The Neurologic Examination

A Fateful Diagnosis

A 62-year-old woman is referred by her family physician to a neurologist. She has been feeling exhausted for several months. Recently, she has also been suffering from muscle cramps, and she has noticed that food occasionally “goes down the wrong pipe.” The neurologist’s examination reveals the following:

Head and cranial nerves: Gag reflex not clearly elicitable, all findings otherwise normal.

Speech: Mildly slurred.

Upper and lower limbs: Asymmetric, marked atrophy of various muscles, no clear abnormality of muscle tone, surprisingly brisk reflexes even in the muscles that are markedly weak and atrophic, visible fasciculations.

Babinski reflex weakly elicitable bilaterally. Coordination normal. Sensation intact in all modalities.

Stance and gait: Marked difficulty standing on the toes and heels due to weakness.

Psychopathologic state: Patient worried and anxious, otherwise normal.

Neuropsychological state: No evident deficits.

General physical examination: Impaired nutritional state and mildly impaired general state of health, blood pressure mildly elevated, cardiovascular examination otherwise normal. Chest clear, abdomen soft, all peripheral pulses palpable.

Assessment: The patient is a 62-year-old woman with muscle atrophy and weakness but no accompanying sensory disturbance. This constellation of findings is present only in myopathy or a disease of the ventral horns of the spinal cord. The fasciculations point toward ventral horn dysfunction rather than myopathy. A disease affecting the nerve roots or peripheral nerves might cause muscle atrophy and weakness, but would also be expected to cause sensory deficits and hypo- or areflexia. This patient’s reflexes are brisker than normal, indicating that her condition affects the pyramidal tracts as well—an inference solidly confirmed by the Babinski sign. Combined dysfunction of the ventral horns and pyramidal tracts is the clinical hallmark of amyotrophic lateral sclerosis, and this diagnosis appears highly likely from the physical findings. The patient’s mildly slurred speech indicates bulbar involvement.

Although many highly informative ancillary tests are available, it would be an error to work up neurologically abnormal patients with only neuroimaging and other high-technology diagnostic procedures. Rather, the neurologist must take a thorough history, perform a full, meticulous clinical neurologic examination, and then document all findings in full. On the basis of these findings, the neurologist can decide what additional tests to order next, in case any are needed.

In this chapter, the components of a systematic neurologic examination (including a neuropsychological examination, if indicated) are described in detail, along with the main abnormal findings. The information provided here should enable the examining physician to localize the underlying lesion in the nervous system anatomically on the basis of the findings. Anatomic localization does not, in itself, reveal the etiology of the problem; further information from the history and additional tests will be needed for this.

3.1 Basic Principles of the Neurologic Examination

Key Point

Neurologic diseases can often be diagnosed on the basis of a carefully elicited history in combination with the physical examination. To ensure completeness, the examining physician should examine all patients according to the same general scheme.

One may either examine the individual components of the nervous system in a particular sequence (cranial nerves, reflexes, and motor, sensory, and autonomic function) or conduct the examination along topographic lines (head, upper limbs, trunk, lower limbs). The presentation in this chapter is topographically organized.

Neurology stands by itself as an independent medical specialty and field of research. Most neurologic illnesses affect only the nervous system. Nonetheless, general medical illnesses often manifest themselves with neurologic symptoms and signs (cf. section ▶ 6.8). The clinical neurologic examination must therefore always include a general physical examination.

The practicing neurologist should emphasize the neurologic aspects of the physical examination without neglecting its general aspects.

Here are some basic principles of physical examination:

The examiner must talk to the patient, briefly explaining the purpose of individual steps in the examination where appropriate. This affords the examiner the opportunity to obtain more information on certain aspects of the clinical history, if necessary.

In principle, the neurologic examination should always be complete and should always be performed in the same sequence, though the examiner is free to use whatever sequence he or she prefers. The individual components of the examination are listed in ▶ Table 3.1. In certain exceptional situations, or on repeated follow-up, a highly experienced clinician may choose to perform only a partial examination. This is generally to be avoided, however, as even the best neurologist can miss something important in this way. A thorough, methodical examination also helps reassure the patient that the physician is competent and attentive.

