Ageneral physical examination (PE) usually accompanies a neurologic examination (NE). The extent of the general PE done depends on the circumstances and may range from minimal to extensive. The general PE in a neurologic patient need not be so detailed or painstaking as in a complicated internal medicine patient, but must be complete enough to reveal any relevant abnormalities. There are many excellent textbooks on physical diagnosis that provide an extensive discussion of general PE techniques.

Even the most compulsive internist doing a “complete physical” performs an NE the average neurologist would be consider cursory. In contrast, the neurologist performs a more complete NE, but only as much general PE as the circumstances dictate. Both are concerned about achieving the proper balance between efficiency and thoroughness. The internist or other primary care practitioner would like to learn how to incorporate the NE into the general PE; the neurologist would like to incorporate as much of the general PE as possible into the NE. In fact, any NE, even a cursory one, provides an opportunity to accomplish much of the general PE simply by observation and a few additional maneuvers.

The general examination begins with observation of the patient during the interview. Even the patient’s voice may be relevant, as hoarseness, dysphonia, aphasia, dysarthria, confusion, and other things of neurologic significance may be apparent even at that early stage. An HEENT exam is a natural byproduct of an evaluation of the cranial nerves. When examining the pupils and extraocular movements, take the opportunity to note any abnormalities of the external eye and ocular adnexa, such as conjunctivitis, exophthalmos, lid retraction, lid lag, xanthelasma, or jaundice. When examining the mouth, as an extension of the general PE, search for any intraoral lesions, leukoplakia, or other abnormality. When examining the optic disc, also examine the retina for any evidence of diabetic or hypertensive retinopathy. While examining neurologic function in the upper extremities, there is ample opportunity to observe for the presence of clubbing, cyanosis, nail changes, hand deformity, arthropathy and so forth to complete the upper extremity examination portion of the general physical examination. Examining the legs and feet for strength, reflexes, sensation, and plantar responses provides an opportunity to coincidentally look at the skin and nails. Check for pretibial edema, leg length discrepancy, swollen or deformed knee or ankle joints, or any other abnormalities. Note the pattern of hair growth, any dystrophic changes in the nails, and feel the pulses in the feet. Do anything else necessary for the lower extremity portion of the general PE. An evaluation of gait and station provides a great deal of information about the musculoskeletal system. Note whether the patient has any orthopedic limitations, such as a varus
deformity of the knee, genu recurvatum, or pelvic tilt. Gait testing also provides a convenient opportunity to examine the lumbosacral spine for tenderness and range of motion. After listening for carotid bruits, it requires little additional effort to palpate the neck for masses and thyromegaly.

The NE can thus serve as a core around which a general PE can be built. At the end of a good NE, one has only to listen to the heart and lungs and palpate the abdomen to have also done a fairly complete general PE. Sometimes it is not so important to do a skillful general PE as to be willing to do any at all, as some findings are obvious if one merely takes the trouble to look. Although there is virtually no part of the general PE that may not occasionally be noteworthy in a particular circumstance, some parts of the general PE are more often relevant and important in patients presenting with neurologic complaints. The general PE as particularly relevant for neurologic patients follows.