Preparation for the Text

We assume that you know basic neuroanatomy and neurophysiology (but we review them anyway). The text teaches the necessary mental and manual skills for the neurologic examination (NE). Your teachers, then freed from teaching these skills by lecturing, can use precious class hours solely to examine patients (Pts). Then, if you can go directly after classes to the clinics and wards, you have the ideal situation for learning the NE.

At the outset, we find that students want to know just what constitutes an NE? Thus we start this text by outlining and demonstrating a full NE. Of course, you can't do the examination now, but you can use the outline in two ways: (1) refer back to it at the end of each chapter, to fit what you have learned into the total examination; (2) take it to the wards and clinics as a guide until you can wean yourself from it.

You must have on hand basic examining equipment (listed shortly) and some learning aids: colored pencils, a hand mirror, and for Chapter 4 a 2- to 3-in. foam rubber ball. Get all the items before starting.

Do the text in order. Skipping around invites confusion because each new step presumes mastery of the previous steps. Allow approximately one hour for each nine pages you want to study.

Because the text requires inspection of one's self and others, study in your own living quarters, preferably with a partner. Do all tests and make all observations called for. The doing results in active, permanent learning by developing your own powers of observation and manual skills. Most of your education to this point has consisted of memorizing lists or concepts compiled by someone else. Now you have to learn how to learn directly from the Pt through your own eyes, ears, and touch. That's what requires all of the doing and makes this text unique.

The text first outlines the NE of the conscious, responsive Pt and then of the unconscious Pt. Beginning with Chapter 1, the text then explains how to do each step.

A. How the history guides the examination

—William Landau, MD

1. You complete much of the NE during the history (Videos OSN 1-1, OSN 1-2, OSN 1-3 and OSN 1-4). Assess the Pt's word articulation, content of speech, and overall mental status. Inspect the facial features. Inspect the eye movements, blinking, and the relation of the palpebral fissures to the iris and look for en or exophthalmos. Inspect the degree of facial movement and expression and note any asymmetry. Observe how the Pt swallows saliva and breathes. Inspect the posture and look for tremors and involuntary movements.

2. Although you must do a minimum basic NE on every Pt, the history and preliminary observations focus attention on specific systems: motor or sensory systems, cranial nerves (CrNs), or cerebral functions. If the history suggests a spinal level lesion, successively test each dermatome for a sensory level and test the perianal region for loss or preservation of sacral sensation. If the history suggests a cerebral lesion, emphasize tests for memory, aphasia, apraxia, and agnosia.

3. Reproduce any circumstances, as discovered during the history, that trigger or aggravate symptoms:

   1. Dizziness when standing up: check for orthostatic hypotension.

   2. Episodic numbness and tingling in the extremities, syncope, or suspected epilepsy: Ask the Pt to hyperventilate.

   3. Weakness in climbing stairs: watch the Pt climb stairs.

   4. Trouble swallowing: give the Pt liquids and solids to swallow.

   5. Pathologic fatigability, particularly of CrN muscles: have the Pt make repetitive eye movements and measure the width of the palpebral fissure at rest and following 1 minute of upward gaze.

B. How to ensure an orderly, complete examination

Younger practitioners are reported to be deficient in physical diagnosis. Unless you do an orderly NE, you will forget some part of it. Neurologists will complete the same tests, although the sequence may differ. Avoid using shortcuts. To remember the sequence we recommend, lay out your instruments in the order of use. Replace each instrument in your bag as you finish with it. When you have replaced every instrument, you have done a complete examination. Lay out your instruments in this way:

A. General behavior and appearance

Is the Pt normal, hyperactive, agitated, quiet, or immobile? Is the Pt neat or slovenly? Does the Pt dress in accordance with age, peers, sex, and background?

B. Stream of talk: does the Pt converse normally?

Is the speech rapid, incessant, under great pressure, or is it slow and lacking in inflection and spontaneity? Is the Pt tangential, discursive, or unable to reach the conversational goal?

C. Mood and affective responses

Is the Pt euphoric, agitated, inappropriately gay, giggling or silent, weeping, or angry? Does the Pt's mood appropriately reflect the topic of the conversation? Is the Pt emotionally labile, histrionic, expansive, or overtly depressed?

