Performing a Complete Neurologic Examination
PURPOSE OF THE COMPLETE NEUROLOGIC EXAMINATION
The purpose of performing a complete neurologic examination is to look for clues to the localization and mechanism of your patient’s neurologic disease process.
WHEN TO PERFORM THE COMPLETE NEUROLOGIC EXAMINATION
A complete neurologic examination should be performed on all patients who present with symptoms that may be due to neurologic dysfunction, such as disorders of consciousness or cognition, dizziness, headache, vision, muscle strength or movement, sensory function, gait, or balance. The neurologic examination should always be performed after a neurologic history has been obtained.
As described in the preceding chapters, there are basic examination elements that should be performed on all patients and basic elements that can be omitted in some situations. For example, pin sensation should be tested on patients who have a sensory complaint, but it can reasonably be omitted in many patients who don’t. There are also procedures that only need to be performed in specific clinical situations, such as oculocephalic testing in the comatose patient, the Dix-Hallpike maneuver in patients with possible positional vertigo, or testing for meningismus in patients with acute headache; such clinical scenario-specific neurologic examination procedures are discussed in Section 3, Neurologic Examination in Common Clinical Scenarios.
NEUROANATOMY OF THE COMPLETE NEUROLOGIC EXAMINATION
The basic relevant neuroanatomy underlying each examination element is briefly described in the previous chapters.
EQUIPMENT NEEDED TO PERFORM THE COMPLETE NEUROLOGIC EXAMINATION
The items needed to perform the complete neurologic examination are listed in Chapter 1, Role of the Neurologic History and Examination in Neurologic Diagnosis.
HOW TO PERFORM THE COMPLETE NEUROLOGIC EXAMINATION
The following, in the order shown, is one step-by-step method of performing the complete neurologic examination in a typical patient (elements of the examination that are optional depending on the clinical situation are listed in parentheses):
Examine the Mental Status
1. If any dysfunction of alertness, language, memory, or any other aspect of cognitive function is suspected or is a concern, or if an abnormality is suggested during your history-taking, formally test mental status as discussed in Chapters 5, 6, 7 and 8; otherwise, informally assess mental status while taking the history and proceed to the examination of the cranial nerves.
Examine the Cranial Nerves
2. Look at the resting size and symmetry of the pupils (see Chapter 10, Examination of the Pupils).
3. Examine the response of each pupil to light (see Chapter 10, Examination of the Pupils).
4. (If indicated, test the pupillary response to near or test for an afferent pupillary defect, as described in Chapter 10, Examination of the Pupils.)
5. Perform a funduscopic examination to look at the optic discs (see Chapter 11, Funduscopic Examination).
6. (If indicated, assess visual acuity, as described in Chapter 12, Examination of Visual Acuity.)
7. Test visual fields to confrontation (see Chapter 13, Visual Field Examination).
8. Test eye movements: first test horizontal eye movements, then test vertical eye movements (see Chapter 14, Examination of Eye Movements).
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