Neurological examination

Further reading

Clinical neurology

Brazis PW, Masdeu JC, Biller J. Localization in Clinical Neurology, 5th edn. Philadelphia:
Lippincott Williams & Wilkins, 2006.

Brust J. Current Diagnosis and Treatment: Neurology. New York: McGraw-Hill, 2006.
Manji H, Wills A, Kitchen N, Dorward N, Connelly S, Mehta A. Oxford Handbook of

Neurology. Oxford: Oxford University Press, 2006.
The Guarantors of Brain. Aids to Examination of the Peripheral Nervous System, 4th edn.

Philadelphia: Saunders, 2000.

Neuroanatomy

Haines DE. Neuroanatomy: An Atlas of Structures, Sections and Systems. Philadelphia:
Lippincott Williams & Wilkins, 2003.

Hirsch M, Kramer T. Neuroanatomy: 3-D Stereoscopic Atlas of the Human Brain. Berlin:
Springer, 1999.

Basic neuroscience

Cooper JR, Bloom FE, Roth RH. The Biochemical Basis of Neuropharmacology, 8th edn.
New York: Oxford University Press, 2003.

Kandel E, Schwartz, JH, Jessell TM. Principles of Neural Science, 4th edn. New York:
McGraw-Hill, 2000.

Shephard GM. The Synaptic Organization of the Brain, 5th edn. New York: Oxford
University Press, 2004.

Psychiatry

Burton, N. Psychiatry, 2nd edn. Oxford: Wiley-Blackwell, 2010.
Folstein MF, Folstein SE, McHugh PR.“Mini-mental state”. A practical method for grading

the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98.

Mind–brain philosophy

Eccles JC, Popper K. The Self and Its Brain. Abingdon, UK: Routledge, 2003.



Index

Note: Page numbers in bold or italic refer to tables or figures respectively.

A Arnold–Chiari malformation, 132
Abducens nerve (VI), 29, 31 Astrocytomas, cerebellar tumour, in
cranial nerve of eye muscle, 28 children, 133
Abnormal gag reflex, in CN IX Asymmetry
assessment, 47–8, 72 contracted spastic hemiplegia, 88
Abnormal movement, 3, 14, 20–1 in lower limb observation, 111
athetosis, 15, 22 Ataxia, 127
chorea, 15, 22 assessment, 130
myoclonus, 15, 22 cerebellar causes, 24
tics, 15, 21 Ataxia telangiectasia, 12
tremor, 14, 21 and gait, 18
Abnormal posture, 13, 20, 85, 88 Ataxic breathing, 177
Accessory nerve (CN XI), 30, 36, 37, 73 Attention and orientation, 136
Accommodation reflex, 36, 38 delirium, 138
Acquired anosmia, 51 dementia, 138
Acromegaly, 12, 188 dementia with Lewy bodies, 148
and gait, 17 psychiatric disorders, 138
Action tremor, 14 Auditory nerve test, 68
in abnormal movement diagnosis, 21 Rinne’s test, 68–9
Acuity, 53 Weber’s test, 69
rapid binocular visual loss, 57 Autonomic nervous system (ANS), 151
rapid monocular visual loss, 57 assessment, 159
Adductor pollicis, 78, 91, 95 bedside examination, 157–8
Adrenergic stimulation see Sympathetic parasympathetic nervous system, 154
nervous system sympathetic nervous system, 152–3
Afferent limb, 28, 33, 66, 72
of light reflex, 36, 37 B
Agraphia, in dominant parietal lobe Balance problems, 3
lesions, 139 Romberg’s test, 23
Alexia, 139 and vestibular system, 10
Alteplase, 172–3 Basal ganglia
Alzheimer’s disease, 136, 140, 146, 147 connections, 12
Aneurysms, peripheral nervous system for executive functions, 138
causes, 73 extrapyramidal system, 10–11
Anhidrosis, 43, 56 Basal meningitis, peripheral nervous
as ANS abnormality, 155 system causes, 73
Ankle, reflex, 109, 113, 118 Bell’s palsy, 12, 46, 188
Antalgic gait, 24 cranial nerve syndrome, 39
Appendicular ataxia, 127 and gait, 17
Argyll Robertson pupil, 43, 56 lower motor neuron lesions, 67

