Clinical Neurological Examination and Localization

Acknowledgments
Contents
About the Author
1: Introduction
	1.1	 Basic Neuroanatomy
2: The Neurological History
	2.1	 Components
		2.1.1	 Demographics
		2.1.2	 History of Present Illness
			2.1.2.1	 Specific Questions to be Enquired in Certain Common Neurological Symptoms
				Motor Weakness
				Headache
				Seizure
				Dizziness
				Numbness
				Diplopia
				Memory Loss
	2.2	 Specific Questions
	2.3	 Negative History
	2.4	 Past Medical History
	2.5	 Family History
	2.6	 Social History
	2.7	 Neurological Examination
		2.7.1	 Format
	2.8	 The Neurological Kit
3: Higher Mental Function
	3.1	 Higher Mental Function
	3.2	 Screening Tests of Higher Mental Function
		3.2.1	 Attention Span and Vigilance
		3.2.2	 Orientation
		3.2.3	 Memory
		3.2.4	 Calculation
		3.2.5	 Abstract Thinking and Judgment
			3.2.5.1	 Abstract Thinking
			3.2.5.2	 Judgment
		3.2.6	 Visuospatial Tests
		3.2.7	 Apraxia
		3.2.8	 Agnosia
		3.2.9	 Appearance, Behavior, Mood, Delusions, and Hallucinations
	3.3	 Specific Lobar Function
	3.4	 Frontal Lobe
		3.4.1	 Functions and Tests According to Functional Regions of Frontal Lobe
			3.4.1.1	 Primary Motor Cortex (Area 4)
		3.4.2	 Premotor Area
		3.4.3	 Supplementary Motor Area (Area 6)
			3.4.3.1	 Released Reflexes
				Grasp
				Sucking (Pout, Spout, Rooting)
				Palmo-Mentalis
				Glabellar Tap
		3.4.4	 Frontal Eye Field Area (Area 8)
		3.4.5	 Broca’s Area (Area 44)
		3.4.6	 Prefrontal Lobe
			3.4.6.1	 Dorsolateral Prefrontal Cortex
			3.4.6.2	 Medial Prefrontal Cortex
			3.4.6.3	 Orbito-Frontal Region
	3.5	 Parietal Lobe
		3.5.1	 Functions of Parietal Lobe and Tests According to Functional Regions of the Parietal Lobe
			3.5.1.1	 Post-Cental Gyrus (Area 3, 1, 2)
			3.5.1.2	 Visual Pathway (Optic Radiation)
			3.5.1.3	 Cuneous (Medial Aspect)
			3.5.1.4	 Superior Parietal and Inferior Parietal Lobe
				Dominant Lobe Lesions
				Nondominant Lobe Lesions
					Constructional Apraxia
					Dressing Apraxia
					Topographic Memory Loss
					Anosognosia
					Hemineglect (Contralateral)
					Hemiasomatognosia
	3.6	 Temporal Lobe
		3.6.1	 Functions and Tests According to Functional Regions of the Temporal Lobe
	3.7	 Occipital Lobe
		3.7.1	 Functions and Tests According to Functional Regions of Occipital Lobe
4: Cranial Nerve Examination
	4.1	 Olfactory Nerve: 1st Cranial Nerve (Figs. 4.1)
		4.1.1	 Neuroanatomy (Figs. 4.2 and 4.3)
		4.1.2	 Clinical Testing
		4.1.3	 Clinical Interpretation
	4.2	 Optic Nerve: 2nd Cranial Nerve
		4.2.1	 Neuroanatomy (Fig. 4.4)
		4.2.2	 Functions
		4.2.3	 Clinical Testing
			4.2.3.1	 Visual Acuity
			4.2.3.2	 Color Vision
			4.2.3.3	 Visual Field testing
			4.2.3.4	 Pupil
			4.2.3.5	 Fundus Examination (Fig. 4.7)
