Ask this patient some questions.
Proceed as follows:
Ask the patient simple questions
Personal details such as name, age, occupation, address and handedness (remember that over 90% of left-handed people have a
dominant left hemisphere).
Test the following:
· Put your tongue out.
· Shut your eyes.
· Touch your nose.
· Two-step commands, such as touch your left ear with your right hand.
· Name familiar objects:
Articulation. Ask the patient to repeat the following:
· British constitution.
· West Register Street.
· Baby hippopotamus.
· Biblical criticism.
Abbreviated mental test:
· Address to recall: 42 West Street.
· Date of birth.
· Recognition of two persons such as doctor and nurse.
· Name of this place.
· Name of the monarch or prime minister.
· Year of World War I or World War II.
· Count backwards from 20 to 1.
· Serially subtract 7 from 200.
Tell the examiner that you would like to check the 'primitive' reflexes:
· Snout refiex: brought about by tapping the upper lip slightly. There is puckering or protrusion of the lips with percussion. The
muscles around the mouth and the base of the nose contract.
· Palmomental re./lex: occurs when a disagreeable stimulus is drawn from the thenar eminence at the wrist to the base of the
thumb (Arch Neurol 1988; 45: 425-7). There is ipsilateral contraction of the orbicularis otis and mentalis muscles. The corner of
the mouth elevates slightly and the skin over the chin wrinkles.
· Sucking reflexes: elicited by tapping or lightly touching the lips with a tongue blade or the examiner's finger. Sucking
movements of the lips occur when they are stroked or touched.
Note. l he above three reflexes are normal m lntants, may be present m normal individuals and are said to be present in a larger
number of patients with neuro-logical disease. They are most often seen in those with diffuse cerebral conditions that affect the
frontal lobes and pyramidal tracts. The occurrence of more than one reflex is more suggestive of disease than normality.
· Grasp reflex: obtained when the examiner's hand is gently inserted into the palm of the patient's hand (when the patient is
distracted, usually by engaging him in conversation). With a positive response the patient grasps the examiner's hand and
continues to grasp it as it is moved. The presence of the grasp reflex indicates disease of the supplementary motor area of the
· Jaw jerk (see p. 108).
This patient has expressive dysphasia (lesion) due to a stroke (aetioJogy) and is unable to express himself (functional status).
Read review on aphasia: N Engl J Med 1992; 326: 531-9.
What do you understand by the term 'dysphasia'?
Dysphasia is a disorder of the content of speech and usually follows a lesion of the dominant cortex:
· When the speech dejectis expressive dysphasia or nominal dysphasia or motor dysphasia, the site of the lesion in the cortex is
the posterior inferior part of the dominant frontal lobe, i.e. Broca's area.
· When the speech defect is sensory dysphasia or receptive dysphasia, the site of the lesion is the superior temporal lobe or
What do you understand by the term 'dysarthria'?
Dysarthria is an inability to articulate properly because of local lesions in the mouth or disorders of speech muscles or their
connections. There is no disorder of the content of speech. The causes of dysarthria are:
· Paralysis of cranial nerves - Bell's palsy, ninth, tenth and eleventh nerves.
· Cerebellar disease - staccato, scanning speech.
· Parkinson's speech - slow, quiet, slurred, monotonous.
· Pseudobulbar palsy - monotonous, high-pitched 'hot potato' speech.
· Progressive bulbar palsy - nasal.
What are the components of speech?
· Phonation: abnormality is called dysphonia.
· Articulation: abnormality is called dysarthria.
· Language: abnormality is called dysphasia.
What are the other dominant hemisphere functions?
· Right-left orientation.
· Finger identification.
What are the non-dominant hemisphere functions?
· Drawing ability.
· Topographic ability.
· Facial recognition.
· Awareness of body and space.
· Motor persistence.
What are the parietal lobe signs?
· Loss of accurate localization of touch, position, joint sense and temperature appreciation.
· Loss of two-point discrimination.
· Sensory inattention.
· Attention hemianopia, homonymous hemianopia, or lower quadrantic hemianopia.
What do you understand by the term 'agnosia'?
Agnosia is a failure to recognize objects despite the fact that the sensory pathways for sight, sound or touch are intact. This is tested
by asking the patient to feel, name and describe the use of certain objects.
What are the different types of agnosia?
Different types of agnosia include:
· Tactile agnosia and astereognosis: where the patient is unable to recognize objects placed in his hands despite the fact that the
sensory system of the hands and fingers is intact and there is adequate motor function to allow him to examine the object. The
lesion is in the parietal lobe.
· Prosopagnosia: inability to recognize a familiar face. The lesion is in the parieto-occipital lobe.
· Visual agnosia: inability to recognize objects despite the fact that the main visual pathways to the occipital cortex are
preserved. The lesion is in the parieto-occipital lobe.
· Anosognosia: the lack of awareness or realization that the limbs are paralysed, weak or have impaired sensation. The lesion is
usually in the non-dominant parietal lobe.
What do you understand by the term 'apraxia'?
Apraxia is the inability to perform purposeful volitional movements in the absence of motor weakness, sensory deficits or severe
incoordination. Usually the defect is in the dominant parietal lobe, with disruption of connections to the motor cortex and to the
What are the different types of apraxia?
Different types ot apraxta include:
· Dressing apraxias: the patient is unable to put on his clothes correctly.
· Gait apraxia: difficulty in walking, although patients may show intact leg move-ments when examined in bed.
· Ideomotor apraxia: patients are unable to perform movements on command. although they may do this automatically, e.g. lick
· Ideational apraxias: difficulty in carrying out a complex series of movements, e.g. to take a match from a box to light a cigarette.
· Constructional apraxia: the patient has difficulty in arranging patterns of blocks or copying designs.
What do you know about dyslexia?
Reading difficulties, including dyslexia, occur as a part of a continuum that also includes normal reading ability. It is not an
all-or-none phenomenon but, like hyper-tension, occurs in degrees. It has been defined as a disorder that is manifested by difficulty
in learning to read despite conventional instruction, adequate intelligence and sociocultural opportunity.
Sir Charles Sherrington (1857-1952), Oxford University, and Lord Edgar Douglas Adrian (1889-1977), Cambridge University, were
awarded the Nobel Prize in 1932 for their discoveries regarding the functions of neurons.