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Key Concepts
The clinical neurologic history and examination are the cornerstones of neurologic diagnosis and
management.
Through the patients history, one can determine the main symptoms, the mode of onset (gradual or
sudden), progression over time (maximal at onset or steadily gaining intensity), and associated illnesses and
risk factors.
The neurologic examination is directed at localization of the disease process so that evaluation and
management may be planned appropriately.
The neurologic examination of a specific patient may be adapted to the patients specific deficit. For
example, a patient with double vision may warrant an extensive cranial nerve examination but a less extensive
assessment of finger strength.
Learning Objectives
On completion of the chapter, the reader will be able to:
1. Describe the importance of the neurologic examination in the diagnosis of neurologic diseases.
2. Determine when abbreviation of the neurologic examination is appropriate in a given patient.
3. Apply the results of a neurologic examination, as written in the patients medical record, to the creation and
monitoring of a pharmacotherapy plan.
4. Recognize the importance of lumbar puncture, electroencephalography, evoked potentials, electromyography,
nerve conduction velocities, carotid Doppler, magnetic resonance angiography, computed tomographic
angiography, transcranial Doppler, computed tomography, magnetic resonance imaging, diusion-weighted
imaging, positron-emission tomography, and single-photon-emission computed tomography in the diagnosis
of a patient with a neurologic illness.
5. Comment on the importance of symmetry in the evaluation of a patient with a neurologic illness.
6. Identify when a patient has a focal neurologic deficit by interpreting the results of the neurologic examination.
Introduction
To contribute most eectively to the care of patients with neurologic illness, one must understand the tools used in
the diagnosis and management of these patients. In addition, clinicians must be able to gather their own data
through a targeted neurologic examination and history taking to ensure optimal pharmacotherapy in neurologic
patients.
Despite technologic advances that have led to the development of sensitive diagnostic tests in
neuroscience, the clinical neurologic history and examination are still the cornerstones of neurologic diagnosis and
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management.1
Domain
Tests Performed
Mental
status
Cranial
nerves
Myasthenia gravis,
Parkinsons disease, stroke,
amyotrophic lateral sclerosis
(ALS)
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Motor
function
Reflexes
Sensory
function
Stroke, peripheral
neuropathy, migraine aura,
diabetes, spinal cord lesions
Gait
A targeted neurologic examination can be performed when a specific deficit is suspected. An example of the
quantification of muscle strength is given in eTable 19-2. During the documentation of the examination results, the
clinician should avoid using poorly defined clinical terms to describe the findings.1 The clinician must synthesize
the results of the history and physical examination to arrive at an anatomic localization of the lesion and create a
dierential diagnosis.1 Readers are encouraged to consult other references to better understand the intricacies of
the neurologic examination.
eTable 19-2 Muscle Strength Evaluation
Grade
Description
No movement; no contraction
Pediatrics
Similar to adults, the chief complaint and history of the presenting illness are very important in the pediatric
neurologic evaluation. They can localize lesions and identify possible etiologies of the presenting illness. Because
of dierent developmental stages of the pediatric population, the history is largely obtained from the family.2
In addition to identifying the temporal and chronological progression of the presenting illness, pediatric history
should address the family history because many of the pediatric illnesses could have an inherited genetic cause.2
A unique aspect of the pediatric evaluation is the developmental history, which is essential to assess the
developmental stage of the patient compared with standard age-related developmental milestones.2 In addition, it
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helps to identify any relation between the current illness and the developmental stage of the patient.2
The neurologic examination of pediatric patients should be adapted to their age and developmental stage. In
addition to the standard domains of the neurologic examination, an assessment of the weight, height, and head
circumference of the patient should be included. These measurements should be evaluated with reference to
special age-adjusted charts to identify any abnormalities.2 The patient should be evaluated for any dysmorphic or
skin color abnormalities. The fontanels should be assessed for size and whether they are open or closed.2
Cerebellar control of ambulation and fine coordination can be assessed by observing the patient during playing
and walking.2 The patients responses to light touch and painful stimuli can be assessed by observing facial
expressions, withdrawal, and avoidance responses to tickling, touching, and finger or toe pinching.2
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stroke, can be evaluated using ultrasonography (referred to as duplex sonography, carotid Doppler, or color-flow
Doppler), magnetic resonance angiography (MRA), spiral computed tomographic angiography (CTA), or intraarterial
angiography.1 The intracranial arterial circulation can be evaluated using transcranial Doppler, MRA, CTA, or
intraarterial angiography.1 Each technique has its own advantages and disadvantages. Intraarterial angiography
provides the best imaging of the smaller arteries of the cerebral circulation but is more invasive than the other
measures.1
Computed tomography (CT) uses x-rays to produce images of slices of the brain that are 1 to 10 mm in
thickness.1 CT revolutionized the practice of neurology by allowing direct imaging of brain anatomy. It is currently
available in most communities and is used to evaluate patients with intracranial disease. CT scans are used to
identify tumors, hemorrhages, infarctions, hydrocephalus, and atrophy, among other intracranial pathologies.1 IV
contrast agents (a contrast-enhanced scan) can provide imaging of vessel structure; they may also be used to
identify areas of breakdown of the bloodbrain barrier as the result of abscesses, other inflammatory conditions,
tumors, or stroke.1
Magnetic resonance imaging (MRI) uses the magnetic properties of the hydrogen atom nucleus and proton to
produce computer-processed scans that provide improved anatomic detail compared with CT scans.1 MRI oers
the advantages of better dierentiating between white and gray matter and delineating lesions close to bone
(brainstem and cerebellum) and has no radiation risk; however, it is not as readily available as CT and is more
expensive.1 MRI has a proven advantage over CT in evaluating lesions in the posterior fossa and in detecting
lesions in the white matter, such as plaques in multiple sclerosis.1 MRI is also useful in the diagnosis of tumors and
very early ischemic stroke (diusion-weighted imaging). Imaging of the spinal canal and its contents can be
accomplished either by MRI myelography or CT myelography. Myelography refers to injecting a contrast agent into
the CSF, so myelography outlines the spinal cord and provides indirect information about the spinal cord; MRI
provides direct imaging of the soft tissue of the spinal cord, providing direct information about injury to the cord.
Compressive lesions can be identified by myelography or MRI; the consequences of the injury (e.g., edema,
infarction) are better seen on MRI.1
Conclusion
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Assessment of the patient with neurologic disease is challenging. The patient, by virtue of the neurologic deficit,
may or may not be able to provide reliable information regarding medication history or extent of illness. In these
situations, the clinician must develop alternate strategies to obtain a complete data set and develop a
pharmacotherapy plan. The ability to interpret and synthesize the results of the neurologic examination and other
diagnostic tests will help a great deal in this quest.
Abbreviations
ALS
CNS
CSF
cerebrospinal fluid
CT
computed tomography
CTA
EEG
electroencephalography
EMG
electromyography
LP
lumbar puncture
MRA
MRI
NCVs
PET
SPECT
References
1. Lowenstein DH, Martin JB, Hauser SL. Approach to the patient with neurologic disease. In: Longo DL, Fauci AS,
Kasper DL, et al. eds. Harrisons Principles of Internal Medicine, 18th ed. New York: McGraw Hill, 2012: 3233
3239.
2. Bernard TJ. Neurologic & muscular disorders. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR, eds.
CURRENT Diagnosis & Treatment: Pediatrics, 20th ed. New York: McGraw-Hill, 2011,
http://www.accessmedicine.com/.
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