- Arcuate scotoma, 20 thalmoscopic examination and, 3 in glaucoma, 26 patient’s, lens for ophthalmoscopic ex- Area amination and, 10 Broca’s, 205 Ataxia. See also Gait Brodmann’s 17Ð19 (visual cortex), 21 in cerebellar disease, 159Ð160 lesions of, 35Ð36 contralateral arm and leg, frontal lobe field defects caused by, 35, 35f lesion causing, 190 gaze palsy and, 80Ð81 miscellaneous diseases causing, 162 Brodmann’s 17 (striate cortex), 21 in normal-pressure hydrocephalus, Brodmann’s 18 (parastriate cortex), 21 161Ð162 lesions of, gaze palsy and, 80Ð81 tests of, 158Ð159 Brodmann’s 19 (peristriate cortex), Ataxic dysarthria, speech in cerebellar dis- 21 ease and, 190 INDEX / 215

Atheroma, carotid artery, pupils in, 66 Botulinin toxin, eye affected by, 67 Atropine, factitious big pupil caused by, 66 Brachial plexus lesions, upper limb af- Axillary nerve fected in, 140Ð144 deltoid muscle and, 136, 138 lateral cord, 141 lesion of, C5 root lesion differentiated lower trunk, 141 from, 143 medial cord, 141 posterior cord, 141 upper trunk, 140Ð142 Babinski response (extensor plantar re- Brachialis muscle, in biceps reflex, sponse), 174, 175 166Ð167 in corticospinal system lesions, 193 Brachialis reflex, 167 Back muscles, weakness of, gait abnormal- Brachioradialis muscle, 133 ities and, 161 in brachialis reflex, 167 Balance, 157Ð162. See also Gait in supinator reflex, 167 Bardet-Biedl syndrome, retinitis pigmen- Brain stem lesions tosa and, 26 caloric testing and, 85 Basal ganglia disease, rigidity in, 126 doll’s eye test and, 85 Bassen-Kornzweig syndrome gaze palsy in, 80 CPEO and, 69 nystagmus in, 73Ð74 retinitis pigmentosa and, 26 signs and symptoms associated with, Bell’s palsy, 104 74 Bell’s phenomenon, 82Ð83 Broca’s aphasia, 206, 207 Betz cells, 191 Broca’s area, 205 Biceps muscle, 133 Brodmann’s areas 17Ð19 (visual cortex), 21 in biceps reflex, 166–167 lesions of, 35Ð36 Bilateral homonymous hemianopsia (corti- anterior, field defects caused by, 35, cal blindness), 36 35f Bilateral simultaneous stimulation, in sen- gaze palsy and, 80Ð81 sory examination, 185 Brodmann’s area 39 (angular gyrus), 205 Binocular vision, testing, 47, 48f Brodmann’s area 40 (supramarginal Birmingham Optical Group test card, for gyrus), 205 near vision testing, 13 Brodmann’s areas 41 and 42 (Wernicke’s Bitemporal hemianopic central scotoma, area), 205 17f, 20Ð21 Brodmann’s area 44 (Broca’s area), 205 Bitter, as taste substance, 104 Bjerrum’s screen, for central visual field testing, 16 C5 root lesion, axillary nerve lesion dif- Blepharospasm, 61 ferentiated from, 143 ptosis differentiated from, 61 C6 root lesion, musculocutaneous or radial Blind spot (physiological scotoma), 20 nerve lesion differentiated from, 143 finding, 20 C7 root lesion, radial nerve lesion differen- Blindness tiated from, 143Ð144 cortical (bilateral homonymous hemi- Calcarine sulcus, 21 anopsia), 36 Calculation ability, 199Ð200 glaucoma causing, 26 Caloric testing, 85 night, in retinitis pigmentosa, 25 in gaze palsy, 80 Blinking, 99Ð102 in unconscious patient, 85, 110 pattern of in myasthenia gravis, 68 of vestibular function, 109Ð110 216 / INDEX

Carotid artery occlusion, pupils in, 66 Clonus, 170Ð172 Cataract surgery, corneal reflex absent af- ankle, 194 ter, 93 in corticospinal system disease, 194 Cataracts, visual acuity affected by, 12 finger, 172 near vision, 13 forearm, 172 Cecocentral scotoma, 20 knee, 172, 194 disease, delirium wrist, 126, 172, 194 caused by, 202 Clostridium boutlinum, toxin of, eye af- Central retinal vein occlusion, 26Ð27 fected by, 67 Central scotoma, 19Ð20, 29 Cochlear nerve, 107Ð109 occipital lobe lesion causing, 23 deafness caused by lesions of, 107Ð109 Central vision (macular vision), 11Ð13, Cochlear nucleus, 107 19 Cogwheel rigidity, 126 Cerebellar disease, 187Ð190 Concentration tests, miscellaneous, 200 dysmetria in, 188Ð189 Concomitant strabismus (nonparalytic stra- ocular, 189 bismus), 56 gait abnormalities in, 159Ð160 Conduction aphasia, 208 gaze palsy and, 81 Conductive hearing loss, 108, 109 muscle tone in, 187 Confrontation testing, of visual fields, nystagmus in, 73Ð74, 189 13Ð15, 14f, 18 signs and symptoms associated with, Confusional states. See also Delirium; De- 74 mentia past pointing in, 188Ð189 sensory examination precluded by, posture in, 187 178 rebound in, 188Ð189 Congenital nystagmus speech in, 190 optokinetic nystagmus absent in, 77 tendon reflexes in, 187Ð188 pendular, 72 tremor in, 188 Conjugate deviation of eyes voluntary movements in, 189 CerebellarÐpontine angle tumor, seventh forced, 79 (facial) nerve palsy and, 105 downward, 82 Cerebral lesions, gaze palsy in, 80 supratentorial gaze “centers” and, CF. See Counting fingers, in vision loss 80Ð81 Chiasm, 22 upward, 82 lesions of, 28Ð33 “wrong way,” 81 anterior, 29Ð30, 29Ð30f Conjugate gaze palsy, 79 of body, 31Ð32, 31Ð32f supratentorial gaze “centers” and, 80Ð81 field defects caused by, 17f, 22, Constrictor muscles, of , vagus 28Ð33, 29Ð33f nerve supplying, 113 lateral, 33, 33f Constructional ability, 200, 201f posterior, 32, 32f Contact lenses, corneal reflex prevented Choked disc. See Papilledema by, 92 Choking, in pharyngeal paresis, 113 Convergence, 66Ð67 Chronic open-angle glaucoma (OAG), excess, 67 26 forced downward gaze and, 82 Chronic progressive external ophthalmo- paralysis/paresis of, 67, 85Ð86 plegia, 68Ð69 supranuclear, 86 ptosis in, 61, 68 Convergence nystagmus, 75 INDEX / 217

Convergence palsy, 67, 85Ð86 Cotton-wool spots/exudates supranuclear, 86 in central retinal vein occlusion, 26Ð27 Convergence-retraction nystagmus, 75 in papilledema, 38 Coordination, tests of Coughing, in pharyngeal paresis, 113 lower limb, 145Ð147, 146f Counting fingers, in vision loss, 12 upper limb, 123Ð125, 124f, 125f Cover test, 46 Corneal reflex, 91–93, 91f, 92f, 173 CPEO. See Chronic progressive external absence of ophthalmoplegia after cataract surgery, 93 . See Nerve(s), cranial in elderly, 93 Cremasteric reflex, 173–174 in ophthalmic nerve lesions, 92 corticospinal system lesions affecting, in thalamic lesions, 93 193 contact lenses preventing, 92 CRVO. See Central retinal vein occlusion methods of elicitation of, 91f Cup (physiologic), ophthalmoscopic exam- Cortex, visual, 21 ination of, 7f, 8Ð9 frontal, gaze palsy and, 80 Cutaneous nerve of thigh, lateral, signs and lesions of, 35Ð36 symptoms of lesions of, 154 anterior, field defects caused by, 35, Cyclophoria, 47 35f field defects caused by, 35, 35f Deafness, 107Ð109 gaze palsy and, 80Ð81 cochlear nerve lesions causing, 107Ð109 occipital conductive, 108, 109 division of, 21 nerve, 108, 109 gaze palsy and, 80, 81 Deep peroneal nerve vision represented in, 22 extensor digitorum longus and, 151 parastriate (area 18), 21 extensor hallucis longus and, 151 gaze palsy and, 80Ð81 tibialis anterior and, 151 peristriate (area 19), 21 Delirium, 201Ð202 striate (area 17), 21 in central nervous system disease, 202 Corti, organ of, 107 drug use and abuse causing, 202 Cortical blindness (bilateral homonymous hypoxia causing, 202 hemianopia), 36 infection causing, 202 Cortical functions, higher, 197Ð203 metabolic disorders causing, 202 Corticobulbar system disease, bilateral, sensory examination precluded by, 178 pseudobulbar palsy caused by, 194 Deltoid muscle, 136, 138 Corticospinal system disease (upper motor Dementia, 197Ð198, 202Ð203 neuron lesions), 191Ð195 anosmia and, 88 clonus in, 194 depression resembling, 201 facial weakness in, 97, 191Ð192 sensory examination precluded by, 178 gait abnormalities in, 160Ð161, 193Ð194 Demonstration, in sensory examination, jaw weakness in, 97, 192 178 miscellaneous manifestations of, Denervation supersensitivity, pupillary, in 193Ð194 Adie’s syndrome, 65 muscle tone in, 192Ð193 Depression, dementia resembled by, 201 power in, 191Ð192 Depression of eye. See Ocular depression reflexes in, 193 Descending supraspinal pathway, sternomastoid and trapezius weakness 191Ð195. See also Corticospinal sys- in, 118 tem disease 218 / INDEX

