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APPROACH TO THE PATIENT WITH NEUROLOGIC DISEASE:
INTRODUCTION
Neurologic diseases are common and costly. According to recent estimates by the World Health
Organization, neurologic disorders affect over 1 billion people worldwide (Table 367-1), constitute
6.3% of the global burden of disease, and cause 12% of global deaths. Most patients with
neurologic symptoms seek care from internists and other generalists rather than from neurologists.
Because therapies now exist for many neurologic disorders, a skillful approach to diagnosis is
essential. Errors commonly result from an overreliance on costly neuroimaging procedures and
laboratory tests, which, while useful, do not substitute for an adequate history and examination.
The proper approach to the patient with a neurologic illness begins with the patient and focuses the
clinical problem first in anatomic and then in pathophysiologic terms; only then should a specific
diagnosis be entertained. This method ensures that technology is judiciously applied, a correct
diagnosis is established in an efficient manner, and treatment is promptly initiated.
Table 367-1 Prevalence of Neurologic and Psychiatric Diseases Worldwide
Disorder Patients, Millions
Nutritional disorders and neuropathies 352
Migraine 326
Trauma 170
Cerebrovascular diseases 61
Epilepsy 50
Dementia 24
Neurologic infections 18
Source: World Health Organization estimates, 20022005.
THE NEUROLOGIC METHOD
Locate the Lesion(S)
The first priority is to identify the region of the nervous system that is likely to be responsible for
the symptoms. Can the disorder be mapped to one specific location, is it multifocal, or is a diffuse
process present? Are the symptoms restricted to the nervous system, or do they arise in the context
of a systemic illness? I s the problem in the central nervous system (CNS), the peripheral nervous
system (PNS), or both? I f in the CNS, is the cerebral cortex, basal ganglia, brainstem, cerebellum,
or spinal cord responsible? Are the pain-sensitive meninges involved? I f in the PNS, could the
disorder be located in peripheral nerves and, if so, are motor or sensory nerves primarily affected,
or is a lesion in the neuromuscular junction or muscle more likely?
The first clues to defining the anatomic area of involvement appear in the history, and the
examination is then directed to confirm or rule out these impressions and to clarify uncertainties. A
more detailed examination of a particular region of the CNS or PNS is often indicated. For example,
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the examination of a patient who presents with a history of ascending paresthesias and weakness
should be directed toward deciding, among other things, if the location of the lesion is in the spinal
cord or peripheral nerves. Focal back pain, a spinal cord sensory level, and incontinence suggest a
spinal cord origin, whereas a stocking-glove pattern of sensory loss suggests peripheral nerve
disease; areflexia usually indicates peripheral neuropathy but may also be present with spinal shock
in acute spinal cord disorders.
Deciding "where the lesion is" accomplishes the task of limiting the possible etiologies to a
manageable, finite number. I n addition, this strategy safeguards against making serious errors.
Symptoms of recurrent vertigo, diplopia, and nystagmus should not trigger "multiple sclerosis" as
an answer (etiology) but "brainstem" or "pons" (location); then a diagnosis of brainstem
arteriovenous malformation will not be missed for lack of consideration. Similarly, the combination
of optic neuritis and spastic ataxic paraparesis should initially suggest optic nerve and spinal cord
disease; multiple sclerosis (MS), CNS syphilis, and vitamin B12 deficiency are treatable disorders
that can produce this syndrome. Once the question, "Where is the lesion?" is answered, then the
question, "What is the lesion?" can be addressed.
Define the Pathophysiology
Clues to the pathophysiology of the disease process may also be present in the history. Primary
neuronal (gray matter) disorders may present as early cognitive disturbances, movement disorders,
or seizures, whereas white matter involvement produces predominantly "long tract" disorders of
motor, sensory, visual, and cerebellar pathways. Progressive and symmetric symptoms often have a
metabolic or degenerative origin; in such cases lesions are usually not sharply circumscribed. Thus,
a patient with paraparesis and a clear spinal cord sensory level is unlikely to have vitamin B12
deficiency as the explanation. A Lhermitte symptom (electric shocklike sensations evoked by neck
flexion) is due to ectopic impulse generation in white matter pathways and occurs with
demyelination in the cervical spinal cord; among many possible causes, this symptom may indicate
MS in a young adult or compressive cervical spondylosis in an older person. Symptoms that worsen
after exposure to heat or exercise may indicate conduction block in demyelinated axons, as occurs
in MS. A patient with recurrent episodes of diplopia and dysarthria associated with exercise or
fatigue may have a disorder of neuromuscular transmission such as myasthenia gravis. Slowly
advancing visual scotoma with luminous edges, termed fortification spectra, indicates spreading
cortical depression, typically with migraine.
