Neurologic Exam-2.4.5.6.7

Examination of Nervous System

Hong Zhang, MD,PhD Department of Neurology Zhongnan Hospital of Wuhan University

Neuroanatomy through Clinical Cases • Hal Blumenfeld Yale University School of Medicine • Publishing Information: September 2001 • ISBN 0-87893-060-4

• • • • • • •

INTRODUCTION MENTAL STATUS CRANIAL NERVES MOTOR EXAM REFLEXES COORDINATION AND GAIT SENSORY EXAM

MOTOR EXAM

MOTOR EXAM The motor exam has several steps including 1. Observation 2. Inspection 3. Palpation 4. Muscle tone testing 5. Functional testing 6. Strength testing of individual muscle groups

MOTOR EXAM First, carefully observe the patient to detect any • Twitches • Tremors • Other involuntary movements • Any unusual paucity of movement suggestive of a movement disorder

MOTOR EXAM •

Next inspect several individual muscles to see if 1. Muscle wasting 2. Hypertrophy 3. Fasciculations (spontaneous quivering movements caused by firing of muscle motor units) • The best muscles to look at for fasciculations in generalized LMN disorders are the intrinsic hand muscles, shoulder girdle, and thigh

MOTOR EXAM • Test muscle tone. Ask the patient to relax, and then passively move each limb at several joints to get a feeling for any resistance or rigidity that may be present

MOTOR EXAM

• General functional tests. Check for drift by having the patient hold up both arms or both legs and close their eyes

MOTOR EXAM Check fine movements by testing 1. rapid finger tapping 2. rapid hand pronation—supination (as in screwing in a light bulb) 3. rapid hand tapping 4. rapid foot tapping against the floor or other object

MOTOR EXAM

• Finally, test the strength of each muscle group and record it in a systematic fashion (see next section)

MOTOR EXAM What is Being Tested? • Involuntary movements and tremors are commonly associated with lesions of the basal ganglia or cerebellum • Tremors can also occasionally be seen with peripheral nerve lesions

MOTOR EXAM What is Being Tested? • Many parts of the motor exam can help distinguish between upper motor neuron and lower motor neuron lesions • Recall that upper motor neurons project via the corticospinal tract to lower motor neurons located in the anterior horn of the spinal cord.

MOTOR EXAM What is Being Tested? • Signs of lower motor neuron lesions include weakness, atrophy, fasciculations, and hyporeflexia (reduced reflexes) • Signs of upper motor neuron lesions include weakness, hyperreflexia (increased reflexes), and increased tone

MOTOR EXAM What is Being Tested? • The hyperreflexia and increased tone seen with corticospinal lesions is apparently caused by damage to pathways that travel in close association with the corticospinal tract rather than directly by damage to the corticospinal tract itself

MOTOR EXAM What is Being Tested? • Note that with acute upper motor neuron lesions there is often flaccid paralysis with decreased tone and decreased reflexes • With time (hours to weeks), increased tone and hyperreflexia usually develop

Signs of Upper Motor Neuron (UMN) and Lower Motor Neuron (LMN) Lesions Sign

UMN Lesions

LMN Lesions

Weakness

Yes

Yes

Atrophy

No*

Yes

Fasciculations

No

Yes

Reflexes

Increased

Decreased

Tone

Increased

Decreased

*Mild atrophy may develop due to disuse

MOTOR EXAM

What is Being Tested? • Increased tone can occur in 1. Upper motor neuron lesions 2. Basal ganglia dysfunction

MOTOR EXAM What is Being Tested? • Slow or awkward fine finger movements or toe tapping in the absence of weakness can signify a subtle abnormality of 1. Corticospinal pathways 2. Cerebellum 3. Basal ganglia

Strength of Individual Muscle Groups Patterns of weakness can help localize a lesion to: 1. Particular cortical or white matter region 2. Spinal cord level 3. Nerve root 4. Peripheral nerve 5. Muscle

Strength of Individual Muscle Groups

• Test the strength of each muscle group and record it in a systematic fashion • It is wise to pair the testing of each muscle group immediately with testing of its contralateral counterpart to enhance detection of any asymmetries

Strength of Individual Muscle Groups Muscle strength is often rated on a scale of 0/5 to 5/5 • 0/5: no contraction • 1/5: muscle flicker, but no movement • 2/5: movement possible, but not against gravity (test the joint in its horizontal plane) • 3/5: movement possible against gravity, but not against resistance by the examiner • 4/5: movement possible against some resistance by the examiner (sometimes this category is subdivided further into 4–/5, 4/5, and 4+/5) • 5/5: normal strength

