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DeMyer’s THE NEUROLOGIC EXAMINATION A P T ROGRAMMED EXT Seventh Edition José Biller, MD, FACP, FAAN, FANA, FAHA Professor and Chairman Department of Neurology Loyola University Chicago Stritch School of Medicine Maywood, Illinois Gregory Gruener, MD, MBA Vice Dean for Education, Stritch School of Medicine Leischner Professor of Medical Education Professor of Neurology Maywood, Illinois Paul W. Brazis, MD Professor of Neurology Mayo Medical School New York Chicago San Francisco Athens London Madrid Mexico City Milan New Delhi Singapore Sydney Toronto DeMyer’s The Neurologic Examination: A Programmed Text, Seventh Edition Copyright © 2017 by McGraw-Hill Education. All rights reserved. Printed in China. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. 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CONTENTS Preface to the Seventh Edition Preface to the First Edition Acknowledgments Preparation for the Text Outline of the Standard Neurologic Examination 1 Examination of the Face and Head 2 A Brief Review of Clinical Neuroanatomy 3 Examination of Vision 4 Examination of the Peripheral Ocular Motor System 5 Examination of the Central Ocular Motor Systems 6 Examination of the Motor Cranial Nerves V, VII, IX, X, XI, and XII 7 Examination of the Somatic Motor System (Excluding Cranial Nerves) 8 Examination for Cerebellar Dysfunction 9 Examination of the Special Senses 10 Examination of the General Somatosensory System 11 The Patient’s Mental Status and Higher Cerebral Functions 12 Examination of the Patient Who Has a Disorder of Consciousness 13 Ancillary Neurodiagnostic Procedures—Lumbar Puncture and Neuroimaging 14 Clinical and Laboratory Tests to Distinguish Conversion Disorder (Functional Neurologic Symptom Disorder) from Organic Disease 15 A Synopsis of the Neurologic Investigation and a Formulary of Neurodiagnosis Index PREFACE to the Seventh Edition This is the seventh edition of Dr. DeMyer’s textbook on The Neurologic Examination. It is the second under the stewardship of the current authors. When first published in 1994, Dr. DeMyer hoped it would fill a gap and function as a self-learning tool that combined with feedback from experienced clinicians and practice at the bedside, would improve the diagnostic skills of a student. It was never meant to be read, but in many respects it was a “to-do” book. It was the active doing or practicing the techniques that Dr. DeMyer felt would engage the student and facilitate learning rather than promote memorization. As bedside examination skills improve, ultimately patients would come to benefit. Currently there is a tendency to undermine the benefits of the physical examination as a foundational skill in clinical diagnosis. Various explanations are given that include limitations of time, increased sensitivity of diagnostic tools or the fact that some physical examination skills or findings, have been shown to not be diagnostic at all. It is certainly true that there are some physical examination practices of only historical interest, but most of the skills in eliciting a history and a relevant physical examination remain critical to proper diagnosis. When properly performed, they provide valuable information to an underlying disease and interpretation of abnormal diagnostic test results often relies on physical examination findings. Finally, the physical examination is of enormous benefit in the effective use of these diagnostic tests and the elimination of unnecessary ones. So, far from being relegated to historical interest, these skills are as important in the development of a clinician as they are for the patients under their care. We want to end this preface by again acknowledging Dr. William E. DeMyer as an esteemed colleague who demonstrated the highest qualities of a physician, master clinician, and teacher. The origin of this book, and the current authors’ intention, is to promote the value of a thoughtful physical examination and interpretation of those findings. We hope this book will fill such a role by becoming a virtual mentor that facilitates learning, through performing and interpreting physical examination findings. If the directions within this book are followed, not only will you benefit, but so will your patients and that is an ultimate responsibility that society expects of us. We hope you enjoy this excursion and we wish you the best as your careers unfold. José Biller, MD Gregory Gruener, MD Paul W. Brazis, MD PREFACE to the First Edition The purpose of this textbook is threefold: (1) to teach how to conduct a neurologic examination, (2) to review the anatomy and physiology for interpreting the examination, and (3) to show which laboratory tests help to clarify the clinical problem. This is not a differential diagnosis text or a systematic description of diseases. Anyone who sets out to write a textbook should place the manuscript on one knee and a student on the other. When the student squirms, sighs, or gives a wrong answer, the author has erred. He should correct it right then, before the ink dries. That is the way I have written this text, on the basis of feedback from the students. The peril of student-on-the-knee teaching is that, even though the student moves his lips, the words and voice remain the teacher’s. To escape from ventriloquism, my text relies strongly on self-observation and induction. First, you learn to observe yourself, not as Narcissus, but as a sample of every man. Whenever possible, you study living flesh, its look, its feel, and its responses. Why study a textbook picture to learn the range of ocular movements when you can hold up a hand mirror? Why memorize the laws of diplopia if you can do a simple experiment on yourself whenever you need to refresh your memory? In the best tradition of science, these techniques supplant the printed word as the source of knowledge. The text becomes a way of extending your own perceptions, of looking at the world through the eyes of experience. Because programmed instruction is the best way for the learner to judge whether learning has taken place, most of the text is programmed. The student is not abandoned to guess whether he has learned something; the program makes him prove that he has. Programming, if abused or overdone, becomes incredibly dull and unmercifully slow. The