THE NEUROLOGIC HISTORY
Attention to the description of the symptoms experienced by the patient and substantiated by family
members and others often permits an accurate localization and determination of the probable cause
of the complaints, even before the neurologic examination is performed. The history also helps to
bring a focus to the neurologic examination that follows. Each complaint should be pursued as far as
possible to elucidate the location of the lesion, the likely underlying pathophysiology, and potential
etiologies. For example, a patient complains of weakness of the right arm. What are the associated
features? Does the patient have difficulty with brushing hair or reaching upward (proximal) or
buttoning buttons or opening a twist-top bottle (distal)? Negative associations may also be crucial.
A patient with a right hemiparesis without a language deficit likely has a lesion (internal capsule,
brainstem, or spinal cord) different from that of a patient with a right hemiparesis and aphasia (left
hemisphere). Other pertinent features of the history include the following:
1. Temporal course of the illness. I t is important to determine the precise time of appearance
and rate of progression of the symptoms experienced by the patient. The rapid onset of a
neurologic complaint, occurring within seconds or minutes, usually indicates a vascular event,
a seizure, or migraine. The onset of sensory symptoms located in one extremity that spread
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over a few seconds to adjacent portions of that extremity and then to the other regions of the
body suggests a seizure. A more gradual onset and less well-localized symptoms point to the
possibility of a transient ischemic attack (TI A). A similar but slower temporal march of
symptoms accompanied by headache, nausea, or visual disturbance suggests migraine. The
presence of "positive" sensory symptoms (e.g., tingling or sensations that are difficult to
describe) or involuntary motor movements suggests a seizure; in contrast, transient loss of
function (negative symptoms) suggests a TI A. A stuttering onset where symptoms appear,
stabilize, and then progress over hours or days also suggests cerebrovascular disease; an
additional history of transient remission or regression indicates that the process is more likely
due to ischemia rather than hemorrhage. A gradual evolution of symptoms over hours or
days suggests a toxic, metabolic, infectious, or inflammatory process. Progressing symptoms
associated with the systemic manifestations of fever, stiff neck, and altered level of
consciousness imply an infectious process. Relapsing and remitting symptoms involving
different levels of the nervous system suggest MS or other inflammatory processes. Slowly
progressive symptoms without remissions are characteristic of neurodegenerative disorders,
chronic infections, gradual intoxications, and neoplasms.
2. Patients' descriptions of the complaint. The same words often mean different things to
different patients. "Dizziness" may imply impending syncope, a sense of disequilibrium, or
true spinning vertigo. "Numbness" may mean a complete loss of feeling, a positive sensation
such as tingling, or even weakness. "Blurred vision" may be used to describe unilateral visual
loss, as in transient monocular blindness, or diplopia. The interpretation of the true meaning
of the words used by patients to describe symptoms obviously becomes even more complex
when there are differences in primary languages and cultures.
3. Corroboration of the history by others. I t is almost always helpful to obtain additional
information from family, friends, or other observers to corroborate or expand the patient's
description. Memory loss, aphasia, loss of insight, intoxication, and other factors may impair
the patient's capacity to communicate normally with the examiner or prevent openness about
factors that have contributed to the illness. Episodes of loss of consciousness necessitate that
details be sought from observers to ascertain precisely what has happened during the event.
4. Family history. Many neurologic disorders have an underlying genetic component. The
presence of a Mendelian disorder, such as Huntington's disease or Charcot-Marie-Tooth
neuropathy, is often obvious if family data are available. More detailed questions about family
history are often necessary in polygenic disorders such as MS, migraine, and many types of
epilepsy. I t is important to elicit family history about all illnesses, in addition to neurologic
and psychiatric disorders. A familial propensity to hypertension or heart disease is relevant in
a patient who presents with a stroke. There are numerous inherited neurologic diseases that
are associated with multisystem manifestations that may provide clues to the correct
diagnosis (e.g., neurofibromatosis, Wilson's disease, neuro-ophthalmic syndromes).
5. Medical illnesses. Many neurologic diseases occur in the context of systemic disorders.
Diabetes mellitus, hypertension, and abnormalities of blood lipids predispose to
cerebrovascular disease. A solitary mass lesion in the brain may be an abscess in a patient
with valvular heart disease, a primary hemorrhage in a patient with a coagulopathy, a
lymphoma or toxoplasmosis in a patient with AI DS, or a metastasis in a patient with
underlying cancer. Patients with malignancy may also present with a neurologic
paraneoplastic syndrome (Chap. 101) or complications from chemotherapy or radiotherapy.
