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Neurological Examination Made Easy
Rajendra Bhalchandra Kenkre
1:
History, Neurological Examination and Equipment
HISTORY
Clarity
Age
Sex
Family History
Social History
Past Medical History
History of Illness
Time Course
Headache
Drug History
Toxins
Travel
Occupation
THE CURRENT NEUROLOGICAL STATE
EQUIPMENT
FIRST IMPRESSIONS
Coming Through the Door
Size of the Patient
Gait
The Voice
The Patient in Bed
THE MENTAL, PHYSICAL AND GENERAL EXAMINATION
Mental Examination
Attention
Orientation
Concentration
Calculation
Memory
Abstract Thought
Visual and Body Perception
Emotional State
Delusions and Hallucinations
Physical Examination
The Peripheral Nerves
Head and Neck
Kernig's Sign
Neck Stiffness
Straight Leg Raising
Back
General Examination
The Ears
The Skin
The Heart
The Lungs
The Abdomen
The Pelvis
The Breasts
The Thyroid
The Glands
The Teeth
The Tongue
The Nails
Koilonychia—Severe Anemia
Lack of Blinking, Absence of Facial Expression (Mask like Face)
2:
Cranial Nerves: General
ANATOMY AND LOCATION OF CRANIAL NERVE ABNORMALITIES
IIIrd NERVE
IVth NERVE
VIth NERVE
Lesions of IIIrd, IVth and VIth Nerves
Nuclear Lesions
Fascicular Lesions
VIIth NERVE
XIIth NERVE
Generalized Problems of Nerve and Muscle
3:
First Cranial Nerve: Olfactory Nerve
THE OLFACTORY NERVE
Tests
Smell
4:
Second Cranial Nerve: Optic Nerve
OPTIC NERVE
TEST FOR VISUAL ACUITY
Confrontation Perimetry
Visual Field Defect
The Pupils
The Reaction to Light
PUPILLARY ABNORMALITIES
The Constricted Pupil (Miosis)
Horner's Syndrome
The Dilated Pupil (Mydriasis)
The Pupil that does not React to Light
The Argyll Robertson Pupil
5:
Fundus
EXAMINING THE FUNDUS
Methods of Examination of Fundus
Features to be Examined
Inspect the Retina
The Disk
Primary Optic Atrophy
Swelling of the Disk
Perimeter
6:
Third, Fourth and Sixth Cranial Nerves: Oculomotor, Trochlear and Abducens
THE OCULOMOTOR
Functions
PURPOSE OF THE TEST
TO ANALYZE NYSTAGMUS
Methods of Examination
EXOPHTHALMOS
HYPERTELORISM
THE CONJUNCTIVA
THE EYELIDS
LID RETRACTION
OCULAR MUSCLE PARALYSIS
TROCHLEAR NERVE
ABDUCENS NERVE
7:
Nystagmus
NYSTAGMUS
Two General Types of Nystagmus
Method of Testing Nystagmus
TYPES OF NYSTAGMUS
Jerk Nystagmus
Vertical Nystagmus
Rotatory Nystagmus
Ataxic Nystagmus
Seesaw Nystagmus
Down-beat Nystagmus
Optokinetic Nystagmus
Pathological Causes of Optokinetic Nystagmus
8:
Fifth Cranial Nerve: Trigeminal Nerve
FUNCTIONS
SENSORY THREE DIVISIONS (FIG. 8.1)
TESTS
SENSORY ABNORMALITIES
Causes
MOTOR WEAKNESS
CAUSES NUCLEAR LESION FIFTH NERVE
9:
Seventh Cranial Nreve: Facial Nerve
FUNCTIONS
PURPOSE OF THE TESTS
METHOD OF EXAMINATION
MOTOR FUNCTIONS
Unilateral Lower Motor Neuron Facial Paralysis
BILATERAL LOWER MOTOR NEURON FACIAL PALSY
Guillain-Barré Syndrome
Brainstem Encephalitis
10:
Eighth Cranial Nerve: Auditory and Vestibular Nerve
FUNCTIONS
The Cochlear Nerve
The Vestibular Nerve
RINNE'S TEST
WEBER'S TEST
