1 Headache. Any unusually frequent or severe headaches?

_ When did this start? How often does it occur?

_ Where in your head do you feel the headaches?

Do the headaches seem to be associated with anything?

(Headache history is discussed inChapter 13.)

2 Head injury.

Ever had any head injury? Please describe.

_ What part of your head was hit?

_ Did you have a loss of consciousness? For how long?

3 Dizziness/vertigo. Ever feel light-headed, a swimming sensation, like feeling faint?

_ When have you noticed this? How often does it occur?

Does it occur with activity, change in position?

_ Do you ever feel a sensation called vertigo, a rotational spinning sensation?

(Note: Distinguish vertigo from dizziness.) Do you feel as if the room spins (objective vertigo)?

Or do you feel that you are spinning (subjective vertigo)?

Did this come on suddenly or gradually?

Syncope

True vertigo is rotational spinning caused by neurologic disease in the vestibular apparatus in the ear or in the vestibular nuclei in the brainstem.

4 Seizures.

Ever had any convulsions?

When did they start?

How often do they occur?

Seizures

a paroxysmal disease characterized by altered or loss of consciousness,

involuntary muscle movements, and sensory disturbances.

_ Course and duration—When a seizure starts, do you have any warning sign?

What type of sign?

_ Motor activity—Where in your body do the seizures begin?

 Do the seizures travel through your body?

On one side or both? Does your muscle tone seem tense or limp?

_ Any associated signs—Color change in face or lips, loss of consciousness, for how long, automatisms (eyelid fluttering, eye rolling, lip smacking), incontinence?

_ Postictal phase—After the seizure, are you told you spend time sleeping or have any confusion, weakness, headache, or muscle ache?

_ Precipitating factors—Does anything seem to bring on the seizures: activity, discontinuing medication, fatigue, stress?

_ Are you on any medication?

_ Coping strategies—How have the seizures affected daily life, occupation?

Aura

5 Tremors.

Any shakes or tremors in the hands or face? When did these start?

_ Do they seem to grow worse with anxiety, intention, or rest?

_ Are they relieved with rest, activity, alcohol? Do they affect daily activities?

6 Weakness.

Any weakness or problem moving any body part?

 Is this generalized or local? Does weakness occur with any particular movement?

(For

example, with proximal or large muscle weakness, it is hard to get up out of a chair or reach for an object; with distal or small muscle weakness,

it is hard to open a jar, write, use scissors, or walk without tripping.)

Paresis

Paralysis

7 Incoordination. Any problem with coordination?

Any problem with balance when walking?

 Do you list to one side? Any falling? Which way?

Do your legs seem to give way? Any clumsy movement?

Dysmetria

8 Numbness or tingling. Any numbness or tingling in any body part?

Does it feel like pins and needles? When did this start?

Where do you feel it? Does it occur with activity?

Paresthesia

9 Difficulty swallowing. Any problem swallowing?

Occur with solids or liquids?

 Have you experienced excessive saliva, drooling?

10 Difficulty speaking. Any problem speaking: with forming words or with saying what you intended to say?

When did you first notice this?

How long did it last?

Dysarthria

dysphasia is difficulty with language comprehension or expression (see Table 5-4, p. 84).

11 Significant past history. Past history of: stroke (cerebrovascular accident),

spinal cord injury,

meningitis or encephalitis,

congenital defect, or alcoholism?

12 Environmental/occupational hazards.

Are you exposed to any environmental/occupational hazards:

insecticides, organic solvents, lead?

_ Are you taking any medications now?

_ How much alcohol do you drink? Each week? Each day?

_ How about other mood-altering drugs:

marijuana, cocaine, barbiturates, tranquilizers?

Additional History for the Aging Adult

1 Any problem with dizziness?

 Does this occur when you first sit or stand up, when you move your head, when you get up and walk just after eating?

Does this occur with any of your medications?

_ (For men) Do you ever get up at night and then feel faint while standing to urinate?

_ How does dizziness affect your daily activities? Are you able to drive safely and to maneuver within your house safely?

_ What safety modifications have you applied at home

Diminished cerebral blood flow and diminished vestibular response may produce staggering with position change,

which increases risk for falls.

Micturition syncope.

2 Have you noticed any decrease in memory, change in mental function?

Have you felt any confusion?

Did this seem to come on suddenly or gradually?

Memory loss and cognitive decline are early indicators of

Alzheimer disease

and can be mistaken for normal cognitive decline of aging¹⁹ (see Table 23-2, 10 Warning Signs of Alzheimer Disease, p. 667).

