Editors: Thomas, James; Monaghan, Tanya Title: Oxford Handbook of Clinical Examination and Practical kills, !

st Edition Co"yright #$%&&' Oxford (ni)ersity Press * Table of Contents * Cha"ter !& + The ,er)o-s ystem Cha"ter !& The ,er)o-s ystem P.%/& Presenting sym"toms in ne-rology The history is key is many ne-rological cases. 0f the "atient cannot gi)e a com"lete story 1e.g. 2hen describing a loss of conscio-sness or sei3-re4, collateral histories sho-ld be gained from any 2itnesses to the e)ent1s4567relati)es, friends, the 8P, or e)en "assers+by. 9n a""roach to ne-rological sym"toms ym"toms can )ary 2ildly in ne-rology and the intricacies of a fe2 are disc-ssed belo2. :or all sym"toms, yo- sho-ld try to -nderstand: The exact nat-re of the sym"tom. The onset 1s-dden; lo2567ho-rs; <ays; =eeks; Months;4.

Change o)er time 1"rogressi)e; 0ntermittent; E"isodes of reco)ery;4. Preci"itating factors. Exacerbating and relie)ing factors. Pre)io-s e"isodes of the same sym"tom. Pre)io-s in)estigations and treatment. 9ssociated sym"toms. 9ny other ne-rological sym"toms.

<i33iness ,arro2 the exact meaning do2n 2itho-t a""earing aggressi)e or disbelie)ing. This term is -sed by different "eo"le to describe rather different things incl-ding56> 9 sense of rotation ? 56@)ertigo56A. 56@ 2imminess56A or 56@lightheadedness56A567a rather nons"ecific sym"tom 2hich can be related to "athology in many different systems.

56@Pre+synco"e56A567the rather -niB-e feeling one gets C-st "rior to fainting. 0ncoordination567many 2ill say they are di33y 2hen, in fact, they canDt 2alk straight d-e to either ataxia or 2eakness.

Headache This sho-ld be treated as yo- 2o-ld any other ty"e of "ain. Establish character, se)erity, site, d-ration, time co-rse, freB-ency, radiation, aggra)ating and relie)ing factors, associated sym"toms.

9sk abo-t facial and )is-al sym"toms. 1 ome different ty"es of headaches are described on ".EFG4.

,-mbness and 2eakness These t2o 2ords are often conf-sed by "atients+describing a leg as 56@n-mb56A 2hen it is 2eak 2ith normal sensation. 9lso, "atients may re"ort 56@n-mbness56A 2hen, in fact, they are ex"eriencing "ins+and+ needles or "ain. Tremor Here, yo- sho-ld establish if the tremor occ-rs only at rest, only 2hen attem"ting an action or both. 0s it 2orse at any "artic-lar time of the day; The se)erity can be established in terms of its f-nctional conseB-ence 1canDt hold a c-"H"-t food to mo-th;4. 9gain, establish exactly 2hat is being described. 9 tremor is a shaking, reg-lar or Cerky in)ol-ntary mo)ement. P.%/! ynco"e This is disc-ssed in Cha"ter '. :alls and loss of conscio-sness 1IOC4 9n eye2itness acco-nt is )ital. Establish also 2hether the "atient act-ally lost conscio-sness or not. Peo"le often describe 56@blacking o-t56A 2hen in fact they sim"ly fell to the gro-nd 1dro" attacks ha)e no IOC4. 9n im"ortant B-estion here is 56@can yo- remember hitting the gro-nd; 56A. 9sk abo-t "receding sym"toms and 2arning signs+they may "oint to2ards a different organ system 1s2eating or 2eakness co-ld be a marker of hy"oglycaemia; "al"itations may indicate a cardiac dysrhythmia4. ei3-res Jery diffic-lt e)en for ex"erienced history+takersK Establish early on if there 2as any im"airment of conscio-sness and seek collateral histories. Iay "ersons -s-ally consider 56@sei3-re56A ? 56@fit56A ? tonic clonic sei3-re. <octorsD -nderstanding of 56@sei3-re56A may be rather different. 9 s-r"rising n-mber of "eo"le also s-ffer 56@"se-dosei3-res56A 2hich are non+organic and ha)e a "sychological ca-se. 9 fe2 "oints to consider: ynco"al attacks can often ca-se a fe2 tonic+clonic Cerks 2hich may be mistaken for e"ile"sy. Tr-e tonic+clinic sei3-res may ca-se tong-e+biting, -rinary and faecal incontinence, or all of the abo)e.

Peo"le "resenting 2ith "se-dosei3-re can ha)e tr-e e"ile"sy as 2ell and )ice )ersa.

Jis-al sym"toms Commonly )is-al loss, do-ble+)ision, or "hoto"hobia 1"ain 2hen looking at bright lights4. Here, establish exactly 2hat is being ex"erienced56756@do-ble )ision56A 1di"lo"ia4 is often

com"lained of 2hen, in fact, the )ision is bl-rred or sight is generally "oor 1amblyo"ia4 or clo-ded. P.%/% The rest of the history 5LM Nemember to ask if the "atient is right or left+handed 1consider disability from loss of f-nction and may also be -sef-l 2hen thinking abo-t cerebral lesions4. <irect B-estioning 0n e)ery "atient, enB-ire abo-t ne-rological sym"toms other than the "resenting com"laint 1headaches, fits, faints, 56@f-nny t-rns56A, blacko-ts, )is-al sym"toms, "ins+and+needles, tingling, n-mbness, 2eakness, incontinence, consti"ation, or -rinary retention4. Past medical history 5LM 9 birth history is im"ortant here, "artic-larly in "atients 2ith e"ile"sy. Orain inC-ry at birth has ne-rological conseB-ences. 9 thoro-gh history is reB-ired, as al2ays, b-t enB-ire es"ecially abo-t: Hy"ertension567if so, 2hat treatment; <iabetes mellit-s5672hat ty"e; =hat treatment;

Thyroid disease. Mental illness 1e.g. de"ression4. Meningitis or ence"halitis. Head or s"inal+inC-ries. E"ile"sy, con)-lsions, or sei3-res. Cancers. H0JH90< 1 tread caref-lly, be tactf-l4.

<r-g history 9sk es"ecially abo-t: 9nticon)-lsant thera"y 1c-rrent or "re)io-s4. Oral contrace"ti)e "ill.

teroids. 9nticoag-lants or anti+"latelet agents.

:amily history 9 thoro-gh history, as al2ays, is im"ortant. 9sk abo-t ne-rological diagnoses and e)idence of missed diagnoses 1sei3-res, blacko-ts etc.4. Tobacco, alcohol 9s im"ortant here as in any other system. ocial history

Occ-"ation567ne-rological disease can im"act significantly on occ-"ation so ask abo-t this at an early stage567some s-ggest right at the beginning of the history. 9lso ask abo-t ex"os-re to hea)y metals or other ne-rotoxins. <ri)ing;567Many ne-rological conditions ha)e im"lications here. 9sk abo-t the home en)ironment thoro-ghly 12ill be )ery -sef-l 2hen considering handica"s and conseB-ences of the diagnosis4. 9sk abo-t s-""ort systems567family, friends, home+hel"s, day centre )isits etc.

P.%/E P.%/P The o-tline examination 0t is easy to get bogged do2n in some of the com"lexities of the ne-rological examination b-t it is not something to be afraid of. t-dents sho-ld embrace it567"ractise often, as a com"etent ne-rological examination is a s-re sign of someone 2ho has s"ent "lenty of time on the 2ards. The follo2ing is a brief o-tline of ho2 it sho-ld be a""roached. 0ns"ection, mood, conscio-s le)el. "eech and higher mental f-nctions.

Cranial ner)es 00+Q00. Motor system. ensation. Co+ordination. 8ait. 9ny extra tests. Other rele)ant examinations.
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k-ll, s"ine, neck stiffness, ear dr-ms, blood "ress-re, anterior chest, carotid arteries, breasts, abdomen, lym"h nodes.

8eneral ins"ection and mental state The ne-rological exam sho-ld start 2ith any cl-es that can be gleaned from sim"ly looking at, and engaging 2ith, the "atient. 9re they accom"anied by carers567and ho2 do they interact 2ith those "eo"le; <o they -se any 2alking aids or other forms of s-""ort;

9ny abnormal mo)ements; 1

".EFF4.

Obser)e the gait as they a""roach the clinic room, if able 1 9ny s"eech dist-rbance; 1 =hat is their mood like;
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".EF&4.

".%/R4.

9 detailed mood assessment 1 9sk the "atient ho2 they feel.

".PG/4 is not necessary here56>

=hat is the state or their clothing, hair, skin, and nails; 0s there any restlessness, ina""ro"riately high s"irits, or "ress-re of s"eech; 9re they ob)io-sly de"ressed 2ith disinterest; 9re they denying any disability;

P.%/F P.%/R "eech and lang-age "eech and lang-age diffic-lties, es"ecially ex"ressi)e dys"hasia, may be extremely distressing for the "atient and their family. This to"ic m-st be a""roached 2ith ca-tion, reass-rance, and a calm serio-sness in the face of "ossible bi3arre and am-sing ans2ers to B-estions. Examination "eech and lang-age "roblems may be e)ident from the start of the history and reB-ire no formal testing. So- sho-ld briefly test their lang-age f-nction by asking them to read or obey a sim"le 2ritten command 1e.g. close yo-r eyes4 and 2rite a short sentence. 0f a""arently "roblematic, s"eech can be tested formally by asking the "atient to res"ond to "rogressi)ely harder B-estions 56> yesHno B-estions, sim"le statements, more com"licated sentences, and finally by asking them to re"eat com"lex "hrases or tong-e+ t2isters 1see belo24.

Oefore C-m"ing to concl-sions, ens-re that the "atient is not deaf 1or that their hearing+ aid is 2orking4 and that they can -s-ally -nderstand English.

<ysarthria 9 defect of artic-lation 2ith lang-age f-nction intact 12riting 2ill be -naffected4. May be a cerebellar lesion, a IM, lesion of the cranial ner)es, an extra"yramidal lesion, or a "roblem 2ith m-scles in the mo-th and Ca2s or their ner)e s-""ly. Iisten for sl-rring and the rhythm of s"eech. Test f-nction of different str-ct-res by asking the "atient to re"eat:

56@Sello2 lorry56A or 2ords 2ith 56@<56A, 56@I56A and 56@T56A 1tong-e f-nction4. 56@Peter Pi"er "icked a "ickle56A or 2ords 2ith 56@P56A and 56@O56A 1li" f-nction4.

Cerebellar lesions: slo2, sl-rred, lo2 )ol-me 2ith eB-al em"hasis on all syllables 156@scanning56A4. :acial 2eakness: s"eech is sl-rred. Extra"yramidal lesions: monotono-s, lo2 )ol-me and lacking in normal rhythm.

<ys"honia <efecti)e )ol-me567h-skiness. (s-ally from laryngeal disease, laryngeal ner)e "alsy or, rarely, m-sc-lar disease s-ch as myaesthenia gra)is. May also be 56@f-nctional56A 1"sychological4. <ys"hasia This is a defect of lang-age, not C-st s"eech, so reading and 2riting may also be affected 1some "atients attem"t to o)ercome s"eaking diffic-lties 2ith a note"ad and "en only to be bitterly disa""ointed4. 0n )ery sim"le terms, the main lang-age areas of the brain are ill-strated o""osite. <eficits can be -nderstood in terms of lesions in one or more of these areas. There are P main ty"es of dys"hasia56> 8lobal dys"hasia 1Ooth OrocaDs and =ernickeDs areas affected4 The "atient is -nable to s"eak or -nderstand s"eech at all. P.%/' Ex"ressi)e dys"hasia 9lso called 56@anterior56A, 56@motor56A, or 56@OrocaDs56A dys"hasia. Iesion in OrocaDs area 1frontal lobe4, in)ol)ed in lang-age "rod-ction. (nderstanding remains intact.

(nable to ans2er B-estions a""ro"riately. "eech is non+fl-ent, broken 2ith abnormal 2ord ordering. (nable to re"eat sentences. 5LM Can be )ery distressing for "atients. 9sk 56@do yo- kno2 2hat yo- 2ant to say, b-t canDt get it o-t;56A and yo-Dll be met 2ith a gratef-l smile, nod, and handshake.

Nece"ti)e dys"hasia 9lso called 56@"osterior56A, 56@sensory56A, or 56@=ernickeDs56A dys"hasia. Iesion in =ernickeDs area creates "roblems -nderstanding s"oken or 2ritten lang-age 1dyslexia4 and "roblems 2ith 2ord+finding.

(nable to -nderstand commands or B-estions. "eech is fl-ent 2ith lots of meaningless grammatical elements. May contain meaningless 2ords. (nable to re"eat sentences. Patients are often -na2are of their s"eech diffic-lty and 2ill talk nonsense contentedly567altho-gh may become fr-strated 2ith other "eo"leDs lack of -nderstandingK
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56@Jargon dys"hasia56A describes a se)ere form of rece"ti)e dys"hasia containing only meaningless 2ords 156@neologisms56A4 and so-nds. Para"hasia is the s-""lementation of one 2ord 2ith another.

Cond-cti)e dys"hasia Iesion in the arc-ate fascic-l-s andHor other connections bet2een the % "rimary lang-age areas. Patient can com"rehend and res"ond a""ro"riately. (nable to re"eat a sentence. ,ominal dys"hasia 9ll lang-age f-nction is intact exce"t for naming of obCects. Ca-sed by lesion in ang-lar gyr-s.

Patient may f-nction 2ith 56@circ-mloc-tion56A. 1e.g. says 56@that thing that 0 2rite 2ith56A if -nable to say 56@"en56A4.

:ig. !&.! im"le re"resentation of the main lang-age areas of the brain. P.%//

Cogniti)e f-nction ,e-rological diseases may affect f-nction s-ch that "atientsD a""earance or comm-nication skills are at odds 2ith their social standing or ed-cational le)el567formal assessment of a "ersonDs mental state is im"ortant. This also allo2s for any f-t-re change to be noted and monitored. The abbre)iated mental test score 1!& "oints4 This ser)es as a brief screening tool 2ith a maxim-m score of !& "oints. 9 more detailed, E& "oint, score is sho2n in Oox !F.!! ".F&E. 5LM 9""roach this gently567"atients often dislike being tested 2itho-t 2arning. 56@<o yo- think 0Dm st-"id;56A 9l2ays ex"lain the "-r"ose of the B-estions567and ask their "ermission to "roceed. Table 10.1 The abbreviated mental test score !.<ate of birth 56T56@=hat is yo-r date of birth;56A %.9ge 56T56@Ho2 old are yo-;56A E.Time 56T56@=hat time is it;56A 56T Correct to the nearest ho-r. 4. Sear 56T56@=hat year is it no2;56A 56T ,ote that hos"ital "atients often lose track of the day or month not the year. F.Place 56T56@=here are 2e;56A or 56@=hat is this "lace;56A 56T The name of the hos"italHclinicHs-rgery. R.Head of 56T56@=hoDs the Prime Minister at the moment;56A state 56T 9 name is reB-ired. -ch descri"tions as 56@That man in all the tro-ble56A 2onDt do+e)en if it is "otentially correctK '.=orld =ar 56T56@=hat year did the second =orld =ar start;56A 00 /.F+min-te 56TTell the "atient an address 1often 56@P% =est treet56A is -sed4 and ask recall them to re"eat it back to yo- to ens-re theyD)e heard it correctly. 9sk them to remember it. :i)e min-tes later, ask them to recall the address. 56T They m-st remember the address in full to score the "oint. G.%&+! 56T56@Co-nt back2ard from %& do2n to !56A 56T Patients sometime need a "rom"t here 56@Iike this: %&, !G, !/, and so on56A. !&Necognition 56T56@=hat Cob do 0 do;56A 1doctor4 and 56@=hat Cob does this manH2oman . do;56A 1n-rse4 56T Both m-st be correct to score a "oint. P.%/G 5LM Hints

Ob)io-sly, if yo-r co-ntry does not ha)e a Prime Minister, s-bstit-te 2ith 56@President56A or 56@Monarch56A. 9gain, a name is reB-ired+56@the U-een56A is not a correct ans2er. =hen testing F+min-te recall:
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0f thinking of an address for the "atient to remember+be caref-l not to gi)e o-t yo-r o2nK Oe2are of re"eating the test too often. Patients may 2ell remember 56@P% =est treet56A from the last time it 2as askedK

P.%G& Cranial ner)e 0: olfactory 9""lied anatomy ensory: smell. Motor: none. :ibres arise in the m-co-s membrane of the nose. 9xons "ass across the cribiform "late to the olfactory b-lb. Olfactory tract r-ns back2ards belo2 the frontal lobe and "roCects, mainly, in the -nc-s of the i"silateral tem"oral lobe. ,ote: olfactory e"itheli-m also contains free ner)e endings of the !st di)ision of cranial ner)e J. Examination ,ot ro-tinely tested -nless the "atient com"lains of a loss of sense of smell 1anosmia4 and exhibits other signs s-ggesti)e of a frontal or tem"oral lobe ca-se 1e.g. t-mo-r4. Cas-al: take a nearby odoro-s obCect 1e.g. coffee or chocolate4 and ask the "atient if it smells normal. :ormal: a series of identical bottles containing recogni3able smells are -sed. The "atient is asked to identify them. Commonly -sed agents: coffee, )anilla, cam"hor, )inegar. Test each nostril se"arately and determine if any loss of smell is -ni+ or bilateral. :indings Oilateral anosmia: -s-ally nasal, not ne-rological. Ca-ses incl-de -""er res"iratory tract infection, tra-ma, smoking, old age, and ParkinsonDs disease. Iess commonly, t-mo-rs of the ethmoid bones or congenital ciliary dysmotility syndromes. (nilateral anosmia: m-co-s+blocked nostril, head tra-ma, s-bfrontal meningioma. 5LM Hints Pe""ermint, ammonia, and menthol stim-late the free trigeminal endings so are not a good test of cranial ner)e 0. P.%G! P.%G% Cranial ner)e 00: o"tic 9""lied anatomy

=ith an -nderstanding of the anatomy of the o"tic ner)es, defects in the )is-al field enable the locali3ation of a lesion 2ithin the brain. The o"tic ner)e begins at the retina 1and is the only "art of the central ner)o-s system that can be directly )is-ali3ed4. The ner)e "asses thro-gh the o"tic foramen and Coins its fello2 ner)e from the other eye at the 56@o"tic chiasm56A C-st abo)e the "it-itary fossa. Here, the fibres from the nasal half of the retina cross o)er. They contin-e in the o"tic tract to the lateral genic-late body. :rom there, they s"lay o-t s-ch that those from the -""er retina "ass thro-gh the "arietal lobe and the others thro-gh the tem"oral lobe. t-dents easily get conf-sed here and 2o-ld do 2ell to get to gri"s 2ith this at an early stageK Oeca-se of the refraction at the lens, images are re"resented on the retina -"side+do2n and back+to+front. Therefore, the nasal half of the retinal recei)es in"-t from the tem"oral "art of the )is-al field in each eye, 2hist the tem"oral half of the retinal recei)es in"-t from the nasal half of the eye. :-rther back in the o"tic system, fibres from the nasal hal)es of the retinas cross, so, for exam"le, the left side of the brain recei)es in"-t from the right side of )ision 1the left tem"oral retina and the right nasal retina4 and )ice )ersa 1see :ig. !&.% ".%GF4. Jis-al ac-ity har"ness, clarity of )ision. :ormally tested -sing a nellenDs Chart. 0n good light, the "atient sho-ld stand Rm a2ay from the chart. Each eye is tested in t-rn and the "atient is asked to read the chart.

