Explain how the concept of a three-dimensional "mask of Trigeminus" enables you to recall the posterior border of the innervation field of CrN V on the surface skin and deep structures (teeth, oral cavity, nasal passages, and sinuses).
Describe the range of functions mediated by CrN V. (Mnemonic: Recite the facial, feeding, and respiratory-related reflexes and certain facial and oral autonomic reflexes of a newborn infant.)
Draw a lateral view of the face to show the area of distribution of the three major sensory divisions of the CrN V and name the three branches (Fig. 10-2).
Draw a dorsal view of the brainstem and show the three subdivisions of the trigeminal sensory nucleus.
Diagram the sensory pathway that connects the sensory nuclei of CrN V with the thalamus (Fig. 10-2).
Explain the unique anatomic and functional features of the mesencephalic nucleus of CrN V.
Describe and demonstrate how to test touch over the trigeminal area.
Explain how to monitor the Pt's attentiveness and suggestibility while testing skin sensation.
Explain why, if you suspect a numb area from the Pt's history, you should begin sensory testing with a normal area and then work from the numb area out to the normal area.
Describe and demonstrate how to test the corneal reflex.
Name the cranial nerves that mediate the corneal reflex.
Describe the corneomandibular and glabellar blink reflexes.
Explain why you should use subtle rather than obvious differences in testing temperature sensation.
Describe and demonstrate how to test for temperature discrimination by the tuning fork versus finger test and the warm and cool tube test.
Explain why you should usually test for temperature discrimination before testing for pain, especially in a child.
Explain the clinical importance of recognizing that the sensory innervation field of CrN V spares the skin over the mandibular angle.
Explain, in principle, how the pattern of sensory loss found during the examination distinguishes organic from hysterical loss of sensation, and describe the usual pattern of hysterical loss of sensation in the arm.
Describe the clinical characteristics of trigeminal neuralgia.
Explain why, in testing for a dermatomal loss of sensation or spinal cord sensory level, the Ex moves the stimulus up and down the trunk but around the limbs (Fig. 2-10).
State the location of the nerve cell body for the primary, secondary, and tertiary neurons in the pathways for pain and temperature, touch, and dorsal column modalities (Fig. 2-28).
Describe the pathways by which touch reaches conscious appreciation from the body and extremities.
Explain the importance of knowing the location of the secondary neuron in the somatic sensory pathways.
Define a lemniscus and name the lemnisci (Table 10-1).
Define the spinal lemniscus.
On a generalized cross section of the brainstem, locate the lemnisci (Fig. 2-14).
Name the one sensation that does not, in fact or theory, have a specific thalamic relay nucleus. (In answering this question, recall how to use your own body to systematically enumerate the senses.)
Describe the two types of pain in terms of time of response to a pinprick and relate these to the kind of peripheral nerve fiber that conducts each type of pain.
Define referred pain and give an example.
Distinguish between nociceptive pain and neurogenic pain.
Diagram the pathway for pain and temperature sensation from the trunk and extremities to the cerebral cortex (Fig. 10-6).
Explain how the pain and temperature pathway from the face resembles and differs from the pathway for the rest of the body (Figs. 10-2 and 10-6).
Describe the order of representation of the entire face and body in the pain and temperature nucleus (substantia gelatinosa of Rolando) and state the location of that nucleus.
Describe a neurosurgical operation on the spinal cord that would abolish pain and temperature sensation but would not abolish touch or cause motor disturbances.
Describe the type of pin to use to test pain sensation and how to hold it to ensure a uniform stimulus for the pinpricks.
Explain why you make multiple pinpricks at each site rather than single pricks in testing pain sensation.
Explain why you should test temperature and pain sensation on the dorsum of the hands and feet rather than on the palms and soles.
Explain why you should always discard a pin after using it to test pain sensation.
Describe how to test for delayed pain and deep pain.
State the evidence suggesting that a neonate or possibly even a fetus might feel pain.
Describe how to test sensation to accurately and reliably determine the level of a spinal cord transection in a newborn or young infant.
State the type of biopsies that aid in investigating disease of small nerve fibers.
Describe the typical distribution of sensory loss in polyneuropathies.
State which nerves to palpate to identify hypertrophic neuropathy.
Describe Tinel's "tapping the nerve" sign.
Describe ancillary procedures commonly used in the differential diagnosis of polyneuropathies.
Describe occipital neuralgia.
Describe the distribution of the sensory deficit in the carpal tunnel syndrome.
Recite the LLOAF/2 mnemonic for the muscles innervated by the median nerve.
Name the most important muscle to test in the carpal tunnel syndrome and demonstrate how to test it.
