Chapter 164: Neurologic Examination

INTRODUCTION

In most patients, the physical examination confirms thoughts formulated during history taking that are often the key to patient evaluation. Time of onset, symptom progression, associated complaints, and exacerbating factors are important historical points to guide appropriate examination and other testing. The neurologic examination does not exist in isolation from the general physical examination or imaging procedures, and it is unusual for the neurologic examination to delineate a problem not already suggested by the patient's history or general physical examination. Few findings of the neurologic examination are pathognomonic of clinical conditions or are sufficiently specific that examination alone secures the diagnosis. Further complicating the value of the neurologic examination is that the sensitivity and specificity of different examination techniques have not been rigorously investigated, and the degree of interobserver variability is not known. The uncooperative patient or patient with altered mental status presents additional challenges in performing a detailed examination.

The idea of performing a "complete" examination in the ED is impractical, because most frequently, a "complete" examination is neither required nor appropriate. An adequate examination is one that is sufficient for the task at hand. Examination of children follows the same framework as that for adults, but even more information is gathered indirectly by observation. For example, interacting with a child playing with a toy or other object allows the examiner to assess vision, extraocular motion, coordination, and strength as the child reaches for and grasps the toy.¹ Traditional neurologic formulation follows a three-tiered approach: (1) Is there a lesion of the nervous system? (2) Where is the lesion? (3) What is the lesion? The examination detailed in this chapter is arbitrarily divided into eight sections with basic and advanced levels described for each section.

ORGANIZATIONAL FRAMEWORK

Organization of the neurologic examination into a framework of subsections is a convenient technique. At the bedside, mentally review the framework as during the examination, and select more detailed tests as needed. Some of the tests grouped in a section assess several aspects of nervous system function, and listing of tests in a particular section is for organizational convenience. For example, visual field testing, although technically a test of higher cortical function, is listed with cranial nerve testing because the examining physician may find it easier to evaluate visual fields during that portion of the examination assessing cranial nerve function. One organizational scheme divides the examination into eight elements:

1. Mental status testing

2. Higher cerebral functions

3. Cranial nerves

4. Sensory examination

5. Motor system

6. Reflexes

7. Cerebellar testing

8. Gait and station

MENTAL STATUS TESTING

A mental status examination is part of every patient encounter. The observation may be brief and descriptive, such as, "The patient is awake, alert, and conversant," or it may be quite detailed. Mental status assesses the emotional and intellectual functioning of the patient. It is important to make some assessment of mental status, ...