The neurologic examination, as commonly done, includes the major categories listed in Table 4.1. Although the examination does not have to be performed in any particular sequence, and every physician develops his own routine for the examination, it is customary to record the neurologic examination in the general format outlined in Table 4.1, or with minor modifications.

The complete neurologic examination can be a complex and arduous undertaking. In fact, few neurologists do a truly complete exam on every patient. As with the general physical examination, the history focuses the neurologic examination so that certain aspects are emphasized in a given clinical situation. The exam done on a typical patient with headache is not the same as that done on a patient with low back pain, or dementia, or cerebrovascular disease. The examination should also be adapted for the circumstances. If the patient is in pain or apprehensive, it may initially focus on the area of complaint, followed later by a more thorough assessment. Only a brief examination may be possible for unstable or severely ill persons until their condition stabilizes. With comatose, combative or uncooperative patients, a compulsively complete examination is an impossibility. However, in each of these situations at least some maneuvers are employed to screen for neurologic dysfunction that is not necessarily suggested by the history. A rapid “screening” or “mini” neurologic examination may initially be adequate for persons with minor or intermittent symptoms. Every patient does not require every conceivable test, but all require a screening examination. The findings on such a screening examination determine the emphasis of a more searching subsequent examination. There are a number of ways to perform a screening examination. Table 4.2 details such an abbreviated examination from DeJong’s The Neurologic Examination.

There are two basic ways to do a traditional neurologic examination, regional and systemic. A system approach evaluates the motor system, then the sensory system, and so on. A regional approach evaluates all the systems in a given region, such as the upper extremities, then the lower extremities. The screening exam outlined in Table 4.3 is an amalgam of the regional and system approaches geared for speed and efficiency. The concept is an examination that requires the nervous system to perform at a high level, relying heavily on sensitive signs, especially the flawless execution of complex functions. If the nervous system can perform a complex task perfectly, it is very unlikely there is significant pathology present, and going through a more extensive evaluation is not likely to prove productive. A neurologic examination that assesses complex functions and seeks signs that are sensitive indicators of pathology is efficient and not overly time consuming.

The examination begins with taking the medical history, which serves as a fair barometer of the mental status. Patients who can relate a logical, coherent, pertinent, and sensible narrative of
their problem will seldom have abnormalities on more formal bedside mental status testing. On the other hand, a rambling, disjointed, incomplete history may be a clue to the presence of some cognitive impairment, even though there is no direct complaint of thinking or memory problems from the patient or the family. Similarly, psychiatric disease is sometimes betrayed by the patient’s demeanor and style of history giving. If there is any suggestion of abnormality from the interaction with the patient during the history taking phase of the encounter, then a more detailed mental status examination should be carried out. Other reasons to do a formal mental status examination are discussed in Chapter 5. Simple observation is often useful. The patient’s gait, voice, mannerisms, ability to dress and undress, and even handshake (grip myotonia) may suggest the diagnosis.

The Table 4.3 screening examination continues by doing everything that requires use of a penlight. Begin by noting the position of the eyelids and the width of the palpebral fissures bilaterally. Check the pupils for light reaction with the patient fixing at distance. If the pupillary light reaction is normal and equal in both eyes, checking the pupillary near reaction is not necessary. Continue by assessing extraocular movements in the six cardinal positions of gaze, having the patient follow the penlight. Be sure the patient has no diplopia or limitation of movement, and that ocular pursuit movements are smooth and fluid. With the eyes in primary and eccentric positions, look for any nystagmus. The eye examination is discussed in more detail in Chapters 9 and 10. With the light still in hand, prepare to examine the pharynx and oral cavity. Examination of trigeminal motor function is accomplished merely by watching the patient’s jaw drop open prior to examining the mouth
and throat. When the pterygoids are unilaterally weak, the jaw invariably deviates toward the weak side on opening. This deviation, while subtle, is a sensitive indicator of trigeminal motor root pathology. Observe the tongue for atrophy or fasciculations. Have the patient phonate and be sure the median raphe of the palate elevates in the midline. There is little to be gained by checking the gag reflex if the patient has no complaints of dysphagia or dysarthria and there is no reason from the history to suspect a brainstem or cranial nerve lesion. Routine elicitation of the gag reflex is rarely informative and is unpleasant for the patient. Have the patient protrude the tongue and move it from side to side.