Chapter 11: Abdomen
Visceral pain in the right upper quadrant may result from liver distenstion against its capsule in alcoholic hepatitis
Visceral periumbilical pain may signify early acute appendicitis from distention of an inflamed appendix.
It gradually changes to parietal pain in the right lower quadrant from inflammation of the adjacent parietal peritoneum
Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree, to the right shoulder or the right posterior chest
Pain from pleurisy or acute myocardial infarction may be referred to the epigastric area
Studies suggest that neuropeptides like 5hydroxtryptophan and substance P mediate interconnected symptoms of pain, bowel dysfunction, and stress
In emergency rooms 40 % to 45% of patients have nonspecific pain, but 15% to 30 % need surgery, usually for appendicitis, intestinal obstruction, or cholecystits
Doubling over with cramping colicky pain indicates renal stone. Sudden knifelike epigastric pain occurs in gallstone pancreatitis
Epigastric pain occurs with gastritis or GERD. Right upper quadrant and upper abdominal pain signify cholecystitis
Note that angina from inferior wall coronary artery disease may present as “indigestion,” but is precipitated by exertion and relieved by rest.
Bloating may occur with inflammatory bowel disease, belching from aerophagia, or swallowing air
Multifactorial causes include delayed gastric emptying (20%-40%), gastritis from H. pylori (20%-
60%), peptic ulcer disease (up to 15% if H, plyori is present), and psychosocial factors
These symptoms or muscosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include reduced salivary flow, which prolongs acid clearance by damping action of bicarbonate buffer; delayed gastric emptying; selected medications; and hiatal hernia
Note that angina from inferior wall coronary ischemia along the diaphragm may present as heartburn
Patients with uncomplicated GERD who do not respond to empiric therapy, patients older than 55 years, and those with “alarm symptoms” warrant endoscopy to detect esophagitis, peptic strictures, or
Barrett’s esophagus (in this condition the squamocolumnar junction is displaced proximally and replaced by intestinal metaplasia, increasing the risk of esophageal cancer 30-fold) Approximately
50% of patients with GERD will have no disease on endoscopy
Right lower quadrant pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, is most likely to predict appendicitis. In women other causes include pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy
Cramping pain radiating to the right or left lower quadrant may be a renal stone
Left lower quadrant pain with a palpable mass may be diverticulitis. Diffuse abdominal pain with absent bowel sounds and firmness, guarding, or rebound on palpation indicates small or large bowel obstructions
Change in bowel habits with mass lesion indicates colon cancer. Intermittent pain for 12 weeks of the preceding 12 months with relief from defection, changed in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), without structural or biochemical abnormalities are symptoms of irritable bowel syndrome
Anorexia, nausea, and vomiting accompany many gastrointestinal disorders; these are all seen in pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, adverse drug reactions, and other conditions. Induced vomiting without nausea is more indicative of anorexia/bulimia
Regurgitation occurs in GERD, esophageal stricture, and esophageal cancer
Vomiting and pain indicate small bowel obstruction.