194 Index

Bell’s phenomenon, 65 Central CN VII lesion
Benign paroxysmal positional vertigo from peripheral CN VII lesion, 62
(BPPV), 69 Central nervous system (CNS) lesions
Bicep muscles, 78 and ANS, 151
in power assessment, 91, 92 Central pain, 86
in reflex assessment, 97 Central retinal artery occlusion, 41–2
Bitemporal hemianopia, 57 Central retinal vein thrombosis, 42
Blood pressures, 151, 159 Central scotoma, 57
as ANS abnormality, 155 Cerebellar syndromes, 131
autonomic functions of CN IX, 72 acquired causes, 132–3
in cardiovascular assessment, 171, 180 developmental or hereditary causes,
Blood vessels 132
arteriosclerotic changes, 58 Cerebellopontine angle
diabetic changes, 58 acoustic neuroma, 70
and livido reticularis, 155 cranial nerve syndrome, 39
Brachial plexitis, 86 lesion, 68
Brachial plexopathy, 102, 158 Cerebellum, 11
Brachial plexus, 80, 81, 82–3, 83 anatomy and physiology, 125–6
and lumbosacral plexus, 108 cerebellar syndromes, 131
power examination, 98 clinical features and pathophysiology,
Brachioradialis, 97 126–8
Bradykinesia, 14 examination, 134
and parkinsonism, 17, 21 general observations, 128–9
Brainstem hemiparetic posture, 178 structural and functional, 126
Brainstem lesions, 175 VANISHD, 129–33
breathing pattern, 177 Cervical intervertebral disc herniations
eyes, 176 clinical features of, 97
ocular reflex, 177 Charcot–Marie–Tooth diseases, 13
pupil, 176–7 and gait, 17
Brainstem syndromes, 40 Chronic liver disease, 128, 129
Broca’s aphasia, 139, 140 Clinical skills, in neurology
Broca’s area, 137, 140 consultation, 1
Buccinator, 65 ethicolegal considerations, 7–8
Bulbar palsy neurological examination, 4–5
cranial nerve syndrome, 39 neurological history, 1–4
patient presenting, 6
C summarising case, 5–6
Caloric testing see Oculovestibular reflex tool kit, of junior doctors, 6–7
Carotid reflex, 72 Clonus, reflex, 118
Carpal tunnel syndrome, 82 Coeliac disease, in cerebellar syndrome,
Cauda equina syndrome, 105, 121–2, 133
156 Cog-wheeling, 89
as ANS abnormality, 158 Cold peripheries, as ANS abnormality,
Caudal vermis syndrome, 131 155, 158
Cavernous sinus syndrome Colour vision, 53
cranial nerve syndrome, 39 Coma patient, examination, 183