CAUSES OF CONDUCTION DEAFNESS
COMMON CAUSES OF PERCEPTION DEAFNESS
IN THE NERVE TRUNK
PURPOSE OF THE TESTS
EXAMINATION OF HEARING
TEST OF AUDITORY FUNCTIONS
Pure Tone Audiometry
TEST OF VESTIBULAR FUNCTIONS
11:
Ninth and Tenth Cranial Nerves: Glossopharyngral and Vagus Nerves
VAGUS NERVE
12:
Eleventh Cranial Nerve: Accessory Nerve
FUNCTIONS OF THE SPINAL ROOT OF THE ELEVENTH NERVE
PURPOSE OF THE TESTS
STERNOMASTOIDS
TRAPEZIUS
ABNORMALITY
COMMON LESIONS
13:
Twelfth Cranial Nerve: Hypoglossal Nerve
PURPOSE OF THE TEST
METHOD OF EXAMINATION
LESIONS
14:
Motor System: General
GENERAL INSPECTION
EXAMINATION OF JOINT MOVEMENT
LOCAL INSPECTION OF THE MUSCLES
TYPES OF MUSCLE WASTING
Selective Muscle Group Wasting
Syringomyelia
Motor Neuron Diseases
Distal Muscle Wasting
MUSCLE POWER
WEAKNESS DUE TO MUSCULAR LESIONS
Myasthenia Gravis
Cholinergic Crisis
Hysterical Weakness
15:
Motor System: Tone
MUSCLE TONE
Testing Tone in the Lower Limbs
Loss of Tone
Common Causes of Hypotonia
COMBINED MOTOR AND SENSORY LESIONS
STATES OF NEUROLOGICAL SHOCK
CEREBELLAR LESIONS
INCREASING TONE
CLONUS
MYOTONIA
16:
Motor System: Arms
ROUTINE TESTS (FIGS 16.1A TO F)
Abductor Pollicis Brevis Nerve Mediun Root T1
Extensor Digitorum Brevis
Flexor Pollicis Longus
Lumbricals and Interossei
Flexor Digitorum Sublimis
Flexor Digitorum Profundus
Abductor Digiti Minimi
Muscles of the Trunk
Intercostals
Muscles of the Thigh and Knees
17:
Motor System: Legs
HAMSTRINGS L5, L1
Sciatic
Quadriceps Femoris L3, L4 Femoral
MUSCLES OF THE LOWER LEG AND ANKLE
Tibialis Anticus L4, L5
Tibialis Posticus L4
ABDOMINAL MUSCLES
MUSCLES OF THE HIP GIRDLE
Adductor Femoris
Gluteus Medius and Minimus
Gluteus Maximus
Peronei
Gastrocnemius
MUSCLES OF THE FOOT AND THE GREAT TOE
Extensor Digitorum Longus
Flexor Digitorum Longus
Extensor Hallucis Longus
Extensor Digitorum Brevis
TYPES OF MUSCLE WEAKNESS
18:
Motor System: Reflexes
MOTOR SENSORY LINKS
ABNORMAL RESPONSES
THE CREMASTERIC REFLEXES
ABNORMAL RESPONSE
THE ANAL REFLEX
PURPOSE OF THE EXAMINATION
THE TENDON REFLEXES
The Upper Limbs
The Biceps Jerk
The Supinator Jerk
The Triceps Jerk
The Pectoral Reflexes
The Finger Flexion Reflex
The Lower Limbs
The Knee Jerk
The Ankle Jerk
THE HOFFMAN REFLEX
WARTENBERG SIGN
ROSSOLIMO'S REFLEX
PRIMITIVE REFLEXES
PALMOMENTAL REFLEX
GRASP REFLEX
ABNORMALITIES OF THE TENDON REFLEXES
REDUCTION OR ABSENCE
TWO IMPORTANT COMBINATIONS OF REFLEX ABNORMALITY
The Inverted Supinator Jerk
Lesions of the Conus Medullaris
THE ABDOMINAL REFLEXES
PLANTAR REFLEX (BABINSKI)
Babinski Response
Lhermitte's Phenomenon
Trousseau's Sign
19:
Basic Principles of Examination of Sensation
ESSENTIAL FEATURES OF THE SENSORY PATHWAY
ARRANGEMENTS OF THE SENSORY FIBERS
MODALITIES OF SENSATION TO BE TESTED
SENSORY DERMATOMES
INDIVIDUAL TESTING OF THE SENSATIONS (FIGS 19.2A TO C)
Touch
Temperature
IMPORTANT POINTS TO REMEMBER IN SENSORY TESTING
THE PROPRIOCEPTIVE SENSATION
20:
Posture and Gait
POSTURE
THE BACK
ABNORMALITIES OF POSTURE
