{"id":2042,"date":"2020-05-20T16:30:02","date_gmt":"2020-05-20T23:30:02","guid":{"rendered":"https:\/\/up.physicaldiagnosispdx.com\/up\/?page_id=2042"},"modified":"2021-01-16T12:40:05","modified_gmt":"2021-01-16T20:40:05","slug":"neurology-t","status":"publish","type":"page","link":"https:\/\/up.physicaldiagnosispdx.com\/up\/neurology-t\/","title":{"rendered":"Neurology Tutorial"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row css=&#8221;.vc_custom_1592155698727{background-color: #fff9f9 !important;}&#8221;][vc_column][vc_column_text]\n<h1><span style=\"font-size: 14pt;\"><strong>Full Neurology Exam<\/strong><\/span><\/h1>\n<ul>\n<li><span style=\"font-size: 12pt;\">Mental status<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Cranial nerves<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Motor examination<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Gait and coordination<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Sensory examination<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2><span style=\"font-size: 12pt;\"><strong>Mental status<\/strong><\/span><\/h2>\n<ul>\n<li><span style=\"font-size: 12pt;\">Level of consciousness, orientation, memory, and attention<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">There are a number of standardized tests of mental status that are used primarily in the detection and assessment of dementia such as the MMSE, MOCA and the SLUMS.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Level of consciousness<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Are they alert, lethargic (sleepy), stuporous (can\u2019t be aroused but may moan or withdraw) or comatose (no purposeful response to stimuli)?<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Orientation<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">What is your name? Where are we? What is today\u2019s date?<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Memory<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Ask them to remember 3 random words (pencil, umbrella, green) and ask them to repeat them (tests registration) and then ask them again after several minutes.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Attention<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Digit span testing is performed by having them repeat a series of numbers- they should be able to easily remember 5 numbers (like a zip code).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Serial 7s is done by asking the patient to start from 100, subtract 7, and then subtract 7 from that number.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Have them spell the word world backwards.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2><span style=\"font-size: 12pt;\"><strong>Cranial Nerves<\/strong><\/span><\/h2>\n<ul>\n<li><span style=\"font-size: 12pt;\">CN I<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Test olfactory with easily recognizable scents one nostril at a time.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN II<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Assess far and near vision using an eye chart.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Assess visual fields in all 4 quadrants.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Funduscopic examination.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN III<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Assess pupils for size, and whether they constrict to light and near vision.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Swinging flashlight.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN III, IV and VI<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Assess extra ocular muscle movement by having them look in the 6 cardinal directions.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Assess diplopia with cover\/uncover testing.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN V<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Test facial sensation in the 3 regions of the face (V1,2,3) with light touch, temperature with the tuning fork.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Test chewing muscle contraction by feeling clenched jaw muscles.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Jaw jerk if trying to differentiate the cause of UE hyperreflexia from cervical vs higher sources.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Normally the jaw jerk is minimal or absent.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN VII<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Test facial muscles by having patient raise eyebrow, keep eyes shut as you try to pry them open gently, puff cheeks with air, show their teeth, tense platysma by turning corners of the mouth down.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Taste (anterior 2\/3rds) with sweet\/salty\/sour on a cotton applicator.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Test corneal reflex in comatose patients<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN VIII<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Hearing assessment, Weber and Rinne.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Vestibular function if comatose or having vertigo with HINTS (head impulse, nystagmus, test of skew) with INFARCT predicting stroke (impulse normal, fast phase alternating, refixation on cover test more consistent with central causes).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">COWS with caloric testing<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN IX, X<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Have them open their mouth, say \u201cah\u201d, look at the palate and uvula.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Gag in comatose.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN XI<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Shrug shoulders with you resisting them, have them turn their head to the side and push their chin towards the midline against your hand.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">CN XII<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Stick out their tongue, point it to left and right.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2><span style=\"font-size: 12pt;\"><strong>Motor Exam<\/strong><\/span><\/h2>\n<h3><span style=\"font-size: 12pt;\"><strong>Inspection<\/strong><\/span><\/h3>\n<ul>\n<li><span style=\"font-size: 12pt;\">Assess patient\u2019s overall appearance.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Positioning (any posturing?); Movements (tremor, chorea).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Muscle bulk<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Look for atrophy, abnormal hypertrophy. Atrophy can be seen in hand\/feet muscles in neuropathic diseases such as diabetes.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Look for fasciculations.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Gait assessment.<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3><span style=\"font-size: 12pt;\"><strong>Palpation and (rarely) percussion<\/strong><\/span><\/h3>\n<ul>\n<li><span style=\"font-size: 12pt;\">This is not routinely performed but should be done if you suspect myositis (should have tenderness) and percussion can be performed if you suspect myotonia.