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In most patients, the physical examination confirms thoughts formulated during history taking that is often the key in patient evaluation. Time of onset, symptom progression, associated complaints, and exacerbating factors are important historical points to guide appropriate examination and other testing. The neurologic examination does not exist in isolation from the general physical examination or imaging procedures, and it rarely delineates a problem not already suggested by the patient’s history or general physical examination. Few findings of the neurologic examination are pathognomonic of clinical conditions or sufficiently specific that examination alone secures the diagnosis. Further complicating the value of the neurologic examination is that the sensitivity and specificity of different examination techniques have not been rigorously investigated, and the degree of interobserver variability is not known.

The idea of performing a “complete” examination in the ED is misleading, because most frequently a “complete” examination is neither required nor appropriate. An adequate examination is one that is sufficient for the task at hand. The examination detailed in this chapter is arbitrarily divided into eight sections, and basic and advanced levels are described for each section. Much of this information should be a review for the reader, but it is hoped that this simple framework will help with organization and in the approach to the patient.

Examination of children follows the same framework as that for adults, but even more information is gathered indirectly by observation. For example, interacting with a child playing with a toy or other object allows the examiner to assess vision, extraocular motion, coordination, and strength as the child reaches for and grasps the toy.1

Traditional neurologic formulation follows a three-tiered approach: (1) Is there a lesion of the nervous system? (2) Where is the lesion? and (3) What is the lesion?

History is the key to answering these questions, with the physical examination useful for confirmation. Findings should be clearly documented without the use of ambiguous terms or abbreviations. After data gathering by history and physical examination, possible answers to these questions can be formulated by integrating history and physical examination findings, which will guide the ED evaluation and disposition. This provides an introduction to problem formulation. More information is available in chapters on specific disease processes in this book and in other references listed at the end of this chapter.

Organization of the neurologic examination along a framework of subsections is a convenient technique. At the bedside, the clinician can mentally review the framework as he or she examines the patient and selects additional tests to explore possibilities suggested by the history. Some of the tests grouped in a section assess several aspects of nervous system function, and listing of tests in a particular section is for organizational convenience. The clinician should keep this organization in mind while at the bedside. For example, visual field testing, although technically a test of higher cortical function, is listed with ...

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