D. Content of thought

Does the Pt correctly perceive reality or have illusions, hallucinations, delusions, misinterpretations, and obsessions? Is the Pt preoccupied with bodily complaints, fears of cancer or heart disease, or other phobias? Does the Pt suffer delusions of persecution, surveillance, and control by malicious persons or forces?

E. Intellectual capacity

Is the Pt bright, average, dull, or obviously demented or suffer from an intellectual disability?

F. Sensorium

1. Consciousness

2. Attention span

3. Orientation for time, place, and person

4. Memory, recent and remote

5. Calculation

6. Fund of information

7. Insight, judgment, and planning

A. Dysphonia

Difficulty in producing voice sounds (phonating).

B. Dysarthria

Difficulty in articulating the individual sounds or the units (phonemes) of speech, the f's, r's, g's, vowels, consonants, labials (CrN VII), gutturals (CrN X), and linguals (CrN XII).

C. Dysprosody

Difficulty with the melody and rhythm of speech, the accent of syllables, the inflections, intonations, and pitch of the voice.

D. Dysphasia

Difficulty in expressing or understanding words as the symbols of communication.

A. Inspect

1. What general impression does the Pt's face make? Do the features suggest a diagnostic syndrome? Any abnormalities in motility and emotional expression?

2. Inspect the head for shape and symmetry.

3. Inspect the hair of scalp, eyebrows, and beard.

4. Compare the palpebral fissures of the two eyes.

5. Inspect contours and proportions of nose, mouth, chin, and ears for malformations.

B. Palpate

For mature Pts, palpate the skull for lumps, depressions, or tenderness and palpate the temporal arteries. For infants, look for asymmetries palpate the fontanelles and sutures and record the occipitofrontal circumference.

C. Auscultate

For bruits over the neck vessels, eyes, temples, and mastoid processes.

D. Transilluminate

Attempt to transilluminate the skull of young infants.

A. Optic group

CrNs II, III, IV, and VI

1. Inspect the widths of palpebral fissures, the interorbital distance, and the relation of lid margins to the limbus. Look for ptosis and en- or exophthalmos.

2. Visual functions: Test each eye separately for acuity (central fields) by newsprint or the Snellen chart and test peripheral fields by confrontation. Test for inattention to simultaneous visual stimuli, if a cerebral lesion is suspected.

3. Ocular motility: Test range of ocular movements and smoothness of pursuit as Pt's eyes follow your finger through all fields of gaze. During convergence, check for miosis. Do the cover-and-uncover test. Check for nystagmus and note any effects of eye movements on it.

4. Record size of pupils. Test pupillary light reflexes.

5. Do ophthalmoscopy. Record presence or absence of venous pulsations.

B. Branchiomotor group and tongue

Branchiomotor CrNs V, VII, IX, X, and XI and somatomotor CrN XII for the tongue

1. CrN V: Inspect the masseter and temporalis muscle bulk and palpate masseter muscles when the Pt bites.

2. CrN VII: Test forehead wrinkling, eyelid closure, mouth retraction, whistling or puffing out of cheeks, and wrinkling of skin over the neck (platysma action). Listen to labial articulations. Check for Chvostek's sign in selected cases.

3. CrN IX and X: Listen for phonation, articulation (labial, lingual, and palatal sounds) and check swallowing, gag reflex, and palatal elevation. Remember the gag reflex is often absent in healthy adults, and studies in stroke patients have not shown a consistent relation between an absent gag reflex and swallowing problems.

4. CrN XI: Inspect sternocleidomastoid and trapezius contours and test strength of head movements and shoulder shrugging.

5. CrN XII: Lingual articulations, midline protrusion, lateral movements. Inspect for atrophy, and fasciculations.

6. If the history suggests pathologic fatigability, request repetitive movements (eye blinks, etc.), and tests for diplopia by prolonged lateral gaze.

7. Assess the rate, regularity, depth, and ease of respiration.

C. Special sensory group

CrNs I, VII, and VIII (CrN II already tested)

1. Olfaction (CrN I): Use aromatic, nonirritating substance, and test each nostril separately having the patients with eyes closed.