<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3><span style=\"font-size: 12pt;\"><strong>Tone<\/strong><\/span><\/h3>\n<ul>\n<li><span style=\"font-size: 12pt;\">Findings in the assessment of tone:<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Normal tone<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Hypotonia<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Hypertonia<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Spasticity, rigidity, and paratonia<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Spasticity is increased tone due to UMN disease that is most apparent in the mid-range of motion and is velocity-dependent.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Rigidity is a continuous resistance to passive movement, and is seen in diseases of the basal ganglia such as Parkinson\u2019s.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Lead pipe rigidity is a continuous resistance to passive movement involving flexors and extensor muscles (no preference, as opposed to spasticity) throughout their full range of movement that is velocity-independent (does not matter if you move them fast or slow).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Cogwheel rigidity is a rigidity with superimposed tremor, leading to the cogwheel sensation, classically seen in Parkinsonism.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Tone can be increased or provoked by moving another part of the body while doing the exam, as by having the patient shake their head back and forth while testing for tremor or cogwheeling in the upper extremity.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Patients with cerebral palsy can have a mixture of spasticity and rigidity.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Paratonia (gegenhalten &#8211; German for against resistance) is the appearance of increased tone, seen in patients with dementing illness who resist all attempts at passive range of motion testing. The increased tone is not present at rest, and is equal and opposite to the force that you apply.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Myotonia is sustained contraction due to impaired relaxation, seen in myotonic dystrophy and myotonia congenita.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Patients with myotonic dystrophy may have a characteristic hand shake, where they are unable to relax their grip after squeezing your hand, and may exhibit percussion myotonia (sustained muscle contraction after inducing stretch reflex).<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none;\"><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3><span style=\"font-size: 12pt;\"><strong>Strength<\/strong><\/span><\/h3>\n<ul>\n<li><span style=\"font-size: 12pt;\">Scale:<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">0 = no movement<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">1 = flicker or fasciculations<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">2 = movement with gravity removed<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">3 = movement against gravity alone, but not against any added resistance<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">4 = movement against some resistance but abnormally weak<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">5 = normal strength<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">When testing muscle strength, the following observations may be helpful:<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Muscles are strongest when they are acting from their shortest position, and are weakest when they are fully lengthened (the opposite of Starling\u2019s law with the heart).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">The biceps and hamstrings are strongest when flexed, triceps and quadriceps are strongest when extended.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">In strong patients, most examiners will be overpowered by testing in their shortest, strongest position, so test them with the muscle lengthened (elbow bent while testing triceps, straight when testing biceps)<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Extend the flexors, flex the extensors to get the strong muscles into a weaker position<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">In general, the antigravity muscles are the strongest. These include the neck extensors, arm extensors, wrist and finger flexors, leg extensors and plantar flexors.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">When testing strength, have an organized approach, starting from the neck and ending with the toes.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">In a simple screening exam, when your suspicion for significant deficits is low, you will just be testing the main muscles of the limbs, while in patients you suspect have a neurologic illness a more complete exam may be appropriate.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">In myopathies, concentrate on the proximal muscles.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Axonal neuropathies, the distal.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Test the following muscle groups:<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<table>\n<tbody>\n<tr>\n<td width=\"42\"><\/td>\n<td width=\"48\"><span style=\"font-size: 12pt;\">Deltoid<\/span><\/td>\n<td width=\"50\"><span style=\"font-size: 12pt;\">Triceps<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">Bicep<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">Wrist Ext<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">Wrist Flex<\/span><\/td>\n<td width=\"63\"><span style=\"font-size: 12pt;\">Digital Interossei<\/span><\/td>\n<td width=\"30\"><span style=\"font-size: 12pt;\">Hip Flex<\/span><\/td>\n<td width=\"39\"><span style=\"font-size: 12pt;\">Hip Ext<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">Knee Flex<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">Knee Ext<\/span><\/td>\n<td width=\"70\"><span style=\"font-size: 12pt;\">Ankle Plantar flex<\/span><\/td>\n<td width=\"90\"><span style=\"font-size: 12pt;\">Ankle<\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Dorsiflex<\/span><\/td>\n<\/tr>\n<tr>\n<td width=\"42\"><span style=\"font-size: 12pt;\">Left<\/span><\/td>\n<td width=\"48\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"50\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"63\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"30\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"39\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"70\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"90\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<\/tr>\n<tr>\n<td width=\"42\"><span style=\"font-size: 12pt;\">Right<\/span><\/td>\n<td width=\"48\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"50\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"63\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"30\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"39\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"44\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"70\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<td width=\"90\"><span style=\"font-size: 12pt;\">5<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span style=\"font-size: 12pt;\"><strong>\u00a0<\/strong><\/span><\/p>\n<h2><span style=\"font-size: 12pt;\"><strong>Reflexes<\/strong><\/span><\/h2>\n<ul>\n<li><span style=\"font-size: 12pt;\">Muscle stretch reflexes assess the integrity of both the sensory neurons on the muscle as well as the motor neurons to the muscle and the connections to and from the brain.