One of the single greatest challenges in performing the neurologic examination for the practicing neurohospitalist is simply recognizing that it is being performed. In a study of new interns evaluating patients with altered mental status, only 41% reported performing a neurologic examination. However, unless one plans to neither see one’s patient, nor listen to one’s patient, nor touch one’s patient, it is impossible to not perform at least some of the neurologic examination. The neurologic examination begins the moment the neurohospitalist lays eyes on the patient and listens as the patient attempts to speak.1–3
Although the neurologic examination may seem intimidating, in part due to the vagary of the language and the antiquity of the signs and symptoms elicited, an efficient neurologic examination can be performed in mere minutes while yielding a potential treasure-trove of information. Your time as a neurohospitalist is extremely valuable and limited—strive for efficiency in your performance. This outline of the neurologic examination strives for efficiency: the necessary neurologic tools (such as the reflex hammer) are removed once and only once, used to completion, and put away. Attempt to perform the neurologic examination the same way every time. Things that one does habitually become habit.
Before delving into specific components on the examination and the examination as it pertains to specific situations, it may be reasonable to sum up the efficient neurologic examination as the following:
Initial survey of the patient: what does the patient look like? Is there any evidence at first glance of facial asymmetry, eyelid ptosis, or focal weakness? Is there any evidence of a rest tremor (which is often best observed while the patient is seated and being interviewed).
Listen to the patient: are they able to understand questions and answer appropriately (with the absence of such implying a possible aphasia or more global encephalopathy, as well as indicating he or she has the ability to hear) and, if so, what is the sound of the patient’s voice? Does it sound normal or is it slurred (ie, dysarthric)?
If possible, when done with initial questions, have the patient stand up from the bed or chair and walk. In standing, do not allow the patient to use his or her arms. Rather, have the arms folded across the chest, isolating the proximal leg muscles.
Have the patient walk down the hall or at least in the room, if possible. In the hospital environment, the patient may not be able to do so due to weakness, intravenous lines, equipment, etc. However, if it can be done, even in a limited capacity, it can be valuable to the neurohospitalist. Have the patient walk away from you, watching the overall balance, the arm swing, and the clearance of the legs and feet. While the patient is walking away from you, have him or her walk on tip toes so you can see the heels clear the ground. In doing so, you have tested the strength of the anterior foreleg muscles (the tibialis anterior).Watch how the patient turns back toward you. Is it normal or is it slow or en bloc? (Also see Chapter 29: Gait Disorders.)
As the patient walks back toward you, have the patient walk on heels (testing the gastrocnemius muscles) and then walk one foot in front of the other (tandem gait).
Have the patient stand in front of you with feet close together but not quite touching, have the patient reach out his or her arms with fingers spread wide apart, and instruct the patient to close his or her eyes. Observe the patient’s station for stability or sway (Romberg).
With the arms outstretched and eyes closed, have the patient touch the tip of each index finger to his or her nose, instructing the patient to touch the middle part of the nose as smoothly as possible.
Have the patient sit on the examination table or hospital bed. Is the patient able to do so? At this point in the examination, the practitioner already has gained knowledge about the patient’s speech/language function, lower extremity strength, and coordination.
Observe the patients face. Does the face appear symmetric? Are the palpebral fissures of roughly the same size?
Observe the patients pupils. Are they of the same size or of different caliber? If different, how different?
Have the patient look straight forward and examine the pupils with a bright light source for pupillary light response, testing each eye individually.
Have the patient look at the junction of the wall and the ceiling of the examination room, forcing the eyeballs upward and bringing the back of the eye into clear view for the funduscopic examination.
Hold your finger a few inches from the patient’s face. Have the patient track your finger as it moves from side-to-side, as well as vertically, then back toward the patient’s nose.
Have the patient smile and bite down. During the examination, try to get the patient to smile or laugh spontaneously at least once (as the facial nerve pathways for spontaneous smile and voluntary smile take different routes).
Examine the patient’s tongue while at rest for evidence of atrophy or fasciculations.
Have the patient turn his or her head side to side against resistance, and then shrug the shoulders. At this point in the examination, the practitioner has complete knowledge of cranial nerve function.
