Appendix: Neurological Examination Instruments978-1-59745-081-2/1.pdf · Appendix: Neurological Examination Instruments All kinds of instruments are available. They vary in price,

Appendix: Neurological Examination Instruments

All kinds of instruments are available. They vary in price, and some are associated with the great ancient heroes of European and British neurology.

Figure 18-1. Neurological examination Instruments. {Continued)

210

APPENDIX: NEUROLOGICAL EXAMINATION INSTRUMENTS / 211

Figure 18-1 (continued). Neurological examination instruments.

The cheapest reflex hammer works exactly the same as the most expensive; the cheapest 128 tuning fork is all you need for examining one aspect of posterior column function. Do not buy an instrument for testing pain sensation. A package of sterile pins is all you need. Each patient is examined with his own pin fliat is then discarded. The instruments in Figure 18^1 can be bought from Kennex Medical Inc., PO Box 870009, Stone Mountain, GA 30087.

Abdominal muscles, weakness of, gaitabnormalities and, 161

Abdominal reflexes, 173, 174fcorticospinal system lesions affecting,

193Abducens nerve (cranial nerve VI)

lateral rectus muscle and, 49lesions of, 57–59

Abductionof arm, 136–138of eye, 45

lateral rectus muscle in, 49–50superior and inferior oblique muscles

in, 54of fingers, 130of thigh, 150of thumb, 130

Abductor pollicis brevis muscle, 130Abductor pollicis longus muscle, 130Abetalipoproteinemia, CPEO in, 69Accommodation, 66–67

in Adie’s syndrome, 65ACG. See Acute angle-closure glaucomaAcoustic nerve (cranial nerve VIII),

107–111. See also Cochlear nerve;Vestibular nerve

cochlear nerve, 107–109diseases of, 110–111tinnitus and, 111vestibular nerve, 109–110

Acoustic neuroma, tinnitus caused by, 111Acuity, visual, 19

distance vision, 11, 12in latent nystagmus, 12, 73in papilledema, 39

Acute angle-closure glaucoma (ACG), 26Adduction

of arm, 138, 139f

of eye, 46defects in, convergence and, 67medial rectus muscle in, 50superior and inferior rectus muscles

in, 53–54Adductor muscles (magnus, longus,

brevis), 150Adie’s syndrome (tonic pupil), 65Afferent pupil defect, 64Aging. See ElderlyAlcohol use and abuse, nystagmus caused

by, 71Alternating movements

lower limb coordination tested with,145–147, 146f

upper limb coordination tested with,123–125, 124f, 125f

Altitudinal field defect, 17fAmblyopia, 10American Medical Association test card,

for near vision testing, 13Amsler grid, in macular degeneration diag-

nosis, 28Amyotrophic lateral sclerosis, jaw weak-

ness in, 96Analgesia

definition of, 179facial, trigeminal nerve disorders caus-

ing, 96Anesthesia, definition of, 179Angiography, fluorescein, in macular de-

generation diagnosis, 28Angle-closure glaucoma, acute (ACG), 26Angular gyrus, 205Anisocoria, 62, 65Ankle clonus, in corticospinal system dis-

ease, 194Ankle reflex, 169–170, 170–171f

Index

NOTE: Page numbers in bold face type indicate a major discussion. A t followinga page number indicates tabular material and an f following a page number indicates a figure.

213

214 / INDEX

Anomic aphasia, 208Anosmia, 87–88

central, 88unilateral, 87

Anterior chiasmal lesions, visual field de-fects caused by, 29–30, 29–30f

Anterior fossa tumors, anosmia caused by,88

Anterior (saccadic) gaze center, 80–81Anterior interosseous nerve

flexor digitorum profundus and, 131flexor pollicis longus and, 133

Anterior ischemic optic neuropathy, 25Anterior tibial muscle, 148, 151, 151f, 153,

154Aphakia, 10Aphasia, 205–211

anomic, 208Broca’s, 206, 207comprehension, 206–207conduction, 208definition of, 205examination of patient with, 206–207fluent speech in, 206global, 208–209naming in, 207reading in, 207repetition in, 206spontaneous speech in, 206types of, 207–209Wernicke’s, 208writing in, 207

Aphonia, 205Apraxia, gait, 157, 161Arcuate fasciculus, 205Arcuate scotoma, 20

in glaucoma, 26Area

Broca’s, 205Brodmann’s 17–19 (visual cortex), 21

lesions of, 35–36field defects caused by, 35, 35fgaze palsy and, 80–81

Brodmann’s 17 (striate cortex), 21Brodmann’s 18 (parastriate cortex), 21

lesions of, gaze palsy and, 80–81Brodmann’s 19 (peristriate cortex),

21

Brodmann’s 39 (angular gyrus), 205Brodmann’s 40 (supramarginal gyrus),

205Brodmann’s 41 and 42 (Wernicke’s

area), 205Brodmann’s 44 (Broca’s area), 205centralis. See Posterior pole

Argyll-Robertson pupils, 64Arm, 121. See also Upper limb

abduction of, 136–138adduction of, 138, 139fcircumference measurement of, 127,

129fArm drift, 122–123, 122fArnold-Chiari malformation, downbeat

nystagmus in, 73Arteriovenous “nicking,” retinal, in hyper-

tension, 43Arteritis, giant cell, of central retinal

artery, 25Artery

carotid, occlusion of, pupils and, 66retinal

branch, occlusion of, 27central

giant cell arteritis of, 25occlusion of, 27

in hypertension, 43occlusion of, 27ophthalmoscopic examination of, 6,

7ftemporal, giant cell arteritis of, 25

Aspirin, tinnitus and, 111Astigmatism, 10

examiner’s, eyeglass use during oph-thalmoscopic examination and, 3

patient’s, lens for ophthalmoscopic ex-amination and, 10

Ataxia. See also Gaitin cerebellar disease, 159–160contralateral arm and leg, frontal lobe

lesion causing, 190miscellaneous diseases causing, 162in normal-pressure hydrocephalus,

161–162tests of, 158–159

Ataxic dysarthria, speech in cerebellar dis-ease and, 190

INDEX / 215

Atheroma, carotid artery, pupils in, 66Atropine, factitious big pupil caused by, 66Axillary nerve

deltoid muscle and, 136, 138lesion of, C5 root lesion differentiated

from, 143

Babinski response (extensor plantar re-sponse), 174, 175

in corticospinal system lesions, 193Back muscles, weakness of, gait abnormal-

ities and, 161Balance, 157–162. See also GaitBardet-Biedl syndrome, retinitis pigmen-

tosa and, 26Basal ganglia disease, rigidity in, 126Bassen-Kornzweig syndrome

CPEO and, 69retinitis pigmentosa and, 26

Bell’s palsy, 104Bell’s phenomenon, 82–83Betz cells, 191Biceps muscle, 133

in biceps reflex, 166–167Bilateral homonymous hemianopsia (corti-

cal blindness), 36Bilateral simultaneous stimulation, in sen-

sory examination, 185Binocular vision, testing, 47, 48fBirmingham Optical Group test card, for

near vision testing, 13Bitemporal hemianopic central scotoma,

17f, 20–21Bitter, as taste substance, 104Bjerrum’s screen, for central visual field

testing, 16Blepharospasm, 61

ptosis differentiated from, 61Blind spot (physiological scotoma), 20

finding, 20Blindness

cortical (bilateral homonymous hemi-anopsia), 36

glaucoma causing, 26night, in retinitis pigmentosa, 25

Blinking, 99–102pattern of in myasthenia gravis, 68

Botulinin toxin, eye affected by, 67Brachial plexus lesions, upper limb af-

fected in, 140–144lateral cord, 141lower trunk, 141medial cord, 141posterior cord, 141upper trunk, 140–142

Brachialis muscle, in biceps reflex,166–167

Brachialis reflex, 167Brachioradialis muscle, 133

in brachialis reflex, 167in supinator reflex, 167

Brain stem lesionscaloric testing and, 85doll’s eye test and, 85gaze palsy in, 80nystagmus in, 73–74

signs and symptoms associated with,74

Broca’s aphasia, 206, 207Broca’s area, 205Brodmann’s areas 17–19 (visual cortex), 21

lesions of, 35–36anterior, field defects caused by, 35,

35fgaze palsy and, 80–81

Brodmann’s area 39 (angular gyrus), 205Brodmann’s area 40 (supramarginal

gyrus), 205Brodmann’s areas 41 and 42 (Wernicke’s

area), 205Brodmann’s area 44 (Broca’s area), 205

C5 root lesion, axillary nerve lesion dif-ferentiated from, 143

C6 root lesion, musculocutaneous or radialnerve lesion differentiated from, 143

C7 root lesion, radial nerve lesion differen-tiated from, 143–144

Calcarine sulcus, 21Calculation ability, 199–200Caloric testing, 85

in gaze palsy, 80in unconscious patient, 85, 110of vestibular function, 109–110

216 / INDEX

Carotid artery occlusion, pupils in, 66Cataract surgery, corneal reflex absent af-

ter, 93Cataracts, visual acuity affected by, 12

near vision, 13Cecocentral scotoma, 20Central nervous system disease, delirium

caused by, 202Central retinal vein occlusion, 26–27Central scotoma, 19–20, 29

occipital lobe lesion causing, 23Central vision (macular vision), 11–13,

19Cerebellar disease, 187–190

dysmetria in, 188–189ocular, 189

gait abnormalities in, 159–160gaze palsy and, 81muscle tone in, 187nystagmus in, 73–74, 189


past pointing in, 188–189posture in, 187rebound in, 188–189speech in, 190tendon reflexes in, 187–188tremor in, 188voluntary movements in, 189

Cerebellar–pontine angle tumor, seventh(facial) nerve palsy and, 105

Cerebral lesions, gaze palsy in, 80CF. See Counting fingers, in vision lossChiasm, 22

lesions of, 28–33anterior, 29–30, 29–30fof body, 31–32, 31–32ffield defects caused by, 17f, 22,