Fecal odor occurs with small bowel obstruction or gastrocolic fistula
Hematemesis may accompany esophageal or gastric varices, gastritis, or peptic ulcer disease
Symptoms of blood loss such as lightheadedness or syncope depend on the rate and volume of bleeding and are rare until blood loss exceeds 500ml
Pt complainant of unpleasant abdominal fullness after light or moderate meals, or early satiety, the inability to eat a full meal. Consider diabetic gastroparesis, anticholiergic medications, gastric outlet obstruction, gastric cancer; early satiety in hepatitis
Indicators of oropharyngeal dysphagia include drooling, nasopharyngeal regurgitation, and cough from aspiration in muscular or neurologic disorders affecting motility; gurgling or regurgitation of undigested food occur in structural conditions like
Zenker’s diverticulum

Pointing to below the sternoclavicular notch indicates esophageal dysphagia
If symptoms provoked by solid foods, consider structural esophageal conditions like esophageal stricture, web or Schatzki’s ring, neoplasm
If solids and liquids, a motility disorder is more likely
Odynophagia or pain on swallowing- consider esophageal ulceration from ration, caustic ingestion, or infection from Candida, cytomegalovirus, herpes simplex, or HIV. Can be pill-induced (aspirin, or non-steroidal anti-inflammatory agents)
Complaining of passing gas consider aerophagia, legumes or other gas-producing foods, intestinal lactase deficiency, irritable bowel syndrome
Acute diarrhea is usually caused by infection; chronic diarrhea is typically noninfectious in origin, as in
Crohn’s disease and ulcerative colitis
High-volume, frequent watery stools usually are from the small intestine
Small-volume stools with tenesmus, or diarrhea with mucus, pus or blood occur in rectal inflammatory conditions
Nocturnal diarrhea usually has pathologic significance
Oil residue, sometimes frothy or floating, occurs with steatorrhea, or fatty diarrheal stools, from malabsorption in celiac sprue, pancreatic insufficiency and small bowel bacterial overgrowth
Diarrhea is common with use of penicillins and macrolides, magnesium-based antacids, metformin, and herbal and alternative medicines
Thin, pencil-like stool occurs in an obstructing
“apple-core” lesion of the sigmoid colon
Consider medications such as anticholinergics agents, calcium-channel blockers, iron supplements, and opiates. Constipations also occurs with diabetes, hypothyroidism, hypercalcemia, multiple sclerosis,
Parkinson’s disease, and systemic sclerosis
Obstipation, no passage of either feces or gas, signifies intestinal obstruction
Melena may appear with as little as 100ml of upper gastro intestinal bleeding, hematochezia if more than
1000 ml of blood, usually from lower gastrointestinal bleeding
Blood on the surface or toilet paper may occur with hemorrhoids
Predominantly unconjugated bilirubin occurs from the first three mechanisms, as in hemolytic anemia
(increased production) and Gilbert’s syndrome
Impaired excretion of conjugated bilirubin occurs with viral hepatitis, cirrhosis, primary biliary cirrhosis, and drug-induced cholestasis, as from oral contraceptives, methyl testosterone, and chlorpromazine
Intrahepatic jaundice can be hepatocellular-
Gallstones or pancreatic carcinoma may obstruct the common bile duct
Dark urine from bilirubin indicates impaired excretion of bilirubin into the gastro intestinal tract
Acholic stools may occur briefly in viral hepatitis; they are common in obstructive jaundice
Itching indicates cholestatic or obstructive jaundice; pain may signify a distended liver capsule, biliary cholic, or pancreatic cancer.
Involuntary voiding or lack of awareness suggests cognitive or neurosensory deficits
Stress incontinence arises from decreased intraurethral pressure obstruction from benign prostatic hyperplasia; also seen with urethral stricture
Pain of sudden overdistention accompanies acute urinary retention
Painful urination accompanies cystitis or urethritis
If dysuria, conside bladder stones, foreign bodes, tumors; also acute prostatitis.