Marfan's syndrome and related collagen disorders predispose to dissection of the cranial
arteries and aneurysmal subarachnoid hemorrhage; the latter may also occur with polycystic
kidney disease. Various neurologic disorders occur with dysthyroid states or other
endocrinopathies. I t is especially important to look for the presence of systemic diseases in
patients with peripheral neuropathy. Most patients with coma in a hospital setting have a
metabolic, toxic, or infectious cause.
6. Drug use and abuse and toxin exposure. I t is essential to inquire about the history of drug
use, both prescribed and illicit. Sedatives, antidepressants, and other psychoactive
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medications are frequently associated with acute confusional states in the elderly.
Aminoglycoside antibiotics may exacerbate symptoms of weakness in patients with disorders
of neuromuscular transmission, such as myasthenia gravis, and may cause dizziness
secondary to ototoxicity. Vincristine and other antineoplastic drugs can cause peripheral
neuropathy, and immunosuppressive agents such as cyclosporine can produce
encephalopathy. Excessive vitamin ingestion can lead to disease; for example vitamin A and
pseudotumor cerebri, or pyridoxine and peripheral neuropathy. Many patients are unaware
that over-the-counter sleeping pills, cold preparations, and diet pills are actually drugs.
Alcohol, the most prevalent neurotoxin, is often not recognized as such by patients, and other
drugs of abuse such as cocaine and heroin can cause a wide range of neurologic
abnormalities. A history of environmental or industrial exposure to neurotoxins may provide
an essential clue; consultation with the patient's coworkers or employer may be required.
7. Formulating an impression of the patient. Use the opportunity while taking the history to form
an impression of the patient. I s the information forthcoming, or does it take a circuitous
course? I s there evidence of anxiety, depression, hypochondriasis? Are there any clues to
defects in language, memory, insight, or inappropriate behavior? The neurologic assessment
begins as soon as the patient comes into the room and the first introduction is made.
THE NEUROLOGIC EXAMINATION
The neurologic examination is challenging and complex; it has many components and includes a
number of skills that can be mastered only through repeated use of the same techniques on a large
number of individuals with and without neurologic disease. Mastery of the complete neurologic
examination is usually important only for physicians in neurology and associated specialties.
However, knowledge of the basics of the examination, especially those components that are
effective in screening for neurologic dysfunction, is essential for all clinicians, especially generalists.
There is no single, universally accepted sequence of the examination that must be followed, but
most clinicians begin with assessment of mental status followed by the cranial nerves, motor
system, sensory system, coordination, and gait. Whether the examination is basic or
comprehensive, it is essential that it be performed in an orderly and systematic fashion to avoid
errors and serious omissions. Thus, the best way to learn and gain expertise in the examination is
to choose one's own approach and practice it frequently and do it in the same exact sequence each
time.
The detailed description of the neurologic examination that follows describes the more commonly
used parts of the examination, with a particular emphasis on the components that are considered
most helpful for the assessment of common neurologic problems. Each section also includes a brief
description of the minimal examination necessary for adequate screening for abnormalities in a
patient who has no symptoms suggesting neurologic dysfunction. A screening examination done in
this way can be completed in 35 min.
Several additional points about the examination are worth noting. First, in recording observations, it
is important to describe what is found rather than to apply a poorly defined medical term (e.g.,
"patient groans to sternal rub" rather than "obtunded"). Second, subtle CNS abnormalities are best
detected by carefully comparing a patient's performance on tasks that require simultaneous
activation of both cerebral hemispheres (e.g., eliciting a pronator drift of an outstretched arm with
the eyes closed; extinction on one side of bilaterally applied light touch, also with eyes closed; or
decreased arm swing or a slight asymmetry when walking). Third, if the patient's complaint is
brought on by some activity, reproduce the activity in the office. I f the complaint is of dizziness
when the head is turned in one direction, have the patient do this and also look for associated signs
on examination (e.g., nystagmus or dysmetria). I f pain occurs after walking two blocks, have the
patient leave the office and walk this distance and immediately return, and repeat the relevant parts
of the examination. Finally, the use of tests that are individually tailored to the patient's problem
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can be of value in assessing changes over time. Tests of walking a 7.5-m (25-ft) distance (normal,
56 s; note assistance, if any), repetitive finger or toe tapping (normal, 2025 taps in 5 s), or
handwriting are examples.
Mental Status Examination
The bare minimum: During the interview, look for difficulties with communication and
determine whether the patient has recall and insight into recent and past events.