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">When a muscle is stretched, as by striking it or its tendon, it will reflexively contract.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Hyperreflexia<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Hyperreflexia is a classic sign of UMN disease and hyperthyroidism.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Hyperreflexia in one limb or in lower but not upper extremities can help localize lesions.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Hyporeflexia<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Hyporeflexia or areflexia can be seen in LMN disease, myopathies, peripheral neuropathies.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Patterns of hyporeflexia or areflexia can also localize lesions or suggest a category of disease.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Peripheral neuropathies are length-dependent, with loss of distal &gt; proximal reflexes.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Absent reflexes is a cardinal feature of Guillain-Barr\u00e9.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Remember that hypothyroidism can cause hung up reflexes, often best seen in the Achilles tendon.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Reflexes are <strong>graded<\/strong> on a 0-4 scale with 2 being normal<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">0 &#8211; No response<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">1 &#8211; Present but only with reinforcement<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">2 &#8211; Normal<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">3 &#8211; Brisk but no clonus<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">4 &#8211; Markedly abnormal, with clonus<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Technique<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">It is all in the wrist &#8211; swing the hammer smoothly and briskly. The amount of force needed varies as some patients have reflexes with even light percussion, while others may require a stronger blow.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">The muscle needs to be as relaxed as possible &#8211; try to distract your patient, move the joint a few times to loosen the muscle.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Reinforcement is the contraction of other muscle groups away from the stretched muscle that may bring out the reflex, such as having the patient clench their teeth when checking upper limb reflexes, or having them grip their fingers and try to pull them apart (Jendrassik maneuver) when checking lower limb reflexes.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Sometimes the muscle can be felt better than seen.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Feel the quadriceps rather than looking for a dramatic leg kick.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Some reflexes are better obtained by tapping your own finger or thumb rather than the tendon.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">This is true for the jaw jerk, biceps, and brachioradialis.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2><\/h2>\n<h2><span style=\"font-size: 12pt;\"><strong>Coordination and Gait<\/strong><\/span><\/h2>\n<p><span style=\"font-size: 12pt;\"><strong>Tests of Cerebellar function<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Arms<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Have the patient hold their arm outstretched with eyes closed, and suddenly push them up or down, looking for oscillations, over correction.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Finger to nose.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Dysdiadochokinesis.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Legs<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Heel to shin.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Heel tapping.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Trunk<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Have the patient sit up from a supine position without using their arms, looking for truncal ataxia.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Tandem gait.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2><span style=\"font-size: 12pt;\"><strong>Sensory Exam<\/strong><\/span><\/h2>\n<ul>\n<li><span style=\"font-size: 12pt;\">Test <strong>light touch<\/strong> bilaterally with your fingers or a piece of cotton.<\/span><\/li>\n<\/ul>\n<ul>\n<li><span style=\"font-size: 12pt;\">One approach is to check both sides in a variety of dermatomes, such as:<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Shoulders (C4)<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Inner\/outer forearm (C6\/T1)<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Thumb\/pinky (C6\/C8)<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Front of thigh (L2)<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Medial\/lateral calf (L4\/5)<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Little toe (S1)<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Medial buttock (S3)<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Test <strong>pain<\/strong> with a disposable pin or a broken tongue blade.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Test<strong> temperature<\/strong> by comparing the cool tuning fork to your (presumably) warm finger, or to something warmed up (like another tuning fork) again with their eyes closed, having them say warm or cold.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Test <strong>vibration<\/strong> with a 128 Hz tuning fork on the distal phalanx of the fingers and toes below the nail bed (a 256 Hz may also be used but there are some standards developed around the 128).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Test<strong> proprioception<\/strong> by holding the sides of the fingers and toes and moving them up or down and seeing if the patient can tell which direction they are moved , again with eyes closed.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Cortical Sensory Functions:<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Two-point <\/strong><\/span><\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Stereognosis<\/strong><\/span><\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Graphesthesia <\/strong><\/span><\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Extinction<\/strong><\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>\u00a0<\/strong><strong>Weakness<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Two questions you should ask when dealing with a neurological problem are; where is the lesion and what is the lesion? The answer to the first question can help in answering the second question, both by narrowing the differential diagnosis, and also by helping you to choose the best follow up imaging or laboratory tests.