In women, internal burning occurs in urethritis, and external burnding in vulvovaginitis
Urgency suggests bladder infection or irritation
In men, painful urination without frequency or urgency suggests urethritis
Abnormally high renal production of urine suggests polyuria. Frequency without polyuria during the day or night suggests bladder disorder or impairment to flow at or below the bladder neck
Stress incontinence with increased intra-abdominal pressure suggests decreased contractility of urethral sphincter or poor support or bladder neck
Urge incontinence, if unable to hold the urine, suggests detrusor overactivity
Overflow incontinence, when the bladder cannot be emptied until bladder pressure exceeds urethral pressure, indicates anatomical obstruction by prostatic neurogenic abnormalities
Functional incontinence may arise from impaired cognition, musculoskeletal problems, or immobility
Kidney pain, fever, and chills occur in acute pyelonephritis
Renal or ureteral colic is caused by sudden obstruction of a ureters, for example, from urinary stones or blood clots
Other classic findings include spider angiomas, palmar erythema, and peripheral
An arched back thrusts the abdomen forward and tightens the abdominal muscles
Pink-purple striae of Cushing’s syndrome
Dilated veins of hepatic cirrhosis or inferior vena cava obstruction

Bulging flanks of ascites; supra-pubic bulge of a distended bladder or pregnant uterus; hernias
Asymmetry from an enlarged organ or mass
Lower abdominal mass of an ovarian or a uterine tumor
Increased peristaltic waves of intestinal obstruction
Increased pulsation of an aortic aneurysm or of increased pulse pressure
Bruits suggest vascular occlusive disease
Bowel sounds may be altered in diarrhea, intestinal obstruction, paralytic ileus, and peritonitis
A bruit in one of these areas that has both systolic and diastolic components strongly suggests renal artery stenosis as the cause of hypertension
Bruits with both systolic and diastolic components suggest the turbulent blood flow of partial arterial occlusion or arterial insufficiency
Friction rubs in liver tumor, gonococcal infection around the liver, splenic infarction
A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction
Pregnant uterus, ovarian tumor, distended bladder, large liver or spleen
Dullness in both flanks prompts further assessment for ascites
In situs inversus (rare), organs are reversed: air bubble on the right, liver dullness on the left
Involuntary rigidity (muscular spasm) typically persists despite these maneuvers. It indicates peritoneal inflammation
Abdominal masses may be categorized in several ways: physiologic (pregnant uterus), inflammatory
(diverticulitis of the colon), vascular (an abdominal aortic aneurysm), neoplastic (carcinoma of the colon), or obstructive (a distended bladder or dilated loop of bowel)
Abdominalpain with coughing or light percussion suggests peritoneal inflammation
Rebound tenderness suggests peritoneal inflammation. If tenderness is felt else than where you were trying to elicit rebound, that area may be the real source of the problem
The span of liver dullness is increased when the liver is enlarged
The span of liver dullness is decreased when the liver is small, or when free air is present below the diaphragm, as from a perforated hollow viscus.
Serial observations may show a decreasing span of dullness with resolution of hepatitis or congestive heart failure or, less commonly, with progression of fulminant hepatitis.
Liver dullness may be displaced downward by the low diaphragm of chronic obstructive pulmonary disease. Span remains normal
Dullness of a right pleural effusion or consolidated lung, if adjacent to liver dullness, may falsely increase the estimate of liver state
Gas in the colon may produce tympany in the right upper quadrant, obscure liver dullness, and falsely decrease the estimate of liver size
Only about half of livers with an edge below the right costal margin are palpable, but when the edge is palpable, the likelihood of Hepatomegaly roughly doubles
Firmness or hardness of liver, bluntness or rounding of its edge, and irregularity of its contour suggest an abnormality of the liver
An obstructed, distended gallbladder may form an oval mass below the edge of the liver and merge with it. It is dull to percussion
The edge of an enlarged liver may be missed by starting palpation too high in the abdomen
Tenderness over the liver suggests inflammation, as in hepatitis, or congestion, as in heart failure
If percussion dullness is present, palpation correctly detects presence or absence of splenomegaly more than 80% of the time
Fluid or solids in the stomach or colon may also cause dullness in Traube’s space
A change in percussion note from tympany to dullness on inspiration suggests splenic enlargement.
This is a positive splenic percussion sign.
The splenic percussion sign may also be positive when spleen size is normal
An enlarged spleen may be missed if the examiner starts too high in the abdomen to feel the lower edge
Splenomegaly is eight times more likely when the spleen is palpable. Causes include portal hypertension, hematologic malignancies, HIV infection, and splenic infarct or hematoma
The spleen tip below is just palpable deep to the let costal margin
The enlarged spleen is palpable about 2 cm below the left costal margin on deep inspiration
A left flank mass may represent marked splenomegaly or an enlarged left kidney. Suspect splenomegaly if a notch is palpated on medial border, the edge extends beyond the midline, percussion is full, and your fingers can probe deep to the medial

and can probe deep to the medial and lateral borders but not between the mass and the costal margin.
