Authors: Lewis, Steven L.
Title: Field Guide to the Neurologic Examination, 1st Edition
Copyright ©2004 Lippincott Williams & Wilkins
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– Neurologic Examination > Putting It All Together > Chapter 40 –
Performing a Complete Neurologic Examination
– Neurologic Examination > Putting It All Together > Chapter 40 –
Performing a Complete Neurologic Examination
Chapter 40
Performing a Complete Neurologic Examination
PURPOSE OF THE COMPLETE NEUROLOGIC EXAMINATION
The purpose of performing a complete neurologic
examination is to look for clues to the localization and mechanism of
your patient’s neurologic disease process.
examination is to look for clues to the localization and mechanism of
your patient’s neurologic disease process.
WHEN TO PERFORM THE COMPLETE NEUROLOGIC EXAMINATION
A complete neurologic examination should be performed on
all patients who present with symptoms that may be due to neurologic
dysfunction, such as disorders of consciousness or cognition,
dizziness, headache, vision, muscle strength or movement, sensory
function, gait, or balance. The neurologic examination should always be
performed after a neurologic history has been obtained.
all patients who present with symptoms that may be due to neurologic
dysfunction, such as disorders of consciousness or cognition,
dizziness, headache, vision, muscle strength or movement, sensory
function, gait, or balance. The neurologic examination should always be
performed after a neurologic history has been obtained.
As described in the preceding chapters, there are basic
examination elements that should be performed on all patients and basic
elements that can be omitted in some situations. For example, pin
sensation should be tested on patients who have a sensory complaint,
but it can reasonably be omitted in many patients who don’t. There are
also procedures that only need to be performed in specific clinical
situations, such as oculocephalic testing in the comatose patient, the
Dix-Hallpike maneuver in patients with possible positional vertigo, or
testing for meningismus in patients with acute headache; such clinical
scenario-specific neurologic examination procedures are discussed in Section 3, Neurologic Examination in Common Clinical Scenarios.
examination elements that should be performed on all patients and basic
elements that can be omitted in some situations. For example, pin
sensation should be tested on patients who have a sensory complaint,
but it can reasonably be omitted in many patients who don’t. There are
also procedures that only need to be performed in specific clinical
situations, such as oculocephalic testing in the comatose patient, the
Dix-Hallpike maneuver in patients with possible positional vertigo, or
testing for meningismus in patients with acute headache; such clinical
scenario-specific neurologic examination procedures are discussed in Section 3, Neurologic Examination in Common Clinical Scenarios.
NEUROANATOMY OF THE COMPLETE NEUROLOGIC EXAMINATION
The basic relevant neuroanatomy underlying each examination element is briefly described in the previous chapters.
EQUIPMENT NEEDED TO PERFORM THE COMPLETE NEUROLOGIC EXAMINATION
The items needed to perform the complete neurologic examination are listed in Chapter 1, Role of the Neurologic History and Examination in Neurologic Diagnosis.
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HOW TO PERFORM THE COMPLETE NEUROLOGIC EXAMINATION
The following, in the order shown, is one step-by-step
method of performing the complete neurologic examination in a typical
patient (elements of the examination that are optional depending on the
clinical situation are listed in parentheses):
method of performing the complete neurologic examination in a typical
patient (elements of the examination that are optional depending on the
clinical situation are listed in parentheses):
Examine the Mental Status
1. If any dysfunction of alertness, language, memory, or
any other aspect of cognitive function is suspected or is a concern, or
if an abnormality is suggested during your history-taking, formally
test mental status as discussed in Chapters 5, 6, 7 and 8; otherwise, informally assess mental status while taking the history and proceed to the examination of the cranial nerves.
any other aspect of cognitive function is suspected or is a concern, or
if an abnormality is suggested during your history-taking, formally
test mental status as discussed in Chapters 5, 6, 7 and 8; otherwise, informally assess mental status while taking the history and proceed to the examination of the cranial nerves.
Examine the Cranial Nerves
2. Look at the resting size and symmetry of the pupils (see Chapter 10, Examination of the Pupils).
3. Examine the response of each pupil to light (see Chapter 10, Examination of the Pupils).
4. (If indicated, test the pupillary response to near or test for an afferent pupillary defect, as described in Chapter 10, Examination of the Pupils.)
5. Perform a funduscopic examination to look at the optic discs (see Chapter 11, Funduscopic Examination).
6. (If indicated, assess visual acuity, as described in Chapter 12, Examination of Visual Acuity.)
7. Test visual fields to confrontation (see Chapter 13, Visual Field Examination).
8. Test eye movements: first test horizontal eye movements, then test vertical eye movements (see Chapter 14, Examination of Eye Movements).
9. (If indicated, test facial sensation, as described in Chapter 15, Examination of Facial Sensation.)
10. Test facial strength (see Chapter 16, Examination of Facial Strength).
11. (If indicated, check jaw strength, as described in Chapter 17, Examination of Jaw Strength.)
12. (If indicated, check hearing and air and bone conduction, as described in Chapter 18, Examination of Hearing.)
13. Look at palatal elevation to phonation (see Chapter 19, Examination of Palatal Function).
14. Assess that the protruded tongue is midline and that it can wiggle from side-to-side (see Chapter 20, Examination of Tongue Movement).
