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APPROACH TO THE PATIENT WITH NEUROLOGIC DISEASE
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and smiles, for a slight weakness may be more evident in these circumstances than on movements to command The auditory meati and tympanic membranes should be inspected with an otoscope A 256 double-vibration tuning fork held next to the ear and on the mastoid discloses hearing loss and distinguishes middle-ear (conductive) from neural deafness Audiograms and other special tests of auditory and vestibular function are needed if there is any suspicion of disease of the eighth nerve or the cochlear and labyrinthine end organs (see Chap 15) The vocal cords must be inspected with special instruments in cases of suspected medullary or vagus nerve disease, especially when there is hoarseness Voluntary pharyngeal elevation and elicited re exes are meaningful if there is a difference on the two sides; bilateral absence of the gag re ex is seldom signi cant Inspection of the tongue, both protruded and at rest, is helpful; atrophy and fasciculations may be seen and weakness detected Slight deviation of the protruded tongue as a solitary nding can usually be disregarded The pronunciation of words should be noted The jaw jerk and the snout, buccal, and sucking re exes should be sought, particularly if there is a question of dysphagia, dysarthria, or dysphonia
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plantar response poses special dif culty because several different re ex responses can be evoked by stimulating the sole of the foot along its outer border from heel to toes These are (1) the quick, high-level avoidance response; (2) the slower, spinal exor nocifensive (protective) re ex ( exion of knee and hip and dorsi exion of toes and foot, triple exion ) dorsi exion of the large toe as part of this re ex is the well-known Babinski sign (see Chap 3); (3) plantar grasp re ex; and (4) support reactions Avoidance and withdrawal responses interfere with the interpretation of the Babinski sign and can sometimes be overcome by utilizing the several alternative stimuli that are known to elicit the Babinski response (squeezing the calf or Achilles tendon, icking the fourth toe, downward scraping of the shin, lifting the straight leg, and others) An absence of the super cial cutaneous re exes of the abdominal, cremasteric, and other muscles are useful ancillary tests for detecting corticospinal lesions
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Testing of Sensory Function
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This is undoubtedly the most dif cult part of the neurologic examination Usually sensory testing is reserved for the end of the examination and, if the ndings are to be reliable, should not be prolonged for more than a few minutes Each test should be explained brie y; too much discussion of these tests with a meticulous, introspective patient may encourage the reporting of useless minor variations of stimulus intensity It is not necessary to examine all areas of the skin surface A quick survey of the face, neck, arms, trunk, and legs with a pin takes only a few seconds Usually one is seeking differences between the two sides of the body (it is better to ask whether stimuli on opposite sides of the body feel the same than to ask if they feel different), a level below which sensation is lost, or a zone of relative or absolute analgesia (loss of pain sensibility) or anesthesia (loss of touch sensibility) Regions of sensory de cit can then be tested more carefully and mapped out Moving the stimulus from an area of diminished sensation into a normal area enhances the perception of a difference The vibration sense may be tested by comparing the thresholds at which the patient and examiner lose perception at comparable bony prominences We usually record the number of seconds for which the examiner appreciates vibration at the malleolus or toe after the patient reports that the fork has stopped buzzing The nding of a zone of heightened sensation ( hyperesthesia ) calls attention to a disturbance of super cial sensation Variations in sensory ndings from one examination to another re ect differences in technique of examination as well as inconsistencies in the responses of the patient Sensory testing is considered in greater detail in Chaps 8 and 9
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