Deviations, ocular. See Ocular deviations doll’s eye test in, cautions for use of, 85, Diencephalon, lesions of, nystagmus in, 74 110 Digastric muscle, anterior belly of, Drug use and abuse mandibular branch of trigeminal delirium caused by, 202 nerve supplying, 89 nystagmus caused by, 71 Diopters, 37 Duchenne-Erb syndrome, upper trunk le- Diphtheria, eye changes in, 67 sions in, 140Ð142 Diplopia/double vision, 45Ð49 Dysarthria eye patch and, 57 aphasia differentiated from, 205 head posture and, 57 ataxic, speech in cerebellar disease and, identifying muscles responsible for, 190 47Ð49, 48f in pseudobulbar palsy, 195 in inferior oblique muscle dysfunction, Dysesthesia, definition of, 179 53 Dysmetria, cerebellar disease causing, in inferior rectus muscle dysfunction, 51 188Ð189 in lateral rectus muscle dysfunction, ocular, 189 49Ð50 Dysphagia in medial rectus muscle dysfunction, 50 in pharyngeal paresis, 113 monocular, 57 in pseudobulbar palsy, 194Ð195 in paresis of convergence, 67 Dysphasia. See Aphasia in superior oblique muscle dysfunction, 53 in superior rectus muscle dysfunction, 51 E chart, for visual acuity testing, 12 in thyroid ocular myopathy, 68Ð69 Echolalia, 205 Direct pupil response to light, 63 Eighth cranial nerve. See Nerve(s), cranial, Disc hyperemia, in papilledema, 37 VIII Distance vision, 11Ð13, 11f Elderly Doll’s eye test, 85 accommodation loss in, 66 in gaze palsy, 80 anosmia in, 88 in unconscious patient, 85, 110 corneal reflex absence in, 93 Dorsal interosseous muscle, 129, 129f, 130 decreased vibration in, 183 Dorsal midbrain syndrome (Parinaud’s facial asymmetry in, 99 syndrome), 83 lower limb tone in, 147 defective downward gaze in, 82, 83 pupil size in, 62 defective upward gaze in, 83 taste sensation in, 104 Dorsal scapular nerve, rhomboid muscles upward gaze affected in, 82 and, 139Ð140 Elevation of eye. See Ocular elevation Dorsiflexion, foot and toes, 151, 151f Eleventh cranial nerve. See Nerve(s), cra- Double vision. See Diplopia nial, XI Downbeat nystagmus, brain stem and cere- End-point nystagmus, 75 bellar lesions causing, 73, 189 Equatorial division, 21 Downward gaze, 82 Esophoria, 46 forced, 82 Esotropia, 46 paralysis of, 82 Eversion, of foot, 151Ð152 Drift, arm, spontaneous, 122Ð123, 122f Exotropia, 46 Drug overdose Extension caloric testing in, cautions for use of, 85, of fingers, 135–136, 135f 110 of forearm, 136 INDEX / 219

of leg, 149, 150f vertical of thigh at hip, 153 lateral rectus muscle in, 50 of thumb, 135 testing, 48 of wrist, 136, 137f Eye opening muscles, in myasthenia Extensor carpi radialis (longus and brevis) gravis, 68 muscles, 136, 137f Eye patch, double vision and, 57 Extensor carpi ulnaris muscle, 136, 137f Eyeglasses, during ophthalmoscopic exam- Extensor digitorum longus muscle, 151, ination 151f examiner’s, 3 Extensor digitorum muscle, 135Ð136, 135f patient’s, 10 Extensor hallucis longus muscle, 148, 151, Eyelid muscles 151f diseases causing weakness of, 67Ð69 Extensor muscle weakness, upper limb, in in myasthenia gravis, 68 corticospinal system lesions, 192 Extensor plantar response (Babinski re- sponse), 174, 175 Facial nerve (cranial nerve VII), 97Ð105 in corticospinal system lesions, 193 anatomy of, 97 Extensor pollicis brevis muscle, 135 autonomic functions of, 102Ð104 Extensor pollicis longus muscle, 135 blinking and, 99Ð102 External ocular muscles diseases of, 104Ð105 in concomitant strabismus, 56 examination of, 98Ð99, 100Ð101f diseases causing weakness of, 67Ð69 motor functions of, 97Ð98 convergence assessment in, 67 palsy of, 105 functions of, 49Ð55 facial weakness differentiated from, in paralytic strabismus, 56Ð57 97Ð98, 98Ð99, 100Ð101f, 105 Exudates parkinsonism and, 105 macular, in papilledema, 38 saliva as function of, 102 retinal sensory root of, 102Ð104 cotton-wool taste as function of, 102 in central retinal vein occlusion, testing, 103Ð104, 103f 26Ð27 tears as function of, 102 in papilledema, 38 Facial numbness, trigeminal nerve disor- in hypertension, 43 ders causing, 96 Eye Facial pain, trigeminal nerve disorders muscles of. See External ocular muscles; causing, 95Ð96 Eyelid muscles Facial weakness, 105 normal, 39, 40f appearance at rest and, 99 in papilledema, 39, 41f in corticospinal system disease (upper Eye closing muscles, in myasthenia gravis, motor neuron lesions), 97, 191Ð192 68 in parkinsonism, 105 Eye movements, 45Ð49 seventh nerve lesion differentiated from, in chronic progressive external ophthal- 97Ð98, 98Ð99, 100Ð101f, 105 moplegia, 68 Factitious big pupil, 66 external ocular muscles and, 49Ð55 Fatigue, sensory examination results af- lateral, testing, 47, 48, 48f fected by, 178 monocular, in concomitant strabismus, Femoral nerve 56 iliopsoas muscle and, 149 terminology related to, 45Ð47 in knee reflex, 169 220 / INDEX

Femoral nerve (cont.) Flexor muscle spasticity, upper limb, in quadriceps femoris muscle and, 149 corticospinal system lesions, 192 signs and symptoms of lesions of, Flexor plantar response, 175 154Ð155 Flexor pollicis brevis muscle, 134 Fields of vision. See also Visual field de- Flexor pollicis longus muscle, 133 fects Fluent speech, in aphasia, 206 central (macular), 11Ð13, 19 Fluorescein angiography, in macular de- equatorial division and, 21 generation diagnosis, 28 gaze palsy and, 80Ð81 Flutter, ocular, cerebellar disease causing, in glaucoma, 26 189 organization of, 21Ð22 Following (smooth pursuit) gaze center, 81 peripheral, testing, 13Ð18 Foot. See also Lower limb confrontation testing for, 13Ð15, 14f, dorsiflexion of, 151, 151f 18 dorsum of, sensory loss of in sciatic perimetry for, 16 nerve lesions, 155 string test for, 14f, 16 eversion of, 151Ð152 Fifth cranial nerve. See Nerve(s), cranial, V inversion of, 151, 152 Finger clonus, 172 plantar flexion of, 151, 152, 152–153 Finger flexion reflex, 167–168, 168f sole of, sensory loss of in sciatic nerve Fingers. See also Upper limb lesions, 155 abduction of, 130 Foramen extension of, 135Ð136, 135f infra-orbital, maxillary branch of flexion of, 131–132, 132f trigeminal nerve in, 89 weakness of, in corticospinal system le- mental, mandibular branch of trigeminal sions, 192 nerve in, 89 First cranial nerve. See Nerve(s), cranial, I ovale First dorsal interosseous muscle, 129, 129f, jaw weakness in disorders of, 97 130 mandibular branch of trigeminal Flame hemorrhages, in papilledema, 38 nerve in, 89 Flexion rotundum, maxillary branch of trigemi- of fingers, 131–132, 132f nal nerve in, 89 reflex and, 167–168, 168f superior orbital, ophthalmic branch of of forearm, 133 trigeminal nerve in, 88 of leg at knee, 153 Forearm, 121. See also Upper limb plantar circumference measurement of, 127, 129f of foot, 151, 152, 152Ð153 extension of, 136 of toes, 152 flexion of, 133 of thigh, 149, 149f, 153 Forearm clonus, 172 of thumb, 133Ð134 Fourth cranial nerve. See Nerve(s), cranial, of wrist, 133, 134f IV Flexor carpi radialis muscle, 133, 134f Fovea Flexor carpi ulnaris muscle, 133, 134f anatomic. See Macula Flexor digitorum longus muscle, 152 ophthalmoscopic examination of, 7f, Flexor digitorum profundus muscle, 131, 9Ð10 132f Foveola. See Fovea Flexor digitorum sublimis/flexor digitorum Freezing, caused by superficialis muscles, 131–132, 132f caloric testing in, cautions for use of, 85 Flexor hallucis longus muscle, 152 doll’s eye test in, cautions for use of, 85 INDEX / 221

Froment’s sign, 143 Gaze “centers,” supratentorial, 80Ð81 Frontal cortex, lesions of, gaze palsy and, anterior (saccadic), 80Ð81 80 following (smooth pursuit), 81 Frontal (saccadic) gaze center, 80Ð81 frontal (saccadic), 80Ð81 Frontal gyrus, middle, lesions of, ocular occipital (smooth pursuit), 81 manifestations of, 80 posterior (smooth pursuit), 81 Frontal lobe lesions, contralateral arm and volitional (saccadic), 80Ð81 leg ataxia caused by, 190 Gaze-evoked nystagmus, 72 Frontalis muscle, in facial weakness vs. Gaze palsy, 79Ð86 seventh nerve lesion, 97, 100f cerebellar, 81 Fundus oculi in cerebral lesions, 80 in hypertension, 43 conjugate, 79 ophthalmoscopic examination of, 2Ð10 optokinetic nystagmus absent in, 76 technique for, 2Ð6, 4f, 5f supratentorial gaze “centers” and, 80Ð81 optokinetic nystagmus absent in, 76 Gag reflex parastriate cortex lesions and, 80Ð81 glossopharyngeal nerve and, 112 pursuit, 79 paresis of pharynx and, 113 reflex, 79 and, 112Ð113 voluntary, 79 Gait, 157Ð162 Gegenhalten, 147 in abdominal weakness, 161 Geniculate body, lateral, 22 abnormal, diseases with, 159Ð162 Geniculate ganglion in cerebellar disease, 159Ð160 herpes affecting, seventh (facial) nerve in corticospinal (upper motor neuron) involvement and, 105 disease, 160Ð161, 193Ð194 taste cells in, 102 hemiplegic, 160 Gennari’s line, 21 in hip girdle weakness, 161 Giant cell arteritis, of central retinal artery, jiggling, 161 25 in lower back weakness, 161 Glasses. See Eyeglasses in miscellaneous disorders, 162 Glaucoma, 26 in normal-pressure hydrocephalus, acute angle-closure (ACG), 26 161Ð162 chronic open-angle (OAG), 26 in parkinsonism, 159 nasal field defects caused by, 33 Romberg test in evaluation of, 158Ð Global aphasia, 208Ð209 159 Glossopharyngeal nerve (cranial nerve in sensory system disease, 160 IX), 102, 111Ð112 tests of, 158Ð159 diseases, 115Ð116 Gait apraxia, 157, 161 evaluation of, 111Ð112, 114 Gastrocnemius muscle, 152, 153 Glossopharyngeal neuralgia, 115Ð116 in ankle reflex, 169–170 Gluteal nerve Gaze inferior, gluteus maximus and, 153 downward, 82 superior, gluteus medius and minimus forced, 82 and tensor fascia lata muscles and, paralysis of, 82 150 primary position of, nystagmus and, 72 Gluteus maximus muscle, 153 upward, 82 Gluteus medius muscle, 150 paralysis of, 82 Gluteus minimus muscle, 150 222 / INDEX