The mental status examination is underway as soon as the physician begins observing and talking
with the patient. I f the history raises any concern for abnormalities of higher cortical function or if
cognitive problems are observed during the interview, then detailed testing of the mental status is
indicated. The patient's ability to understand the language used for the examination, cultural
background, educational experience, sensory or motor problems, or comorbid conditions need to be
factored into the applicability of the tests and interpretation of results.
The Folstein mini-mental status examination (MMSE) (Table 371-5) is a standardized screening
examination of cognitive function that is extremely easy to administer and takes <10 min to
complete. Using age-adjusted values for defining normal performance, the test is 85% sensitive
and 85% specific for making the diagnosis of dementia that is moderate or severe, especially in
educated patients. When there is sufficient time available, the MMSE is one of the best methods for
documenting the current mental status of the patient, and this is especially useful as a baseline
assessment to which future scores of the MMSE can be compared.
I ndividual elements of the mental status examination can be subdivided into level of consciousness,
orientation, speech and language, memory, fund of information, insight and judgment, abstract
thought, and calculations.
Level of consciousness is the patient's relative state of awareness of the self and the environment,
and ranges from fully awake to comatose. When the patient is not fully awake, the examiner should
describe the responses to the minimum stimulus necessary to elicit a reaction, ranging from verbal
commands to a brief, painful stimulus such as a squeeze of the trapezius muscle. Responses that
are directed toward the stimulus and signify some degree of intact cerebral function (e.g., opening
the eyes and looking at the examiner or reaching to push away a painful stimulus) must be
distinguished from reflex responses of a spinal origin (e.g., triple flexion responseflexion at the
ankle, knee, and hip in response to a painful stimulus to the foot).
Orientation is tested by asking the person to state his or her name, location, and time (day of the
week and date); time is usually the first to be affected in a variety of conditions.
Speech is assessed by observing articulation, rate, rhythm, and prosody (i.e., the changes in pitch
and accentuation of syllable and words).
Language is assessed by observing the content of the patient's verbal and written output, response
to spoken commands, and ability to read. A typical testing sequence is to ask the patient to name
successively more detailed components of clothing, a watch or a pen; repeat the phrase "No ifs,
ands, or buts"; follow a three-step, verbal command; write a sentence; and read and respond to a
written command.
Memory should be analyzed according to three main time scales: (1) immediate memory is
assessed by saying a list of three items and having the patient repeat the list immediately, (2)
short-term memory is tested by asking the patient to recall the same three items 5 and 15 min
later, and (3) long-term memory is evaluated by determining how well the patient is able to provide
a coherent chronologic history of his or her illness or personal events.
Fund of information is assessed by asking questions about major historic or current events, with
special attention to educational level and life experiences.
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Abnormalities of insight and judgment are usually detected during the patient interview; a more
detailed assessment can be elicited by asking the patient to describe how he or she would respond
to situations having a variety of potential outcomes (e.g., "What would you do if you found a wallet
on the sidewalk?").
Abstract thought can be tested by asking the patient to describe similarities between various objects
or concepts (e.g., apple and orange, desk and chair, poetry and sculpture) or to list items having
the same attributes (e.g., a list of four-legged animals).
Calculation ability is assessed by having the patient carry out a computation that is appropriate to
the patient's age and education (e.g., serial subtraction of 7 from 100 or 3 from 20; or word
problems involving simple arithmetic).
Cranial Nerve Examination
The bare minimum: Check the fundi, visual fields, pupil size and reactivity, extraocular
movements, and facial movements.
The cranial nerves (CN) are best examined in numerical order, except for grouping together CN I I I ,
I V, and VI because of their similar function.
CN I (OLFACTORY)
Testing is usually omitted unless there is suspicion for inferior frontal lobe disease (e.g.,
meningioma). With eyes closed, ask the patient to sniff a mild stimulus such as toothpaste or coffee
and identify the odorant.
CN II (OPTIC)
Check visual acuity (with eyeglasses or contact lens correction) using a Snellen chart or similar tool.
Test the visual fields by confrontation, i.e., by comparing the patient's visual fields to your own. As
a screening test, it is usually sufficient to examine the visual fields of both eyes simultaneously;
individual eye fields should be tested if there is any reason to suspect a problem of vision by the
history or other elements of the examination, or if the screening test reveals an abnormality. Face
the patient at a distance of approximately 0.61.0 m (23 ft) and place your hands at the periphery
of your visual fields in the plane that is equidistant between you and the patient. I nstruct the
patient to look directly at the center of your face and to indicate when and where he or she sees
one of your fingers moving. Beginning with the two inferior quadrants and then the two superior
quadrants, move your index finger of the right hand, left hand, or both hands simultaneously and
observe whether the patient detects the movements. A single small- amplitude movement of the
finger is sufficient for a normal response. Focal perimetry and tangent screen examinations should
be used to map out visual field defects fully or to search for subtle abnormalities. Optic fundi should
be examined with an ophthalmoscope, and the color, size, and degree of swelling or elevation of the
optic disc noted, as well as the color and texture of the retina. The retinal vessels should be checked
for size, regularity, arterial-venous nicking at crossing points, hemorrhage, exudates, etc.