Confirm findings with further evaluation
Attributes favoring an enlarged kidney over an enlarged spleen include preservation of normal tympany in the left upper quadrant and the ability to probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders
Causes of kidney enlargement include hydronephrosis, cysts, and tumors,
Bilateral enlargement suggests polycystic kidney disease
Pain with pressure or fist percussion suggests pyelonephritis but may also have musculoskeletal cause
Bladder distension from outlet obstruction due to urethral stricture, prostatic hyperplasia; also from medications and neurologic disorders such as stroke, multiple sclerosis
Suprapubic tenderness in bladder infection
Risk factors for abdominal aortic aneurysm (AAA) are age 65 years or older, history of smoking, male gender, and a first-degree relative with a history of
AA repair
A periumbilical or upper abdominal mass with expansile pulsations that is 3 cm or more wide suggests an AAA. Sensitivity of palpation increases as AAAs enlarge : for widths of 3.0-3.9 cm, 29%;
4.0-4.9 cm, 50%; > 5.0cm, 76%
Screening by palpation followed by ultrasound decreases mortality, especially in male smokers 65 years or older. Pain may signal rupture. Rupture is 15 times more likely in AAAs > 4 cm than in smaller aneurysms
Ascites from increased hydrostatic pressure in cirrhosis, congestive heart failure, constrictive pericarditis, or inferior vena cava or hepatic osmotic pressure in nephritic syndrome, malnutrition. Also in ovarian cancer
In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top
An easily palpable impulse suggests ascites.
A positive fluid wave, shifting dullness, and peripheral edema make the diagnosis of ascites highly likely
The pain of appendicitis classically begins near the umbilicus, then shifts to the right lower quadrant, where coughing increases it. Older patients report this pattern less frequently than younger ones
Localized tenderness anywhere in the right lower quadrant, even in the right flank may indicate appendicitis
Early voluntary guarding may be replaced by involuntary muscular rigidity
Right sided rectal tenderness may also be caused by an inflamed adnexa or an inflamed seminal vesicle
Rebound tenderness suggests peritoneal inflammation, if appendicitis
Pain in the right lower quadrant during left-sided pressure suggests appendicitis ( a positive Rovsing’s sign). So dose right lower quadrant pain on quick withdrawal (referred rebound tenderness)
Increased abdominal pain on either maneuver(place hand on right knee and ask to raise thich against hand or turn to left side and extend right leg to hip and flexion) constitutes a positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix
Right hypogastric pain constitutes a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix
Localized pain with this maneuver(cutaneous hyperesthesia-pick up folds of skin without pinching on the abdomen) in all or part of the right lower quadrant, may accompany appendicitis
A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy’s sign of acute cholecystitis.
Hepatic tenderness may also increase with this maneuver(hook left thumb of you right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin) is usually less well localized)
The bulge of a hernia will usually appear with raising both head and shoulders off the table
The cause of intestinal obstruction or peritonitis may be missed by overlooking a strangulated femoral hernia
A mass in the abdominal wall remains palpable; an intra-abdominal mass is obscured by muscular contraction

Chapter 17: The Nervous system
Subarachonoid hemorrhage may present as “the worst headace of my life”
Severe headache in meningitis.
Dull headaches affected by coughing, sneezing or sudden movement, especially in the same location, in mass lesions such as brain or abscess
Light-headedness in palpitations, near syncope from vasovagal stimulation, low blood pressure, febrile illness, and others.
Vertigo in inner-ear conditions, brainstem tumor
Diplopia, dysarthria, ataxia in vertebrobasilar transient ischemic attack (TIA) or stroke
Weakness or paralysis in transient ischemic attack or stroke
Focal weakness may arise from ischemic, vascular, or mass lesions in the central nervous system; also from peripheral nervous system; also from peripheral nervous system disorders, or diseases in muscle themselves
Bilateral proximal weakness in myopathy.
Bilateral, predominantly distal weakness in polyneuropathy.
