Authors: Campbell, William W.
Title: Pocket Guide and Toolkit to DeJong’s Neurologic Examination, 1st Edition
Copyright ©2008 Lippincott Williams & Wilkins
> Table of Contents > Section B
– History, Physical Examination, and Overview of the Neurologic
Examination > Chapter 3 – The General Physical Examination
– History, Physical Examination, and Overview of the Neurologic
Examination > Chapter 3 – The General Physical Examination
Chapter 3
The General Physical Examination
Ageneral physical
examination (PE) usually accompanies a neurologic examination (NE). The
extent of the general PE done depends on the circumstances and may
range from minimal to extensive. The general PE in a neurologic patient
need not be so detailed or painstaking as in a complicated internal
medicine patient, but must be complete enough to reveal any relevant
abnormalities. There are many excellent textbooks on physical diagnosis
that provide an extensive discussion of general PE techniques.
examination (PE) usually accompanies a neurologic examination (NE). The
extent of the general PE done depends on the circumstances and may
range from minimal to extensive. The general PE in a neurologic patient
need not be so detailed or painstaking as in a complicated internal
medicine patient, but must be complete enough to reveal any relevant
abnormalities. There are many excellent textbooks on physical diagnosis
that provide an extensive discussion of general PE techniques.
Even the most compulsive internist doing a “complete
physical” performs an NE the average neurologist would be consider
cursory. In contrast, the neurologist performs a more complete NE, but
only as much general PE as the circumstances dictate. Both are
concerned about achieving the proper balance between efficiency and
thoroughness. The internist or other primary care practitioner would
like to learn how to incorporate the NE into the general PE; the
neurologist would like to incorporate as much of the general PE as
possible into the NE. In fact, any NE, even a cursory one, provides an
opportunity to accomplish much of the general PE simply by observation
and a few additional maneuvers.
physical” performs an NE the average neurologist would be consider
cursory. In contrast, the neurologist performs a more complete NE, but
only as much general PE as the circumstances dictate. Both are
concerned about achieving the proper balance between efficiency and
thoroughness. The internist or other primary care practitioner would
like to learn how to incorporate the NE into the general PE; the
neurologist would like to incorporate as much of the general PE as
possible into the NE. In fact, any NE, even a cursory one, provides an
opportunity to accomplish much of the general PE simply by observation
and a few additional maneuvers.
The general examination begins with observation of the
patient during the interview. Even the patient’s voice may be relevant,
as hoarseness, dysphonia, aphasia, dysarthria, confusion, and other
things of neurologic significance may be apparent even at that early
stage. An HEENT exam is a natural byproduct of an evaluation of the
cranial nerves. When examining the pupils and extraocular movements,
take the opportunity to note any abnormalities of the external eye and
ocular adnexa, such as conjunctivitis, exophthalmos, lid retraction,
lid lag, xanthelasma, or jaundice. When examining the mouth, as an
extension of the general PE, search for any intraoral lesions,
leukoplakia, or other abnormality. When examining the optic disc, also
examine the retina for any evidence of diabetic or hypertensive
retinopathy. While examining neurologic function in the upper
extremities, there is ample opportunity to observe for the presence of
clubbing, cyanosis, nail changes, hand deformity, arthropathy and so
forth to complete the upper extremity examination portion of the
general physical examination. Examining the legs and feet for strength,
reflexes, sensation, and plantar responses provides an opportunity to
coincidentally look at the skin and nails. Check for pretibial edema,
leg length discrepancy, swollen or deformed knee or ankle joints, or
any other abnormalities. Note the pattern of hair growth, any
dystrophic changes in the nails, and feel the pulses in the feet. Do
anything else necessary for the lower extremity portion of the general
PE. An evaluation of gait and station provides a great deal of
information about the musculoskeletal system. Note whether the patient
has any orthopedic limitations, such as a varus
patient during the interview. Even the patient’s voice may be relevant,
as hoarseness, dysphonia, aphasia, dysarthria, confusion, and other