Grasp reflex, 175–176 High myopia, ophthalmoscopic examina- Groucho Marx maneuver, in seventh (fa- tion in patient with, 10 cial) nerve evaluation, 98, 100f Hip girdle, weakness of, gait abnormalities Guillain-Barré syndrome (infectious and, 161 polyneuritis), seventh (facial) nerve Hippus, 62 involvement in, 104 History Gyrus dementia and, 197Ð198 angular, 205 in sensory disturbances, 177 middle frontal, lesions of, ocular mani- in upper limb dysfunction, 121Ð122 festations of, 80 in visual loss, 24 supramarginal, 205 HM. See Hand movements only Hoffmann’s reflex, 168–169 Holmes-Adie syndrome, 65 Hallucinatory answers, in touch evalua- Homonymous field defects tion, 180 hemianopia, 17f, 20 Hamstring muscles (biceps, semitendi- hemianopia, bilateral (cortical blind- nous, semimembranous), 153 ness), 36 Hand. See also Upper limb optokinetic nystagmus absent in, 76 visual examination of, 127Ð128, 129f Horizontal field defect, 17f Hand movements only, visual acuity test- Horner’s syndrome, 62, 65 ing and, 12 pupils in, 62, 65 Head injury, anosmia caused by, 87Ð88 Hydrocephalus, normal-pressure, gait af- Head posture, abnormal, double vision fected in, 161Ð162 and, 57 Hypalgesia, definition of, 179 Hearing evaluation, 107Ð109 Hyperemia, optic disc, in papilledema, Heel sliding, lower limb coordination 37 tested with, 146, 146f Hyperesthesia Heel tapping, lower limb coordination definition of, 179 tested with, 145Ð146, 146f facial, trigeminal nerve disorders caus- Hemianopia, 20 ing, 96 bilateral homonymous, 36 Hyperopia (hypermetropia), 10 homonymous, 17f, 20 lens for ophthalmoscopic examination with macular loss, 21 and, 10 with macular sparing, 17f, 21 Hyperpathia, definition of, 179 occipital lobe lesion causing, 23 Hyperphoria, 47 with macular splitting, 17f, 20Ð21 Hypertension, fundus changes in, 43 Hemifacial defect, 99 Hypertropia, 46 Hemiparesis, cortical lesion causing, 192 Hypoesthesia, definition of, 179 Hemiplegic gait, 160 Hypoglossal nerve (cranial nerve XII), Hemorrhages, retinal 118Ð120 flame-shaped, 38 diseases of, 120 globular subhyaloid, 38 examination of, 118Ð120, 119f in hypertension, 43 Hypophoria, 47 in papilledema, 38 Hypothenar eminence, 127 splinter, 38 Hypotonia, cerebellar lesions causing, Herpes simplex infection, seventh (facial) 187 nerve involvement and, 105 Hypotropia, 46 Heterophoria (latent strabismus), 46 Hypoxia, delirium caused by, 202 INDEX / 223

Iliopsoas muscle, 149, 149f, 153 Jaw weakness Inattention field defect, 15 in amyotrophic lateral sclerosis, 96 optokinetic nystagmus absent in, 76 in corticospinal system disease (upper Increased intracranial pressure, optic nerve motor neuron lesions), 97, 192 head swelling caused by. See Pa- in foramen ovale disorders, 97 pilledema in myasthenia gravis, 96 Infections, delirium caused by, 202 in poliomyelitis, 96 Infectious polyneuritis (Guillain-Barré in trigeminal nerve disorders, 96Ð97 syndrome), seventh (facial) nerve in- Jerk nystagmus, 71. See also Nystagmus volvement in, 104 brain stem and cerebellar lesions caus- Inferior gluteal nerve, gluteus maximus ing, 73 and, 153 latent, 72Ð73 Inferior oblique muscle, 53 primary eye position and, 72 Inferior rectus muscle, 51, 53Ð54 Jiggling gait, 161 Infra-orbital foramen, maxillary branch of Jugular foramen syndrome, 116 trigeminal nerve in, 89 INO. See Internuclear ophthalmoplegia Kearns-Sayre syndrome Instruments, for neurological examination, CPEO in, 69 210, 210Ð211f retinitis pigmentosa and, 26 Intelligence Klumpke syndrome, lower trunk lesions diseases of, 201Ð203 in, 141 testing, 197Ð203 Knee, leg flexion at, 153 Intention tremor Knee clonus, 172 cerebellar, 188 in corticospinal system disease, 194 terminal, 123Ð124 Knee reflex, 169 Intermediate nerve (sensory root of sev- difficulty eliciting, 172 enth cranial nerve), 102Ð103 Internuclear ophthalmoplegia, 84 Interosseous nerve Language, 205. See also Speech anterior , 114, 115f in finger flexion, 131 paralysis of, 113, 114 flexor pollicis longus and, 133 vagus nerve supplying, 113Ð114 posterior Latent nystagmus, 72Ð73 extensor carpi ulnaris and, 136 visual acuity affected by, 12, 73 extensor digitorum and, 135 Lateral chiasmal lesions, field defects extensor pollicis longus/extensor pol- caused by, 33, 33f licis brevis and, 135 Lateral cutaneous nerve of thigh, signs and Intracranial pressure, increased, optic symptoms of lesions of, 154 nerve head swelling caused by. See Lateral geniculate body, 22 Papilledema Lateral rectus muscle, 49Ð50 Intraocular pressure, elevated, in glau- Lateralization, tests of, 125 coma, 26 Latissimus dorsi muscle, 138 Inversion, of foot, 151, 152 Leber’s optic neuropathy, 28 Leg, 145. See also Lower limb Jaeger’s test type, for near vision test- circumference measurement of, 147 ing, 13 extension of, 149, 150f Jaw jerk, 165, 165f flexion of at knee, 153 in pseudobulbar palsy, 195 strength of, 148, 153Ð154 224 / INDEX

Leg and arm ataxia, contralateral, frontal Mandibular branch of trigeminal nerve, 89, lobe lesions causing, 190 89f Leg circumference, measuring, 149, 150f motor function mediated through, Leg raising test, supine, 145 94Ð95, 95f LGB. See Lateral geniculate body Marcus Gunn pupil, 64 Light reaction (pupillary), 63 Masseter muscle direct and consensual, 63 in jaw jerk, 165 Limbs. See Lower limb; Upper limb mandibular branch of trigeminal nerve Litigation, medicolegal, sensory examina- supplying, 89, 94, 95f tion and, 178Ð179 Maxillary branch of trigeminal nerve, 89, Logical thinking, evaluation of, 199 89f Long thoracic nerve, serratus anterior mus- Mecholyl, pupillary response to, in Adie’s cle and, 140 syndrome, 65 Lower limb, 145Ð155 Medial longitudinal fasciculus lesions coordination evaluation and, 145Ð147, internuclear ophthalmoplegia caused by, 146f 84 examination of, 149Ð154 “one-and-a-half” syndrome caused by, muscle tone and, 147Ð148 84 corticospinal system lesions affecting, Medial rectus muscle, 50 192 in thyroid ocular myopathy, 69 nerve lesions affecting, signs and symp- Median nerve toms of, 154Ð155 abductor pollicis brevis and, 130 power (strength) of, 148, 153Ð154 flexor carpi radialis and, 133 corticospinal system lesions affecting, flexor digitorum profundus and, 131 192 flexor digitorum sublimis/flexor digito- single root lesions affecting, signs and rum superficialis and, 131 symptoms of, 154 flexor pollicis brevis and, 134 size of, 147 flexor pollicis longus and, 133 Lower motor neuron lesions, facial weak- lesions of, upper limb involvement in, ness caused by, 97 142 Lumbar root lesions, signs and symptoms opponens pollicis and, 130 of, 154 Medicolegal litigation, sensory examina- tion of patient and, 178Ð179 Memory, 198Ð199 Macula, 22 diseases of, 201Ð203 anatomic. See Posterior pole immediate, 198 ophthalmoscopic examination of, 7f, intermediate, 198 9Ð10 remote, 199 Macular degeneration, 28 Meningioma, anosmia caused by, 88 Macular exudates, in papilledema, 38 Mental foramen, mandibular branch of Macular fibers, 22 trigeminal nerve in, 89 nasal, 22 Metabolic disorders, delirium caused by, Macular loss, hemianopia with, 21 202 Macular sparing, hemianopia with, 17f, 21 Metacarpal phalangeal joints, 136 occipital lobe lesion causing, 23 Midbrain lesions, pupils in, 66 Macular splitting, hemianopia with, 17f, Middle frontal gyrus, lesions of, ocular 20Ð21 manifestations of, 80 Macular vision (central vision), 11Ð13, 19 Miosis, pontine, 66 INDEX / 225