Index-D 195

brainstem lesions, 175–7 Cranial nerves (CNs) II–XII, 186
cortical patterns, 177–8 cough, 71, 156
eyes and reflexes, 180–2 eye movement, 29, 59–60, 63, 176, 181
Glasgow Coma Scale (GCS) score, 178, facial movement, 19
179 facial sensation, 46, 75
Common peroneal neuropathy, 108 field defects, 28, 53–4, 57
Conjugate gaze abnormalities, 63 fundi for papilloedema, 58
Cortical atrophy, 148 palate, 71
Cortical bladder, as ANS abnormality, pupil, 42–3, 52–3, 56, 176–7, 182
159 Cranial nerves (CNs) III, IV and VI
Cortical release signs, 141, 145 down and out, 44
grasp reflex, 145 lateral rectus palsy, 44–5
palmomental reflex, 145 ptosis, 44
pout reflex, 145–6 in stroke assessment, 170
Corticobasal degeneration, 140, 148 titled head, 44
Corticospinal tract, 10 Cranial nerves (CNs) IX, X, 47–8
in pyramidal system, 10 abnormal gag reflex, 47–8
Cranial nerve (CN) II, pathophysiology, 38 displaced uvula, 47
central retinal artery occlusion, 41–2 laryngeal nerve palsy, 48
central retinal vein thrombosis, 42 Cranial nerves
diabetic retinopathy, 38, 41 examination summary, 75
hemianopia, 42 location of, 31
hypertensive retinopathy, 41 see also Head and neck
pale disc, 38 Creutzfeldt–Jakob disease
swollen optic disc, 38 in abnormal movement diagnosis, 22
Cranial nerve (CN) V
absent corneal reflex, 45 D
brisk jaw jerk, 46 Dandy–Walker malformation, 132
motor lesion, 66 Deafness
sensory lesion, 66 conductive, 70
trigeminal neuralgia, 46 sensorineural, 70
Cranial nerve (CN) VII Decerebrate posture, 178
bilateral lesions, 67 Declarative memories, 138
cranial asymmetry, 46 Decorticate posture, 178
lower motor neuron lesions, 67 Deltoid muscles, 78, 91
sensory lesion, 66 in power assessment, 92, 97
upper motor neuron lesions, 66–7 Dementia with Lewy bodies, 140, 148
Cranial nerve (CN) VIII Dermatomal distribution, in
conductive hearing loss, 47 paraesthesia, 87
sensorineural deafness, 47 Dermatomes, 79, 101
Cranial nerve (CN) XI of lower limb, 120
trapezius, weakness of, 48 Dermatomyositis
Cranial nerve (CN) XII and gait, 18
slow and spastic tongue, 48 Deviated uvula, in CN X palsy, 72
wasted tongue, 49 Diabetic retinopathy, 38, 41
Cranial nerve syndromes, 39 staging of, 41

196 Index

Displaced uvula, 47 Eye movement
Doll’s eyes reflex see Oculocephalic reflex disorders, 63
Dominant hemisphere strokes, 166 muscles and nerves of, 59
Dopa-responsive dystonia, 20 muscles involved in, 33
Dorsal column, 87–8, 100, 122 resting movements, 60
proprioception, 101, 123 types of, 59
vibration, 101, 122–3 Eyes, in coma patients
Dorsal column–medial lemniscus resting position, 176
pathway, 9, 10 spontaneous movement, 176
Double vision, 5, 60, 61
Driver and Vehicle Licensing Agency in F
the U.K., 189 Facial asymmetry
Driving restrictions, 8 in head and neck, diagnosis, 50
Dry eyes, 65 see also Lacrimation, in CN Facial nerve (VII), 31, 34
VII assessment cranial nerve of face, 29
‘Dual stream model’, 136–7 for facial expression muscles, 27, 34
Dysarthria, 39, 72, 128, 139 innervations, 66
Dysdiodochokinesia, 99, 128, 131 and tear production, 65
as cerebellar lesion indication, 119 Facial sensation, in CN VII assessment,
Dyslexia, 139 29, 39, 46, 75
Dysmetria, 99 Fasciculations, 13, 85, 88, 89
as cerebellar lesion indication, 119 in lower limb observation, 111
Dysphasia, 139 Femoral nerve, 105, 107
expressive dysphasia, 139–40 iliacus, hip flexor, 107
nominal dysphasia, 140 peripheral nerve, of lower limb, 106
receptive dysphasia, 139 Femoral neuropathy, 107
Dysphonia, 72, 139 Finger nose, 103
Dystonia First dorsal interosseous, 78, 91
in abnormal posture diagnosis, 20 Flaccid, 92–4, 112 see also Reduced tone
and tremor, 14 myopathy, 92–3
Dystonic posture neuromuscular junction, 93
testing for, 19, 20 neuropathy, 93–4
radiculopathy, 94
E Flexor carpi ulnaris, 78, 91
Efferent limb, of light reflex, 36, 37 Flexor digitorum, 108
Encephalitis, 50, 180 Flexor digitorum profundus I and II,
in cerebellar syndrome, 133 78, 91
Ependymomas, in children, 133 Flexor digitorum profundus III and IV, 78
Epley manoeuvre, 70 Flexor pollicis longus, 78, 91
Extensor carpi radialis longus, 80–1, Flocullonodular lobe, 11
91, 93 Focal dystonia, 14
Extensor carpi ulnaris, 81, 91, 93 Foot deformities
Extensor digitorum, 91, 93 in lower limb observation, 111
Extensor hallucis longus, dorsiflexes of Foot drop, 16, 108, 109
great toe, 106 Fourth nerve palsy, 63
Extensor pollicis brevis, 91, 93 Friedreich’s ataxia, 129, 188