things of neurologic significance may be apparent even at that early
stage. An HEENT exam is a natural byproduct of an evaluation of the
cranial nerves. When examining the pupils and extraocular movements,
take the opportunity to note any abnormalities of the external eye and
ocular adnexa, such as conjunctivitis, exophthalmos, lid retraction,
lid lag, xanthelasma, or jaundice. When examining the mouth, as an
extension of the general PE, search for any intraoral lesions,
leukoplakia, or other abnormality. When examining the optic disc, also
examine the retina for any evidence of diabetic or hypertensive
retinopathy. While examining neurologic function in the upper
extremities, there is ample opportunity to observe for the presence of
clubbing, cyanosis, nail changes, hand deformity, arthropathy and so
forth to complete the upper extremity examination portion of the
general physical examination. Examining the legs and feet for strength,
reflexes, sensation, and plantar responses provides an opportunity to
coincidentally look at the skin and nails. Check for pretibial edema,
leg length discrepancy, swollen or deformed knee or ankle joints, or
any other abnormalities. Note the pattern of hair growth, any
dystrophic changes in the nails, and feel the pulses in the feet. Do
anything else necessary for the lower extremity portion of the general
PE. An evaluation of gait and station provides a great deal of
information about the musculoskeletal system. Note whether the patient
has any orthopedic limitations, such as a varus
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deformity
of the knee, genu recurvatum, or pelvic tilt. Gait testing also
provides a convenient opportunity to examine the lumbosacral spine for
tenderness and range of motion. After listening for carotid bruits, it
requires little additional effort to palpate the neck for masses and
thyromegaly.
The NE can thus serve as a core around which a general
PE can be built. At the end of a good NE, one has only to listen to the
heart and lungs and palpate the abdomen to have also done a fairly
complete general PE. Sometimes it is not so important to do a skillful
general PE as to be willing to do any at all, as some findings are
obvious if one merely takes the trouble to look. Although there is
virtually no part of the general PE that may not occasionally be
noteworthy in a particular circumstance, some parts of the general PE
are more often relevant and important in patients presenting with
neurologic complaints. The general PE as particularly relevant for
neurologic patients follows.
PE can be built. At the end of a good NE, one has only to listen to the
heart and lungs and palpate the abdomen to have also done a fairly
complete general PE. Sometimes it is not so important to do a skillful
general PE as to be willing to do any at all, as some findings are
obvious if one merely takes the trouble to look. Although there is
virtually no part of the general PE that may not occasionally be
noteworthy in a particular circumstance, some parts of the general PE
are more often relevant and important in patients presenting with
neurologic complaints. The general PE as particularly relevant for
neurologic patients follows.
VITAL SIGNS
Determining the blood pressure in both arms is useful in
patients with suspected cerebrovascular disease, and measuring the
blood pressure with the patient supine, seated, and upright may be
necessary in some circumstances. The pulse rate and character are
important, especially if increased intracranial pressure is suspected.
A bounding pulse occurs in aortic regurgitation or hyperthyroidism and
a small, slow pulse in aortic stenosis, all of which may have
neurologic complications. Abnormalities of respiration, such as
Cheyne-Stokes, Biot, or Kussmaul breathing may be seen in coma and
other neurologic disorders. Either hyperpnea or periods of apnea may
occur in increased intracranial pressure and in disturbances of the
hypothalamus.
patients with suspected cerebrovascular disease, and measuring the
blood pressure with the patient supine, seated, and upright may be
necessary in some circumstances. The pulse rate and character are
important, especially if increased intracranial pressure is suspected.
A bounding pulse occurs in aortic regurgitation or hyperthyroidism and
a small, slow pulse in aortic stenosis, all of which may have
neurologic complications. Abnormalities of respiration, such as
Cheyne-Stokes, Biot, or Kussmaul breathing may be seen in coma and
other neurologic disorders. Either hyperpnea or periods of apnea may
occur in increased intracranial pressure and in disturbances of the
hypothalamus.