28–33, 29–33flateral, 33, 33fposterior, 32, 32f

Choked disc. See PapilledemaChoking, in pharyngeal paresis, 113Chronic open-angle glaucoma (OAG),

26Chronic progressive external ophthalmo-

plegia, 68–69ptosis in, 61, 68

Clonus, 170–172ankle, 194in corticospinal system disease, 194finger, 172forearm, 172knee, 172, 194wrist, 126, 172, 194

Clostridium boutlinum, toxin of, eye af-fected by, 67

Cochlear nerve, 107–109deafness caused by lesions of, 107–109

Cochlear nucleus, 107Cogwheel rigidity, 126Concentration tests, miscellaneous, 200Concomitant strabismus (nonparalytic stra-

bismus), 56Conduction aphasia, 208Conductive hearing loss, 108, 109Confrontation testing, of visual fields,

13–15, 14f, 18Confusional states. See also Delirium; De-

mentiasensory examination precluded by,

178Congenital nystagmus

optokinetic nystagmus absent in, 77pendular, 72

Conjugate deviation of eyesforced, 79

downward, 82supratentorial gaze “centers” and,

80–81upward, 82

“wrong way,” 81Conjugate gaze palsy, 79

supratentorial gaze “centers” and, 80–81Constrictor muscles, of pharynx, vagus

nerve supplying, 113Constructional ability, 200, 201fContact lenses, corneal reflex prevented

by, 92Convergence, 66–67

excess, 67forced downward gaze and, 82paralysis/paresis of, 67, 85–86

supranuclear, 86Convergence nystagmus, 75

INDEX / 217

Convergence palsy, 67, 85–86supranuclear, 86

Convergence-retraction nystagmus, 75Coordination, tests of

lower limb, 145–147, 146fupper limb, 123–125, 124f, 125f

Corneal reflex, 91–93, 91f, 92f, 173absence of

after cataract surgery, 93in elderly, 93in ophthalmic nerve lesions, 92in thalamic lesions, 93

contact lenses preventing, 92methods of elicitation of, 91f

Cortex, visual, 21frontal, gaze palsy and, 80lesions of, 35–36

anterior, field defects caused by, 35,35f

field defects caused by, 35, 35fgaze palsy and, 80–81

occipitaldivision of, 21gaze palsy and, 80, 81vision represented in, 22

parastriate (area 18), 21gaze palsy and, 80–81

peristriate (area 19), 21striate (area 17), 21

Corti, organ of, 107Cortical blindness (bilateral homonymous

hemianopia), 36Cortical functions, higher, 197–203Corticobulbar system disease, bilateral,

pseudobulbar palsy caused by, 194Corticospinal system disease (upper motor

neuron lesions), 191–195clonus in, 194facial weakness in, 97, 191–192gait abnormalities in, 160–161, 193–194jaw weakness in, 97, 192miscellaneous manifestations of,

193–194muscle tone in, 192–193power in, 191–192reflexes in, 193sternomastoid and trapezius weakness

in, 118

Cotton-wool spots/exudatesin central retinal vein occlusion, 26–27in papilledema, 38

Coughing, in pharyngeal paresis, 113Counting fingers, in vision loss, 12Cover test, 46CPEO. See Chronic progressive external

ophthalmoplegiaCranial nerves. See Nerve(s), cranialCremasteric reflex, 173–174

corticospinal system lesions affecting,193

CRVO. See Central retinal vein occlusionCup (physiologic), ophthalmoscopic exam-

ination of, 7f, 8–9Cutaneous nerve of thigh, lateral, signs and

symptoms of lesions of, 154Cyclophoria, 47

Deafness, 107–109cochlear nerve lesions causing, 107–109conductive, 108, 109nerve, 108, 109

Deep peroneal nerveextensor digitorum longus and, 151extensor hallucis longus and, 151tibialis anterior and, 151

Delirium, 201–202in central nervous system disease, 202drug use and abuse causing, 202hypoxia causing, 202infection causing, 202metabolic disorders causing, 202sensory examination precluded by, 178

Deltoid muscle, 136, 138Dementia, 197–198, 202–203

anosmia and, 88depression resembling, 201sensory examination precluded by, 178

Demonstration, in sensory examination,178

Denervation supersensitivity, pupillary, inAdie’s syndrome, 65

Depression, dementia resembled by, 201Depression of eye. See Ocular depressionDescending supraspinal pathway,

191–195. See also Corticospinal sys-tem disease

218 / INDEX

Deviations, ocular. See Ocular deviationsDiencephalon, lesions of, nystagmus in, 74Digastric muscle, anterior belly of,

mandibular branch of trigeminalnerve supplying, 89

Diopters, 37Diphtheria, eye changes in, 67Diplopia/double vision, 45–49

eye patch and, 57head posture and, 57identifying muscles responsible for,

47–49, 48fin inferior oblique muscle dysfunction,

53in inferior rectus muscle dysfunction, 51in lateral rectus muscle dysfunction,

49–50in medial rectus muscle dysfunction, 50monocular, 57in paresis of convergence, 67in superior oblique muscle dysfunction,

53in superior rectus muscle dysfunction, 51in thyroid ocular myopathy, 68–69

Direct pupil response to light, 63Disc hyperemia, in papilledema, 37Distance vision, 11–13, 11fDoll’s eye test, 85

in gaze palsy, 80in unconscious patient, 85, 110

Dorsal interosseous muscle, 129, 129f, 130Dorsal midbrain syndrome (Parinaud’s

syndrome), 83defective downward gaze in, 82, 83defective upward gaze in, 83

Dorsal scapular nerve, rhomboid musclesand, 139–140

Dorsiflexion, foot and toes, 151, 151fDouble vision. See DiplopiaDownbeat nystagmus, brain stem and cere-

bellar lesions causing, 73, 189Downward gaze, 82

forced, 82paralysis of, 82

Drift, arm, spontaneous, 122–123, 122fDrug overdose

caloric testing in, cautions for use of, 85,110

doll’s eye test in, cautions for use of, 85,110

Drug use and abusedelirium caused by, 202nystagmus caused by, 71

Duchenne-Erb syndrome, upper trunk le-sions in, 140–142

Dysarthriaaphasia differentiated from, 205ataxic, speech in cerebellar disease and,

190in pseudobulbar palsy, 195

Dysesthesia, definition of, 179Dysmetria, cerebellar disease causing,

188–189ocular, 189

Dysphagiain pharyngeal paresis, 113in pseudobulbar palsy, 194–195

Dysphasia. See Aphasia

E chart, for visual acuity testing, 12Echolalia, 205Eighth cranial nerve. See Nerve(s), cranial,

VIIIElderly

accommodation loss in, 66anosmia in, 88corneal reflex absence in, 93decreased vibration sense in, 183facial asymmetry in, 99lower limb tone in, 147pupil size in, 62taste sensation in, 104upward gaze affected in, 82Elevation of eye. See Ocular elevation

Eleventh cranial nerve. See Nerve(s), cra-nial, XI

End-point nystagmus, 75Equatorial division, 21Esophoria, 46Esotropia, 46Eversion, of foot, 151–152Exotropia, 46Extension

of fingers, 135–136, 135fof forearm, 136

INDEX / 219

of leg, 149, 150fof thigh at hip, 153of thumb, 135of wrist, 136, 137f

Extensor carpi radialis (longus and brevis)muscles, 136, 137f

Extensor carpi ulnaris muscle, 136, 137fExtensor digitorum longus muscle, 151,

151fExtensor digitorum muscle, 135–136, 135fExtensor hallucis longus muscle, 148, 151,

151fExtensor muscle weakness, upper limb, in

corticospinal system lesions, 192Extensor plantar response (Babinski re-

sponse), 174, 175in corticospinal system lesions, 193

Extensor pollicis brevis muscle, 135Extensor pollicis longus muscle, 135External ocular muscles

in concomitant strabismus, 56diseases causing weakness of, 67–69

convergence assessment in, 67functions of, 49–55in paralytic strabismus, 56–57

Exudatesmacular, in papilledema, 38retinal

cotton-woolin central retinal vein occlusion,

26–27in papilledema, 38

in hypertension, 43Eye

muscles of. See External ocular muscles;Eyelid muscles

normal, 39, 40fin papilledema, 39, 41f

Eye closing muscles, in myasthenia gravis,68

Eye movements, 45–49in chronic progressive external ophthal-

moplegia, 68external ocular muscles and, 49–55lateral, testing, 47, 48, 48fmonocular, in concomitant strabismus,

56terminology related to, 45–47

verticallateral rectus muscle in, 50testing, 48

Eye opening muscles, in myastheniagravis, 68

Eye patch, double vision and, 57Eyeglasses, during ophthalmoscopic exam-

inationexaminer’s, 3patient’s, 10

Eyelid musclesdiseases causing weakness of, 67–69in myasthenia gravis, 68

Facial nerve (cranial nerve VII), 97–105anatomy of, 97autonomic functions of, 102–104blinking and, 99–102diseases of, 104–105examination of, 98–99, 100–101fmotor functions of, 97–98palsy of, 105

facial weakness differentiated from,97–98, 98–99, 100–101f, 105

parkinsonism and, 105saliva as function of, 102sensory root of, 102–104taste as function of, 102

testing, 103–104, 103ftears as function of, 102

Facial numbness, trigeminal nerve disor-ders causing, 96

Facial pain, trigeminal nerve disorderscausing, 95–96

Facial weakness, 105appearance at rest and, 99in corticospinal system disease (upper

motor neuron lesions), 97, 191–192in parkinsonism, 105seventh nerve lesion differentiated from,

97–98, 98–99, 100–101f, 105Factitious big pupil, 66Fatigue, sensory examination results af-

fected by, 178Femoral nerve

iliopsoas muscle and, 149in knee reflex, 169

220 / INDEX

Femoral nerve (cont.)quadriceps femoris muscle and, 149signs and symptoms of lesions of,

