Neurology Short Cases Flashcards
Test for orientation, Calculation, short-term and long-term memory
Orientation: tell time, place, person
Calculation: serial 7s from 100 or serial 3s from 20
Short-term: Repeat 3 objects then test after 5 mins
Long-term: Recall home address, telephone number
Test for comprehension, expression and repetition of language
Comprehension: Follow simple commands
Expression: Name objects
Repetition: Repeat a given phrase
Outline of GCS
Score for good or poor prognosis
>11 = good prognosis <4 = poor prognosis
1) Eye opening: spontaneous, to speech, to pain, none
2) Verbal response: Orientated, confused, words, sounds/ grunts, none
3) Motor response to “stick out tongue”: obey command, localize to pain in supraorbital area and hand move up to chin, localize to pain in supraorbital area and elbow flex, Decorticate position, Decerebrate position, none
Test for sensory inattention
Test for visual inattention
Sensory: Touch patient on each upper limb with patient’s eyes closed
Tell which part is touched
Visual: first do visual field test (normal), then ask patient to point to finger which moves on either side of visual field
Test for bradykinesia?
10 second test: flex and extend fingers as quickly as possible, or finger opposition
Wrist rotation as fast as possible
Stomping foot
Interpret:
- Slurred speech
- Deconjugate eye movement
- Cannot balance, cannot tandem-walk
- Power normal in UL and LL
- Fails to do hand clap test
- Fails to accurately place finger in finger-nose test
Causes?
Cerebellar syndrome
- Dysarthria
- Nystagmus
- Intention tremor with past-pointing and dysdiadochokinesia
- Wide-based, ataxic gait (MUST EXCLUDE MUSCLE WEAKNESS FIRST)
Causes:
1) Cerebellar degeneration: idiopathic, paraneoplastic, familial
2) Toxins and drugs: alcohol, anti-convulsant
3) Cerebellar infarct, hemorrhage, tumor
Investigations for cerebellar syndrome
CT/ MRI brain
Serum: paraneoplastic anti-neuronal autoantibodies
CSF: infection and inflammation
Interpret:
Dysphagia +/- hoarseness of voice
Partial ptosis and loss of sweating on left face
Nystagmus towards the left side
Loss of pain and temperature sensation below the face on right
Loss of some facial sensation
Ddx?
Causes?
Lateral medullary syndrome
Ddx:
Acute vestibular neuronitis
Benign positional vertigo
focal neurological signs are absent except nystagmus
Causes:
Brainstem infarct from local thrombotic occlusion (Vertebral artery 85%, PICA 15%), arterial thromboembolism (vertebral artery dissection), cardioembolism
Brainstem hemorrhage
Acute brainstem demyelination: MS
Leukoencephalopathy (drugs, hypertension, autoimmune disease)
Interpret:
Impaired visual acuity , afferent pupillary defect with poor direct and consensual pupillary light response
Impaired adduction in one eye with nystagmus in the contralateral eye (nystagmus + deconjugate gaze)
Unsteady and stiff gait, Increased ankle and knee reflexes + bilateral Babinski reflex, weak LL
Some dysarthria intention tremor and post-pointing
Dx?
DDx?
Multiple sclerosis: demyelinating disease of CNS, relapsing-remitting symptoms
Optic neuritis
Internuclear opthalmoplegia
Spastic paraparesis
Cerebellar signs
Ddx:
- Neuromyelitis optica
CNS manifestation of rheumatological disease
Interpret:
Lack of facial expressions, some drooping saliva, infrequent blinking
Forward flexion of trunk on standing
Soft and monotonous voice
Stiff, shuffling gait with little arm swing
Resting tremor asymmetrical
Slow movement
Dx?
Ddx?
Other motor signs?
Parkinson’s disease: degeneration of dopaminergic nigrostriatal neurons (neuromelanin), decrease dopamine activity
Ddx:
- Progressive supranuclear palsy: no resting tremor
- Lewy body dementia: hallucination and psychosis in early stage, dementia later
- Multisystem atrophy: Bilateral cord palsy causing stridor + pyramidal or cerebellar signs
- Wilson’s disease: young, Kayer- Fleischer ring, limb contractures, psychosis, jaundice
- Cerebral small vessel diseases - Parkinsonism features
- Benign essential tremor: Postural tremor symmetrical
Bradykinesia
Power, sensation and deep tendon reflexes preserved
Interpret:
Symmetrical proximal limb and neck weakness
Muscle tenderness
Normal sensation, no atrophy
+/- Purple heliotropic rash in butterfly distribution over cheeks and eyelids, blanches with pressure
Dx?