CN III, IV, VI (OCULOMOTOR, TROCHLEAR, ABDUCENS)
Describe the size and shape of pupils and reaction to light and accommodation (i.e., as the eyes
converge while following your finger as it moves toward the bridge of the nose). To check
extraocular movements, ask the patient to keep his or her head still while tracking the movement of
the tip of your finger. Move the target slowly in the horizontal and vertical planes; observe any
paresis, nystagmus, or abnormalities of smooth pursuit (saccades, oculomotor ataxia, etc.). I f
necessary, the relative position of the two eyes, both in primary and multidirectional gaze, can be
assessed by comparing the reflections of a bright light off both pupils. However, in practice it is
typically more useful to determine whether the patient describes diplopia in any direction of gaze;
true diplopia should almost always resolve with one eye closed. Horizontal nystagmus is best
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assessed at 45 and not at extreme lateral gaze (which is uncomfortable for the patient); the target
must often be held at the lateral position for at least a few seconds to detect an abnormality.
CN V (TRIGEMINAL)
Examine sensation within the three territories of the branches of the trigeminal nerve (ophthalmic,
maxillary, and mandibular) on each side of the face. As with other parts of the sensory examination,
testing of two sensory modalities derived from different anatomic pathways (e.g., light touch and
temperature) is sufficient for a screening examination. Testing of other modalities, the corneal
reflex, and the motor component of CN V (jaw clenchmasseter muscle) is indicated when
suggested by the history.
CN VII (FACIAL)
Look for facial asymmetry at rest and with spontaneous movements. Test eyebrow elevation,
forehead wrinkling, eye closure, smiling, and cheek puff. Look in particular for differences in the
lower versus upper facial muscles; weakness of the lower two-thirds of the face with preservation of
the upper third suggests an upper motor neuron lesion, whereas weakness of an entire side
suggests a lower motor neuron lesion.
CN VIII (VESTIBULOCOCHLEAR)
Check the patient's ability to hear a finger rub or whispered voice with each ear. Further testing for
air versus mastoid bone conduction (Rinne) and lateralization of a 512-Hz tuning fork placed at the
center of the forehead (Weber) should be done if an abnormality is detected by history or
examination. Any suspected problem should be followed up with formal audiometry.
For further discussion of assessing vestibular nerve function in the setting of dizziness,
hearing loss, or coma, see Chaps. 21, 30, and 274, respectively.
CN IX, X (GLOSSOPHARYNGEAL, VAGUS)
Observe the position and symmetry of the palate and uvula at rest and with phonation ("aah"). The
pharyngeal ("gag") reflex is evaluated by stimulating the posterior pharyngeal wall on each side
with a sterile, blunt object (e.g., tongue blade), but the reflex is often absent in normal individuals.
CN XI (SPINAL ACCESSORY)
Check shoulder shrug (trapezius muscle) and head rotation to each side (sternocleidomastoid)
against resistance.
CN XII (HYPOGLOSSAL)
I nspect the tongue for atrophy or fasciculations, position with protrusion, and strength when
extended against the inner surface of the cheeks on each side.
Motor Examination
The bare minimum: Look for muscle atrophy and check extremity tone. Assess upper
extremity strength by checking for pronator drift and strength of wrist or finger
extensors. Tap the biceps, patellar, and Achilles reflexes. Test for lower extremity
strength by having the patient walk normally and on heels and toes.
The motor examination includes observations of muscle appearance, tone, strength, and reflexes.
Although gait is in part a test of motor function, it is usually evaluated separately at the end of the
examination.
APPEARANCE
I nspect and palpate muscle groups under good light and with the patient in a comfortable and
symmetric position. Check for muscle fasciculations, tenderness, and atrophy or hypertrophy.
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I nvoluntary movements may be present at rest (e.g., tics, myoclonus, choreoathetosis), during
maintained posture (pill-rolling tremor of Parkinson's disease), or with voluntary movements
(intention tremor of cerebellar disease or familial tremor).