154–155Fields of vision. See also Visual field de-

fectscentral (macular), 11–13, 19equatorial division and, 21gaze palsy and, 80–81in glaucoma, 26organization of, 21–22peripheral, testing, 13–18

confrontation testing for, 13–15, 14f,18

perimetry for, 16string test for, 14f, 16

Fifth cranial nerve. See Nerve(s), cranial, VFinger clonus, 172Finger flexion reflex, 167–168, 168fFingers. See also Upper limb

abduction of, 130extension of, 135–136, 135fflexion of, 131–132, 132fweakness of, in corticospinal system le-

sions, 192First cranial nerve. See Nerve(s), cranial, IFirst dorsal interosseous muscle, 129, 129f,

130Flame hemorrhages, in papilledema, 38Flexion

of fingers, 131–132, 132freflex and, 167–168, 168f

of forearm, 133of leg at knee, 153plantar

of foot, 151, 152, 152–153of toes, 152

of thigh, 149, 149f, 153of thumb, 133–134of wrist, 133, 134f

Flexor carpi radialis muscle, 133, 134fFlexor carpi ulnaris muscle, 133, 134fFlexor digitorum longus muscle, 152Flexor digitorum profundus muscle, 131,

132fFlexor digitorum sublimis/flexor digitorum

superficialis muscles, 131–132, 132fFlexor hallucis longus muscle, 152

Flexor muscle spasticity, upper limb, incorticospinal system lesions, 192

Flexor plantar response, 175Flexor pollicis brevis muscle, 134Flexor pollicis longus muscle, 133Fluent speech, in aphasia, 206Fluorescein angiography, in macular de-

generation diagnosis, 28Flutter, ocular, cerebellar disease causing,

189Following (smooth pursuit) gaze center, 81Foot. See also Lower limb

dorsiflexion of, 151, 151fdorsum of, sensory loss of in sciatic

nerve lesions, 155eversion of, 151–152inversion of, 151, 152plantar flexion of, 151, 152, 152–153sole of, sensory loss of in sciatic nerve

lesions, 155Foramen

infra-orbital, maxillary branch oftrigeminal nerve in, 89

mental, mandibular branch of trigeminalnerve in, 89

ovalejaw weakness in disorders of, 97mandibular branch of trigeminal

nerve in, 89rotundum, maxillary branch of trigemi-

nal nerve in, 89superior orbital, ophthalmic branch of

trigeminal nerve in, 88Forearm, 121. See also Upper limb

circumference measurement of, 127, 129fextension of, 136flexion of, 133

Forearm clonus, 172Fourth cranial nerve. See Nerve(s), cranial,

IVFovea

anatomic. See Maculaophthalmoscopic examination of, 7f,

9–10Foveola. See FoveaFreezing, coma caused by

caloric testing in, cautions for use of, 85doll’s eye test in, cautions for use of, 85

INDEX / 221

Froment’s sign, 143Frontal cortex, lesions of, gaze palsy and,

80Frontal (saccadic) gaze center, 80–81Frontal gyrus, middle, lesions of, ocular

manifestations of, 80Frontal lobe lesions, contralateral arm and

leg ataxia caused by, 190Frontalis muscle, in facial weakness vs.

seventh nerve lesion, 97, 100fFundus oculi

in hypertension, 43ophthalmoscopic examination of, 2–10

technique for, 2–6, 4f, 5f

Gag reflexglossopharyngeal nerve and, 112paresis of pharynx and, 113vagus nerve and, 112–113

Gait, 157–162in abdominal weakness, 161abnormal, diseases with, 159–162in cerebellar disease, 159–160in corticospinal (upper motor neuron)

disease, 160–161, 193–194hemiplegic, 160in hip girdle weakness, 161jiggling, 161in lower back weakness, 161in miscellaneous disorders, 162in normal-pressure hydrocephalus,

161–162in parkinsonism, 159Romberg test in evaluation of, 158–

159in sensory system disease, 160tests of, 158–159

Gait apraxia, 157, 161Gastrocnemius muscle, 152, 153

in ankle reflex, 169–170Gaze

downward, 82forced, 82paralysis of, 82

primary position of, nystagmus and, 72upward, 82

paralysis of, 82

Gaze “centers,” supratentorial, 80–81anterior (saccadic), 80–81following (smooth pursuit), 81frontal (saccadic), 80–81occipital (smooth pursuit), 81posterior (smooth pursuit), 81volitional (saccadic), 80–81

Gaze-evoked nystagmus, 72Gaze palsy, 79–86

cerebellar, 81in cerebral lesions, 80conjugate, 79

optokinetic nystagmus absent in, 76supratentorial gaze “centers” and,

80–81optokinetic nystagmus absent in, 76parastriate cortex lesions and, 80–81pursuit, 79reflex, 79voluntary, 79

Gegenhalten, 147Geniculate body, lateral, 22Geniculate ganglion

herpes affecting, seventh (facial) nerveinvolvement and, 105

taste cells in, 102Gennari’s line, 21Giant cell arteritis, of central retinal artery,

25Glasses. See EyeglassesGlaucoma, 26

acute angle-closure (ACG), 26chronic open-angle (OAG), 26nasal field defects caused by, 33

Global aphasia, 208–209Glossopharyngeal nerve (cranial nerve

IX), 102, 111–112diseases, 115–116evaluation of, 111–112, 114

Glossopharyngeal neuralgia, 115–116Gluteal nerve

inferior, gluteus maximus and, 153superior, gluteus medius and minimus

and tensor fascia lata muscles and,150

Gluteus maximus muscle, 153Gluteus medius muscle, 150Gluteus minimus muscle, 150

222 / INDEX

Grasp reflex, 175–176Groucho Marx maneuver, in seventh (fa-

cial) nerve evaluation, 98, 100fGuillain-Barré syndrome (infectious

polyneuritis), seventh (facial) nerveinvolvement in, 104

Gyrusangular, 205middle frontal, lesions of, ocular mani-

festations of, 80supramarginal, 205

Hallucinatory answers, in touch evalua-tion, 180

Hamstring muscles (biceps, semitendi-nous, semimembranous), 153

Hand. See also Upper limbvisual examination of, 127–128, 129f

Hand movements only, visual acuity test-ing and, 12

Head injury, anosmia caused by, 87–88Head posture, abnormal, double vision

and, 57Hearing evaluation, 107–109Heel sliding, lower limb coordination

tested with, 146, 146fHeel tapping, lower limb coordination

tested with, 145–146, 146fHemianopia, 20

bilateral homonymous, 36homonymous, 17f, 20with macular loss, 21with macular sparing, 17f, 21

occipital lobe lesion causing, 23with macular splitting, 17f, 20–21

Hemifacial defect, 99Hemiparesis, cortical lesion causing, 192Hemiplegic gait, 160Hemorrhages, retinal

flame-shaped, 38globular subhyaloid, 38in hypertension, 43in papilledema, 38splinter, 38

Herpes simplex infection, seventh (facial)nerve involvement and, 105

Heterophoria (latent strabismus), 46

High myopia, ophthalmoscopic examina-tion in patient with, 10

Hip girdle, weakness of, gait abnormalitiesand, 161

Hippus, 62History

dementia and, 197–198in sensory disturbances, 177in upper limb dysfunction, 121–122in visual loss, 24

HM. See Hand movements onlyHoffmann’s reflex, 168–169Holmes-Adie syndrome, 65Homonymous field defects

hemianopia, 17f, 20hemianopia, bilateral (cortical blind-

ness), 36optokinetic nystagmus absent in, 76

Horizontal field defect, 17fHorner’s syndrome, 62, 65

pupils in, 62, 65Hydrocephalus, normal-pressure, gait af-

fected in, 161–162Hypalgesia, definition of, 179Hyperemia, optic disc, in papilledema,

37Hyperesthesia

definition of, 179facial, trigeminal nerve disorders caus-

ing, 96Hyperopia (hypermetropia), 10

lens for ophthalmoscopic examinationand, 10

Hyperpathia, definition of, 179Hyperphoria, 47Hypertension, fundus changes in, 43Hypertropia, 46Hypoesthesia, definition of, 179Hypoglossal nerve (cranial nerve XII),

118–120diseases of, 120examination of, 118–120, 119f

Hypophoria, 47Hypothenar eminence, 127Hypotonia, cerebellar lesions causing,

187Hypotropia, 46Hypoxia, delirium caused by, 202

INDEX / 223

Iliopsoas muscle, 149, 149f, 153Inattention field defect, 15

optokinetic nystagmus absent in, 76Increased intracranial pressure, optic nerve

head swelling caused by. See Pa-pilledema

Infections, delirium caused by, 202Infectious polyneuritis (Guillain-Barré

syndrome), seventh (facial) nerve in-volvement in, 104

Inferior gluteal nerve, gluteus maximusand, 153

Inferior oblique muscle, 53Inferior rectus muscle, 51, 53–54Infra-orbital foramen, maxillary branch of

trigeminal nerve in, 89INO. See Internuclear ophthalmoplegiaInstruments, for neurological examination,

210, 210–211fIntelligence

diseases of, 201–203testing, 197–203

Intention tremorcerebellar, 188terminal, 123–124

Intermediate nerve (sensory root of sev-enth cranial nerve), 102–103

Internuclear ophthalmoplegia, 84Interosseous nerve

anteriorin finger flexion, 131flexor pollicis longus and, 133

posteriorextensor carpi ulnaris and, 136extensor digitorum and, 135extensor pollicis longus/extensor pol-

licis brevis and, 135Intracranial pressure, increased, optic

nerve head swelling caused by. SeePapilledema

Intraocular pressure, elevated, in glau-coma, 26

Inversion, of foot, 151, 152

Jaeger’s test type, for near vision test-ing, 13

Jaw jerk, 165, 165fin pseudobulbar palsy, 195

Jaw weaknessin amyotrophic lateral sclerosis, 96in corticospinal system disease (upper

motor neuron lesions), 97, 192in foramen ovale disorders, 97in myasthenia gravis, 96in poliomyelitis, 96in trigeminal nerve disorders, 96–97