Observe the patient’s muscles at rest for evidence of atrophy or fasciculations. Muscle bulk cannot be observed beneath clothing. Patients that present with weakness must be examined in an examination gown. Fasciculations, if present, are often readily visible if one takes the time to view them. This is a literally a greatly overlooked examination skill (the true skill is the patience to do it) as the presence of fasciculations immediately localizes to the motor neuron or proximal nerve root.
Check the tone of the upper extremity muscles. Have the patient open and close the opposite hand as this may accentuate cogwheel rigidity.
Check muscle strength. It is the authors’ preference to routinely check each of the following movements: shoulder abduction (deltoid muscle, C5–C6 nerve root, upper trunk of the brachial plexus, posterior cord, axillary nerve), forearm flexion at the elbow (C5–C6 nerve root, upper trunk of the brachial plexus, anterior cord, musculocutaneous nerve), forearm extension at the elbow (C5–C6 nerve root, upper trunk of the brachial plexus, posterior cord, radial nerve), wrist flexion (C6–C7 nerve root, upper and middle trunk of the brachial plexus, anterior cord, median nerve), and finger abduction (finger spreading; C8–T1 nerve root, lower trunk of the brachial plexus, medial cord, ulnar nerve). In doing this sequence, the examiner has tested every relevant cervical nerve root, each component of the brachial plexus, and all major upper extremity nerves. If there is weakness detected, additional muscles supplied by a specific root and/or nerve can be tested further.
Check muscle stretch reflexes (MSRs). It is critical to have a reflex hammer of sufficient weight. It is the authors’ experience that stethoscopes are not adequate reflex hammers (fingers alone also typically fail to provide adequate force, except in the pathologically brisk patient). Patients are ideally lying flat for the examination of the upper extremity, or at least sitting comfortably in a relaxed state. The relevant upper extremity reflexes include the biceps (C5–C6 nerve root, musculocutaneous nerve), brachioradialis (C5–C6 nerve root, radial nerve), and triceps (C7–C8 nerve root, radial nerve). Finger flexors can also be tested. With the reflex hammer in hand, it is the authors’ preference to then test the lower extremity reflexes. For efficiency, a tool should only be taken out once. Relevant lower extremity reflexes include the patellar reflexes (L3–L4 nerve root, femoral nerve) and Achilles (S1–S2 nerve root, tibial nerve). The bottom of the foot should then be stroked while observing for flexor plantar responses or extensor response (Babinski sign; it is worth noting there is no “negative Babinski” in Neurology).
Lower extremity strength can be tested, although it should be pointed out that this has possibly already been done if the patient was able to walk. In having the patient stand (hip flexor muscles, L2–L4 nerve roots, femoral nerve), walk on toes (L4–L5 nerve roots, tibialis anterior muscle), and walk on heels (L5–S1 nerve roots, gastrocnemius muscle) all relevant nerve roots and major nerves have been tested. It is the authors’ preference as a matter of routine to examine the bulk of the extensor digitorum brevis by palpating the lateral foot with toes extended, as this muscle is typically absent in chronic neuropathies and radiculopathies.
As the reflex examination, starting in the upper extremities and working downward to the ankles, has brought the examiner to the patient’s feet, the sensory examination can easily follow working from the feet upward (which also makes pathophysiologic sense as most sensory disorders are length-dependent in nature).
The toes can be moved to assess for position sense. The patient should be able to detect a movement of as little as 1° excursion. If abnormal, check at the ankles, then knees, and so on until a level is reached that is normal. Findings should be noted as present, diminished, or absent.
With a 128-Hz tuning fork, check vibratory sense as the toes by striking the tuning fork with sufficient force. Again, continue to move upward until finding a level that is normal. The bony pelvic rim, lower rib, and clavicle can be used to assess for a sensory level. Check side-to-side; if the patient notes an asymmetry, try to quantify the difference (“If this side is 100, what is this side?”)
While the authors have found few things to be less reliable than examination of pinprick and light touch sensation, it is still done as a matter of routine. The broken-off edge of a cotton tip swab or single-use safety pin is often of sufficient sharpness. If an abnormality is noted, it is often useful to simply hand the sharp object to the patient and ask him or her to trace out the area that has reduced sensory response. The authors have rarely found a patient report of vague, patchy, sensory disturbance to be of significant localizing value.