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Time course: Can help answer what the lesion is.<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Acute <\/strong>(seconds to hours)<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Suggests ischemia, hemorrhage, seizure, or trauma.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Subacute <\/strong>(days to months)<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Suggests an expanding lesion, as in tumors or infection, or demyelination.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>\u00a0<\/strong><strong>Rules for localization of weakness<\/strong><\/span><\/h1>\n<h2><span style=\"font-size: 12pt;\"><strong>Upper motor neuron<\/strong><\/span><\/h2>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"font-size: 12pt;\">Includes nervous tissue from the cortex down to (but not including) the anterior horn cells.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Features:<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li><span style=\"font-size: 12pt;\">Increased tone, especially in the UE flexors and LE extensors.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Hyperactive reflexes.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">\u201cPyramidal pattern\u201d of weakness (weak UE extensors\/abductors, weak LE flexors\/adductors).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Positive Babinski, Hoffman\u2019s, pronator drift, or rolling tests.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Decrease in the superficial reflexes (abdominal, cremasteric, anal).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">May have sensory findings, which may be cortical (astereognosis, agraphesthesia) or may affect entire limb.<\/span><\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Motor cortex lesions <\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Can affect the contralateral half the body or just one part of the body.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Presence of aphasia, visual field defects, cortical sensory loss or seizures locate the lesion in the cortex.There may also be sensory loss if the sensory cortex is also involved.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Internal capsule<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Remember FATL (face, arm, trunk, leg) as they all run close together in the posterior limb. There is no cortical sensory loss or any of the above cortical signs with a stroke here.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Brainstem<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Face involvement means brainstem or above (exception is CN V which extends to upper cervical cord).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Look for cranial nerve involvement on the ipsilateral side, body contralateral.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">CN III and IV in midbrain.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">CN VI and VII in pons.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">CN VIII in pontomedullary junction.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">CN IX-XII in medulla.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Cord lesions<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Spinal cord lesion suggested by findings of a sensory level, pain and temperature loss on contralateral side of body, no deficits in face, presence of LMN findings as well (atrophy, fasciculations).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Above C5, ipsilateral hemiparesis that spares the face (face means brainstem).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Between C5 and T1, variable ipsilateral arm with paresis of the leg.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Below T1, just the leg.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Trauma, demyelinating diseases, epidural abscess, other infections, infarctions (anterior spinal artery supplies anterior 2\/3rds of cord), B12 deficiency, tumors (cord compression), disc herniation.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">In cervical disc herniation, there may be LMN findings at the level of where the disc compresses (laterally) the nerve root, and often UMN findings below that level from myelopathy (compression of the cord, from herniation centrally) along with sensory disturbances.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">The classic presentation of cervical myelopathy is weakness in the upper and lower extremities, possibly urine\/bowel incontinence and a spastic gait (only 1\/3<sup>rd<\/sup> complain of neck pain).<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Compression of the cord from a herniated disc is seen in cervical disc herniations not lumbar, as the spinal cord <a href=\"https:\/\/login.liboff.ohsu.edu\/login?url=http:\/\/accessmedicine.mhmedical.com\/ViewLarge.aspx?figid=45403262\">ends at about the L2 vertebrae<\/a> (thoracic discs rarely herniate).<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Central herniation of the lumbar vertebra can cause cauda equina syndrome by impinging upon the sacral nerve roots.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<h2><span style=\"font-size: 12pt;\"><strong>Lower motor neuron<\/strong><\/span><\/h2>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"font-size: 12pt;\">Includes the anterior horn cell, root\/plexus, and peripheral nerve.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Motor neuron diseases<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">ALS, mixed upper and lower motor neuron findings.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Polio, Coxsackie, West Nile virus, and a newer enterovirus can also cause anterior horn disease.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Radiculopathy or polyradiculopathy (single or multiple nerve roots)<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Radiculopathy causes sensory loss in a dermatomal distribution, weakness in a myotome distribution.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Disc prolapse (as above).<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Lumbar is usually in the L5-S1 distribution, with back pain along with radicular pain\/paresthesias\/numbness in the distribution of the nerve root.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">L4 leads to weak quadriceps, loss of patellar reflex.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">L5 leads to weak dorsiflexion of foot and great toe, loss of medial hamstring reflex.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">S1 leads to weak plantar flexion and loss of Achilles reflex.