Weakness made worse with repeated effort and improved with rest suggests myasthenia gravis
Loss of sensation, paresthesias, and dysesthesias in central lesions in the brain and spinal cord, as well as disorders of peripheral sensory roots and nerves; parestesisas in the hands aroud the mouth in hyperventilation.
Burning pain in painful sensory neuropathy
Young people with emotional stress and warning symptoms of flushing, warmth, or nausea may have vasodepressor (or vasovagal) syncope of slow onset, slow offset.
Cardiac syncope from arrhythmias, more common in older patients, ofetne with suddent onset, and sudden offset
The common but often overlooked restless legs syndrome, usually benign
Olfactory- Loss of smell in sinus conditions, head trauma, smoking, aging, and the use of cocaine. Also in Parkinson disease
Optic- Disc pallor in optic atrophy; disc bulging in papilledema
Prechiamsmal, or anterior defects, in glaucoma, reinal emboli, optic neuritis (visual acuity poor)
Bitemporal hemianopsias from defects at the optic chiasm usually from pituitary tumor
Homonymous hemianopsias or quadrantanopsia in postchiasmal lesions, usually in the parietal lobe, with associated findings of stroke (visual acuity normal)
Optic and Oculomotor- Minimal constriction in the larger pupil if abnormality of the papillary constrictor muscle from iris disorder or CN II palsy with parasympathetic denervation, ptosis, and opthalmoplegia (eyes not aligned)
Pupils constrict to light in Horner’s syndrome, but due to sympathetic degeneration, the affected pupil remains small (miosis) due to abnormal papillary dilator muscle
Oculomotor, Trochlear, and Abducens- Monocular diplopia in local problems with glasses or contact lenses; cataracts; astigmatism; ptosis
Binocular diplopia in CN II, IV, VI neuropathy (40% patients), eye muscle disease from myasthenia gravis, trauma, thyroid ophthalmopathy, internuclear ophthalmoplegia
Ptosis in 3 rd nerve palsy (CN III) Horner’s syndrome
(ptosis, meiosis, anhydrosis), myasthenia gravis
Trigeminal (Motor)- Difficulty clenching the jaw or moving it to the opposite side in masseter and lateral pterygoid weakness, respectively
Unilateral weakness in CNV pontine lesions; bilateral weakness in cerebral hemispheric disease because of bilateral cortical innervation
Central nervous system patterns from stroke include facial and body sensory loss on same side but from contralateral cortical or thalamic lesions
Ipsilateral face but contralateral body sensory loss in brainstem lesions
Trigeminal (Sensory)- Isolated facial sensory loss in peripheral nerve disorders like trigeminal neuralgia
Absent blinking from CN V or VII lesion
Absent blinking and sensorineural hearing loss in acoustic neuroma
Facial- Flattening of the nasolabial fold and drooping of the lower eyelid suggest facial weakness
A peripheral injury to CN VII, as in Bell’s palsy, affects both the upper and lower face
A central lesion affects mainly the lower face
Loss of taste, hyperacusis, increased or decreased tearing also in Bell’s palsy
In unilateral facial paralysis, the mouth droops on the paralyzed side when the patient smiles or grimaces
Acoustic- The whispered voice test is both sensitive
(>90%) and specific (>80) when assessing presence or absence of hearing loss
Excess cerumen, otosclerosis, otitis media in conductive hearing loss; presbyacusis from aging, most commonly in sensorineural hearing loss
Vertigo with hearing loss and nystagmus in
Meniere’s disease
Glossopharyngeal and Vagus- Hoarseness in vocal cord paralysis
Nasal voice in paralysis of the palate
Pharyngeal or palatal weakness
The palate fails to rise with a bilateral lesion of the vagus nerve

In unilateral paralysis, one side of the palate fails to rise and, together with the uvula, is pulled toward the normal side
Unilateral absence of this reflex suggests a lesion of
CN IX, perhaps CN X
Spinal Accessory- Trapezius weakness with atrophy and fasciculations indicates a peripheral nerve disorder
In trapezius muscle paralysis, the shoulder droops, and the scapula is displaced downward and laterally
A supine patient with bilateral weakness of the sternomastoids has difficulty raising the head off the pillow
Hypoglossal- For poor articulation, or dysarthria
Tongue atrophy and fasciculations in amyotrophic lateral sclerosis, polio
In a unilateral cortical lesion, the protruded tongue deviates transiently in a direction away from the side of the cortical lesion, toward the side of weakness
Abnormal positions alert you to neurologic deficits such as paralysis
Muscular atrophy refers to a loss of muscle bulk, or wasting. It results from diseases of the peripheral nervous system such as diabetic neuropathy, as well as diseases of the muscles themselves
Hypertrophy is an increase in bulk with proportionate strength, whereas increased bulk with diminished strength is called pseudohypertrophy (seen in the
Duchenne form of muscular dystrophy)
Flattening of the thenar and hypothenar eminences and furrowing between the metacarpals sugget atrophy.