Index-H 197

Frontalis muscle, 65 H
Frontal–temporal dementia, 141 Haemorrhagic stroke, 164, 169
Frontotemporal dementia, 147 Hallpike’s manoeuvre, 69
Fundi, in CN II assessment, 58 Hallucis longus flex, 108
Fundoscopy, 52, 55 Handedness, 186
ophthalmoscope adjustment, 55 Head and neck, 27
CN I (olfactory nerve), 27
G CN II (optic nerve), 28, 38–42
Gag reflex test, for mouth, 72 CN III, IV and V (eye muscle nerve), 29,
Gait, 186 31, 44–5
abnormal posture and movements, CN IX (glossopharyngeal nerve), 34–6,
18–22 47–8
assessment, 22–5, 27 CN V (trigeminal nerve), 31, 46
asymmetrical gait, 16–17 CN VII (facial nerve), 31, 34
basal ganglia/extrapyramidal system, CN VIII (vestibulocochlear nerve), 34,
10–11, 12 47
broad-based symmetrical gait, 15–16 CN X (vagus nerve), 36, 47–8
in CN VIII assessment, 75 CN XI (accessory nerve), 36, 48
cerebellum, 11 CN XII (hypoglossal nerve), 36, 48–9
functional gait, 17 ears, CN VIII, 67–70
general inspection, 12–16, 27 eyes, CN II and III, 52–8
narrow-based symmetrical gait, 16 eyes, CN III, IV and VI, 59–62
pyramidal system, 10 face, CN V and VII, 62–7
sensory input, 9–10 mouth, CN IX, X, XII, 71–3
Gastrocnemius, plantarflexes, 108 neck, CN XI, 73–5
Gaze paresis, 181 nose, CN I, 50–1
Generalised wasting papillary reflexes, 36–8
in head and neck, diagnosis, 50 pupil, 42–3
Glasgow Coma Scale (GCS) score Head drop, 50, 73
in coma patient, 178, 179 Head rotated, 50
in stroke assessment, 170 Head tilted, 50
Glaucoma, 58 Head turning test, in CN VIII assessment,
Global encephalopathies, 140 69–70
Glossopharyngeal nerve (IX), 34–6 Headaches, 3, 132, 133
lower cranial nerves, mouth, 30 haemorrhagic stroke, 169
Glossopharyngeal neuralgia history of, 188
peripheral, 73 Heart rate variability
Glove and stocking, in paraesthesia, 87 as ANS abnormality, 155–6
Gluteal nerve, 105, 106 Heel–shin, co-ordination, 119
peripheral nerve, of lower limb, 106 Hemiballismus, 11
Gluteus maximus (GluMax), 106 Hemiplegia
Gluteus medius (GluMe), power, 106 in head and neck, diagnosis, 50
Gluteus minimis (GluMi), power, 106 in gait assessment, 16, 23
Guillain–Barré syndrome, 5, 39, 49, 73, Hemi-sensory distribution, in
158, 188 paraesthesia, 87