Ddx?
Cause?
Polymyositis
Dermatomyositis (with purple heliotropic rash)
Ddx:
- Polymyalgia rhuematica: temporal arteritis
- Limb girdle muscular dystrophy
- Myasthenia gravis: fatigable, involves eyes
- SLE: rash, myositis, photosensitive butterfly rash on face
Cause:
Underlying malignancies: ovarian, pancreatic, breast, nasopharyngeal… etc
Interpret:
- Cannot name objects
- Cannot repeat sentences
- Can understand fully
- Non-fluent speech an cannot find right words
Expressive dysphasia
Broca area in inferolateral frontal lobe
Interpret:
- Cannot understand
- Fluent speech, fast but words do not make sense
Dx?
Formal term to describe the pattern of speech?
Receptive dysphasia
Wernicke’s area in temporal lobe
Paraphasia: forming sentences that don’t make sense
Neologism: forming new words
Causes of dysphasia?
Ischemic stroke*
Hemorrhagic stroke
Dementia: Alzheimer’s, frontotemporal dementia
Encephalitis: HSV
Tumor in relevant area
How to accurately test for receptive dysphasia
Test with 2-3 stages of command
Partial receptive dysphasia might be able to obey one stage command
Interpret: (not likely tested)
- Clawing of fingers
- Ulcers and scars on hands
- Wasting of small hand muscles and ulnar area of forearms
- Some dermatomal loss of pain and temperature sensation of upper limbs
+/- Horner’s syndrome, kyphoscoliosis, short neck
Dx?
Causes?
Other signs if the brain stem is involved?
Syringomyelia (syringobulbia)
Foramen magnum lesion causing expansion of central spinal canal
Spina bifida, tumor, trauma
+/- Diplopia and nystagmus (medial longitudinal bundle)
+/- Facial numbness (trigeminal sensor nuclei)
+/- weakness of SCM and trapezius (XI)
+/- soft palatal paralysis, dysarthria, tongue muscle wasting and fasciculation (XII nuclei)
Describe the lesion that causes syringomyelia
Fluid-filled expanded syrinx arising from central spinal cord in the cervical and thoracic regions
Affects decussating fibers of spinothalamic tract + anterior horn of spinal segments + sympathetic fibers at C8/T1 +/- Corticospinal tract
Interpret:
Flexed right elbow, no movement
Spasticity of right upper arm and weakness
Brisk biceps, supinator and triceps reflexes of right upper limb
Drooling of saliva
Hemiplegic
No cortical signs
Cerebral infarction or subcortical hemorrhage - stroke
Causes of partial ptosis (3)
How to differentiate?
Horner’s syndrome: Partial* ptosis, miotic reactive pupil*, anhidrosis, enophthalmos
Myasthenia gravis: Partial ptosis that worsens with gaze, time of day + opthalmoplegia
Partial CNIII palsy: complete ptosis with opthalmoplegia and dilated unreactive pupil
Size and response of pupils
Interpret:
Complete ptosis of right eye with right dilated pupil in depressed and abducted position
Right efferent pupillary reflex defect
Bilateral afferent responses spared
Dysconjugate eye movement: right eye cannot look up and adduct
Complete CNIII palsy
Interpret:
Symmetrical spasticity and weakness of bilateral LL
Brisk knee and ankle reflexes, symmetrical
Clonus in right ankle
Bilateral Babinski reflex
Reduced sensation in all modalities in both lower limbs
Spastic paresis caused by thoracic cord lesion (most likely), e.g. vertebral collapse caused by bony metastasis
Interpret:
Facial numbness and drooling on right side
Recent URTI
Loss of nasolabial fold on right face
Right upper and lower facial muscle weakness
Cannot close right eyelid
Increase lacrimation from right eye
No loss of sensory sensation
Other signs and symptoms?
Right lower motor neuron facial palsy/ right facial nerve palsy/ Bell’s palsy
Loss of taste in anterior 2/3 of tongue and hyperacusis
Examine external auditory meatus and eardrum: exclude otitis media and Ramsay-Hunt syndrome
Difference in epileptic seizure and epilepsy?