GENERAL APPEARANCE
The general appearance of the patient may reveal
evidence of acute or chronic illness; fever, pain, or distress;
evidence of weight loss; abnormal posture of the trunk, head, or
extremities; the general level of motor activity; unusual mannerisms;
bizarre activities; restlessness; or immobility. Weight loss and
evidence of malnutrition may indicate hyperthyroidism, Alzheimer
disease, Whipple disease, celiac disease, or amyloidosis. The body fat
level and distribution, together with the hair distribution and the
secondary sexual development are important in the diagnosis of
endocrinopathies and disorders of the hypothalamus. Note any
outstanding deviations from normal development such as gigantism,
dwarfism, gross deformities, amputations, contractures, and
disproportion or asymmetries between body parts.
evidence of acute or chronic illness; fever, pain, or distress;
evidence of weight loss; abnormal posture of the trunk, head, or
extremities; the general level of motor activity; unusual mannerisms;
bizarre activities; restlessness; or immobility. Weight loss and
evidence of malnutrition may indicate hyperthyroidism, Alzheimer
disease, Whipple disease, celiac disease, or amyloidosis. The body fat
level and distribution, together with the hair distribution and the
secondary sexual development are important in the diagnosis of
endocrinopathies and disorders of the hypothalamus. Note any
outstanding deviations from normal development such as gigantism,
dwarfism, gross deformities, amputations, contractures, and
disproportion or asymmetries between body parts.
Specific abnormal postures may occur in diseases of the
nervous system. Spastic hemiparesis causes flexion of the upper
extremity with flexion and adduction at the shoulder, flexion at the
elbow and wrist, and flexion and adduction of the fingers; in the lower
extremity there is extension at the hip, knee, and ankle, with an
equinus deformity of the foot. In Parkinson disease and related
syndromes there is flexion of the neck, trunk, elbows, wrists, and
knees, with stooping, rigidity, masking, slowness of movement, and
tremors. In myopathies there may be lordosis, protrusion of the
abdomen, a waddling gait, and hypertrophy of the calves. Peripheral
nerve disease may cause wrist or foot drop or a claw hand. These
neurogenic abnormalities may be confused with deformities due to such
things as Dupuytren contracture, congenital pes cavus, changes due to
trauma or arthritis, development abnormalities, habitual postures, and
occupational factors.
nervous system. Spastic hemiparesis causes flexion of the upper
extremity with flexion and adduction at the shoulder, flexion at the
elbow and wrist, and flexion and adduction of the fingers; in the lower
extremity there is extension at the hip, knee, and ankle, with an
equinus deformity of the foot. In Parkinson disease and related
syndromes there is flexion of the neck, trunk, elbows, wrists, and
knees, with stooping, rigidity, masking, slowness of movement, and
tremors. In myopathies there may be lordosis, protrusion of the
abdomen, a waddling gait, and hypertrophy of the calves. Peripheral
nerve disease may cause wrist or foot drop or a claw hand. These
neurogenic abnormalities may be confused with deformities due to such
things as Dupuytren contracture, congenital pes cavus, changes due to
trauma or arthritis, development abnormalities, habitual postures, and
occupational factors.
Head
The skull houses the brain and abnormalities of the head
are common and often very important. Inspect the shape, symmetry, and
size of the head, noting any apparent abnormalities or irregularities.
Premature closure of cranial sutures can produce a wide variety of
abnormally shaped skulls. Other deformities or developmental anomalies
include hydrocephaly, macrocephaly, microcephaly, asymmetries or
abnormalities of contour, disproportion between the facial and the
cerebral portions,
are common and often very important. Inspect the shape, symmetry, and
size of the head, noting any apparent abnormalities or irregularities.
Premature closure of cranial sutures can produce a wide variety of
abnormally shaped skulls. Other deformities or developmental anomalies
include hydrocephaly, macrocephaly, microcephaly, asymmetries or
abnormalities of contour, disproportion between the facial and the
cerebral portions,
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scars,
and signs of recent trauma. In children, it is informative to measure
the head circumference. Dilated veins, telangiectatic areas, or
port-wine angiomas on the scalp or face may overlie a cerebral
hemangioma, especially when such nevi are present in the trigeminal
nerve distribution.
Palpation of the skull may disclose deformities due to
old trauma, burr hole or craniotomy defects, tenderness, or scars. If
there is a postoperative skull defect, note any bulging or tumefaction.
The size and patency of the fontanelles is important in infants.
Bulging of the fontanelles and suture separation can occur with
increased intracranial pressure in children. Meningoceles and
encephaloceles may cause palpable skull defects. Tumors may involve the
scalp and skull. Palpable masses involving the scalp or skull may be
metastatic carcinoma, lymphoma, leukemia, dermoid, or multiple myeloma.
