Adams and Victor's Principles of Neurology

 
THE NEUROLOGIC EXAMINATION
The neurologic examination begins with observations of
the patient while the history is being obtained. The manner
in which the patient tells the story of his illness may betray
confusion or incoherence in thinking, impairment of mem-
ory or judgment, or difficulty in comprehending or express-
ing ideas. The physician should learn to obtain this type of
information without embarrassment to the patient. A com-
mon error is to pass lightly over inconsistencies in history
and inaccuracies about dates and symptoms, only to dis-
cover later that these flaws in memory were the essential
features of the illness. Asking the patient to give his own
interpretation of the possible meaning of symptoms may
sometimes expose unnatural concern, anxiety, suspicious-
ness, or even delusional thinking. Young physicians and
students also have a natural tendency to “normalize” the
patient, often collaborating with a hopeful family in the
misperception that no real problem exists. This attempt at
sympathy does not serve the patient and may delay the
diagnosis of a potentially treatable disease.
One then generally proceeds from an examination of the
cranial nerves, neck, and trunk to the testing of motor,
reflex, and sensory functions of the upper and lower limbs.
This is followed by an assessment of the function of sphinc-
ters and the autonomic nervous system and testing for
meningeal irritation by examining the suppleness of the
neck and spine. Gait and station (standing position) should
be observed before or after the rest of the examination.
When an abnormal finding is detected, whether cogni-
tive, motor, or sensory, it becomes necessary to analyze the
problem in a more elaborate fashion. Details of these more
extensive examinations are to be found in appropriate
chapters of the book (motor: Chaps. 3, 4, and 5; sensory:
Chaps. 8 and 9; and cognitive and language disorders:
Chaps. 22 and 23).
The neurologic examination is ideally performed and
recorded in a relatively uniform manner in order to avoid
omissions and facilitate the subsequent analysis of case
records. Some variation in the precise order of examina-
tion from physician to physician is understandable, but
each examiner should establish an accustomed pattern.
Even when it is impractical to perform the examination in
the customary way, as in patients who are unable to coop-
erate because of age or cognitive deficiency, it is good
practice to record the findings in an orderly fashion. If cer-
tain portions are not performed (e.g., olfactory testing in a
completely uncooperative patient), this omission should
be stated so that those reading the description at a later
time are not left wondering whether an abnormality was
not previously detected.
The thoroughness of the neurologic examination of neces-
sity must be governed by the type of clinical problem
presented by the patient. To spend a half hour or more
testing cerebral, cerebellar, cranial nerve, and sensorimo-
tor function in a patient seeking treatment for a simple
compression palsy of an ulnar nerve is pointless and
uneconomical. The examination must also be modified
according to the condition of the patient. Obviously, many