MLF. See Medial longitudinal fasciculus dorsal interosseous, 129, 129f, 130 Monocular diplopia, 57 extensor carpi radialis (longus and bre- Mood, 200Ð201 vis), 136, 137f Motor functions extensor carpi ulnaris, 136, 137f of fifth cranial (trigeminal) nerve, extensor digitorum, 135Ð136, 135f 94Ð95, 95f extensor digitorum longus, 151, 151f of seventh cranial (facial) nerve, 97Ð98 extensor hallucis longus, 148, 151, 151f Motor neurons extensor pollicis brevis, 135 lower, lesions of, facial weakness extensor pollicis longus, 135 caused by, 97 external ocular upper, lesions of, 191Ð195 in concomitant strabismus, 56 clonus in, 194 diseases causing weakness of, 67Ð69 facial weakness caused by, 97 convergence assessment in, 67 gait abnormalities in, 160Ð161, functions of, 49Ð55 193Ð194 in paralytic strabismus, 56Ð57 jaw weakness and, 97 first dorsal interosseous, 129, 129f, 130 miscellaneous manifestations of, flexor carpi radialis, 133, 134f 193Ð194 flexor carpi ulnaris, 133, 134f muscle tone affected by, 192Ð193 flexor digitorum longus, 152 power affected by, 191Ð192 flexor digitorum profundus, 131, 132f reflexes affected by, 193 flexor digitorum sublimis/flexor digito- sternomastoid and trapezius weakness rum superficialis, 131–132, 132f caused by, 118 flexor hallucis longus, 152 Movements, alternating flexor pollicis brevis, 134 lower limb coordination tested with, flexor pollicis longus, 133 145Ð147, 146f frontalis, in facial weakness vs. seventh upper limb coordination tested with, nerve lesion, 97, 100f 123Ð125, 124f, 125f gastrocnemius, 152, 153 Multiple sclerosis CPEO in, 69 in ankle reflex, 169–170 gait abnormalities in, 161 gluteus maximus, 153 Muscle(s) gluteus medius, 150 abdominal, weakness of, gait abnormali- gluteus minimus, 150 ties and, 161 hamstring (biceps, semitendinous, semi- abductor pollicis brevis, 130 membranous), 153 abductor pollicis longus, 130 iliopsoas, 149, 149f, 153 anterior tibial, 148, 151, 151f, 153, 154 inferior oblique, 53 biceps, 133 inferior rectus, 51, 53Ð54 in biceps reflex, 166–167 lateral rectus, 49Ð50 brachialis, in biceps reflex, 166–167 latissimus dorsi, 138 brachioradialis, 133 masseter in brachialis reflex, 167 in jaw jerk, 165 in supinator reflex, 167 mandibular branch of trigeminal constrictor, of pharynx, 113 nerve supplying, 89, 94, 95f deltoid, 136, 138 medial rectus, 50 digastric, anterior belly of, mandibular in thyroid ocular myopathy, 69 branch of trigeminal nerve supply- mylohyoid, mandibular branch of ing, 89 trigeminal nerve supplying, 89 226 / INDEX

Muscle(s) (cont.) trapezius oblique testing, 116Ð118, 137, 138Ð139 inferior, 53 upper motor neuron lesion affecting, superior, 51Ð53, 54, 54f 118 opponens pollicis, 130Ð131, 131f triceps, 136 orbicularis oculi, in facial weakness vs. in triceps reflex, 167 seventh nerve lesion, 97Ð98 upper limb flexor, spasticity of, 192 pectoralis major, 138, 139f yoke, in paralytic strabismus, 56Ð57 peroneus brevis, 151Ð152 Muscle stretch (tendon) reflexes, 163Ð173. peroneus longus, 151Ð152 See also specific type and Reflexes platysma, 99, 101f cerebellar disease affecting, 187Ð188 posterior tibial, 152 corticospinal system lesions affecting, pronator, testing tone of, 127, 128f 193 pterygoid pendular, 187Ð188 jaw weakness and, 97 reinforcement of, 172Ð173, 172f mandibular branch of trigeminal Muscle tone, 125Ð126 nerve supplying, 89, 94 cerebellar lesions affecting, 187 quadriceps femoris, 147Ð148, 149, 150f, corticospinal system lesions affecting, 153 192Ð193 in knee reflex, 169 lower limb rectus corticospinal system lesions affecting, inferior, 51, 53Ð54 192 lateral, 49Ð50 testing, 147Ð148 medial, 50 upper limb in thyroid ocular myopathy, 69 corticospinal system lesions affecting, superior, 50Ð51, 52Ð53f, 53Ð54 192 rhomboid, 139Ð140 testing, 125Ð127, 128f serratus anterior, 140 Muscular dystrophy soleus, 152, 153 hip/back/abdominal weakness in, gait in ankle reflex, 169–170 abnormalities and, 161 sternomastoid, 116, 117f sternomastoid muscle affected in, 118 spinal accessory nerve supplying, 116 Musculocutaneous nerve upper motor neuron lesion affecting, biceps muscle and, 133 118 in biceps reflex, 166–167 stylopharyngeus, glossopharyngeal lesion of, C6 root lesion differentiated nerve supplying, 111 from, 143 superior oblique, 51Ð53, 54, 54f Mute patient, 205 superior rectus, 50Ð51, 52Ð53f, 53Ð54 Myasthenia gravis supraspinatus, 136Ð137 CPEO in, 69 temporalis, mandibular branch of jaw weakness in, 96 trigeminal nerve supplying, 89, 94 ocular manifestations of, 67Ð68 tensor fascia lata, 150 sternomastoid muscle affected in, 118 teres major, 138 Mylohyoid muscle, mandibular branch of of thigh, adductor magnus/longus/bre- trigeminal nerve supplying, 89 vis, 150 Myopathy tibialis anterior, 148, 151, 151f, 153, 154 myotubular, CPEO in, 69 tibialis posterior, 152 ocular, thyroid, 68Ð69 INDEX / 227

Myopia, 11 facial numbness (analgesia/hyper- high, ophthalmoscopic examination in esthesia/paresthesia) and, 96 patient with, 10 facial pain and, 95Ð96 lens for ophthalmoscopic examination jaw jerk and, 165 and, 10 jaw weakness and, 96Ð97 Myotonic dystrophy, 68 mandibular branch of, 89, 89f temporalis and masseter muscles af- motor function mediated fected in, 96 through, 94Ð95, 95f Myotubular myopathy, CPEO in, 69 maxillary branch of, 89, 89f motor function and, 94Ð95, 95f ophthalmic branch of, 88Ð89, 89f Nasal field, optic inversion and, 21 lesions of, corneal reflex absent Nasal macular fibers, 22 in, 92 Nasopharyngeal carcinoma, anosmia pain and, 90Ð91 caused by, 88 peripheral anatomy of, 88Ð90, 89f Near vision, 11f, 13 sensory testing and, 90Ð93 Nerve(s) spinal nucleus and tract of, 93, 94f abducens. See Nerve(s), cranial, VI temperature sensation and, 93 acoustic. See Nerve(s), cranial, VIII VI (abducens nerve) anterior interosseous lateral rectus muscle and, 49 flexor digitorum profundus and, 131 lesions of, 57Ð59 flexor pollicis longus and, 133 VII (facial nerve), 97Ð105 axillary anatomy of, 97 deltoid muscle and, 136, 138 autonomic functions of, 102Ð104 lesion of, C5 root lesion differentiated blinking and, 99Ð102 from, 143 diseases of, 104Ð105 cochlear, 107Ð109 examination of, 98Ð99, 100Ð101f deafness caused by lesions of, motor functions of, 97Ð98 107Ð109 palsy of, 105 cranial facial weakness differentiated I (olfactory nerve), 87Ð88 from, 97Ð98, 98Ð99, II (optic nerve), lesions of, 24Ð34. See 100Ð101f, 105 also under Optic parkinsonism and, 105 field defects caused by, 22, 24Ð34 saliva as function of, 102 III (oculomotor nerve) sensory root of, 102Ð104 inferior oblique muscle and, 53 taste as function of, 102 lesions of, 59Ð60 testing, 103Ð104, 103f medial rectus muscle and, 50 tears as function of, 102 palsy of VIII (acoustic nerve), 107Ð111. See ptosis in, 62 also Cochlear nerve; Vestibular pupils in, 62Ð63, 63, 65 nerve superior rectus muscle and, 51 cochlear nerve, 107Ð109 IV (trochlear nerve) diseases of, 110Ð111 lesions of, 60 tinnitus and, 111 superior oblique muscle and, 51 vestibular nerve, 109Ð110 V (trigeminal nerve), 88Ð97 IX (glossopharyngeal nerve), 102, corneal reflex and, 91–93, 91f, 92f 111Ð112, 114 diseases of, 95Ð97 diseases affecting, 115Ð116 228 / INDEX

