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
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 ...