The thoroughness and focus of the neurologic examination must be governed by the type of clinical problem presented by the patient. To spend a half hour or more testing cerebral, cerebellar, cranial nerve, and sensorimotor function in a patient seeking treatment for a simple compression palsy of an ulnar nerve is pointless and uneconomical. Conversely, if the main problem relates to hand function, a detailed examination of the motor, sensory and higher order functions of the hand are undertaken. The examination must also be modified according to the condition of the patient. Obviously, many parts of the examination cannot be carried out in a comatose patient; also, infants and small children, as well as patients with psychiatric disease, must be examined in special ways. Similarly, the examination in acute situations that require urgent resolution must be necessarily compressed to address to essential minimum that allows intelligent initial steps.
When an abnormal finding is detected, whether cognitive, motor, or sensory, it becomes necessary to analyze the problem in a more elaborate fashion. Details of these sensitive examinations are addressed in appropriate chapters of the book and, cursorily, below.
The neurologic examination is ideally performed and recorded in a relatively uniform manner in order to avoid omissions and facilitate the subsequent analysis of records. Some variation in the order of examination from physician to physician is understandable, but each examiner over time establishes a consistent pattern. If certain portions are intentionally not performed, these omissions should be stated so that those reading the description at a later time are not left wondering whether an abnormality was not previously detected.
Portions of the general physical examination that may be particularly informative in the patient with neurologic disease should be included. For example, examination of the heart rate and blood pressure, as well as carotid and cardiac auscultation, may be essential in a patient with stroke. Likewise, the skin and eyes can reveal a number of conditions that pertain to congenital, metabolic, and infectious causes of neurologic disease. Aspects of general appearance, such as obesity or cachexia, may offer guidance to the likelihood of certain systemic illnesses.
The Detailed Examination of Patients With Neurologic Symptoms
An inordinately large number of tests of neurologic function have been devised, and it is not proposed to review all of them here. Many tests are of doubtful value or are repetitions of simpler ones and to perform all of them on one patient would be unproductive. The danger with all clinical tests is to regard them as indicators of a particular disease rather than as ways of uncovering disordered functioning of the nervous system. The following approaches are relatively simple and provide the most useful information.
Numerous guides to the examination of the nervous system are available (see the references at the end of this chapter). For a full account of these methods, the reader is referred to monographs on the subject, including those of Biller and colleagues (DeMyer’s), Spillane (Bickerstaff’s) Campbell (DeJong’s The Neurological Examination), and of the staff members of the Mayo Clinic, each of which approaches the subject from a different point of view.
Testing of Higher Cortical Functions
Broadly speaking, the mental status examination has two main components, although the separation is somewhat artificial: the psychiatric aspects, which incorporate affect, mood, and normality of thought processes and content; and the cognitive aspects, which include the level of consciousness, awareness (attention), language, memory, visuospatial, and other executive abilities. These functions are tested in detail if the patient’s history or behavior has provided a reason to suspect some defect.