3 Have you ever noticed any tremor?

Is this in your hands or face?

Is this worse with anxiety, activity, rest?

Does the tremor seem to be relieved with alcohol, activity, rest?

Does the tremor interfere with daily or social activities?

Senile tremor is relieved by alcohol, but this is not a recommended treatment.

Assess if the person is abusing alcohol in effort to relieve tremor.

4 Have you ever had any sudden vision change, fleeting blindness?

Did this occur along with weakness?

Did you have any loss of consciousness?

Cranial Nerve I—Olfactory Nerve

Do not test routinely. Test the sense of smell in those who report loss of smell,

those with head trauma,

and those with abnormal mental status, and when the presence of an intracranial lesion is suspected.

First, assess patency by occluding one nostril at a time and asking the person to sniff.

Then, with the person's eyes closed, occlude one nostril and present an aromatic substance.

Use familiar, conveniently obtainable, and non-noxious smells, such as coffee, toothpaste, orange, vanilla, soap, or peppermint.

Alcohol wipes smell familiar and are easy to find but are irritating.

One cannot test smell when air passages are occluded with upper respiratory infection or with sinusitis.

Anosmia—decrease or loss of smell occurs bilaterally with tobacco smoking, allergic rhinitis, and cocaine use.

Normally, a person can identify an odor on each side of the nose.

 Smell normally is decreased bilaterally with aging.

Any asymmetry in the sense of smell is important.

Cranial Nerve II—Optic Nerve

Test visual acuity and test visual fields by confrontation (see Chapter 14).

Using the ophthalmoscope, examine the ocular fundus to determine the color, size, and shape of the optic disc (see Chapter 14).

Visual field loss (see Table 14-5, p. 316).

Papilledema with increased intracranial pressure;

optic atrophy (see Table 14-9, p. 320).

Cranial Nerves III, IV, and VI—Oculomotor, Trochlear, and Abducens Nerves

Palpebral fissures are usually equal in width or nearly so.

Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation (see Chapter 14).

Ptosis (drooping) occurs with myasthenia gravis, dysfunction of cranial nerve III, or Horner syndrome (see Table 14-2).

Increasing intracranial pressure causes a sudden, unilateral, dilated and nonreactive pupil.

Assess extraocular movements by the cardinal positions of gaze (see Chapter 14).

Nystagmus is a back-and-forth oscillation of the eyes. End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally.

Assess any other nystagmus carefully, noting:

_ Presence of nystagmus in one or both eyes.

_ Pendular movement (oscillations move equally left to right) or

jerk (a quick phase in one direction, then a slow phase in the other).

Classify the jerk nystagmus in the direction of the quick phase.

_ Amplitude. Judge whether the degree of movement is fine, medium, or coarse.

_ Frequency. Is it constant, or does it fade after a few

beats?

_ Plane of movement. Horizontal, vertical, rotary, or a combination?

Strabismus (deviated gaze) or limited movement (see Table 14-1, p. 311).

Nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

Cranial Nerve V—Trigeminal Nerve

Motor Function.

Fig. 23-9

Muscles should feel equally strong on both sides.

Next, try to separate the jaws by pushing down on the chin; normally you cannot.

Decreased strength on one or both sides.

Asymmetry in jaw movement.

Pain with clenching of teeth.

Sensory Function.

Fig. 23-10

Corneal Reflex.

The test is limited clinically because an absent blink occurs in only one third of the cases of acoustic neuroma and only then when the tumor has grown quite large.

^21a

Cranial Nerve VII—Facial Nerve

Motor Function.

Fig. 23-11

Fig. 23-12

Muscle weakness is shown by flattening of the nasolabial fold,

drooping of one side of the face,

lower eyelid sagging, and escape of air from only one cheek that is pressed in.

Loss of movement and asymmetry of movement occur with both central nervous system lesions

(e.g., brain attack or stroke that affects the lower face on one side) and peripheral nervous system lesions

(e.g., Bell's palsy that affects the upper and lower face on one side).

Cranial Nerve VIII—Acoustic (Vestibulocochlear) Nerve

Test hearing acuity by the ability to hear normal conversation and by the whispered voice test (see Chapter 15).

Cranial Nerves IX and X—Glossopharyngeal and Vagus Nerves

Motor Function.

Touch the posterior pharyngeal wall with a tongue blade, and note the gag reflex.

Also note that the voice sounds smooth and not strained.

Absence or asymmetry of soft palate movement or tonsillar pillar movement.

Following a stroke, dysfunction in swallowing may increase risk for aspiration.

Hoarse or brassy voice occurs with vocal cord dysfunction; nasal twang occurs with weakness of soft palate.