Jerk nystagmus, 71. See also Nystagmusbrain stem and cerebellar lesions caus-

ing, 73latent, 72–73primary eye position and, 72

Jiggling gait, 161Jugular foramen syndrome, 116

Kearns-Sayre syndromeCPEO in, 69retinitis pigmentosa and, 26

Klumpke syndrome, lower trunk lesionsin, 141

Knee, leg flexion at, 153Knee clonus, 172

in corticospinal system disease, 194Knee reflex, 169

difficulty eliciting, 172

Language, 205. See also SpeechLarynx, 114, 115f

paralysis of, 113, 114vagus nerve supplying, 113–114

Latent nystagmus, 72–73visual acuity affected by, 12, 73

Lateral chiasmal lesions, field defectscaused by, 33, 33f

Lateral cutaneous nerve of thigh, signs andsymptoms of lesions of, 154

Lateral geniculate body, 22Lateral rectus muscle, 49–50Lateralization, tests of, 125Latissimus dorsi muscle, 138Leber’s optic neuropathy, 28Leg, 145. See also Lower limb

circumference measurement of, 147extension of, 149, 150fflexion of at knee, 153strength of, 148, 153–154

224 / INDEX

Leg and arm ataxia, contralateral, frontallobe lesions causing, 190

Leg circumference, measuring, 149, 150fLeg raising test, supine, 145LGB. See Lateral geniculate bodyLight reaction (pupillary), 63

direct and consensual, 63Limbs. See Lower limb; Upper limbLitigation, medicolegal, sensory examina-

tion and, 178–179Logical thinking, evaluation of, 199Long thoracic nerve, serratus anterior mus-

cle and, 140Lower limb, 145–155

coordination evaluation and, 145–147,146f

examination of, 149–154muscle tone and, 147–148


nerve lesions affecting, signs and symp-toms of, 154–155

power (strength) of, 148, 153–154corticospinal system lesions affecting,

192single root lesions affecting, signs and

symptoms of, 154size of, 147

Lower motor neuron lesions, facial weak-ness caused by, 97

Lumbar root lesions, signs and symptomsof, 154

Macula, 22anatomic. See Posterior poleophthalmoscopic examination of, 7f,

9–10Macular degeneration, 28Macular exudates, in papilledema, 38Macular fibers, 22

nasal, 22Macular loss, hemianopia with, 21Macular sparing, hemianopia with, 17f, 21

occipital lobe lesion causing, 23Macular splitting, hemianopia with, 17f,

20–21Macular vision (central vision), 11–13, 19

Mandibular branch of trigeminal nerve, 89,89f

motor function mediated through,94–95, 95f

Marcus Gunn pupil, 64Masseter muscle

in jaw jerk, 165mandibular branch of trigeminal nerve

supplying, 89, 94, 95fMaxillary branch of trigeminal nerve, 89,

89fMecholyl, pupillary response to, in Adie’s

syndrome, 65Medial longitudinal fasciculus lesions

internuclear ophthalmoplegia caused by,84

“one-and-a-half” syndrome caused by,84

Medial rectus muscle, 50in thyroid ocular myopathy, 69

Median nerveabductor pollicis brevis and, 130flexor carpi radialis and, 133flexor digitorum profundus and, 131flexor digitorum sublimis/flexor digito-

rum superficialis and, 131flexor pollicis brevis and, 134flexor pollicis longus and, 133lesions of, upper limb involvement in,

142opponens pollicis and, 130

Medicolegal litigation, sensory examina-tion of patient and, 178–179

Memory, 198–199diseases of, 201–203immediate, 198intermediate, 198remote, 199

Meningioma, anosmia caused by, 88Mental foramen, mandibular branch of

trigeminal nerve in, 89Metabolic disorders, delirium caused by,

202Metacarpal phalangeal joints, 136Midbrain lesions, pupils in, 66Middle frontal gyrus, lesions of, ocular

manifestations of, 80Miosis, pontine, 66

INDEX / 225

MLF. See Medial longitudinal fasciculusMonocular diplopia, 57Mood, 200–201Motor functions

of fifth cranial (trigeminal) nerve,94–95, 95f

of seventh cranial (facial) nerve, 97–98Motor neurons

lower, lesions of, facial weaknesscaused by, 97

upper, lesions of, 191–195clonus in, 194facial weakness caused by, 97gait abnormalities in, 160–161,

193–194jaw weakness and, 97miscellaneous manifestations of,

193–194muscle tone affected by, 192–193power affected by, 191–192reflexes affected by, 193sternomastoid and trapezius weakness

caused by, 118Movements, alternating



Multiple sclerosisCPEO in, 69gait abnormalities in, 161

Muscle(s)abdominal, weakness of, gait abnormali-

ties and, 161abductor pollicis brevis, 130abductor pollicis longus, 130anterior tibial, 148, 151, 151f, 153, 154biceps, 133

in biceps reflex, 166–167brachialis, in biceps reflex, 166–167brachioradialis, 133

in brachialis reflex, 167in supinator reflex, 167

constrictor, of pharynx, 113deltoid, 136, 138digastric, anterior belly of, mandibular

branch of trigeminal nerve supply-ing, 89

dorsal interosseous, 129, 129f, 130extensor carpi radialis (longus and bre-

vis), 136, 137fextensor carpi ulnaris, 136, 137fextensor digitorum, 135–136, 135fextensor digitorum longus, 151, 151fextensor hallucis longus, 148, 151, 151fextensor pollicis brevis, 135extensor pollicis longus, 135external ocular

in concomitant strabismus, 56diseases causing weakness of, 67–69

convergence assessment in, 67functions of, 49–55in paralytic strabismus, 56–57

first dorsal interosseous, 129, 129f, 130flexor carpi radialis, 133, 134fflexor carpi ulnaris, 133, 134fflexor digitorum longus, 152flexor digitorum profundus, 131, 132fflexor digitorum sublimis/flexor digito-

rum superficialis, 131–132, 132fflexor hallucis longus, 152flexor pollicis brevis, 134flexor pollicis longus, 133frontalis, in facial weakness vs. seventh

nerve lesion, 97, 100fgastrocnemius, 152, 153

in ankle reflex, 169–170gluteus maximus, 153gluteus medius, 150gluteus minimus, 150hamstring (biceps, semitendinous, semi-

membranous), 153iliopsoas, 149, 149f, 153inferior oblique, 53inferior rectus, 51, 53–54lateral rectus, 49–50latissimus dorsi, 138masseter

in jaw jerk, 165mandibular branch of trigeminal

nerve supplying, 89, 94, 95fmedial rectus, 50

in thyroid ocular myopathy, 69mylohyoid, mandibular branch of

trigeminal nerve supplying, 89

226 / INDEX

Muscle(s) (cont.)oblique

inferior, 53superior, 51–53, 54, 54f

opponens pollicis, 130–131, 131forbicularis oculi, in facial weakness vs.

seventh nerve lesion, 97–98pectoralis major, 138, 139fperoneus brevis, 151–152peroneus longus, 151–152platysma, 99, 101fposterior tibial, 152pronator, testing tone of, 127, 128fpterygoid

jaw weakness and, 97mandibular branch of trigeminal

nerve supplying, 89, 94quadriceps femoris, 147–148, 149, 150f,

153in knee reflex, 169

rectusinferior, 51, 53–54lateral, 49–50medial, 50

in thyroid ocular myopathy, 69superior, 50–51, 52–53f, 53–54

rhomboid, 139–140serratus anterior, 140soleus, 152, 153

in ankle reflex, 169–170sternomastoid, 116, 117f

spinal accessory nerve supplying, 116upper motor neuron lesion affecting,

118stylopharyngeus, glossopharyngeal

nerve supplying, 111superior oblique, 51–53, 54, 54fsuperior rectus, 50–51, 52–53f, 53–54supraspinatus, 136–137temporalis, mandibular branch of

trigeminal nerve supplying, 89, 94tensor fascia lata, 150teres major, 138of thigh, adductor magnus/longus/bre-

vis, 150tibialis anterior, 148, 151, 151f, 153, 154tibialis posterior, 152

trapeziustesting, 116–118, 137, 138–139upper motor neuron lesion affecting,

118triceps, 136

in triceps reflex, 167upper limb flexor, spasticity of, 192yoke, in paralytic strabismus, 56–57

Muscle stretch (tendon) reflexes, 163–173.See also specific type and Reflexes

cerebellar disease affecting, 187–188corticospinal system lesions affecting,

193pendular, 187–188reinforcement of, 172–173, 172f

Muscle tone, 125–126cerebellar lesions affecting, 187corticospinal system lesions affecting,

192–193lower limb


testing, 147–148upper limb


testing, 125–127, 128fMuscular dystrophy

hip/back/abdominal weakness in, gaitabnormalities and, 161

sternomastoid muscle affected in, 118Musculocutaneous nerve

biceps muscle and, 133in biceps reflex, 166–167lesion of, C6 root lesion differentiated

from, 143Mute patient, 205Myasthenia gravis

CPEO in, 69jaw weakness in, 96ocular manifestations of, 67–68sternomastoid muscle affected in, 118