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Polyradiculopathy may be difficult to distinguish from a polyneuropathy, imaging and lab studies may be needed<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">\u00a0(Main causes are infections such as herpes, Lyme disease, cancers, sarcoid)<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Plexopathy<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Trauma, autoimmune, inflammatory, tumor (weakness\/sensory loss in more than one spinal or peripheral nerve distribution).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Traumatic evulsion of C5-6 nerve roots.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">From birth trauma or trauma separating head and shoulder leads to Erb-Duchenne paralysis.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Recall C5-6 innervate the suprascapular, axillary and musculocutaneous nerves to the supra\/infraspinatus, deltoid, biceps and brachialis, so the arm hangs at the side (weak supraspinatus or deltoid), the arm is extended (weak biceps\/brachialis), shoulder is internally rotated (weak infraspinatus) &#8211; called\u00a0 \u201cwaiter\u2019s tip\u201d position.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\">Klumpke paralysis is from C8-T1, can be seen after a fall arrested by grabbing an object or by traction on an abducted arm, or by a Pancoast tumor, leading to wasting of the small muscles of the hand and a claw handed appearance.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Peripheral mononeuropathy<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Entrapment, trauma, diabetes &#8211; carpal tunnel is classic.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Deficits in the distribution of a single peripheral nerve.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Mononeuritis multiplex<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Multiple single nerves affected, seen in diabetes, vasculitis (granulomatous polyangiitis, PAN, Churg-Strauss), sarcoidosis and infections such as Lyme, HIV and leprosy.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Polyneuropathy<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Toxic, metabolic, nutritional, etc.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Usual presentation is symmetric distal sensory loss, burning sensations, or weakness (stocking\/glove distribution).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">In axonal, sensory loss predominates; in demyelinating, motor predominates.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Demyelinating neuropathies <\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">MS, ADEM, Guillain-Barr\u00e9, CIDP, many inherited conditions including Charcot Marie Tooth.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Affects motor and sensory (the large myelinated fibers, not the unmyelinated).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Not length dependent so not distal &gt; proximal.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Reflexes lost early.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Nerve conduction velocities slowed.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-size: 12pt;\"><strong>Axonal neuropathies<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Often nutritional, metabolic, and toxic causes.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Charcot Marie Tooth (1 is demyelinating, 2 is axonal).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Distal &gt; proximal loss (length dependent).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Reflexes present until late.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Small &gt; large fiber involvement.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Usually symmetric.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Nerve conduction velocities may be normal.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Neuromuscular junction <\/strong><\/span><\/li>\n<li style=\"list-style-type: none;\">\n<ul>\n<li><span style=\"font-size: 12pt;\">NMJ diseases (MG, Lambert Eaton, botulism) tend to fluctuate during the day or over days, and may fatigue (as in MG) or improve (as in Lambert Eaton) with repetitive activity.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Variable weakness is the hallmark of NMJ disorders.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">NMJ diseases also usually affect the ocular muscles (ptosis, diplopia).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Patchy involvement that doesn\u2019t conform with an anatomic distribution.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Tone normal or decreased.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Reflexes usually normal in MG, and reduced or absent in LE.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">No sensory loss.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Myopathies<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">\u00a0Same as LMN lesions except no fasciculations and reflexes are decreased or absent.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Affect the large proximal muscles (shoulder\/hip), and can have associated pain.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Look for the rash of dermatomyositis, medications such as statins, family history of muscular dystrophy or myotonic dystrophy.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\"><strong>Functional<\/strong><\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Normal tone, bulk, reflexes<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Erratic weakness<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>Upper motor neuron signs<\/strong><\/span><\/h1>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Hyperreflexia<\/strong><\/span><a href=\"https:\/\/up.physicaldiagnosispdx.com\/up\/neurology\/neurology-m\/hyperreflexia\/\"><img decoding=\"async\" loading=\"lazy\" class=\"alignright wp-image-1659\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png\" alt=\"\" width=\"63\" height=\"63\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-150x150.png 150w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581.png 512w\" sizes=\"auto, (max-width: 63px) 100vw, 63px\" \/><\/a><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\">Muscle stretch reflexes assess the integrity of both the sensory neurons on the muscle as well as the motor neurons to the muscle and the connections to and from the brain.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">When a muscle is stretched, as by striking it or its tendon, it will reflexively contract.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Hyperreflexia is a classic sign of UMN disease and hyperthyroidism<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Hyperreflexia in one limb or in lower but not upper extremities can help localize lesions<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Clonus<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Clonus is the repeating contraction of a stretched muscle. Normally, if a muscle is stretched rapidly, it will contract, which then puts a stretch on the antagonistic muscle, which contracts. For example, rapidly dorsiflexing the ankle stretches the gastrocnemius, causing it to contract, resulting in plantar flexion, which stretches the anterior tibialis, causing dorsiflexion, which stretches the gastrocnemius, which may cause another planar flexion. In UMN disease this process may continue for several beats (non-sustained) or indefinitely (sustained) so long as steady stretch is applied to the gastrocnemius by dorsiflexing the ankle because of disinhibition that normally quells the excessive contractions. To elicit clonus, for example in the ankle, briskly dorsiflex the ankle, and maintain some pressure on the foot.