198 Index

Hemispheric syndrome, 131 Ischaemic stroke, 132
Hepatomegaly, 129 causes of, 163
Hereditary ataxias, 132 major risk factors, 164
Heredodegenerative dystonia, 14 Ishihara plates, 7, 52, 53
Higher cortical function
attention and orientation, 136, 138 J
cognition domain, bedside testing, Jaw jerk test, for CN V assessment
141–8 motor function diagnosis, 64
executive function, 138, 141 Jugular foramen syndrome
language, 136–7, 138–40 cranial nerve syndrome, 39
memory, 137–8, 141
Mini-Mental State Examination K
(MMSE), 135 Knee, power assessment, 115
Revised Addenbrooke’s Cognitive Knee reflex, 106, 113, 118
Examination (ACE-R), 136 Korsakoff’s syndromes, 133
summary of, 149
visuoperceptual function and L
calculation, 137, 140–1 Lacrimation, in CN VII assessment, 34,
Hip, in power assessment, 115 65, 75
History taking, 1 see also Neurological Lacunar syndrome, 162, 165
history Lambert–Eaton myasthenic syndrome
Holmes–Adie pupil, 42, 56 fatigable weakness in, 85
Homonymous hemianopia, 57 key clinical and laboratory features of,
Homonymous quadrantanopia, 58 96
Horner’s syndrome, 43 Language, 138–9
Huntington’s disease assessment, 143
in abnormal movement diagnosis, 22 comprehension, 139
and gait, 18 reading, 139
heredodegenerative dystonia, 14 speech, 139–40
Hyperacute UMN lesions, 89 writing, 139
Hypertensive retinopathy, 41 Laryngeal nerve palsy, 48
grading of, 41 Latent strabismus
Hypoglossal nerve (XII), 36 eye deviation, 60
lower cranial nerves, mouth, 30 Lateral column, 88, 100, 121–2
Hypomimia, 19 Lateral medulla syndrome see
Wallenberg syndrome
I Lateral medullary infarction
Increased tone, 89 central nervous system causes, 72
Infections, 3, 39, 56 Lateral pons
Intention tremor, 99, 128, 130 brainstem syndrome, 40
as cerebellar lesion indication, 119 Left nerve palsy, 45
Internuclear ophthalmoplegia, 45, 61, 63 Levator palpebrae superioris
Intervertebral disc prolapse, 108 ptosis, 44
lumbar disc prolapsed, 109 Livido reticularis
servical and thoracic disc prolapsed, as ANS abnormality, 155
108–9 LOAF, 81

Index-M 199

Locked-in syndrome, 181 Mediastinal pathology, peripheral
Long-term memory, 137–8 nervous system, 73
Loss of consciousness, 3 Medulla, in sensory input, 9
Lower limbs, 105, 186 Medulloblastomas, cerebellar tumour, in
co-ordination, 119 children, 133
examination of, 124 Memory, 3, 137–8, 141
femoral nerve, 107 deficits in, 138
gluteal nerve, 106 and dementia, 147
intervertebral disc prolapse, 109–10 mini-mental state examination, 135
intervertebral discs, 108–9 testing of, 145
lower motor neurons, 106 Meningism, in head and neck, diagnosis,
lumbosacral plexus, 108 50, 179
obturator nerve, 107 Midbrain tegmentum, brainstem
power, 112–17 syndrome, 40
reflexes, 117–19 Midline lesions, for ataxia, 24
sciatic nerve, 107–8 Mild cognitive impairment, 146
sensation, 120–4 Mini-mental state examination (MMSE),
tone, 112 135
upper motor neurons, 106 Mononeuropathy, 101
Lower motor neurons (LMNs), 106, 113 Motor neuron disease, 39
ankle reflex, 118 central nervous system causes, 72, 74
mononeuropathies, 117 fasciculations, 89, 111
myopathy, 113 Multiple sclerosis, 133, 188
polyneuropathies, 117 in cerebellar syndrome, 133
root lesion, 117 optic neuritis in, 42, 56
sacral plexopathies, 117 in scissoring, 23
weakness pattern, 85 Muscarinic stimulation see
Lumbosacral plexus, 108 Parasympathetic nervous system
Lymphadenopathy, 68, 73 Muscle examination, in upper limb, 86
in CN XI assessment, 74 Muscle wasting, 88
in CN XII assessment, 49 in lower limb observation, 111
see also Wasting
M Muscles of mastication, in CN V
Magnetic gait, 16 assessment, 29
Major cerebral arteries Muscles of peroneal nerve, power
circle of Willis and, 164 assessment, 116
Mandibular (V3) division, 31 Muscles of tibial nerve, power
distribution of, 34 assessment, 116
Masseter muscles, 62 Myasthenia gravis, 188
Maxillary (V2) division, 31 fatigable weakness in, 85
distribution of, 34 and gait, 17
Medial longitudinal fasciculus (MLF), 61 key clinical and laboratory features of, 96
Medial medulla syndrome, brainstem Myelopathy, 102, 124
syndrome, 40 Myopathy, 44
Medial pons, brainstem syndrome, 40 in flaccid weakness, 92–3
Median nerve, 78, 81–2, 83, 100, 101 in gait assessment, 24
Median nerve entrapment, 82 in LMN lesion, 113