Mylohyoid muscle, mandibular branch oftrigeminal nerve supplying, 89

Myopathymyotubular, CPEO in, 69ocular, thyroid, 68–69

INDEX / 227

Myopia, 11high, ophthalmoscopic examination in

patient with, 10lens for ophthalmoscopic examination

and, 10Myotonic dystrophy, 68

temporalis and masseter muscles af-fected in, 96

Myotubular myopathy, CPEO in, 69

Nasal field, optic inversion and, 21Nasal macular fibers, 22Nasopharyngeal carcinoma, anosmia

caused by, 88Near vision, 11f, 13Nerve(s)

abducens. See Nerve(s), cranial, VIacoustic. See Nerve(s), cranial, VIIIanterior interosseous

flexor digitorum profundus and, 131flexor pollicis longus and, 133

axillarydeltoid muscle and, 136, 138lesion of, C5 root lesion differentiated

from, 143cochlear, 107–109

deafness caused by lesions of,107–109

cranialI (olfactory nerve), 87–88II (optic nerve), lesions of, 24–34. See

also under Opticfield defects caused by, 22, 24–34

III (oculomotor nerve)inferior oblique muscle and, 53lesions of, 59–60medial rectus muscle and, 50palsy of

ptosis in, 62pupils in, 62–63, 63, 65

superior rectus muscle and, 51IV (trochlear nerve)

lesions of, 60superior oblique muscle and, 51

V (trigeminal nerve), 88–97corneal reflex and, 91–93, 91f, 92fdiseases of, 95–97

facial numbness (analgesia/hyper-esthesia/paresthesia) and, 96

facial pain and, 95–96jaw jerk and, 165jaw weakness and, 96–97mandibular branch of, 89, 89f

motor function mediatedthrough, 94–95, 95f

maxillary branch of, 89, 89fmotor function and, 94–95, 95fophthalmic branch of, 88–89, 89f

lesions of, corneal reflex absentin, 92

pain perception and, 90–91peripheral anatomy of, 88–90, 89fsensory testing and, 90–93spinal nucleus and tract of, 93, 94ftemperature sensation and, 93

VI (abducens nerve)lateral rectus muscle and, 49lesions of, 57–59

VII (facial nerve), 97–105anatomy of, 97autonomic functions of, 102–104blinking and, 99–102diseases of, 104–105examination of, 98–99, 100–101fmotor functions of, 97–98palsy of, 105

facial weakness differentiatedfrom, 97–98, 98–99,100–101f, 105

parkinsonism and, 105saliva as function of, 102sensory root of, 102–104taste as function of, 102

testing, 103–104, 103ftears as function of, 102

VIII (acoustic nerve), 107–111. Seealso Cochlear nerve; Vestibularnerve

cochlear nerve, 107–109diseases of, 110–111tinnitus and, 111vestibular nerve, 109–110

IX (glossopharyngeal nerve), 102,111–112, 114

diseases affecting, 115–116

228 / INDEX

Nerve(s) (cont.)cranial (cont.)

X (vagus nerve), 112–116diseases affecting, 115–116evaluation of, 114larynx and, 113–114palate and, 112–113, 113fpharynx muscles and, 113vocal cord function and, 114

XI (spinal accessory nerve), 116–118diseases of, 118testing, 116–118, 117f, 138–139trapezius muscle and, 138–139

XII (hypoglossal nerve), 118–120diseases of, 120examination of, 118–120, 119f

deep peronealextensor digitorum longus and, 151extensor hallucis longus and, 151tibialis anterior and, 151

dorsal scapular, rhomboid muscles and,139–140

facial. See Nerve(s), cranial, VIIfemoral

iliopsoas muscle and, 149in knee reflex, 169quadriceps femoris muscle and, 149signs and symptoms of lesions of,

154–155glossopharyngeal. See Nerve(s), cranial,

IXgluteal

inferior, 153superior, 150

hypoglossal. See Nerve(s), cranial, XIIinferior gluteal, gluteus maximus and,

153intermediate (sensory root of seventh

cranial nerve), 102–103interosseous

anteriorin finger flexion, 131flexor pollicis longus and, 133

posteriorextensor carpi ulnaris and, 136extensor digitorum and, 135extensor pollicis longus/extensor

pollicis brevis and, 135

lateral cutaneous of thigh, signs andsymptoms of lesions of, 154

long thoracic, serratus anterior muscleand, 140

mandibular, 89, 89fmotor function mediated through,

94–95, 95fmaxillary, 89, 89fmedian

abductor pollicis brevis and, 130flexor carpi radialis and, 133flexor digitorum profundus and, 131flexor digitorum sublimis/flexor digi-

torum superficialis and, 131flexor pollicis brevis and, 134flexor pollicis longus and, 133lesions of, upper limb involvement in,

142opponens pollicis and, 130

musculocutaneousbiceps muscle and, 133in biceps reflex, 166–167lesion of, C6 root lesion differentiated

from, 143obturator

adductor muscles and, 150signs and symptoms of lesions of, 154

oculomotor. See Nerve(s), cranial, IIIolfactory. See Nerve(s), cranial, Iophthalmic, 88–89, 89f

lesions of, corneal reflex absent in, 92optic. See Nerve(s), cranial, IIpectoral, pectoralis muscle and, 138peripheral, lesions of

pain sensation in, 181, 185touch sensation in, 180, 185

peronealdeep

extensor digitorum longus and, 151extensor hallucis longus and, 151tibialis anterior and, 151

signs and symptoms of lesions of, 155posterior interosseous

extensor carpi ulnaris and, 136extensor digitorum and, 135extensor pollicis longus/extensor pol-

licis brevis and, 135

INDEX / 229

posterior tibialflexor digitorum longus and flexor

hallucis longus muscles and, 152signs and symptoms of lesions of, 155

radialabductor pollicis longus and, 130in brachialis reflex, 167brachioradialis and, 133extensor carpi radialis and, 136extensor carpi ulnaris and, 136extensor digitorum and, 135extensor pollicis longus/extensor pol-

licis brevis and, 135lesions of

C6 root lesion differentiated from,143

C7 root lesion differentiated from,143–144

upper limb involvement in,141–142

in supinator reflex, 167triceps and, 136

scapular, rhomboid muscles and,139–140

sciatichamstring muscles and, 153signs and symptoms of lesions of, 155

spinal, iliopsoas muscle and, 149spinal accessory. See Nerve(s), cranial,

XIsubscapular, teres major muscle and, 138superficial peroneal, peroneus longus

and brevis muscles and, 151–152superior gluteal, gluteus medius and

minimus and tensor fascia latamuscles and, 150

suprascapular, supraspinatus muscleand, 136

thoracic, long, serratus anterior muscleand, 140

thoracodorsal, latissimus dorsi and, 138tibial

in ankle reflex, 169–170gastrocnemius muscle and, 152posterior

flexor digitorum longus and flexorhallucis longus muscles and,152

signs and symptoms of lesions of,155

soleus muscle and, 152tibialis posterior muscle and, 152

trigeminal. See Nerve(s), cranial, Vtrochlear. See Nerve(s), cranial, IVulnar

dorsal interossei and, 130flexor carpi ulnaris and, 133flexor digitorum profundus and, 131flexor pollicis brevis and, 134lesions of

T1 root lesion differentiated from,144

upper limb involvement in, 142–143vagus. See Nerve(s), cranial, Xvestibular, 109–110

testing function of, 109–110Nerve deafness, 108, 109Neuralgia, glossopharyngeal, 115–116Neuritis

optic, 25, 42retrobulbar, 24–25, 42

pupils in, 64Neurological examination instruments,

210, 210–211fNeuroma, acoustic, tinnitus caused by, 111Neuropathy, optic, 28

anterior ischemic, 25Leber’s, 28

Neuroretinitis, 42Night blindness, in retinitis pigmentosa, 25Ninth cranial nerve. See Nerve(s), cranial,

IXNormal-pressure hydrocephalus, gait af-

fected in, 161–162Null position, 72Number recall test, 199Number writing, in sensory examination,

184Numbness

facial, trigeminal nerve disorders caus-ing, 96

patient’s perception of, 121Nystagmus, 71–77

alcohol causing, 71brain stem lesions causing, 73–74


230 / INDEX

Nystagmus (cont.)cerebellar lesions causing, 73–74, 189


congenital, 72–73optokinetic nystagmus absent in, 77pendular, 72

convergence, 75convergence-retraction, 75diencephalon lesions causing, 74downbeat, 73

brain stem and cerebellar lesionscausing, 73, 189

drugs causing, 71end-point, 75gaze-evoked, 72in internuclear ophthalmoplegia, 84jerk, 71

brain stem and cerebellar lesionscausing, 73

latent, 72–73primary eye position and, 72

latent, 72–73visual acuity affected by, 12, 73

lesion sites and, 73–74optokinetic (railroad), 76–77pendular, 71

acquired, 74brain stem and cerebellar lesions

causing, 74congenital, 72diencephalon lesions causing, 74primary eye position and, 72

periodic alternating, 75primary eye position and, 72rebound, 75signs and symptoms associated with, 74types of, 71–73upbeat, brain stem and cerebellar lesions

causing, 73, 189vestibular lesions causing, 74


voluntary, 75–76

OAG. See Chronic open-angle glaucomaOblique muscles

inferior, 53superior, 51–53, 54, 54f

Obturator nerveadductor muscles and, 150signs and symptoms of lesions of, 154

Occipital cortexdivision of, 21lesions of, gaze palsy and, 80, 81vision represented in, 22

Occipital (smooth pursuit) gaze center, 81Occipital lobe, 21

lesions of, 35field defects caused by, 23, 35, 35f

Ocular convergence, 66–67excess, 67forced downward gaze and, 82paralysis/paresis of, 67, 85–86

supranuclear, 86Ocular depression, 46

inferior rectus muscle in, 51lateral rectus muscle in, 50medial rectus muscle in, 50superior oblique muscle in, 51–53,

54fOcular deviations

conjugateforced, 79

downward, 82supratentorial gaze “centers” and,

80–81upward, 82

“wrong way,” 81secondary, in paralytic strabismus, 56skew, 84

Ocular dysmetria (ocular flutter/opso-clonus), cerebellar disease causing,189

Ocular elevation, 46inferior oblique muscle in, 53lateral rectus muscle in, 50medial rectus muscle in, 50superior rectus muscle in, 50–51, 52f

Ocular muscles. See External ocular mus-cles

Ocular myopathy, thyroid, 68–69Ocular near response, 64, 67Ocular rotation, 46, 55

inferior oblique muscle in, 53inferior rectus muscle in, 51superior oblique muscle in, 51–53, 54fsuperior rectus muscle in, 51, 53f