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Babinski\u2019s<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\">An assessment for upper motor neuron disease.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Before performing this exam, which can feel noxious, explain to the patient what you are doing and why &#8211; it may be helpful to demonstrate it in their hand.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Stroke the <em>lateral<\/em> foot from the heel to the ball of the foot then across the <em>ball of the foot<\/em> (not all the way to the base of the toes) towards the big toe.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">The normal response is for the toes to plantar flex (downward).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\"><em>Dorsiflexion<\/em> of the great toe (<em>up going<\/em>) and downward fanning of the other toes indicates disease in the upper motor neuron tract.<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Hoffman\u2019s<\/strong><\/span><a href=\"https:\/\/up.physicaldiagnosispdx.com\/up\/neurology\/neurology-m\/hoffmans-sign\/\"><img decoding=\"async\" loading=\"lazy\" class=\"alignright wp-image-1659\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png\" alt=\"\" width=\"63\" height=\"63\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-150x150.png 150w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581.png 512w\" sizes=\"auto, (max-width: 63px) 100vw, 63px\" \/><\/a><br \/>\n<span style=\"font-size: 12pt;\">Nail of middle finger is flicked downward, flexing the finger, causing it to rebound into extension; if their thumb and index finger flexes the Hoffman\u2019s sign is present, suggesting UMN disease.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Spasticity<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Spasticity is increased tone due to UMN disease that is most apparent in the mid-range of motion and is velocity-dependent.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Pronator drift<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\">Sometimes patients with subtle weakness won\u2019t have any deficits detectable on strength examination. Subtle weakness may be detected on pronator drift.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Have the patient hold their arms stretched out in front of them with the palms up, close their eyes and have them maintain this position for about 10 seconds (some sources advocate a minute or more).<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Inability to hold this position, especially any downward pronation or flexion is a sign of upper motor neuron weakness.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Crossed adductor reflex<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Spread of a reflex to other muscles not being tested. A sign of upper motor neuron disease.<\/span><\/p>\n<p>&nbsp;<\/p>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>Lower motor neuron signs<\/strong><\/span><\/h1>\n<p><span style=\"font-size: 12pt;\"><strong>\u00a0<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Fasciculations<\/strong><\/span><a href=\"https:\/\/up.physicaldiagnosispdx.com\/up\/neurology\/neurology-m\/3861-2\/\"><img decoding=\"async\" loading=\"lazy\" class=\"alignright wp-image-1659\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png\" alt=\"\" width=\"63\" height=\"63\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-150x150.png 150w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581.png 512w\" sizes=\"auto, (max-width: 63px) 100vw, 63px\" \/><\/a><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\">These are subtle, subcutaneous movements that represent contractions of a motor unit, seen in LMN disease (especially those involving anterior horn cells), but can be entirely benign.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">In LMN lesions they are thought to represent the repetitive discharges of dying motor units.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Myokymia is the state of nearly continuous fasciculations causing a rippling appearance, associated with demyelinating diseases such as Guillain-Barre and MS.<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Atrophy<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\">Reduced bulk (atrophy) suggests LMN disease or muscle disuse.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Places to look for atrophy include the thenar eminence and the dorsal interosseous muscles in length dependent neuropathies (as in long standing, poorly controlled diabetes). Patterns of atrophy can suggest the site of nerve or muscle disease.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Peroneal muscles in Charcot-Marie-Tooth, the most common inherited neuromuscular disorder (1\/2500).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Temporal muscles in myotonic dystrophy.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>Ophthalmoplegia<\/strong><\/span><\/h1>\n<p><span style=\"font-size: 12pt;\">Weakness or paralysis of the muscles of the eye.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Internuclear ophthalmoplegia<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\">Seen in multiple sclerosis, due to a lesion in the medial longitudinal fasciculus, a pathway that connects the nuclei of cranial nerve III and VI to allow for coordinated abduction and adduction, essentially yoking the eyes together.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">On lateral gaze, abduction occurs but adduction is impaired producing diplopia, with jerk nystagmus in the contralateral abducting eye.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Unlike 3<sup>rd<\/sup> nerve palsy, normal adduction is maintained during convergence as the lesion isn\u2019t with the medial rectus muscle, which works normally, but in the MLF &#8211; in convergence the signals don\u2019t go through the heavily myelinated MLF.<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Nystagmus<\/strong><\/span><\/p>\n<ul>\n<li><span style=\"font-size: 12pt;\">Involuntary jerking movements of the eyes. Can occur side to side, up and down, or in a circular pattern.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Nystagmus can be a sign of cerebellar disease, drug toxicities, vestibular disease, multiple sclerosis or other CNS diseases.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">In malnourished patients, alcoholics, bariatric surgery patients, and others with nystagmus, especially with gait disturbances and mental status changes, think of Wernicke\u2019s encephalopathy, which is a medical emergency.<\/span>\n<ul>\n<li><span style=\"font-size: 12pt;\">Responds to thiamine.