Neurofibromas of the scalp occur in von Recklinghausen disease.
Localized swelling of the scalp may occur with osteomyelitis of the
skull. Exostoses may indicate an underlying meningioma. Hydrocephalus
that develops prior to suture closure often results in an enlarged,
sometimes massive, head. Frontal bossing is another sign of
hydrocephalus. Giant cell arteritis may cause induration and tenderness
of the superficial temporal arteries. Transillumination may be useful
in the diagnosis of hydrocephalus and hydranencephaly.
old trauma, burr hole or craniotomy defects, tenderness, or scars. If
there is a postoperative skull defect, note any bulging or tumefaction.
The size and patency of the fontanelles is important in infants.
Bulging of the fontanelles and suture separation can occur with
increased intracranial pressure in children. Meningoceles and
encephaloceles may cause palpable skull defects. Tumors may involve the
scalp and skull. Palpable masses involving the scalp or skull may be
metastatic carcinoma, lymphoma, leukemia, dermoid, or multiple myeloma.
Neurofibromas of the scalp occur in von Recklinghausen disease.
Localized swelling of the scalp may occur with osteomyelitis of the
skull. Exostoses may indicate an underlying meningioma. Hydrocephalus
that develops prior to suture closure often results in an enlarged,
sometimes massive, head. Frontal bossing is another sign of
hydrocephalus. Giant cell arteritis may cause induration and tenderness
of the superficial temporal arteries. Transillumination may be useful
in the diagnosis of hydrocephalus and hydranencephaly.
Percussion of the skull may disclose dullness on the
side of a tumor or subdural hematoma, or a tympanitic percussion note
in hydrocephalus and increased intracranial pressure in infants and
children. Auscultatory percussion (percussion over the mid-frontal area
while listening over various parts of the head with the stethoscope)
may reveal relative dullness on the side of a mass lesion or subdural
hematoma.
side of a tumor or subdural hematoma, or a tympanitic percussion note
in hydrocephalus and increased intracranial pressure in infants and
children. Auscultatory percussion (percussion over the mid-frontal area
while listening over various parts of the head with the stethoscope)
may reveal relative dullness on the side of a mass lesion or subdural
hematoma.
Auscultation of the head is sometimes useful. Bruits may
be heard best over the temporal regions of the skull, the eyeballs, and
the mastoids. Cephalic bruits may occur with angiomas, aneurysms,
arteriovenous malformations, neoplasms that compress large arteries,
and in the presence of atherosclerotic plaques that partially occlude
cerebral or carotid arteries. They may also occur in the absence of
disease. Ocular bruits usually signify occlusive intracranial
cerebrovascular disease. A carotid bruit may be transmitted to the
mastoid. An ocular bruit in a patient with an arteriovenous aneurysm
may disappear on carotid compression. Murmurs may be transmitted from
the heart or large vessels; systolic murmurs heard over the entire
cranium in children are not always of pathologic significance.
be heard best over the temporal regions of the skull, the eyeballs, and
the mastoids. Cephalic bruits may occur with angiomas, aneurysms,
arteriovenous malformations, neoplasms that compress large arteries,
and in the presence of atherosclerotic plaques that partially occlude
cerebral or carotid arteries. They may also occur in the absence of
disease. Ocular bruits usually signify occlusive intracranial
cerebrovascular disease. A carotid bruit may be transmitted to the
mastoid. An ocular bruit in a patient with an arteriovenous aneurysm
may disappear on carotid compression. Murmurs may be transmitted from
the heart or large vessels; systolic murmurs heard over the entire
cranium in children are not always of pathologic significance.