Strength of Individual Muscle Groups • While testing muscle strength, it is important to keep in mind anatomic information such as which nerves, nerve roots, and brain areas control each muscle and to allow this information to guide the exam • Compare proximal versus distal weakness because these features can sometimes suggest muscle versus nerve disease, respectively

Upper Extremity Strength Testing

Action

Muscles

Nerves

Finger extension

Extensor digitorum, Extensor indicis, Extensor digiti minimi

Radial nerve (posterior C7, C8 interosseous nerve)

Thumb abduction in plane of palm

Abductor pollicis longus

Radial nerve (posterior C7, C8 interosseous nerve)

Finger abduction

Dorsal interossei, Abductor digiti Ulnar nerve minimi

C8, T1

Finger and thumb adduction in plane of palm

Adductor pollicis, Palmar interossei

C8, T1

Ulnar nerve

Nerve Roots

Action

Muscles

Nerves

Nerve Roots

Thumb opposition

Opponens pollicis

Median nerve

C8, T1

Thumb abduction perpendicular to plane of palm

Abductor pollicis brevis

Median nerve

C8, T1

Flexion at distal interphalangeal joints digits 2, 3

Flexor digitorum profundus to digits 2, 3

Median nerve

C7, C8

Flexion at distal interphalangeal joints digits 4, 5

Flexor digitorum profundus to digits 4, 5

Ulnar nerve

C7, C8

Action

Muscles

Nerves

Nerve Roots

Wrist flexion and hand abduction

Flexor carpi radialis

Median nerve

C6, C7

Wrist flexion and hand adduction

Flexor carpi ulnaris

Ulnar nerve

C7, C8, T1

Radial nerve

C5, C6

Wrist extension and hand Extensor carpi radialis abduction

Action

Muscles

Nerves

Nerve Roots

Elbow flexion (with forearm supinated)

Biceps, Brachialis

Musculocutaneous nerve

C5, C6

Elbow extension

Triceps

Radial nerve

C6, C7, C8

Axillary nerve

C5, C6

Arm abduction at shoulder Deltoid

Lower Extremity Strength Testing

Action

Muscles

Nerves

Nerve Roots

Hip flexion Iliopsoas

Femoral nerve, and L1-L3 L1, L2, L3, nerve roots L4

Knee extension

Quadriceps

Femoral nerve

L2, L3, L4

Knee flexion

Hamstrings (semitendinosus, semimembranosus, biceps femoris)

Sciatic nerve

L5, S1, S2

Superior gluteal nerve

L4, L5, S1

Leg Gluteus medius, Gluteus minimus, Tensor abduction fasciae latae

Action

Muscles

Leg adduction Obturator externus, Adductor longus, magnus, and brevis, Gracilis

Nerves

Nerve Roots

Obturator nerve

L2, L3, L4

Toe dorsiflexion

Extensor hallucis longus, Extensor digitorum Deep peroneal nerve longus

L5, S1

Foot dorsiflexion

Tibialis anterior

L4, L5

Deep peroneal nerve

Action

Muscles

Nerves

Nerve Roots

Foot plantar Triceps surae (gastrocnemius, soleus) flexion

Tibial nerve

S1, S2

Foot eversion Peroneus longus, Peroneus brevis

Superficial peroneal nerve

L5, S1

Foot inversion

Tibal nerve

L4, L5

Tibalis posterior

SENSORY EXAM

1.Primary sensation — asymmetry, senso 2.Cortical sensation, including extinction

Primary sensation - asymmetry, sensory level • Light touch is best tested with a cottontipped swab, but a light finger touch will often suffice, as long as care is taken to make the stimulus fairly reproducible • Test the relative sharpness of pain by randomly alternating stimuli with the sharp or dull end of a safety pin (always use a new pin for each patient)

Primary sensation - asymmetry, sensory level

• Temperature sensation can be tested with a cool piece of metal such as a tuning fork

Primary sensation - asymmetry, sensory level • Test vibration sense by placing a vibrating tuning fork on the ball of the patient's right or left large toe or fingers and asking him to report when the vibration stops • Take care not to place the tuning fork on a bone, since bones conduct the vibration to much more proximal sites, where they can be detected by nerves far from the location being tested