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Can be induced in susceptible patients by the infusion of dextrose without thiamine.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>\u00a0<\/strong><strong>Gait abnormalities<\/strong><\/span><a href=\"https:\/\/up.physicaldiagnosispdx.com\/up\/neurology\/neurology-m\/spastic-gait\/\"><img decoding=\"async\" loading=\"lazy\" class=\"alignright wp-image-1659\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png\" alt=\"\" width=\"63\" height=\"63\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-150x150.png 150w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581.png 512w\" sizes=\"auto, (max-width: 63px) 100vw, 63px\" \/><\/a><\/h1>\n<ul>\n<li><span style=\"font-size: 12pt;\">Gait evaluation can be informative, revealing evidence of conditions such as UMN disease (scissoring gait or hemiplegic gait) myopathy (waddling gait), and peripheral sensory neuropathy or foot drop (high stepping).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Walking on toes and heels screens for weakness in the plantar flexors (S1, S2) and dorsiflexors (L4, L5)<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Antalgic gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Caused by a painful leg, the patient with an antalgic gait spends less time bearing weight on the affected side (shortened stance phase) and more time with the affected leg in the air (enhanced swing phase).<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Hemiplegic (spastic) gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">The patient holds the affected leg stiffly without flexing freely at the hip, knee, or ankle. The leg rotates outward in a semicircular fashion, first away from and then toward the body (circumduction).<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Magnetic gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\"><strong>\u00a0<\/strong>Associated with normal pressure hydrocephalus, the patient does not lift the legs far off the floor, as if they are attached to it by a \u201cmagnet\u201d.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Shuffling gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">The Parkinsonian shuffling gait is characterized by reduced or absent arm swing, forward bent torso, short or shuffling steps, hesitation in initiation, festination (quickening of steps), and \u201cfreezing\u201d when encountering obstacles.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Steppage gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Caused by paralysis of the pretibial and peroneal muscles, leading to the inability to dorsiflex the foot (foot drop). Steps are regular and even but there is overlifting and slapping of the involved foot.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Cerebellar gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">There is a wide base (separation of legs), irregular cadence, unsteadiness, and lateral veering. Sometimes referred to as a \u201cdrunken\u201d gait.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Waddling gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Slightly widened base with overlifting of hip(s), characteristic of myopathies.<\/span><\/p>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>Parkinson\u2019s disease<\/strong><\/span><\/h1>\n<p><span style=\"font-size: 12pt;\"><strong>Masked facies<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">Reduced facial muscle movement.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>Shuffling gait<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">The Parkinsonian shuffling gait is characterized by reduced or absent arm swing, forward bent torso, short or shuffling steps, hesitation in initiation, festination (quickening of steps), and \u201cfreezing\u201d when encountering obstacles.<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-size: 12pt;\"><strong>\u00a0<\/strong><strong>Pill-rolling tremor<\/strong><\/span><\/p>\n<p><span style=\"font-size: 12pt;\">The tremor of Parkinson\u2019s disease occurs at rest, is coarse, rhythmic, and low frequency (3 to 5 Hz), often involving the hands, as if the patient is rolling a pill between their fingers. The tremor subsides upon willful movement.<\/span><\/p>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>Horner\u2019s syndrome<\/strong><\/span><\/h1>\n<p><img decoding=\"async\" loading=\"lazy\" class=\"wp-image-1659 alignright\" src=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png\" alt=\"\" width=\"63\" height=\"63\" srcset=\"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-300x300.png 300w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581-150x150.png 150w, https:\/\/up.physicaldiagnosispdx.com\/up\/wp-content\/uploads\/iconfinder_multimedia_audio_media-38_3790581.png 512w\" sizes=\"auto, (max-width: 63px) 100vw, 63px\" \/><span style=\"font-size: 12pt;\">Characterized by miosis, anhidrosis and ptosis\u00a0<\/span><\/p>\n<p>&nbsp;<\/p>\n<hr \/>\n<p>&nbsp;<\/p>\n<h1><span style=\"font-size: 14pt;\"><strong>Bell\u2019s palsy<\/strong><\/span><\/h1>\n<ul>\n<li><span style=\"font-size: 12pt;\">Bell\u2019s palsy is a peripheral nerve injury leading to paralysis of the entire half of the face.<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">In strokes, only one of the 2 UMNs are affected, so the upper face is still innervated, and the patient can raise their eyebrows (strokes spare the forehead).<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Bell\u2019s palsy is often associated with other CN VII deficits such as decreased taste, hyperacusis, and either increased or decreased tearing<\/span><\/li>\n<li><span style=\"font-size: 12pt;\">Bell\u2019s palsy can also result in <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMicm1507967#t=article\">synkinesis<\/a>, in which the damaged nerves regenerate aberrantly and supply different muscles.<\/span><\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\"><strong>Synkinesis<\/strong><\/span><\/h1>\n<p><span style=\"font-size: 12pt;\">Synkinesis describes the involuntary movement of a muscle that occurs with the voluntary movement of a different muscle. It is thought to develop primarily as a result of aberrant regeneration of nerve fibers after traumatic injury and can be a sequela of Bell\u2019s palsy.<\/span><\/p>\n<p>&nbsp;<\/p>\n<hr \/>\n<div id=\"bp-page-1\" class=\"page\" data-page-number=\"1\" data-loaded=\"true\">\n<h1 class=\"textLayer\"><span style=\"font-size: 14pt;\">Abnormal pupils<\/span><\/h1>\n<ul>\n<li class=\"textLayer\">If pupils are unequal (anisocoria), test them in dim light and with bright light and assess the pupil\u2019s response.\n<ul>\n<li>If the greatest difference between the pupils is in dim light, the smaller pupil isn\u2019t dilating normally (as in Horner\u2019s or simple anisocoria)<\/li>\n<li>If the greatest difference is in bright light, the larger pupil isn\u2019t constricting (as in Adie\u2019s or parasympathetic inhibition).<\/li>\n<li>If they respond normally but are unequal in size, this is called essential anisocoria.