Nerve(s) (cont.) lateral cutaneous of thigh, signs and cranial (cont.) symptoms of lesions of, 154 X (vagus nerve), 112Ð116 long thoracic, serratus anterior muscle diseases affecting, 115Ð116 and, 140 evaluation of, 114 mandibular, 89, 89f larynx and, 113Ð114 motor function mediated through, palate and, 112Ð113, 113f 94Ð95, 95f pharynx muscles and, 113 maxillary, 89, 89f vocal cord function and, 114 median XI (spinal accessory nerve), 116Ð118 abductor pollicis brevis and, 130 diseases of, 118 flexor carpi radialis and, 133 testing, 116Ð118, 117f, 138Ð139 flexor digitorum profundus and, 131 trapezius muscle and, 138Ð139 flexor digitorum sublimis/flexor digi- XII (hypoglossal nerve), 118Ð120 torum superficialis and, 131 diseases of, 120 flexor pollicis brevis and, 134 examination of, 118Ð120, 119f flexor pollicis longus and, 133 deep peroneal lesions of, upper limb involvement in, extensor digitorum longus and, 151 142 extensor hallucis longus and, 151 opponens pollicis and, 130 tibialis anterior and, 151 musculocutaneous dorsal scapular, rhomboid muscles and, biceps muscle and, 133 139Ð140 in biceps reflex, 166–167 facial. See Nerve(s), cranial, VII lesion of, C6 root lesion differentiated femoral from, 143 iliopsoas muscle and, 149 obturator in knee reflex, 169 adductor muscles and, 150 quadriceps femoris muscle and, 149 signs and symptoms of lesions of, 154 signs and symptoms of lesions of, oculomotor. See Nerve(s), cranial, III 154Ð155 See glossopharyngeal. See Nerve(s), cranial, olfactory. Nerve(s), cranial, I IX ophthalmic, 88Ð89, 89f gluteal lesions of, corneal reflex absent in, 92 inferior, 153 optic. See Nerve(s), cranial, II superior, 150 pectoral, pectoralis muscle and, 138 hypoglossal. See Nerve(s), cranial, XII peripheral, lesions of inferior gluteal, gluteus maximus and, pain sensation in, 181, 185 153 touch sensation in, 180, 185 intermediate (sensory root of seventh peroneal cranial nerve), 102Ð103 deep interosseous extensor digitorum longus and, 151 anterior extensor hallucis longus and, 151 in finger flexion, 131 tibialis anterior and, 151 flexor pollicis longus and, 133 signs and symptoms of lesions of, 155 posterior posterior interosseous extensor carpi ulnaris and, 136 extensor carpi ulnaris and, 136 extensor digitorum and, 135 extensor digitorum and, 135 extensor pollicis longus/extensor extensor pollicis longus/extensor pol- pollicis brevis and, 135 licis brevis and, 135 INDEX / 229 posterior tibial signs and symptoms of lesions of, flexor digitorum longus and flexor 155 hallucis longus muscles and, 152 soleus muscle and, 152 signs and symptoms of lesions of, 155 tibialis posterior muscle and, 152 radial trigeminal. See Nerve(s), cranial, V abductor pollicis longus and, 130 trochlear. See Nerve(s), cranial, IV in brachialis reflex, 167 ulnar brachioradialis and, 133 dorsal interossei and, 130 extensor carpi radialis and, 136 flexor carpi ulnaris and, 133 extensor carpi ulnaris and, 136 flexor digitorum profundus and, 131 extensor digitorum and, 135 flexor pollicis brevis and, 134 extensor pollicis longus/extensor pol- lesions of licis brevis and, 135 T1 root lesion differentiated from, lesions of 144 C6 root lesion differentiated from, upper limb involvement in, 142Ð143 143 vagus. See Nerve(s), cranial, X C7 root lesion differentiated from, vestibular, 109Ð110 143Ð144 testing function of, 109Ð110 upper limb involvement in, Nerve deafness, 108, 109 Neuralgia, glossopharyngeal, 115Ð116 141Ð142 Neuritis in supinator reflex, 167 optic, 25, 42 triceps and, 136 retrobulbar, 24Ð25, 42 scapular, rhomboid muscles and, pupils in, 64 139Ð140 Neurological examination instruments, sciatic 210, 210Ð211f hamstring muscles and, 153 Neuroma, acoustic, tinnitus caused by, 111 signs and symptoms of lesions of, 155 Neuropathy, optic, 28 spinal, iliopsoas muscle and, 149 anterior ischemic, 25 spinal accessory. See Nerve(s), cranial, Leber’s, 28 XI Neuroretinitis, 42 subscapular, teres major muscle and, 138 Night blindness, in retinitis pigmentosa, 25 superficial peroneal, peroneus longus Ninth cranial nerve. See Nerve(s), cranial, and brevis muscles and, 151Ð152 IX superior gluteal, gluteus medius and Normal-pressure hydrocephalus, gait af- minimus and tensor fascia lata fected in, 161Ð162 muscles and, 150 Null position, 72 suprascapular, supraspinatus muscle Number recall test, 199 and, 136 Number writing, in sensory examination, thoracic, long, serratus anterior muscle 184 and, 140 Numbness thoracodorsal, latissimus dorsi and, 138 facial, trigeminal nerve disorders caus- tibial ing, 96 in ankle reflex, 169–170 patient’s perception of, 121 gastrocnemius muscle and, 152 Nystagmus, 71Ð77 posterior alcohol causing, 71 flexor digitorum longus and flexor brain stem lesions causing, 73Ð74 hallucis longus muscles and, signs and symptoms associated with, 152 74 230 / INDEX

Nystagmus (cont.) Obturator nerve cerebellar lesions causing, 73Ð74, 189 adductor muscles and, 150 signs and symptoms associated with, signs and symptoms of lesions of, 154 74 Occipital cortex congenital, 72Ð73 division of, 21 optokinetic nystagmus absent in, 77 lesions of, gaze palsy and, 80, 81 pendular, 72 vision represented in, 22 convergence, 75 Occipital (smooth pursuit) gaze center, 81 convergence-retraction, 75 Occipital lobe, 21 diencephalon lesions causing, 74 lesions of, 35 downbeat, 73 field defects caused by, 23, 35, 35f brain stem and cerebellar lesions Ocular convergence, 66Ð67 causing, 73, 189 excess, 67 drugs causing, 71 forced downward gaze and, 82 end-point, 75 paralysis/paresis of, 67, 85Ð86 gaze-evoked, 72 supranuclear, 86 in internuclear ophthalmoplegia, 84 Ocular depression, 46 jerk, 71 inferior rectus muscle in, 51 brain stem and cerebellar lesions lateral rectus muscle in, 50 causing, 73 medial rectus muscle in, 50 latent, 72Ð73 superior oblique muscle in, 51Ð53, primary eye position and, 72 54f latent, 72Ð73 Ocular deviations visual acuity affected by, 12, 73 conjugate lesion sites and, 73Ð74 forced, 79 optokinetic (railroad), 76Ð77 downward, 82 pendular, 71 supratentorial gaze “centers” and, acquired, 74 80Ð81 brain stem and cerebellar lesions upward, 82 causing, 74 “wrong way,” 81 congenital, 72 secondary, in paralytic strabismus, 56 diencephalon lesions causing, 74 skew, 84 primary eye position and, 72 Ocular dysmetria (ocular flutter/opso- periodic alternating, 75 clonus), cerebellar disease causing, primary eye position and, 72 189 rebound, 75 Ocular elevation, 46 signs and symptoms associated with, 74 inferior oblique muscle in, 53 types of, 71Ð73 lateral rectus muscle in, 50 upbeat, brain stem and cerebellar lesions medial rectus muscle in, 50 causing, 73, 189 superior rectus muscle in, 50Ð51, 52f vestibular lesions causing, 74 Ocular muscles. See External ocular mus- signs and symptoms associated with, cles 74 Ocular myopathy, thyroid, 68Ð69 voluntary, 75Ð76 Ocular near response, 64, 67 Ocular rotation, 46, 55 OAG. See Chronic open-angle glaucoma inferior oblique muscle in, 53 Oblique muscles inferior rectus muscle in, 51 inferior, 53 superior oblique muscle in, 51Ð53, 54f superior, 51Ð53, 54, 54f superior rectus muscle in, 51, 53f INDEX / 231

Oculomotor nerve (cranial nerve III) Optic nerve fibers, ventral nasal, 22 inferior oblique muscle and, 53 Optic neuritis, 25, 42 lesions of, 59Ð60 Optic neuropathy, 28 medial rectus muscle and, 50 anterior ischemic, 25 palsy of Leber’s, 28 ptosis in, 62 Optic radiation, 22 pupils in, 62Ð63, 63, 65 lesions of, 34 superior rectus muscle and, 51 field defects caused by, 23, 34, 34f Oculopharyngeal dystrophy, 68 optokinetic nystagmus absent in, 76 Oculosympathetic palsy (Horner’s syn- posterior, field defects caused by, 35, drome), 62, 65 35f pupils in, 62, 65 Optic tract, 22 OKN. See Optokinetic nystagmus lesions of, 33Ð34 Old age. See Elderly field defects caused by, 23, 33Ð34, Olfactory nerve (cranial nerve I), 87Ð88 33Ð34f “One-and-a-half” syndrome, 84 Optokinetic nystagmus, 76Ð77 One hundred minus seven test, 200 Orbicularis oculi muscles, in facial weak- Open-angle glaucoma, chronic (OAG), 26 ness vs. seventh nerve lesion, 97Ð98 Ophthalmic branch of trigeminal nerve, Orbital fissure, superior, ophthalmic 88Ð89, 89f branch of trigeminal nerve in, 88 lesions of, corneal reflex absent in, 92 Orbital foramen, superior, ophthalmic Ophthalmoplegia branch of trigeminal nerve in, 88 chronic progressive external, 68Ð69 Organ of Corti, 107 ptosis in, 61, 68 Organicity, tests of, 125 internuclear, 84 Orientation, 198 Ophthalmoscope, 1, 2f technique for fundus examination with, 2Ð6, 4f, 5f Pain Opponens pollicis muscle, 130Ð131, 131f in Bell’s palsy, 104 Opposition of thumb, 130Ð131, 131f deep, testing perception of, 182 Opsoclonus, cerebellar disease causing, facial, trigeminal nerve disorders caus- 189 ing, 95Ð96 Optic atrophy, 28 sensation of, 90Ð91 in papilledema, 28, 38 cumulative, 181 Optic chiasm. See Chiasm delayed, 181 Optic disc (optic nerve head). See also Op- superficial, 180Ð181 tic nerve Pain fibers, facial, 102 edema of, in hypertension, 43 “Pain spots,” 181 in glaucoma, 26 Palate, vagus nerve supplying muscles of, hyperemia of, in papilledema, 37 112Ð113, 112f normal, 39, 40f Palmar-mental reflex, 176 ophthalmoscopic examination of, 7f, 8 Palsy (paralysis) in papilledema, 37, 38, 39, 41f. See also Bell’s, 104 Papilledema convergence, 67, 85Ð86 Optic inversion, 21 supranuclear, 86 Optic nerve (cranial nerve II). See also Op- downward gaze, 82 tic disc facial nerve, 105 lesions of, 24Ð34. See also specific type facial weakness differentiated from, field defects caused by, 22, 24Ð34 97Ð98, 98Ð99, 100Ð101f, 105 232 / INDEX