TONE
Muscle tone is tested by measuring the resistance to passive movement of a relaxed limb. Patients
often have difficulty relaxing during this procedure, so it is useful to distract the patient to minimize
active movements. I n the upper limbs, tone is assessed by rapid pronation and supination of the
forearm and flexion and extension at the wrist. I n the lower limbs, while the patient is supine the
examiner's hands are placed behind the knees and rapidly raised; with normal tone the ankles drag
along the table surface for a variable distance before rising, whereas increased tone results in an
immediate lift of the heel off the surface. Decreased tone is most commonly due to lower motor
neuron or peripheral nerve disorders. I ncreased tone may be evident as spasticity (resistance
determined by the angle and velocity of motion; corticospinal tract disease), rigidity (similar
resistance in all angles of motion; extrapyramidal disease), or paratonia (fluctuating changes in
resistance; frontal lobe pathways or normal difficulty in relaxing). Cogwheel rigidity, in which
passive motion elicits jerky interruptions in resistance, is seen in parkinsonism.
STRENGTH
Testing for pronator drift is an extremely useful method for screening upper limb weakness. The
patient is asked to hold both arms fully extended and parallel to the ground with eyes closed. This
position should be maintained for 10 s; any flexion at the elbow or fingers or pronation of the
forearm, especially if asymmetric, is a sign of potential weakness. Muscle strength is further
assessed by having the patient exert maximal effort for the particular muscle or muscle group being
tested. I t is important to isolate the muscles as much as possible, i.e., hold the limb so that only the
muscles of interest are active. I t is also helpful to palpate accessible muscles as they contract.
Grading muscle strength and evaluating the patient's effort is an art that takes time and practice.
Muscle strength is traditionally graded using the following scale:
0 = no movement
1 = flicker or trace of contraction but no associated movement at a joint
2 = movement with gravity eliminated
3 = movement against gravity but not against resistance
4 = movement against a mild degree of resistance
4 = movement against moderate resistance
4+ = movement against strong resistance
5 = full power
However, in many cases it is more practical to use the following terms:
Paralysis = no movement
Severe weakness = movement with gravity eliminated
Moderate weakness = movement against gravity but not against mild resistance
Mild weakness = movement against moderate resistance
Full strength
Noting the pattern of weakness is as important as assessing the magnitude of weakness. Unilateral
or bilateral weakness of the upper limb extensors and lower limb flexors ("pyramidal weakness")
suggests a lesion of the pyramidal tract, bilateral proximal weakness suggests myopathy, and
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bilateral distal weakness suggests peripheral neuropathy.
REFLEXES
Muscle Stretch Reflexes
Those that are typically assessed include the biceps (C5, C6), brachioradialis (C5, C6), and triceps
(C7, C8) reflexes in the upper limbs and the patellar or quadriceps (L3, L4) and Achilles (S1, S2)
reflexes in the lower limbs. The patient should be relaxed and the muscle positioned midway
between full contraction and extension. Reflexes may be enhanced by asking the patient to
voluntarily contract other, distant muscle groups (J endrassik maneuver). For example, upper limb
reflexes may be reinforced by voluntary teeth-clenching, and the Achilles reflex by hooking the
flexed fingers of the two hands together and attempting to pull them apart. For each reflex tested,
the two sides should be tested sequentially, and it is important to determine the smallest stimulus
required to elicit a reflex rather than the maximum response. Reflexes are graded according to the
following scale:
0 = absent 3 = exaggerated
1 = present but diminished 4 = clonus
2 = normoactive
Cutaneous Reflexes
The plantar reflex is elicited by stroking, with a noxious stimulus such as a tongue blade, the lateral
surface of the sole of the foot beginning near the heel and moving across the ball of the foot to the
great toe. The normal reflex consists of plantar flexion of the toes. With upper motor neuron lesions
above the S1 level of the spinal cord, a paradoxical extension of the toe is observed, associated with
fanning and extension of the other toes (termed an extensor plantar response, or Babinski sign).
However, despite its popularity, the reliability and validity of the Babinski sign for identifying upper
motor neuron weakness is limitedit is far more useful to rely on tests of tone, strength, stretch
reflexes, and coordination. Superficial abdominal reflexes are elicited by gently stroking the
abdominal surface near the umbilicus in a diagonal fashion with a sharp object (e.g., the wooden
end of a cotton-tipped swab) and observing the movement of the umbilicus. Normally, the umbilicus
will pull toward the stimulated quadrant. With upper motor neuron lesions, these reflexes are
absent. They are most helpful when there is preservation of the upper (spinal cord level T9) but not
lower (T12) abdominal reflexes, indicating a spinal lesion between T9 and T12, or when the
response is asymmetric. Other useful cutaneous reflexes include the cremasteric (ipsilateral
elevation of the testicle following stroking of the medial thigh; mediated by L1 and L2) and anal
(contraction of the anal sphincter when the perianal skin is scratched; mediated by S2, S3, S4)
reflexes. I t is particularly important to test for these reflexes in any patient with suspected injury to
the spinal cord or lumbosacral roots.
