Today's lesson delves into the crucial first steps of a neurological examination: gathering a patient's history and conducting a physical examination. You'll learn how to effectively obtain patient information and systematically assess neurological function, laying the groundwork for accurate diagnosis and treatment.
The neurological history is the foundation of any diagnosis. It's like being a detective, gathering clues to solve the case. Start by collecting the patient's demographic information (age, sex, occupation) and chief complaint (why are they here?). Then, explore the History of Present Illness (HPI) in detail, using open-ended questions and focusing on the onset, location, character, aggravating factors, relieving factors, timing, and severity (OLDCARTS). Example: "Tell me about the headache. When did it start? Where is the pain located? What does it feel like?" Don't forget to investigate past medical history (PMH), including any prior neurological issues, surgeries, and medications. Family history (FH) of neurological diseases can also be important. Social history (SH), including smoking, alcohol and drug use, and occupational exposures, is also relevant.
This section assesses the patient's level of consciousness, orientation, memory, language, and cognitive function. Start by observing the patient's appearance and behavior. Assess orientation to person, place, and time (e.g., "What is your name? Where are we? What year is it?"). Evaluate short-term and long-term memory using questions like, "What did you have for breakfast?" or "What is your date of birth?" Assess language skills by asking the patient to repeat phrases, name objects, and follow commands. Check for aphasia (language impairment) if there is difficulty speaking or understanding. Example: Ask patient to follow these commands: “Point to your nose, then your left ear, then your right eye.”
The cranial nerves control important functions like vision, smell, eye movement, facial sensation, facial expression, hearing, swallowing, and tongue movement. Each nerve is tested specifically. For example, for CN I (Olfactory), ask the patient to identify familiar scents. For CN II (Optic), assess visual acuity (Snellen chart), visual fields (confrontation), and fundoscopic examination (looking at the optic disc). For CN III, IV, and VI (Oculomotor, Trochlear, and Abducens), assess pupillary response, eye movements, and eyelid droop. For CN VII (Facial), assess facial symmetry (smile, frown, raise eyebrows). For CN VIII (Vestibulocochlear), assess hearing. For CN IX and X (Glossopharyngeal and Vagus), assess swallowing, gag reflex, and voice. For CN XI (Spinal Accessory), assess shoulder shrug and head turning. For CN XII (Hypoglossal), assess tongue movement.
This section evaluates muscle strength, tone, and bulk. Observe the patient's gait (walking) and posture. Assess muscle strength in all major muscle groups (arms, legs, etc.) using a grading scale (e.g., 0/5 = no movement, 5/5 = normal strength). Test muscle tone by passively moving the patient's limbs, feeling for spasticity (increased tone) or flaccidity (decreased tone). Check muscle bulk by visually inspecting the muscles and palpating for wasting or hypertrophy. Example: Ask the patient to push against your hand with their arm. Grade the resistance from 0 to 5.
This involves assessing the patient's ability to feel light touch, pain, temperature, vibration, and position sense. Test light touch with a cotton wisp, pain with a pinprick, and temperature with warm and cold objects. Assess vibration sense using a tuning fork placed on bony prominences. Assess position sense (proprioception) by moving the patient's finger or toe and asking them to identify its position with their eyes closed. Example: Ask the patient to close their eyes and identify if they are feeling the cotton wisp on their arm.
Reflexes are involuntary responses to stimuli, providing information about the integrity of the nervous system. Use a reflex hammer to test deep tendon reflexes (e.g., biceps, triceps, patellar, Achilles). Grade reflexes on a scale (e.g., 0 = absent, 2+ = normal, 4+ = hyperactive). Assess for pathological reflexes, such as the Babinski sign (upgoing toe), which indicates an upper motor neuron lesion. Example: Tap the patellar tendon with a reflex hammer and observe for knee extension. A Babinski sign requires stroking the sole of the foot to observe if the big toe goes up or down.
This section assesses the patient's ability to perform coordinated movements. Observe gait and balance. Perform the finger-to-nose test (patient touches their nose, then your finger). Perform the heel-to-shin test (patient runs their heel down the opposite shin). Assess rapid alternating movements (e.g., pronation/supination of the forearms). Example: Ask the patient to touch their nose with their index finger, then touch your finger, repeatedly.
Accurate and detailed documentation is critical. Document each component of the neurological examination systematically. Use clear and concise language. Note any abnormalities, using appropriate grading scales or descriptors. Example: “Patient is alert and oriented to person, place, and time. Cranial nerves II-XII grossly intact. Strength 5/5 in all extremities. Reflexes 2+ and symmetric. Negative Babinski signs bilaterally.”
Explore advanced insights, examples, and bonus exercises to deepen understanding.
Building on yesterday's foundation, let's explore the subtleties often overlooked in the initial neurological assessment. Remember, this isn't just a checklist; it's a detective game. Subtle clues and discrepancies can point to specific neurological issues.
Patient History: Beyond the Basics We touched upon history-taking yesterday. Now consider how you might adjust your approach based on presenting symptoms:
The Physical Exam: Beyond the Checklist While the structured exam is crucial, pay attention to how a patient performs everyday tasks. Does their gait seem off? Does their speech slur? These observations can provide critical insights that a standardized test might miss.
Read the following case study and answer the questions below:
A 65-year-old male presents with a 3-week history of progressive weakness in his left arm, accompanied by tingling sensations in his fingers. He denies any history of head trauma or fever. Upon examination, you note: Decreased strength in left bicep and tricep, diminished reflexes in the left arm, normal sensation to light touch, and a normal gait.
Watch a short video clip of a patient performing everyday tasks (e.g., walking, reaching for an object). Document all the subtle neurological findings you observe. Discuss your findings with a peer.
Understanding the nuances of neurological diagnostics goes beyond clinical settings. It's essential for:
Develop a Standardized Patient Scenario: Create a brief patient scenario with realistic presenting symptoms. Include a detailed history and a description of a physical exam, including expected findings. Then, exchange scenarios with a peer and evaluate each other's work.
Consider these topics for further exploration:
Resources: Browse online medical journals, and medical textbooks (like 'Adams and Victor's Principles of Neurology') for in-depth studies. Also, watch expert demonstrations of the neurological examination.
Role-play with a partner. One person plays the role of a patient reporting a headache. The other person is the doctor, asking questions to gather the history (OLDCARTS, PMH, FH, SH) to assess the patient's complaint.
Create a table with the 12 cranial nerves. For each nerve, list its function, how to test it, and common abnormalities associated with damage to the nerve. Research the tests to perform.
Create a series of questions that test your knowledge of the tests used to assess sensory function. Practice by asking questions to your peers.
Imagine you are a doctor in a clinic. You are asked to evaluate a patient complaining of weakness in their left arm. Describe how you would perform the history and physical examination to investigate the patient's complaints and assess this issue, listing specific steps, and any testing you'd consider.
Review the functions of the different parts of the brain (cerebrum, cerebellum, brainstem) to prepare for the next lesson, which will focus on localizing neurological lesions based on examination findings. Learn the different tests for each section of the neurological examination.
We're automatically tracking your progress. Sign up for free to keep your learning paths forever and unlock advanced features like detailed analytics and personalized recommendations.