2. Taste (CrN VII): Use salt or sugar (test if CrN VII lesion is suspected).

3. Hearing (CrN VIII):

   1. Do otoscopy.

   2. Assess threshold and acuity by noting the Pt's ability to hear conversational speech and to hear a tuning fork, a watch tick, or finger rustling.

   3. If history or preceding tests suggest a hearing deficit, perform the air–bone conduction test of Rinne and the vertex lateralizing test of Weber.

   4. If the history suggests a cerebral lesion, test for auditory inattention to bilateral simultaneous stimuli and sound localization by using finger rustling.

   5. In infants, uncooperative, or unconscious Pts, try the auditopalpebral reflex as a crude screening test.

4. Vestibular function (CrN VIII): If the history indicates the need, test for the vestibulo-ocular reflex with the doll's eye maneuver (or caloric irrigation) and test for positional nystagmus.

D. Somatic sensation of the face

Test the sensation of the trigeminal area now to obviate returning to the face after examining the Pt's anogenital area and feet

1. Corneal reflex (CrN V–VII arc)

2. Light touch over the three divisions of CrN V

3. Temperature discrimination over the three divisions of CrN V

4. Pain perception over the three divisions of CrN V

A. Inspection

1. Inspect the Pt's posture and general activity level and look for tremors or other involuntary movements.

2. Gait testing: free walking, toe and heel walking, tandem walking, deep knee bend; have a child hop on each foot, skip, and run.

3. Undress the Pt and assess the somatotype (the build or body Gestalt) but preserve modesty with drapes or underwear.

4. Observe the size and contour of the muscles. Look for atrophy, fasciculations, hypertrophy, asymmetries, and joint malalignments.

5. Search the entire skin surface for lesions, in particular neurocutaneous stigmata such as caféau-lait spots.

B. Palpate muscles

If on inspection they seem atrophic, or hypertrophic or the history suggests tenderness or spasms

C. Strength testing

1. Shoulder girdle: Try to press the arms down after the Pt abducts them to shoulder height (Table 7-2). Look for scapular winging.

2. Upper extremities: Test biceps, triceps, wrist dorsiflexors, grip, and the strength of finger abduction and extension.

3. Abdominal muscles: Have the Pt do a sit up. Watch for umbilical migration.

4. Lower extremities: Test hip flexors, abductors and adductors, knee flexors, foot dorsiflexors, invertors, and evertors. (The previous deep knee bend tested the knee extensors, and toe walking tested the plantar flexors.)

5. Grade strength on a scale from 0 to 5 or describe as paralysis or severe, moderate, or minimal weakness, or normal. Record the pattern of any weakness such as proximal versus distal, right versus left, or upper extremity versus lower extremity.

D. Muscle tone and range of movements

Manipulate the joints to test for spasticity, clonus, rigidity or hypotonia, and range of movements.

E. Muscle stretch (deep) reflexes

Grade responses 0 to 4 (Table 7-3) and designate whether clonic. See Fig. NE-1.

1. Jaw jerk (CrN V afferent; CrN V efferent)

2. Biceps reflex (C5–6)

3. Brachioradialis reflex (C5-6)

4. Triceps reflex (C7–8)

5. Finger flexion reflex (C7–T1)

6. Quadriceps reflex (knee jerk; L2–4)

7. Medial Hamstrings reflex (L5–S1)

8. Triceps surae reflex (ankle jerk; S1–2)

9. Toe flexion reflex (S1–2)

F. Percussion of muscle

Percuss the thenar eminence for percussion myotonia and test for a myotonic grip if the Pt has generalized muscular weakness.

G. Skin and muscle (superficial) reflexes

1. Abdominal skin and muscle reflexes (upper quadrants T8–9; lower quadrants T11–12) elicited by scraping the skin tangential to or toward the umbilicus. Look for umbilical migration (Beevor sign) in Pts suspected of having thoracic spinal cord lesions.

2. Cremasteric reflex (afferent L1; efferent L2) elicited by scratching the skin of the medial thigh.

3. Anal pucker reflex (S4–5) and bulbocavernosus reflex (S3–S4) in Pts suspected of having sacral or cauda equina lesions.

