7: Examination of the Somatic Motor System (Excluding Cranial Nerves)

INTRODUCTION

I. INSPECTION OF THE BODY CONTOURS, POSTURES, AND GAIT

A. Initial inspection

1. The motor examination begins the instant you meet the patient (Pt). Study every activity: How the Pt sits, stands, walks and gestures; the postures; and the general activity level. Unobtrusive observation of the Pt's spontaneous activity often discloses more than formal tests, particularly in infants or mentally ill Pts.

2. For the formal examination, the Pt undresses and stands under an overhead light. Underclothes remain in place, in deference to modesty, but at some time you must look under them. If you leave one-third of the body covered, you can do only two-thirds of an examination. Before the cock crows, one of you will violate this commandment: thou shalt undress every Pt. Your own anxieties about viewing nudity may exceed those of the Pt about being viewed nude. After all, the Pt came to you expecting an examination.

3. Next, ponder, yes ponder, the Pt's somatotype or body build. Compare the Pt's contours and proportions with those of a standard normal person of like age and sex and with those of family members. From abnormalities in the Pt's Gestalt, sometimes from just a glance at the silhouette, the examiner (Ex) can diagnose an immense number of syndromes, such as arachnodactyly, achondroplastic dwarfism, and Down's syndrome.

4. Next, scrutinize the size and contours of the Pt's muscles, looking for atrophy or hypertrophy, body asymmetry, joint malalignments, fasciculations, tremors, and involuntary movements. Proceed in an orderly, rostrocaudal, face-neck-shoulder-arm-forearm-hand-chest-abdomen-thigh-leg-foot-toe sequence and continually compare right and left sides.

B. Station and gait testing

1. Next, observe the Pt's station, the steadiness and verticality of the standing posture. Then test the gait by asking the Pt to walk freely across the room. Look for unsteadiness, a broad-based gait, and lack of arm swinging. Ask the Pt to walk on the toes, heels, and in tandem (from heel to toe along a straight line). Request a deep knee bend. Ask a child to hop on each foot and to run. Watching the Pt walk is the single most important part of the entire neurologic examination. An essay at the end of Chapter 8 details gait analysis, after you have a better concept of what to look for.

2. Now, rehearse the five steps of Section VI A of the Standard Neurologic Examination (NE). Yes, I'll ask you to demonstrate them by and by.

II. PRINCIPLES OF STRENGTH TESTING