INDEX / 231

Oculomotor nerve (cranial nerve III)inferior oblique muscle and, 53lesions of, 59–60medial rectus muscle and, 50palsy of


superior rectus muscle and, 51Oculopharyngeal dystrophy, 68Oculosympathetic palsy (Horner’s syn-

drome), 62, 65pupils in, 62, 65

OKN. See Optokinetic nystagmusOld age. See ElderlyOlfactory nerve (cranial nerve I), 87–88“One-and-a-half” syndrome, 84One hundred minus seven test, 200Open-angle glaucoma, chronic (OAG), 26Ophthalmic branch of trigeminal nerve,

88–89, 89flesions of, corneal reflex absent in, 92

Ophthalmoplegiachronic progressive external, 68–69

ptosis in, 61, 68internuclear, 84

Ophthalmoscope, 1, 2ftechnique for fundus examination with,

2–6, 4f, 5fOpponens pollicis muscle, 130–131, 131fOpposition of thumb, 130–131, 131fOpsoclonus, cerebellar disease causing,

189Optic atrophy, 28

in papilledema, 28, 38Optic chiasm. See ChiasmOptic disc (optic nerve head). See also Op-

tic nerveedema of, in hypertension, 43in glaucoma, 26hyperemia of, in papilledema, 37normal, 39, 40fophthalmoscopic examination of, 7f, 8in papilledema, 37, 38, 39, 41f. See also

PapilledemaOptic inversion, 21Optic nerve (cranial nerve II). See also Op-

tic disclesions of, 24–34. See also specific type

field defects caused by, 22, 24–34

Optic nerve fibers, ventral nasal, 22Optic neuritis, 25, 42Optic neuropathy, 28

anterior ischemic, 25Leber’s, 28

Optic radiation, 22lesions of, 34

field defects caused by, 23, 34, 34foptokinetic nystagmus absent in, 76posterior, field defects caused by, 35,

35fOptic tract, 22

lesions of, 33–34field defects caused by, 23, 33–34,

33–34fOptokinetic nystagmus, 76–77Orbicularis oculi muscles, in facial weak-

ness vs. seventh nerve lesion, 97–98Orbital fissure, superior, ophthalmic

branch of trigeminal nerve in, 88Orbital foramen, superior, ophthalmic

branch of trigeminal nerve in, 88Organ of Corti, 107Organicity, tests of, 125Orientation, 198

Painin Bell’s palsy, 104deep, testing perception of, 182facial, trigeminal nerve disorders caus-

ing, 95–96sensation of, 90–91

cumulative, 181delayed, 181

superficial, 180–181Pain fibers, facial, 102“Pain spots,” 181Palate, vagus nerve supplying muscles of,

112–113, 112fPalmar-mental reflex, 176Palsy (paralysis)

Bell’s, 104convergence, 67, 85–86

supranuclear, 86downward gaze, 82facial nerve, 105

facial weakness differentiated from,97–98, 98–99, 100–101f, 105

232 / INDEX

Palsy (paralysis) (cont.)gaze, 79–86

cerebellar, 81in cerebral lesions, 80conjugate, 79

optokinetic nystagmus absent in,76

supratentorial gaze “centers” and,80–81

optokinetic nystagmus absent in, 76

parastriate cortex lesions and, 80–81

pursuit, 79reflex, 79voluntary, 79

inferior rectus muscle, 51lateral rectus muscle, 49, 50medial rectus muscle, 50oculomotor


oculosympathetic (Horner’s syndrome),62, 65

pupils in, 62, 65palatal, 113–114, 114fpharyngeal, 113pseudobulbar, 115, 194–195Saturday night, 141superior oblique muscle, 53superior rectus muscle, 51supranuclear convergence, 86third nerve


upward gaze, 82Papilledema, 37–42

identification of, 38–39optic atrophy and, 28, 38visual acuity and, 39

Papillitis, 42Paracentral scotoma, in glaucoma, 26Paralysis. See PalsyParalytic strabismus, 56–57Parastriate cortex (area 18), 21. See also

Visual cortexlesions of, gaze palsy and, 80–81

Paresis. See Palsy

Paresthesiadefinition of, 179facial, trigeminal nerve disorders caus-

ing, 96Parietal lobe lesions, 34

field defects caused by, 23, 34, 34fsensation affected in, 185touch sensation affected in, 180

Parinaud’s syndrome, 83defective downward gaze in, 82, 83defective upward gaze in, 83

Parkinsonismfacial weakness in, 105gait abnormalities in, 159upward gaze in, 82

Passive movement, sense of, 183Passive stretching, resistance to, muscle

tone as, 125. See also Muscle tonePast pointing, cerebellar disease causing,

188–189Patch (eye), double vision and, 57Paton’s lines (retinal wrinkling), in

papilledema, 38, 42Pectoral nerve, pectoralis muscle and, 138Pectoralis major muscle, 138, 139fPendular nystagmus, 71

acquired, 74brain stem and cerebellar lesions caus-

ing, 74congenital, 72diencephalon lesions causing, 74primary eye position and, 72

Pendular tendon reflexes, in cerebellar dis-ease, 188–189

Pericentral retinitis pigmentosa, 26Perimetry, 16Periodic alternating nystagmus, 75Peripheral nerve lesions

pain sensation in, 181, 185touch sensation in, 180, 185

Peripheral vision, 19testing, 13–18



Peristriate cortex (area 19), 21. See alsoVisual cortex

INDEX / 233

Peroneal nervedeep

extensor digitorum longus and, 151

extensor hallucis longus and, 151tibialis anterior and, 151

signs and symptoms of lesions of, 155Peroneus brevis muscle, 151–152Peroneus longus muscle, 151–152Perserveration, 207Pharyngeal reflex, 112, 173Pharynx

constrictor muscles of, 113vagus nerve supplying muscles of, 113

Physiologic cup, ophthalmoscopic exami-nation of, 7f, 8–9

Pilocarpine, pupillary response to, inAdie’s syndrome, 65

Pinealoma, Parinaud’s syndrome causedby, 83

Pinhole effectexaminer’s refractive error during oph-

thalmoscopic examination and, 3vision testing and, 13

Plantar flexionof foot, 151, 152, 152–153of toes, 152

Plantar reflex, 174–175corticospinal system lesions affecting,

193Plastic rigidity, 126Platysma muscle, 99, 101fPoliomyelitis, jaw weakness in, 96Polymyositis, sternomastoid muscle af-

fected in, 118Polyneuritis

cranialis, 116infectious (Guillain-Barré syndrome),

seventh (facial) nerve involvementin, 104

Pontine lesionsgaze palsy in, 83–84miosis caused by, 66“one-and-a-half” syndrome caused by,

84sternomastoid muscle affected in, 118

Position of gaze, primary, nystagmus and,72

Position sense, evaluation of, 183–184Posterior chiasmal lesions, field defects

caused by, 32, 32fPosterior fossa, periodic alternating nys-

tagmus and, 75Posterior (smooth pursuit) gaze center, 81Posterior interosseous nerve

extensor carpi ulnaris and, 136extensor digitorum and, 135extensor pollicis longus/extensor polli-

cis brevis and, 135Posterior pole (retinal), 22

ophthalmoscopic examination of, 7f,9–10

Posterior root lesions, sensation affectedin, 185

Posterior tibial muscle, 152Posterior tibial nerve

flexor digitorum longus and flexor hallu-cis longus muscles and, 152

signs and symptoms of lesions of, 155Posture (postural maintenance)

cerebellar disease affecting, 187double vision and, 57upper limb, 122–123, 123f

Power. See also Weaknesscorticospinal system (upper motor neu-

ron) disease affecting, 191–192lower limb, 148, 153–154upper limb, 192

Presbyopia, 11Pretectum, lesions of, upward gaze palsy

in, 82Primary eye position, nystagmus and, 72Primitive reflexes, 175–176. See also spe-

cific typePronator muscle tone, testing, 127, 128fProprioception, defective, gait abnormali-

ties in, 160Proximal pain and peripheral anesthesia

clue, 177Pseudobulbar palsy, 115, 194–195Pseudoretinitis pigmentosa, 26Pterygoid muscle

jaw weakness and, 97mandibular branch of trigeminal nerve

supplying, 89, 94Pterygopalatine ganglion, 102

234 / INDEX

Ptosis, 61–62bilateral, 62

in myasthenia gravis, 68blepharospasm differentiated from,

61in chronic progressive external

ophthalmoplegia, 61, 68Horner’s syndrome and, 62in oculopharyngeal dystrophy, 68third nerve palsy and, 62

Pupils, 62–66abnormal, causes and types of, 64–66in Adie’s syndrome, 65afferent defect of, 64Argyll-Robertson, 64big, factitious, 66in carotid artery occlusion, 66consensual response to light, 63denervation supersensitivity of, 65direct response to light, 63equality of, 62–63examination of, 63–64in Horner’s syndrome, 62, 65light reaction of, 63Marcus Gunn, 64in midbrain lesions, 66near reaction of, 64, 67in newborn, 62in oculomotor nerve lesions/third nerve

palsy, 62–63, 63, 65in pontine lesions, 66size of, 62

differences in (anisocoria), 62, 65medications affecting (factitious big

pupil), 66small. See Miosisswinging flashlight test in evaluation of,

64tonic, 65

Pursuit gaze palsy, 79Pursuit movements, testing, 47–48, 48fPyramidal tract, 191–195. See also Corti-

cospinal system disease

Quadrantanopia, 17fQuadriceps femoris muscle, 147–148, 149,

150f, 153in knee reflex, 169

Radial nerveabductor pollicis longus and, 130in brachialis reflex, 167brachioradialis muscle and, 133extensor carpi radialis and, 136extensor carpi ulnaris and, 136extensor digitorum and, 135extensor pollicis longus/extensor polli-

cis brevis and, 135lesions of

C6 root lesion differentiated from,143

C7 root lesion differentiated from,143–144

upper limb involvement in, 141–142in supinator reflex, 167triceps and, 136in triceps reflex, 167