Demonstrate Phalen's sign.
State the usual site of entrapment of the ulnar nerve.
Name two muscles in the hand that can be readily tested for weakness from an ulnar neuropathy.
Describe the distribution of the sensory disturbance in entrapment of the lateral femoral cutaneous nerve.
Contrast the sensory and motor deficits from entrapment of the common peroneal nerve and the posterior tibial nerve.
Describe the site of the lesion and distribution of the pain in Morton's metatarsalgia.
Contrast the clinical findings on the NE of a Pt with an acute compression of the L5 nerve root with compression of the S1 root from intervertebral disc herniation. (Hint: Cover the L5 and S1 columns in Table 10-2 and recite the findings.)
Describe how to do the sciatic nerve stretching tests and the biomechanics involved.
In a nonpsychiatric Pt, what is generally the best way to identify the distribution of radicular pain?
Explain how an EMG can help localize the myotome affected in root compression syndromes.
In the straight-knee leg-raising test, explain why, when the Ex stops just short of eliciting pain and then manually dorsiflexes the Pt's foot, pain is produced.
Describe the results and significance when the straight-knee leg-raising test on one side produces radicular pain in the other leg.
Explain why the distribution of pain from L5 or S1 may affect the buttock, hip, or thigh as much as or more than radiating down into the foot.
Describe several methods of examining the back and leg of a Pt with the sciatica syndrome in addition to the standard testing of sensation, strength, and MSRs (Section VII F 2).
Show how to test the one muscle usually exclusively innervated by L5.
List a number of disorders or comorbidities involved in the differential diagnosis of sciatica.
Describe ancillary studies often required in the differential diagnosis of sciatica.
Define proprioceptive sensation.
Explain how the etymology of the word proprioception applies to its use in neurology.
Summarize the reasoning that led Sherrington to recognize a proprioceptive system.
Diagram the skeletomuscular proprioceptive pathway from the foot and hand (Fig. 10-14).
Describe the location of the second-order neuron in the dorsal column proprioceptive pathway from the extremities. State where its axon decussates and the name of the pathway it takes to the thalamus.
Diagram the sensory homunculus in the dorsal columns and give the technical terms for the fasciculi of the dorsal columns (the arm dorsal column and the leg dorsal column; Fig. 2-12D).
Contrast the nature of the stimuli received by deep and superficial receptors.
Discuss the relation between the concepts of the mechanoreceptors (dorsal column modalities) and classic Newtonian physics.
Describe and demonstrate how to test for position sense in the digits.
Explain why testing digits 3 or 4 provides a greater challenge to the Pt's position sense than digits 1, 2, or 5 and why, if you find normal position sense in digits 3 and 4, you do not have to test other digits or proximal joints in the routine screening NE (Fig. 10-16).
State which joints you examine next to determine the severity of the loss, if the Pt has no position sense in digits 3 and 4 in the hands or feet.
Discuss whether a normal person who is attending to the stimulus will make any errors in digit position.
State the probability that a Pt who has no position sense will correctly guess the up or down position of the digit.
Describe the methods of making position sense testing more challenging than simple up or down alternatives.
In up or down position sense testing, state the minimum number of trials necessary to make success by chance improbable.
Discuss the clinical interpretation when the Pt consistently gives the wrong or exactly opposite answer to the up or down position of the digit.
Discuss the reason the sensory examination requires such a high degree of skill on the part of the Ex.
Discuss some reasons inexperienced Exs may misinterpret the Pt's response to sensory testing as unreliable.
Recite the instructions the Ex gives the Pt for the swaying (Romberg) test.
Give an operational description of the Romberg test.
Give an interpretational description of the Romberg test.
State the critical sensory pathway for maintaining the upright posture with the eyes closed.
Explain why you ask the Pt to stand with the feet together for the Romberg test.
Describe how to divert the hysterical patient into performing well in the Romberg test.
Describe the effect of closing the eyes on cerebellar and sensory dystaxia.
Describe how to differentiate sensory from cerebellar ataxia (Table 10-3).
Describe the result of the swaying test in a normal person, in a hysteric, in Pts with lesions of the cerebellum or dorsal column, and in Pts with vertigo.
Describe and demonstrate how to test for vibration sense.
Explain how to monitor the Pt's attentiveness and reliability in testing vibration sense.
Describe the directional scratch test for dorsal column dysfunction.
Review the pathways for conscious perception of touch, temperature and pain, position, and vibration.
Demonstrate how to test for two-point discrimination.
Compare the relative impairment of the foregoing sensations by lesions of the PNS or central pathways up to the somesthetic cortex.