Palsy (paralysis) (cont.) Paresthesia gaze, 79Ð86 definition of, 179 cerebellar, 81 facial, trigeminal nerve disorders caus- in cerebral lesions, 80 ing, 96 conjugate, 79 Parietal lobe lesions, 34 optokinetic nystagmus absent in, field defects caused by, 23, 34, 34f 76 sensation affected in, 185 supratentorial gaze “centers” and, touch sensation affected in, 180 80Ð81 Parinaud’s syndrome, 83 optokinetic nystagmus absent in, defective downward gaze in, 82, 83 76 defective upward gaze in, 83 parastriate cortex lesions and, 80Ð Parkinsonism 81 facial weakness in, 105 pursuit, 79 gait abnormalities in, 159 reflex, 79 upward gaze in, 82 voluntary, 79 Passive movement, sense of, 183 inferior rectus muscle, 51 Passive stretching, resistance to, muscle lateral rectus muscle, 49, 50 tone as, 125. See also Muscle tone medial rectus muscle, 50 Past pointing, cerebellar disease causing, oculomotor 188Ð189 ptosis in, 62 Patch (eye), double vision and, 57 pupils in, 62Ð63, 63, 65 Paton’s lines (retinal wrinkling), in oculosympathetic (Horner’s syndrome), papilledema, 38, 42 62, 65 Pectoral nerve, pectoralis muscle and, 138 pupils in, 62, 65 Pectoralis major muscle, 138, 139f palatal, 113Ð114, 114f Pendular nystagmus, 71 pharyngeal, 113 acquired, 74 pseudobulbar, 115, 194Ð195 brain stem and cerebellar lesions caus- Saturday night, 141 ing, 74 superior oblique muscle, 53 congenital, 72 superior rectus muscle, 51 diencephalon lesions causing, 74 supranuclear convergence, 86 primary eye position and, 72 third nerve Pendular tendon reflexes, in cerebellar dis- ptosis in, 62 ease, 188Ð189 pupils in, 62Ð63, 63, 65 Pericentral retinitis pigmentosa, 26 upward gaze, 82 Perimetry, 16 Papilledema, 37Ð42 Periodic alternating nystagmus, 75 identification of, 38–39 Peripheral nerve lesions optic atrophy and, 28, 38 pain sensation in, 181, 185 visual acuity and, 39 touch sensation in, 180, 185 Papillitis, 42 Peripheral vision, 19 Paracentral scotoma, in glaucoma, 26 testing, 13Ð18 Paralysis. See Palsy confrontation testing for, 13Ð15, 14f, Paralytic strabismus, 56Ð57 18 Parastriate cortex (area 18), 21. See also perimetry for, 16 Visual cortex string test for, 14f, 16 lesions of, gaze palsy and, 80Ð81 Peristriate cortex (area 19), 21. See also Paresis. See Palsy Visual cortex INDEX / 233

Peroneal nerve Position sense, evaluation of, 183Ð184 deep Posterior chiasmal lesions, field defects extensor digitorum longus and, caused by, 32, 32f 151 Posterior fossa, periodic alternating nys- extensor hallucis longus and, 151 tagmus and, 75 tibialis anterior and, 151 Posterior (smooth pursuit) gaze center, 81 signs and symptoms of lesions of, 155 Posterior interosseous nerve Peroneus brevis muscle, 151Ð152 extensor carpi ulnaris and, 136 Peroneus longus muscle, 151Ð152 extensor digitorum and, 135 Perserveration, 207 extensor pollicis longus/extensor polli- Pharyngeal reflex, 112, 173 cis brevis and, 135 Pharynx Posterior pole (retinal), 22 constrictor muscles of, 113 ophthalmoscopic examination of, 7f, vagus nerve supplying muscles of, 113 9Ð10 Physiologic cup, ophthalmoscopic exami- Posterior root lesions, sensation affected nation of, 7f, 8Ð9 in, 185 Pilocarpine, pupillary response to, in Posterior tibial muscle, 152 Adie’s syndrome, 65 Posterior tibial nerve Pinealoma, Parinaud’s syndrome caused flexor digitorum longus and flexor hallu- by, 83 cis longus muscles and, 152 Pinhole effect signs and symptoms of lesions of, 155 examiner’s refractive error during oph- Posture (postural maintenance) thalmoscopic examination and, 3 cerebellar disease affecting, 187 vision testing and, 13 double vision and, 57 Plantar flexion upper limb, 122Ð123, 123f of foot, 151, 152, 152Ð153 Power. See also Weakness of toes, 152 corticospinal system (upper motor neu- Plantar reflex, 174–175 ron) disease affecting, 191Ð192 corticospinal system lesions affecting, lower limb, 148, 153Ð154 193 upper limb, 192 Plastic rigidity, 126 Presbyopia, 11 Platysma muscle, 99, 101f Pretectum, lesions of, upward gaze palsy Poliomyelitis, jaw weakness in, 96 in, 82 Polymyositis, sternomastoid muscle af- Primary eye position, nystagmus and, 72 fected in, 118 Primitive reflexes, 175Ð176. See also spe- Polyneuritis cific type cranialis, 116 Pronator muscle tone, testing, 127, 128f infectious (Guillain-Barré syndrome), Proprioception, defective, gait abnormali- seventh (facial) nerve involvement ties in, 160 in, 104 Proximal pain and peripheral anesthesia Pontine lesions clue, 177 gaze palsy in, 83Ð84 Pseudobulbar palsy, 115, 194Ð195 miosis caused by, 66 Pseudoretinitis pigmentosa, 26 “one-and-a-half” syndrome caused by, Pterygoid muscle 84 jaw weakness and, 97 sternomastoid muscle affected in, 118 mandibular branch of trigeminal nerve Position of gaze, primary, nystagmus and, supplying, 89, 94 72 Pterygopalatine ganglion, 102 234 / INDEX

Ptosis, 61Ð62 Radial nerve bilateral, 62 abductor pollicis longus and, 130 in myasthenia gravis, 68 in brachialis reflex, 167 blepharospasm differentiated from, brachioradialis muscle and, 133 61 extensor carpi radialis and, 136 in chronic progressive external extensor carpi ulnaris and, 136 ophthalmoplegia, 61, 68 extensor digitorum and, 135 Horner’s syndrome and, 62 extensor pollicis longus/extensor polli- in oculopharyngeal dystrophy, 68 cis brevis and, 135 third nerve palsy and, 62 lesions of Pupils, 62Ð66 C6 root lesion differentiated from, abnormal, causes and types of, 64Ð66 143 in Adie’s syndrome, 65 C7 root lesion differentiated from, afferent defect of, 64 143Ð144 Argyll-Robertson, 64 big, factitious, 66 upper limb involvement in, 141Ð142 in carotid artery occlusion, 66 in supinator reflex, 167 consensual response to light, 63 triceps and, 136 denervation supersensitivity of, 65 in triceps reflex, 167 direct response to light, 63 Railroad nystagmus (optokinetic nystag- equality of, 62Ð63 mus), 76Ð77 examination of, 63Ð64 RAO. See Retinal arteries, occlusion of in Horner’s syndrome, 62, 65 Rapid alternating movements light reaction of, 63 lower limb coordination tested with, Marcus Gunn, 64 145Ð147, 146f in midbrain lesions, 66 upper limb coordination tested with, near reaction of, 64, 67 123Ð125, 124f, 125f in newborn, 62 RD. See Retinal detachment in oculomotor nerve lesions/third nerve Rebound, cerebellar disease causing, palsy, 62Ð63, 63, 65 188Ð189 in pontine lesions, 66 Rebound nystagmus, 75 size of, 62 Rectus muscles differences in (anisocoria), 62, 65 inferior, 51, 53Ð54 medications affecting (factitious big lateral, 49Ð50 pupil), 66 medial, 50 small. See Miosis in thyroid ocular myopathy, 69 swinging flashlight test in evaluation of, superior, 50Ð51, 52Ð53f, 53Ð54 64 tonic, 65 Reflection, minimizing during ophthalmo- Pursuit gaze palsy, 79 scopic examination, 3 Pursuit movements, testing, 47Ð48, 48f Reflex arc, 163 Pyramidal tract, 191Ð195. See also Corti- Reflex gaze palsy, 79 cospinal system disease Reflex hammer, 209f, 211 Reflexes, 163Ð176. See also Responses abdominal, 173, 174f Quadrantanopia, 17f ankle, 169Ð170, 170Ð171f Quadriceps femoris muscle, 147Ð148, 149, Babinski, 174, 175, 193 150f, 153 biceps, 166Ð167 in knee reflex, 169 brachialis, 167 INDEX / 235