Railroad nystagmus (optokinetic nystag-mus), 76–77

RAO. See Retinal arteries, occlusion ofRapid alternating movements



RD. See Retinal detachmentRebound, cerebellar disease causing,

188–189Rebound nystagmus, 75Rectus muscles

inferior, 51, 53–54lateral, 49–50medial, 50

in thyroid ocular myopathy, 69superior, 50–51, 52–53f, 53–54

Reflection, minimizing during ophthalmo-scopic examination, 3

Reflex arc, 163Reflex gaze palsy, 79Reflex hammer, 209f, 211Reflexes, 163–176. See also Responses

abdominal, 173, 174fankle, 169–170, 170–171fBabinski, 174, 175, 193biceps, 166–167brachialis, 167

INDEX / 235

corneal, 91–93, 91f, 92f, 173absence of

after cataract surgery, 93in elderly, 93in ophthalmic nerve lesions, 92in thalamic lesions, 93

contact lenses preventing, 92methods of elicitation of, 91f


cremasteric, 173–174finger flexion, 167–168, 168fgag

glossopharyngeal nerve and, 112paresis of pharynx and, 113vagus nerve and, 112–113

grasp, 175–176Hoffmann’s, 168–169knee, 169

difficulty eliciting, 172palmar-mental, 176pharyngeal, 112, 173plantar, 174–175, 193primitive, 175–176sucking, 176superficial, 173–175, 193supinator, 167tendon (muscle stretch), 163–173

cerebellar disease affecting, 187–188corticospinal system lesions affecting,


triceps, 167upper motor neuron lesions affecting,

193Reflexogenic zone, of tendon reflex, 164Relative scotoma, 19Responses. See also Reflexes

extensor plantar (Babinski), 174, 175in corticospinal system lesions, 193

flexor plantar, 175Retina. See also under Retinal

abnormal, 37–43arteriovenous “nicking” of, 43in hypertension, 43lesions of, 24–34. See also specific type

field defects caused by, 22

ophthalmoscopic examination of, 2–10,5f

organization of, 21in papilledema, 37–42posterior pole of, 22

ophthalmoscopic examination of, 7f,9–10

Retinal arteriesbranch, occlusion of, 27central

giant cell arteritis of, 25occlusion of, 27

in hypertension, 43occlusion of, 27ophthalmoscopic examination of, 6, 7f

Retinal detachment, 27Retinal exudates

cotton-woolin central retinal vein occlusion,

26–27in papilledema, 38

in hypertension, 43Retinal hemorrhages

flame-shaped, 38globular subhyaloid, 38in hypertension, 43in papilledema, 38splinter, 38

Retinal veinsbranch, occlusion of, 27central, occlusion of, 26–27ophthalmoscopic examination of, 6–8,

7fin papilledema, 37, 37–38pulsation of, 6–7, 7f

Retinal wrinkling, in papilledema, 38, 39Retinitis

central serous, 25pigmentosa, 25

atypical, 26Retinopathy, pigmentary, 26Retrobulbar neuritis, 24–25, 42

pupils in, 64Rhomboid muscles, 139–140Rigidity, 126

cogwheel, 126plastic, 126

Rinne test, 108

236 / INDEX

Romberg test, 158–159Root lesion

C5, axillary nerve lesion differentiatedfrom, 143

C6, musculocutaneous or radial nervelesion differentiated from, 143

C7, radial nerve lesion differentiatedfrom, 143–144

lumbar, signs and symptoms of, 154posterior, sensation affected in, 185sacral, signs and symptoms of, 154T1, ulnar nerve lesion differentiated

from, 144Rotation (eye), 46, 55

inferior oblique muscle in, 53inferior rectus muscle in, 51superior oblique muscle in, 51–53, 54fsuperior rectus muscle in, 51, 53f

RP. See Retinitis, pigmentosa

Saccadic center, 80–81Saccadic movements, testing, 47–48, 48fSaccule, testing of, 109–110Sacral root lesions, signs and symptoms of,

154Saliva, sensory cells/fibers in, 102Salt, as taste substance, 104Sarcoidosis, anosmia in, 88Saturday night palsy, 141Scapula, fixation of, 138–140Scapular nerve, dorsal, rhomboid muscles

and, 139–140Schizophrenia, speech in, 205Sciatic nerve

hamstring muscles and, 153signs and symptoms of lesions of, 155

Scotoma, 17f, 19absolute, 19arcuate, 20

in glaucoma, 26bitemporal hemianopic central, 17f,

20–21cecocentral, 20central, 19–20, 29

occipital lobe lesion causing, 23in glaucoma, 26paracentral, 26, 30

physiological (blind spot), 20finding, 20

relative, 19Second cranial nerve. See Nerve(s), cra-

nial, IISecondary deviation, in paralytic strabis-

mus, 56Sectoral retinitis pigmentosa, 26Segmental reflex arc, 163Seizures, ocular manifestations of, 80Semicircular canals, testing of, 109–110Sensation, 177–185

disturbances ofgait abnormalities and, 160terminology related to, 179trigeminal nerve lesions causing, 88

loss of on dorsum of foot, in sciaticnerve lesions, 155

of paindeep, 182superficial, 180–181

of passive movement, 183of position, 183–184of temperature, 181–182testing, 90–93, 177–185

bilateral simultaneous stimulationand, 185

demonstration in, 178number writing and, 184rules of examination and, 178–179stereognosis and, 184subjectivity of findings in, 177two-point discrimination and, 184

of touch, 179–180of vibration, 182–183

Sensory examination. See Sensation, test-ing

Serratus anterior muscle, 140Seventh cranial nerve. See Nerve(s), cra-

nial, VIIShock, spinal, 193Shoulder, weakness of, fixation of scapula

and, 138–140Single hand clapping, 124–125, 125fSixth cranial nerve. See Nerve(s), cranial,

VISkew deviation, 84Smell, 87–88

INDEX / 237

Smooth pursuit center, 81Snellen card, for visual acuity testing,

11–12Sole of foot, sensory loss of in sciatic

nerve lesions, 155Soleus muscle, 152, 153

in ankle reflex, 169–170Solitary nucleus, taste cells in, 102Sour, as taste substance, 104Spasticity, 126

in corticospinal system lesions, 192upper limb flexor muscle, 192

Spatial ability, evaluation of, 200, 201fSpectacles. See EyeglassesSpeech

anatomic basis of, 205–206comprehension and, 206–207disorders of, 205–211. See also Aphasia

in cerebellar disease, 190examination of patient with, 206–207

fluent, 206nonfluent, 206repetition and, 206spontaneous, 206

Spinal accessory nerve (cranial nerve XI),118

diseases of, 118testing, 116–118, 117f, 138–139trapezius muscle and, 138–139

Spinal cord, subacute combined degenera-tion of, vibratory sense loss in, 183

Spinal cordlesions of

pain sensation affected in, 181, 185sensation affected in, 185touch sensation affected in, 180, 185

subacute combined degeneration of, lossof vibratory sense in, 183

Spinal nerves, iliopsoas muscle and, 149Spinal shock, 193Spinal trigeminal nucleus and tract, 93, 94fSplinter hemorrhages, in papilledema, 38Spontaneous arm drift, 122–123, 122fSpontaneous speech, in aphasia, 206Squint, 46–47

in paralytic strabismus, 56Stance, 157–162. See also GaitStephens syndrome, CPEO in, 69

Stereognosis, in sensory examination, 184

Sternomastoid muscle, 116, 117fspinal accessory nerve supplying, 116upper motor neuron lesion affecting, 118

Stimulus threshold, for tendon reflex, 164Strabismus, 47

accommodative, 56concomitant (nonparalytic), 56latent (heterophoria), 46paralytic, 56–57

Strength. See also Weaknesscorticospinal system (upper motor neu-

ron) disease affecting, 191–192lower limb, 148, 153–154upper limb, 192

Striate cortex (area 17), 21. See also Visualcortex

String test, for visual field testing, 14f, 16Stroke, ocular manifestations of, 80Stylopharyngeus muscle, glossopharyngeal

nerve supplying, 111Subacute combined degeneration of spinal

cord, vibratory sense loss in, 183Subhyaloid hemorrhages, globular, in pa-

pilledema, 38Submandibular ganglion, 102Subscapular nerve, teres major muscle

and, 138Sucking reflex, 176Suggestion, sensory examination results

affected by, 178Sulcus, calcarine, 21Superficial pain sensation, evaluation of,

180–181Superficial peroneal nerve, peroneus

longus and brevis muscles and,151–152

Superficial reflexes, 173–175. See alsospecific type


Superior gluteal nerve, gluteus medius andminimus and tensor fascia lata mus-cles and, 150

Superior oblique muscle, 51–53, 54, 54fSuperior orbital fissure, ophthalmic branch

of trigeminal nerve in, 88

238 / INDEX

Superior orbital foramen, ophthalmicbranch of trigeminal nerve in, 88

Superior rectus muscle, 50–51, 52–53f,53–54

Superior salivatory nucleus, 102Supinator reflex, 167Supine leg raising test, 145Supramarginal gyrus, 205Supranuclear convergence palsy, 86Suprascapular nerve, supraspinatus muscle

and, 136Suprasegmental systems, reflex arc and,

163Supraspinal pathway, descending, 191–

195. See also Corticospinal systemdisease

Supraspinatus muscle, 136–137Supratentorial gaze “centers,” 80–81Sweet, as taste substance, 104Swinging flashlight test, 64Swollen disc. See PapilledemaSylvian aqueduct syndrome (Parinaud’s

syndrome), 83defective downward gaze in, 82, 83defective upward gaze in, 83

SyndromeAdie’s (tonic pupil), 65Bardet-Biedl, retinitis pigmentosa and,

26Bassen-Kornzweig


dorsal midbrain. See Syndrome, Parin-aud’s

Duchenne-Erb, upper trunk lesions in,140–142

Guillain-Barré (infectious polyneuritis),seventh (facial) nerve involvementin, 104

Holmes-Adie, 65Horner’s, 62, 65

pupils in, 62, 65jugular foramen, 116Kearns-Sayre


Klumpke, lower trunk lesions in, 141“one-and-a-half,” 84

Parinaud’s (dorsal midbrain/sylvianaqueduct), 83

defective downward gaze in, 82, 83defective upward gaze in, 83

Stephens, CPEO in, 69sylvian aqueduct. See Syndrome, Parin-

aud’sUsher’s, retinitis pigmentosa and, 26

T1 root lesion, ulnar nerve lesion differ-entiated from, 144

Takayasu’s disease, carotid involvementin, pupils in, 66

Tasteglossopharyngeal nerve in, 102, 111sensory fibers in, 102testing, 103–104, 103f

Tears, cells/fibers in secretion of, 102Temperature sensation, 181–182

fifth cranial nerve and, 93Temporal arteries, giant cell arteritis of,

25Temporal crescent visual field defect, 35,

35fTemporal field, optic inversion and, 21Temporal lobe lesions, 34

field defects caused by, 23, 34, 34fTemporalis muscle, mandibular branch of

trigeminal nerve supplying, 89, 94Tendon (muscle stretch) reflexes, 163–173.