Primitive Reflexes
With disease of the frontal lobe pathways, several primitive reflexes not normally present in the
adult may appear. The suck response is elicited by lightly touching the center of the lips, and the
root response the corner of the lips, with a tongue blade; the patient will move the lips to suck or
root in the direction of the stimulus. The grasp reflex is elicited by touching the palm between the
thumb and index finger with the examiner's fingers; a positive response is a forced grasp of the
examiner's hand. I n many instances stroking the back of the hand will lead to its release. The
palmomental response is contraction of the mentalis muscle (chin) ipsilateral to a scratch stimulus
diagonally applied to the palm.
SENSORY EXAMINATION
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The bare minimum: Ask whether the patient can feel light touch and the temperature of
a cool object in each distal extremity. Check double simultaneous stimulation using light
touch on the hands.
Evaluating sensation is usually the most unreliable part of the examination, because it is subjective
and is difficult to quantify. I n the compliant and discerning patient, the sensory examination can be
extremely helpful for the precise localization of a lesion. With patients who are uncooperative or lack
an understanding of the tests, it may be useless. The examination should be focused on the
suspected lesion. For example, in spinal cord, spinal root, or peripheral nerve abnormalities, all
major sensory modalities should be tested while looking for a pattern consistent with a spinal level
and dermatomal or nerve distribution. I n patients with lesions at or above the brainstem, screening
the primary sensory modalities in the distal extremities along with tests of "cortical" sensation is
usually sufficient.
The five primary sensory modalitieslight touch, pain, temperature, vibration, and joint position
are tested in each limb. Light touch is assessed by stimulating the skin with single, very gentle
touches of the examiner's finger or a wisp of cotton. Pain is tested using a new pin, and
temperature is assessed using a metal object (e.g., tuning fork) that has been immersed in cold and
warm water. Vibration is tested using a 128-Hz tuning fork applied to the distal phalanx of the great
toe or index finger just below the nail bed. By placing a finger on the opposite side of the joint being
tested, the examiner compares the patient's threshold of vibration perception with his or her own.
For joint position testing, the examiner grasps the digit or limb laterally and distal to the joint being
assessed; small 1- to 2-mm excursions can usually be sensed. The Romberg maneuver is primarily
a test of proprioception. The patient is asked to stand with the feet as close together as necessary
to maintain balance while the eyes are open, and the eyes are then closed. A loss of balance with
the eyes closed is an abnormal response.
"Cortical" sensation is mediated by the parietal lobes and represents an integration of the primary
sensory modalities; testing cortical sensation is only meaningful when primary sensation is intact.
Double simultaneous stimulation is especially useful as a screening test for cortical function; with
the patient's eyes closed, the examiner lightly touches one or both hands and asks the patient to
identify the stimuli. With a parietal lobe lesion, the patient may be unable to identify the stimulus on
the contralateral side when both hands are touched. Other modalities relying on the parietal cortex
include the discrimination of two closely placed stimuli as separate (two-point discrimination),
identification of an object by touch and manipulation alone (stereognosis), and the identification of
numbers or letters written on the skin surface (graphesthesia).
Coordination Examination
The bare minimum: Test rapid alternating movements of the hands and the finger-to-
nose and heel-knee-shin maneuvers.
Coordination refers to the orchestration and fluidity of movements. Even simple acts require
cooperation of agonist and antagonist muscles, maintenance of posture, and complex
servomechanisms to control the rate and range of movements. Part of this integration relies on
normal function of the cerebellar and basal ganglia systems. However, coordination also requires
intact muscle strength and kinesthetic and proprioceptive information. Thus, if the examination has
disclosed abnormalities of the motor or sensory systems, the patient's coordination should be
assessed with these limitations in mind.
Rapid alternating movements in the upper limbs are tested separately on each side by having the
patient make a fist, partially extend the index finger, and then tap the index finger on the distal
thumb as quickly as possible. I n the lower limb, the patient rapidly taps the foot against the floor or
the examiner's hand. Finger-to-nose testing is primarily a test of cerebellar function; the patient is
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asked to touch his or her index finger repetitively to the nose and then to the examiner's
outstretched finger, which moves with each repetition. A similar test in the lower extremity is to
have the patient raise the leg and touch the examiner's finger with the great toe. Another cerebellar
test in the lower limbs is the heel-knee-shin maneuver; in the supine position the patient is asked to
slide the heel of each foot from the knee down the shin of the other leg. For all these movements,
the accuracy, speed, and rhythm are noted.