Localized atrophy of the thenar and hypothenar eminences in median and ulnar nerve damage, respectively
Other causes of muscular atrophy include motor neuron diseases, any disease that affects the peripheral motor system projecting from the spinal cord, rheumatoid arthritis, and protein-calorie malnutrition
Fasciculations with atrophy and muscle weakness suggest disease of the peripheral motor unit
Decreased resistance suggests disease of the peripheral nervous system, cerebellar disease, or the acute stages of spinal cord injury
Marked floppiness indicates muscle hypotonia or flaccidity, usually from a disorder of the peripheral motor system
Spasticity is increased resistance that worsens at the extremems of range
Spasticity, seen in central corticospinal tract diseases, is rate-dependent, increasing with rapid movement.
Rigidity is increased resistance throughout the range of movement and in both directions (not ratedependent)
Impaired strength is called weakness, or paresis.
Absence of strength is called paralysis, or plegia
Hemiparesis refers to weakness of one half of the body
Paraplegia means paralysis of the legs
Quadriplegia, paralysis of all four limbs
Weakness of extension is seen in peripheral nerve disease such as radial nerve damage and in central nervous system disease producing hemiplegia, as in stroke or multiple sclerosis
A weak grip in cervical radiculopathy, de Quervain’s tenosynovitis, carpal tunnel syndrome, arthritis, epicondylitis
Weak finger abduction in ulnar nerve disorders
Weak opposition of the thumb in median nerve disorders such as carpal tunnel syndrome
Symmetric weakness of the proximal muscles suggests a mypathy or muscle disorder
Symmetric weakness of distal muscles suggests a polyneuropathy, or disorder of peripheral nerves
Arms- (rapid alternating movement)In cerebellar disease look for nystagmus, dysarthria, hypotonia, and taxia
In cerebellar disease, one movement cannot be followed quickly by its opposite and movements are slow, irregular, and clumsy
This abnormality is called dysdiadochokinesis
Upper motor neuron weakness and basal ganglia disease may movements, but not in the same manner
Legs(rapid alternating movement)-
Dysdiadochokinesis in cerebellar disease
Arms- (Point-to-point movements0 In cerebellar disease movements are clumsy, unsteady, and inappropriately varying in their speed, force, and direction
The finger may initially overshoot its mark, but finally reaches it fairly well, termed dysmetria
An intention tremor may appear toward the end of the movement
Cerebellar disease causes incoordination that worsens with eyes closed. If present, this suggests loss of position sense
Repetitive and consistent deviation to one side referred to as past pointing, worse with the eyes closed, suggests cerebellar or vestibular disease
Legs- (Heel-to-shin test) In cerebellar disease, the heel may overshoot the knee and then oscillate from side to side down the shin
When position sense is lost, the heel is lifted too high and the patient tries to look with eyes closed, performance is poor
Gait- Abnormalities of gait increase risk of falls
A gait that lacks coordination, with reeling and instability, is called ataxic.