Cranial Nerve XI—Spinal Accessory Nerve

Examine the sternomastoid and trapezius muscles for equal size.

Check equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the chin (Fig. 23-13).

Then ask the person to shrug the shoulders against resistance (Fig. 23-14).

These movements should feel equally strong on both sides.

Atrophy.

Muscle weakness or paralysis occurs with a stroke or following injury to the peripheral nerve

(e.g., surgical removal of lymph nodes).

Cranial Nerve XII—Hypoglossal Nerve

Inspect the tongue. No wasting or tremors should be present.

Note the forward thrust in the midline as the person protrudes the tongue.

Also ask the person to say “light, tight, dynamite,” and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct.

Atrophy.

Fasciculations.

Tongue deviates to side with lesions of the hypoglossal nerve (when this occurs,

deviation is toward the paralyzed side).

INSPECT AND PALPATE THE MOTOR SYSTEM

Muscles

Size.

Compare the right side with the left.

Muscle groups should be within the normal size limits for age and should be symmetric bilaterally.

 When muscles in the extremities look asymmetric, measure each in centimeters and record the difference.

A difference of 1 cm or less is not significant.

Note that it is difficult to assess muscle mass in very obese people.

Atrophy—abnormally small muscle with a wasted appearance; occurs with disuse, injury, lower motor neuron disease such as polio, diabetic neuropathy.

Hypertrophy—increased size and strength; occurs with isometric exercise.

Strength.

Chapter 22

Tone.

Fig. 23-15

Limited range of motion.

Pain with motion.

Flaccidity—decreased resistance, hypotonia occur with peripheral weakness.

Spasticity and rigidity—types of increased resistance that occur with central weakness (see Table 23-4, Abnormalities in Muscle Tone, p. 669).

Involuntary Movements.

If they are present, note their location, frequency, rate, and amplitude.

Note if the movements can be controlled at will.

Gait.

Normally, the person moves with a sense of freedom.

The gait is smooth, rhythmic, and effortless; the opposing arm swing is coordinated; the turns are smooth.

The step length is about 15 inches from heel to heel.

Stiff, immobile posture. Staggering or reeling.

Wide base of support.

Lack of arm swing or rigid arms.

Unequal rhythm of steps.

 Slapping of foot. Scraping of toe of shoe.

Ataxia—uncoordinated or unsteady gait (see Table 23-6, Abnormal Gaits, p. 672).

Ask the person to walk a straight line in a heel-to-toe fashion (tandem walking) (Fig. 23-16).

This decreases the base of support and will accentuate any problem with coordination.

Normally, the person can walk straight and stay balanced.

23

Crooked line of walk.

Widens base to maintain balance.

Staggering, reeling, loss of balance.

An ataxia that did not appear with regular gait may appear now.

Inability to tandem walk is sensitive for an upper motor neuron lesion, such as multiple sclerosis, and for acute cerebellar dysfunction,

such as alcohol intoxication.

The Romberg Test.

Once in a stable position, ask the person to close the eyes and to hold the position (Fig. 23-17). Wait about 20 seconds.

 Normally, a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur.

(Stand close to catch the person in case he or she falls.)

Sways, falls, widens base of feet to avoid falling.

Positive

You eliminate the advantage of orientation with the eyes, which had compensated for sensory loss.

 A positive Romberg sign occurs with cerebellar ataxia (multiple sclerosis, alcohol intoxication), loss of proprioception, and loss of vestibular function.

Rapid Alternating Movements (RAM).

Fig. 23-19

Lack of coordination.

Slow, clumsy, and sloppy response is termed

dysdiadochokinesia

and occurs with cerebellar disease.

Alternatively, ask the person to touch the thumb to each finger on the same hand, starting with the index finger,

then reverse direction (Fig. 23-20).

Normally, this can be done quickly and accurately.

Lack of coordination.

Dysmetria

with cerebellar disorders or acute alcohol intoxication.

Past-pointing

Intention tremor when reaching to a visually directed object.

Finger-to-Finger Test.

Fig. 23-21

After a few times, move your finger to a different spot.

The person's movement should be smooth and accurate.

Finger-to-Nose Test.

Ask the person to touch the tip of his or her nose with each index finger, alternating hands and increasing speed.

Normally, this is done with accurate and smooth movement.

Misses nose.

Worsening of coordination when the eyes are closed occurs with cerebellar disease or alcohol intoxication.

Heel-to-Shin Test.

to place the heel on the opposite knee and run it down the shin from the knee to the ankle (Fig. 23-22).