The n-mber abo)e each line indicates the distance at 2hich a "erson 2ith normal sight sho-ld be able to read it. Necord the line reached567allo2 a maxim-m of errors "er line.
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0ndicate res-lts as: distance from chartHdistance it sho-ld be read e.g. 56@RHER56A.

0f the "atient canDt see any of the letters, record 2hether they can: Co-nt fingers held in front of their face 1C:4. ee hand mo)ements 12a)e yo-r hand4.

Percei)e light.
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Necord as C:, HM, PI, or ,PI 1not "ercei)e light4.

Colo-r )ision ,ot tested ro-tinely and not considered in this book. Tested -sing 0shihara "lates. Jis-al fields The area that each eye can see 2itho-t mo)ing can be ma""ed o-t. They are not circ-lar567eyebro2s and nose obstr-ct s-"eriorly and nasally 2hereas there is no obstr-ction laterally.

itting o""osite the "atient, the examinerDs left )is-al field 1for exam"le4 sho-ld be an exact mirror image of the "atientDs right )is-al field. 0n this 2ay, the "atientDs fields can be tested against the examinerDs. P.%GE 8ross defects and )is-al neglect 1inattention4 it o""osite the "atient, V!m a"art, eyes le)el. Test first for gross defects and )is-al neglect 2ith both eyes o"en.
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Naise yo-r arms -" and o-t to the sides so that one hand is in the -""er right B-adrant of yo-r )ision and one in the -""er left. 9sk the "atient to look directly at yo- 156@look at my nose56A4. Mo)e one index finger and ask the "atient, 2hilst looking straight at yo-, to "oint to the hand 2hich is mo)ing. Test 2ith the right, left, and then both hands. Test the lo2er B-adrants in the same 2ay. 0f )is-al neglect is "resent, the "atient 2ill be able to see each hand mo)ing indi)id-ally b-t re"orts seeing only one hand 2hen both are mo)ing 1com"are 2ith sensory inattention ".EP&4.

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Testing each eye 0n the same "osition as abo)e, ask the "atient to co)er their right eye 2hile yo- co)er yo-r left and look directly at one another. o 10f yo- 2ere no2 to trace the o-ter borders of yo-r )ision in the air half 2ay bet2een yo-rself and the "atient, if sho-ld be almost identical to the area seen by the "atient4.

Test each B-adrant indi)id-ally:

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tretch yo-r arm o-t and -" so that yo-r hand is C-st o-tside yo-r field of )ision, an eB-al distance bet2een yo- and the "atient. lo2ly bring yo-r hand into the centre 1"erha"s 2iggling one finger4 and ask the "atient to say 56@yes56A as soon as they can see it. So- sho-ld both be able to see yo-r hand at the same time. Test -""er right and left, lo2er right and left indi)id-ally, bringing yo-r hand in from each corner of )ision at a time. 5LM Ens-re that the "atient remains looking directly at yo- 1many 2ill attem"t to t-rn and look at the hand if not "rom"ted correctly4.

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Ma" o-t any areas of )is-al loss in detail, finding borders. Test if any )is-al loss extends across the midline hori3ontally or )ertically. Test each eye in t-rn 1yo- both may reB-ire a short break bet2een eyes as this reB-ires considerable concentration4.

Ne"eat the abo)e "roced-re 2ith a red+headed "in or similar small red obCect to ma" o-t areas of )is-al loss in more detail.
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9sk the "atient to say 56@yes56A 2hen they see the "in as red. tart by ma""ing o-t the blind s"ot 2hich sho-ld be V!F#W lateral from the centre at the midline 1this tests both yo-r techniB-e and the "atientDs reliability as a 2itness before "roceeding4.

<ecide if any defect is of a B-adrant, half the )is-al field or another sha"e and in 2hich eye, or both. Necord by dra2ing the defect in % circles re"resenting the "atientDs )is-al fields as sho2n in :ig. !&.% ".%GF.

0f the "atient is -nable to coo"erate Iike m-ch of the ne-rological examination, gross defects can be seen 2itho-t the "atientDs coo"eration 1conf-sed or dro2sy4. Test for res"onse to 56@menace56A by bringing yo-r hand in shar"ly from the side, sto""ing C-st short of hitting the "atient in the eye. 0f yo-r hand can be seen, the "atient 2ill blink. Test )ision on the left and the right. P.%GP ome common )is-al field defects Com"are the defects belo2 2ith the corres"onding n-mber on :ig. !&.% sho2ing the "osition of the lesion and a re"resentation of the fields as it sho-ld be recorded in the "atientDs notes. T-nnel )ision: a conf-sing term. 9 constricted )is-al field, gi)ing the im"ression of looking do2n a "i"e or t-nnel may be ca-sed by gla-coma, retinal damage or "a"illoedema. 56@T-b-lar56A )ision is often f-nctional. Enlarged blind s"ot: ca-sed by "a"illoedema.

(nilateral field loss: 1!4 blindness in one eye ca-sed by de)astating damage to the eye, its blood s-""ly, or o"tic ner)e. Central scotoma: a hole in the )is-al field 1mac-lar degeneration, )asc-lar lesion or, if bilateral, toxins4. 0f bilateral, may indicate a )ery small defect in the corres"onding area of the occi"ital cortex 1m-lti"le sclerosis4. Oitem"oral hemiano"ia: 1%4 the nasal half of both retinas and, therefore, the tem"oral half of each )is-al field is lost 1damage to the centre of the o"tic chiasm s-ch as "it-itary t-mo-r, cranio"haryngioma, s-"rasellar meningioma4. Oinasal hemiano"ia: the nasal half of each )is-al field is lost 1)ery rare4.

Homonymo-s hemiano"ia: 1E4 may be 56@left56A or 56@right56A. Commonly seen in stroke "atients. The right or left side of )ision in both eyes is lost 1e.g. the nasal field in the right eye and the tem"oral field in the left eye4. 0f the central "art of )ision 1corres"onding to the mac-la4 is s"ared, the lesion is likely in the o"tic radiation, 2itho-t mac-la s"arring, the lesion is in the o"tic tract. Homonymo-s B-adrantano"ia: corres"onding B-arters of the )ision is lost in each eye 1e.g. the -""er tem"oral field in the right and the -""er nasal field in the left4.
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(""er B-adrantano"ias 1P4 s-ggest a lesion in the tem"oral lobe. Io2er B-adrantano"ias 1F4 s-ggest a lesion in the "arietal lobe.

P.%GF

:ig. !&.% Ne"resentation of the )is-al tracts from the retina to the occi"ital cortex sho2ing main str-ct-res and ex"ected )is-al field loss according to the site of the lesion. P.%GR Cranial ner)e 00: o"hthalmosco"y <irect o"hthalmosco"ic examination of the f-nd-s is a )ital "art of any ne-rological examination b-t often a)oided as it is considered diffic-lt. 0t can "ro)ide the obser)er 2ith )ital information abo-t the condition of the o"tic ner)e head. 0t takes "ractise b-t the ex"erienced obser)er can gain )ie2s of the f-nd-s, mac-lar region, and the retinal )asc-lar arcades. 0t is 2orth "ractising at e)ery o""ort-nity. The direct o"hthalmosco"e gi)es a greatly magnified )ie2 of the f-nd-s b-t gaining a )ie2 of the "eri"heral retina beyond the eB-ator reB-ires examination 2ith the slit lam" or the indirect o"hthalmosco"e567not co)ered in this book.

:or a com"lete o"hthalmosco"ic examination it is often 2orth dilating the "-"il by instilling a fe2 dro"s of mydriatic 1!X tro"icamide or !X cyclo"entolate4 into the inferior conC-ncti)al sac. =ith a little "ractise one often finds that this is not necessary for a ro-tine examination. 0f yo- "lan to dilate the "-"il, ask the "atient if they ha)e any history of angle clos-re gla-coma or e"isodes of seeing haloes aro-nd lights at night+time. 0f yo- s-s"ect this, or the anterior chamber of the eye a""ears shallo2, it is best to err on the side of ca-tion567dilating the "-"il co-ld occl-de the drainage angle and "reci"itate an ac-te attack. Examination Performed in a dimly lit room 2ith the "atient sitting or lying do2n. 9sk the "atient to foc-s on a distant obCect and kee" their eyes still 1relaxes accommodation as m-ch as "ossible4.

Iook thro-gh the o"hthalmosco"e VE&cm a2ay from the "atient and bring the light in nasally from the tem"oral field to land on the "-"il.
o

The "-"il 2ill a""ear red and o"acities in the )is-al axis 2ill a""ear as black dots or lines. Oy cycling thro-gh the different lenses of the o"hthalmosco"e, yo- sho-ld be able to gain an im"ression of 2here these o"acities lie. Possible locations are the cornea, aB-eo-s, lens 1and its anterior and "osterior ca"s-les4 and )itreo-s.

<ial -" a hy"ermetro"ic 1"l-s4 lens on the o"hthalmosco"e to foc-s on the corneal s-rface and mo)e in as close as "ossible to the "atientDs eye567by grad-ally 5YZ the "o2er of the lens yo- can examine the cornea, iris and lens in t-rn. 1:ormal examination of these str-ct-res is best done 2ith the slit lam" b-t a great deal of information can be gained 2ith the direct o"hthalmosco"e.4 Contin-e to 5YZ the "o2er of the lens -ntil yo- can shar"ly foc-s on the retinal )essels. 0t is often best to "ick -" one of the )asc-lar arcades in the "eri"hery and track them in to2ards the o"tic disc. This allo2s the "eri"heral B-adrants to be examined in t-rn before )ie2ing the o"tic disc. Take time to look at the )essels caref-lly, "artic-larly 2here the arteries cross the )eins. 9sk the "atient to look directly into the light of the o"hthalmosco"e to gain a )ie2 of the mac-lar region.

=e thank <r Tom :earnley for contrib-ting this to"ic. P.%G' The normal f-nd-s The o"tic disc The healthy disc is a "ale "inkHyello2 colo-r and ro-nd or slightly o)al in sha"e. The margins bet2een the disc and the s-rro-nding retina sho-ld be cris" and 2ell defined. Occasionally a s-rro-nding ring is "resent 2hich may be slightly lighter or darker in colo-r.

9t the centre of the disc is the "hysiological c-". 0t a""ears "aler in colo-r com"ared to the rest of the disc.

The mac-lar region Iocated tem"orally from the o"tic disc. This is the region 2ith the maxim-m concentration of cones.

9t the centre of the mac-la is the fo)ea+a tiny "it de)oid of blood )essels and res"onsible for fine resol-tion. <isease in)ol)ing the mac-la and fo)ea can ca-se de)astating )is-al loss.

The retinal )essels The central retinal artery and )ein enter and lea)e the globe in the centre of the o"tic disc. Jeins a""ear larger and darker in colo-r in com"arison to the arteries.

"ontaneo-s )eno-s "-lsations are seen in many normal eyes. 9rterial "-lsations sho-ld not be )isible in normal eyes.

:ig. !&.E The normal a""earance of the f-nd-s of the right eye. 5LM Hint Jie2 the mac-la by directing the light on the most sensiti)e "art of the eye. This can often be -n"leasant for the "atient and 2ill lead to more marked miosis and a restricted )ie2. P.%G/ 9bnormal findings on f-ndosco"y O"tic disc s2elling 9""earance The o"tic disc is raised, s2ollen, and enlarged.

The disc often a""ears darker in colo-r. The margins of the disc are bl-rred and become indistinct from the adCacent retina. Netinal )essels can be seen arching do2n from the raised disc to2ards the "eri"heral retina. 0n se)ere cases retinal haemorrhage may be seen aro-nd the disc.

5LM The term "a"illoedema is often, incorrectly, -sed to describe o"tic disc s2elling. 56@Pa"illoedema56A is s2elling of the o"tic disc d-e to raised intracranial "ress-re. Ca-ses "ace occ-"ying lesions incl-ding intracranial malignancy, s-bd-ral haematoma, and cerebral abscess. -barachnoid haemorrhage 1commonly associated 2ith )itreo-s haemorrhage4.

Chronic meningitis. 0dio"athic intracranial hy"ertension 100H4. Malignant hy"ertension. 0schaemic o"tic ne-ro"athy.

O"tic disc c-""ing 9""earance The "hysiological c-" is 5Y[ in res"ect to the rest of the disc. Netinal )essels kink shar"ly as they emerge o)er the rim of the c-".

Haemorrhages may be "resent.

Ca-ses Most commonly one of the )ario-s ty"es of gla-coma. O"tic atro"hy 9""earance Pale o"tic disc d-e to loss of ner)e fibres in the o"tic ner)e head. Ca-se 0schaemic o"tic ne-ro"athy. O"tic ne-ritis.

Tra-ma. O"tic ner)e com"ression.

=e thank <r Tom :earnley for contrib-ting this to"ic. P.%GG

:ig. !&.P e)ere "a"illoedema. ,ote ho2 the disc margins are bl-rred and there is a lack of the normal c-""ing at the disc.

:ig. !&.F O"tic disc c-""ing, in this case secondary to gla-coma. ,ote ho2 the )essels seem to disa""ear o)er the edge of the disc as if falling do2n a hole.

:ig. !&.R O"tic atro"hy. The o"tic disc is "ale and 2ell demarcated. P.E&&

Netinal haemorrhages 9""earance The a""earance of a haemorrhage de"ends on its location 2ithin the )ario-s layers of the retina. <ee" haemorrhages a""ear as 56@dots56A d-e to the close "acking of the cells in this region. More s-"erficial haemorrhages in the ner)e fibre layer a""ear as more 2ides"read 56@blotches56A. Ca-ses Many "athological "rocesses incl-ding: <iabetes mellit-s. Hy"ertension.

-barachnoid haemorrhage. Olood dyscrasias. ystemic )asc-litis. Jalsal)a related. Tra-ma. Oacterial endocarditis 1kno2n s"ecifically as Noth s"ots4.

CentralHbranch retinal artery occl-sion 9""earance Iarge areas of ischaemic 2hite retina associated 2ith s-dden catastro"hic )is-al loss. Calcific, cholesterol or fibrin+"latelet emboli can often be seen occl-ding the retinal arteryH branch. Ca-ses Either embolic or thrombotic 1remember giant cell arteritis also4. CentralHbranch retinal )ein occl-sion 9""earance Iarge, 2ides"read flame sha"ed haemorrhages classically gi)ing the f-nd-s a 56@stormy s-nset56A a""earance. 9ssociated 2ith grad-al onset "ainless bl-rred )ision and )is-al loss. O"tic disc s2elling may be "resent. Ca-ses

Olood dyscrasias. <iabetes mellit-s. 8la-coma.

:oster+\ennedy yndrome 9""earance (nilateral o"tic atro"hy. Contralateral "a"illoedema.

Central scotoma. 9nosmia 1)ariable4. ystemic sym"toms s-ch as headache, di33iness, )ertigo, and )omiting. Meningioma of o"tic ner)e, olfactory groo)e or s"henoid 2ing. :rontal lobe t-mo-r.

Ca-ses

P.E&! P.E&% The "-"ils 9""lied anatomy The "-"il is the a"ert-re at the centre of the iris. Jariation in "-"il si3e is bro-ght abo-t by % m-scles in the iris -nder the control of the a-tonomic ner)o-s system. "hincter "-"illae m-scle567fo-nd in the iris at the margin of the "-"il. 0nner)ated by "arasym"athetic fibres. Constricts the "-"il 1miosis4. <ilator "-"illae m-scle567radially arranged smooth m-scle. 0nner)ated by sym"athetic ner)o-s system. <ilates the "-"il 1mydriasis4. The "-"illary light res"onse The "-"illary light res"onse has afferent and efferent limbs that can be affected se"arately in a n-mber of "athologies. The afferent fibres lea)e the eye in the o"tic ner)e and se"arate in the midbrain to syna"se 2ith the Erd ner)e n-clei. Efferent "ath2ay fibres then tra)el to syna"se in the ciliary ganglion before inner)ating the s"hincter "-"illae. Examination 0ns"ect both "-"ils in good light567is there a discre"ancy in si3e 1anisocoria4 or sha"e; 1This is "resent in %FX of the 56@normal56A "o"-lation and does not necessarily indicate "athology. 0t may be secondary to "re)io-s oc-lar inflammatory disease, tra-ma or s-rgery.4 0f anisocoria is "resent one m-st determine 2hich of the "-"ils is the 56@correct si3e56A.
o

9 "athologically constricted "-"il is more ob)io-s in dim light as the normal "-"il dilates. 9 "athologically large "-"il 2ill be more a""arent in bright ill-mination 2hen the normal "-"il 2ill constrict.

