Body and Limb Position and Spontaneous Movements
Patients with acute monoparesis or hemiparesis have variable spontaneous movements of the affected limb(s). Often, comatose patients with acute hemiplegia lie with the affected leg externally rotated and occasionally have unilateral twitching, unilateral myoclonic jerks, or spontaneous unilateral or asymmetric bilateral decerebrate or decorticate movements (see
Chapter 6). Various metabolic disturbances may produce bilateral myoclonic jerks (seen with uremia) and asterixis (irregular flapping movements of the hands with the arms out straight and the wrists extended) in association with tremor and diffuse twitching (seen with hepatic failure, hypoglycemia, or hyponatremia).
General Appearance and Hygiene
These traits usually reflect the patient’s self-image and may provide information about underlying preexisting medical or neurologic conditions.
Specific Signs of Chronic Illness
Observation of some specific signs of chronic illness may provide information about the underlying pathophysiology for various neurologic signs and symptoms, including altered levels of consciousness. Although the odor of alcohol on a patient’s breath usually indicates alcohol intoxication, one must also consider superimposed subdural hematoma, other intracranial hemorrhage, trauma, seizure, Wernicke’s encephalopathy, or infection. Other examples are the smell of ketones, which often indicates diabetic ketoacidosis, and fetor hepaticus, which suggests liver failure. Lacerations on the lateral borders of the tongue (recent seizure), needle marks on the arms (drug intoxication), and skin ecchymoses and petechiae (recent trauma or bleeding disorder) may also be very helpful signs.