4. Elicit the plantar reflex (Babinski maneuver; afferent Sl; efferent L5–S1–2).

H. Cerebellar system (gait and hypotonia tested previously)

1. Finger-to-nose and rapid alternating hand movements

2. Heel-to-knee movement

I. Nerve root stretching tests

1. Do leg raising tests in Pts with low back or leg pain:

   1. The straight-knee leg raising test (Lasegue sign)

   2. The bent-knee leg raising test (Kernig sign)

2. In Pts with suspected meningeal irritation, test for nuchal rigidity and concomitant leg flexion (Brudzinski sign) and do the leg raising tests.

A. Superficial sensory modalities (include trigeminal area if not previously tested)

1. Light touch over hands, trunk, and feet

2. Temperature discrimination over hands, trunk, and feet

3. Pain perception over hands, trunk, and feet

B. Deep sensory modalities

1. Test vibration perception at fingers and toes

2. Test position sense of fingers and toes by using the fourth digits

3. Test for astereognosis

4. Do the directional scratch test

5. Romberg (swaying) test

C. Determine the distribution pattern of any sensory loss

Dermatomal, peripheral nerve(s), plexus, central pathway, or nonorganic

1. Do a complete mental status examination, emphasizing tests of the sensorium (Section II of this outline).

2. Test higher level sensory functions, if the history or mental status examination suggests a cerebral lesion: test for graphagnosia, finger agnosia, poor two-point discrimination, right or left disorientation, topagnosia, and tactile, auditory, and visual inattention to bilateral simultaneous stimuli. Test for tactile inattention to simultaneous ipsilateral stimulation of face and hand and of foot and hand.

1. Write a three-line summary of the pertinent positive historical and physical findings. (If you can't summarize it in three lines, you don't understand the problem.)

2. Write down a provisional clinical diagnosis and outline the differential diagnosis.

3. Make a list of the clinical problems.

4. Develop a sequential plan of management for

   1. Diagnostic tests to differentiate the diagnostic possibilities

   2. Therapy: state the therapeutic goals

   3. Management of the emotional, educational, and socioeconomic problems that the illness causes the Pt

   4. Identification of and evaluation of other persons now known as "at risk" because of the Pt's illness, if the illness is infectious, genetic, or environmentally induced

For the unknown Pt brought in off the street, two examiners are desirable, one for the emergency management of the Pt, and the other to obtain a history. Contact family, friends, police, the Pt's past physicians, or anyone who witnessed the events when the Pt lost consciousness. Ask about:

1. Possibility of head trauma.

2. A seizure disorder.

3. Insulin/diabetes mellitus, alcohol.

4. A recent change in mood, behavior, thinking, or neurologic condition.

5. Access to depressant medications or street drugs.

6. Allergies, insect bites, and other causes of anaphylactic shock.

7. Heart, liver, lung, or kidney disease.

8. Past hospitalizations for serious health problems.

9. Consider red herrings. Ask about any signs, such as abnormal pupils or strabismus, that may antedate the current episode of unconsciousness and confuse the diagnosis.

On first approaching the comatose Pt, the examiner must follow a specific ritual, summarized by the ABCDEE mnemonic. This ritual detects any of the five H's that threaten the brain: Hypoxia, Hypotension, Hypoglycemia, Hyperthermia, and Herniation.

1. A and B = Airway and Breathing. Ensure that the Pt has an open airway and is breathing. Otherwise the brain, which requires a continuous supply of O₂ and glucose, will start to die within 5 minutes of total oxygen deprivation.

2. C = Circulation. The blood must circulate to deliver O₂ and glucose to the brain. Breathing and circulation must be restored within minutes.

3. D = Dextrose. The circulating blood must contain enough dextrose to nourish the brain.

4. EE = Examine the Eyes. Examination of pupillary size and reactions, the optic fundi, and the position and movement of the eyes spontaneously and in response to the vestibulo-ocular reflex reveals more about the neurologic status of the unconscious Pt than any other steps in the examination. Fixed pupils and fixed eyes indicate trouble.

