System

Fourth Edition

^ Humana Press

How to Examine the Nervous System

How to Examine the Nervous System fourth edition

Member of the Order of Canada Doctor of Science of the University of Manitoba Fellow of the Royal College of Physicians of London Fellow of the Royal College of Physicians and Surgeons of Canada Professor of Medicine, Section of Neurology University of Manitoba, Health Sciences Centre

Winnipeg, Canada

With a Foreword by Lewis P. Rowland, MD

Columbia University Medical Center,

New York

Totowa, New Jersey

© 2006 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512

humanapress.com

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Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices. The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication. Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change in dosages and for additional warnings and contraindications. This is of utmost importance when the recommended drug herein is a new or infrequent used drug. It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients. Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice. The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication.

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Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1 e-ISBN 1-59745-081-2

ISSN 1099-7768

This book is dedicated to the memory and influences of two men:

J.D. Adamson, MD (Manitoba), MRCP (Edinburgh), FRCP (Canada), Professor and Chairman, Department of Medicine, University of Manitoba, 1939-1951

L.G. Bell, OC, MBE, MD (Manitoba), LLD (Queens University, Kingston, Ontario), FRCP (London and Canada), FACP, Professor and Chairman, Department of Medicine, University of Manitoba, 1951-1964

I had the good luck to be taught by both of these doctors. J.D. Adamson could take a better history and elicit more information from a patient than anyone I have ever met. He considered every new patient a fascinating storyteller. He asked few questions, managed to keep the patient on the subject, and was completely enthralled as the history unwound. He knew the words and music of disease.

L.G. Bell could see more in 10 seconds at the bedside and do a better physical examination than anyone else. He had a great ability to find, see, and feel (or maybe smell) abnormal physical signs. One learned as much from watching him examine as from listening to J.D. Adamson listen.

Both of these men taught hundreds of students, interns, and residents. Each had great respect for the skills of the other. They were cultured, well-read, humorous humans and great bedside doctors who dearly loved medicine and teaching.

A man does not learn to understand anything unless he loves it.—Goethe

Contents

Foreword by Lewis P. Rowland ix

Preface xi

Acknowledgments xiii

1. The Ophthalmoscope, the Fundus Oculi, and Central and Peripheral Vision 1

2. Loss of Vision 19

3. The Abnormal Retina 37

4. Eye Movements, Diplopia, and

Cranial Nerves 3,4, and 6 45

5. Ptosis and the Pupils: Myasthenia Gravis and Other Diseases of the Eye and Eyelid Muscles 61

6. Nystagmus 71

7. Conjugate Gaze Palsies and Forced Conjugate Deviation 79

9. Cranial Nerves 8-12 107

10. The Upper Limb 121

11. The Lower Limb 145

12. Stance, Gait, and Balance 157

13. Reflexes 163

14. Sensation 177

15. The Cerebellum 187

16. The Corticospinal System 191

17. Higher Cortical Functions: Intelligence and Memory 197

18. Disorders of Speech 205

Appendix: Neurological Examination Instruments 210

Index 213

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