200 Index

Myotonic dystrophy type 1 Oculocephalic reflex, 177
and gait, 17 Oculomotor nerve (III), 29
cranial nerve of eye muscle, 28
N Oculovestibular reflexes, 177, 182
Nasolabial folds, 62 Olfactory nerve (I), 27
Neck stiffness, 50, 186 cranial nerve of nose and eye, 28
Nerve root disease, 117 Onuf’s nucleus, 105
Nerve root, 87 Ophthalmic (V1) division, 31
Neuroacanthocytosis, distribution of, 34
heredodegenerative dystonia, 14 Ophthalmoscope, 6
Neurofibromatosis, 188 Opponens pollicis, 78, 91
and gait, 18 Opsoclonus, resting eye movement,
Neurogenic bladder, as ANS abnormality, 60, 63
156, 158 Optic atrophy, 58
Neuroimaging, patient expectation, 8 Optic disc, in CN II assessment, 58
Neurological history, 1–2 Optic nerve (II), 28
drug history, 4 cranial nerve of eye, 28
family history, 4 distribution of, 34
meeting patient, 2 Optic neuritis, 58
neurological systems review, 2–3 Orbicularis oculi, 65
past medical history, 3 Orbicularis oris, 65
psychiatric history, 4 Orientation, 186
social history, 3 Otoscope, in CN VIII assessment, 68, 75
systems review, 4 Oxford classification system, of stroke,
Neurological screening examination, 161–2
186 lacunar syndrome, 162, 165
Neurology consultation, 1 partial anterior circulation syndrome,
aims, 1–2 162, 163, 165
Neurology toolkit, of junior doctors, 7 posterior circulation syndrome, 162,
Neuromuscular junction lesion, 63 163, 166
Neuromuscular junction, 85, 93 total anterior circulation syndrome
Neuropathic pain, 86 (TACS), 162, 163, 165–6
Non-anatomical distribution, in
paraesthesia, 87 P
Non-dominant hemisphere strokes Pain, in upper limb assessment, 86
141, 166 Pale disc, 38
Non-neurological disease, 13 Papillitis see Optic neuritis
Nystagmus, 40, 49, 61, 127–8, 130 Papilloedema, 38, 58
resting eye movement, 60 Paraesthesia, in upper limb assessment,
86–7
O Paraneoplastic syndromes, 133
Obturator nerve, 105, 107 Parasympathetic nervous system, 151,
adductors, of lower limb, 107 154
peripheral nerve, of lower limb, 106 components of, 153
Ocular flutter, resting eye movement, 60 preganglionic and postganglionic
Ocular reflexes, 177 neurons, 151

Index-R 201

Parietal lobe posture, 178 Ptosis
Parkinson’s disease, 188 in head and neck, diagnosis, 50
in abnormal movement diagnosis, Pudendal nerve, 105
20–1 Pupil abnormalities
and gait, 17 as ANS abnormality, 158
in gait assessment, 23 Pupil, 52–3, 56, 176–7
and tremor, 21 accommodation reaction test, 53
Parotid glands, in CN V assessment, constricted pupil, 43
66, 75 dilated pupil, 42–3
and facial nerves, 35 large pupils, 56
Partial anterior circulation syndrome light-near dissociation, 56
(PACS), 162, 163, 165 RAPD, 53
Peripheral nerve, 83 relative afferent pupillary defect, 56
distribution, in paraesthesia, 87 small pupils, 56
in lower limbs, 106 Pupillary reflex arc, 33
in sensory examination, 100, 121 Pupillary reflexes, 36
Peripheral nervous system lesions accommodation reflex, 38
and ANS, 151 light reflex, 36–7
Peripheral nystagmus, 127 Pursuit eye movement, in CN III, IV and VI
Peroneus longus and brevis, 106 assessment, 61
Pin-prick (PP) testing, 7, 83, 121, 170 occipital lobes in, 59
Plantar reflex, 118, 170, 181 Pyramidal system, 10
Polymyositis, 188
Polyneuropathies, 87, 102, 117, 123 Q
Poor co-ordination, 99, 119, 131 Quadriceps muscle, 114, 115
Poor cough, in CN X assessment, 72 Queen Square Screening Test for
Poor heel walking, 24 Cognitive Deficits, 7
Posterior aphasia see Receptive aphasia
Posterior circulation syndrome, 162, R
163, 166 Radial nerve, 78, 80–1, 83
Postural hypotension, 21 power assessment of, 93
as ANS abnormality, 155, 158 Radicular pain, 86
Presenting patients, 6 Radiculopathy, 86, 102
Primary dystonia, 14 Ramsay–Hunt syndrome
Primitive reflexes, 141 cranial nerve syndrome, 39
Progressive supranuclear palsy, 141, Receptive aphasia, 139
148 Red reflex, 55
Pronator drift, 13, 85, 88, 89 Reduced tone, 89
Pronator teres, 78 Relative afferent papillary defect (RAPD),
Proprioception, sensation, 101, 123 42, 43, 53
Pseudobulbar palsy Resting eye movement, in CN III, IV and
cranial nerve syndrome, 39 VI assessment, 60
Pseudo-dementia Resting tachycardia, as ANS abnormality,
and depression, 138 155
Psychogenic tremor, 14 Resting tremor, 14
in abnormal movement diagnosis, 21 in abnormal movement diagnosis, 21