5. Measure the body temperature.

1. Check respiration: Observe the rate and rhythm of respiration. Note the Pt's color and verify air exchange by inspection, palpation, or auscultation. Look for suprasternal retraction and abdominal respiration. For inspiratory stridor, pull the mandible forward and reposition the Pt. For apnea, intubate and assist ventilation with an Ambu bag or ventilator and O₂ as needed. Note any odors such as alcohol. Before any neck maneuvers, stabilize the neck and spine, in case the Pt has had a neck injury.

2. Check circulation: Palpate and auscultate the precordium. If the Pt has no heartbeat, start cardiac resuscitation. Palpate the carotid and femoral pulses. Inspect for jugular vein distention and pedal edema. Take blood pressure.

   1. With hypotension, treat for shock. Secure an intravenous line and restore blood volume with normal saline or, Ringer lactate, or whole blood or blood substitutes. See Section IV for processing of a blood sample.

   2. With hypertension, consider a heart or brain attack (acute stroke) or hypertensive encephalopathy as the cause for the unconsciousness. Consider antihypertensive medication, but lower the blood pressure gradually over hours.

3. Check blood sugar level: Prick the Pt's finger for a glucose oxidase tape test (Dextrostix). Give 50 mL of 50% glucose intravenously stat for demonstrated or suspected hypoglycemia. Add 100 mg of thiamine daily if the Pt is suspected of being an alcoholic.

4. Check the eyes: Record the pupillary size in millimeters. Use a scale. Do not guess. Check the pupillary light reflex. With unilaterally or bilaterally dilated pupils that do not react to light, notify a neurosurgeon stat.

   1. Inspect for ptosis and spontaneous blinking and perform the eyelid release test and corneal reflex.

   2. Examine ocular alignment, position, and motility:

      1. Record alignment and the position of the eyes.

      2. Record any spontaneous movements of the eyes.

      3. Check the vestibulo-ocular reflex by the doll's eye test, unless a cervical injury is suspected. Otherwise, do caloric irrigation, if no ocular movements are elicited.

      4. Do ophthalmoscopy. Record presence or absence of venous pulsations and the condition of the optic disc. Active venous pulsations virtually exclude increased intracranial pressure as the cause of unconsciousness.

   3. Test faciociliary and spinociliary reflexes.

   4. Remove contact lenses to preserve the corneas.

   5. Consider administering naloxone, if pinpoint pupils suggest opiate intoxication.

   6. Do not instill pupillo-active drugs.

5. Record the Pt's temperature.

6. Inspect and palpate the Pt's head: Look for localized edema or swelling from recent trauma. Look for blood behind the ear (Battle sign) and around the eyes (raccoon eyes) and for blood or cerebrospinal fluid from the nose. Do an otologic examination to look for blood behind the eardrum, perforated tympanic membrane, or cerebrospinal fluid otorrhea.

7. Test for nuchal rigidity: Avoid neck manipulation, if a neck injury is suspected. In that case, obtain cervical spine films.

8. Inspect the Pt for persistent diagnostic postures, spontaneous movements, or patterned or repetitive movements:

   1. Note whether the Pt makes spontaneous and equal movements of the face and all four extremities or lies still in a flaccid or compliant, dumped-in-a-heap posture, indicating deep coma or flaccid quadriparesis.

   2. Look for a predominant posture:

      1. Persistent deviation of the eyes and head

      2. Opisthotonus

      3. Decerebrate (extensor) or decorticate (flexor) posturing

      4. Clenched jaws or immobile neck or extremities, indicating tetanus

   3. Check specifically for hemiplegia by looking for paralysis of the lower part of the face on one side and of the ipsilateral extremities, as opposed to spontaneous or pain-induced movements on the opposite side.

      1. The affected muscles in acute hemiplegia are usually flaccid (hypotonic). Do the eyelid release test. Look for flaccidity of the cheek manifested by retraction on inspiration and puffing out during expiration. Inflict pain by supraorbital compression to check for unilateral absence of grimacing. Test muscle tone by passive manipulation of all extremities and do the wrist-, arm-, and leg-dropping tests.