Epileptic seizure = Brief and unprovoked stereotyped disturbance of behavior, emotion, motor function or sensation due to cortical neuronal discharge
Epilepsy: recurrent unprovoked seizures
Interpret:
Increased fatigue in general Increase fatigue in all four limbs Double vision, both pupils reactive to light, impaired abduction of right eye increased fatigue later in the day Decreased exercise tolerance from limb weakness No dysarthria or dysphagia Coherent speech 4/5 muscle power All reflexes normal No cerebellar signs
Dx?
Test?
MG
Tensilon test: IV edophonium ejection
Acetylcholine receptor antibody test
Nerve stimulation test
Describe the gait pattern in cerebral stroke, cerebellar stroke and parkinsons
hemiplegic gait (stroke),
wide-based ataxic gait (cerebellar),
shuffling, festinating gait with stooped posture and lack of arm swing (Parkinsonism)
Signs of meningeal irritation/ meningitis
→ Brudzinski’s sign: passive neck flexion → hip flexion
→ Kernig’s sign: knee extension with flexed hip → hamstring spasms
Distinguish between dysphasia, dysarthria and dysphonia
□ Dysphasia: disorder in use of language (content)
→ Site: higher centres, hemispheric
□ Dysarthria: difficulty with articulation
→ Site: motor apparatus for articulation and related nerves
□ Dysphonia: altered quality of voice with ↓volume
→ Site: vocal cords and related nerves
Causes of dysarthria
→ Pseudobulbar palsy: spastic dysarthria
→ Facial weakness: slurred speech
→ Extrapyramidal disease: monotonous speech (due to bradykinesia and rigidity)
→ Alcohol intoxication, cerebellar diseases: loss of coordination, slow/slurred speech
Dominant Parietal lobe signs
Dominant parietal lobe signs:
→ Acalculia: ask to calculate, eg. serial 7s
→ Agraphia: ask to write
→ Left-right disorientation: ask to show left or right hand
→ Finger agnosia: ask to name each fingers
→ Dysphasias
Non-dominant parietal lobe signs
Non-dominant parietal lobe signs:
→ Sensory and visual inattention/extinction:
- Normal bilateral sensory fields
- Stimuli from one side disappear when two sides are tested together
- Usually tested together with PNS sensory examination
→ Spatial neglect: ask to fill in numbers on an empty clock face
→ Construction apraxia: ask to copy an object you drew
→ Dressing apraxia: ask to put shirt (that has been turned inside out) back on
Visual field defect in parietal lobe lesion
→ Homonymous lower quadrantanopia
Test for CNI
Causes of loss of smell
Test smell
□ Place aromatic non-irritant materials close to nose, eg. alcohol swipes
Nasal cavity:
→ URTI (most common)
→ Smoking
Olfactory receptors:
→ Aging
Olfactory bulb and fibres: → Ethmoid tumours → Basal skull fracture or frontal fracture → Pituitary surgery → Meningioma of olfactory groove → Meningitis
Subsequent tests for visual acuity defects e.g. patient cannot even read first 2 lines
□ Can pt count fingers?
□ If no, can pt detect movement?
□ If no, can pt respond to light?
Correction for refractive error
Refractive error should be corrected by pinhole
Causes of Acute unilateral vision loss
Focal vascular
- Retinal a. or v. occlusion
- Temporal arteritis (prominent artery, tender on palpation
- Non-arteritic ischaemic optic neuropathy
Other focal
- Optic neuritis
Causes of acute bilateral vision loss
Diffuse vascular
- Bilateral occipital lobe infarct
Diffuse traumatic
- Bilateral occipital trauma
- Bilateral optic nerve damage (eg. methyl alcohol poisoning)
Other diffuse
- Somatic conversion disorder
Causes of gradual bilateral vision loss
Diffuse eye degenerative
- Cataract
- Glaucoma
- Macular degeneration
- Diabetic neuropathy
Other diffuse chronic
- Bilateral optic nerve or chiasmal compression
- Bilateral CN II damage (eg. tobacco amblyopia)
Causes of bitemporal hemianopia
Lesion at Optic chiasm
- Pituitary tumour
- Craniopharyngioma
- Suprasellar meningioma
Causes of homonymous hemianopia
No macular sparing = Post-chiasmic lesion
- Vascular lesions
- Tumour
With macular sparing = Occipital vascular lesion
- Non-destructive ischaemia at occipital lobe
Causes of Homonymous quandrant-anopia
Superior quadrant = Temporal Vascular lesions or Tumour
Inferior quadrant = Parietal Vascular lesions or Tumours
Causes of ptosis and ectropion
Ptosis: dropping of upper eyelid
- LPS with CN3 and SN component
- CN3 palsy (complete) vs Horner syndrome (partial)
Ectropion: drooping of lower eyelid
- Often with eye irritation and watering due to defective drainage
- D/dx: degenerative, CN7 palsy
Which CN are tested in pupillary light reflex?
