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Key Clinical Questions

  • image What elements of the history and examination are most useful in lesion localization?

  • image What elements of the neurologic examination can be assessed at the bedside without formal testing?

  • image What tests can be performed on the unresponsive patient?

  • image What scales and tools are used to document the findings of the neurologic exam?

The neurologic examination is central to the evaluation of patients with neurologic complaints. It relies heavily on the history and on hypothesis-driven physical testing. The neurologic examination can provide a great deal of information quickly. Even when it is not diagnostic, it guides the appropriate choice of imaging and ancillary testing. However, if it is performed in a cursory fashion, one can easily miss clues to a diagnosis that may not be apparent on imaging. This chapter reviews the essential elements of the neurologic examination in evaluating patients in the hospital.


The history allows the hospitalist to narrow the range of diagnostic testing and perform a more focused and higher yield neurologic examination.

CASE 104-1

A 57-year-old right-handed man presents with an episode of syncope while typing a manuscript. He recalls no prior episodes but does have a history of well-controlled hypertension and hyperlipidemia. You are called by the emergency department physician to admit the patient to telemetry and rule out an arrhythmia. The patient recalls similar episodes that he has had for as long as he can remember. They were bothersome during school but are brief and infrequent now. He also notes that they were worse when he was tired.

The patient’s physical examination was unrevealing. A computed tomography (CT) scan of his brain was negative, but an electroencephalogram (EEG) showed occasional epileptiform discharges from the left hemisphere. The patient was begun on anticonvulsants at a very low dose and has had no further episodes.

When taking the neurologic history, the hospitalist should focus first on localizing the lesion, and then on developing a differential diagnosis. Missed diagnoses are common in neurology when one jumps to a conclusion before establishing where the problem lies. Tempo is helpful. Does the process wax and wane, as in delirium? Is it steadily progressive, as in dementia? Or does decline occur in a stepwise fashion, as with multiple strokes? In patients with muscle weakness, pay attention to the pattern of weakness. Difficulty rising from a chair, carrying heavy loads, or brushing or washing hair suggests proximal weakness. Problems with opening a jar, opening a car door, or turning a key in a lock suggest distal weakness. In patients with sensory symptoms, is there loss of sensation (negative phenomena), such as the numbness resulting from stroke, or inappropriate sensation (positive phenomena), such as tingling from nerve root compression?

Without a detailed history, this patient might have been admitted to telemetry and had extensive and inappropriate cardiac investigations. ...

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