The examination is completed by observing the patient arise from a chair, stand and walk. An abnormality of stance or gait may be the most prominent or only neurologic abnormality, as in certain cerebellar or frontal lobe syndromes; and an impairment of posture and highly automatic adaptive movements in walking may provide diagnostic clues in the early stages of diseases such as Parkinson disease. Having the patient walk in tandem on a straight line may bring out a lack of balance and walking on the sides of the soles may elicit dystonic postures in the hands and trunk. Hopping or standing on one foot may also betray a lack of balance or weakness. Standing with feet together and eyes closed will bring out disequilibrium due to sensory loss (Romberg test) that is usually attributable to a disorder of the large diameter sensory fibers in the nerves and posterior columns of the spinal cord. Disorders of gait are discussed in Chap. 6.
The Screening Neurological Examination
In the situation of a patient without neurologic symptoms, brevity is desirable but any test that is undertaken should be done carefully and recorded. Accurate recording of negative data may be useful in relation to some future illness that requires examination. As indicated in Table 1-4, the patient’s orientation, insight, judgment, and the integrity of language function are readily assessed in the course of taking the history. With respect to the cranial nerves, the size of the pupils and their reaction to light, ocular movements, visual and auditory acuity, and movements of the face, palate, and tongue should be tested. Observing the bare outstretched arms for atrophy, weakness (pronator drift), tremor, or abnormal movements; checking the strength of the extended and outstretched fingers; inquiring about sensory disturbances; and eliciting the biceps, brachioradialis, and triceps reflexes are usually sufficient for the upper limbs. Inspection of the legs while the feet, toes, knees, and hips are actively flexed and extended; elicitation of the patellar, Achilles, and plantar reflexes; testing of vibration and position sense in the fingers and toes; and assessment of coordination by having the patient alternately touch his nose and the examiner’s finger and run his heel up and down the front of the opposite leg, and observation of walking complete the essential parts of the neurologic examination.
This entire procedure adds only a few minutes to the physical examination but the routine performance of these simple tests provides clues to the presence of disease of which the patient is not aware. For example, the finding of absent Achilles reflexes and diminished vibratory sense in the feet and legs alerts the physician to the possibility of diabetic or nutritional neuropathy, even when the patient does not report symptoms.
Although subject to obvious limitations, careful examination of the stuporous or comatose patient yields considerable information concerning the function of the nervous system. It is remarkable that, with the exception of cognitive function, almost all parts of the nervous system, including the cranial nerves, can be evaluated in the comatose patient. The demonstration of signs of focal cerebral or brainstem disease or of meningeal irritation is useful in the differential diagnosis of diseases that cause stupor and coma. The adaptation of the neurologic examination to the comatose patient is described in Chap. 16.
THE ANXIOUS, DEPRESSED, PSYCHOTIC, OR HYSTERICAL PATIENT
One is compelled in the examination of psychiatric patients to be unusually critical of their statements and reports or symptoms. Many people, even those without psychiatric conditions, are highly suggestible and may display changes in sensory and motor function. The depressed patient, for example, may perceive impaired memory or weakness when actually there is neither amnesia nor reduced power, or the sociopath or hysteric may feign paralysis. The opposite is as often true: psychotic patients may make accurate observations of their symptoms, only to have them ignored because of their mental state. It is well to keep in mind that patients with even the most extreme psychiatric disease are subject to all of the neurologic conditions typical of others of their age.