Question

220 UNIT I Physical Examination B. Motor system I. Muscles Sine, strength, tone Involuntary movements 2·Cerebellar function Rapid alternative movements Finger to finger test Finger to nose test Heel to shin test Gait Romberg test C. Sensory system 1. Spinothalamic tract Light touch 2. Posterior column tract Vibration Position (kinesthesia) Tactile discrimination Stereognosis Graphesthesia Two-point discrimination D. Reflexes Bi Tri BR PL Abd Cre Bab 0-absent, 1+-hypoactive, 2+-normal, 3+2 hyperactive, 4+-hyperactive with clonus, t -dorsiflexion, plantar flexion.

Answer 1

B 1. Tone. Muscle tone represents the resistance to passive movement of a joint. Unlike spasticity, which is characteristic of upper motor neuron disease , rigidity, the hallmark of hypokinesia, is increased tone of both flexor and extensormuscles.   Strength is conveniently tested by having the patient resist your force as you attempt to move their body part against the direction of pull of the muscle that you are evaluating. This is graded on a scale of 0-5, with "0" representing absolutely no visible contraction and “5” being normal. involuntary movements

• Adventitious movment disorder (e.g., chorea dystonic posture, tremor, myoclonus, seizure).
• Fasciculation
• Myotonia on attempted active movement

2 finger to finger test__.a test for coordination and position sense of the upper limbs; the subject is asked to approximate the ends of the indexfingers; assesses cerebellar function. finger to nose test--Perhaps the most popular test of coordination, however, is the finger—nose—finger test, in which the patient is asked to alternately touch their nose and the examiner's finger as quickly as possible. heel to shin test-Have the patient repeat this movement with the other foot. An inability to perform this motion in a relatively rapid cadence is abnormal. The heel to shin test is a measure of coordination and may be abnormal if there is loss of motor strength, proprioception or a cerebellar lesion   

Gait

This is an important part of any neurologic exam. It is particularly important to observe the symmetry of the gait, the ability to walk with a narrow base, the length of the stride when walking at a normal pace, and the ability to turn with a minimum of steps and without loss of equilibrium. When observing a normal person from behind, the medial parts of the feet strike a line and there is no space visible between the legs at the time of heel strike. This is a narrow-based gait and deviation from this can be measured in the amount of distance laterally each foot strikes from the line that their body is following. Tandem walking (the ability to walk on a line) may be used to evaluate for stability of gait, recognizing that many normal elderly patients have trouble with this.

Damage to virtually any part of the nervous system may be reflected in gait. An antalgic gait, or the limp caused by pain is familiar to any practitioner. Patients with unilateral weakness may favor one side, and if the weakness is spastic (i.e., from upper motor neuron damage) the patient may hold the lower limb stiffly. S/he will drag the weak limb around the body in a "circumducting" pattern. A staggering or reeling gait (like that of the drunk) is suggestive of cerebellar dysfunction. Generally, the patient with true vertigo will tend to fall to the one side repeatedly (especially with the eyes closed). A patient with foot drop will tend to lift the foot high (steppage gait). Hip girdle weakness often results in a "waddle," with the hips shifting toward the side of weakness when the opposite foot is lifted from the floor (of course, if both sides are weak the hips will shift back and forth as they take each step). Patients with Parkinson disease often have difficulty initiating gait; the steps are usually short, although the gait is narrow-based. If severe, the patient may be propulsive (they may even fall). Patients who are "glue footed" (sliding their feet along the ground rather than stepping normally) may be suffering from damage or degeneration of both frontal lobes or the midline portion of the cerebellum. When damage to these areas is severe the patient may be severely retropulsive (tending to fall over backwards repeatedly). Dorsal column injury may result in a gait in which the patient "stamps" his or her feet, and usually also needs to look at the feet in order walk. Patients with painful neuropathy of the feet may walk as if they are "walking on eggs" and patients with spinal stenosis may walk with a stooped posture (a "simian" posture).

The Original Romberg test

The test is performed as follows:

1. The patient is asked to remove his shoes and stand with his two feet together. The arms are held next to the body or crossed in front of the body.
2. The clinician asks the patient to first stand quietly with eyes open, and subsequently with eyes closed. The patient tries to maintain his balance. For safety, it is essential that the observer stand close to the patient to prevent potential injury if the patient were to fall. When the patients closes his eyes, he should not orient himself by light, sense or sound, as this could influence the test result and cause a false positive outcome.
3. The Romberg test is scored by counting the seconds the patient is able to stand with eyes closed.
4. The literature does not report alternative methods for scoring a Romberg test.
5. To make the Romberg test more difficult, the clinician can attempt to disturb the patient's balance with a perturbation. It is important that the clinician does not exaggerate the perturbation.
6. A Romberg test can also be used as follow-up assessment for patients with balance and/or proprioception impairments by comparing several different assessments with each other.
7. If the clinician observes that the patient is able to stand for longer periods of time with the eyes closed, it is evident that the patient's balance and proprioceptive deficits have decreased[3][7][4][8].
8. The Romberg test is positive when the patient is unable to maintain balance with their eyes closed. Losing balance can be defined as increased body sway, placing one foot in the direction of the fall, o