See also specific typecerebellar disease affecting, 187–188corticospinal system lesions affecting,


Tensor fascia lata muscle, 150Tenth cranial nerve. See Nerve(s), cranial,

XTeres major muscle, 138Terminal intention tremor, 123–124Thalamus, lesions of, corneal reflex absent

in, 93Thenar eminence, 127

wrist lesions causing wasting of, 142Thermal stimulus, sensation of, 181–182

fifth cranial nerve and, 93

INDEX / 239

Thigh, 145. See also Lower limbabduction of, 150adduction of, 150extension of at hip, 153flexion of, 149, 149f, 154lateral cutaneous nerve of, signs and

symptoms of lesions of, 154Thinking, evaluation of, 199Third cranial nerve. See Nerve(s), cranial,

IIIThoracic nerve, long, serratus anterior

muscle and, 140Thoracodorsal nerve, latissimus dorsi and,

138Thought disorder, 205Thumb. See also Upper limb

abduction of, 130extension of, 135flexion of, 133–134opposition of, 130–131, 131f

Thyroid ocular myopathy, 68–69Tibial nerve

in ankle reflex, 169–170gastrocnemius muscle and, 152posterior

flexor digitorum longus and flexorhallucis longus muscles and, 152

signs and symptoms of lesions of, 155

soleus muscle and, 152tibialis posterior muscle and, 152

Tibialis anterior muscle, 148, 151, 151f,153, 154

Tibialis posterior muscle, 152Tic douloureux, 96Tinnitus, 111Toes. See also Lower limb

dorsiflexion of, 151, 151fplantar flexion of, 152

Tone, muscle. See Muscle toneTongue, hypoglossal nerve supplying, 118

testing function of, 118–120, 119fTonic pupil (Adie’s syndrome), 65Touch sensation, 179–180Trapezius muscle

testing, 116–118, 137, 138–139upper motor neuron lesion affecting,

118

Tremorcerebellar, 188intention, 188

terminal, 123–124Triceps muscle, 136

in triceps reflex, 167Trigeminal nerve (cranial nerve V), 88–97

corneal reflex and, 91–93, 91f, 92fdiseases of, 95–97facial numbness (analgesia/hyperesthe-

sia/paresthesia) and, 96facial pain and, 95–96jaw jerk and, 165jaw weakness and, 96–97motor function and, 94–95, 95fpain perception and, 90–91peripheral anatomy of, 88–90, 89fsensory testing and, 90–93spinal nucleus and tract of, 93, 94ftemperature sensation and, 93

Trochlear nerve (cranial nerve IV)lesions of, 60superior oblique muscle and, 51

Tumoranterior fossa, anosmia caused by, 88cerebellar–pontine angle, seventh (fa-

cial) nerve palsy and, 105Tuning fork, 211

for vibration sense testing, 182–183Twelfth cranial nerve. See Nerve(s), cra-

nial, XIITwo-point discrimination, in sensory ex-

amination, 184

Ulnar nervedorsal interossei and, 130flexor carpi ulnaris and, 133flexor digitorum profundus and, 131flexor pollicis brevis muscle and, 134lesions of

T1 root lesion differentiated from,144

upper limb involvement in, 142– 143Unconscious patient, vestibular function

evaluation in, 110Upbeat nystagmus, brain stem and cerebel-

lar lesions causing, 73, 189

240 / INDEX

Upper limb, 121–144abnormalities of, 140–144alternating movements and, 123–125,

124f, 125fcoordination evaluation and, 123–125,

124f, 125fexamination of, 130–140

directed, 121undirected, 121–122

movement of in walking, 157muscle tone and, 125–127, 128fpostural maintenance and, 122–123,

123fpower (strength) of, corticospinal sys-

tem lesions affecting, 192size of, 127–130, 129f

Upper motor neuron lesions, 191–195clonus in, 194facial weakness in, 97, 191–192gait abnormalities in, 160–161, 193–194jaw weakness and, 97, 192miscellaneous manifestations of,

193–194muscle tone in, 192–193power affected by, 191–192reflexes affected by, 193sternomastoid and trapezius weakness

in, 118Upward gaze, 82

paralysis of, 82Usher’s syndrome, retinitis pigmentosa

and, 26Utricle, testing of, 109–110

VA. See Visual acuityVagus nerve (cranial nerve X), 112–116

diseases affecting, 115–116Valsalva maneuver, retinal vein pulsation

and, 8Vein, retinal

branch, occlusion of, 27central, occlusion of, 26–27ophthalmoscopic examination of, 6–8,

7fin papilledema, 37, 37–38pulsation of, 6–7, 7f

Ventral nasal optic nerve fibers, 22

Vertical eye movementslateral rectus muscle in, 50testing, 48

Vertigo, 109, 110Vestibular apparatus, testing of, 109–110Vestibular lesions, nystagmus in, 74

signs and symptoms associated with, 74

Vestibular nerve, 109–110testing function of, 109–110

Vibration sense, evaluation of, 182–183Vision, 10–18

binocular, testing, 47, 48fcentral (macular), 11–13, 19distance, 11–13, 11floss of, 19–36

diagnosis of, 17f, 23–24diseases causing, 24–36. See also spe-

cific diseasehistory in, 24terminology related to, 19–23

near, 11f, 13peripheral, 19

testing, 13–18confrontation testing for, 13–15,

14f, 18perimetry for, 16string test for, 14f, 16

terminology related to, 10–11, 19–23Visual acuity, 19

counting fingers testing and, 12distance vision expressed as, 11, 12in latent nystagmus, 12, 73in papilledema, 39

Visual cortex, 21frontal, gaze palsy and, 80lesions of, 35–36

anterior, 35, 35ffield defects caused by, 35, 35fgaze palsy and, 80–81

occipitaldivision of, 21gaze palsy and, 80, 81vision represented in, 22

parastriate (area 18), 21gaze palsy and, 80–81

peristriate (area 19), 21striate (area 17), 21

INDEX / 241

Visual field defects, 17f, 22–23. See alsospecific type

altitudinal, 17fanterior chiasmal lesions causing,

29–30, 29–30fbilateral homonymous hemianopsia

(cortical blindness), 36chiasmal lesions causing, 17f, 22, 29–

33congruous, 23crescent, temporal, 35, 35fgaze palsy and, 80–81in glaucoma, 26hemianopia, 17f, 20

with macular loss, 21with macular sparing, 17f, 21, 23with macular splitting, 17f, 20–21

homonymoushemianopia, 17f, 20hemianopsia, bilateral, 36optokinetic nystagmus absent in, 76

horizontal, 17finattention, 15

optokinetic nystagmus absent in, 76lateral chiasmal lesions causing, 33,

33fquadrantanopia, 17ftemporal field, 35, 35f

Visual fields. See also Visual field defectscentral (macular), 11–13, 19equatorial division and, 21gaze palsy and, 80–81in glaucoma, 26organization of, 21–22peripheral, testing, 13–18



Visual fixation, disorders of, optokineticnystagmus absent in, 76

Visual pathways, 21–23arrangement of fibers in, 21–22

Vocal cordsexamination of, 114, 115fparalysis of, 113–114

Volitional (saccadic) gaze center, 80–81

Voluntary gaze palsy, 79Voluntary movements, cerebellar disease

affecting, 189Voluntary nystagmus, 75–76

Walking, 157–158. See also GaitWeakness. See also Power

abdominal, gait abnormalities and, 161back muscle, gait abnormalities and,

161extensor muscle, upper limb, in corti-

cospinal system lesions, 192external ocular muscle, diseases caus-

ing, 67–69convergence assessment in, 67

eyelid muscle, diseases causing, 67–69facial, 105

appearance at rest and, 99in corticospinal system disease (upper

motor neuron lesions), 97,191–192

in parkinsonism, 105seventh nerve lesion differentiated

from, 97–98, 98–99, 100–101f,105

finger, in corticospinal system lesions,192

hip girdle, gait abnormalities and, 161jaw

in amyotrophic lateral sclerosis, 96in corticospinal system disease (upper

motor neuron lesions), 97, 192in foramen ovale disorders, 97in myasthenia gravis, 96in poliomyelitis, 96

in muscular dystrophy, 161shoulder, fixation of scapula and,

138–140sternomastoid, in corticospinal system

disease (upper motor neuron le-sions), 118

trapezius, in corticospinal system dis-ease (upper motor neuron lesions),118

upper limb, in corticospinal system le-sions, 192

242 / INDEX

Weber test, 108Welch-Allyn ophthalmoscope, 1, 2fWernicke’s aphasia, 208Wernicke’s area, 205Whispered speech, in hearing evaluation,

107–108Wing scapula, 138–140Wrinkling, retinal, in papilledema, 38Wrist. See also Upper limb

extension of, 136, 137f

flexion of, 133, 134flesions at, 142

Wrist clonus, 126, 172in corticospinal system disease, 194

Writing, in aphasia, 207“Wrong way” conjugate deviation, 81

Yoke muscles, in paralytic strabismus,56–57

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