Normally, the person moves the heel in a straight line down the shin.

Spinothalamic Tract

Pain.

Break a tongue blade lengthwise, forming a sharp point at the fractured end and a dull spot at the rounded end.

Lightly apply the sharp point or the dull end to the person's body in a random, unpredictable order (Fig. 23-23).

Ask the person to say “sharp” or “dull,” depending on the sensation felt.

(Note that the sharp edge is used to test for pain; the dull edge is used as a general test of the person's responses.)

Hypoalgesia—decreased pain sensation.

Analgesia—absent pain sensation.

Hyperalgesia—increased pain sensation.

Let at least 2 seconds elapse between each stimulus to avoid summation.

With summation, frequent consecutive stimuli are perceived as one strong stimulus.

Discard tongue blade to prevent transmitting any possible infection.

Temperature.

otherwise, you may omit it because the fiber tracts are much the same.

Place the flat side of the tuning fork on the skin;

its metal always feels cool. This can alternate with the warmth of your hand.

Light Touch.

and brush it over the skin in a random order of sites and at irregular intervals (Fig. 23-24).

This prevents the person from responding just from repetition.

Include the arms, forearms, hands, chest, thighs, and legs.

Ask the person to say “now” or “yes” when touch is felt.

Compare symmetric points.

Hypoesthesia—decreased touch sensation.

Anesthesia—absent touch sensation.

Hyperesthesia—increased touch sensation.

Posterior Column Tract

Vibration.

Use a low-pitch tuning fork (128 Hz or 256 Hz) because its vibration has a slower decay.

Strike the tuning fork on the heel of your hand, and hold the base on a bony surface of the fingers and great toe (Fig. 23-25).

Ask the person to indicate when the vibration starts and stops.

If the person feels the normal vibration or buzzing sensation on these distal areas, you may assume proximal spots are normal and proceed no further.

If no vibrations are felt, move proximally and test ulnar processes and ankles, patellae, and iliac crests.

Compare the right side with the left side.

If you find a deficit, note whether it is gradual or abrupt.

Unable to feel vibration.

Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism).

 Often, this is the first sensation lost.

Peripheral neuropathy is worse at the feet and gradually improves as you move up the leg,

as opposed to a specific nerve lesion,

which has a clear zone of deficit for its dermatome (see Table 23-9, Patterns of Sensory Loss, p. 675).

Tactile Discrimination (Fine Touch).

As a prerequisite, the person needs a normal or near-normal sense of touch and position sense.

Stereognosis.

With the person's eyes closed, place a familiar object (paper clip, key, coin, cotton ball, or pencil) in his or her hand and ask the person to identify it (Fig. 23-27).

Normally, a person will explore it with the fingers and correctly name it.

Test a different object in each hand;

testing the left hand assesses right parietal lobe functioning.

Astereognosis—inability to identify object correctly.

Occurs in sensory cortex lesions (e.g., brain attack [stroke]).

Graphesthesia.

With the person's eyes closed, use a blunt instrument to trace a single digit number or a letter on the palm (Fig. 23-28).

Ask the person to tell you what it is.

Graphesthesia is a good measure of sensory loss if the person cannot make the hand movements needed for stereognosis,

as occurs in arthritis.

Two-Point Discrimination.

Apply the two points of an opened paper clip lightly to the skin in ever-closing distances.

 Note the distance at which the person no longer perceives two separate points.

The level of perception varies considerably with the region tested;

it is most sensitive in the fingertips (2 to 8 mm) and

least sensitive on the upper arms, thighs, and back (40 to 75 mm).

An increase in the distance it normally takes to identify two separate points occurs with

sensory cortex lesions.

Extinction.

Ask the person to state how many sensations are felt and where they are.

Normally, both sensations are felt.

The ability to recognize only one of the stimuli occurs with sensory cortex lesion;

the stimulus is extinguished on the side opposite the cortex lesion.

Point Location.

Tell the person, “Put your finger where I touched you.”

You can perform this test simultaneously with light touch sensation.

With a sensory cortex lesion, the person cannot localize the sensation accurately,

even though light touch sensation may be retained.

Clonus

Hyperreflexia

This occurs with upper motor neuron lesions (e.g., a brain attack).

Hyporeflexia,

It occurs with interruption of sensory afferents or destruction of motor efferents and anterior horn cells (e.g., spinal cord injury).

4+ Very brisk, hyperactive with clonus, indicative of disease

3+ Brisker than average, may indicate disease, probably normal

2+ Average, normal

1+ Diminished, low normal, or occurs only with reinforcement

0 No response

Reinforcement

is another technique to relax the muscles and enhance the response (Fig. 23-29).