How to distinguish which nerve has defect?
CN2 afferent + CN3 efferent
□ Test direct vs consensual response
□ CN3 palsy: pupil dilates and fixed regardless of light
Swinging flashlight test for relative afferent pupillary defect (RAPD)
→ Paradoxical dilation of affected pupil
→ Shows defect of afferent pathway
→ D/dx: CN2 palsy, unilateral ↓VA
How to test for visual accommodation
□ Ask pt to look into distance then to a close object (~30cm)
□ Normal: constriction of both pupils
Causes of Miosis
- Horner’s syndrome – with partial ptosis, disturbance of sweating
- Argyll Robertson pupil – small irregular pupils with light-near dissociation
- Drugs – opioids, parasympathomimetics…
Causes of mydriasis
Mydriasis (dilated pupil)
- CN III palsy – with ptosis and ophthalmoplegia
- Adie’s tonic pupil – with light-near dissociation
- Ocular causes – eg. iris trauma
- Parinaud’s syndrome – dorsal midbrain lesion
Mid-dilated pupils with upgaze palsy
Light-near dissociation - Migraine
- Drugs – anticholinergic, TCAs, NSAIDs,
antihistamines, OCs
Types and Causes of nystagmus
Nysgtamus can be
□ Pendular: equal velocity + amplitude in all directions
□ Jerk: fast phase (specifying direction) + slow phase
□ Jerky horizontal nystagmus: vestibular, cerebellar or central (INO)
□ Jerky vertical nystagmus: cerebellar or central
□ Pendular nystagmus: retinal, congenital
Causes of CNIII palsy
Midbrain lesion: infarction, demyelination, tumour, basilar aneurysm compression**
Cavernous sinus lesion: with CN IV, V1, VI palsies
- Tumour
- Intracavernous aneurysm
- Cavernous sinus thrombosis
Orbital fissure/orbit lesion: proptosis, CN IV, V1, VI palsies
- Orbital tumour
- Periosteitis
Interpeduncular cistern lesion
Describe CNIII palsy signs
- Binocular diplopia, worse on contralateral gaze
- 1o position: abducted + mildly depressed
- Impaired elevation, depression, adduction
- Ptosis
- Mydriatic pupils with impaired/absent pupillary
light reflex
Describe CNIV signs (SO)
- Binocular diplopia, worse on down, contralateral gaze and ipsilateral head tilt
- 1o position: slightly elevated and extorted
- Impaired depression upon adduction
- Head may tilt to opposite side to minimize diplopia
Describe CNVI signs (LR)
- Binocular diplopia, worse on ipsilateral gaze
- 1o position: adducted
- Impaired abduction
- Often a/w ipsilateral face-turn
How to locate lesion by pattern of sensory/motor loss in CNV
Dissociated sensory loss due to separate
locations of trigeminal nuclei:
- Motor at pons
- Light touch at pons
- Proprioceptive at midbrain
- Temperature/pain at medulla to C2
Test for CNV reflexes
Corneal reflex: tests CN V1 (afferent) + VII (efferent)
Jaw jerk: Normal: slight/no closure of mouth □ Bilateral UMN V3 lesion: ↑jerk → Reason: hyperreflexia in masseter → Occurs in pseudobulbar palsy
3 trigeminal sensory divisions
Opthalmic
Maxillary
Mandibular
Test for 5 branches of CNVII motor division
□ Temporal (frontalis) → ask pt to look up, following your finger (fix pt’s head when you do it)
□ Zygomatic (orbicularis oculi) → ask pt to close eyes and attempt to open them
□ Buccal (buccinator) → ask pt to blow up the cheeks and try to press on them to feel the tone
□ Marginal mandibular (levator anguli oris) → ask pt to show teeth
□ Cervical (platysma) → ask pt to depress mandible against pressure and feel for platysma tone
Signs of CNVII palsy
Facial weakness
□ Facial asymmetry
□ Failure to close eyes (orbicularis oculi)
□ Unilateral drooping of corner of mouth (orbicularis oris)
□ Smoothing of facial wrinkles, eg. wrinkled forehead, nasolabial folds
□ Stapedius → ask for hyperacusis
□ Taste of anterior 2/3 of tongue → ask for loss of taste
□ Secretion of lacrimal and oronasal glands → ask for dry eyes and dry mouth
UMN and LMN supply of CN VII motor branches
