Conjugate Deviation
1. Have the patient open her mouth without protruding the tongue
Look in her mouth. How thick is the tongue? Is it flat, wrinkled,
mov-ing, or still? A wasted tongue will appear to be lower in the mouth than the normal tongue. Is the midline of the tongue in the midline of the mouth?
2. Have the patient push her tongue straight out of her mouth. In some diseases the tongue cannot be protruded beyond the teeth. The tongue normally comes out in the midline. If one half of the tongue is weak or paralyzed, the tongue will always come out of the mouth to the weak side, irrespective of whether it is an upper or lower motor neuron lesion.
In milder degrees of weakness it may be necessary to have the patient push her tongue into her cheek while you hold your finger outside the cheek. Do this on both the right and left sides (Figure 9 ^ ) .
Most normal people can extend the tongue from the mouth for about one third to one half its length. The tongue can also be alternatively protruded
Figure 9-4. To test the strength of the tongue, the patient pushes it into the cheel<
against the examiner's finger on the right and then on the ieft.
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and withdrawn back into the mouth rapidly. This “trombone” movement of the tongue is normal and becomes slower and abnormal in some diseases.
Ask the patient to protrude her tongue and then wiggle it from side to side.
When you know how most people do this, you will quickly recognize ab-normal tongue movements.
Ask the patient to rapidly repeat the sound “la-la-la-la.”
Parkinsonism, cerebellar lesions, or weakness and wasting of the tongue will make the sound abnormal.
Diseases of the Twelfth Cranial Nerve
Most bilateral lesions of the tongue are the result of amyotrophic lateral sclerosis. (See also the lower cranial nerves described above.)
The Upper Limb 1 0
The arm is between the shoulder and the elbow; the forearm is between the elbow and the wrist.
Assessment of upper limb function may be directed when the patient says, for example, “I have a pain in my right neck and shoulder and numb-ness in my fingers and I drop things from my right hand.” He must have a disease of the spinal cord, canal, root, or brachial plexus. The nature of his complaint thus will direct your thinking.
When there are direct symptoms, try to convert these into defects of func-tion. If the patient says, “My hand is numb,” then you will want to ask,
“Does bath [dish] water feel equally hot on both your hands? Can you put your hand in your pocket [purse] and bring out a key or a coin and know what it is without first looking at it? Has your handwriting changed? Can you tie your necktie [put your earrings or contact lenses in] as well as you used to? Can you do up buttons, zippers, or hooks and sew, type, play the guitar, and work your personal computer as well as you always could?”
Also, remember that numbness implies a sensory disorder when doctors use the word, but not so with patients. Patients with pure motor lesions, basal ganglion disorders, and other nonsensory lesions sometimes describe the affected part as “numb.”
In contrast is the undirected assessment of upper limb function. The pa-tient’s family, or perhaps his employer, says, “He cannot do his office work as well as he could a year ago. He seems to shuffle a bit when he walks, and he does not stand up straight anymore.” What has this to do with the arms?
While you are taking the patient’s history, you notice that his right arm has not lifted off the armrest of the chair once in 30 min. When he emphasizes spoken speech with a gesture, only the left hand “does the talking.” All the normal, small, useless movements such as adjusting the knot in the necktie, sliding the glasses up onto the nose, or rubbing the cheek with a finger are done with the left hand. The patient has parkinsonism. The most obvious physical sign is the immobility of the right upper limb. Once you have thought of the diagnosis, you make your inquiries from a different perspec-tive, and yes, the patient, on reflection, admits that his handwriting is differ-ent in the past 2 years and, yes, the newspaper does appear to tremble on oc-casion when he is tired and holding it up in front of him. But the presenting
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complaints were a gait disorder and inability to perform on the job; the right upper limb was supposedly symptom-free.
The most important things to look at during history taking in any patient are the face, the stance, and the upper limbs. While the patient answers ques-tions, watch him. Similarly, do not let anyone else go to get your patient from the waiting area. Get him yourself, then watch the patient as you intro-duce yourself and as he gets out of the chair, goes with you to the consulting room, sits, and gets ready to tell his story.
If he gets out of the chair by pushing down on the chair arms or on his knees with his hands, his quadriceps are weak. If he seems to rock back and forth in the chair two or three times before “launching” himself to stand, he is stiff because of parkinsonism, medication, or some other cause. Do his arms swing as he walks? Does his right arm come forward synchronously with his left leg? Are there excessive, random, restless, small movements of the hands and arms, suggesting chorea? Is there a repetitive, stereotyped hand-and-arm movement such as wiping the lips every 15 s, as one might see in a patient with tardive dyskinesia?
POSTURAL MAINTENANCE
When the examination of cranial nerves and visual fields is complete and the patient is still sitting on the examining table with his legs hanging over the side, do the following:
• Ask him to hold his arms out in front of him at shoulder level (loosely, not rigid) with a few degrees of flexion at the elbow, his fingers separated, and the palms uppermost.
• Then ask him to close his eyes (Figure 10–1) and watch him for 10 or 15 s.
If one arm begins to drift down toward the floor or down and out, or occa-sionally up, this is evidence of organic disease. The test is not specific but it is objective. The disease may be in the sensory system (ipsilateral or con-tralateral), the contralateral basal ganglia, upper motor neuron system, or ip-silateral cerebellum.
If both arms drift toward the floor, the test is uninformative. The patient does not understand or he is tired, obtunded, on drugs, or ill in a generalized way.
If neither arm drifts, gently tap first one arm and then the other to the side and then toward the floor. As you do this, ask the patient to keep his arms in their original position and not allow you to dislodge them. If one arm is
Figure 1 0 - 1 . To examine the arms for drift, start witln tlnem in tlnis position, witln tine patient's eyes ciosed.
more easily displaced than the other, this is of the same significance as spon-taneous arm drift.
ALTERNATING MOVEMENTS
The patient's ability to perform alternative movements with the upper limbs can be specifically abnormal, as in cerebellar disease or parkinsonism.
Alternating movements may be nonspecifically abnormal in upper motor neuron lesions or with a parietal lobe sensory defect or in the presence of dyskinesia. Testing rapid alternating movements is most informative when they are normal on one side of the body but not on the other.
1. With the patient sitting and his eyes open, asli him to touch his nose