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Chapter 207. The Neurologic Examination

David J. Likosky, MD, SFHM; Scott Andy Josephson, MD

  1. What elements of the history and examination are most useful in lesion localization?

  2. What elements of the neurologic examination can be assessed at the bedside without formal testing?

  3. What tests can be performed on the unresponsive patient?

  4. 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 directed, 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 neurologic examination.

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Case 207-1

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 focus should be, first, on localizing the lesion and, second, on developing a differential diagnosis. Missed diagnoses are common in neurology when jumping to a conclusion before establishing where the problem may lie. Tempo is helpful: is the process waxing and waning, as in delirium, steadily progressive, as in dementia, or in a stepwise decline, as from multiple strokes? During which activities is weakness more pronounced: rising from a chair, carrying heavy loads, or brushing or washing hair, as with proximal weakness, or opening a jar, opening a car door, or turning a key in a lock, as with distal weakness? Is the sensory phenomenon negative, such as the numbness resulting from a stroke, or positive, 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. He might have been discharged with the diagnosis of unexplained syncope and gone on to have a seizure at an inopportune time. With a careful history, he leaves instead with a ...

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