reader is required to inspect each grain of sand but should have been shown the whole shoreline at a glance. Some programs err by bristling with objectivity, causing one to ask, “Isn’t there a human being around here somewhere? Didn’t someone think this, decide it, maybe even guess at it a little?” For interludes, I use quotations, anecdotes, and poetry. I even stoop to mnemonics. Sometimes I cajole without pretending, as is customary in textbooks, that the pages have been purified, relieved of an author. I am very much here, poking my head out of a paragraph now and then or peering at you through an asterisk. When I see that you are weary from filling in blanks, I offer some whimsy. When you overflow with something to say, I ask for an essay answer. Sometimes you are invited to anticipate the text, to match wits against the problem without the spoon. At all times as you practice the neurologic examination, I stand at your elbow, guiding your moves and interpretations. You should be able to do an accomplished neurologic examination when you finish the book. And lastly, I include references. Only one reader in a hundred uses them? I am interested in him, too, in his precious curiosity. These then are the secrets: a lot of self-observation, a lot of programming, some irony and humor, a few editorials, and occasionally a summarizing paragraph, like this one. And as the leaven, lest they vanish from medical education, reminders of the bittersweet flowers of the mind, of tenderness, of understanding and compassion, like this stanza from Yeats, because it is perhaps all that should preface a text like this, into which I have poured the best teaching that I can offer; yet the wish always exceeds the result, ah me, by far: Had I the heavens’ embroidered cloths, Enwrought with gold and silver light, The blue and the dim and the dark cloths Of night and light and the half light, I would spread the cloths under your feet; But I, being poor, have only my dreams; I have spread my dreams under your feet; Tread softly because you tread on my dreams. To the many colleagues who have shared their knowledge with me over the years, I am deeply grateful. I especially want to thank Dr. Alexander T. Ross, my own preceptor in clinical neurology, and many friends in the basic disciplines of neurology, Drs. Ralph Reitan, Charles Ferster, Sidney Ochs, Wolfgang Zeman, and Jans Muller. For their day-to-day help I thank my wife, Dr. Marian DeMyer, Dr. Mark Dyken, and the many medical students, interns, and residents who suffered through the stuttering phases of the programming. I also thank Miss Irene Baird, who meticulously, maternally made the drawings; Mrs. Faith Halstead, who typed and retyped the burgeoning manuscript; medical artist James Glore; and photographer Joseph Demma. William E. DeMyer, MD ACKNOWLEDGMENTS I want to thank my family for their support and motivation which helped to once again bring this work to a successful completion. In particular, I wish to express endless gratitude to my wife Rhonda for her unfailing patience. José Biller I want to thank my wife Catherine for making sure I spend time with our family and not just me alone with my keyboard; our great sons, Ethan and Michael; and our new grandson Henry, who is getting ready to follow in their footsteps. Gregory Gruener I would like to thank my wife and family for their continued support. Paul W. Brazis PREPARATION FOR THE TEXT We assume that you know basic neuroanatomy and neurophysiology (but we review them anyway). The text teaches the necessary mental and manual skills for the neurologic examination (NE). Your teachers, then freed from teaching these skills by lecturing, can use precious class hours solely to examine patients (Pts). Then, if you can go directly after classes to the clinics and wards, you have the ideal situation for learning the NE. At the outset, we find that students want to know just what constitutes an NE? Thus we start this text by outlining and demonstrating a full NE. Of course, you can’t do the examination now, but you can use the outline in two ways: (1) refer back to it at the end of each chapter, to fit what you have learned into the total examination; (2) take it to the wards and clinics as a guide until you can wean yourself from it. You must have on hand basic examining equipment (listed shortly) and some learning aids: colored pencils, a hand mirror, and for Chapter 4 a 2- to 3-in. foam rubber ball. Get all the items before starting. Do the text in order. Skipping around invites confusion because each new step presumes mastery of the previous steps. Allow approximately one hour for each nine pages you want to study. Because the text requires inspection of one’s self and others, study in your own living quarters, preferably with a partner. Do all tests and make all observations called for. The doing results in active, permanent learning by developing your own powers of observation and manual skills. Most of your education to this point has consisted of memorizing lists or concepts compiled by someone else. Now you have to learn how to learn directly from the Pt through your own eyes, ears, and touch. That’s what requires all of the doing and makes this text unique. TABLE NE-1 • Abbreviations AP Anteroposterior ARAS Ascending reticular activating system BE Branchial efferent BP Blood pressure C Cervical CAT Computerized axial tomography Cm Centimeter CNS Central nervous system Cps Cycles per second CrN Cranial nerve CrNs Cranial nerves CSF Cerebrospinal fluid EEG Electroencephalogram EMG Electromyography Ex Examiner F False GSA General somatic afferent GSE General somatic efferent GVA General visceral afferent GVE General visceral efferent ICA Internal carotid artery L Lateral, left, or lumbar LMN Lower motor neuron LP Lumbar puncture MLF Medial longitudinal fasciculus Mm Millimeters MRA Magnetic resonance angiography MRI Magnetic resonance imaging MSR Muscle stretch reflex NE Neurologic examination O Oxygen 2 OFC Occipitofrontal circumference Pt Patient R Right RBC Red blood cells RF Reticular formation S Sacral SA Somatic afferent SCA Superior cerebellar artery SCM Sternocleidomastoid muscle SSSS Solely special sensory set (cranial nerves I, II, and VIII) SVA Special visceral afferent T True or thoracic TNR Tonic neck reflex UMN Upper motor neuron V Vertical WBC White blood cells