**Table 3.1** The neurologic examination
Region	Findings
General	Blood pressure, pulse
	Weight, height
	Temperature
	Heart
	Lungs
	Lymph nodes (enlarged?)
	Peripheral pulses (palpable?)
Cognition and behavior	Handedness (right or left)
	Level of consciousness (awake, somnolent, stuporous, comatose)
	Behavior (normal, abnormal)
	Mood (normal, depressed, euphoric)
	Orientation (day, month, year, location)
	Language Production (normal, aphasic, dysarthric, hoarse) Comprehension Repetition Naming, word-finding
	Memory History (clear, vague, unobtainable) Short-term memory (number sequence forward and backward; words)
	Apraxia? (use of toothbrush, comb, and hammer)
	Neglect? (none, visual, somatosensory, motor)
Head and cranial nerves	Head freely mobile, no meningismus
	Skull not tender to percussion
	No supra- or infraorbital point tenderness
	Carotid pulsations strong bilaterally, without bruits
	Temporal artery pulsations strong bilaterally, without tenderness
	No meningismus
	No bruits
	No occipital point tenderness
	Perioral reflexes not exaggerated
	Olfactory nerve (CN I)
	Coffee correctly identified by smell in both nostrils (spontaneously named/chosen from list)
	Optic nerve (CN II)
	Corrected visual acuity (distance): R/L
	Visual fields full to confrontation
	Optic discs normal bilaterally
	Oculomotor, trochlear, and abducens nerves (CN III, IV, and VI)
	Eye movements full and coordinated
	Eye position parallel, cover test normal
	No pathologic nystagmus
	Pupils equal, round, midsized, and symmetric, with prompt reaction to light and convergence
	Trigeminal nerve (CN V)
	Sensation in the face intact
	Corneal reflex symmetrically elicitable
	Masseter strong bilaterally
	Facial nerve (CN VII)
	Spontaneous mimesis normal
	Voluntary movement of facial muscles normal
	Vestibulocochlear nerve (CN VIII)
	Hearing subjectively normal
	Finger-rubbing heard in both ears
	Weber test: not lateralized
	Head-impulse test: normal bilaterally
	VOR suppression test normal
	Glossopharyngeal and vagus nerves (CN IX and X)
	Palatal veil symmetric at rest, elevates symmetrically
	Gag reflex intact
	Swallowing subjectively unimpaired
	Accessory nerve (CN XI)
	Sternocleidomastoid strength and bulk full and symmetric
	Trapezius strength and bulk full and symmetric
	Hypoglossal nerve (CN XII)
	Tongue symmetric, protrudes in the midline, freely mobile
Upper limbs	Bulk normal bilaterally Tone normal bilaterally Full mobility throughout Raw strength normal in all muscle groups (weakness should be graded on scale of ▶ Table 3.5) Postural testing normal bilaterally, without sinking or pronator drift Rapid alternating movements performed well bilaterally No rebound phenomenon Finger-tapping Finger–nose test accurate bilaterally, no intention tremor No hand or finger tremor Reflexes: Biceps, triceps, and brachioradialis reflexes symmetric, of medium strength Mayer reflex elicitable bilaterally Hoffmann sign, Trömner reflex not exaggerated bilaterally Sensation bilaterally intact to touch Pain sensation bilaterally intact Temperature sensation bilaterally intact Two-point discrimination < 5 mm bilaterally Position sense in the fingers bilaterally intact Vibration sense bilaterally intact Stereognosis bilaterally intact, prompt Coin recognition bilaterally intact
Trunk	Spine unremarkable, no tenderness to percussion Sensation on trunk intact; “saddle” sensation intact Reflexes: Abdominal skin reflex symmetrically intact Cremaster reflex bilaterally present (males only) Small Schober index: …/… cm Finger-to-floor distance: …/… cm
Lower limbs	Bulk normal bilaterally Tone normal bilaterally Full mobility throughout Raw strength normal in all muscle groups (weakness should be graded on scale of ▶ Table 3.5) Lasègue sign negative bilaterally No nerve trunk tenderness Postural testing (supine position) normal bilaterally, without sinking Heel–knee–shin test accurate bilaterally Reflexes: Quadriceps reflex and Achilles reflex symmetric, of medium strength Babinski response absent bilaterally Gordon reflex negative bilaterally Oppenheim reflex negative bilaterally Sensation bilaterally intact to touch Pain sensation bilaterally intact Temperature sensation bilaterally intact Vibration sense bilaterally intact Position sense in the toes bilaterally intact Graphesthesia (number recognition) good on both legs
Stance and gait	Patient can stand up normally from a sitting position Upright stance Romberg test negative (with various positions of the head) Can stand on either leg for 5 seconds Normal gait with normal accessory movements Normal length of steps Number of steps needed to turn 180 degrees Walks well on heels bilaterally Walks well on tiptoes bilaterally Steady tandem gait Can hop on either leg Postural stability intact No gait deviation with eyes closed
Abbreviations: CN, cranial nerve; VOR, vestibulo-ocular reflex. Note: If this table, or one like it, is used in practice to document the findings of the clinical neurological examination, the examiner should note all abnormal findings in the appropriate place and place a check (✓) or plus sign (+) next to all examined items that are normal. The record will then show which (if any) elements of the examination have been omitted. Items in italics should, in principle, be examined in every patient. Only experienced examiners should perform a restricted neurologic examination.

Patients should be examined unclothed, after being given clear instructions about which clothes to remove, usually everything but their underwear. The spine cannot be examined if the upper body is covered; if the patient is wearing socks, sensation cannot be tested in the feet, and the Babinski reflex cannot be elicited.

Although the examination should always be systematic and complete, the tentative diagnosis (or diagnoses) suggested by the history will direct the clinician to pay particular attention to certain aspects of the examination. There is no sense in the mechanical, unthinking performance of a rigidly identical examination on every patient.

Deviating from the usual order of examination may be advisable for psychological reasons. For example, if the patient mainly has symptoms in the lower limbs or the back, one can begin the examination with the spine.

As soon as possible after the examination is completed, the examiner should document the findings in writing. Global statements such as “Neuro OK” are worthless. The findings can be summarized in an outline such as the one provided in ▶ Table 3.1. The main purpose of precise documentation is to let the clinician follow the development of a disease process from one examination to the next. It is also obviously indispensable for medicolegal reasons.

Moreover, certain findings should be quantified or numerically graded, particularly muscle strength (see ▶ Table 3.5). Sensory disturbances should be documented precisely in terms of their topography and extent.