An evaluation of the facies (the facial expression) may
aid in neurologic diagnosis. Gross abnormalities are found in such
conditions as acromegaly, cretinism, myxedema, hyperthyroidism, and
Down syndrome. In some neurologic disorders there are characteristic
changes in facial expression and mobility, such as the fixed (“masked”)
face of parkinsonism, the immobile face with precipitate laughter and
crying seen in pseudobulbar palsy, the grimacing of athetosis and
dystonia, and the ptosis and weakness of the facial muscles seen in
some myopathies and myasthenia gravis.
aid in neurologic diagnosis. Gross abnormalities are found in such
conditions as acromegaly, cretinism, myxedema, hyperthyroidism, and
Down syndrome. In some neurologic disorders there are characteristic
changes in facial expression and mobility, such as the fixed (“masked”)
face of parkinsonism, the immobile face with precipitate laughter and
crying seen in pseudobulbar palsy, the grimacing of athetosis and
dystonia, and the ptosis and weakness of the facial muscles seen in
some myopathies and myasthenia gravis.
Eyes
Ophthalmologic abnormalities can provide many clues to
the etiology of neurologic disease as well as to the presence of
underlying systemic disease that may be causing neurologic
symptomatology. Examples of findings of possible neurologic relevance
include bilateral exophthalmos due to thyroid eye disease; unilateral
proptosis due to thyroid eye disease, carotid-cavernous fistula,
meningocele, encephalocele, or histiocytosis X; corneal clouding from
mucopolysaccharidosis; Brushfield spots on the iris due to Down
syndrome or Lisch nodules in neurofibromatosis; keratoconjunctivitis
sicca due to Sjögren syndrome or other collagen vascular diseases;
depositions of amyloid in the conjunctiva; herpes zoster ophthalmicus;
pigmented pingueculae due to Gaucher disease; Kayser-Fleischer rings in
Wilson disease; unilateral arcus senilis from carotid stenosis;
tortuous conjunctival vessels in ataxia telangectasia; scleritis in
Wegener granulomatosis; and nonsyphilitic interstitial keratitis in
Cogan syndrome.
the etiology of neurologic disease as well as to the presence of
underlying systemic disease that may be causing neurologic
symptomatology. Examples of findings of possible neurologic relevance
include bilateral exophthalmos due to thyroid eye disease; unilateral
proptosis due to thyroid eye disease, carotid-cavernous fistula,
meningocele, encephalocele, or histiocytosis X; corneal clouding from
mucopolysaccharidosis; Brushfield spots on the iris due to Down
syndrome or Lisch nodules in neurofibromatosis; keratoconjunctivitis
sicca due to Sjögren syndrome or other collagen vascular diseases;
depositions of amyloid in the conjunctiva; herpes zoster ophthalmicus;
pigmented pingueculae due to Gaucher disease; Kayser-Fleischer rings in
Wilson disease; unilateral arcus senilis from carotid stenosis;
tortuous conjunctival vessels in ataxia telangectasia; scleritis in
Wegener granulomatosis; and nonsyphilitic interstitial keratitis in
Cogan syndrome.
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Ears
Examination of the ears is particularly important in
patients with hearing loss or vertigo. It is important to exclude a
perforated tympanic membrane. Examination of the ear canal may reveal a
glomus tumor in a patient with jugular foramen syndrome, vesicles due
to herpes zoster infection, or evidence of a posterior fossa
cholesteatoma. CSF otorrhea may cause a clear or bloody ear discharge.
Before performing a caloric examination in a comatose patient it is
important to be certain the ear canals are clear and the tympanic
membranes intact.
patients with hearing loss or vertigo. It is important to exclude a
perforated tympanic membrane. Examination of the ear canal may reveal a
glomus tumor in a patient with jugular foramen syndrome, vesicles due
to herpes zoster infection, or evidence of a posterior fossa
cholesteatoma. CSF otorrhea may cause a clear or bloody ear discharge.
Before performing a caloric examination in a comatose patient it is
important to be certain the ear canals are clear and the tympanic
membranes intact.