Primary sensation - asymmetry, sensory level • Test joint position sense by moving one of the patient's fingers or toes up and down and asking the patient to report which way it moves • Hold the digit lightly by the sides while doing this so that tactile inputs don't provide significant clues to the direction of movement • The digit should be moved very slightly because normal individuals can detect movements that are barely perceptible by eye

Primary sensation - asymmetry, sensory level • Two-point discrimination can be tested with a special pair of calipers, or a bent paper clip, alternating randomly between touching the patient with one or both points • The minimal separation (in millimeters) at which the patient can distinguish these stimuli should be recorded in each extremity

Primary sensation - asymmetry, sensory level • Comparisons should be made from one side of the body to the other and from proximal to distal on each extremity • Note especially if there is a sensory level corresponding to a particular spinal segment below which sensation abruptly changes, since such a change may indicate a spinal cord lesion requiring emergency intervention • Whenever there are uncertainties in the sensory exam, or other parts of the exam, a good strategy is to repeat the relevant portions of the exam several times

Cortical Sensation, Including Extinction • Higher-order aspects of sensation, or cortical sensation, should be tested as well • To test graphesthesia, ask the patient to close their eyes and identify letters or numbers that are being traced onto their palm or the tip of their finger

Cortical Sensation, Including Extinction

• To test stereognosis, ask the patient to close their eyes and identify various objects by touch using one hand at a time

Cortical Sensation, Including Extinction • Test for tactile extinction on double simultaneous tactile stimulation • Note that graphesthesia, stereognosis, and extinction cannot reliably be tested for unless primary sensation is intact bilaterally

Cortical Sensation, Including Extinction What is Being Tested? Somatosensory deficits can be caused by lesions in 1. Peripheral nerves 2. Nerve roots 3. Posterior columns 4. Anterolateral sensory systems in the spinal cord or brainstem 5. Thalamus 6. Sensory cortex

Cortical Sensation, Including Extinction What is Being Tested? • Position and vibration sense ascend in the posterior column pathway and cross over in the medulla • Pain and temperature sense cross over shortly after entering the spinal cord and then ascend in the anterolateral pathway

Cortical Sensation, Including Extinction What is Being Tested? • Intact primary sensation with deficits in cortical sensation such as agraphesthesia or astereognosis suggests a lesion in the contralateral sensory cortex • Severe cortical lesions can cause deficits in primary sensation as well

Cortical Sensation, Including Extinction What is Being Tested? • Extinction with intact primary sensation is a form of hemineglect that is most commonly associated with lesions of the right parietal lobe • Extinction can also be seen in right frontal or subcortical lesions, or sometimes in left hemisphere lesions causing mild right hemineglect

Cortical Sensation, Including Extinction What is Being Tested? The pattern of sensory loss can provide important information that helps localize lesions to 1. Particular nerves 2. Nerve roots 3. Regions of the spinal cord 4. Brainstem 5. Thalamus 6. Cortex

REFLEXES

1.Deep Tendon Reflexes 2.Plantar Response 3.Finger Flexors 4.Reflexes Tested in Special Situations

Deep Tendon Reflexes • Check the deep tendon reflexes using impulses from a reflex hammer to stretch the muscle and tendon • The limbs should be in a relaxed and symmetric position, since these factors can influence reflex amplitude • In muscle strength testing, it is important to compare each reflex immediately with its contralateral counterpart so that any asymmetries can be detected

Deep Tendon Reflexes • If you cannot elicit a reflex, you can sometimes bring it out by certain reinforcement procedures • For example, have the patient gently contract the muscle being tested by raising the limb very slightly, or have them concentrate on forcefully contracting a different muscle group just at the moment when the reflex is tested • When reflexes are very brisk, clonus is sometimes seen. This is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch

Deep Tendon Reflexes Deep tendon reflexes are often rated according to the following scale • 0: Absent reflex • 1+: Trace, or seen only with reinforcement • 2+: Normal • 3+: Brisk • 4+: Nonsustained clonus (i.e., repetitive vibratory movements) • 5+: Sustained clonus

Deep Tendon Reflexes • Deep tendon reflexes are normal if they are 1+, 2+, or 3+ unless they are asymmetric or there is a dramatic difference between the arms and the legs • Reflexes rated as 0, 4+, or 5+ are usually considered abnormal • In addition to clonus, other signs of hyperreflexia include spreading of reflexes to other muscles not directly being tested and crossed adduction of the opposite leg when the medial aspect of the knee is tapped