Test the "-"il res"onses to direct and consens-al light. This is best done in a dimly lit room. 9sk the "atient to look into the distance to ens-re the eye is relaxed and 56@dis+ accommodated56A. hine a light -"2ards from C-st inferior to the lo2er lid to a)oid da33ling the "atient.

Constriction of the "-"ils sho-ld be seen almost instantaneo-sly in res"onse to ill-mination in both the ill-minated eye 1direct4 and the non+ill-minated eye 1consens-al4. Ne"eat for both eyes.

The afferent limb of the "-"illary light "ath2ay is assessed -sing the Marc-s+8-nn s2inging light test to look for a relati)e afferent "-"il defect 1N9P<4. 0f "resent:
o

hine light in the normal eye and both "-"ils constrict. 1The consens-al res"onse in the affected eye is intact.4 2ing the light to the affected eye and both "-"ils dilate. 19fferent dri)e to ca-se constriction of the "-"ils from the affected eye is red-ced in com"arison to that of the -naffected eye.4 2ing the light back to the normal eye and both "-"ils constrict.

:inally, check the near reflex 1the efferent limb of the "-"il reflex4. 9sk the "atient to foc-s on a distant obCect and then look immediately to yo-r index finger held VE&cm in front of their face.
o

The normal res"onse 2ill be for the "-"ils to constrict in res"onse to con)ergence and accommodation.

P.E&E :indings: some "-"il abnormalities 9rgyll+Nobertson "-"il Midbrain lesions ca-sed by ne-rosy"hilis target the more dorsally located fibres that s-bser)e the light res"onse. The )entrally located fibres res"onsible for accommodation are s"ared. 9""earance: a small irreg-lar "-"il that accommodates b-t does not react to light. Ca-ses: ne-rosy"hilis and diabetes mellit-s. Holmes+9die "-"il <ener)ation of iris and ciliary body d-e to ciliary ganglionitis 1altho-gh some 2o-ld dis"-te thisK4. 9ssociated loss of tendon reflexes is seen in some "atients and is termed Holmes+9die syndrome. 9""earance: -nilateral dilated "-"il567accommodates 1and relaxes4 )ery slo2ly and sho2s absent or de"ressed light reflex -"ersensiti)e to &.!X "ilocar"ine 1m-scarinic agonist ca-sing constriction4. Ca-ses: -s-ally idio"athic and "redominates in yo-ng ad-lt females 15A]:5A6 5^_ %:!4. May also follo2 irido"legia or oc-lar tra-ma. HornerDs syndrome 0nterr-"tion of the sym"athetic ner)e s-""ly to the iris. 9""earance: -nilateral miotic "-"il 2ith "artial "tosis 1d-e to "aralysis of M-llerDs m-scle567a small smooth m-scle in the -""er lid4. Mo)ement of the -""er lid sho-ld be intact as the le)ator m-scle is s-""lied by the oc-lomotor ner)e. There is also a )ariable

interr-"tion of s-domotor inner)ation to the i"silateral side of the face. 2eating is absent if the lesion occ-rs "roximal to the carotid "lex-s, after 2hich the s-domotor fibres se"arate. Ca-ses: the "rotracted co-rse of the sym"athetic "ath2ay makes it )-lnerable to disr-"tion at many different "oints. Ca-ses incl-de: congenital567often associated 2ith an alteration in iris "igment 1heterochromia4; inC-ry or s-rgery to the neck 1a)-lsion of C/ and T! ner)e roots res-lts in \l-m"keDs "aralysis4; m-lti"le sclerosis; ca)erno-s sin-s disease; neo"lasia in)ol)ing the mediastin-m, cer)ical cord or the a"ex of the l-ng; infarction567secondary to occl-sion of the basilar or "osterior inferior cerebellar artery; thoracic aortic ane-rysm; syringomyelia or syringob-lbia.

Oox !&.! More on the N9P< 9t rest the "atientDs "-"ils 2ill be eB-al and of normal si3e. 0t is 56@relati)e56A beca-se the res"onse seen 2hen light is shone on the affected "-"il is diminished relati)e to the res"onse seen 2hen light is shone in the normal "-"il, and 56@afferent56A since it demonstrates a "roblem in the afferent limb of the light res"onse in the affected eye. 0t indicates -nilateralHasymmetrical o"tic ner)e disease or extensi)e retinal "athology. 9n N9P< 2ill not be seen in "atients 2ith corneal or lens o"acities. =e thank <r Tom :earnley for contrib-ting this to"ic. P.E&P Cranial ner)es 000, 0J, and J0 The Erd 1oc-lomotor4, Pth 1trochlear4 and Rth 1abd-cens4 ner)es are considered together as their "rimary f-nction is to "ro)ide motor inner)ation to the extrinsic m-scles of the eye. Connections exist 2ith the hori3ontal ga3e centre in the "ons and the )ertical ga3e centre in the midbrain. 9""lied anatomy: 000 Motor: le)ator "al"ebrae s-"erioris, s-"erior rect-s, medial rect-s, inferior rect-s, inferior obliB-e. 19ll the extrinsic m-scles of the eye exce"t the lateral rect-s and s-"erior obliB-e.4 9-tonomic: "arasym"athetic s-""ly to the constrictor 1s"hincter4 "-"illae of the iris and ciliary m-scles. The main oc-lomotor n-cle-s lies anterior to the aB-ed-ct of the midbrain. The Edinger+=est"hal n-cle-s 1accessory "arasym"athetic n-cle-s4 lies "osterior to the oc-lomotor n-cle-s. :ibres "ass anteriorly, thro-gh the ca)erno-s sin-s and enter the orbit thro-gh the s-"erior orbital fiss-re. 9""lied anatomy: 0J Motor: s-"erior obliB-e. The n-cle-s lies C-st inferiorly to that of the oc-lomotor ner)e and has connections 2ith the cerebral hemis"heres, )is-al cortex and ner)es 000, J0, and J000. 0ts fibres "ass "osteriorly and immediately cross one another. They then tra)el thro-gh the ca)erno-s sin-s, entering the orbit thro-gh the s-"erior orbital fiss-re. 9""lied anatomy: J0 Motor: lateral rect-s. The n-cle-s lies beneath the Pth )entricle. 0t connects 2ith the n-clei of the 000 and 0J cranial ner)es thro-gh the medial longit-dinal fascic-l-s. 0t emerges from the "ons and tra)els thro-gh the ca)erno-s sin-s to enter the orbit thro-gh the s-"erior orbital fiss-re.

Examination The "atient sho-ld be sitting facing yo- 2ith their eyes straight ahead. Ens-re )is-al ac-ity has already been assessed and recorded. 0ns"ect the "osition of the lids. o 0s there "tosis 1droo"ing of the lid4;
o

9re the e"icanthic folds "rominent; 1This may ca-se "se-dosB-int4.

Iook at the "osition of the eyes in ne-tral ga3e.

o

9n asymmetrical "osition s-ggests strabism-s 1sB-int4 and this sho-ld be assessed 2ith the co)er test 1see Oox !&.% ".E&R4.

9sk the "atient to follo2 yo-r index finger in )ertical, hori3ontal and obliB-e "lanes a)oiding extremes of ga3e. <ra2ing a large imaginary 56@H56A directly in front of the "atient.
o o

0s nystagm-s "resent 1ra"id 56@to and fro56A mo)ements of the eyes4; 9sk the "atient if they see do-ble at any stage; 1<i"lo"ia.4

P.E&F

The "atientDs eyes sho-ld be able to follo2 the mo)ing target smoothly. This is termed "-rs-it. 1Often slo2ed or interr-"ted 2ith saccades in H-ntingtonDs chorea and ParkinsonDs disease.4 ,o2 hold -" yo-r index finger on one side of their head and yo-r th-mb on the other567in their tem"oral )is-al fields. 9sk the "atient to look B-ickly bet2een finger and th-mb. This tests saccadic eye mo)ements567they sho-ld be acc-rate, smooth and ra"id. 9sk the "atient to look from a distant obCect to a near obCect567the eyes sho-ld con)erge smoothly and eB-ally in association 2ith accommodation and "-"il constriction. This is called con)ergence.

5LM Hints Patients 2ill often attem"t to t-rn their head to look at yo-r mo)ing finger. This can be o)ercome in % 2ays: :-lly ex"lain the examination before beginning. Often, an instr-ction s-ch as 56@"lease follo2 the ti" of my finger 2ith yo-r eyes b-t kee" yo-r head still56A 2orks 2onders. 0f the "atient contin-es to t-rn their head, yo- can stabili3e it by gently "lacing yo-r free hand on their forehead. =e thank <r Tom :earley for contrib-ting this to"ic. P.E&R

9bnormal findings Ptosis 1droo"ing of the lid4 Ca-ses incl-de: =eakness of the le)ator m-scle in myasthenia gra)is. Erd ner)e "alsy.

<isr-"tion of the insertion of the le)ator m-scle into the tarsal "late of the lid either thro-gh s-rgery or tra-ma.

trabism-sHsB-int 9bnormality of coordinated eye mo)ements. <i)ergent sB-int: one eye is directed to2ards the target, the other is t-rned laterally. 0n con)ergent sB-int, the other eye is t-rned medially. B-int is broadly categori3ed into % forms. ,on+"aralytic seen in childhood. Ooth eyes ha)e a f-ll range of mo)ement b-t only one of the eyes is directed to2ards the target of fixation. Paralytic sB-int: mo)ement of one or more of the extraoc-lar m-scles is 5YZ d-e to disease of the m-scle, a ner)e "alsy, or a "hysical obstr-ction to mo)ement in a "artic-lar direction 1e.g. tethering, tra-ma, or neo"lasm4. Oox !&.% The co)er+-nco)er test (sed for f-rther analysis of non+"aralytic sB-int. The "atient sho-ld be sitting in front of yo-. Present a fixation target in front of them 1the to" of yo-r "en for exam"le4.

9sk them to co)er their right eye. Closely obser)e the -nco)ered left eye+one of three res"onses is "ossible:
o o o

The eye doesnDt mo)e567normal The eye mo)es nasally to fixate567di)ergent sB-int "resent The eye mo)es tem"orally to fixate567con)ergent sB-int "resent.

,o2 re"eat the test co)ering the left eye.

5LM Pick -" a s-btle sB-int by holding a "en torch abo-t E&cm a2ay from the centre of the "atients face. The reflection of light sho-ld be from the same "osition on the cornea in both eyes. 0f this is not the case, the fixating eye 2ill ha)e the central reflection. 9 more so"histicated assessment of sB-int is made in eye clinics -sing a synto"hore. 5LM :-rther assessment of a sB-int sho-ld al2ays in)ol)e a detailed examination of the cornea, lens, )itreo-s and retina to excl-de o"acities and abnormalities. P.E&'

,ystagm-s Oscillating mo)ements of the eyes567se)eral s-bclassifications exist based on clinical a""earance and lesion location. =atch the mo)ements caref-lly. 9re the to and fro "hases of the mo)ements the same s"eed in both directions or is one more ra"id than the other; Jestib-lar: a ty"e of Cerk nystagm-s 1to and fro mo)ements are of different )elocities4. Ca-sed by disease in the labyrinth or its central connections. The fast "hase is a2ay from the side of the lesion. There are often hori3ontal and rotary com"onents. (s-ally only "resent in the ac-te "hase of labyrinthine disease. Pend-lar nystagm-s: the )elocity of the mo)ements is the same in both directions. Often a congenital condition associated 2ith 5YZ )is-al ac-ity. 9lso seen in cerebro)asc-lar disease and m-lti"le sclerosis.
o

5LMPatients 2ith acB-ired nystagm-s 2ill often com"lain of contin-al mo)ement of their )is-al en)ironment 1oscillo"sia4, 2hich is not the case 2ith congenital nystagm-s.

O"tokinetic nystagm-s: this is a normal res"onse of the eye 2hen trying to follo2 a mo)ing obCect 1e.g. 2hen looking from the 2indo2 of a train4. 0t is formally assessed -sing a rotating dr-m "ainted 2ith )ertical black and 2hite lines. Mo)ements are controlled by the cerebral hemis"here to2ards 2hich the dr-m is rotating ca-sing "-rs-it mo)ement in the direction of rotation follo2ed by saccadic mo)ement back in the o""osite direction. <efecti)e o"tokinetic nystagm-s is seen in lesions of the dee" "arietal lobe 2hen dr-m rotation is to2ards the affected cerebral hemis"here. ("beat nystagm-s: the fast "hase is -"2ards. Ca-ses incl-de brainstem disease or intoxication 2ith alcohol and a n-mber of other dr-gs incl-ding "henytoin. <o2nbeat nystagm-s: the fast "hase is do2n2ard. een in toxic states and demyelinating disease. 9lso herniation of cerebellar tiss-e thro-gh the foramen magn-m as seen in Chiari malformation. 8a3e e)oked nystagm-s: the fast "hase is to2ard the direction of action of the affected m-scle. (s-ally seen in dysf-nction of extraoc-lar m-scles secondary to intrinsic 2eakness or ner)e "alsy.

5LM Hint =hen assessing nystagm-s try to a)oid the extremes of lateral ga3e 1i.e. not *E&#W4. This 2ill elicit end+"oint nystagm-s567a "hysiological res"onse not to be conf-sed 2ith a "athological "rocess. =e thank <r Tom :earnley for contrib-ting this to"ic. P.E&/ Palsies of cranial ner)es 000, 0J, and J0 000: oc-lomotor 9""earance: the "-"il is dilated and res"onds to neither light nor accommodation. 9ll the extraoc-lar m-scles are "aralysed exce"t for the lateral rect-s and the s-"erior obliB-e. The

-no""osed action of these ca-se the eye to look do2n and o-t. Paralysis of the le)ator m-scle ca-ses com"lete "tosis. Ca-ses: diabetes mellit-s 1"-"il s"aring4, lesions in)ol)ing the s-"erior orbital fiss-re, ca)erno-s sin-s disease, ane-rysm of the "osterior comm-nicating artery, =eberDs syndrome 1associated contralateral hemi"legia4. 0J: trochlear 9""earance: Paralysis of the s-"erior obliB-e ca-ses the eye to ele)ate 2hen add-cting. The "atient com"lains of di"lo"ia and 2ill ha)e diffic-lty looking do2n2ards and in2ards on the affected side. The "atient may try to com"ensate for this by tilting their head a2ay from the side of the lesion 1oc-lar torticollis4. Ca-ses: tra-ma, s-rgery, diabetes mellit-s, atherosclerosis, neo"lasia. J0: abd-cens 9""earance: "aralysis of the lateral rect-s m-scle means the eye cannot be abd-cted from the midline and the -no""osed action of the medial rect-s lea)es the eye de)iated nasally at rest. The "atient com"lains of di"lo"ia in hori3ontal ga3e. Iesions in the Rth ner)e n-cle-s also in)ol)e the lateral ga3e centre and lead to a ga3e "aresis. Ca-ses: diabetes mellit-s, atherosclerosis, m-lti"le sclerosis, neo"lastic lesions, raised intracranial "ress-re leading to com"ression of the ner)e on the edge of the "etro-s tem"oral bone 1a false locali3ing sign4, tra-ma, s-rgery. Combined ner)e "alsies <-e to the close "roximity of ner)es 000, 0J, and J0 at "oints along their co-rses, lesions at s"ecific anatomical locations can lead to combined ner)e "alsies. The ca)erno-s sin-s 9ll E ner)es in)ol)ed in oc-lomotor control along 2ith sym"athetic fibres to the iris and the o"hthalmic and maxillary di)isions of the trigeminal ner)e "ass thro-gh here. Common lesions incl-de: carotico+ca)erno-s fist-la; ex"anding "it-itary t-mo-r; ca)erno-s sin-s thrombosis+ associated 2ith "ro"tosis and inCection of conC-ncti)al )essels 1chemosis4; ane-rysm. The orbit 9 com"lex range of o"hthalmo"legias can res-lt from any com"ressi)e lesion located 2ithin the orbit. Pro"tosis may be "resent 2ith )ariable o"tic ner)e in)ol)ement. Many lesions may directly im"inge -"on the extraoc-lar m-scles as 2ell as the inner)ating ner)es. P.E&G The s-"erior orbital fiss-re The s-"erior orbital fiss-re transmits all the ner)es s-""lying the extraoc-lar m-scles along 2ith the o"hthalmic di)ision of the trigeminal ner)e. 0nflammation or a lesion at the s-"erior orbital fiss-re leads to Tolosa+H-nt syndrome567a com"lex -nilateral o"hthalmo"legia associated 2ith anaesthesia o)er the forehead and oc-lar "ain. ome other eye mo)ement disorders 0ntern-clear o"hthalmo"legia This is interr-"tion of the medial longit-dinal fascic-l-s, connecting the n-clei of cranial ner)es 000 and J0 on o""osite sides. Jol-ntary ga3e to2ards one side is initiated by the o""osite cerebral hemis"here. <escending fibres then dec-ssate to the hori3ontal ga3e centre in the "ons and "ara"ontine retic-lar formation 2here f-rther im"-lses are transmitted directly to the Rth ner)e n-cle-s ca-sing abd-ction of the

i"silateral eye. ConC-gate add-ction of the contralateral eye is bro-ght abo-t by im"-lses transmitted )ia the medial longit-dinal fascic-l-s to the Erd ner)e n-cle-s th-s maintaining binoc-lar single )ision. 9""earance 0m"aired add-ction in the i"silateral eye in -nilateral lesions+nystagm-s is often seen in the abd-cting eye. Oilateral lesions often ca-se )ertical nystagm-s and im"aired )ertical "-rs-it.

