Physical examination maneuver
Physical Exam
Nystagmus Characterization
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Observe the eyes with the patient looking straight ahead and then holding gaze to the right, left, up, and down (avoid extreme end-gaze, which can produce normal end-point nystagmus). Note whether involuntary oscillation is present, its plane (horizontal, vertical, torsional, or mixed), the direction of the fast phase, whether it is present at rest or only on gaze, and whether it changes direction with the direction of gaze.
How to Interpret
Showing 4 of 5 findings
Stroke
HINTS exam concerning (central pattern) in a patient with acute vestibular syndrome
Rule in
Helpful
Rule out
Very helpful
Evidence:Strong
Nystagmus present in a patient with confirmed acute ischemic stroke
Rule in
Very helpfulDerived CI
Rule out
Not helpfulDerived CI
Evidence:Moderate
Vestibular Dysfunction
Purely vertical (down-beating or up-beating), purely torsional, or vertical-torsional spontaneous nystagmus
Rule in
Helpful
Rule out
Not helpful
Evidence:Strong
HINTS exam reassuring (peripheral pattern) in a patient with acute vestibular syndrome
Rule in
Very helpfulDerived CI
Rule out
Very helpfulDerived CI
Evidence:Moderate
Related Bedside Tests
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Alternate Cover Test
aka Cross-cover test, Test of skew
Rule in:VHSkew Deviation, VHVestibular Dysfunction, HStroke +1 more
Rule out:VHStroke, VHVestibular Dysfunction, HSkew Deviation +1 more
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Extraocular Movements
Rule in:VHStroke, SHHyperthyroidism, SHMyasthenia Gravis +9 more
Rule out:HMyasthenia Gravis, SHHyperthyroidism, NHOrbital Fracture +9 more
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Head Impulse Test
aka Head thrust test; Halmagyi test
Rule in:VHVestibular Dysfunction, HStroke
Rule out:VHStroke, VHVestibular Dysfunction
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HINTS Exam
Rule in:VHVestibular Dysfunction, HStroke
Rule out:VHStroke, VHVestibular Dysfunction
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Pupillary Light Reaction
Rule in:VHSerious Eye Disease, HPoor Neurologic Outcome, HStructural Brain Lesion +11 more
Rule out:SHPoor Neurologic Outcome, SHSerious Eye Disease, SHStructural Brain Lesion +11 more
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Gait Assessment
Rule in:VHStroke, HFalls, HVascular Parkinsonism +24 more
Rule out:SHDementia, SHVascular Parkinsonism, MHFalls +24 more