OVERVIEW OF THE NEUROLOGIC EXAMINATION
One of the single greatest challenges in performing the neurologic examination for the practicing neurohospitalist is simply recognizing that it is being performed. In a study of new interns evaluating patients with altered mental status, only 41% reported performing a neurologic examination. However, unless one plans to neither see one’s patient, nor listen to one’s patient, nor touch one’s patient, it is impossible to not perform at least some of the neurologic examination. The neurologic examination begins the moment the neurohospitalist lays eyes on the patient and listens as the patient attempts to speak.1-3
Although the neurologic examination may seem intimidating, in part due to the vagary of the language and the antiquity of the signs and symptoms elicited, an efficient neurologic examination can be performed in mere minutes while yielding a potential treasure-trove of information. Your time as a neurohospitalist is extremely valuable and limited—strive for efficiency in your performance. This outline of the neurologic examination strives for efficiency: the necessary neurologic tools (such as the reflex hammer) are removed once and only once, used to completion, and put away. Attempt to perform the neurologic examination the same way every time. Things that one does habitually become habit.
Before delving into specific components on the examination and the examination as it pertains to specific situations, it may be reasonable to sum up the efficient neurologic examination as the following:
Initial survey of the patient: what does the patient look like? Is there any evidence at first glance of facial asymmetry, eyelid ptosis, or focal weakness? Is there any evidence of a rest tremor (which is often best observed while the patient is seated and being interviewed).
Listen to the patient: are they able to understand questions and answer appropriately (with the absence of such implying a possible aphasia or more global encephalopathy, as well as indicating he or she has the ability to hear) and, if so, what is the sound of the patient’s voice? Does it sound normal or is it slurred (ie, dysarthric)?
If possible, when done with initial questions, have the patient stand up from the bed or chair and walk. In standing, do not allow the patient to use his or her arms. Rather, have the arms folded across the chest, isolating the proximal leg muscles.
Have the patient walk down the hall or at least in the room, if possible. In the hospital environment, the patient may not be able to do so due to weakness, intravenous lines, equipment, etc. However, if it can be done, even in a limited capacity, it can be valuable to the neurohospitalist. Have the patient walk away from you, watching the overall balance, the arm swing, and the clearance of the legs and feet. While the patient is walking away from you, have him or her walk on tip toes so you can see the heels clear ...