corneal, 91Ð93, 91f, 92f, 173 ophthalmoscopic examination of, 2Ð10, absence of 5f after cataract surgery, 93 organization of, 21 in elderly, 93 in papilledema, 37Ð42 in ophthalmic nerve lesions, 92 posterior pole of, 22 in thalamic lesions, 93 ophthalmoscopic examination of, 7f, contact lenses preventing, 92 9Ð10 methods of elicitation of, 91f Retinal arteries corticospinal system lesions affecting, branch, occlusion of, 27 193 central cremasteric, 173Ð174 giant cell arteritis of, 25 finger flexion, 167–168, 168f occlusion of, 27 gag in hypertension, 43 glossopharyngeal nerve and, 112 occlusion of, 27 paresis of pharynx and, 113 ophthalmoscopic examination of, 6, 7f vagus nerve and, 112Ð113 Retinal detachment, 27 grasp, 175Ð176 Retinal exudates Hoffmann’s, 168Ð169 cotton-wool knee, 169 in central retinal vein occlusion, difficulty eliciting, 172 26Ð27 palmar-mental, 176 in papilledema, 38 pharyngeal, 112, 173 in hypertension, 43 plantar, 174Ð175, 193 Retinal hemorrhages primitive, 175Ð176 flame-shaped, 38 sucking, 176 globular subhyaloid, 38 superficial, 173Ð175, 193 in hypertension, 43 supinator, 167 in papilledema, 38 tendon (muscle stretch), 163Ð173 splinter, 38 cerebellar disease affecting, 187Ð188 Retinal veins corticospinal system lesions affecting, branch, occlusion of, 27 193 central, occlusion of, 26Ð27 pendular, 187Ð188 ophthalmoscopic examination of, 6Ð8, reinforcement of, 172Ð173, 172f 7f triceps, 167 in papilledema, 37, 37Ð38 upper motor neuron lesions affecting, pulsation of, 6Ð7, 7f 193 Retinal wrinkling, in papilledema, 38, 39 Reflexogenic zone, of tendon reflex, 164 Retinitis Relative scotoma, 19 central serous, 25 Responses. See also Reflexes pigmentosa, 25 extensor plantar (Babinski), 174, 175 atypical, 26 in corticospinal system lesions, 193 Retinopathy, pigmentary, 26 flexor plantar, 175 Retrobulbar neuritis, 24Ð25, 42 Retina. See also under Retinal pupils in, 64 abnormal, 37Ð43 Rhomboid muscles, 139Ð140 arteriovenous “nicking” of, 43 Rigidity, 126 in hypertension, 43 cogwheel, 126 lesions of, 24Ð34. See also specific type plastic, 126 field defects caused by, 22 Rinne test, 108 236 / INDEX

Romberg test, 158Ð159 physiological (blind spot), 20 Root lesion finding, 20 C5, axillary nerve lesion differentiated relative, 19 from, 143 Second cranial nerve. See Nerve(s), cra- C6, musculocutaneous or radial nerve nial, II lesion differentiated from, 143 Secondary deviation, in paralytic strabis- C7, radial nerve lesion differentiated mus, 56 from, 143Ð144 Sectoral retinitis pigmentosa, 26 lumbar, signs and symptoms of, 154 Segmental reflex arc, 163 posterior, sensation affected in, 185 Seizures, ocular manifestations of, 80 sacral, signs and symptoms of, 154 Semicircular canals, testing of, 109Ð110 T1, ulnar nerve lesion differentiated Sensation, 177Ð185 from, 144 disturbances of Rotation (eye), 46, 55 gait abnormalities and, 160 inferior oblique muscle in, 53 terminology related to, 179 inferior rectus muscle in, 51 trigeminal nerve lesions causing, 88 superior oblique muscle in, 51Ð53, 54f loss of on dorsum of foot, in sciatic superior rectus muscle in, 51, 53f nerve lesions, 155 RP. See Retinitis, pigmentosa of pain deep, 182 superficial, 180Ð181 Saccadic center, 80Ð81 of passive movement, 183 Saccadic movements, testing, 47Ð48, 48f of position, 183Ð184 Saccule, testing of, 109Ð110 of temperature, 181Ð182 Sacral root lesions, signs and symptoms of, testing, 90Ð93, 177Ð185 154 bilateral simultaneous stimulation Saliva, sensory cells/fibers in, 102 and, 185 Salt, as taste substance, 104 demonstration in, 178 Sarcoidosis, anosmia in, 88 number writing and, 184 Saturday night palsy, 141 rules of examination and, 178Ð179 Scapula, fixation of, 138–140 stereognosis and, 184 Scapular nerve, dorsal, rhomboid muscles subjectivity of findings in, 177 and, 139Ð140 two-point discrimination and, 184 Schizophrenia, speech in, 205 of touch, 179Ð180 Sciatic nerve of vibration, 182Ð183 hamstring muscles and, 153 Sensory examination. See Sensation, test- signs and symptoms of lesions of, 155 ing Scotoma, 17f, 19 Serratus anterior muscle, 140 absolute, 19 Seventh cranial nerve. See Nerve(s), cra- arcuate, 20 nial, VII in glaucoma, 26 Shock, spinal, 193 bitemporal hemianopic central, 17f, Shoulder, weakness of, fixation of scapula 20Ð21 and, 138Ð140 cecocentral, 20 Single hand clapping, 124Ð125, 125f central, 19Ð20, 29 Sixth cranial nerve. See Nerve(s), cranial, occipital lobe lesion causing, 23 VI in glaucoma, 26 Skew deviation, 84 paracentral, 26, 30 Smell, 87Ð88 INDEX / 237

Smooth pursuit center, 81 Stereognosis, in sensory examination, Snellen card, for visual acuity testing, 184 11Ð12 Sternomastoid muscle, 116, 117f Sole of foot, sensory loss of in sciatic spinal accessory nerve supplying, 116 nerve lesions, 155 upper motor neuron lesion affecting, 118 Soleus muscle, 152, 153 Stimulus threshold, for tendon reflex, 164 in ankle reflex, 169–170 Strabismus, 47 Solitary nucleus, taste cells in, 102 accommodative, 56 Sour, as taste substance, 104 concomitant (nonparalytic), 56 Spasticity, 126 latent (heterophoria), 46 in corticospinal system lesions, 192 paralytic, 56Ð57 upper limb flexor muscle, 192 Strength. See also Weakness Spatial ability, evaluation of, 200, 201f corticospinal system (upper motor neu- Spectacles. See Eyeglasses ron) disease affecting, 191Ð192 Speech lower limb, 148, 153Ð154 anatomic basis of, 205Ð206 upper limb, 192 comprehension and, 206Ð207 Striate cortex (area 17), 21. See also Visual disorders of, 205Ð211. See also Aphasia cortex in cerebellar disease, 190 String test, for visual field testing, 14f, 16 examination of patient with, 206Ð207 Stroke, ocular manifestations of, 80 fluent, 206 Stylopharyngeus muscle, glossopharyngeal nonfluent, 206 nerve supplying, 111 repetition and, 206 Subacute combined degeneration of spinal spontaneous, 206 cord, vibratory sense loss in, 183 Spinal accessory nerve (cranial nerve XI), Subhyaloid hemorrhages, globular, in pa- 118 pilledema, 38 diseases of, 118 Submandibular ganglion, 102 testing, 116Ð118, 117f, 138Ð139 Subscapular nerve, teres major muscle trapezius muscle and, 138Ð139 and, 138 Spinal cord, subacute combined degenera- Sucking reflex, 176 tion of, vibratory sense loss in, 183 Suggestion, sensory examination results Spinal cord affected by, 178 lesions of Sulcus, calcarine, 21 pain sensation affected in, 181, 185 Superficial pain sensation, evaluation of, sensation affected in, 185 180Ð181 touch sensation affected in, 180, 185 Superficial peroneal nerve, peroneus subacute combined degeneration of, loss longus and brevis muscles and, of vibratory sense in, 183 151Ð152 Spinal nerves, iliopsoas muscle and, 149 Superficial reflexes, 173Ð175. See also Spinal shock, 193 specific type Spinal trigeminal nucleus and tract, 93, 94f corticospinal system lesions affecting, Splinter hemorrhages, in papilledema, 38 193 Spontaneous arm drift, 122Ð123, 122f Superior gluteal nerve, gluteus medius and Spontaneous speech, in aphasia, 206 minimus and tensor fascia lata mus- Squint, 46Ð47 cles and, 150 in paralytic strabismus, 56 Superior oblique muscle, 51Ð53, 54, 54f Stance, 157Ð162. See also Gait Superior orbital fissure, ophthalmic branch Stephens syndrome, CPEO in, 69 of trigeminal nerve in, 88 238 / INDEX

Superior orbital foramen, ophthalmic Parinaud’s (dorsal midbrain/sylvian branch of trigeminal nerve in, 88 aqueduct), 83 Superior rectus muscle, 50Ð51, 52Ð53f, defective downward gaze in, 82, 83 53Ð54 defective upward gaze in, 83 Superior salivatory nucleus, 102 Stephens, CPEO in, 69 Supinator reflex, 167 sylvian aqueduct. See Syndrome, Parin- Supine leg raising test, 145 aud’s Supramarginal gyrus, 205 Usher’s, retinitis pigmentosa and, 26 Supranuclear convergence palsy, 86 Suprascapular nerve, supraspinatus muscle and, 136 T1 root lesion, ulnar nerve lesion differ- Suprasegmental systems, reflex arc and, entiated from, 144 163 Takayasu’s disease, carotid involvement Supraspinal pathway, descending, 191Ð in, pupils in, 66 195. See also Corticospinal system Taste disease glossopharyngeal nerve in, 102, 111 Supraspinatus muscle, 136Ð137 sensory fibers in, 102 Supratentorial gaze “centers,” 80Ð81 testing, 103Ð104, 103f Sweet, as taste substance, 104 Tears, cells/fibers in secretion of, 102 Swinging flashlight test, 64 Temperature sensation, 181Ð182 Swollen disc. See Papilledema fifth cranial nerve and, 93 Sylvian aqueduct syndrome (Parinaud’s Temporal arteries, giant cell arteritis of, syndrome), 83 25 defective downward gaze in, 82, 83 Temporal crescent visual field defect, 35, defective upward gaze in, 83 35f Syndrome Temporal field, optic inversion and, 21 Adie’s (tonic pupil), 65 Temporal lobe lesions, 34 Bardet-Biedl, retinitis pigmentosa and, field defects caused by, 23, 34, 34f 26 Temporalis muscle, mandibular branch of Bassen-Kornzweig trigeminal nerve supplying, 89, 94 CPEO and, 69 Tendon (muscle stretch) reflexes, 163Ð173. retinitis pigmentosa and, 26 See also specific type dorsal midbrain. See Syndrome, Parin- cerebellar disease affecting, 187Ð188 aud’s corticospinal system lesions affecting, Duchenne-Erb, upper trunk lesions in, 193 140Ð142 pendular, 187Ð188 Guillain-Barré (infectious polyneuritis), reinforcement of, 172Ð173, 172f seventh (facial) nerve involvement Tensor fascia lata muscle, 150 in, 104 Tenth cranial nerve. See Nerve(s), cranial, Holmes-Adie, 65 X Horner’s, 62, 65 Teres major muscle, 138 pupils in, 62, 65 Terminal intention tremor, 123Ð124 jugular foramen, 116 Thalamus, lesions of, corneal reflex absent Kearns-Sayre in, 93 CPEO and, 69 Thenar eminence, 127 retinitis pigmentosa and, 26 wrist lesions causing wasting of, 142 Klumpke, lower trunk lesions in, 141 Thermal stimulus, sensation of, 181Ð182 “one-and-a-half,” 84 fifth cranial nerve and, 93 INDEX / 239