Ask the person to perform an isometric exercise in a muscle group somewhat away from the one being tested.

For example, to enhance a patellar reflex, ask the person to lock the fingers together and “pull as hard as you can.”

Then strike the tendon.

To enhance a biceps response, ask the person to clench the teeth or to grasp the thigh with the opposite hand.

Biceps Reflex (C5 to C6).

Fig. 23-30

Triceps Reflex (C7 to C8).

Strike the triceps tendon directly just above the elbow (Fig. 23-31).

The normal response is extension of the forearm.

 Alternately, hold the person's wrist across the chest to flex the arm at the elbow,

and tap the tendon.

Brachioradialis Reflex (C5 to C6).

Strike the forearm directly, about 2 to 3 cm above the radial styloid process (Fig. 23-32).

 The normal response is flexion and supination of the forearm.

Quadriceps Reflex (“Knee Jerk”) (L2 to L4).

 Strike the tendon directly just below the patella (Fig. 23-33).

Extension of the lower leg is the expected response.

You also will palpate contraction of the quadriceps.

For the person in the supine position,

use your own arm as a lever to support the weight of one leg against the other leg (Fig. 23-34).

This maneuver also flexes the knee.

Achilles Reflex (“Ankle Jerk”) (L5 to S2).

 Hold the foot in dorsiflexion, and strike the Achilles tendon directly (Fig. 23-35).

Feel the normal response as the foot plantar flexes against your hand.

For the person in the supine position,

flex one knee and support that lower leg against the other leg so that it falls “open.”

Dorsiflex the foot, and tap the tendon (Fig. 23-36).

Clonus.

Support the lower leg in one hand.

With your other hand, move the foot up and down a few times to relax the muscle.

Then stretch the muscle by briskly dorsiflexing the foot.

Hold the stretch (Fig. 23-37).

With a normal response, you feel no further movement.

When clonus is present,

you will feel and see rapid, rhythmic contractions of the calf muscle and movement of the foot.

Clonus is repeated reflex muscular movements.

A hyperactive reflex with sustained clonus

(lasting as long as the stretch is held)

occurs with upper motor neuron disease.

Abdominal Reflexes—Upper (T8 to T10), Lower (T10 to T12).

Use the handle end of the reflex hammer, a wood applicator tip, or the end of a split tongue blade to stroke the skin.

Move from each corner of the abdomen toward the midline at both the upper and lower abdominal levels (Fig. 23-38).

The normal response is ipsilateral contraction of the abdominal muscle with an observed deviation of the umbilicus toward the stroke.

When the abdominal wall is very obese, pull the skin to the opposite side and feel it contract toward the stimulus.

Superficial reflexes are absent with diseases of the pyramidal tract (e.g.,

they are absent on the contralateral side with brain attack).

Cremasteric Reflex (L1 to L2).

On the male, lightly stroke the inner aspect of the thigh with the reflex hammer or tongue blade (see Fig. 23-38).

Note elevation of the ipsilateral testicle.

Plantar Reflex (L4 to S2).

With the reflex hammer, draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot,

like an upside-down J (Fig. 23-39, A).

The normal response is plantar flexion of the toes and inversion and flexion of the forefoot.

Except in infancy,

the abnormal response is dorsiflexion of the big toe and fanning of all toes,

which is a positive Babinski sign, also called “upgoing toes” (Fig. 23-39, B).

This occurs with UMN disease of the corticospinal (or pyramidal) tract.

Senile tremors

These benign tremors include an intention tremor of the hands, head nodding (as if saying “yes” or “no”), and tongue protrusion.

 Dyskinesias are the repetitive stereotyped movements in the jaw, lips, or tongue that may accompany senile tremors.

No associated rigidity is present.

Distinguish senile tremors from tremors of parkinsonism.

The latter includes rigidity and slowness and weakness of voluntary movement.

The Glasgow Coma Scale (GCS).

quantitativetool (Fig. 23-59

The scale is divided into three areas:

eye opening, verbal response, and motor response.

Each area is rated separately, and a number is given for the person's best response.

The three numbers are added; the total score reflects the brain's functional level.

A fully alert, normal person has a score of 15,

whereas a score of 7 or less reflects coma.

Serial assessments can be plotted on a graph to illustrate visually whether the person is stable, improving, or deteriorating.

The GCS assesses the functional state of the brain as a whole, not of any particular site in the brain.

The scale is easy to learn and master, has good interrater reliability, and enhances interprofessional communication by providing a common language.