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 reflex 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, 53–54 Abducens nerve (cranial nerve VI) Adductor muscles (magnus, longus, lateral rectus muscle and, 49 brevis), 150 lesions of, 57–59 Adie’s syndrome (tonic pupil), 65 Abduction Afferent pupil defect, 64 of arm, 136–138 Aging. See Elderly of eye, 45 Alcohol use and abuse, nystagmus caused lateral rectus muscle in, 49–50 by, 71 superior and inferior oblique muscles Alternating movements in, 54 lower limb coordination tested with, of fingers, 130 145–147, 146f of thigh, 150 upper limb coordination tested with, of thumb, 130 123–125, 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, 66–67 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- 107–111. See also Cochlear nerve; ness in, 96 Vestibular nerve Analgesia cochlear nerve, 107–109 definition of, 179 diseases of, 110–111 facial, trigeminal nerve disorders caus- tinnitus and, 111 ing, 96 vestibular nerve, 109–110 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, 87–88 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, 29–30, 29–30f 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, 80–81 Arm, 121. See also Upper limb Anterior interosseous nerve abduction of, 136–138 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, 122–123, 122f 154 Arnold-Chiari malformation, downbeat Aphakia, 10 nystagmus in, 73 Aphasia, 205–211 Arteriovenous “nicking,” retinal, in hyper- anomic, 208 tension, 43 Broca’s, 206, 207 Arteritis, giant cell, of central retinal comprehension, 206–207 artery, 25 conduction, 208 Artery definition of, 205 carotid, occlusion of, pupils and, 66 examination of patient with, 206–207 retinal fluent speech in, 206 branch, occlusion of, 27 global, 208–209 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, 207–209 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 17–19 (visual cortex), 21 in cerebellar disease, 159–160 lesions of, 35–36 contralateral arm and leg, frontal lobe field defects caused by, 35, 35f lesion causing, 190 gaze palsy and, 80–81 miscellaneous diseases causing, 162 Brodmann’s 17 (striate cortex), 21 in normal-pressure hydrocephalus, Brodmann’s 18 (parastriate cortex), 21 161–162 lesions of, gaze palsy and, 80–81 tests of, 158–159 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, 140–144 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, 140–142 Babinski response (extensor plantar re- Brachialis muscle, in biceps reflex, sponse), 174, 175 166–167 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, 157–162. 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, 73–74 retinitis pigmentosa and, 26 signs and symptoms associated with, Bell’s palsy, 104 74 Bell’s phenomenon, 82–83 Broca’s aphasia, 206, 207 Betz cells, 191 Broca’s area, 205 Biceps muscle, 133 Brodmann’s areas 17–19 (visual cortex), 21 in biceps reflex, 166–167 lesions of, 35–36 Bilateral homonymous hemianopsia (corti- anterior, field defects caused by, 35, cal blindness), 36 35f Bilateral simultaneous stimulation, in sen- gaze palsy and, 80–81 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, 20–21 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, 143–144 cortical (bilateral homonymous hemi- Calcarine sulcus, 21 anopsia), 36 Calculation ability, 199–200 glaucoma causing, 26 Caloric testing, 85 night, in retinitis pigmentosa, 25 in gaze palsy, 80 Blinking, 99–102 in unconscious patient, 85, 110 pattern of in myasthenia gravis, 68 of vestibular function, 109–110 216 / INDEX Carotid artery occlusion, pupils in, 66 Clonus, 170–172 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 Central nervous system disease, delirium wrist, 126, 172, 194 caused by, 202 Clostridium boutlinum, toxin of, eye af- Central retinal vein occlusion, 26–27 fected by, 67 Central scotoma, 19–20, 29 Cochlear nerve, 107–109 occipital lobe lesion causing, 23 deafness caused by lesions of, 107–109 Central vision (macular vision), 11–13, Cochlear nucleus, 107 19 Cogwheel rigidity, 126 Cerebellar disease, 187–190 Concentration tests, miscellaneous, 200 dysmetria in, 188–189 Concomitant strabismus (nonparalytic stra- ocular, 189 bismus), 56 gait abnormalities in, 159–160 Conduction aphasia, 208 gaze palsy and, 81 Conductive hearing loss, 108, 109 muscle tone in, 187 Confrontation testing, of visual fields, nystagmus in, 73–74, 189 13–15, 14f, 18 signs and symptoms associated with, Confusional states. See also Delirium; De- 74 mentia past pointing in, 188–189 sensory examination precluded by, posture in, 187 178 rebound in, 188–189 Congenital nystagmus speech in, 190 optokinetic nystagmus absent in, 77 tendon reflexes in, 187–188 pendular, 72 tremor in, 188 Conjugate deviation of eyes voluntary movements in, 189 Cerebellar–pontine 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 80–81 Chiasm, 22 upward, 82 lesions of, 28–33 “wrong way,” 81 anterior, 29–30, 29–30f Conjugate gaze palsy, 79 of body, 31–32, 31–32f supratentorial gaze “centers” and, 80–81 field defects caused by, 17f, 22, Constrictor muscles, of pharynx, vagus 28–33, 29–33f nerve supplying, 113 lateral, 33, 33f Constructional