Thigh, 145. See also Lower limb Tremor abduction of, 150 cerebellar, 188 adduction of, 150 intention, 188 extension of at hip, 153 terminal, 123Ð124 flexion of, 149, 149f, 154 Triceps muscle, 136 lateral cutaneous nerve of, signs and in triceps reflex, 167 symptoms of lesions of, 154 Trigeminal nerve (cranial nerve V), 88Ð97 Thinking, evaluation of, 199 corneal reflex and, 91–93, 91f, 92f Third cranial nerve. See Nerve(s), cranial, diseases of, 95Ð97 III facial numbness (analgesia/hyperesthe- Thoracic nerve, long, serratus anterior sia/paresthesia) and, 96 muscle and, 140 facial pain and, 95Ð96 Thoracodorsal nerve, latissimus dorsi and, jaw jerk and, 165 138 jaw weakness and, 96Ð97 Thought disorder, 205 motor function and, 94Ð95, 95f Thumb. See also Upper limb pain perception and, 90Ð91 abduction of, 130 peripheral anatomy of, 88Ð90, 89f extension of, 135 sensory testing and, 90Ð93 flexion of, 133–134 spinal nucleus and tract of, 93, 94f opposition of, 130Ð131, 131f temperature sensation and, 93 Thyroid ocular myopathy, 68Ð69 Trochlear nerve (cranial nerve IV) Tibial nerve lesions of, 60 in ankle reflex, 169–170 superior oblique muscle and, 51 gastrocnemius muscle and, 152 Tumor posterior anterior fossa, anosmia caused by, 88 flexor digitorum longus and flexor cerebellarÐpontine angle, seventh (fa- hallucis longus muscles and, 152 cial) nerve palsy and, 105 signs and symptoms of lesions of, Tuning fork, 211 155 for vibration sense testing, 182Ð183 soleus muscle and, 152 Twelfth cranial nerve. See Nerve(s), cra- tibialis posterior muscle and, 152 nial, XII Tibialis anterior muscle, 148, 151, 151f, Two-point discrimination, in sensory ex- 153, 154 amination, 184 Tibialis posterior muscle, 152 Tic douloureux, 96 Tinnitus, 111 Ulnar nerve Toes. See also Lower limb dorsal interossei and, 130 dorsiflexion of, 151, 151f flexor carpi ulnaris and, 133 plantar flexion of, 152 flexor digitorum profundus and, 131 Tone, muscle. See Muscle tone flexor pollicis brevis muscle and, 134 , hypoglossal nerve supplying, 118 lesions of testing function of, 118Ð120, 119f T1 root lesion differentiated from, Tonic pupil (Adie’s syndrome), 65 144 Touch sensation, 179Ð180 upper limb involvement in, 142Ð 143 Trapezius muscle Unconscious patient, vestibular function testing, 116Ð118, 137, 138Ð139 evaluation in, 110 upper motor neuron lesion affecting, Upbeat nystagmus, brain stem and cerebel- 118 lar lesions causing, 73, 189 240 / INDEX

Upper limb, 121Ð144 Vertical eye movements abnormalities of, 140Ð144 lateral rectus muscle in, 50 alternating movements and, 123Ð125, testing, 48 124f, 125f Vertigo, 109, 110 coordination evaluation and, 123Ð125, Vestibular apparatus, testing of, 109Ð110 124f, 125f Vestibular lesions, nystagmus in, 74 examination of, 130Ð140 signs and symptoms associated with, directed, 121 74 undirected, 121Ð122 Vestibular nerve, 109Ð110 movement of in walking, 157 testing function of, 109Ð110 muscle tone and, 125Ð127, 128f Vibration sense, evaluation of, 182Ð183 postural maintenance and, 122Ð123, Vision, 10Ð18 123f binocular, testing, 47, 48f power (strength) of, corticospinal sys- central (macular), 11Ð13, 19 tem lesions affecting, 192 distance, 11Ð13, 11f size of, 127Ð130, 129f loss of, 19Ð36 Upper motor neuron lesions, 191Ð195 diagnosis of, 17f, 23Ð24 clonus in, 194 diseases causing, 24Ð36. See also spe- facial weakness in, 97, 191Ð192 cific disease gait abnormalities in, 160Ð161, 193Ð194 history in, 24 jaw weakness and, 97, 192 terminology related to, 19Ð23 miscellaneous manifestations of, near, 11f, 13 193Ð194 peripheral, 19 muscle tone in, 192Ð193 testing, 13Ð18 power affected by, 191Ð192 confrontation testing for, 13Ð15, reflexes affected by, 193 14f, 18 sternomastoid and trapezius weakness perimetry for, 16 in, 118 string test for, 14f, 16 Upward gaze, 82 terminology related to, 10Ð11, 19Ð23 paralysis of, 82 Visual acuity, 19 Usher’s syndrome, retinitis pigmentosa counting fingers testing and, 12 and, 26 distance vision expressed as, 11, 12 Utricle, testing of, 109Ð110 in latent nystagmus, 12, 73 in papilledema, 39 Visual cortex, 21 VA. See Visual acuity frontal, gaze palsy and, 80 Vagus nerve (cranial nerve X), 112Ð116 lesions of, 35Ð36 diseases affecting, 115Ð116 anterior, 35, 35f Valsalva maneuver, retinal vein pulsation field defects caused by, 35, 35f and, 8 gaze palsy and, 80Ð81 Vein, retinal occipital branch, occlusion of, 27 division of, 21 central, occlusion of, 26Ð27 gaze palsy and, 80, 81 ophthalmoscopic examination of, 6Ð8, vision represented in, 22 7f parastriate (area 18), 21 in papilledema, 37, 37Ð38 gaze palsy and, 80Ð81 pulsation of, 6Ð7, 7f peristriate (area 19), 21 Ventral nasal optic nerve fibers, 22 striate (area 17), 21 INDEX / 241

Visual field defects, 17f, 22Ð23. See also Voluntary gaze palsy, 79 specific type Voluntary movements, cerebellar disease altitudinal, 17f affecting, 189 anterior chiasmal lesions causing, Voluntary nystagmus, 75Ð76 29Ð30, 29Ð30f bilateral homonymous hemianopsia (cortical blindness), 36 Walking, 157Ð158. See also Gait chiasmal lesions causing, 17f, 22, 29Ð Weakness. See also Power 33 abdominal, gait abnormalities and, 161 congruous, 23 back muscle, gait abnormalities and, crescent, temporal, 35, 35f 161 gaze palsy and, 80Ð81 extensor muscle, upper limb, in corti- in glaucoma, 26 cospinal system lesions, 192 hemianopia, 17f, 20 external ocular muscle, diseases caus- with macular loss, 21 ing, 67Ð69 with macular sparing, 17f, 21, 23 convergence assessment in, 67 with macular splitting, 17f, 20Ð21 eyelid muscle, diseases causing, 67Ð69 homonymous facial, 105 hemianopia, 17f, 20 appearance at rest and, 99 hemianopsia, bilateral, 36 in corticospinal system disease (upper optokinetic nystagmus absent in, 76 motor neuron lesions), 97, horizontal, 17f 191Ð192 inattention, 15 in parkinsonism, 105 optokinetic nystagmus absent in, 76 seventh nerve lesion differentiated lateral chiasmal lesions causing, 33, from, 97Ð98, 98Ð99, 100Ð101f, 33f 105 quadrantanopia, 17f finger, in corticospinal system lesions, temporal field, 35, 35f 192 Visual fields. See also Visual field defects hip girdle, gait abnormalities and, 161 central (macular), 11Ð13, 19 jaw equatorial division and, 21 in amyotrophic lateral sclerosis, 96 gaze palsy and, 80Ð81 in corticospinal system disease (upper in glaucoma, 26 motor neuron lesions), 97, 192 organization of, 21Ð22 in foramen ovale disorders, 97 peripheral, testing, 13Ð18 in myasthenia gravis, 96 confrontation testing for, 13Ð15, 14f, in poliomyelitis, 96 18 in muscular dystrophy, 161 perimetry for, 16 shoulder, fixation of scapula and, string test for, 14f, 16 138Ð140 Visual fixation, disorders of, optokinetic sternomastoid, in corticospinal system nystagmus absent in, 76 disease (upper motor neuron le- Visual pathways, 21Ð23 sions), 118 arrangement of fibers in, 21–22 trapezius, in corticospinal system dis- Vocal cords ease (upper motor neuron lesions), examination of, 114, 115f 118 paralysis of, 113Ð114 upper limb, in corticospinal system le- Volitional (saccadic) gaze center, 80Ð81 sions, 192 242 / INDEX

Weber test, 108 flexion of, 133, 134f Welch-Allyn ophthalmoscope, 1, 2f lesions at, 142 Wernicke’s aphasia, 208 Wrist clonus, 126, 172 Wernicke’s area, 205 in corticospinal system disease, 194 Whispered speech, in hearing evaluation, Writing, in aphasia, 207 107Ð108 “Wrong way” conjugate deviation, 81 Wing scapula, 138Ð140 Wrinkling, retinal, in papilledema, 38 Wrist. See also Upper limb Yoke muscles, in paralytic strabismus, extension of, 136, 137f 56Ð57