Nose, Mouth, and Throat
Perforation of the nasal septum may be a clue to cocaine
abuse. A saddle nose may be a sign of congenital syphilis, evidence of
bacterial infection a sign of cavernous sinus thrombosis, and watery
drainage may be due to CSF rhinorrhea. In pernicious anemia the tongue
is smooth and translucent with atrophy of the fungiform and filiform
papillae, and associated redness and lack of coating (atrophic
glossitis). In thiamine deficiency the tongue is smooth, shiny,
atrophic, and reddened. A triple furrowed tongue is seen in myasthenia
gravis; lingua plicata in Melkersson-Rosenthal syndrome; and
macroglossia in amyloid, myxedema, and Down syndrome. Other potential
findings include xerostomia in Sjögren syndrome, a lead line along the
gums in lead toxicity, trismus in tetanus or polymyositis, and mucosal
ulceration in Behcet disease. Notched teeth are a sign of congenital
syphilis (Hutchinson teeth).
abuse. A saddle nose may be a sign of congenital syphilis, evidence of
bacterial infection a sign of cavernous sinus thrombosis, and watery
drainage may be due to CSF rhinorrhea. In pernicious anemia the tongue
is smooth and translucent with atrophy of the fungiform and filiform
papillae, and associated redness and lack of coating (atrophic
glossitis). In thiamine deficiency the tongue is smooth, shiny,
atrophic, and reddened. A triple furrowed tongue is seen in myasthenia
gravis; lingua plicata in Melkersson-Rosenthal syndrome; and
macroglossia in amyloid, myxedema, and Down syndrome. Other potential
findings include xerostomia in Sjögren syndrome, a lead line along the
gums in lead toxicity, trismus in tetanus or polymyositis, and mucosal
ulceration in Behcet disease. Notched teeth are a sign of congenital
syphilis (Hutchinson teeth).
Neck
Note any adenopathy, thyroid masses or enlargement,
deformities, tenderness, rigidity, tilting, or other abnormalities of
posture, asymmetries, changes in contour, or pain on movement. Normally
the neck can be flexed so that the chin rests on the chest, and rotated
from side to side without difficulty. Meningeal irritation may cause
nuchal rigidity, head retraction, and opisthotonos. Neck movement may
also be restricted with cervical spondylosis, cervical radiculopathy,
and dystonias. In the Klippel-Feil syndrome, syringomyelia, and
platybasia the neck may be short and broad, movement limited, and the
hairline low. The carotid arteries should be cautiously and lightly
palpated bilaterally, one at a time, and any abnormality or inequality
noted, followed by auscultation for carotid bruits.
deformities, tenderness, rigidity, tilting, or other abnormalities of
posture, asymmetries, changes in contour, or pain on movement. Normally
the neck can be flexed so that the chin rests on the chest, and rotated
from side to side without difficulty. Meningeal irritation may cause
nuchal rigidity, head retraction, and opisthotonos. Neck movement may
also be restricted with cervical spondylosis, cervical radiculopathy,
and dystonias. In the Klippel-Feil syndrome, syringomyelia, and
platybasia the neck may be short and broad, movement limited, and the
hairline low. The carotid arteries should be cautiously and lightly
palpated bilaterally, one at a time, and any abnormality or inequality
noted, followed by auscultation for carotid bruits.
Respiratory System and Thorax
Neurologic complications of pulmonary disease are
common. Note the respiratory rate, rhythm, depth, and character of
respirations. Pain on breathing, dyspnea, orthopnea, or shortness of
breath on slight activity may be significant. Respiratory insufficiency
is a frequent occurrence in neuromuscular disease. It may also be
necessary to examine the breasts and search for axillary
lymphadenopathy.
common. Note the respiratory rate, rhythm, depth, and character of
respirations. Pain on breathing, dyspnea, orthopnea, or shortness of
breath on slight activity may be significant. Respiratory insufficiency
is a frequent occurrence in neuromuscular disease. It may also be
necessary to examine the breasts and search for axillary
lymphadenopathy.
Cardiovascular System
The cardiovascular examination is important because of
the frequency of neurologic complications of hypertension,
atherosclerosis, endocarditis, arrhythmias, and valvular disease.
Evidence of atherosclerosis involving the peripheral blood vessels
often correlates with cerebrovascular disease.
the frequency of neurologic complications of hypertension,
atherosclerosis, endocarditis, arrhythmias, and valvular disease.
Evidence of atherosclerosis involving the peripheral blood vessels
often correlates with cerebrovascular disease.
