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 Nerve
Roots

Finger extension Extensor digitorum, Extensor Radial nerve (posterior C7, C8

indicis, Extensor digiti minimi interosseous nerve)

Thumb abduction in Abductor pollicis longus Radial nerve (posterior C7, C8

plane of palm interosseous nerve)

Finger abduction Dorsal interossei, Abductor digiti Ulnar nerve C8, T1

minimi

Finger and thumb Adductor pollicis, Palmar Ulnar nerve C8, T1

adduction in plane of interossei
palm
Action Muscles Nerves Nerve
Roots

Thumb opposition Opponens pollicis Median nerve C8, T1

Thumb abduction Abductor pollicis brevis Median nerve C8, T1

perpendicular to plane of
palm

Flexion at distal Flexor digitorum profundus to Median nerve C7, C8

interphalangeal joints digits 2, 3
digits 2, 3

Flexion at distal Flexor digitorum profundus to Ulnar nerve C7, C8

interphalangeal joints digits 4, 5
digits 4, 5
Action Muscles Nerves Nerve
Roots

Wrist flexion and hand Flexor carpi radialis Median nerve C6, C7
abduction

Wrist flexion and hand Flexor carpi ulnaris Ulnar nerve C7, C8,
adduction T1

Wrist extension and hand Extensor carpi radialis Radial nerve C5, C6
abduction
Action Muscles Nerves Nerve
Roots

Elbow flexion (with Biceps, Brachialis Musculocutaneous C5, C6

forearm supinated) nerve

Elbow extension Triceps Radial nerve C6, C7,

C8

Arm abduction at shoulder Deltoid Axillary nerve C5, C6

Lower Extremity Strength Testing
Action Muscles Nerves Nerve
Roots

Hip flexion Iliopsoas Femoral nerve, and L1-L3 L1, L2, L3,
nerve roots L4

Knee Quadriceps Femoral nerve L2, L3, L4

extension

Knee Hamstrings (semitendinosus, Sciatic nerve L5, S1, S2

flexion semimembranosus, biceps femoris)

Leg Gluteus medius, Gluteus minimus, Tensor Superior gluteal nerve L4, L5, S1
abduction fasciae latae
Action Muscles Nerves Nerve
Roots

Leg adduction Obturator externus, Adductor longus, Obturator nerve L2, L3, L4
magnus, and brevis, Gracilis

Toe Extensor hallucis longus, Extensor digitorum Deep peroneal nerve L5, S1
dorsiflexion longus

Foot Tibialis anterior Deep peroneal nerve L4, L5

dorsiflexion
Action Muscles Nerves Nerve
Roots

Foot plantar Triceps surae (gastrocnemius, soleus) Tibial nerve S1, S2

flexion

Foot eversion Peroneus longus, Peroneus brevis Superficial peroneal L5, S1

nerve

Foot Tibalis posterior Tibal nerve L4, L5

inversion
SENSORY EXAM
1.Primary sensation — asymmetry, senso

2.Cortical sensation, including extinction

Primary sensation - asymmetry,
sensory level
• Light touch is best tested with a cotton-
tipped 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 / D-
L-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 (hemi-
asomatognosia)
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 self-
destructive 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!