With that, the routine neurologic examination has been completed. Though fairly long in text, this can typically be completed in 3–4 minutes.
Another great challenge of the neurologic examination is the seeming complexity and diversity of neuroanatomy and neurologic disease. From the novice to the expert, the nearly endless array of neurologic disorders, names, and syndromes can be daunting. However, when evaluating a patient and performing the neurologic examination, it may be helpful to keep in mind that for all of the complexity, most neurologic diseases affect either the central nervous system (CNS) or the peripheral nervous system (PNS), with only a select few diseases affecting both systems simultaneously. Localization in neurology, and thus the rapid determination of necessary ancillary neurologic testing, can be as simple in the hospital setting as localizing neurologic disease to the CNS or PNS.4
Critical neurologic examination findings that help best localize include:
Mental status examination findings (with alterations in mental status immediately indicating a disorder of the CNS).
The pupillary examination (specifically findings of pupil asymmetry, which should often be assumed to be central in nature until proven otherwise).
The presence of a sensory level localizing to the spinal cord.
The presence of pathologic upper motor neuron findings (hyper-reflexia and increased tone being the most crucial, as well as potentially mild weakness and mild muscle loss in the chronic state) indicating a CNS disorder.
Acquiring information related to the patient’s mental status does not require a specific “section” of the overall patient examination (ie, one does not need to pause and announce, “I am now going to examine your mental status”). As you acquire information about the patient, observe the way they act and listen to them speak; you are performing the mental status examination. Examination of speech, language, and mental status is one continuous accumulation of information by the examiner.
Note the general appearance and behavior of the patient. Make note of every detail possible: are they quiet or agitated, appear well groomed and appropriately dressed or unkempt, etc.?
Note the pattern of speech (covered further below).
Note the patient’s mood. Is it stable, labile, appropriate/inappropriate?
Consider the patient’s intellectual ability. Do they seem to have normal intelligence or findings suggestive of an intellectual disability or dementia?
Consider the patient’s overall “level of sensorium” (what is the “content of consciousness.”)
Sensorium, or our awareness of self, can be considered to include: consciousness; attention span; orientation for time, place, and person; memory (recent and remote); fund of information; insight, judgment, and planning; and calculation.
The state of consciousness reflects the level of arousal and the sum of cognitive functions of the brain.
Arousal depends on the integrity of physiologic mechanisms that take origin from the reticular formation.
Conscious behavior depends on relatively intact functional areas of the cerebral hemispheres that interact extensively and deeper activating structures housed in the brainstem, thalamus, and hypothalamus.
Focal lesions usually do not produce stupor and coma.
Pathologic processes that can impair consciousness include:
Conditions that widely and directly depress the functions of both cerebral hemispheres.
Abnormalities that depress or destroy the brainstem ascending reticular activating system (ARAS).
Testing of each of the above may include the following:
Consciousness: Is the patient awake and responsive? Are the responses indicative of someone aware of self and the environment?
Attention span: Can the patient attend long enough to comprehend and respond appropriately (can be tested by having the patient spell “WORLD” backward or recite the months of the year backward)?
Orientation: Is the patient aware of who they are, where they are, and when it is?
Memory: How well does the patient recall the details of their medical history? Test the patient’s memory with “trivia” appropriate to the patient’s perceived knowledge base (“Who are the last 5 presidents?”). Give the patient 3 unrelated objects to recall immediately and after several minutes. Ask the patient to recall relatively recent events (“What did you eat at your last meal?).
Fund of information: Ask the patient about current events. If they cannot discuss any—why not?
Insight, judgment, and planning: Ask what the patient plans to do. Are the plans realistic to your expectation of the patient?
Calculation: Test calculation by querying simple math questions, including the ability to subtract 7s serially from 100.
Are the patient’s responses emotionally appropriate in terms of quality and quantity (the patient’s affect)?
Blunted, bland, or indifferent affect occurs commonly in hysteria, schizophrenia, and bilateral frontal lobe lesions.