Ataxia may be due to cerebellar disease, loss of position sense or intoxication
Tandem (walk heel-to-toe in a straightline) walking may reveal an ataxia not previously obvious

Walking on toes and heels may reveal distal muscular weakness in the legs
In ability to heel-walk is a sensitive test for corticospinal tract damage
Difficulty with hopping may be due to weakness, lack of position sense, or cerebellar dysfunction
Difficulty doing shallow knee bend suggests proximal weakness (extensors of the hip), weakness of the quadriceps (the extensor of the knee) or both
Proximal muscle weakness involving the pelvic girdle and legs causes difficulty with both of these activities(knee bend and rising from sitting)
Stance
Romberg Test- In taxia from dorsal column disease and loss of position sense, vision compensates for te sensory loss
The patient stands fairly well with eyes open but loses balance when they are closed, a positive
Romberg sign.
In cerebellar ataxia, the patient has difficulty standing with feet together whether the eyes are open or closed
Test for Pronator Drift- Pronator drift is the pronation of one forearm. It is both sensitive and specific for a corticospinal tract lesion originating in the contralateral hemisphere
Downward drift of the arm with flexion of fingers and elbow may also occur
A sideward or upward drift, sometimes with searching, writhing movements of the hands, suggests loss of position sense- the patient may not recognize the fisplacement and , if told to correct it, does so poorly
In cerebellar incoordination, the arm returns to its original position but over shoots and bounces
Meticulous sensory mapping helps to establish the level of a spinal cord lesion and to determine whether a more peripheral lesion is in a nerve root, a marjor peripheral nerve, or one of its branches
Hemisensory loss from a lesion in the spinal cord or higher pathways
Symmetric distal sensory loss suggests a polyneuropathy, as described in the example on the next page. You may miss this finding unless you compare distal and proximal areas
Here all sensation in the hand is lost. Repetitive testing in a proximal direction reveals a gradual ghange to normal sensation at the wrist. The pattern fits neither a peripheral nerve nor a dermatome
If bilateral, it suggests the “glove and stocking” sensory loss of a polyneuropathy, often seen in alcoholism and diabetes
Analagesia refers to absence of pain sensation, hypalgesia to decreased sensitivity to pain, and hyperalgesia to increased sensitivity
Anesthesia absence of touch sensation, hypesthesia is decreased sensitivity, and hyperesthesia is increased sensitivity
Vibration sense is often the first sensation to be lost in a peripheral neuropathy. Common causes include diabetes and alcoholism.
Vibration sense is also lost in posterior column disease, as in tertiary syphilis or vitamin B12 deficiency
Testing vibration sense in the trunk may be useful in estimating the level of a cord lesion
Loss of position sense, like loss of vibration sense, in tabes dorsalis, multiple sclerosis, or B12 deficiency from posterior column disease; and in peripheral neuropathy from diabetes
When touch and position sense are normal or only slightly impaired, a disproportionate decrease in or loss of discriminative sensations suggests disease of the sensory cortex
Stereognosis, number identification, and two-point discrimination are also impaired in posterior column disease
Astereognosis refers to the inability to recognize objects placed in the hand
The ability to recognize numbers like asterognosis, suggests a lesion in the sensory cortex
Lesions of the sensory cortex increase the distance between two recognizable points
Lesions of the sensory cortex impair the ability to localize points accurately
With lesions of the sensory cortex, only one stimulus may be recognized. The stimulus on the side opposite the damaged cortex is extinguished
In spinal cord injury, the sensory level may be several segments lower than the spinal lesion, for reasons that are not well understood. Tapping for level of vertebral pain may be helpful
Hyperactive reflexes (hyperreflexia) in central nervous system lesions along the descending corticospinal t ract. Look for associated upped motor nuron findings of weakness, spasticity, or a positive
Babinski sign
Hypoactive or absent reflexes (hyporeflexia) in diseases of spinal nerve roots, spinal nerves, plexuses, or peripheral nerves. Look for associated finings of lower motor unit disease, namely weakness, atrophy, and fasciculations
The slowed relaxation phase of reflexes in hypothyroidism is often easily seen and felt in the ankle reflex
Sustained lonus indicates central nervous system disease. The ankle plantar flexes and dorisflexes repetitively and rhymically
Abdominal reflexes may be absent in both central and peripheral nerve disorders
Dorsiflextion of the big toe is a positive Babinski response from a central nervous system lesion in the corticospinal tract; also seen in unconscious states from drug or alcohol intoxication or the postictal period following a seizure
A marked Babinski response is occasionally accompanied by reflex flexion at hip or knee

Loss of the anal reflex suggests a lesion in the S2-3-4 reflex arc, as in a cauda equine lesion
Neck stiffness and resistance to flexion in 90% of patients with acute bacterial meningitis and in 20% and 85% with subarachnoid hemorrhage. Also in arthritis and neck injury
Flexion of the hips and knees is a positive
Brudziniki’s sign and suggests meningeal inflammation
Pain and increased resistance to extending the knee are a positive kernig’s sign.