Deep Tendon Reflexes What is Being Tested? • Deep tendon reflexes may be diminished by abnormalities in 1. Muscles 2. Sensory neurons 3. Lower motor neurons 4. Neuromuscular junction 5. Acute upper motor neuron lesions 6. Mechanical factors such as joint disease

Deep Tendon Reflexes What is Being Tested? • Abnormally increased deep tendon reflexes are associated with upper motor neuron lesions Deep tendon reflexes can be influenced by 1. Age 2. metabolic factors such as thyroid dysfunction or electrolyte abnormalities 3. anxiety level of the patient

Deep Tendon Reflexes Reflex

Main Spinal Nerve Roots Involved

Biceps

C5, C6

Brachioradialis C6 Triceps

C7

Patellar

L4

Achilles Tendon S1

Plantar Response • Test the plantar response by scraping an object across the sole of the foot beginning from the heel, moving forward toward the small toe, and then arcing medially toward the big toe • The normal response is downward contraction of the toes • The abnormal response, called Babinski's sign, is characterized by an upgoing big toe and fanning outward of the other toes

Plantar Response • In some patients the toes are "silent," moving neither up nor down • If the toes are downgoing on one side and silent on the other, the silent side is considered abnormal • The presence of Babinski's sign is always abnormal in adults, but it is often present in infants, up to the age of about 1 year

Finger Flexors • Finger flexor reflexes can help demonstrate hyperreflexia in the upper extremities • Test finger flexors by tapping gently on the palm with the reflex hammer • You can elicit Hoffmann's sign by holding the patient's middle finger loosely and flicking the fingernail downward, causing the finger to rebound slightly into extension

REFLEXES What is Being Tested? • Babinski's sign is associated with upper motor neuron lesions anywhere along the corticospinal tract • Note that it may not be possible to elicit Babinski's sign if there is severe weakness of the toe extensors • Hoffmann's sign, or heightened finger flexor reflexes suggest an upper motor neuron lesion affecting the hands

COORDINATION AND GAIT

1.Appendicular Coordination 2.Romberg test 3.Gait

Appendicular Coordination

• Rapid alternating movements, such as wiping one palm alternately with the palm and dorsum of the other hand, should be tested

Appendicular Coordination

• The most popular test of coordination is the finger—nose—finger test, in which the patient is asked to alternately touch their nose and the examiner's finger as quickly as possible

Appendicular Coordination

• Ataxia is best revealed if the examiner's finger is held at the extreme of the patient's reach, and if the examiner's finger is occasionally moved suddenly to a different location

Appendicular Coordination • Test for overshoot by having the patient raise both arms suddenly from their lap to the level of your hand • In addition, you can apply pressure to the patient's outstretched arms and then suddenly release it

Appendicular Coordination • To test the accuracy of movements in a way that requires very little strength, you can draw a line on the crease of the patient's thumb and then ask the patient to touch the line repeatedly with the tip of their forefinger

Appendicular Coordination What is Being Tested? • Normal performance of these motor tasks depends on the integrated functioning of multiple sensory and motor subsystems 1. position sense pathways 2. lower motor neurons 3. upper motor neurons 4. basal ganglia 5. cerebellum

Appendicular Coordination What is Being Tested? • In order to convincingly demonstrate that abnormalities are due to a cerebellar lesion, one must first test for normal joint position sense, strength, and reflexes and confirm the absence of involuntary movements caused by basal ganglia lesions

Appendicular Coordination What is Being Tested? • Appendicular ataxia is usually caused by lesions of the cerebellar hemispheres and associated pathways • Truncal ataxia is often caused by damage to the midline cerebellar vermis and associated pathways

Romberg Test • Ask the patient to stand with their feet together (touching each other) • Then ask the patient to close their eyes • Remain close at hand in case the patient begins to sway or fall

Romberg Test What is Being Tested? With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability • These are vision, proprioception, and vestibular sense • If there is a mild lesion in the vestibular or proprioception systems, the patient is usually able to compensate with the eyes open

Romberg Test What is Being Tested? • When the patient closes their eyes, however, visual input is removed and instability can be brought out • If there is a more severe proprioceptive or vestibular lesion, or if there is a midline cerebellar lesion causing truncal instability, the patient will be unable to maintain this position even with their eyes open