      2. Test the intact side of the hemiplegic Pt for paratonia (gegenhalten). Record the result of tonus testing as normal, flaccid, spastic, rigid, paratonia, or flexibilitas cerea (waxy flexibility). Waxy flexibility occurs in catatonic schizophrenia and some organic encephalopathies.

   4. Look for cyclic activities such as shivering, chewing movements, and tremors. Look for subtle manifestations of epilepsy such as eyelid fluttering, mouth twitching, myoclonic jerks, and finger or toe twitching.

9. Strip the Pt completely: Empty all of the Pt's pockets, purse, wallet, or belongings. Look for Identacards for diabetes or epilepsy, medications, suicide notes, or drug paraphernalia.

10. Search the entire skin surface: Look for needle marks indicating subcutaneous injections of insulin or intravenous injections, bruises, petechiae, entry wounds, and turgor. Roll the Pt over and check the back.

11. Elicit the muscle stretch reflexes: Begin with the glabellar tap to elicit the orbicularis oculi reflexes. Next, elicit the jaw jerk and work down through the customary stretch reflexes. Directly compare the reflexes on both sides of the body.

12. Try to elicit Chvostek sign: Tap on the face at the point anterior to the ear and just below the zygomatic bone.

13. Elicit the superficial reflexes: Abdominal, cremasteric, and plantar reflexes.

14. Attempt to elicit primitive reflexes: Sucking, and lip-pursing reflexes, grasp reflexes, forced groping, and traction responses.

15. Complete the physical examination: Abdominal palpation and percussion. Percuss for a distended bladder.

16. Initiate monitoring process and address Glasgow Coma Scale (Sum totalling between 3 and 15): See Fig. 12-1.

    1. Monitor pupillary size, equality and response to light, pulse, blood pressure, respiration, and temperature continuously or at regular frequent intervals. Consult a neurosurgeon about inserting an intracranial pressure monitor, if increased intracranial pressure is suspected.

    2. Record the Pt's level of consciousness by responses to voice, loud sound, light, and pain. Check the responses to pain inflicted by compression of the supraorbital notch and nail beds of all four extremities. Record the extremity response as none, extension, flexion, appropriate brushing, or movement on command.

    3. Proposed guideline for the neurologic examination in patients with altered levels of consciousness (Fleck and Biller, 2004, Table NE-2).

1. Draw blood sample and anchor intravenous catheter or central line, as needed:

   1. Blood sugar (in addition to preliminary dextrose test tape)

   2. Complete blood cell count and hematocrit

   3. Blood urea nitrogen

   4. Arterial blood gases, pH, and osmolality

   5. Electrolytes (Na, K, Ca, and Cl)

   6. TSH

   7. Toxicology screen on blood and urine

   8. Typing and cross-matching

2. Place a vial of the Pt's serum in the refrigerator for later chemical or toxicologic testing, as indicated by new information.

3. Obtain urine specimen. Use an external bag or catheterize, if the Pt is in-continent or has a distended bladder. Freeze a sample of urine for later testing, as indicated by new information. Test the first specimen for:

   1. Specific gravity

   2. Sugar and ketones

   3. Protein

   4. Consider a toxicology screen

4. Insert a nasogastric tube or orogastric tube (if patient suspected of having a skull base fracture or nasal injury) and collect stomach contents in case the Pt has ingested poison or fails to improve and the diagnosis remains obscure. Save a sample of the aspirate for toxicology screening. However, inserting the tube may induce vomiting or gagging, thereby increasing the intrathoracic and the intracranial pressure.

5. Consider immediate computed tomography (CT) or MRI of the head.

6. Consider electroencephalographic monitoring, if a postictal state or status epilepticus is suspected.

At the very least, assign the Pt to one of the five basic etiologic types of coma: intracranial lesion, toxic-metabolic disorder, anoxia, ischemia, or mental illness. See Fig. NE-2.

Additional neurologic tests to consider are magnetic resonance imaging (MRI), lumbar puncture (LP), and angiography. In general, CT or MRI should precede the LP because the scan may disclose the diagnosis or impending brain herniation, making the tap unnecessary or dangerous. Obtain radiographs of the cervical spine, if trauma is suspected.