Con)ergence remains intact. The "atient 2ill com"lain of hori3ontal di"lo"ia d-e to im"aired add-ction on the affected side567not d-e to nystagm-s in the abd-cting eye.

Common ca-ses: cerebro)asc-lar disease, m-lti"le sclerosis. Iesions of the "ara"ontine retic-lar formation 1PPN:4 The PPN: is res"onsible for conC-gate eye mo)ements in hori3ontal ga3e. 9""earance :ail-re of hori3ontal eye mo)ements to2ards the side of the lesiona hori3ontal ga3e "aresis. 9n i"silateral intern-clear o"hthalmo"legia if the lesion extends to in)ol)e the MI:.

Preser)ation of )ertical ga3e. Contralateral de)iation of the eyes in the ac-te "hase.

Ca-ses: )asc-lar disease, demyelinating disease, neo"lasia. Parina-dDs syndrome Iesions occ-rring in the dorsal midbrain in)ol)e the )ertical ga3e centrehence also kno2n as dorsal midbrain syndrome. 9""earance 0m"aired -"2ard ga3e in both eyes res-lting in con)ergence, retraction of the globe into the orbit and nystagm-s. Iight+near dissociation of the "-"ils+the near reflex is intact b-t res"onse to light is "oor. Ca-ses: demyelinating disease, )asc-lar disease affecting the dorsal midbrain, enlarged Erd )entricle. P.E!& Cranial ner)e J: trigeminal 9""lied anatomy ensory: facial sensation in E branches+o"hthalmic 1J!4, maxillary 1J%4, mandib-lar 1JE4. <istrib-tion sho2n in :ig. !&.E. Motor: m-scles of mastication. ,er)e originates in the "ons, tra)els to trigeminal ganglion at the "etro-s tem"oral bone and s"lits56> J! "asses thro-gh the ca)erno-s sin-s 2ith 000 and exits )ia the s-"erior orbital fiss-re;

J% lea)es )ia the infraorbital foramen 1also s-""lies the "alate and naso"harynx4; JE exits )ia the foramen o)ale 2ith the motor "ortion. Examination 0ns"ection 0ns"ect the "atientDs face5672asting of the tem"oralis 2ill sho2 as hollo2ing abo)e the 3ygomatic arch. Testing motor f-nction 9sk the "atient to clench their teeth and feel both sides for the b-lge of the masseter and tem"oralis. 9sk the "atient to o"en their mo-th 2ide+the Ca2 2ill de)iate to2ards the side of a J lesion.

9gain ask them to o"en their mo-th b-t "ro)ide resistance by holding their Ca2 closed 2ith one of yo-r hands.

Testing sensory f-nction 9ssess light+to-ch for each branch and ask the "atient to say 56@yes56A if they can feel it. o Choose E s"ots to test on each side to make the examination easy to remember567forehead, cheek, and mid+2ay along Ca2.

:or each branch, com"are left to right. 0gnore minor differences 1itDs rather diffic-lt to "ress 2ith exactly the same force each timeK4 Test "in+"rick sensation at the same s"ots -sing a sterile "in. Tem"erat-re sensation is not ro-tinely tested+consider only if abnormalities in light+to-ch or "in+"rick are fo-nd. (se s"ecimen t-bes or other small containers f-ll of hot or cold 2ater.

:indings =asting of m-scles: long+term J "alsy, M,<, myotonic dystro"hy. Ioss of all sensory modalities: J ganglion lesion 1;her"es 3oster4.

Ioss of light to-ch only5672ith loss of sensation on i"silateral side of the body: contralateral "arietal lobe 1sensory cortex4 lesion. Ioss of light+to-ch in J only: lesion at sensory root "ons. Ioss of "in+"rick only567along 2ith contralateral side of body: i"silateral brainstem lesion. Ioss of sensation in a 56@m-33le56A distrib-tion 1nose, li"s, anterior cheeks4: damage to the lo2er "art of the s"inal sensory n-cle-s 1syringomyelia, demyelination4.

P.E!!

:ig. !&.' <istrib-tion of the sensory branches of the trigeminal ner)e. J! ? o"hthalmic, J% ? maxillary, JE ? mandib-lar. ,ote that J! extends to the )ertex and incl-des the cornea and JE does not incl-de the angle of the Ca2. Neflexes Ja2 Cerk

Ex"lain to the "atient 2hat is abo-t to ha""en as this co-ld a""ear rather threateningK 9sk the "atient to let their mo-th hang loosely o"en. Place yo-r finger hori3ontally across their chin and ta" yo-r finger 2ith a "atella hammer. :eel and 2atch Ca2 mo)ement.
o

There sho-ld be a slight clos-re of the Ca2 b-t this )aries 2idely in normal "eo"le. 9 brisk and definite clos-re may indicate an (M, lesion abo)e the le)el of the "ons 1e.g. "se-dob-lbar "alsy4.

Corneal reflex 9fferent ? J!, efferent ? J00. 9sk the "atient to look -" and a2ay from yo-. 8ently to-ch the cornea 2ith a 2is" of cotton 2ool. Oring this in from the side so it cannot be seen a""roaching.

=atch both eyes. 9 blink is a normal res"onse.

o o

,o res"onse ? i"silateral J! "alsy. Iack of blink on one side only ? J00 "alsy.

5LM =atch o-t for contact lensesK+2ill gi)e red-ced sensation. 9sk the "atient to remo)e them first.

5LM Hints ,ote the sensory distrib-tionK The angle of the Ca2 is not s-""lied by JE b-t by the great a-ric-lar ner)e 1C%, CE4. =hen testing the corneal reflex, to-ch the cornea 1o)erlies the iris4, not the conC-ncti)a 1o)erlies the sclera4. P.E!% Cranial ner)e J00: facial 9""lied anatomy ensory: external a-ditory meat-s, tym"anic membrane, small "ortion of skin behind ear. "ecial sensation: taste anterior %HE of tong-e. Motor: m-scles of facial ex"ression, sta"edi-s. 9-tonomic: "arasym"athetic s-""ly to lacrimal glands. The n-cle-s lies in the "ons, the ner)e lea)es at the cerebello"ontine angle 2ith J000. The ner)e gi)es off a branch to the sta"edi-s at the genic-late ganglion 2hilst the maCority of the ner)e lea)es the sk-ll )ia the stylomastoid foramen and tra)els thro-gh the "arotid gland. Examination M-scles of facial ex"ression Here, yo- test both left and right at the same time. ome "atients ha)e diffic-ltly -nderstanding the instr-ctions567the a-thors recommend a B-ick demonstration follo2ing each command allo2ing the "atient to mirror yo- 1e.g. 56@"-ff o-t yo-r cheeks like this56>56A4. This exam can be rather embarrassing567the examiner "-lling eB-ally strange faces lightens the mood and aids the "atientDs co+o"eration and enth-siasm. Iook at the "atientDs face at rest. Iook for asymmetry in the nasolabial folds, angles of the mo-th and forehead 2rinkles. 9sk the "atient to raise their eyebro2s 156@look -"K56A4 and 2atch the forehead 2rinkle.

9ttem"t to "ress their eyebro2s do2n and note any 2eakness. 9sk the "atient to 56@close yo-r eyes tightly56A. =atch, then test against resistance 2ith yo-r finger and th-mb. 56@<onDt let me "-ll them a"art.56A 9sk the "atient to blo2 o-t their cheeks. =atch for air esca"ing on one side. 9sk the "atient to bare their teeth. 56@ ho2 me yo-r teethK56A Iook for asymmetry. 9sk the "atient to "-rse their li"s. 56@=histle for meK56A Iook for asymmetry. The "atient 2ill al2ays smile after 2histling 1see belo24.

The 56@2histle+smile56A sign 9 fail-re to smile 2hen asked to 2histle 12histle+smile negati)e4 is -s-ally d-e to 56@emotional "aresis56A of the facial m-scles and is synonymo-s 2ith Parkinsonism. External a-ditory meat-s

This sho-ld be examined briefly if only J00 is examined+can be done as "art of J000 if examining all the cranial ner)es. Taste This is rarely tested o-tside s"ecialist clinics. Each side is tested se"arately by -sing cotton b-ds di""ed in the sol-tion of choice a""lied to each side of the tong-e in t-rn. Oe s-re to s2ill the mo-th 2ith distilled 2ater bet2een each taste sensation. Test: s2eet, salty, bitter 1B-inine4, and so-r 1)inegar4. P.E!E

:ig. !&./ Testing the m-scles of facial ex"ression as described o""osite. 1a4 eyebro2s; 1b4 eyelids; 1c4 "-ffing o-t the cheeks; 1d4 baring teeth; 1e4 2histle :indings (""er motor ner)e lesion: 2ill ca-se loss of facial mo)ement on the i"silateral side b-t 2ith "reser)ation of forehead 2rinkling+both sides of the forehead recei)e bilateral ner)o-s s-""ly. 1(nilateral ? CJ9 etc, Oilateral ? "se-dob-lbar "alsy, motor ne-ron disease.4 Io2er motor ner)e lesion: 2ill ca-se loss of all mo)ement on the i"silateral side of the face 1-nilateral ? demyelination, t-mo-rs, OellDs "alsy, "ontine lesions, cerebello"ontine angle lesions; bilateral ? sarcoid, 8O , myaesthenia gra)is4.

OellDs "alsy: idio"athic -nilateral IM, J00 "aresis.

Namsay+H-nt syndrome: -nilateral "aresis ca-sed by her"es at the genic-late ganglion 1look for her"es rash on the external ear4.

5LM Hints OellDs "henomenon is the -"2ard mo)ement of the eyeballs 2hen the eye closes. This occ-rs in the normal state b-t can be clearly seen if the eyelids fail to close d-e to J00 "alsy. J00 "alsy does not ca-se eyelid "tosis.

Iongstanding J00 "alsy can ca-se fibro-s contraction of the m-scles on the affected side res-lting in more "rono-nced nasolabial fold 1the re)erse of the ex"ected findings4. Oilateral J00 "alsy 2ill ca-se a sagging, ex"ressionless face and is often missed.

P.E!P Cranial ner)e J000: )estib-locochlear 9""lied anatomy ensory: hearing 1cochlear4, balanceHeB-ilibri-m 1)estib-lar4. Motor: none The /th ner)e com"rises % "arts. The cochlear branch originates in the organ of Corti in the ear, "asses thro-gh the internal a-ditory meat-s to its n-cle-s in the "ons. :ibres "ass to the s-"erior gyr-s of the tem"oral lobes. The )estib-lar branch arises in the -tricle and semicirc-lar canals, Coins the a-ditory fibres in the facial canal, enters the brainstem at the cerebello"ontine angle and ends in the "ons and cerebell-m. Examination EnB-ire first abo-t sym"toms567hearing lossHchanges or balance "roblems. Peri"heral )estib-lar lesions ca-se ataxia d-ring "aroxysms of )ertigo b-t not at other times.

Oegin by ins"ecting each ear as described in

Cha"ter R.

Hearing Test each ear se"arately. Co)er one by "ressing on the trag-s or create 2hite+noise by r-bbing yo-r fingers together at the external a-ditory meat-s. im"le test of hearing =his"er a n-mber into one ear and ask the "atient to re"eat it. Ne"eat 2ith the other ear.

Oe caref-l to 2his"er at the same )ol-me in each ear 1the end of ex"iration is best4 and at the same distance 1abo-t R&cm4.

NinneDs test Ta" a F!%H3` t-ning fork and hold adCacent to the ear 1air cond-ction, :ig. !&.Ga4. Then a""ly the base of the t-ning fork to the mastoid "rocess 1bone cond-ction4567see :ig. !&.Gb.

9sk the "atient 2hich "osition so-nds lo-der.

o o o

1,ormal ? air cond-ction * bone cond-ction ? 56@NinneDs "ositi)e56A4 0n ne-ral 1or "erce"ti)e4 deafness, NinneDs test 2ill remain "ositi)e. 0n cond-cti)e deafness, the findings are re)ersed 1bone *air4.

=eberDs test Ta" a F!%H3 t-ning fork and hold the base against the )ertex or forehead at the midline 1see :ig. !&.Gc4. 9sk the "atient if it so-nds lo-der on one side.
o o

0n ne-ral deafness, the tone is heard better in the intact ear. 0n cond-cti)e deafness, the tone is heard better in the affected ear.

P.E!F

:ig. !&.G 1a4 Testing air cond-ction. 1b4 Testing bone cond-ction. 1c4 Position of the t-ning fork for =eberDs Test. Jestib-lar f-nction T-rning test 9sk the "atient to stand facing yo-, arms o-tstretched.

9sk them to march on the s"ot, then close their eyes 1contin-e marching4. =atchK
o

The "atient 2ill grad-ally t-rn to2ard the side of the lesionsometimes 2ill t-rn right ro-nd !/&#W.

Hall"ikeDs manoe-)re 9 test for benign "ositional )ertigo 1OPJ4. <o not test those 2ith kno2n neck "roblems or "ossible "osterior circ-lation im"airment. =arn the "atient abo-t 2hat is to ha""en. it the "atient facing a2ay from the edge of the bed s-ch that 2hen they lie back their head 2ill not be s-""orted 1o)er the edge4.

T-rn their head to one side and ask them to look in that direction. Iie them back B-ickly567s-""orting their head so that it lies abo-t E&#W belo2 the hori3ontal. =atch for nystagm-s 1affected ear 2ill be lo2ermost4. Ne"eat 2ith the head t-rned in the other direction
o o

,o nystagm-s ? normal. ,ystagm-s, 2ith a slight delay 1V!& secs4 and fatigable 1canDt be re"eated s-ccessf-lly for V!&+!F min-tes4 ? OPJ. ,ystagm-s, no delay and no fatig-ing ? central )estib-lar syndrome.

P.E!R Cranial ner)es 0Q and Q The Gth 1glosso"haryngeal4 and !&th 1)ag-s4 ner)es are considered together as they ha)e similar f-nctions and 2ork together to control "harynx, larynx and s2allo2. 9""lied anatomy: 0Q ensory: "harynx, middle ear. "ecial sensation: taste on "osterior !HE of tong-e. Motor: stylo"haryngeo-s. 9-tonomic: "arotid gland. Originates in the med-lla, "asses thro-gh the C-g-lar foramen. 9""lied anatomy: Q ensory: tym"anic membrane, external a-ditory canal, and external ear. 9lso "ro"rioce"tion from thorax and abdomen. Motor: "alate, "harynx, and larynx. 9-tonomic: carotid barorece"tors. Originates in med-lla and "ons, lea)es the sk-ll )ia C-g-lar foramen. Examination Pharynx

9sk the "atient to o"en their mo-th and ins"ect the -)-la 1-se a tong-e de"ressor if necessary4. 0s it central or de)iated to one side; 0f so, 2hich side; 9sk the "atient to say 56@aah56A. =atch the -)-la. 0t sho-ld mo)e -"2ards centrally. <oes it de)iate to one side;

8ag reflex This is -n"leasant for the "atient and sho-ld only be tested if a 0Q or Q ner)e lesion is s-s"ected 1afferent signal ? 0Q, efferent ? Q4. =ith the "atientDs mo-th o"en 2ide, gently to-ch the "osterior "haryngeal 2all on one side 2ith a tong-e de"ressor or other sterile stick. =atch the -)-la 1it sho-ld lift -"4.

Ne"eat on the o""osite side. 9sk the "atient if they felt the % to-ches+and 2as there any difference in sensation; 9sk the "atient to co-gh567normal character; 8rad-al onsetHs-dden; Iisten to the "atientDs s"eech567note )ol-me, B-ality and 2hether it a""ears to fatig-e 1B-ieter as time goes on4. Test s2allo2:
o

Iarynx

9t each stage, 2atch the s2allo2 action567% "hases or one smooth mo)ement; <elay bet2een fl-id lea)ing mo-th 1oral "hase4 and "harynxHlarynx reacting 1"haryngeal "hase4; 9ny co-ghingHchoking; 9ny 56@2et56A )oice; 5LM Terminate the test at the first sign of the "atient as"irating. Offer the "atient a teas"oon of 2ater to s2allo2. Ne"eat x E. Offer the "atient a si" of 2ater. Ne"eat x E. Offer the "atient the glass for a mo-thf-l of 2ater. Ne"eat x E.

o o o o

P.E!' :indings ()-la Mo)es to one side ? Q lesion on the o""osite side. ,o mo)ement ? m-scle "aresis.

Mo)es 2ith 56@aah56A b-t not gag and 5YZ "haryngeal sensation ? 0Q "alsy. 8rad-al onset of a deliberate co-gh ? )ocal cord "alsy.

Co-gh

56@=et56A, b-bbly )oice and co-gh 1before the s2allo2 test4 ? "haryngeal and )ocal cord "alsy 1Q "alsy4. Poor s2allo2 and as"iration ? combined 0Q and Q or lone Q lesion.

P.E!/ Cranial ner)e Q0: accessory 9""lied anatomy ensory: none. Motor: sternocleidomastoids and -""er "art of tra"e3ii. The accessory ner)e is com"osed of 56@cranial56A and 56@s"inal56A "arts. The cranial accessory ner)e arises from the n-cle-s ambig--s in the med-lla. The s"inal accessory ner)e from the lateral "art of the s"inal cord do2n to CF as a series of rootlets. These Coin together and ascend adCacent to the s"inal cord, "assing thro-gh the foramen magn-m to Coin 2ith the cranial "ortion of the accessory ner)e. 0t lea)es the sk-ll )ia the C-g-lar foramen. The cranial "ortion Coins 2ith the )ag-s ner)e 1Q4. The s"inal "ortion inner)ates the sternocleidomastoids and the -""er fibres of the tra"e3ii. 5LM ,ote that each cerebral hemis"here controls the i"silateral sternocleidomastoid and the contralateral tra"e3i-s. Examination The cranial "ortion of the accessory ner)e cannot be tested se"arately. 0ns"ect the sternocleidomastoids. Iook for 2asting, fascic-lations, hy"ertro"hy, and any abnormal head "osition. 9sk the "atient to shr-g their sho-lders and obser)e.