202 Index

Reticular activating system (RAS), 175 Snellen chart, 49, 52, 53
Revised Addenbrooke’s Cognitive Snellen pocket chart, 7
Examination (ACE-R), 136 Social behaviours, 138
Rinne’s test, 47 Spasticity, 89, 92, 94–5, 112
in CN VIII assessment, 68–9 cortical lesions, 95
Romberg’s test, in gait assessment, 23 spinal cord injury, 95
Rostral vermis syndrome, 131 see also Increased tone
Speech problems, 3
S Speech, 186
Saccades, in CN III, IV and VI assessment, Spinal cord anatomy, and lesions, 84
61 Spinal cord bladder, as ANS abnormality,
Saccadic eye movement, 61 158
frontal lobes in, 59 Spontaneous nystagmus, 127–8
Saccadic oscillations, resting eye Square wave jerks, resting eye
movement, 60, 63 movement, 60
Saddle anaesthesia, as ANS abnormality, Stapedius muscle weakness, hyperacusis
156 of, 65, 75
Sciatic nerve, 105, 107 Stereognosis, 7
common peroneal nerve, 107–8 Sternocleidomastoid muscle, in CN XI
‘hamstrings’ flex, 107 assessment, 73
peripheral nerve, of lower limb, 106 Stroke, 87, 188
tibial nerve, 108 in abnormal posture diagnosis, 20
Sciatic neuropathy, 109 Stroke patient, examination, 161
Scissoring, in gait assessment, 23 examination of, 174
Scute stroke, 5 history, 167–9
Second palmar interosseous, 78, 91 neurological examination, 169–70
Secondary dystonia, 14 thrombolysis, 172–3
Segawa’s disease see Dopa-responsive Sturge–Weber syndrome
dystonia and gait, 17
Segmental dystonia, 14 Suspected multiple sclerosis
Seizures, 3 case summarizing, 5
history, 188 Suspected myasthenia gravis, 4, 6
Semantic memory, 141 Suspected simple migraine, 4
Senile meiosis, 43 Swallowing, in CN IX, X and XII
Sensorineural deafness, 47 assessment, 72, 75
Sensory input, 9–10 Swollen optic disc, 38
Sensory loss, 87–8 Sympathetic nervous system, 151,
Sensory symptoms, 3 152–3
Short-term memory, 137 components of, 153
Sixth nerve palsy, 63 preganglionic and postganglionic
Skew deviation, eye deviation, 60, 63 neurons, 151
Skin erythema, as ANS abnormality, 156 Symptom, time course, 2
Skin problems, 3 Syndromic appearance, 85
Small fibre peripheral neuropathies, 86 Syrinx
Small muscles of foot, 108 central nervous system causes, 72