Emotional lability (excessively easy laughing/crying) occurs in diffuse brain diseases damaging particularly frontal areas.
Focal cognitive disorders of consciousness
Agnosia: “not knowing.” The inability to understand the meaning, import, or symbolic significance of ordinary sensory stimuli even though the appropriate sensory pathways and sensorium are intact. Agnosias will usually occur due to lesions of the association areas of the brain.
Agraphognosia (agraphesthesia): the graphic sense of numbers or letters written on the skin; the patient cannot identify a number or numbers traced in the palm.
Prosopagnosia: the inability to recognize faces in person or photos (but will recognize the person by voice and can describe the face as there is no visual disturbance); the causative lesion is usually in the inferomedial temporo-occipital region, often bilateral but usually right-sided if unilateral.
Autotopagnosia: the inability to locate, identify, and orient one’s body parts (“Touch your right hand to your left ear”); the causative lesion is usually near the left angular gyrus.
Anosognosia: lack of awareness of a bodily defect (patient is unaware of left-sided weakness and sensory loss); usually associated with right parietal lesions but can occur with acute left parietal lesions.
Inattention to double simultaneous cutaneous stimuli: the patient only recognizes one stimulus despite stimuli being applied to both limbs at the same time.
Apraxia: the inability to perform a voluntary act even though the motor system, sensory system, and mental status are relatively intact. The patient is often unaware of the deficit and can automatically perform some of the tasks that cannot be done voluntarily.
Dressing apraxias and constructional apraxias usually occur with right posterior parietal lesions.
Alexia without agraphia: patients are able to write but unable to read words (including those just written); due to a lesion in the left occipital lobe that extends to the posterior corpus callosum disconnecting the right visual cortex from language areas in the left temporal lobe.
Listen to the patient—how do they sound and do they make sense?
“Labial sounds” require strong lip action, “lingual sounds” (D, G, J) require strong tongue-tip elevation, and “vowel sounds” require palatal elevation.
“Dysphonia” refers to a disorder in the sound of speech related to the larynx (and inability to phonate); there is the production of crude vowels only.
“Dysarthria” refers to faulty articulation of speech (while the content, or language, is normal).
“Dysprosody” refers to abnormalities in intonations, melody, pauses, and phrasing that adds emotion to speech.
“Dysphasia” refers to a disturbance of language function.
Articulation can be tested with the “KLM test:” kuhkuhkuh tests the soft palate, la lala tests the tongue, and mi mimi tests the lips.
“Aphasia” is the inability to understand or express words as symbols for communication.
When attempting to converse with a patient, consider if the patient’s speech is fluent, if the patient comprehends, and if the patient is able to repeat.
Fluency refers to the rate, quantity, and ease of speech production.
Nonfluent speech has minimal word output (<50 words/min), shortened phrase length (1-4 words), with usually effortful production and poor articulation; nonfluency indicates damage to frontal language centers.5
Fluent speech has generous verbal output with normal phrase length, easy production, and appropriate articulation.
Comprehension requires the patient to understand the spoken language; comprehension impairment usually reflects damage to temporoparietal language regions.
Repetition is a distinct language function; impaired repetition occurs with damage to perisylvian language areas.
Listen for paraphasic errors and word-finding difficulty. Paraphasia is substitution of incorrect words or sounds for intended words.
Literal (phonemic) paraphasia: part of the work is misspoken (“apple” becomes “apfle”).
Global paraphasia: an entire incorrect word is substituted for the intended word (“apple” becomes “bicycle”).
Semantic paraphasia: substituted word is from the same semantic field (“apple” becomes “orange”).
Neologisticparaphasia: an entirely novel “word” is created (“apple” becomes “brifun”).
Anomia: word-finding difficulty.
Circumlocution: patients “talk around” words they fail to retrieve.
Putting it together:
Are they able to produce spontaneous speech?
Is the speech fluent or nonfluent? Are there paraphasic errors?
Is the patient able to repeat a complex sentence (“No ifs, ands, or buts”)
Is the patient able to comprehend?