□ UMN supply
→ Contralateral to temporal and zygomatic
→ Bilateral to buccal, marginal mandibular and cervical
□ LMN supply → always ipsilateral
Signs of CNVIII palsy (3)
□ Acute vertigo
□ Hearing loss
□ Tinnitus
Test for CNVIII
Hearing:
□ Cover opposite ear with finger
□ Rub fingers near ear and ask for response
□ Suspect partial deafness → Rinne’s and Weber’s tests
Rinne’s test:
□ 256Hz vibrating tuning fork on mastoid process
□ No longer hear sound → placed in line with external auditory meatus
□ Rinne-positive = air conduction > bone conduction → normal
□ Rinne-negative = air conduction < bone conduction
→ conductive deafness
Weber’s test:
□ 256Hz vibrating tuning fork on centre of forehead
□ Ask pt to locate source of sound
□ Normal → central
□ Sensorineural deafness → contralateral deviation
□ Conductive deafness → ipsilateral deviation
Causes of conductive hearing loss (not exhaustive)
Trauma: tympanic membrane rupture, ossicular disruption
Infection: Otitis media, cholesteatoma
Wax
Otosclerosis tumors
Causes of Cochlear sensorineural loss (not exhaustive)
Congenital: aplastic maternal rubella
Trauma: petrous temporal fracture
Infections: Mumps, measles, meningitis
Drugs: Streptomycin
Causes of vertigo (not exhaustive)
Trauma
Suppurative labyrinthitis
BPV
Meniere’s disease
Vestibular neurontiis
Features of CN IX palsy
- Sensory loss in oropharynx
- Loss of gag reflex
- Dysphagia
Features of CNX palsy
- Palatal weakness:
Unilateral – minimal
Bilateral – nasal regurgitation of fluid, hypernasality - Pharyngeal weakness:
Unilateral – drooping wall on affected side
Bilateral – marked dysphagia - Laryngeal weakness:
SLN – unable to sing high pitch
Unilateral RLN – choking, hoarseness
Bilateral RLN – airway obstruction
Test for CNIX and CNX palsy
Inspection:
□ Ask pt to open mouth and say ‘ah’
□ Use tongue depressor to depress tongue
□ Normal: soft palate rise symmetrically with no uvula deviation
□ CN X palsy: uvula deviated to normal side (unopposed musculus uvulae)
Gag reflex: tests CN IX (afferent) and CN X (efferent)
□ Touch palate/pharynx/tonsil on one side until ‘gagging’
□ Compare sensitivity on each side
□ Normal: bilateral palatal contraction
□ Absent: CN IX or CN X palsy
Other signs:
□ Hoarseness: ask pt to speak then to cough
→ Characteristics ‘bovine cough’ in RLN lesions
□ Dysphagia: ask pt to swallow water
Test for CNXI
Trapezius: □ Ask pt to shrug shoulder □ Feel bulk of trapezius muscles □ Attempt to push shoulders down □ CN XI palsy → weakness
Sternocleidomastoid:
□ Ask pt to turn head to the side against resistance
□ Feel bulk of sternocleidomastoid
□ CN XI palsy → wasting
Test for CNXII
□ Difficulty in swallowing
□ Sensation of choking if tongue slips back into throat
Inspection:
□ Ask pt to open mouth and inspect the tongue
→ Atrophy (↑folds, wasting) = LMN lesion
→ Fasciculation (small wriggling movements) = LMN lesion (normal if happens in protrusion)
□ Ask pt to protrude tongue
→ Deviation → ipsilateral LMN lesion
Features of UMN and LMN lesions in CNXII
□ UMN lesion:
→ Unilateral → no S/S
→ Bilateral → small, immobile (spastic) tongue
□ LMN lesion:
→ Unilateral → fasciculation, wasting and weakness
→ Bilateral → dysarthria
Signs of LMN lesion in upper or lower limbs
Hypotonia
Fasciculation
Hyporeflexia
How to distinguish UMN lesion from cerebellar lesion using extended arms
Ask pt to hold hands out with palms facing up and close eyes
□ UMN lesion → pronator drift (sensitive sign)
(arm gradually pronates and drifts downward)
□ Cerebellar lesion → slow upward + pronation drift
□ Proprioceptive defect → finger random movement
Signs of extrapyramidal lesions e.g. Parkinson’s
→ ‘Lead-pipe’ rigidity: steady ↑resistance throughout movement
→ ‘Cog-wheel’ rigidity: ‘lead-pipe’ + tremor
MRC muscle power grading?