Index-V 203

T Trigeminal nerve (V), 31
cranial nerve of eye muscle, 28
Tap rhythm, co-ordination, 119 cranial nerve of face, 29
Taste, in CN VII assessment, 29, 34, 65, distribution of, 34
72, 75 sensory loss, lesion location, 67
Tropicamide, 6
Temporalis muscles, 62 Tuberous sclerosis, and gait, 18
Tumours, 63, 133
Test for retropulsion, in gait assessment, central nervous system causes, 72
lower motor neuron facial nerve l
23 esions, 35
Third nerve palsy, 63 peripheral nervous system causes, 72
Tuning forks, 7
Throat swabs, 7
U
Thrombolytic therapy, contraindications Ulnar nerve, 78, 82, 83, 101
to, 168 Upper limb examination, 186
axillary nerve, 80
Tibial nerve, 108 brachial plexus, 82–3
coordination, 98–9
Tibial neuropathy, 108 functional assessment, 86
median nerve, 81–2
posterior tarsal tunnel, 108 motor neurons, 77–80
Tibialis anterior, foot dorsiflexion, 106, musculocutaneous nerve, 80
peripheral nerve, 78
108, 116 power, 90–5
radial nerve, 80–1
in muscle wasting, 111 reflexes, 96–8
sensation, 99–102
Tibialis posterior, 108 sensory disturbance, patterns, 86–8
sensory function, 83–4
‘Tingly bits’, 86 system summary, 103
tone, 77
Tolosa–Hunt syndrome ulnar nerve, 82
cranial nerve syndrome, 39 weakness patterns, 85–6
Upper motor neurons (UMNs), 106,
Tone and limb reflexes, 182 113
crossed adductor reflex, 119
Tongue extensor plantar reflex, 119
in CN IX assessment, 30 hyper-reflexia, 118
in CN VII assessment, 29 persistent clonus, 119
in CN XII assessment, 30 weakness pattern, 85

slow tongue, 48 V
Vagus nerve (X), 36
wasted tongue, 49 lower cranial nerves, mouth, 30

Tongue depressors, 7

Tonic pupils, 56

Total anterior circulation syndrome
(TACS), 162, 163, 165–6

Transient ischaemic attacks (TIAs), 163
major risk factors, 164

Trapezius muscle, in CN XI assessment,

73

Tremor

in abnormal movement diagnosis, 21

action tremor, 14
and Parkinson’s disease, 21

psychogenic tremor, 14

resting tremor, 14

testing for, 19
Tricep muscles, 78
in power assessment, 91, 93
in reflex assessment, 97

204 Index

Valsalva manoeuvre, as ANS abnormality, homonymous hemianopia, 57
158 homonymous quadrantanopia, 58
VANISHD (Vertigo, Ataxia, Nystagmus, unilateral total visual field loss, 57
Intention tremor, Speech disturbance, visual neglect, 54–5
Hypotonia and Dysdiodokokinesia), Visual problems, 3
125, 129 Visuospatial functions, 144
ataxia, 127, 130 von Recklinghausen’s disease see
dysdiodokokinesia, 128, 131 Neurofibromatosis
hypotonia, 128, 131
intention tremor, 128, 130 W
nystagmus, 127–8, 130 Wallenberg syndrome, brainstem
speech disturbance, 128, 130 syndrome, 40
vertigo, 127, 129 Warm peripheries, as ANS abnormality,
Vascular dementia, 146 155
Vermal cerebellar lesions, for ataxia, 24 Wasting, 13, 49, 85, 88
Vermis, 11 Weak toe walking, 24
Vestibular lesion, 70 Weakness, 3
Vestibular nerve, 69 pyramidal distribution of, 13
Vestibular system, 10 Weber syndrome, brainstem syndrome,
Vestibulocochlear nerve (VIII), 34 40
cranial nerve of ears, 29 Weber’s test, 47, 69
Vestibulo-ocular eye movement, Wernicke’s aphasia see Receptive aphasia
cerebellar vestibular nuclei in, 59 Wernicke’s area, 137
Vibration, sensation, 83, 101, 122–3 Wernicke’s syndromes
Visual field, in CN II assessment, 53–4 Wilson’s disease
bitemporal hemianopia, 57 in abnormal movement diagnosis, 22
blind spot, 54 and gait, 18
central scotoma, 57 heredodegenerative dystonia, 14
concentric reduction of, 57 Working memory, 137, 138 see also
defects, localization, 32 Short-term memory