Broca’s aphasia: nonfluent speech, impaired repetition, intact comprehension
Wernicke’s aphasia: fluent speech with paraphasias and neologisms, impaired repetition, a severely disturbed comprehension
Global aphasia: nonfluent speech, impaired repetition, impaired comprehension
Conduction aphasia: fluent speech with some phonemic paraphasias, impaired repetition, intact comprehension
Transcortical motor aphasia: nonfluent speech, intact repetition, and intact comprehension
Transcortical sensory aphasia: fluent speech with paraphasic errors and echolalia (automatic repetition of overheard phrases), preserved repetition, and intact comprehension
Mixed transcortical aphasia: minimal spontaneous speech, intact repetition, impaired comprehension
Ask the patient to read and write
Decreased reading comprehension is characteristic of delirium.
Writing disturbance is the most sensitive language abnormality in delirium; the most salient characteristics are abnormalities in the mechanics of writing: the formation of letters and words is indistinct, and words and sentences wander in different directions.
Many texts argue that gait is the single most important component in the neurologic examination, as it encompasses so many different systems (motor strength, sensation, coordination, vision to some extent). So, why is it often reserved for the end of the neurologic examination when it is the richest and most efficient aspect of the examination? If possible in the hospital setting, have the patient get out of bed (with assistance if needed), to observe gait. Accommodation for lines may be necessary. If the patient cannot stand and walk, it is important to consider that in the neurologic differential.
Have the patient arise from the bed or chair; have the patient place their hands on their shoulders.
Station refers to the patient’s manner of standing; in normal station, a person stands with the head up, chest out, and abdomen in.
Have the patient stand with feet close together but not touching and extend the arms out with fingers spread.
Romberg sign: the patient will sway or fall with eyes closed due to impaired proprioceptive pathways (which may be central or peripheral).
False Romberg sign: patient sways from the hips instead of ankles; may sway through a wide arc but regain balance.
In cerebellar disease, the patient may sway or fall with eyes open or closed.
Vermal lesion: may sway backward, forward, or to either side.
Hemispheric lesion: falls toward the affected side.
With the patient still standing, have the patient flex his or her neck so the chin touches the test. Patients may report a lightening-like pain that radiates down the spine or into a limb (Lhermitte sign, also known as the barber chair phenomenon).
A Lhermitte sign (which has been inaccurately recorded through time as a sign when it is actual a symptom as it is patient-reported) is highly suggestive of spinal cord pathology, particularly intrinsic demyelinating lesions due to multiple sclerosis, vitamin B12 deficiency, as well as far less common causes such as copper deficiency, nitrous oxide toxicity, and delayed radiation-induced myelopathy.
A “reverse Lhermitte sign” has also been reported: as opposed to flexing the neck, the patient extends the neck back, also resulting in a lightening-like pain; the etiology is often an extramedullary compressive source, such as a spinal meningioma or herniated disk.
Have the patient walk in the room or hall, examining normal gait, toe walking, heel walking, and tandem gait.
Spastic gait: stiff-legged with scissoring or legs and toe walking.
Ataxic gait: broad based, unsteady, often falling to one side.
Frontal gait: slow, shuffling, magnetic; patients can perform cycling movements on their backs better than how they can walk.
Parkinsonian gait: slow and shuffling; difficulty initiating gait, festination, and en bloc turns.
Dyskinetic gait: dance like (chorea), flinging (ballistic), or writhing (athetoid).
Ask the patient to extend the arms straight out, inspecting for wavering during volitional maintained posture (postural tremor).
Have the patient place their finger on the tip of their nose, inspecting for tremor that increases as the finger approaches the nose (intention type of kinetic tremor) and whether the patient fails to precisely place the tip of the finger to the tip of the nose (dysmetria).The examiner can also have the patient touch his or her nose, and then touch the examiner’s fingers held in front of the patient. It is important to stand far enough away from the patient that he or she has to reach; often times the examiner stands far too close.
Ask the patient to pat their thigh, striking the palm of the hand and then the back of the hand (dysdiadochokinesia).
Have the patient hold their arms out; inform them you will tap their arm; tap the arm firmly; patients with cerebellar disorders will overshoot on attempting to return to the original position quickly.
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