<\/li>\n<\/ul>\n<\/li>\n<li class=\"textLayer\">When testing the pupils, shine a light into them and look to see if they constrict, both directly (when the light is shone into the eye) and consensually (when you shine a light into one eye, the other should also constrict).<\/li>\n<li class=\"textLayer\">Check for pupil constriction when the patient looks at objects up close after shifting their gaze from far away objects (accommodation) -you can do this by moving your finger from a few feet away towards the patient\u2019s nose while observing their pupils-easier to see in dim light, where the pupils start out bigger.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li class=\"textLayer\">\n<h2><span style=\"font-size: 12pt;\">Marcus Gunn pupil (relative afferent pupil defect)<\/span><\/h2>\n<ul>\n<li class=\"textLayer\">This is the most common pupil defect, characterized by asymmetric pupillary constriction to light, but these pupils are equal (no anisocoria).<\/li>\n<li class=\"textLayer\">Main etiology is optic neuritis, but other diseases of the optic nerve or retina may cause it.\n<ul>\n<li class=\"textLayer\">The swinging flashlight test is performed by shining a light for 1-2 seconds in one eye and then moving the light to the other. Have the patient look at a distant object to not cause confounding pupil constriction due to accommodation<\/li>\n<li class=\"textLayer\">Normally, the direct and consensual responses are equal but in diseases of the optic nerve or retina, the direct response is less than normal, so that when the light passes from the \u201cgood\u201d eye, rather than constriction one will see a slight, paradoxical dilation of the pupil, as the perceived light is dimmer than in the good eye, and the consensual response will also be decreased symmetrically<\/li>\n<li class=\"textLayer\">The consensual response in the affected eye, however, is intact, so when light is shone in the good eye, even the bad eye constricts normally (since the consensual response is independent of the optic nerve and retina from the bad eye)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div>\n<p>&nbsp;<\/p>\n<div id=\"bp-page-1\" class=\"page\" data-page-number=\"1\" data-loaded=\"true\">\n<ul>\n<li>\n<h2><span style=\"font-size: 12pt;\">Anisocoria<\/span><\/h2>\n<ul>\n<li>\n<h3><span style=\"font-size: 12pt;\">Adie\u2019s (tonic) pupil<\/span><\/h3>\n<ul>\n<li>This is due to denervation of parasympathetics from the ciliary ganglion, impairing pupillary constriction to light, but with preserved accommodation (so called light: near dissociation, also seen in the Argyll-Robertson pupil)<\/li>\n<li>There is either no constriction to light or delayed constriction, followed by delayed dilation once the light is removed from the eye<\/li>\n<li>Classically seen in women in their 30s\/40s, may be associated with absent lower extremity reflexes (Holmes-Adie syndrome)<\/li>\n<li>Will constrict with unusual sensitivity to low dosepilocarpine (non-selective muscarinic agonist), which would have a minimal effect on the normal pupil, but in Adie\u2019s has marked response due to denervation hypersensitivity<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>\n<h3><span style=\"font-size: 12pt;\">Argyll Robertson pupil<\/span><\/h3>\n<ul>\n<li>Classically due to tertiary syphilis, causing damage to nerve fibers in the midbrain, resulting in bilateral small, irregularly shaped pupils that like Adie\u2019s pupil, have light: near dissociation; they accommodate but don\u2019t react (to light)<\/li>\n<\/ul>\n<\/li>\n<li>\n<h3><span style=\"font-size: 12pt;\">Horner\u2019s syndrome<\/span><\/h3>\n<ul>\n<li>This triad of unilateral ptosis, miosis, anhydrosis (eyelid droop, small pupil and lack of sweating) is caused by compression of the sympathetics along their pathway from the hypothalamus down to the second order neuron that passes over the apex of the lung and then up to the third order neuron via the sympathetic chain to the third order neuron that passes in the internal carotid where the long ciliary nerve goes to the orbit to innervate the pupillary dilator muscle.<\/li>\n<li>The miosis in Horner\u2019s is due to loss of sympathetics to the pupillary dilator muscle, and unlike CN III lesions and Adie\u2019s pupil the miosis is more apparent in the dark than the light.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<\/div>\n<div id=\"bp-page-2\" class=\"page\" data-page-number=\"2\" data-loaded=\"true\">\n<div class=\"ba-Layer ba-Layer--region\" data-testid=\"ba-Layer--region\">\n<h1 class=\"ba-RegionAnnotations-list\"><span style=\"font-size: 14pt;\">Progressive supranuclear palsy<\/span><\/h1>\n<\/div>\n<\/div>\n<div id=\"bp-page-3\" class=\"page\" data-page-number=\"3\" data-loaded=\"true\">\n<ul>\n<li class=\"textLayer\">Characterized by impaired vertical eye movements, usually with impaired downgaze then up gaze and eventually leading to global gaze paresis<\/li>\n<li class=\"textLayer\">Preserved involuntary (VOR) movements but impaired voluntary (saccades, pursuit)<\/li>\n<li class=\"textLayer\">Parkinsonian signs are present, although the tremor is not as pronounced<\/li>\n<li class=\"textLayer\">Patients develop frontal lobe dementia, postural instability, pseudobulbar palsy, and an extensor axial rigidity, especially of the neck.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<hr \/>\n<h1><span style=\"font-size: 14pt;\">Charcot-Marie-Tooth disease<\/span><\/h1>\n<ul>\n<li>Charcot-Marie-Tooth disease is the most common inherited cause of polyneuropathy<\/li>\n<li>Pes cavus (high arched feet) and hammertoes (the proximal interphalangeal joint of the toe is bent upward) are commonly found on physical examination.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<\/div>\n<hr \/>\n<h1><span style=\"font-size: 12pt;\">Sources and further reading:<\/span><\/h1>\n<ul>\n<li><span style=\"font-size: 12pt;\">Ropper AH, Samuels MA, Klein JP, eds. Adam and Victor\u2019s Principles of Neurology. 10th ed. China: McGraw-Hill Education; 2014.<\/span><\/li>\n<\/ul>\n[\/vc_column_text][\/vc_column][\/vc_row]\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row css=&#8221;.vc_custom_1592155698727{background-color: #fff9f9 !important;}&#8221;][vc_column][vc_column_text] Full Neurology Exam Mental status Cranial nerves Motor examination Gait and coordination Sensory examination &nbsp; Mental status Level of consciousness, orientation, memory, and attention There are a number of standardized tests of mental status that are used primarily in the detection and assessment of dementia such<\/p>\n","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"closed","template":"","meta":{"nf_dc_page":"","_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-2042","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/2042","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/comments?post=2042"}],"version-history":[{"count":3,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/2042\/revisions"}],"predecessor-version":[{"id":9996,"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/pages\/2042\/revisions\/9996"}],"wp:attachment":[{"href":"https:\/\/up.physicaldiagnosispdx.com\/up\/wp-json\/wp\/v2\/media?parent=2042"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}