Abdomen
Examination of the abdomen may reveal abnormal masses,
enlarged viscera, abnormal pulsations or respiratory movements, or the
presence of fluid. Hepatomegaly is common in cirrhosis, hepatitis,
carcinoma, and amyloidosis; splenomegaly is common in mononucleosis,
amyloidosis, and lymphoma. Ecchymosis of the flank may be evidence that
a lumbosacral plexopathy is due to retroperitoneal hematoma. Ascites
may be a clue to hepatic encephalopathy in a patient in a coma.
enlarged viscera, abnormal pulsations or respiratory movements, or the
presence of fluid. Hepatomegaly is common in cirrhosis, hepatitis,
carcinoma, and amyloidosis; splenomegaly is common in mononucleosis,
amyloidosis, and lymphoma. Ecchymosis of the flank may be evidence that
a lumbosacral plexopathy is due to retroperitoneal hematoma. Ascites
may be a clue to hepatic encephalopathy in a patient in a coma.
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Genitalia and Rectum
Examination of the genitalia, not often called for in
neurologic patients, could reveal a chancre or the ulcerations of
Behcet disease. The angiomas in Fabry disease are often found on the
scrotum. A rectal examination is often necessary in patients with
evidence of myelopathy or a cauda equina or conus medullaris syndrome.
neurologic patients, could reveal a chancre or the ulcerations of
Behcet disease. The angiomas in Fabry disease are often found on the
scrotum. A rectal examination is often necessary in patients with
evidence of myelopathy or a cauda equina or conus medullaris syndrome.
Spine
Examination of the spine is often important in
neurologic patients. Note any deformity, abnormality of posture or
motility, localized tenderness or muscle spasm. Tuberculosis and
neoplasms of the spine may cause a marked kyphosis (gibbus); muscular
dystrophy often results in an increased lumbar lordosis; and scoliosis
is common in syringomyelia and Friedreich ataxia. Localized rigidity
with a slight list or scoliosis and absence of the normal lordosis are
frequent symptoms of lumbosacral radiculopathy. Dimpling of the skin or
unusual hair growth over the sacrum suggest spinal dysraphism.
neurologic patients. Note any deformity, abnormality of posture or
motility, localized tenderness or muscle spasm. Tuberculosis and
neoplasms of the spine may cause a marked kyphosis (gibbus); muscular
dystrophy often results in an increased lumbar lordosis; and scoliosis
is common in syringomyelia and Friedreich ataxia. Localized rigidity
with a slight list or scoliosis and absence of the normal lordosis are
frequent symptoms of lumbosacral radiculopathy. Dimpling of the skin or
unusual hair growth over the sacrum suggest spinal dysraphism.
Extremities
Note any limb deformities, contractures, edema, or color
changes. Any variation from the normal in the size or shape of the
hands, feet, or digits, as well as deformities, joint changes,
contractures, pain or limitation of movement, localized tenderness,
wasting, clubbed fingers, or ulcerations may be significant. Edema may
be evidence of congestive heart failure or cardiomyopathy. Arthropathy
may be a sign of connective tissue disease, sarcoidosis, or Whipple
disease. Painless arthropathy (Charcot joint) occurs when a joint is
deafferented. Decreased peripheral pulses occur in Takayasu disease as
well as atherosclerosis. Acrocyanosis occurs in ergotism. Palmar
erythema may be a clue to alcohol abuse. Diseases of the nervous system
are found in association with such skeletal and developmental anomalies
as syndactyly, polydactyly, and arachnodactyly.
changes. Any variation from the normal in the size or shape of the
hands, feet, or digits, as well as deformities, joint changes,
contractures, pain or limitation of movement, localized tenderness,
wasting, clubbed fingers, or ulcerations may be significant. Edema may
be evidence of congestive heart failure or cardiomyopathy. Arthropathy
may be a sign of connective tissue disease, sarcoidosis, or Whipple
disease. Painless arthropathy (Charcot joint) occurs when a joint is
deafferented. Decreased peripheral pulses occur in Takayasu disease as
well as atherosclerosis. Acrocyanosis occurs in ergotism. Palmar
erythema may be a clue to alcohol abuse. Diseases of the nervous system
are found in association with such skeletal and developmental anomalies
as syndactyly, polydactyly, and arachnodactyly.