9sk the "atient to shr-g again, -sing yo-r hands on their sho-lders to "ro)ide resistance. 9sk the "atient to t-rn their head to each side, first 2itho-t and then 2ith resistance 1-se yo-r hand on their cheek4.

:indings 0solated accessory ner)e lesions are )ery rare. Q0 lesions -s-ally "resent as "art of a 2ider 2eakness or ne-rological syndrome. Oilateral 2eakness: 2ith 2asting ca-sed by m-sc-lar "roblems or motor ne-ron disease. (nilateral 2eakness 1tra"e3i-s and sternomastoid same side4: s-ggests a "eri"heral ne-rological lesion.

(nilateral 2eakness 1tra"e3i-s and sternomastoid of o""osite sides4: -s-ally 2ith hemi"legia s-ggests an (M, lesion i"silateral to the 2eak sternomastoid.

5LM Hints Nemember that the action of the sternocleidomastoid is to t-rn the head to the o""osite side 1e.g. "oor head t-rning to the left indicates a 2eak right sternocleidomastoid4.

=hen "ro)iding resistance to head t-rning, be s-re to "ress against the "atientDs cheek 1see :ig. !&.!&4. Iateral "ress-re to the Ca2 can ca-se "ain and inC-ry, "artic-larly in the elderly and frail.

P.E!G

:ig. !&.!& 1a4 (sing resistance against lateral head+t-rning. Oe caref-l not to a""ly "ress-re to the "atientDs Ca2. 1b4 Testing the tra"e3i-s against resistance. P.E%& Cranial ner)e Q00: hy"oglossal 9""lied anatomy ensory: none.

Motor: m-scles of the tong-e. ,-cle-s lies on the floor of 0J )entricle. :ibres "ass )entrally, lea)ing the brainstem lateral to the "yramidal tracts. Iea)es the sk-ll )ia the hy"oglossal foramen. Examination 9sk the "atient to o"en 2ide and ins"ect the tong-e on the floor of the mo-th. Iook for si3e and e)idence of fascic-lation. 9sk the "atient to "rotr-de the tong-e. Iook for de)iation or abnormal mo)ements.

9sk the "atient to mo)e the tong-e in and o-t re"eatedly, then side+to+side. To test for s-btle 2eakness, "lace yo-r finger on the "atientDs cheek and ask them to "-sh against it from the inside -sing their tong-e.

:indings 9 IM, ne-ron lesion 2ill ca-se fascic-lations on the affected side and a de)iation to2ards the affected side on "rotr-sion. There 2ill also be a 2eakness on "ressing the tong-e a2ay from the affected side. 9 -nilateral -""er motor ne-ron lesion 2ill rarely ca-se any clinically ob)io-s signs.

9 bilateral -""er motor ne-ron lesion 2ill gi)e a small, globally 2eak tong-e 2ith red-ced mo)ements. 9 bilateral IM, lesion 1e.g. motor ne-ron disease4 2ill also "rod-ce a small, 2eak tong-e. 9 ra"id 56@in and o-t56A mo)ement on "rotr-sion 1trombone tremor4 can be ca-sed by cerebellar disease, extra+"yramidal syndromes and essential tremor.

5LM Hint Ni""ling mo)ements may be seen if the tong-e is held "rotr-ded for long "eriods. This is normal and sho-ld not be mistaken for fascic-lations. P.E%! P.E%% Motor: a""lied anatomy The motor system is com"lex and a detailed descri"tion is beyond the sco"e of this book. =hat follo2s is a brief o)er)ie2. Cortex The "rimary motor area is the "recentral gyr-s of the cerebr-m and it is here, along 2ith adCacent cerebral areas, that initiation of )ol-ntary mo)ement occ-rs. M-scle gro-"s are re"resented by areas of the cortex from medial to lateral as sho2n o""osite. The si3e of the area dedicated to m-scle corres"onds 2ith the "recision of mo)ement 1? the n-mber of motor -nits4 that are in)ol)ed. Pyramidal 1direct4 "ath2ays These are concerned 2ith "recise, )ol-ntary mo)ements of the face, )ocal cords, hands and feet.

The sim"lest "ath2ays consist of % ne-rons. The first 56@-""er motor ne-ron56A 1(M,4 originates in the cerebral cortex, "asses do2n thro-gh the internal ca"s-le, brainstem and s"inal cord 2here it syna"ses 2ith a 56@lo2er motor ne-ron56A 1IM,4. This, in t-rn, lea)es the cord to syna"se 2ith the skeletal m-scle fibres. There are E "yramidal tracts: Iateral corticos"inal: control of "recise mo)ement in the hands and feet and re"resents G&X of the (M, axons. These crosso)er 1dec-ssate4 in the med-lla oblongata before contin-ing to descend so that ner)es from the right side of the brain control m-scles on the left of the body and )ice )ersa. 9nterior corticos"inal: control of the neck and tr-nk and holds !&X of the (M, axons. These do not cross in the med-lla b-t descend in the anterior 2hite col-mns of the s"inal cord. They dec-ssate at se)eral s"inal le)els and exit at the cer)ical and -""er thoracic segments.

Corticob-lbar: )ol-ntary m-scles of the eyes, face, tong-e, neck, and s"eech. Terminate at n-clei in the "ons and med-lla, some crossed, others not. Control of cranial ner)es 000, 0J, J, J0, J00, 0Q, Q, Q0, and Q00.

Extra"yramidal 1indirect4 "ath2ays 9ll the other descending "ath2ays. These are com"lex circ-its in)ol)ing the cortex, limbic system, basal ganglia, cerebell-m, and cranial ner)e n-clei. There are F maCor tracts controlling "recise mo)ements of the hands and feet, mo)ement of the head and eyes in res"onse to )is-al stim-li, m-scle tone, and tr-ncal stability and balance. Oasal gangliaHn-clei: com"lex circ-its concerned 2ith the "rod-ction of a-tomatic mo)ement, "lanning mo)ement seB-ences. 9lso a""ear to inhibit intrinsically excitable circ-its. Cerebell-m 0n)ol)ed in learning and "erforming skilled, a-tomatic mo)ements 1e.g. r-nning, "laying the "iano4, "ost-re, and balance. Monitors intention, recei)es signals as to act-al mo)ements, com"ares the difference, and makes correcti)e adC-stments. P.E%E

:ig. !&.!! Coronal section thro-gh the motor cortex sho2ing the re"resentation of different m-scle gro-"s. ,ote the larger areas gi)en to those m-scles "erforming "recise mo)ements567hands, face, li"s. Oox !&.E 9 2ord abo-t f-nctional 2eakness Iarge "arts of the ne-rological examination rely on the co+o"eration of the "atient. Occasionally, "atients gi)e the a""earance of ne-rological disability 2hich does not exist+for any n-mber of "sychiatric or "sychosocial reasons. The examination here is )ery diffic-lt e)en for )ery ex"erienced "ractitioners. Consider a 56@f-nctional56A com"onent to the "roblem if yo- see: 9bnormal distrib-tion of 2eakness. ,ormal reflexes and tone des"ite 2eakness.

Mo)ements are )ariable and "o2er erratic. Jariation is seen on re"eat testing.

Caref-l hereK <onDt C-m" to concl-sions. <o not ass-me sym"toms are f-nctional if they are -n-s-al. 9ll "atients sho-ld be gi)en the benefit of the do-bt. 56@:-nctional56A 2eakness is a diagnosis largely of excl-sion. P.E%P Motor: ins"ection and tone 0ns"ection

9s for any other system, the examination begins 2hen yo- first set eyes on the "atient and contin-es thro-gh the history taking.

9ny 2alking aids or abnormal gait 1see ".EF&4; hake hands567abnormalities of mo)ement; trength; Nelaxation; 9ny abnormal mo)ements 2hen sitting; 9ny ob)io-s 2eaknesses 1e.g. hemi"legia4; <oes the "atient ha)e good sitting balance;

0ns"ection can then be formali3ed at the examination stage of the enco-nter. The "atient sho-ld be seated or lying comfortably 2ith as m-ch of their body ex"osed as "ossible. Iook at all m-scle gro-"s for: 9bnormal "ositioning567d-e to 2eakness or contract-res. =asting.

:ascic-lation 1irreg-lar contractions of small areas of m-scle4.

Make a "oint of ins"ecting the sho-lder girdle, small m-scles of the hand, B-adrice"s, anterior com"artment of lo2er leg and ankle. Iook at the foot for contract-res or abnormalities of sha"e. Tone The aim is to test resting tone in the limbs. This takes "ractise and the feel of normal, 5YZ or 5Y[ tone can only be ta-ght thro-gh ex"erience. The assessment can be diffic-lt as it relies on the "atient being relaxed and telling the "atient to relax -s-ally has the o""osite effectK They can be distracted by a co-nting task or told to relax the limb 56@as if yo-Dre aslee"56A. Ho2e)er, distracting the "atient 2ith light con)ersation is a generally s-ccessf-l "loy. So- sho-ld also re"eat the follo2ing manoe-)res at different s"eeds and inter)als to catch the "atient at an -ng-arded moment. 9rms Take the "atientDs hand in yo-rs 1as if shaking it4 and hold their elbo2 2ith yo-r other hand 1see :ig. !&.!%a4. :rom this "osition, yo- can: o Pronate and s-"inate the "atientDs forearm.
o o

Noll the "atientDs 2rist thro-gh ER&#W. :lex and extend the "atientDs elbo2.

Iegs

Hi": 2ith the "atient lying flat, legs straight, hold onto the "atientDs knee and roll it from side to side 1see :ig. !&.!%b4. \nee: 2ith the "atient in the same "osition, "-t yo-r hand behind the "atientDs knee and raise it B-ickly 1:ig. !&.!%c4. =atch the heel+it sho-ld lift from the bedHco-ch slightly if tone is normal.

9nkle: holding the foot and the lo2er leg, flex and dorsiflex the ankle 1:ig. !&.!%d4.

P.E%F

:ig. !&.!% Testing tone. 1a4 Testing the -""er limb. 1b4 Testing tone at the hi". 1c4 Testing tone at the knee. 1d4 Testing tone at the ankle. :indings ,ormal tone: slight resistance in mo)ement 1feel thro-gh ex"erienceK4 5YZ tone: 56@flaccid56A d-e to IM, or cerebellar lesions or myo"athies.

5Y[ tone:
o

"asticity 1clas"+knife rigidity4: the limb a""ears stiff. =ith 5Y[ "ress-re, there is a s-dden 56@gi)e56A and the limb mo)es. een in (M, lesions. Nigidity 1lead+"i"e4: the limb is eB-ally stiff thro-gh all mo)ements. Nigidity 1cog2heel4: an extra"yramidal sign, ca-sed by a tremor s-"erim"osed on a rigid limb. The limb mo)es in a sto"+go halting fashion. 8egenhalten: 1"aratonia4 seen in bilateral frontal lobe damage and catatonic states. Tone 5Y[ 2ith 5Y[ "ress-re from the examiner567the "atient a""ears to be resisting mo)ement.

o o

Myotonia: a slo2 relaxation after action5672hen asked to make a fist, the "atient is -nable the release it B-ickly and 2ill be slo2 to let go of a hand+shake 1e.g. myotonic dystro"hy4. <ystonia: the limb or head has an abnormal "ost-re that looks rather -ncomfortable.

P.E%R Motor: -""er limb "o2er 5LM 9s for the m-scles of the face, the examiner sho-ld demonstrate each mo)ement, mirroring the "atient. 1see :ig. !&.!E4. This also allo2s each action that the "atient makes to be o""osed by the same 1or similar4 m-scle gro-"s in the examiner567test their fingers against yo-r fingers and so on. Each m-scle gro-" sho-ld be graded from & to F according to the MNC system sho2n o""osite. Examining the -""er limbs also allo2s for both sides to be tested at once, allo2ing a direct com"arison bet2een left and right. 1see :ig.!&.!E4. Oe caref-l not to h-rt frail and elderly "atients or those 2ith O9, N9, and other rhe-matological diseaseK ho-lder 9bd-ction: 1CF4. 9sk the "atient to abd-ct their arms 2ith elbo2s bent. 56@9rms -" like a chickenK56A 9sk them to hold still as yo- attem"t to "-sh their arms do2n. 9dd-ction: 1CR, C'4. The "atient sho-ld hold their arms tightly to their sides 2ith elbo2s bent. So- attem"t to "-sh their arms o-t. Elbo2

:lexion: 1CF, CR4. the "atient sho-ld hold their elbo2s bent and s-"inated in front of them. Hold the "atient at the elbo2 and 2rist and attem"t to extend their arm. 56@<onDt let me straighten yo-r armK56A Extension: 1C'4. Patient holds "osition abo)e as yo- resist extension at the elbo2 by "-shing on their distal forearmH2rist. 56@P-sh me a2ayK56A :lexion: 1CR, C'4. =ith arms s-"inated, the "atient sho-ld flex the 2rist and hold as yoattem"t to extend it by "-lling from yo-r o2n 2rists. Extension: 1CR, C'4. The o""osite manoe-)re to that abo)e. The "atient holds their hand o-t straight and resists yo-r attem"ts to bend it. :lexion: 1C/4. 9sk the "atient to sB-ee3e yo-r fingers or 1better4 ask the "atient to gri" yo-r fingers "alm+to+"alm 1see :ig. !&.!Ec4 and resist yo-r attem"ts to "-ll their hand o"en.

=rist

:ingers

Extension: 1C', C/4. 9sk the "atient to hold their fingers o-t straight567yo- s-""ort their 2rist 2ith one hand and attem"t to "-sh their fingers do2n 2ith the side of yo-r hand o)er their first inter"halangeal Coints. 9bd-ction: 1T!4. 9sk the "atient to s"lay their fingers o-t and resist yo-r attem"ts to "-sh them together. 9dd-ction: 1T!4. Holding the "atientDs middle, ring, and little finger 2ith one hand and their index finger 2ith the other, ask the "atient to "-ll their fingers together or "lace a "iece of "a"er bet2een their o-tstretched fingers and ask them to resist yo-r attem"ts to "-ll it a2ay.

Pronator drift 9 -sef-l test of s-btle 2eakness. The "atient is asked to hold their arms o-tstretched in front, "alms -"2ards and eyes closed. 0f one side is 2eak, the arm 2ill "ronate and slo2ly drift do2n2ards. P.E%' Oox !&.P Medical Nesearch Co-ncil 1MNC4 "o2er classification F ? ,ormal "o2er. P ? Mo)ement against resistance b-t not normal.

E ? Mo)ement against gra)ity, b-t not against resistance. % ? Mo)ement 2ith gra)ity eliminated 1e.g. can mo)e leg side+to+side on bed b-t not lift it4. ! ? Contractions b-t no mo)ement seen. & ? ,o mo)ement.

:ig. !&.!E Testing "o2er in the -""er limbs. 1a4 ho-lder mo)ements. 1b4 Elbo2 mo)ements. 1c4 :inger flexion. 1d4 :inger extension. 1e4 :inger abd-ction. 1f4 :inger add-ction. P.E%/ Motor: lo2er limb "o2er The "atient sho-ld be seated on a co-ch or bed 2ith their legs o-tstretched in front of them. The limbs sho-ld be ex"osed as m-ch as "ossible so that contractions of the m-scles can be seen. 9gain, "o2er is tested for each m-scle gro-" on one side then the other, com"aring left 2ith right and scored according to the MNC scale. Hi" :lexion: 1I!, I%, IE4. =ith the lo2er limbs lying on the bedHco-ch, the "atient is asked to raise each leg, kee"ing the knee straight. The examiner can o""ose the mo)ement by "-shing do2n on the thigh C-st abo)e the knee. 56@ to" me from "-shing do2nK56A

Extension: 1IF, !4. 9sk the "atient to kee" their leg "ressed against the bed as yoattem"t to lift it567either 2ith a hand beneath the calf or the ankle. 56@ to" me lifting yo-r leg -"K56A 9bd-ction: 1IP, IF, !4. 9sk the "atient to mo)e their leg o-t to the side as yo- o""ose the mo)ement 2ith a hand on the lateral thigh. 56@ to" me "-shing yo-r legs togetherK 56A 9dd-ction: 1I%, IE, IP4. =ith the legs central, "-t yo-r hand on the medial thigh and attem"t to "-ll the leg o-t to the side against resistance. 56@<onDt let me "-ll yo-r legs a"artK56A :lexion: 1IF, !4. Take hold of the "atientDs knee 2ith one hand and their ankle 2ith the other and flex the leg to abo-t R&#W. 1The "atient may think yo- 2ant them to resist this so often a B-ick instr-ction 56@bend at the knee56A is reB-ired.4 9sk the "atient to bend their leg f-rther 156@sto" me straightening yo-r leg o-t56A4 and o""ose the mo)ement at their ankle. Extension: 1IE, IP4. =ith the "atientDs leg in the "osition abo)e, ask the "atient to extend their leg 156@"-sh me a2ay56A, 56@straighten yo-r leg o-t56A4 as yo- o""ose it. 9lternati)ely, attem"t to bend the "atientDs leg from a straightened starting "osition. Plantar flexion: 1 !, %4. =ith the "atientDs leg o-t straight and ankle relaxed, "-t yo-r hand on the ball of the foot and ask the "atient to "-sh yo- a2ay. 56@P-sh do2n and sto" me "-shing backK56A <orsiflexion: 1IP, IF4. :rom the starting "osition abo)e, hold the "atientDs foot C-st abo)e the toes and ask them to "-ll their foot back2ards. Patients often attem"t to mo)e their entire leg here so 56@cock yo-r foot back and sto" me "-shing yo-r foot do2n56A 2ith an accom"anying hand gest-re hel"s.