A Stooped Position
Kyphoscoliosis
Excessive Lordosis
Bradykinesia and Cogwheel Rigidity
Rigid Spine
Tender Spine
ABNORMALITIES OF EQUILIBRIUM
Rombergism
Proximal Group Muscles
GAIT
ABNORMALITIES
High Stepping Gait
Co-ordination Test
Finger Nose Test
ABNORMALITY IN CEREBELLAR LESIONS AND WILSON'S DISEASE
Disdiadokinesis
Heel Shin Test
Wilson's Disease
21:
Involuntary Movements
INVOLUNTARY MOVEMENTS OF FACE AND NECK
Facial Tics
Habit Spasms
Hemifacial Spasms
Facial Myokymia
Perioral Tremor
Spasmodic Torticollis
Tardive Dyskinesia
Titubation
Tremors
Thyrotoxicosis
Alcoholism
Intention Tremor
Red Nucleus Tremor
Benedikt's Syndrome
Wilson's Disease
Asterixis
Pseudoathetosis or “Sensory Wandering”
Athetosis
Opisthotonus
Focal or Partial Epilepsy
ABNORMAL MOVEMENTS
Myoclonic Jerks
Pathological Causes
22:
Speech
VARIETIES OF DYSARTHRIA
Spastic Dysarthria
Common Causes
Rigid Dysarthria
Palilalia
Common Cause
Ataxic Dysarthria
Common Causes
DISORDER OF SPEECH
Dyslexia
Methods of Differentiation
The Analysis of Dysarthria
Myasthenic Dysarthria
The Analysis of Dysphasia
Spontaneous Speech
Does He Persevere (Perseveration)
Comprehension
Naming Objects
Repetition
Reading
Writing
Calculation
Varieties of Dysphasia
Broca's Dysphasia
Wernicke's Dysphasia
Conduction Dysphasia
Stuttering and Stammering
23:
Frontal Parietal Lobe and Clinical Syndromes with Specific Areas of Cerebral Cortex
THE PARIETAL LOBE AND DISORDERS OF THE BODY SCHEME
Gerstman's Syndrome
Sensory Inattention
Agraphesthesia
Sensory Agnosia
Prosopagnosia
Visual Inattention
CLINICAL SYNDROMES ASSOCIATED WITH SPECIFIC-AREAS OF THE CEREBRAL CORTE
The Frontal Lobes (Fig. 23.1)
Prefrontal Cortex
The Temporal Lobes (Fig. 23.2)
The Occipital Lobes
Subcortical Syndromes
Visual Recognition
Visual Object Agnosia
Visual Agnosia for Colors
Visual Agnosia for Space
24:
The Autonomic Nervous System
GENERAL INSPECTION
Cardiovascular Reflexes
Blood Pressure Response
Heart Rate Responses
The Valsalva's Maneuver
Skin Response
Temperature
Pilomotor Response
Scrotal Response
A Sweating Test
Thermography
EXAMINATION OF BLADDER FUNCTIONS
25:
Electroencephalography and Peripheral Electrophysiology
ELECTROENCEPHALOGRAPHY (EEG)
Clinical Value
Technique of Examination
Physiological Rhythms
Lambda Waves
K-complexes
Abnormal Rhythms
The Delta Activity
Focal Discharges
Spikes
Spikes and Waves Discharges
Myoclonus
Hypsarrythmia
Periodicity
Methods of Stimulation
Hyperventilation
Photic Stimulation
Sleep Deprivation
More Advanced Recording Technique
Sphenoidal Leads
Depth Electrodes and Electrocorticography
PERIPHERAL ELECTROPHYSIOLOGY
Electromyography
Normal Records
Abnormal Records
Denervation
Nerve Conduction Studies
Motor Nerve Conduction Velocity (MNCV)
Investigation for Peripheral Nerve Lesion
Localization of a Lower Motor Neuron Lesion
Myotonia
In Demonstrating Myasthenia
Demonstration of Abnormality
Demonstration of Antagonistic Activity
Evoked Potentials
26:
Cerebrospinal Fluid, Biopsy and General Medical Investigation
EXAMINATION OF CEREBROSPINAL FLUID (CSF)
Indications
Contraindications
Local Sepsis
Technique of Lumbar Puncture
Interpretation of Findings
The CSF Pressure
Higher Pressure
Collection
Examination
A Blood Stained Fluid
The Cells
Polymorphonuclear Pleocytosis
Lymphocytic Pleocytosis
Distinguishing Cell Types
The Protein Content
Electrophoresis of the Cerebrospinal Fluid
Low Glucose
Fluorescent Treponemal Antibody
Bacteriology and Virology
Serological Tests for Syphilis
Treponemal Immobilization Test
BIOPSY
Brain Biopsy
GENERAL MEDICAL INVESTIGATIONS
Suspected Vasculitis
Peripheral Neuropathy
Genetic Tests
27:
Neuroepidemiology
PARKINSON'S DISEASES
EPIDEMIOLOGY OF STROKE
28:
Neuroradiology and Imaging
PLAIN RADIOGRAPHS
The Skull
Indications
The Calvarium
Normal Asymmetry
The Basi-Occiput
The Choroid Plexus
The Falx
Abnormal Intracranial Calcification
Neoplasms
The Choroid Plexus
Basal Ganglia Calcification
Intracranial Air
The Spine
The Pedicles
The Vertebral Canal
MYELOGRAPHY
CT SCAN (FIGS 28.1 TO 28.4)
Intracranial Tumor
Oligodendroglioma
Meningioma
Metastasis
Lymphoma
Vascular Diseases
Primary Intracerebral Hemorrhage
Subarachnoid Hemorrhage
Subdural Hematoma
Lesions of the Venous System
MAGNETIC RESONANCE IMAGING (FIGS 28.5 AND 28.6)
T2 Weighted Images
MRI
Indications and Uses
The Brain
Infections and Inflammations
Cerebrovascular Disease
ANGIOGRAPHY
Cerebral Angiography (Figs 28.7 and 28.8)
Arch Angiography
Magnetic Resonance Angiography
Spinal Angiography
POSITRON EMISSION TOMOGRAPHY
29:
Neurorehabilitation
MULTIPLE SCLEROSIS
SPINAL CORD
Blood Supply of the Spinal Cord
Veins
Spinal Cord Injury
HEAD INJURY
30:
Neurogenetics
TERMINOLOGY
Proband
Simple Heterozygotes
X-linked Dominant Inheritance
Maternal Inheritance
Mitochondria and Genes
X-linked Recessive Inheritance
IMPORTANT TECHNIQUES
ETHICAL ASPECTS
31:
Examination of Consciousness, Brain Death, Coma, Sleep and Sleep Disorders
HOW TO ASSESS THE DEGREE OF ALTERED CONSCIOUSNESS?
The Unconscious Patient
The Purpose of the Examination
History
Premonitory Symptoms
Drowsiness
Stupor
Delirium
Locked in Syndrome
Coma
Confusion and Disorientation
Methods of Differentiation
The Analysis of Dysarthria
Psychogenic Unresponsiveness
The Locked in State
Persistent Vegetative State
Metabolic Causes of Coma
Diabetic Coma
Renal Coma
Hepatic Coma
Pancreatic Encephalopathy
Salt and Water Imbalance
Treatment with Glucose and Thiamine
Disturbance of Calcium and Magnesium
Drug
Hypoxia and Hypercarbia
Disturbance of Thermoregulation
Hypothermia
Cerebrovascular Causes of Coma (Fig. 31.1)
Other Miscellaneous Causes of Coma
The Management of the Unconscious Patient
Resuscitation
Prognosis in Coma
SLEEP AND SLEEP DISORDERS
Disorder of Sleep
Narcolepsy
Restless Leg Syndrome
Klein-Levin Syndrome
BRAINSTEM DEATH
Tests of Confirming Brain Death
INDEX
TOC
Index
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