0 – no movement
1 – flicker of contraction w/o movement
2 – movement possible but not against gravity (i.e. horizontal movement)
3 – movement against gravity
4- – slight movement against resistance
4 – moderate movement against resistance
4+ – submaximal movement against resistance
5 – normal power
All upper limb motor tests and corresponding spinal levels
Shoulder abduction
(C5-6)
Shoulder adduction
(C6-8)
Elbow flexion
(C5-6)
Elbow extension
(C7-8)
Wrist flexion
(C6-7)
Wrist extension
(C7-8)
Finger flexion
(C7-8)
Finger extension
(C7-8)
Finger abduction
(C8-T1)
Finger adduction
(C8-T1)
Thumb opposition
(C8-T1)
Thumb abduction
(C7-8)
Spinal levels for all upper and lower limb reflexes
- Ankle jerk – S1-2
- Knee jerk – L3-4
- Biceps/supinator jerk – C5-6
- Triceps jerk – C7(-8)
- Hoffman reflex – C(7-)8
Bicep jerk level, nerve
Bicep jerk (C5-6): □ Nerve: musculocutaneous n., biceps tendon
Supinator jerk level, nerve, location
Normal vs abnormal jerk?
Supinator jerk (C5-6): □ Nerve: radial nerve, Place finger ~10cm from base of thumb
□ Look for: elbow flexion
□ Finger flexion + elbow extension = inverted supinator jerk
→ Characteristic of spinal cord lesion at C5-6
→ C5-6 LMN lesion → no supinator and bicep jerks
Triceps jerk level, nerve
Triceps jerk (C7-8, C7 major): □ Nerve: radial nerve, few inches above olecranon at triceps tendon
Test for upper limb spinothalamic and DCML pathways
Spinothalamic: pinprick for pain sensation with orange stick
DCML: Vibration with 128Hz tuning fork at DIP, wrist, olecranon, shoulder
Proprioception by moving thumb with pt eyes closed
4 patterns of sensory loss
□ Dermatome → spinal cord or nerve root
□ Single peripheral nerve territory → peripheral nerve
□ Glove-and-stocking distribution → peripheral neuropathy
□ Hemisensory loss → unilateral spinal cord, upper brainstem, thalamus, cerebral
Features of upper limb miscoordination
Finger-nose test: Cerebellar signs may present as
→ Dysmetria (past-pointing): over-shooting or under-shooting
→ Intention tremor: increasing tremor when target is approached
Rapidly alternating movements: dysdiadochokinesia
Rebound: Excessive swinging and failure to return into original position
Test for lower limb tone
Lift the leg suddenly with both hands in popliteal fossa: ↑tone → leg kicks upward with heel leaving the bed
Ankle clonus: Hyperreflexia = persistent oscillatory movement
All tests for lower limb power
Hip flexion (L1-2) Hip extension (L5-S1)
Hip adduction (L2-3) Hip abduction (L4-5)
Knee extension (L3-4) Knee flexion (L5-S1)
Dorsiflexion (L4-5) Plantar flexion (S1-2)
Toe extension (L5) Ankle eversion (L5-S1) Ankle inversion (L5-S1)
Locations for LL dermatomes
L1: Mid-inguinal point L2: Mid thigh L3: Medial epicondyle L4: Medial malleolus L5: 3rd MTP S1: Heel S2: popliteal fossa S3: buttock
Tests for LL coordination
Heel-shin test: Cerebellar disorder = clumsiness
Rhomberg test:
- Check balance with eyes open: Cerebellar ataxia = poor balance or excessive swaying (‘negative’ Rhomberg test)
- Check balance again with eyes closed: Sensory ataxia (poor proprioception) = poor balance or excessive swaying
(‘positive’ Rhomberg test)
Gait: tandem (heel-to-toe) walking, gait ataxia (cerebellar sign)