\nee

9nkle

P.E%G

:ig. !&.!P Testing "o2er in the lo2er limb against resistance. 1a4 :lexing the hi". 1b4 Extending the hi". 1c4 :lexingHextending the knee. 1d4 Plantar flexion at the ankle. 1e4 <orsiflexion at the ankle. P.EE& Tendon reflexes Theory The s-dden stretch of a m-scle is detected by the m-scle s"indle 2hich initiates a sim"le % ne-ron reflex arc, ca-sing that m-scle to contract. Tendons are str-ck 2ith a tendon hammer 1ca-sing a s-dden stretch of the m-scle4 and the res-ltant contraction obser)ed. 0n IM, lesions or myo"athies, the reflex is 5YZ or absent, b-t 5Y[ or 56@brisk56A in (M, lesions. TechniB-e

The tendons are ta""ed 2ith a tendon hammer. :or each reflex, test the right, then left and com"are. The hammer sho-ld be held at the far end of the handle and s2-ng in a loose mo)ement from the 2rist. The "atient sho-ld be relaxed 1see ".E%P4. Examination Oice"s: 1CF, CR4. =ith the "atient seated, lie their arms across their abdomen. Place yo-r th-mb across the bice"s tendon and strike it 2ith the tendon hammer as abo)e. =atch the bice"s for contraction. -"inator: 1CF, CR4. The m-scle tested is act-ally the brachioradialis. =ith the "atientDs arms lying loosely across their abdomen, "-t yo-r fingers on the radial t-berosity and ta" 2ith the hammer. The arm 2ill flex at the elbo2. 0f brisk, the fingers may also flex.

Trice"s: 1C'4. Taking hold of the "atientDs 2rist, flex their arm to VG&#W. Ta" the trice"s tendon abo-t Fcm s-"erior to the olecranon "rocess of the -lna. =atch the trice"s. :ingers: 1C/4. This is only "resent if tone is "athologically t. =ith yo-r "alm -" and the "atientDs arm "ronated, lie their fingers on yo-rs. trike the back of yo-r fingers. The "atientDs fingers 2ill flex. \nee: 1IE, IP4. =ith the "atientDs leg extended, -se one hand behind their knee to lift their leg to VR&#W. Ta" the "atella tendon and 2atch the B-adrice"s. 0f brisk, "roceed to testing for clon-s here:
o

\nee clon-s: 2ith the "atientDs leg extended, "lace yo-r th-mb and index finger o)er the s-"erior edge of the "atella. Create a s-dden do2n2ard 1to2ard the feet4 mo)ement, and hold. =atch the B-adrice"s. 9ny beat of clon-s here is abnormal.

9nkle: 1 !, %4. =ith the hi" flexed and externally rotated and the knee flexed to VG&#W, hold the foot and ta" the 9chilles tendon. =atch the calf m-scles for contractionHankle flexion.
o

9lternati)ely, 2ith the leg extended and relaxed, "lace yo-r hand on the ball of the foot and strike yo-r hand 2ith the hammer.

Neinforcement 0f the reflex is absent, it can sometimes be elicited by asking the "atient to "erform a 56@reinforcing56A action 2hich acts to increase the acti)ity of ne-rons in the s"inal cord. This effect is short+li)ed, ho2e)er, so yo- sho-ld aim to test the reflex in the first !& seconds of the reinforcement. :or -""er limb reflexes, ask the "atient to clench their teeth. :or lo2er limb reflexes, ask the "atient to lock their fingers together, "-lling in o""osite directions. P.EE!

:ig. !&.!F Testing tendon reflexes. 1a4 Oice"s. 1b4 Trice"s. 1c4 -"inator. 1d4 :ingers. 1e4 \nee. 1f4 9nkle. 1g4 9lternati)e method for ankle. Oox !&.F Necording tendon reflexes: These are -s-ally recorded as a list567or often by a""lying the n-mbers belo2 to the a""ro"riate area of a stick+man sketch. & ? absent #a ? "resent only 2ith reinforcement

!b ? 5YZHless than normal %b ? normal

Eb ? briskHmore than normal.

P.EE% Other reflexes 0n normal "ractice, the "lantar res"onse is the only one of the follo2ing ro-tinely tested. 9bdominal reflex This test relies on obser)ing the abdominal m-scles567is, therefore, less easy in those 2ith a co)ering of fat. 0t is also less ob)io-s in children, the elderly, m-lti"aro-s "atients, or those 2ho ha)e had abdominal s-rgery. The "atient sho-ld be lying on their back, relaxed, abdomen ex"osed. (sing an orange stick or similar, stroke each of the P segments of the abdomen, in a brief mo)ement to2ards the -mbilic-s.

9s each segment is stroked, the abdominal m-scles 2ill reflexly contract. -mmari3e the findings diagrammatically -sing a sim"le %cd% grid and indicating the "resence or absence of a res"onse by marking marking 56@b56A and 56@+56A res"ecti)ely. 156@#a56A for an intermediate res"onse4.

The -""er segments are s-""lied by T/+TG, the lo2er by T!&+T!!. Cremasteric reflex 1I!, I%.4 <-e to its nat-re, this reflex is )ery rarely tested and reB-ires a f-ll ex"lanation and consent from the "atient first. =ith the male "atient standing and naked from the 2aist do2n, yo- sho-ld lightly stroke the -""er as"ect of their inner thigh. The i"silateral cremaster m-scle contracts and the testicle 2ill briefly rise. Plantar res"onse 1IF, !, %.4 This is sometimes, ina""ro"riately, called the Oabinski reflex The "atient sho-ld be lying comfortably, legs o-tstretched. =arn the "atient that yo- are abo-t to to-ch the sole of their foot 1this may "re)ent a startled 56@2ithdra2al56A res"onse4.

troke the "atientDs sole5672ith an orange stick or similar dis"osable item 1many "eo"le -se their finger nail b-t this has ob)io-s im"lications for sterilityK4. So- sho-ld stroke from the heel, -" the lateral as"ect of the sole to the base of the Fth toe. 0f there is no res"onse, the stroke can be contin-ed along the ball of the foot to the base of the big toe. =atch the big toe for its initial mo)ement.
o o

,ormal res"onse is "lantar flexion of the big toe. (""er motor ner)e lesions 2ill ca-se the big toe to dorsiflex. This is 56@the Oabinski res"onse56A.

<oc-ment yo-r findings -sing arro2s:

o o o

5YZ for "lantar flexion. 5Y[ for dorsiflexion. + for an absent res"onse.

0f the leg is 2ithdra2n and the heel mo)es in a 56@ticklish56A reaction, this is called a 56@2ithdra2al56A res"onse and the test sho-ld be re"eated.

P.EEE

:ig. !&.!R Testing the "lantar res"onse. The arro2 sho2s the direction that the stroke sho-ld take. 9nkle clon-s 9 rhythmical contraction of a m-scle 2hen s-ddenly stretched567a sign of hy"erreflexia d-e to (M, lesion. =ith the "atient lying on the bed, knee straight and thigh slightly externally rotated, s-ddenly dorsiflex the foot. More than E beats of clon-s567as long as the foot is held dorsiflexed567is abnormal. P.EEP Primiti)e reflexes These are reflexes seen in the ne2born567b-t may still be "resent in a fe2 normal ad-lts. They ret-rn some2hat in the elderly b-t are seen mainly in frontal lobe disease and ence"halo"athy. The "rimiti)e reflexes are not ro-tinely tested -nless the examiner is looking s"ecifically for frontal lobe signs or ParkinsonDs disease.

8labellar ta" (sing yo-r index finger, re"eatedly ta" 1gently4 the "atientDs forehead bet2een the eyebro2s. 0f normal, the "atient 2ill blink only 2ith the first E or P ta"s. Palmo+mental reflex So- sho-ld stroke the "atientDs "alm, -sing shar" firm "ress-re from the radial side to the -lnar. =atch the "atientDs chin.

0f the reflex is "resent, there 2ill be a contraction of the i"silateral mentalis seen in the neck and chin.

8ras" reflex 8ently stroke yo-r fingers o)er the "atientDs "alm in a radial+-lnar direction, telling the "atient not to gri" yo-r hand. 0f "resent, the "atient 2ill in)ol-ntarily gras" yo-r hand and seemingly ref-se to let go. no-t 1or "o-t4 reflex =ith the "atientDs eyes closed, gently ta" their li"s 2ith yo-r fingers or 1)ery ca-tio-sly4 2ith a "atellar hammer. 9n in)ol-ntary "-ckering of the li"s is a "ositi)e reflex. -ckling reflex =ith the "atientDs eyes closed, gentle stim-lation at the corner of their mo-th 2ill res-lt in a s-ckling action at the mo-th. The "atientDs head may also t-rn to2ards the stim-l-s. P.EEF P.EER ensory: a""lied anatomy The sensory system, like the rest of the ner)o-s system, is )astly com"lex. The follo2ing is a sim"lified ex"lanation 2hich sho-ld "ro)ide eno-gh backgro-nd to make sense of the examination techniB-e and findings. "inal roots and dermatomes 9 s"inal ner)e arises at each s"inal le)el, containing sensory and motor ne-rons ser)ing a s"ecific segment of the body. The area of skin s-""lied by the sensory ne-rons corres"onding to each s"inal le)el can be ma""ed o-t567each segment is called a dermatome. ee :igs. !&.!/ and !&.!G on the follo2ing "ages. There is considerable o)erla" s-ch that loss of sensation in C-st one dermatome is -s-ally not testable 1and textbooks sho2 a marked )ariation in dermatome ma"sK4. Medical st-dents sho-ld stri)e to become familiar 2ith the dermatomal distrib-tion at an early stage. omatic sensory "ath2ays

There are % main s"inal "ath2ays for sensory im"-lses. The clinical im"ortance of these can be seen in s"inal cord damage and is s-mmarised on ".EFR. Posterior col-mns These con)ey light to-ch, "ro"rioce"tion, and )ibration sense567as 2ell as stereognosis 1the ability to recogni3e an obCect by to-ch4, 2eight discrimination, and kinaesthesia 1the "erce"tion of mo)ement4. ,er)es from rece"tors extend -" the i"silateral side of the s"inal cord to the med-lla, their axons forming the 56@"osterior col-mns56A 1fascic-l-s gracilis and fascic-l-s c-neat-s4. The second order ne-rons dec-ssate 1cross o)er4 at the med-lla and tra)el in the medial lemnisc-s to the thalam-s. :rom there, the im"-lse is con)eyed to the sensory cortex. "inothalamic tract This carries "ain and tem"erat-re sensation. :rom a clinical "oint of )ie2, the im"ortant difference here is that the first order ne-rons syna"se in the "osterior grey horn on Coining the s"inal cord. The second order ne-rons then cross o)er and ascend the contralateral side of the cord in the s"inothalamic tract to the thalam-s. The sensory cortex This is located at the "ostcentral gyr-s, C-st "osterior to the motor cortex. M-ch like the motor stri", the areas recei)ing stim-li from )ario-s "arts of the body can be ma""ed o-t 1see :ig. !&.!'4. 9 lesion affecting one area 2ill ca-se sensory loss in the corres"onding body area on the contralateral side 1see sensory "ath2ays abo)e4. P.EE'

:ig. !&.!' The sensory cortex ma" sho2ing areas corres"onding to the different "arts of the body. ,ote the large areas gi)en o)er to the fingers and li"s. P.EE/

:ig. !&.!/ The dermatomes 1anterior )ie24. t-dents 2o-ld do 2ell to be familiar 2ith these diagrams, "artic-larly the limbs.567note im"ortant landmarks to aid recall. 1C' co)ers the middle finger, TP lies at the le)el of the ni""les, T!& o)er the -mbilic-s4. P.EEG

:ig. !&.!G The dermatomes 1"osterior )ie24. P.EP& ensory examination This examination can be diffic-lt567as it reB-ires concentration and co+o"eration on the "art of both the "atient and the examiner. The res-lts de"end on the "atientDs res"onse and are, therefore, "artly s-bCecti)e. Many "atients "ro)e -nreliable 2itnesses d-e to a lack of -nderstanding or attem"ts to "lease the examiner. Ed-cation, ex"lanation, and reass-rance are, therefore, im"ortant at all times.

Often, sensory loss 1"artic-larly )ibration and tem"erat-re4 are not noticed by the "atient and re)ealing them d-ring the co-rse of an examination may be -"setting. This sho-ld be borne in mind as yo- "roceed. TechniB-e So-r examination sho-ld be infl-enced by the history. 0n "ractice, only light to-ch is tested as a B-ick 56@screening56A exam if no deficit is ex"ected. 0f yo- are to test )ibration sense and "ro"rioce"tion, it may be best to test these first as they reB-ire the least concentration and can be -sed by yo- to assess the "atientsD reliability as a 2itness before testing the other sensory modalities. :or each modality, yo- sho-ld begin at any area of s-""osed deficit and 2ork o-t2ards, ma""ing the affected area567then mo)e to a systematic examination from head to toe. 9l2ays test one side, then the other for each limbHbody area. So- sho-ld aim, at least, to test one s"ot in each dermatome. Iight to-ch =ith the "atientDs eyes closed, to-ch their skin 2ith a 2is" of cotton 2ool and ask them to say 56@yes56A 2hen it is felt. The inter)al bet2een each to-ch sho-ld be irreg-lar and -n"redictable. 0n "ractice, a gentle to-ch 2ith a finger is often -sed. Ho2e)er, this risks testing 56@"ress-re56A not 56@light to-ch56A sensation567it is also harder to ens-re eB-al force is a""lied in all areas.

<o not, as many do, make tiny stroking mo)ements on the skin567this stim-lates hair fibres and, again, is not a test of 56@light to-ch56A. Oe a2are of areas 2here 5YZ sensation is ex"ected 1foot call-ses etc.4. 9fter testing each limbHbody area, do-ble check 2ith the "atient 56@did that feel the same all o)er;56A and ex"lore any areas of abnormal sensation more thoro-ghly before mo)ing on.

ensory inattention This is a s-btle b-t often clinically im"ortant sign of "arietal lobe dysf-nction. The "atient feels a stim-l-s on the affected "art567b-t not 2hen there is com"etition from a stim-l-s on the o""osite side. 9sk the "atient to close their eyes and to tell yo- if they feel a to-ch on their left or right567-se any body "art567commonly hands and feet as a B-ick 56@screen56A.

To-ch the right hand, then the left hand, then both. The to-ches sho-ld be re"eated randomly to confirm the res-lt.
o

E.g. in a right sided "arietal lesion, the "atient 2ill feel both left and right stim-li b-t 2hen both sides are to-ched, they 2ill only be able to feel the stim-l-s on the left.

P.EP!

Jibration sense 9 !%/H3 t-ning fork 1com"are 2ith C,+J0004 is -sed. 9sk the "atient to close their eyes, ta" the t-ning fork and "lace the base on a bony "rominence567ask if the "atient can feel the )ibration. 0f 56@yes56A, confirm by taking hold of the t-ning fork 2ith yo-r other hand to sto" the )ibration after asking the "atient to tell yo- 2hen the )ibration ceases.

9s al2ays, com"are left to right and 2ork in a systematic fashion, testing bony "rominences to incl-de:
o

:inger ti", 2rist, elbo2, sho-lder, anterior s-"erior iliac s"ine, tibial t-berosity, matatarso+"halangeal Coint and toes.

Pro"rioce"tion Testing "ro"rioce"tion in the 2ay described belo2 is rather cr-de and res-lts m-st be inter"reted 2ith the rest of the history and examination. Ioss of "osition sense is -s-ally distal. tart by testing the "atientDs big toe as belo2. This techniB-e can be -sed at any Coint. =ith the "atientDs eyes closed and leg relaxed, gras" the distal "halanyx of the big toe from the sides. =hilst stabili3ing the rest of the foot, yo- sho-ld mo)e the toe -" and do2n at the Coint.

9sk the "atient if they can feel any mo)ement567and in 2hich direction. :lex and extend the Coint, sto""ing at inter)als to ask the "atient 2hether the toe is 56@-"56A or 56@do2n56A. 0f "ro"rioce"tion is absent, test other Coints, 2orking "roximally. 5LM The toe is gri""ed from the sides567if held incorrectly, "ress-re on the nail may s-ggest the toe is "ressed do2n and so on. 5LM ,ormal "ro"rioce"tion sho-ld allo2 the "atient to identify )ery s-btle mo)ements 2hich are barely )isible.

Oox !&.R NombergDs sign 9 f-rther test of Coint "osition sense. =hen "ro"rioce"tion is lost in the limbs, "atients can often stand and mo)e normally as long as they can see the limb in B-estion.

Perform 2ith care567only if yo- are able to safely catch the "atient in the e)ent of a fallK 9sk the "atient to stand567and yo- stand facing them. 9sk the "atient to close their eyes. 0f there is loss of "ro"rioce"tion, the "atient 2ill lose their balance and fall567if so, catch them 2ith care, asking them to o"en their eyes again immediately if they ha)enDt already done so.

P.EP% Pain 1"in+"rick4 (se a dis"osable "in or safety "in567not a hy"odermic needle as these break the skin 1a line of tiny 2o-nds -" a "atientDs arm or 2ee"ing oedema -" a shin is an infection risk and )ery embarrassingK4. Test as yo- 2o-ld for light to-ch, gently "ressing the "in on the skin. Test each dermatome in a systematic 2ay, ma""ing o-t abnormalities.

On each to-ch, ask the "atient to say 2hether it feels shar" or d-ll. Occasionally test the "atientDs reliability as a 2itness 2ith a negati)e control by -sing the o""osite 1bl-nt4 end of the "in.

Tem"erat-re This is not ro-tinely tested o-tside of s"ecialist clinics. Ioss of tem"erat-re sensation may be e)ident from the history 1accidental b-rns;4. =hen tested, test t-bes or similar )essels containing hot and ice+cold 2ater are -sed567and each dermatome tested as abo)e.