15. (If indicated, as described in Chapter 21,
Examination of the Sternocleidomastoid and Trapezius Muscles, check the
strength of the sternocleidomastoid and trapezius muscles.)
Examination of the Sternocleidomastoid and Trapezius Muscles, check the
strength of the sternocleidomastoid and trapezius muscles.)
16. (If indicated, examine taste, as described in Chapter 22, Examination of Taste.)
17. (If indicated, examine the patient’s sense of smell, as described in Chapter 23, Examination of Smell.)
Examine Motor Function
18. Test for drift of the outstretched arms (see Chapter 25, Examination of Upper Extremity Muscle Strength).
19. Look for fasciculations or atrophy in the muscles (see Chapter 24, Approach to the Motor Examination).
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20. Test upper extremity muscle strength (see Chapter 25,
Examination of Upper Extremity Muscle Strength). The following are
muscles that can be quickly and easily tested in all patients as a good
sampling of proximal and distal muscles in multiple root and nerve
distributions:
Examination of Upper Extremity Muscle Strength). The following are
muscles that can be quickly and easily tested in all patients as a good
sampling of proximal and distal muscles in multiple root and nerve
distributions:
-
Deltoid
-
Biceps
-
Triceps
-
Wrist extensors
-
Finger extensors
-
Interossei
Additional upper extremity muscles, as described in Chapter 25,
Examination of Upper Extremity Muscle Strength, may need to be tested
when weakness is found or you are trying to pinpoint a particular nerve
or root distribution of weakness.
Examination of Upper Extremity Muscle Strength, may need to be tested
when weakness is found or you are trying to pinpoint a particular nerve
or root distribution of weakness.
21. Test lower extremity muscle strength (see Chapter 26,
Examination of Lower Extremity Muscle Strength). The following can be
quickly and easily tested in all patients as a good sampling of
proximal and distal muscles in multiple root and nerve distributions:
Examination of Lower Extremity Muscle Strength). The following can be
quickly and easily tested in all patients as a good sampling of
proximal and distal muscles in multiple root and nerve distributions:
-
Hip flexors
-
Extension at the knees
-
Flexion at the knees
-
Foot dorsiflexion
-
Foot plantar flexion
Additional lower extremity muscles, as described in Chapter 26,
Examination of Lower Extremity Muscle Strength, may need to be tested
when weakness is found or you are trying to pinpoint a particular nerve
or root distribution of weakness.
Examination of Lower Extremity Muscle Strength, may need to be tested
when weakness is found or you are trying to pinpoint a particular nerve
or root distribution of weakness.
22. (If indicated, assess tone, as described in Chapter 27, Examination of Tone.)
Examine Sensory Function
23. Test vibration sense (and position sense, if indicated), as described in Chapter 30, Examination of Vibration and Position Sensation.
24. (If indicated, examine pinprick sensation, as discussed in Chapter 29, Examination of Pinprick Sensation.)
25. (If indicated, examine cortical sensation, as described in Chapter 31, Examination of Cortical Sensation.)
Examine Cerebellar Function
26. Test the finger-to-nose maneuver (see Chapter 34, Testing of Upper Extremity Cerebellar Function).
27. (If indicated, test the heel-to-shin maneuver, as described in Chapter 35, Testing of Lower Extremity Cerebellar Function.)
Examine the Muscle Stretch Reflexes
28. Test the biceps jerks, triceps jerks, knee jerks, and ankle jerks (see Chapter 37, Examination of the Muscle Stretch Reflexes).
Examine for the Babinski Response
29. Test for the Babinski response on each foot (see Chapter 38, Testing for the Babinski Response).
Examine the Gait and Test for the Romberg Sign
30. Watch the patient walk (see Chapter 39, Examination of Gait.)
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31. Watch the patient perform a tandem gait (see Chapter 39, Examination of Gait).
32. (If indicated, watch the patient walk forward on his or her heels and then on his or her toes, as described in Chapter 39, Examination of Gait.)
33. Test for the Romberg sign (see Chapter 32, Romberg Testing).
NORMAL FINDINGS
Normal findings for each component of the neurologic examination are discussed in previous chapters.
ABNORMAL FINDINGS
Abnormal findings for each component of the neurologic examination are discussed in previous chapters.
ADDITIONAL POINTS
-
The items listed in How to Perform the
Complete Neurologic Examination (even excluding the examination
elements in parentheses) constitute a thorough neurologic examination.
With practice, this examination can be performed quickly and easily,
and it can give you a good idea of the integrity of your patient’s
central and peripheral nervous system; any abnormalities you find
should help you in localizing your patient’s neurologic dysfunction. -
There is no single correct order or way
to perform a neurologic examination. The method described in How to
Perform the Complete Neurologic Examination, starting with the mental
status, then proceeding down from the head (cranial nerves) and ending
with the toes (the Babinski sign) and gait, is one common method.
Choose an order that you are comfortable with and try to be consistent
to avoid forgetting important examination elements. It’s usually a good
idea to do all of the examination elements of a category together
(e.g., perform all muscle strength testing together as one component of
the examination, starting with the upper extremities and proceeding to
the lower extremities).