2‐point
Cognition and Mental State
Queen Square Cognitive Screening Tests are excellent; there are many others.
Orientation and alertness
Language and Literacy
Praxis and Memory &c.
Follow with clinical psychometry if need be – see Chapters 5 and 22.
Skull, Scalp and Spine
Skull & scalp: contour, circumference, old burr holes, pulseless vessels, skull bruits.
For bruits, to abolish noise:
Say: ‘gently close your eyes’.
Rest stethoscope bell over one closed lid.
‘Open your other eye, and just stop breathing, briefly’.
Spine: contour, scars, deformity, pain, bruits, hair tufts, dimples, sinuses.
Cranial Nerves
I: Olfaction
Use clove oil, peppermint, eucalyptus &c – or soap, coffee and/or an orange (see Chapter 13).
II: Vision, Pupils and Fundi
Acuity: use a 3 metre Snellen chart. Correct refraction with lenses or pinhole – make one if necessary.
Fields: finger confrontation is reliable, and/or use 5 mm white/red pinheads. Ask the patient to cover their left eye; fix gaze of their right with your left eye. Fields are not flat: move target along a circumference, c. 50 cm away.
Central defects: Amsler grid, or, use text: ‘….are there any holes in the print?’
Colour vision: Ishihara or 100 Hue cards.
Pupils:dim lights, bright torchapproach from temporal side avoids convergencecross‐illuminate – second torch lights up a dark iris – many an unreactive pupil constrictsrelative afferent pupillary defect: swinging light test.
Fundi: develop your own technique.I seat the patient gazing horizontally at an object, and say: ‘…. its fine if you blink….’For the left fundus, I look through my ophthalmoscope with my left eye and cover my right.
III, IV and VI Diplopia: 4 Patterns and 4 Formal Rules
Most double vision fits one of four patterns:
VI: Abducens Palsy
Complaint: double vision – two images side by side
Evident convergent squint
Double vision disappears on looking away from the weak lateral rectus and vice versa; worse towards it – the squinting eye
No pupil abnormality.
Remember: a lateral rectus palsy can be caused by a VIth nerve lesion, by muscle or neuromuscular junction disease.
III: Oculomotor Palsy (complete)
A complete IIIrd causes:
Ptosis – upper lid drops and covers eye
Large pupil unreactive to light (contralateral pupil constricts normally)
An eye (lift upper lid) that’s ‘Down & Out’.
A partial IIIrd spares parasympathetic fibres (these fibres run beneath the nerve ‐ separate blood supply). Pupil: normal. Ptosis: incomplete.
Internuclear Ophthalmoplegia (INO)
INO = damage to brainstem medial longitudinal fasciculus.
Disconjugate horizontal eye movements – eyes move at different velocities. Look at the patient’s forehead: otherwise you fixate on one eye and miss what’s happening to the other.
Incomplete ADDuction of one eye.
Coarse jerk nystagmus on lateral gaze in the other eye (on ABDuction).
INO is left‐sided when there is failure of left ADDuction (looking right).
IV: Trochlear Palsy
A rarity, compared with others:
Double vision on looking down, twisted images, a.k.a. torsional diplopia
Head tilt: away from side of superior oblique weakness
No obvious squint.
When diplopia does not fit one of the patterns above, Formal Rules help.
1 False image: usually the less distinct and more peripheral
2 Diplopia: occurs in positions dependent upon contraction of a weak muscle
3 False image: is projected in direction of pull of the weak muscle
4 Image separation: increases in direction of pull of the weak muscle.
Dificulties: these include myasthenia, where diplopia varies; also blurring/false‐framing is easily accomplished, sometimes deliberately, by converging too closely. Diplopia is normal at extremes of gaze.
V: Trigeminal, Sensory and Motor
Most with sensory loss
