Appendix B: The Neurological Examination of the Patient

Introduction

• Mental Status

  • Alertness and Attentiveness

  • Behavior, Mood, and Thought

  • Orientation and Memory

  • Cognitive Abilities

  • Language Disorders

• Cranial Nerve Function

  • Olfactory Nerve (Cranial N. I)

  • Optic Nerve (Cranial N. II)

  • Oculomotor, Trochlear, and Abducens Nerves (Cranial N. III, IV, VI)

  • Trigeminal Nerve (Cranial N. V)

  • Facial Nerve (Cranial N. VII)

  • Vestibulocochlear Nerve (Cranial N. VIII)

  • Glossopharyngeal and Vagus Nerves (Cranial N. IX, X)

  • Spinal Accessory Nerve

  • Hypoglossal Nerve (Cranial N. XII)

• Musculoskeletal System

• Sensory Systems

• Motor Coordination

• Gait and Stance

• Balance

• Deep Tendon Reflexes

The key to the analysis of signs and symptoms referable to the nervous system is a rigorous neurological examination of the patient. This examination begins with an assessment of the patient's mental functioning.

Mental Status

Alertness and Attentiveness

A patient's level of consciousness is defined in terms of responses to stimuli. Rather than simply using terms such as lethargy, obtundation, stupor, and coma, the examiner needs to note the minimal stimulus that elicits a response (eg, voice, shaking the patient, applying pain) and the response (eg, sustained alertness vs. fleeting eye opening with mumbling).

An impaired attention span is usually apparent during history taking. It can be tested more formally by having the patient repeat a series of numbers or count backward from 20. Sequential digit testing is sensitive, but the test is not specific; difficulty may connote impairment of immediate (working) memory.

Inattentiveness so severe that meaningful interaction with the environment is impossible is characteristic of delirium. Such patients are often agitated.

Behavior, Mood, and Thought

Neuropsychiatric abnormalities can be identified in this part of the mental status examination. Affect, the outward expression of mood, may be manifested in clothing, facial expression, amount and type of activity, and stream of conversation. If depression is suspected, the patient should be specifically queried; mood may be more disturbed than affect suggests.

Schizophrenic patients may demonstrate indifference, flattening of affect, or inappropriate mood. They may appear hostile and paranoid. Behavior sometimes suggests hallucinations even when they are denied. Schizophrenic speech may reveal loosening of associations, incoherence, blocking, stereotypy, or distractibility.

Slowing of speech and activity is a manifestation of medial frontal lobe damage (abulia). Lesions of the frontal lobe also produce social disinhibition, inappropriate jocularity, and difficulty sustaining goal-directed behavior.

Orientation and Memory

People aware of their own identity as well as of the basic facts of their surroundings (hospital, home address, city, state; time of day, day of week, month, year) are said to be "oriented to person, place, and time." Memory impairment secondary to brain injury or a dementing illness is usually greater for recent than remote events; such patients are disoriented to place and time but not to person. Disorientation is neither a ...