Nemember to ens-re the exterior of the t-be is dry.

P.EPE P.EPP Co+ordination Co+ordination sho-ld be tested in conC-nction 2ith gait 1 ".EF&4. Cerebellar lesions ca-se

incoordination on the i"silateral side 1 ".EF'4. :or each of the follo2ing, com"are "erformance on the left and right. (""er limbs :inger+nose test 9sk the "atient to to-ch the end of their nose 2ith their index finger. Hold yo-r o2n finger o-t in front of them567at armDs reach from the "atient567and ask them to then to-ch the ti" of yo-r finger 2ith theirs.

9sk them to mo)e bet2een their nose and yo-r finger 1:ig. !&.%&4. Iook for intention tremor 12orse as it a""roaches the target4 and 56@"ast+"ointing56A 1missing the target entirely4. The test can be made more diffic-lt by mo)ing the "osition of yo-r finger each time the "atient to-ches their nose.

Na"id alternating mo)ements 1This is hard to describe and sho-ld be demonstrated to the "atient4. 9sk the "atient to re"eatedly s-"inate and "ronate their forearm kee"ing the other arm still s-ch that they cla" their hands "alm+to+"alm, then back+to+"alm and so on 1see :ig. !&.%!4. 9lternati)ely, ask them to mimic scre2ing in a light+b-lb.
o

lo2 and cl-msy ? dysdiadokokinesis. This is the inability to "erform ra"idly alternating mo)ements 1diadoke ? 8reek for s-ccession4. M-ch conf-sion seems to s-rro-nd this, 2ith many st-dents thinking that the act-al test is called dysdiadokokinesis. This is not the case.

Nebo-nd :rom a resting 1arms at their side4 "osition, the "atient sho-ld be asked to B-ickly abd-ct their arms and sto" s-ddenly at the hori3ontal. o 0n cerebellar disease, there 2ill be delay in sto""ing and the arm 2ill oscillate abo-t the intended final "osition.

9lternati)ely, "-ll on the "atientDs flexed arms 1as if testing elbo2 flexion "o2er4 and s-ddenly let go. 0f lacking co+ordination, the "atient 2ill hit hisHherself in the face. This test does little for doctor+"atient tr-st and ra""ort and is rarely "erformed for ob)io-s reasons1K4

Io2er limbs Heel+shin test =ith the "atient sitting, legs o-tstretched, ask them to slide the heel of one foot -" and do2n the shin of the other leg at a moderate "ace. o 9 lack of coordination 2ill manifest as the heel mo)ing side to side abo-t the intended "ath.
o

0n sensory567as o""osed to cerebellar567ataxia 1lack of "ro"rioce"tion4, "atients 2ill "erform 2orse 2ith their eyes closed.

:oot ta""ing The "atient ta"s yo-r hand 2ith their foot as fast as "ossible. o ,O The non+dominant side "erforms "oorly in normal indi)id-als. P.EPF

:ig. !&.%& :inger+nose testing.

:ig. !&.%! Testing ra"idly alternating mo)ements. This can be rather hard to describe to a "atient567a brief demonstration is -s-ally reB-ired. P.EPR ome "eri"heral ner)es

Peri"heral ner)e lesions may occ-r in isolation 1e.g. tra-ma, com"ression, neo"lasia4 or as "art of a 2ider "athology 1e.g. monone-ritis m-lti"lex4. The follo2ing "ages describe the signs follo2ing lesions of a selection of "eri"heral ner)es. (""er limb Median ner)e 1CR+T!4 Motor: m-scles of the anterior forearm, exce"t flexor car"i -lnaris, and 56@IO9:56A 1lateral % l-mbricals, o""onens "ollicis, abd-ctor "ollicis bre)is and flexor "ollicis bre)is4. ensory: th-mb, anterior index and middle fingers as 2ell as some of the radial side of the "alm 1see :ig. !&.%%4.

Examining a lesion:
o o

=eakness and 2asting of the thenar eminence. =ith the hand lying flat, "alm -", hold yo-r "en abo)e the th-mb and ask the "atient to mo)e their th-mb )ertically to to-ch it 156@"en+to-ching test56A4567they 2ill not be able to. ,O567often "o2er is good here des"ite sym"toms and ob)io-s car"el t-nnel syndromeK :or lesions of the ner)e at the c-bital fossa, "erform OchsnerDs Clas"ing Test for 2eakness of flexor digitor-m s-"erficialis567ask the "atient to clas" their hands together. 0f a lesion is "resent, the index finger 2ill fail to flex.

(lnar ner)e 1C/+T!4 Motor: all the small m-scles of the hand exce"t IO9: 1see abo)e4 and flexor car"i -lnaris. ensory: -lnar side of hand, little finger and half of ring finger 1see :ig. !&.%%4.

Examining a lesion:
o

Hard to test. There may be )isible 2asting of the small m-scles of the hand 2ith cla2ing of the fingers 1extension at the "halangeo+metacar"al Coints and flexion at the inter"halangeal Coints4. :romentDs sign: 9sk the "atient to gras" a "iece of "a"er bet2een their th-mb and forefinger. 9lternati)ely, ask them to make a fist. The th-mb is -nable to add-ct so 2ill flex instead 1see :ig. !&.%E4.

Nadial ner)e 1CF+C/4 Motor: trice"s, brachioradialis, and extensors of the hand. ensory: a small area o)er the anatomical sn-ff box567hard to test.

Examining a lesion:

Iook for 56@2rist dro"56A. 0f not ob)io-s, ask the "atient to flex at the elbo2, "ronate the forearm and extend the 2rist 1yo- may need to demonstrate4. =rist 2eakness 2ill become clear.

P.EP'

:ig. !&.%% ensory distrib-tion of the maCor "eri"heral ner)es in the hand. There is considerable o)erla" and the small area s-""lied by the radial ner)e may not be detectable clinically.

:ig. !&.%E :romentDs sign. 1a4 ,ormal. 1b4 :romentDs "ositi)e. P.EP/ Io2er limb Iateral c-taneo-s ner)e of the thigh 1I%+IE4 Motor: none.

ensory: the lateral as"ect of the thigh 1see :ig. !&.%P4. Examining a lesion:
o

There may be some sensory loss as indicated b-t, in "ractice, this is )ery hard to test.

Common "eroneal ner)e 1IP+ %4 Motor: anterior and lateral com"artments of the leg. ensory: the dors-m of the foot and anterior as"ect of the leg.

Examining a lesion:
o

56@:oot+dro"56A 2ith corres"onding gait 1 dorsiflexion 1

".EF&4. =eakness of foot

".E%/4 and e)ersion. Preser)ed in)ersion. 1:ig. !&.%Pb.4

,O. 0n an IF lesion, there 2ill be a similar deficit b-t 2ill also dis"lay a 2eakness of in)ersion, hi" abd-ction and knee flexion.

:emoral ner)e 1I%+IP4 Motor: B-adrice"s. ensory: medial as"ect of thigh and leg 1see :ig. !&.%Pd4.

Examining a lesion:
o

=eakness of knee extension is only slightly affected567hi" add-ction is "reser)ed 1 ".E%/4.

tretch: =ith the "atient lying "rone, abd-ct the hi", flex the knee and "lantar+ flex the foot. The stretch test is "ositi)e if "ain is felt in the thighHing-inal region.

ciatic ner)e 1IP+ E4 Motor: all the m-scles belo2 the knee and some hamstrings. ensory: "osterior thigh, ankle and foot 1see :ig. !&.%Pc4.

Examining a lesion:
o

:oot dro" and 2eak knee flexion 1 \nee Cerk reflex 1

".E%/4.

".EE&4 is "reser)ed b-t ankle Cerk and "lantar res"onse 1

".EE%4 are absent.

tretch test: 2ith the "atient lying s-"ine, hold the ankle and lift the leg, straight, to G&#W. Once there, dorsiflex the foot. 0f "ositi)e, "ain 2ill be felt at the back of the thigh.

Oox !&.' TinelDs sign 9 test for ner)e com"ression. Commonly -sed at the 2rist to test for median ner)e com"ression in car"al t-nnel syndrome. Perc-ss the ner)e o)er the site of "ossible com"ression 1at the 2rist, gently ta" centrally near the flexor "almaris tendon4. 0f the ner)e is com"ressed, the "atient 2ill ex"erience tingling in the distrib-tion of the ner)e on each ta". P.EPG

:ig. !&.%P <istrib-tion of the sensory com"onent of some lo2er limb ner)es. 1a4 Iateral c-taneo-s ner)e of the thigh. 1b4 Common "eroneal ner)e. 1c4 ciatic ner)e. 1d4 :emoral ner)e. P.EF& 8ait

This is easily missed from the ne-rological examination567it is often diffic-lt to test in a cro2ded 2ard or cram"ed cons-lting room. Ho2e)er, yo- sho-ld try to incor"orate it into yo-r assessment. 8ait can be obser)ed informally as the "atient makes their 2ay to the clinic room or ret-rns to their chair on the 2ard. =atch the "atient stand567and -se the same o""ort-nity for NombergDs test 1 Oox !&.R ".EP!4. Patient may be sim"ly lacking in confidence and this 2ill be e)ident later. <o not test if yos-s"ect a se)ere "roblem 2ith balance. Examination 9sk the "atient to 2alk a fe2 metres, t-rn and 2alk back to yo-. ,ote es"ecially:
o o o o o o o

(se of 2alking aids. ymmetry. i3e of "aces. Iateral distance bet2een the feet. Ho2 high the feet and knees are lifted. Oony deformities. <ist-rbance of normal gait by abnormal mo)ements.

So- may 2ant to consider asking the "atient to:

o o

=alk on ti"+toes 1inability ? ! or gastrocnemi-s lesion4. =alk on their heels 1inability ? IPHIF lesion567foot dro"4.

:indings Hemi"legia: one side 2ill be ob)io-sly 2eaker than the other 2ith the "atient tilting "el)is to lift the 2eak leg 2hich may s2ing o-t to the side. 8ait may be -nsafe 2itho-t the -se of 2alking aid. 56@ cissoring56A: if both legs are s"astic 1cerebral "alsy, M 4, toes drag on floor, tr-nk s2ays from side+to+side, and legs cross o)er on each ste".

Parkinsonism: flexed "ost-re 2ith small, sh-ffling ste"s. ,o or little arm+s2ing. <iffic-lty starting, sto""ing and t-rning. 8ait seems h-rried 156@festinant56A4 as legs attem"t to "re)ent body falling for2ards. Cerebellar ataxia: broad based 1legs 2ide4 gait 2ith l-mbering body mo)ements and )ariable distance bet2een ste"s. <iffic-lty t-rning 1be there to catch themK4. ensory ataxia: 1loss of "ro"rioce"tion4 "atient reB-ires more sensory in"-t to be s-re of leg "osition so lifts legs high 156@high+ste""ing56A4 and stam"s feet do2n 2ith a 2ide+

based gait567may also 2atch legs as they 2alk. NombergDs "ositi)e 1see ".EP!4.

Oox !&.R

=addling: 12eakness of "roximal lo2er limb m-scles4 "atient fails to tilt "el)is as normal so 5Y[ rotation to com"ensate567also at the sho-lders. May also see 5Y[ l-mbar lordosis. :oot dro": 1IPHIF lesion, sciatic, or common "eroneal ner)es4 fail-re to dorsiflex the foot leads to a 56@high+ste""ing56A gait 2ith 5Y[ flexion at the hi" and knee. 0f bilateral, may indicate "eri"heral ne-ro"athy. P.EF!

9"raxic: 1-s-ally frontal lobe "athology s-ch as normal "ress-re hydroce"hal-s or cerebro)asc-lar disease4 "roblems 2ith gait e)en if all other mo)ements may be normal. Patient may a""ear fro3en to the s"ot and -nable to initiate 2aking. Mo)ements are disCointed once 2alking. Marche c "etits "as: 1diff-se cortical dysf-nction4 ("right "ost-re, small ste"s 2ith a normal arm+s2ing. Painf-l gait: The ca-se 2ill normally be ob)io-s from the history. The "atient lim"s 2ith an asymmetrical gait d-e to "ainf-l mo)ement. :-nctional: 1also kno2n as hysterical4 8ait "roblems 2ill be )ariable and inconsistent, often 2ith bi3arre and elaborate conseB-ences. May fall 2itho-t ca-sing inC-ry. Often 2orse 2hen 2atched.

P.EF% 0m"ortant "resenting "atterns ,eck stiffness Ca-sed by a n-mber of conditions "ro)oking "ainf-l extensor m-scle s"asm incl-ding bacterial and )iral meningitis, s-barachnoid haemorrhage, "arkinsonism, raised intracranial "ress-re, cer)ical s"ondylosis, cer)ical lym"hadeno"athy, and "haryngitis. 5LM ,one of the follo2ing tests sho-ld be cond-cted if there is s-s"icion of cer)ical inC-ry or instability. Testing stiffness Iie the "atient flat. Taking their head in yo-r hands, gently rotate it to the sides in a 56@no56A mo)ement, feeling for stiffness.

Iift the head off the bed and 2atch the hi"s and knees567the chin sho-ld easily to-ch the chest.

Or-d3inskiDs sign =hen the head is flexed by the examiner, the "atient briefly flexes at the hi"s and knees567a test for meningeal irritation. \ernigDs sign 9 f-rther test of meningeal irritation. =ith the "atient lying flat, flex their hi" and knee, holding the 2eight of the leg yo-rself.

=ith the hi" flexed to G&#W, extend the knee Coint so as to "oint the leg at the ceiling. 0f 56@"ositi)e56A, there 2ill be resistance to leg straightening 1ca-sed by hamstring s"asm as a res-lt of inflammation aro-nd the l-mbar s"inal roots4 and "ain felt at the back of the neck.

IhermitteDs "henomenon 9 test for an intrinsic lesion in the cer)ical cord 1not meningeal irritation4. =hen the neck is flexed as abo)e, the "atient feels an electric shock+like sensation do2n the centre of their back. P.EFE

:ig. !&.%F Testing for \ernigDs sign. The "atientDs leg is flexed at the hi" and knee, then extended at the knee as abo)e. 0f "ositi)e, there is resistance to knee extension in this "osition and "ain is felt at the back of the neck. P.EFP (""er motor and lo2er motor ner)e lesions (""er motor ne-ron 1(M,4 lesions

<efined as damage abo)e the le)el of the anterior horn cell567any2here from the s"inal cord to the "rimary motor cortex. ,o m-scle 2asting 1altho-gh 2ill ha)e dis-se atro"hy in long+term 2eakness4. 5Y[ tone. 56@ "asticity56A 1clas"+knife4 d-e to stretch reflex hy"ersensiti)ity.

Ty"ical "attern of 2eakness is termed 56@"yramidal56A:

o o

(""er limbs: 2eak abd-ctors and extensors. Io2er limbs: 2eak add-ctors and flexors.

5Y[ tendon reflexes and clon-s. ("+going "lantar res"onse.

Io2er motor ne-ron 1IM,4 lesions M-scle 2asting. :ascic-lations. 5YZ tone

:laccid 2eakness. 5YZ tendon reflexes. Plantar res"onse may be do2n+going or absent.

Oox !&./ ome definitions of 2eakness Mono"legia: one limb affected. Hemi"legia: one side of the body 1left or right4. Para"legia: both lo2er limbs affected. U-adri"legia: all P limbs. Motor ne-ron disease 1M,<4 ee

OHCMR, ".EGP. <amage to anterior horn cells, med-lla, and s"inal tracts. (M, and IM, "attern of 2eakness. :ascic-lations almost al2ays "resent. Neflexes normal or 5Y[ -ntil later in the disease. Plantar res"onse is -"+going. External oc-lar m-scles almost ne)er in)ol)ed. ,o sensory dist-rbance 1disting-ishing the "resentation from a "olyne-ro"athy4.

P.EFF Parkinsonism 9 "attern of sym"toms com"rising an akinetic+rigid syndrome. Parkinsonism has a n-mber of ca-ses incl-ding dr-g+ind-ced and other intracranial "athologies. The diagnosis of ParkinsonDs disease 1loss of do"aminergic ne-rons in the s-btantia nigra4 is often inacc-rate and there is no single test. ee OHCMR, ".E/%.

9 triad of resting tremor, bradykinesia and rigidity. :ace: mask+like and ex"ressionless facies, little blinking, "ositi)e glabellar ta" reflex 1 ".EEP4.

8ait: flexed "ost-re 2ith 5YZ arm s2ing. 8ait is 56@festinant56A meaning 56@h-rried56A often in small, sh-ffling ste"s 2ith feet barely lifted off gro-nd. lo2 to start and diffic-lty sto""ing. Tone: 5Y[ tone 2ith 56@cog2heel56A or 56@lead+"i"e56A rigidity 1 Tremor: 56@"ill+rolling56A flexion at the th-mb and forefinger at P+/H3. "eech: extra"yramidal dysarthria, soft, B-iet, and hesitant s"eech. So- may ha)e to 2ait some time for the ans2er to a B-estionK =riting: 2riting is small and neat 56@microgra"hia56A. ".E%P4.

9bnormal mo)ements defined 9kathisia: motor restlessness 2ith a feeling of m-scle B-i)ering and an inability to remain in a sitting "osition. 9thetosis: slo2, 2rithing in)ol-ntary mo)ements often 2ith flexion, extension, "ronation, and s-"ination of the fingers and 2rists.