Romberg Test What is Being Tested? • Note that instability can also be seen with lesions in other parts of the nervous system such as the upper or lower motor neurons or the basal ganglia, so these should be tested for separately in other parts of the exam

Gait • Observe the patient walking toward you and away from you in an open area with plenty of room • Note stance (how far apart the feet are), posture, stability, how high the feet are raised off the floor, trajectory of leg swing and whether there is circumduction (an arced trajectory in the medial to lateral direction), leg stiffness and degree of knee bending, arm swing, tendency to fall or swerve in any particular direction, rate and speed, difficulty initiating or stopping gait, and any involuntary movements that are brought out by walking • Turns should also be observed closely

Gait • When following a patient over several visits, it may be useful to time him walking a fixed distance, and to count the number of steps he took and the number of steps he required to turn around • The patient's ability to rise from a chair with or without assistance should also be recorded

Gait • To bring out abnormalities in gait and balance, ask the patient to do more difficult maneuvers • To bring out subtle gait abnormalities or asymmetries, it may be appropriate in some cases to ask the patient to walk on their heels, their toes, or the insides or outsides of their feet, to stand or hop on one leg, or to walk up stairs

Gait • Test tandem gait by asking the patient to walk a straight line while touching the heel of one foot to the toe of the other with each step • Patients with truncal ataxia caused by damage to the cerebellar vermis or associated pathways will have particular difficulty with this task, since they tend to have a wide-based, unsteady gait, and become more unsteady when attempting to keep their feet close together

Gait What is Being Tested? Gait involves multiple sensory and motor systems,including 1. Vision 2. Proprioception 3. Lower motor neurons 4. Upper motor neurons 5. Basal ganglia 6. Cerebellum 7. Higher-order motor planning systems in the association cortex

Gait • Gait apraxia is a perplexing (and somewhat controversial) abnormality in which the patient is able to carry out all of the movements required for gait normally when lying down, but is unable to walk in the standing position, thought to be associated with frontal disorders or normal pressure hydrocephalus

MENTAL STATUS

1. Level of Alertness, Attention & Cooperation 2. Orientation 3. Memory 4. Language 5. Calculations, Right-Left Confusion, Finger Agno 6. Apraxia 7. Neglect & Constructions 8. Sequencing Tasks & Frontal Release Signs 9. Logic & Abstraction 10.Delusions & Hallucinations 11.Mood

Level of Alertness, Attention and Cooperation • Be as specific as possible in documenting the level of alertness, making note of what the patient can or cannot do in response to which stimuli • We can test attention by seeing if the patient can remain focused on a simple task, such as spelling a short word forward and backward (W-O-R-L-D / DL-R-O-W is a standard), repeating a string of integers forward and backward (digit span), or naming the months forward and then backward • Degree of cooperation should be noted, especially if it is abnormal, since this will influence many aspects of the exam

Level of Alertness, Attention and Cooperation What is Being Tested? • Level of consciousness is severely impaired in damage to: 1. Brainstem reticular formation 2. Bilateral lesions of the thalami 3. Cerebral hemispheres

Level of Alertness, Attention and Cooperation What is Being Tested? • Level of consciousness may also be mildly impaired in 1. Unilateral cortical or thalamic lesions 2. Toxic factors 3. Metabolic factors

Level of Alertness, Attention and Cooperation What is Being Tested? • Generalized impaired attention and cooperation are relatively nonspecific abnormalities that can occur in 1. Different focal brain lesions 2. Diffuse abnormalities such as dementia or encephalitis 3. Behavioral or mood disorders

Orientation: A Caveat to Those Who Write "A&O×3" • Ask for the patient's full name, the location, and the date, and note the exact response • A common practice is to substitute full documentation of the mental status exam with brief phrases such as "alert and oriented" or "alert and oriented to person, place, and time"—abbreviated as "A&O×3."