Gait Examination
The bare minimum: Observe the patient while walking normally, on the heels and toes,
and along a straight line.
Watching the patient walk is the most important part of the neurologic examination. Normal gait
requires that multiple systemsincluding strength, sensation, and coordinationfunction in a highly
integrated fashion. Unexpected abnormalities may be detected that prompt the examiner to return
in more detail to other aspects of the examination. The patient should be observed while walking
and turning normally, walking on the heels, walking on the toes, and walking heel-to-toe along a
straight line. The examination may reveal decreased arm swing on one side (corticospinal tract
disease), a stooped posture and short-stepped gait (parkinsonism), a broad-based unstable gait
(ataxia), scissoring (spasticity), or a high-stepped, slapping gait (posterior column or peripheral
nerve disease), or the patient may appear to be stuck in place (apraxia with frontal lobe disease).
NEUROLOGIC DIAGNOSIS
The clinical data obtained from the history and examination are interpreted to arrive at an anatomic
localization that best explains the clinical findings (Table 367-2), to narrow the list of diagnostic
possibilities, and to select the laboratory tests most likely to be informative. The laboratory
assessment may include (1) serum electrolytes; complete blood count; and renal, hepatic,
endocrine, and immune studies; (2) cerebrospinal fluid examination; (3) focused neuroimaging
studies (Chap. 368); or (4) electrophysiologic studies (Chap. e45). The anatomic localization, mode
of onset and course of illness, other medical data, and laboratory findings are then integrated to
establish an etiologic diagnosis.
Table 367-2 Findings Helpful for Localization Within the Nervous System
Signs
Cerebrum Abnormal mental status or cognitive impairment
Seizures
Unilateral weaknessa and sensory abnormalities including head and limbs
Visual field abnormalities
Movement abnormalities (e.g., diffuse incoordination, tremor, chorea)
Brainstem I solated cranial nerve abnormalities (single or multiple)
"Crossed" weaknessa and sensory abnormalities of head and limbs, e.g.,
weakness of right face and left arm and leg
Spinal cord Back pain or tenderness
Weaknessa and sensory abnormalities sparing the head
Mixed upper and lower motor neuron findings
Sensory level
Sphincter dysfunction
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The neurologic examination may be normal even in patients with a serious neurologic disease, such
as seizures, chronic meningitis, or a TI A. A comatose patient may arrive with no available history,
and in such cases the approach is as described in Chap. 274. I n other patients, an inadequate
history may be overcome by a succession of examinations from which the course of the illness can
be inferred. I n perplexing cases it is useful to remember that uncommon presentations of common
diseases are more likely than rare etiologies. Thus, even in tertiary care settings, multiple strokes
are usually due to emboli and not vasculitis, and dementia with myoclonus is usually Alzheimer's
disease and not due to a prion disorder or a paraneoplastic cause. Finally, the most important task
of a primary care physician faced with a patient who has a new neurologic complaint is to assess the
urgency of referral to a specialist. Here, the imperative is to rapidly identify patients likely to have
nervous system infections, acute strokes, and spinal cord compression or other treatable mass
lesions and arrange for immediate care.
Spinal roots Radiating limb pain
Weaknessb or sensory abnormalities following root distribution (see Figs. 23-
2 and 23-3)
Loss of reflexes
Peripheral nerve Mid or distal limb pain
Weaknessb or sensory abnormalities following nerve distribution (see Figs.
23-2 and 23-3)
"Stocking or glove" distribution of sensory loss
Loss of reflexes
Neuromuscular
junction
Bilateral weakness including face (ptosis, diplopia, dysphagia) and proximal
limbs
I ncreasing weakness with exertion
Sparing of sensation
Muscle Bilateral proximal or distal weakness
Sparing of sensation
a
Weakness along with other abnormalities having an "upper motor neuron" pattern, i.e., spasticity,
weakness of extensors > flexors in the upper extremity and flexors > extensors in the lower
extremity, hyperreflexia.
b
Weakness along with other abnormalities having a "lower motor neuron"
pattern, i.e., flaccidity and hyporeflexia.
FURTHER READINGS
Blumenthal H: Neuroanatomy Through Clinical Cases, 2nd ed. Sunderland, MA, Sinauer, 2010
Campbell WW: DeJong's The Neurological Examination, 6th ed. Philadelphia, Lippincott Williams &
Wilkins, 2005
Ropper AH, Samuels M: Adams and Victor's Principles of Neurology, 9th ed. New York, McGraw-Hill,
2009
Copyright The McGraw-Hill Companies. All rights reserved.
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