Ole"haros"asm: intermittent s"asm of m-scles aro-nd the eyes. Chorea: non+rhythmical, dance+like, s"asmodic mo)ements of the limbs or face. 9""ear "se-do+"-r"osef-l 1the "atient often hides the condition by t-rning a s"asm into a )ol-ntary mo)ement567e.g. the arm s-ddenly lifts -" and the "atient "retends they 2ere adC-sting their hair4. <yskinesia: re"etiti)e, a-tomatic mo)ements that sto" only d-ring slee". Tardi)e dyskinesia: dyskinetic mo)ements often of the face 1li"+smacking, t2isting of the mo-th4. Often a side+effect of ne-role"tic thera"y. <ystonia: markedly 5Y[ tone often 2ith s"asms ca-sing -ncomfortable+looking "ost-res. Hemiballism-s: )iolent in)ol-ntary flinging mo)ements of the limbs on one side567rather like se)ere chorea. Myoclon-s: brief, shock+like mo)ement of a m-scle or m-scle+gro-". Pse-doathetosis: 2rithing limb mo)ements 1often fingerHarm4 m-ch like athetosis b-t ca-sed by a loss of "ro"rioce"tion. The arm ret-rns to the normal "osition 2hen the "atient notices it straying. Myokymia: contin-o-s B-i)ering and ri""ling mo)ements of m-scles at rest like a 56@bag or 2orms56A. :acial myokymia: es"ecially near the eyes.

Tic: re"etiti)e, acti)e, habit-al, "-r"osef-l contractions ca-sing stereoty"ed actions. Can be s-""ressed for brief "eriods 2ith effort. Tit-bation: rhythmical contraction of the head. May be either 56@yes+yes56A or 56@no+ no56A mo)ements. Tremor: re"etiti)e, alternating mo)ements, -s-ally in)ol-ntary.

P.EFR "inal cord lesions 9s ne-rons in some s"inal cord tracts relate to the contralateral side of the body, others the i"silateral side, certain ty"es of s"inal cord damage 2ill gi)e "redictable "atterns of motor and sensory loss. Com"lete section of the cord Ioss of all modalities belo2 the le)el of the lesion. Hemisection of the cord 9lso kno2n a 56@Oro2n+ eB-ard syndrome56A`. Motor: belo2 the le)el of the lesion, (M, "attern of 2eakness on i"silateral side. ensory: belo2 the le)el of the lesion:
o o o

Contralateral loss of "ain and tem"erat-re sensation. 0"silateral loss of light+to-ch, )ibration sense, and "ro"rioce"tion. 1Iight to-ch may remain intact as some fibres tra)el in the s"inothalamic tract.4

Posterior col-mn loss Ioss of )ibration sense and "ro"rioce"tion on both sides belo2 the le)el of the lesion. -bac-te combined degeneration of the cord 56@Posterolateral col-mn syndrome56A often d-e to )itamin O!% deficiency. Ioss of )ibration sense and "ro"rioce"tion on both sides belo2 the le)el of the lesion. (M, 2eakness in lo2er limbs, absent ankle reflexes.

1also "eri"heral sensory ne-ro"athy, o"tic atro"hy and dementia567see ".REP4.

OHCMR,

9nterior s"inal artery occl-sion Ioss of "in+"rick and tem"erat-re sensation belo2 the lesion. 0ntact light+to-ch, )ibration sense, and "ro"rioce"tion Central lesions E.g. syringomyelia567longit-dinal ca)ities in the central "art of the s"inal cord and brainstem. Ioss of "ain and tem"erat-re sensation o)er the neck, sho-lders, and arms in a 56@ca"e56A distrib-tion. 0ntact )ibration sense, "ro"rioce"tion, and light to-ch.

9tro"hy and areflexia in the arms. (M, 2eakness in the lo2er limbs. Iook also for scoliosis d-e to 2eakness of "ara)ertebral m-scles.

P.EF' Cerebellar lesions 1 ee also

OHCMR, ".E/'4 igns are i"silateral to the lesion and may incl-de: ".E&'4. ".%/R4.

,ystagm-s 1

"eech is staccato, scanning 1

5YZ tone, drift and tremor in limbs 1-""er es"ecially4. :inger+nose testing 1 <ysdiadokokinesis 1 Nebo-nd 1 ".EPP4. ".EPP4 may re)eal intention tremor and "ast+"ointing. ".EPP4.

Pend-lar Cerks567best seen in the knee. Test the tendon reflex at the knee as normal. 0f 56@"end-lar56A, the extensor res"onse 2ill contin-e to se)eral beats. Poor sitting balance. 9taxic gait.

<ist-rbance of higher f-nctions 9 selection of testable conseB-ences of cortical lesions56> Parietal lobe

ensory and )is-al inattention 1 Jis-al field defects 1 ".%GP4.

".EP& and ".%GE4.

9gnosias 1lack of sensory "erce"t-al abilities4.

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Hemi+neglect567"atient ignores one side of their body. 9somatagnosia567"atient fails to recogni3e o2n body "art. 9nosagnosia567"atient is -na2are of ne-rological deficits.

:inger agnosia567"atient is -nable to sho2 yo- different fingers 2hen reB-ested 1e.g. 56@sho2 me yo-r index finger56A4. 9stereognosis567inability to recogni3e an obCect by to-ch alone. 9gra"haesthesia567inability to recogni3e letters or n-mbers 2hen traced on the back of the hand. Proso"agnosia567inability to recogni3e faces 1test 2ith family members or famo-s faces from a nearby maga3ine4.

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9"raxias 1inability to "erform mo)ements or -se obCects correctly4.

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0deational a"raxia567-nable to "erform task b-t -nderstands 2hat is reB-ired. 0deomotor a"raxia567"erforms task b-t makes mistakes 1e.g. "-ts tea into kettle and "o-rs milk into c-"4. <ressing a"raxia567inability to dress correctly 1test 2ith a dressing go2n4. One of a n-mber of a"raxias named after the action tested.

8erstmannDs syndrome: Night+left dissociation, finger agnosia, dysgra"hia 12riting defect4, dyscalc-lia 1test 2ith serial 's567 ".F&%4.

Tem"oral lobe Memory loss567confab-lation 1in)ented stories and details4. :rontal lobe Primiti)e reflexes. Concrete thinking 1-nable to ex"lain "ro)erbs567e.g. ask to ex"lain 2hat 56@a bird in the hand is 2orth t2o in the b-sh56A means4.

Ioss of smell sensation. 8ait a"raxia 1 ".EF&4.

P.EF/ Myo"athies M-scle disease ca-ses a 2eakness similar to that of IM, lesions 2ith no sensory loss. Tendon reflexes are red-ced or absent. The ca-ses and ty"es are n-mero-s 1 OHCMR, ".EG/4. Myotonias Characteri3ed by contin-ed, in)ol-ntary m-scle contraction after )olo-ntary effort has ceased. Myotonic dystro"hy: 1a defect of skeletal m-scle Cl+ channels ca-sed by a trin-cleotide re"eat, -s-ally. Oecomes e)ident age %&+F&4.

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<istal limb 2eakness. =eak sternomastoids 1e)ident by 2eakness of neck flexion 2ith normal "o2er on neck extension4. =eak facial m-scles 1ex"ressionless face4. Test by shaking the "atientDs hand567they may be -nable to let go. 9lso associated 2ith frontal baldness, cataracts 1look for thick glasses4, mild intellect-al im"airment, cardiomyo"athy, hy"ogonadism, and gl-cose intolerance.

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Perc-ssion myotonia:
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Ta" the "atientDs thenar eminence, this 2ill ca-se contraction and )ery slo2 relaxation of abd-ctor "ollicis bre)is.

Myaesthenia gra)is 9n a-toimm-ne disease 2ith antibodies against acetylcholine rece"tors. Com"lex "alsies567incl-ding extraoc-lar m-scles. =eakness is "roximal and often incl-des the eyelids 1"tosis4 and m-scles of mastication. =eakness increases 2ith -se. Patients re"ort 5Y[ se)erity of sym"toms at the end of the day.

0n the early stages, 2ill feel tired as they ex"end extra energy in "erforming ro-tine tasks. :riends may notice "tosis 1see :ig. !&.%F4. Test for fatig-ability:
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9sk the "atient to look to the ceiling and hold the "osition. =atch for "tosis. 9sk the "atient to hold their arms abo)e their head567or o-t to the sides5672atch for 5Y[ 2eakness.

P.EFG ome characteristic headaches s-mmari3ed Tension headache Oilateral567frontal, tem"oral. ensation of tightness radiating to neck and sho-lders.

Can last for days. ,o associated sym"toms.

-barachnoid haemorrhage -dden, dramatic onset 56@like being hit 2ith a brick56A. Occi"ital initially567may become generali3ed.

9ssociated 2ith neck stiffness and sometimes "hoto"hobia.

in-sitis :rontal, felt behind the eyes or o)er the cheeks. Ethmoid sin-sitis is felt dee" behind the nose.

O)erlying skin may be tender. =orse on bending for2ards. Iasts !+% 2eeks. 9ssociated 2ith cory3a.

Tem"oral 1giant cell4 arteritis <iff-se, s"reading from the tem"le567-nilateral. Tender o)erlying tem"oral artery 1"ainf-l br-shing hair4.

;Ca2 cla-dication 2hilst eating. ;bl-rred )ision567can lead to loss of )ision if se)ere and -ntreated.

Meningitis 8enerali3ed.

9ssociated 2ith neck stiffness and signs of meningism 1 ,a-sea, )omiting, "hoto"hobia.

".EF%4.

1P-r"-ric rash is ca-sed by se"ticaemia, not meningitis "er se4.

Cl-ster headache Na"id onset, -s-ally felt o)er one eye. 9ssociated 2ith a blood+shot, 2atering eye, and facial fl-shing.

May also ha)e rhinorrhoea 1r-nny nose4. Iast for a fe2 2eeks at a time.

Naised intracranial "ress-re 8enerali3ed headache, 2orse 2hen lying do2n, straining, co-ghing, on exertion or in the morning. Headache may 2ake the "atient in the early ho-rs.

May be associated 2ith dro2siness, )omiting, and focal ne-rology.

Migraine (nilateral567rarely crosses the midline`. ThrobbingH"o-nding headache.

9ssociated 2ith "hoto"hobia, na-sea, )omiting, and neck stiffness.

May ha)e "receding a-ra.

Hence the name. 56@Migraine56A is a shortening of 56@hemicrani-m56A 1say the %nd and Erd syllables o-t lo-d if yo- donDt belie)e -s4 meaning 56@half the head56A. P.ER& The -nconscio-s "atient History Eye+2itness acco-nt; tate of clothing567loss of continence; Iook for alert necklaceHbracelet. Iook in 2allet, "-rse etc. Examination 1see also OHCMR, ".'''4 9OC: 1co)ered in detail in other Oxford Handbooks4. o 0s the air2ay "atent; ho-ld the "atient be in the reco)ery "osition;
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Meas-re res"iratory rate, note "attern of breathing. 0s O% needed; Cyanosis; :eel "-lse. Iisten to chest. Meas-re heart rate, OP.

kin: look for inC-ry, "etechial haemorrhage, e)idence of 0J dr-g+-se. Mo)ementsH"ost-re:

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=atchK 0s the "atient still or mo)ing; 9ll P limbs mo)ing eB-ally; 9ny abnormal mo)ements567fitting, myoclonic Cerks; Test tone and com"are both sides. B-ee3e the nail bed to test the res"onse to "ain 1all P limbs4. Test tendon reflexes and "lantar res"onse. <ecorticate "ost-re: 1lesion abo)e the brainstem4 flexion and internal rotation of the arms, extension of the lo2er limbs. <ecerebrate "ost-re: 1lesion in the midbrain4 extension at the elbo2, "ronation of the forearm and extension at the 2rist. Io2er limbs extended.

Conscio-sness: attem"t to 2ake the "atient by so-nd. 9sk their name. 0f res"onsi)e, are they able to artic-late a""ro"riately;567,ote the best res"onse. Oe a2are of "ossible dys+ or a"hasia 2hich may ca-se an ina""ro"riate res"onse in an other2ise alert indi)id-al.
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core le)el of conscio-sness according to the 8C 1Oox !&.G4.

,eck: do not examine if there may ha)e been tra-ma. Test for meningeal irritation 1 ".EF%4567these signs 5YZ as coma dee"ens. Head: ins"ect for signs of tra-ma and facial 2eakness. Test "ain sense.
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OattleDs sign: br-ising behind the ear ? a base of sk-ll fract-re.

EarsHnose: look for C : leakage or bleeding. Test any clear fl-id for gl-cose 1"ositi)e res-lt ? C :4. 0ns"ect eardr-ms. Tong-eHmo-th: Iook for c-ts on the tong-e 1sei3-res4, corrosi)e material aro-nd the mo-th. mell breath for alcohol or ketosis. Test the gag reflex567absent in brainstem disease or dee" coma. Eyes:
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P-"ils: meas-re si3e in mm. 9re they eB-al 1 ".E&%4; Test direct and consens-al light res"onses. P-"ils 5Y[ 2ith atro"ine, tricyclic antide"ressants, and am"hetamine; 5YZ 2ith mor"hine and metabolic coma. Test corneal reflex. :-ndi: look es"ecially for "a"illoedema and retino"athy. <ollDs head manoe-)re: take the "atientDs head in yo-r hands and t-rn it from side+ to+side. The eyes sho-ld mo)e to stay fixed on an obCect567indicates an intact brainstem.

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P.ER!

Nest of the body: a brief b-t thoro-gh exam. Iook es"ecially for tra-ma, fract-res, signs of li)er disease 1 ".%!/4 and added heart so-nds. Other bedside tests: test -rine, ca"illary gl-cose and tem"erat-re.

Oox !&.G 8lasgo2 Coma cale 18C 4 This is an obCecti)e score of conscio-sness. Ne"eated testing is -sef-l for C-dging 2hether coma is dee"ening or lifting. There are E categories as belo2. ,ote that the lo2est score in each is 56@!56A meaning that the lo2est "ossible 8C ? E 1e)en if the "atient is deadK4 Eye o"ening 1max P "oints4 "ontaneo-sly o"en P O"en to 1any4 )erbal stim-l-s E O"en in res"onse to "ainf-l stim-l-s% ,o eye o"ening at all !

Oest )erbal res"onse 1max F "oints4 Con)ersing and orientated 1normal4 F Con)ersing b-t disorientated and conf-sed P 0na""ro"riate 2ords 1random 2ords, no con)ersation4E 0ncom"rehensible so-nds 1moaning etc4 % ,o s"eech at all ! Oest motor res"onse 1max R "oints4 Obeying commands 1e.g. raise yo-r hand4 R Iocalising to "ain 1mo)es hand to2ards site of stim-l-s4F =ithdra2s to "ain 1"-lls hand a2ay from stim-l-s4 P 9bnormal flexion to "ain 1decorticate "ost-ring4 E 9bnormal extension to "ain 1decerebrate "ost-ring4 % ,o res"onse at all ! Oox !&.!& 9JP( 9 m-ch more sim"lified score -sed in ra"id assessment of conscio-sness and often by non+ s"ecialist n-rses in monitoring conscio-s le)el. 9 ? 9lert J ? res"onds to Joice P ? res"onds to Pain ( ? (nres"onsi)e P.ER% The elderly "atient <iagnosing and managing ne-rological illness can be com"lex, b-t the combination of cogniti)e fail-re and the effects of an ageing ne-rological system can "resent significant challenges for clinicians. Presentations of ne-rological disease are )aried, and the range of diagnoses di)erse. E"ile"sy, "arkinsonism, and dementias are all common "roblems in older age567so resist the tem"tation to restrict yo-r diagnoses to stroke or T09. History =itness histories: are )ital. Many "atients may attend 2ith )ag-e sym"toms that may be -nder"layed. Partial com"lex sei3-res may be )ery diffic-lt to diagnose567so "-rs-e 2itness histories from families, neighbo-rs, home care staff etc. EnB-ire not C-st abo-t the "resent incident, b-t "rior f-nction and any decline. <r-g history: falls are a common "resentation and often m-ltifactorial. 9l2ays remember to ask abo-t any dr-gs that may lo2er blood "ress-re, e)en if the "rimary ca-se of the fall is d-e to ne-rological disease.

0nterc-rrent illness: may "reci"itate f-rther sei3-res or make "re+existing ne-rological signs seem 2orse. <onDt r-sh to diagnose a 2orsening of the original "roblem567caref-l assessment "ays di)idends. Cognition and mood disorders: often com"licate "resentations. Iook for cl-es in the history and ask 2itnesses.

:-nctional history: a key "art of the ne-rological history. The disease itself may be inc-rable567f-nctional "roblems often are not.

Examination Obser)e: ,on )erbal cl-es may "oint to mood or cogniti)e disorders. Handshakes and facial ex"ressions are an im"ortant "art of the examination Think: abo-t "atterns of illness, and attem"t to identify if there are single or m-lti"le lesions. There may often be more than one diagnosis567e.g. cerebro)asc-lar disease and "eri"heral ne-ro"athy d-e to diabetes.

9ssess cognition: -se a scale yo- are comfortable 2ith s-ch as the 9bbre)iated Mental Test core 1 9MT ".%//; MM E ".F&E4567b-t remember no half marksK

8ait: e)en sim"le obser)ation of a "atientDs 2alking can rea" re2ards. 9l2ays incl-de it in yo-r examination 2here "racticable and note 2hy if -nable. Thera"y colleag-es: sharing obser)ations is a -sef-l "ractice. Thera"ists are a h-ge fo-nt of kno2ledge and ex"erience so seek to learn from them.

P.ERE 9dditional "oints Comm-nicating diagnoses: many diagnoses567e.g. dementia and motor ne-ron disease,567can be de)astating, so be tho-ghtf-l in yo-r a""roach. Clarify 2hat the "atient kno2s, and 2hat has already been said567learn first from yo-r seniors ho2 to ex"lain the diagnosis, and more im"ortantly talk abo-t its im"act. 0t is also )ital to reass-re567many "atients 2ith benign essential tremors are terrified that they may ha)e ParkinsonDs disease Managing -ncertainty: many diagnoses are not clear, es"ecially in the early stages of diseases. Try to resist labelling yo-r "atients 2hen a diagnosis is -nclear; be o"en abo-t -ncertainty567"atients often co"e 2ith it better than their doctors. =e thank <r Nichard :-ller for "ro)iding this "age.