Orientation: A Caveat to Those Who Write "A&O×3" For example, for the orientation section on a patient Harry Smith, you should write the following • Name: "Harry Smith" Location: "Hospital," but does not know which one Date: "1942," and does not know month, date, or season • You should never write instead: "The patient was A&O×2," since this is ambiguous and makes it hard to know what the patient's true mental status was at the time of the exam

Orientation: A Caveat to Those Who Write "A&O×3" What is Being Tested? • The main usefulness of this set of questions is that it is so standard • It tests mainly recent and longer-term memory (see below), but as in all other parts of the exam, the response is also influenced by level of alertness, attentiveness, and language capabilities

Memory Recent memory • Ask the patient to recall three items or a brief story after a delay of 3 to 5 minutes • Be sure the information has been registered by asking the patient to repeat it immediately before initiating the delay

Memory Recent memory • A timer, such as a digital watch alarm should be used to provide 1. A consistent interval from patient to patient 2. To prevent the examiner from forgetting to ask for the test items

Memory Remote memory • Ask the patient about historical or verifiable personal events

Memory What is Being Tested? • Memory can be impaired on many different timescales • Impaired ability to register and recall something within a few seconds after it was said is an abnormality that blends into the category of impaired attention • If immediate recall is intact, then difficulty with recall after about 1 to 5 minutes usually signifies damage to the limbic memory structures located in the medial temporal lobes and medial diencephalon • Loss of memory without these time characteristics may signify damage to areas other than the medial temporal and medial diencephalic structures

Language Spontaneous speech • Note the patient's fluency, including phrase length, rate, and abundance of spontaneous speech • Also note tonal modulation and whether paraphasic errors (inappropriately substituted words or syllables), neologisms (nonexistent words), or errors in grammar are present

Language Comprehension • Can the patient understand simple questions and commands? • Comprehension of grammatical structure should be tested as well; • For example, "Mike was shot by John. Is John dead?"

Language Naming • Ask the patient to name some easy (pen, watch, tie, etc.) and some more difficult (fingernail, belt buckle, stethoscope, etc.) objects • Naming parts of objects is often more difficult • Write down what was said to enable follow-up comparisons

Language Repetition • Can the patient repeat single words and sentences (a standard is "no ifs ands or buts")? • Again, titrate function using a range of easy to difficult tests, and write down what the patient says

Language Reading • Ask the patient to read single words, a brief passage, and the front page of the newspaper aloud and test for comprehension

Language

Writing • Ask the patient to write their name and write a sentence

Language What is being tested? • Different kinds of language abnormalities are caused by lesions in 1. Dominant (usually left) frontal lobe, including Broca's area 2. Left temporal and parietal lobes, including Wernicke's area 3. Subcortical white matter and gray matter structures, including thalamus and caudate nucleus 4. Nondominant hemisphere

Calculations, Right-Left Confusion, Finger Agnosia, Agraphia • Impairment of all four of these functions in an otherwise intact patient is referred to as Gerstmann's syndrome • Gerstmann's syndrome is caused by lesions in the dominant parietal lobe, aphasia is often (but not always) present as well, which can make the diagnosis difficult or impossible

Gerstmann's syndrome • Calculations. Can the patient do simple addition, subtraction, and so on? • Right–left confusion. Can the patient identify right and left body parts? • Finger agnosia. Can the patient name and identify each digit? • Agraphia. Can the patient write their name and a sentence?

Apraxia • The term apraxia will be used here to mean inability to follow a motor command that is not due to a primary motor deficit or a language impairment • It is apparently caused by a deficit in higher-order planning or conceptualization of the motor task

Apraxia • Test for apraxia by asking the patient to do complex tasks, using commands such as "Pretend to comb you hair" or "Pretend to strike a match and blow it out" and so on. • Patients with apraxia perform awkward movements that only minimally resemble those requested, despite having intact comprehension and an otherwise normal motor exam

Apraxia • Constructional apraxia in patients who have visuospatial difficulty drawing complex figures • Ocular apraxia in patients who have difficulty directing their gaze • Dressing apraxia in patients who have difficulty getting dressed

Apraxia What is Being Tested? • Although apraxia indicates brain dysfunction, it can be caused by lesions in many different regions, so exact localization is often difficult • Apraxia is commonly present in lesions affecting the language areas and adjacent structures of the dominant hemisphere

Neglect and Constructions • Hemineglect is an abnormality in attention to one side of the universe that is not due to a primary sensory or motor disturbance. • In sensory neglect, patients ignore visual, somatosensory, or auditory stimuli on the affected side, despite intact primary sensation

Neglect and Constructions • In motor neglect, normal strength may be present, however, the patient often does not move the affected limb unless attention is strongly directed toward it. • Sensory and motor neglect are usually tested as part of the visual, auditory, somatosensory, and motor exams

Neglect and Constructions • Patients with anosognosia may be strikingly unaware of severe deficits on the affected side • For example, some patients with acute stroke who are completely paralyzed on the left side believe there is nothing wrong and may even be perplexed about why they are in the hospital • Some patients do not even comprehend that affected limbs belong to them (hemiasomatognosia)

