Physical Exam Special Tests

MMSE Indication

cognitive impairment or cognitive deficit

Language Screen Indication

language complaint or concern

aphasia

Language Screen Interpretation

suggestive of aphasia (determine subtype)

Grandfather Passage Indication

speech complaint or concern

dysarthria

Grandfather Passage Interpretation

suggests dysarthria (determines subtype)

Fatiguability Indication

NMJ concern (MG or LEMS)

Ocular Fatiguability Procedure

hold finger midline above patient eyes

have patient stare for 1 minute

Extremity Fatiguability Procedure

repetitive arm flaps or squats

Ocular Fatiguability Interpretation

worsening ptosis indicates MG

Extremity Fatiguability Interpretation

worsened weakness indicates MS

improved weakness indicated LEMS

Temperature Indication

sensory pathway dysfunction (spinothalamic)

Temperature Procedure

tuning fork in cold or hot water

touch to patient skin and have them identify temperature

Temperature Interpretation

inability to differentiate hot vs cold indicates impaired temperature sensation (spinothalamic tract)

Sensory Level Indication

spinal cord lesion or myelopathy

Sensory Level Procedure

patient eyes closed

test pinprick on trunk, comparing sides

identify dermatome where sensation changes

Sensory Level Interpretation

clear sensory level where sensation decreases indicates spinal cord lesion at that level

Stereognosis Indication

cortical sensory dysfunction (parietal lobe)

Stereognosis Procedure

ask patient to identify familiar object placed in hand

Stereognosis Interpretation

inability to identify object even with intact sensation indicates cortical sensory impairment (parietal lobe)

Number Identification Indication

cortical sensory dysfunction (parietal lobe)

Number Identification Procedure

draw number in patient palm using back of pen

have them identify

Number Identification Interpretation

inability to identify number even with intact sensation indicates cortical sensory impairment (parietal lobe)

Point Localization Indication

cortical sensory dysfunction (parietal lobe)

Point Localization Procedure

touch patient then have them open eyes and identify where

Point Localization Interpretation

inability to localize point even with intact sensation indicates cortical sensory impairment (parietal lobe)

2 Point Discrimination Indication

cortical sensory dysfunction (peripheral sensory loss)

2 Point Discrimination Procedure

tap skin on finger/toe pads with 2 blunt points (paperclip)

move closer until patient can’t feel 2 points

measure distance between points

2 Point Discrimination Interpretation

distance of >5mm in fingers or >8mm on toe indicates cortical sensory dysfunction (peripheral sensory loss)

Rapid Alternating Movements Indication

cerebellar dysfunction

Rapid Alternating Movements Procedure

quickly tap palm of both hands on thighs, tap back of hands on thighs

quickly tap floor with foot

quickly tap index finger to thumb

Rapid Alternating Movements Interpretation

slowness, irregularity, or inability to perform indicates cerebellar dysfunction

Plantar Reflex (Babinski) Indication

UMN lesion

Plantar Reflex (Babinski) Procedure

start with patient ankle dorsiflexed

stroke bottom of foot from heel —> 5th toe —> great toe

Plantar Reflex (Babinski) Interpretation

dorsiflexion of great toe +/- toe fanning indicates UMN lesion

Ankle Clonus Indication

UMN lesion

Ankle Clonus Procedure

hold knee in mild dorsiflexion

alternate dorsiflexion and plantarflexion of ankle

quickly dorsiflex ankle and look for oscillations

Ankle Clonus Interpretation

sustained clonus indicates UMN dysfunction

Cremasteric Reflex Indication

L1-L2 spinal cord or peripheral nerve dysfunction

Cremasteric Reflex Procedure

obtain consent

stroke proximal medial thigh and look for testicular rising

Cremasteric Reflex Interpretation

absence of reflex indicates L1-L2 dysfunction

Abdominal Reflex Indication

UMN lesion

Abdominal Reflex Procedure

stroke toward umbilicus in all quadrants with reflex hammer handle

observe for muscle contractions

Abdominal Reflex Interpretation

absent reflexes indicate UMN disease

Visual Extinction Indication

cortical lesion (nondominant parietal lobe)

Visual Extinction Procedure

establish intact visual fields

patient looks straight ahead

present visual stimuli on right, left, and both sides

Visual Extinction Interpretation

failure to detect one of the simultaneous stimuli indicates visual extinction or neglect

Sensory Extinction Indication

cortical lesion (nondominant parietal lobe)

Sensory Extinction Procedure

establish intact sensation to touch

touch patient on right, left, and both sides of the body

Sensory Extinction Interpretation

failure to detect one of the simultaneous stimuli indicates visual extinction or neglect

Kernig Sign Indication

meningeal irritation or meningitis

Kernig Sign Procedure

patient supine

flex knee and hip, then extend knee

Kernig Sign Interpretation

pain and resistance to interpretation

Brudzinski Sign Indication

meningeal irritation or meningitis

Brudzinski Sign Procedure

patient supine

passively flex neck

Brudzinski Sign Interpretation

hip and knee flexion during maneuver

Nuchal Rigidity Indication

meningeal irritation or meningitis

Nuchal Rigidity Procedure

patient supine

test ease of neck flexion, extension, and rotation

Nuchal Rigidity Interpretation

neck rigidity