Skin
A careful examination of the skin can provide important
evidence regarding the nature of a neurologic condition. Findings of
possible neurologic relevance include: spider angiomas in alcohol
abuse; erythema chronicum migrans in Lyme disease; purpura and
petechiae in thrombotic thrombocytopenic purpura, meningococcemia, and
Rocky Mountain spotted fever (all of which may have prominent
neurologic manifestations); livedo reticularis in antiphospholipid
syndrome and cryoglobulinemia; hyperpigmentation in Nelson syndrome,
carotenemia, or Addison disease; and the numerous dermatologic
manifestations of the neurocutaneous syndromes. Other important
findings include signs of scleroderma; ichthyosis; scars, needle marks,
or other evidence of intravenous substance abuse; bruises; and trophic
changes. The degree of moisture or perspiration may be neurologically
pertinent, and any localized or generalized increase or decrease in
perspiration should be recorded. Skin changes may be of diagnostic
significance in the endocrinopathies, diseases of the hypothalamus, and
dysautonomia. In parkinsonism the skin may be greasy and seborrheic.
Herpes zoster causes a vesicular eruption in the distribution of the
involved root. Hemangiomas of the spinal cord may be accompanied by
skin nevi in the same metamere. Symmetrically placed, painless,
recurring, poorly healing lesions of the extremities may occur in
syringomyelia and hereditary sensory neuropathy. Dermatomyositis causes
characteristic skin lesions. Peripheral nerve disease, tabes dorsalis,
and myelopathy may produce trophic changes in the skin. Skin changes
may also be a manifestation of vitamin deficiency.
evidence regarding the nature of a neurologic condition. Findings of
possible neurologic relevance include: spider angiomas in alcohol
abuse; erythema chronicum migrans in Lyme disease; purpura and
petechiae in thrombotic thrombocytopenic purpura, meningococcemia, and
Rocky Mountain spotted fever (all of which may have prominent
neurologic manifestations); livedo reticularis in antiphospholipid
syndrome and cryoglobulinemia; hyperpigmentation in Nelson syndrome,
carotenemia, or Addison disease; and the numerous dermatologic
manifestations of the neurocutaneous syndromes. Other important
findings include signs of scleroderma; ichthyosis; scars, needle marks,
or other evidence of intravenous substance abuse; bruises; and trophic
changes. The degree of moisture or perspiration may be neurologically
pertinent, and any localized or generalized increase or decrease in
perspiration should be recorded. Skin changes may be of diagnostic
significance in the endocrinopathies, diseases of the hypothalamus, and
dysautonomia. In parkinsonism the skin may be greasy and seborrheic.
Herpes zoster causes a vesicular eruption in the distribution of the
involved root. Hemangiomas of the spinal cord may be accompanied by
skin nevi in the same metamere. Symmetrically placed, painless,
recurring, poorly healing lesions of the extremities may occur in
syringomyelia and hereditary sensory neuropathy. Dermatomyositis causes
characteristic skin lesions. Peripheral nerve disease, tabes dorsalis,
and myelopathy may produce trophic changes in the skin. Skin changes
may also be a manifestation of vitamin deficiency.
Hair and Nails
Hair texture and distribution are important in the
evaluation of endocrinopathies. Premature graying of the hair may be
familial and of no clinical significance, but is frequently observed in
pernicious
evaluation of endocrinopathies. Premature graying of the hair may be
familial and of no clinical significance, but is frequently observed in
pernicious
P.27
anemia,
and may occur in hypothalamic and other disorders. Poliosis occurs with
Vogt-Kayanaga-Harada disease. Transverse discoloration of the nails
(Mees lines) may occur with arsenic poisoning and debilitated states;
clubbing of the nails occurs with bronchogenic carcinoma or heart
disease. Abnormal nail bed capillary loops may be a sign of
dermatomyositis.
Nodes
Lymphadenopathy may occur in lymphoma, mononucleosis,
HIV, Lyme disease, Niemann-Pick disease, Gaucher disease, phenytoin
pseudolymphoma, sarcoidosis, Whipple disease, and in many other
conditions that may also have neurologic manifestations.
HIV, Lyme disease, Niemann-Pick disease, Gaucher disease, phenytoin
pseudolymphoma, sarcoidosis, Whipple disease, and in many other
conditions that may also have neurologic manifestations.