Neglect and Constructions •

Certain drawing tasks, such as asking the patient to bisect a line or draw a clock face, can demonstrate neglect • Construction tasks involving drawing complex figures or manipulating blocks or other objects in space may be abnormal as a result of 1. Neglect or other visuospatial impairments. 2. Other cognitive difficulties, such as impaired sequencing or apraxia

Neglect and Constructions What is Being Tested? • Hemineglect is most common in lesions of the right (nondominant) parietal lobe, causing patients to neglect the left side • Left-sided neglect can also be seen in 1. Right frontal lesions 2. Right thalamic or basal ganglia lesions 3. Right midbrain

Neglect and Constructions What is Being Tested? • In left parietal lesions a much milder neglect is usually seen affecting the patient's right side • Abnormal constructions demonstrating neglect can occur with right parietal lesions • Generally, impaired visuospatial function is more severe with damage to the nondominant (right) hemisphere

Sequencing Tasks and Frontal Release Signs • Frontal lobe lesions in adults can cause the reemergence of certain primitive reflexes that are normally present in infants • Frontal release signs include the grasp, snout, root, and suck reflexes • Grasp reflex is the most useful in evaluating frontal lobe dysfunction

Sequencing Tasks and Frontal Release Signs • Patients with frontal lobe dysfunction may have particular difficulty in changing from one action to the next when asked to perform a repeated sequence of actions • Asked to continue drawing a silhouette pattern of alternating triangles and squares (written alternating sequencing task), they may get stuck on one shape and keep drawing triangles

Sequencing Tasks and Frontal Release Signs • The Luria manual sequencing task, in which the patient is asked to tap the table with a fist, open palm, and side of open hand and then to repeat the sequence as quickly as possible

Sequencing Tasks and Frontal Release Signs • Motor impersistence, a form of distractibility in which patients only briefly sustain a motor action in response to a command such as "Raise your arms" or "Look to the right" • Ability to suppress inappropriate behaviors can be tested by the auditory Go-No-Go test, in which the patient moves a finger in response to one sound, but must keep it still in response to two sounds

Logic and Abstraction • Can the patients solve simple problems such as the following: "If Mary is taller than Jane, and Jane is taller than Ann, who's the tallest?" • How do they interpret proverbs such as "Don't cry over spilled milk"? • How well can they comprehend similarities such as "How are a car and an airplane alike?" • How well can they generalize and complete a series—for example, "Continue the following: AZ BY CX D_"? • Educational background must always be taken into account in interpretations of these tests

Logic and Abstraction What is Being Tested? • These functions can be abnormal in damage to a variety of brain areas involving higher-order association cortex and are not well localized

Delusions and Hallucinations •

Does the patient have any delusional thought processes? • Does he have auditory or visual hallucinations? 1. "Do you ever hear things that other people don't hear or see things that other people don't see?" 2. "Do you feel that someone is watching you or trying to hurt you?" 3. "Do you have any special abilities or powers?"

Delusions and Hallucinations What is Being Tested? • These abnormalities can be seen in 1. Toxic or metabolic abnormalities 2. Other causes of diffuse brain dysfunction 3. Primary psychiatric disorders

Delusions and Hallucinations What is Being Tested? • Abnormal sensory phenomena can be caused by focal lesions or seizures in visual, somatosensory, or auditory cortex, • Thought disorders can be caused by lesions in the association cortex and limbic system

Mood • Does the patient have signs of depression, anxiety, or mania? • Signs of major depression include depressed mood, changes in eating and sleeping patterns, loss of energy and initiative, low self-esteem, poor concentration, lack of enjoyment of previously pleasurable activities, and selfdestructive or suicidal thoughts and behavior • Anxiety disorders are characterized by preoccupation with worrisome thoughts • Mania causes patients to be abnormally active and cognitively disorganized

Mood What is Being Tested? • These disorders are often considered 1. Psychiatric in origin 2. Focal brain lesions 3. Toxic or metabolic abnormalities such as thyroid dysfunction

Mood What is Being Tested? • Depressed patients with somatization or conversion disorders often have complaints such as pain, numbness, weakness, or even seizure like activity • Neurologic disorders such as brain tumors, strokes, metabolic derangements, and so on can produce confusional states that may be misinterpreted as psychiatric in origin

THANK YOU!