		4.2.4	 Fluorescein Angiography
		4.2.5	 Optical Coherence Tomography (OCT)
	4.3	 Oculomotor (3rd), Trochlear (4th), and Abducens (6th) Cranial Nerves
		4.3.1	 Neuroanatomy
		4.3.2	 Supranuclear Ocular Movements
		4.3.3	 Saccades
		4.3.4	 Pursuit
		4.3.5	 Convergence
		4.3.6	 Vestibular Eye Movements
		4.3.7	 Nystagmus
			4.3.7.1	 Pendular Nystagmus
			4.3.7.2	 Jerk Nystagmus
		4.3.8	 Non-nystagmus Ocular Oscillatory Movements
	4.4	 Ooculomotor or 3rd Cranial Nerve
	4.5	 Trochlear Nerve 4th Cranial Nerve
	4.6	 Abducens or 6th Cranial Nerve
		4.6.1	 Clinical Evaluation
			4.6.1.1	 Ocular Movements
			4.6.1.2	 Diplopia Testing
			4.6.1.3	 Saccadic Eye Movement
			4.6.1.4	 Evaluate Convergence
			4.6.1.5	 Vestibulo-Ocular Reflex (Dolls Eye Movement)
			4.6.1.6	 Evaluation of Nystagmus
		4.6.2	 Clinical Interpretation
	4.7	 Trigeminal or 5th Cranial Nerve
		4.7.1	 Neuroanatomy
		4.7.2	 Sensory Component
		4.7.3	 Motor Component
		4.7.4	 Clinical Evaluation
		4.7.5	 Localization of 5th Nerve According to Signs
	4.8	 Facial Nerve or 7th Cranial Nerve
		4.8.1	 Neuroanatomy (Figs. 4.26 and 4.27)
		4.8.2	 Intracranial Course
		4.8.3	 Extracranial Course
		4.8.4	 Clinical Testing
		4.8.5	 Upper Motor Facial Palsy (UMN)
		4.8.6	 Lower Motor Facial Palsy
		4.8.7	 Sites of LMN 7th Palsy
	4.9	 Vestibulocochlear or 8th Cranial Nerve
		4.9.1	 Neuroanatomy
		4.9.2	 Clinical Testing
			4.9.2.1	 Tests of Cochlear Function
			4.9.2.2	 Tests of Vestibular Function
		4.9.3	 Electronystagmography (ENG)
	4.10	 The Glossopharyngeal (IXth) and Vagus (X) Nerves
		4.10.1	 Neuroanatomy
		4.10.2	 Function
			4.10.2.1	 Glossopharyngeal (IX) (Fig. 4.30)
			4.10.2.2	 Vagus (X) (Figs. 4.31 and 4.32)
		4.10.3	 Clinical Testing
	4.11	 Spinal Accessory Nerve: 11th Cranial Nerve
		4.11.1	 Neuroanatomy
		4.11.2	 Clinical Testing
	4.12	 The Hypoglossal Nerve or XIIth Cranial Nerve
		4.12.1	 Neuroanatomy
		4.12.2	 Clinical Testing
5: Examination of Speech
	5.1	 Language Disorders or Aphasia
		5.1.1	 Spontaneous Speech
		5.1.2	 Comprehension of Speech
		5.1.3	 Repetition
		5.1.4	 Paraphasic Errors
		5.1.5	 Naming: Word Finding Difficulty (Anomia)
		5.1.6	 Reading (Alexia)
		5.1.7	 Writing (Agraphia)
	5.2	 Dysarthria
		5.2.1	 Clinical Evaluation
	5.3	 Dysphonia
6: Motor System Examination
	6.1	 Muscles of Head, Neck, and Face
	6.2	 Muscles of Upper Limb
	6.3	 Muscles of Trunk
	6.4	 Muscles of Lower Limb
7: Reflexes
	7.1	 Superficial Reflexes
		7.1.1	 Abdominal Reflex (T1–T12)
		7.1.2	 Cremasteric Reflex (L1)
		7.1.3	 Anal Reflex (S4/5)
		7.1.4	 Bulbocavernosus (S3/4)
		7.1.5	 Plantar Response or Babinski Response (S1)
	7.2	 Deep Tendon Reflexes
		7.2.1	 Reinforcement of Reflex
		7.2.2	 Grading of Deep Tendon Reflex
		7.2.3	 Components of a Brisk Reflex