When bilateral, it suggests meningeal irritation
Compression of a lumbosacral nerve root may also cause resistance, together with pain in the low back and the posterior thigh. Only one leg is usually involved
Compression of the spinal nerve root as it exits through the vertebral foramen causes a painful radiculopathy and associated muscle weakness and dermatomal sensory loss, usually from a herniated disc
More than 95% of disc herniations occur at L5-S1, where the spine angles sharply posterior.
Look for confirming ipsilateral calf wasting and weak ankle dorsiflexion, which make the diagnosis five times more likely
Pain radiating into the ipsilateral leg is a positive straight-leg test for lumbosacral radiculopathy
Foot dosiflexion can further increase leg pain in lumbosacral radiculopathy, sciatic neuropathy, or both
Increased pain when the contralateral healthy leg is raised is a positive crossed straight-leg-raising sign
Assessing the degree of elevation stretch the affected nerve roots and sciatic nerve
Sensitivity and specificity of positive ipsilateral straight-leg raise for disc herniatio is roughly 95% and 25%
Of crossed straight-leg raise, 40% and 90%
Sudden, brief, nonrhythmic flexion of the hands and fingers indicates asterixis, sseen in liver disease, urernia, and hypercapnia
In winging, shown next, the medial border of the scapula juts backward. It suggests weakness of the serratus anterior muscle, seen in muscular dystrophy or injury to the long thoracic nerve
The stuporous or comatose- Five clinical signs strongly predict death or poor outcome, with likelihood rations of 5to 12; at 24 hours- absent corneal response, absent papillary response, absent withdrawal response to pain, no motor response; at
72 hours no motor resposnse
A lethargic patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep
An obtunded patient opens the eyes and looks at you, but responds slowly and is somewhat confused.
Alertness and interest in the environment is decreased
A stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment
A comatose paitent remains unarousable with eyes closed. There is no evident response to inner need or external stimuli
Structural lesions from stroke, abscess, or tumor mass may lead to asymmetrical pupils and loss of light reaction
In structural hemispheric lesions, the eyes “look at the lesion’ in the affected hemisphere
In a comatose patient with absence of doll’s eye movements, the ability to move both eyes to one side is lost, suggesting a lesion of the midbrain or pons
No response to stimulation suggests brainstem injury
Two stereotypic responses predominate: decorticate rigidtiry and decerebrate rigidit
No response on one side suggests a corticospiinal tract lesions
The hemiplegia of sudden cerebral accidents is usually flaccid at first. The limp hand drops to form a right angle with the wrist
A flaccid arm drops rapidly, like a flail
In acute hemiplegia, the flaccid leg falls more rapidly
In acute hemiplegia, the flaccid leg falls rapidly int extension, with external rotation at the hip
cherry red color of carbon monoxide poisoning
reflex loss in coma and lesions affecting CN V or CN
VII
Blood or cerebrospinal fluid in the nose or the ears suggests a skull fracture
Otitis media suggests a possible brain abscess
Toungue injury suggests a seizure