		7.2.4	 Inverted Reflex
		7.2.5	 Hung Up Reflex
		7.2.6	 Pendular Jerk
8: Sensory System Examination
	8.1	 Exteroceptive Sensations
	8.2	 Proprioceptive Sensations
		8.2.1	 Pain and Temperature Pathway
			8.2.1.1	 Segmental Sensory Dermatomes
		8.2.2	 Sensory Areas According to Peripheral Nerves
		8.2.3	 Sensory Loss Patterns
	8.3	 Clinical Testing
9: Cerebellar Examination and Examination of Posture, Stance, and Gait
	9.1	 Cerebellar Signs
		9.1.1	 Vermian
		9.1.2	 Hemispherical cerebellar signs
	9.2	 Clinical Tests
		9.2.1	 Dysmetria
			9.2.1.1	 Finger–Nose Test
			9.2.1.2	 Knee-Skin-Heel Test
		9.2.2	 Dysdiadokokinesia
		9.2.3	 Titubation
		9.2.4	 Intention tremor
		9.2.5	 Truncal Ataxia
		9.2.6	 Pendular Knee Jerk
		9.2.7	 Holmes Rebound phenomenon
		9.2.8	 Hypotonia
	9.3	 Posture, Stance, and Gait
		9.3.1	 Posture and Stance
		9.3.2	 Gait
	9.4	 Common Gait Disorders
		9.4.1	 Asymmetrical Gait
			9.4.1.1	 Hemiplegic Gait
			9.4.1.2	 Foot Drop
		9.4.2	 Symmetrical Gait
			9.4.2.1	 Apraxic Gait
			9.4.2.2	 Sensory Ataxia
			9.4.2.3	 Cerebellar Gait
			9.4.2.4	 Paraplegic or Quadriplegic Gait
			9.4.2.5	 Waddling Gait
			9.4.2.6	 Antalgic Gait
10: Involuntary Movements
	10.1	 Types of Movement Disorders
		10.1.1	 Hypokinetic Disorders
		10.1.2	 Hyperkinetic Disorders
			10.1.2.1	 Tremor
				Postural Tremor
				Action Tremor
				Intention Tremor
				Rest Tremor
				Certain Other Tremors
			10.1.2.2	 Chorea
			10.1.2.3	 Athetosis
			10.1.2.4	 Tics
			10.1.2.5	 Hemi-Ballismus
			10.1.2.6	 Dystonia
			10.1.2.7	 Asterixis
			10.1.2.8	 Myoclonus
			10.1.2.9	 Tardive Dyskinesias
11: Examination of Skull, Spine, Nerves, and Neurocutaneous Markers
	11.1	 Skull
	11.2	 Spine
	11.3	 Thickened Nerves
	11.4	 Neurocutaneous Markers
		11.4.1	 Neurofibroma
		11.4.2	 Sturge Weber Syndrome
		11.4.3	 Tuberous Sclerosis
		11.4.4	 Ataxia telangiectasia
		11.4.5	 Hypomelanosis of Ito
		11.4.6	 Von-Hippel-Lindau Disease
12: Autonomic Nervous System Examination
	12.1	 History
	12.2	 Tests for Autonomic Nervous System
		12.2.1	 Inspection of skin
		12.2.2	 Cardiovascular Reflexes
		12.2.3	 Sweating Tests or Sudomotor Tests
		12.2.4	 Rectum
		12.2.5	 Bladder
		12.2.6	 Pupillary Signs
		12.2.7	 Laboratory Tests
13: Examination of the Unconscious Patient
	13.1	 Q 1. What Is the Level of Consciousness?
	13.2	 Q 2. Is the Neurological Examination Focal or Generalized?
	13.3	 Q3 What Is the Possible Site and Etiology of the Lesion?
		13.3.1	 Pattern of Respiration (Fig. 13.3)
		13.3.2	 Motor Status
		13.3.3	 Pupils
		13.3.4	 Ocular Movements
		13.3.5	 Reflexes
		13.3.6	 Sensory Evaluation
		13.3.7	 Other Aspects of Neurological Evaluation
14: Summary of Localization
	14.1	 LMN Lesions
	14.2	 UMN Lesion and Sites