abnormalities, usually positive, indicate typically over‐activity from release of inhibition, such as spasticity.
Neurological Examination: Preliminary Assessment
Gordon Holmes wrote in 1946: ‘More can often be learned of a patient’s disabilities by observing his ordinary actions, as dressing and undressing, walking when apparently unobserved, than by specific tests’. We rely on this approach intuitively – it is the way we form impressions and gauge people. Refine these skills. Think about:
Greeting, manner, orientation, attention, mental state, mood, personal hygiene, dress
Cognitive clues – turning to a companion before answering implies uncertainty
Speech, language, facial appearance
Gait, stance, clumsiness, weakness, involuntary movements, sensory symptoms
Risk factors, lifestyle, tobacco, alcohol, drugs, religion, illness beliefs, fears
Disability, aids, state benefits, aspects of daily living, driving, employment, sports
Endocrine or other clues – hypothyroidism, hypopituitarism, bruises
Relations with GP, hospital staff, attitudes towards treatment, expectations.
Brief Neurological Examination
Detailed examination is impracticable in a busy practice. We need a robust, safe and rapid approach:
Impressions (see above), gait, balance, arm swinging
Head: visual acuity, fundi, pupils, eye and face movements, tongue
Limbs: posture of arms outstretched, wasting, fasciculation, tone, power, coordination, reflexes, plantars
Sensation: ask the patient
Brief general exam, BP lying/standing.
Detailed Examination
The Queen Square scheme is adapted into Table 4.1.
Table 4.1 Detailed examination.
| History and general assessment |
| Complaints, past and family history |
| Personal (confidential) issues, alcohol drugs, tobacco, travel, occupation |
| Previous opinions, medical notes |
| Review of systems |
| Examination |
| Initial appraisal, mental state, cognition, speech |
| Stance, gait, balance, hand preference, skull, spine |
| Cranial Nerves I‐XII |
| Motor System |
| Movements, upper limb posture, wasting, tone, power, reflexes, coordination, diaphragm, neck |
| Sensation (sensory chart) |
| Posterior columns: vibration (128 Hz, VS), joint position (JPS), light touch (LT), 2‐point |
| Spinothalamic: pain (PP), hot/cold (TM) |
| General Physical Examination |
| CVS, BP standing/lying, respiratory, abdomen, endocrine, skin, nodes, joints |
| Summary, Formulation & Provisional Diagnosis |
Cognition and Mental State
Queen Square Cognitive Screening Tests are excellent; there are many others.
Orientation and alertness
Language and Literacy
Praxis and Memory &c.
Follow with clinical psychometry if need be – see Chapters 5 and 22.
Skull, Scalp and Spine
Skull & scalp: contour, circumference, old burr holes, pulseless vessels, skull bruits.
For bruits, to abolish noise:
Say: ‘gently close your eyes’.
Rest stethoscope bell over one closed lid.
‘Open your other eye, and just stop breathing, briefly’.
Spine: contour, scars, deformity, pain, bruits, hair tufts, dimples, sinuses.
Cranial Nerves
I: Olfaction
Use clove oil, peppermint, eucalyptus &c – or soap, coffee and/or an orange (see Chapter 13).
II: Vision, Pupils and Fundi
Acuity: use a 3 metre Snellen chart. Correct refraction with lenses or pinhole – make one if necessary.
Fields: finger confrontation is reliable, and/or use 5 mm white/red pinheads. Ask the patient to cover their left eye; fix gaze of their right with your left eye. Fields are not flat: move target along a circumference, c. 50 cm away.
Central defects: Amsler grid, or, use text: ‘….are there any holes in the print?’
Colour vision: Ishihara or 100 Hue cards.
Pupils:dim lights, bright torchapproach from temporal side avoids convergencecross‐illuminate – second torch lights up a dark iris – many an unreactive pupil constrictsrelative afferent pupillary defect: swinging light test.
Fundi: develop your own technique.I seat the patient gazing horizontally at an object, and say: ‘…. its fine if you blink….’For the left fundus, I look through my ophthalmoscope with my left eye and cover my right.
III, IV and VI Diplopia: 4 Patterns and 4 Formal Rules
Most double vision fits one of four patterns:
VI: Abducens Palsy
Complaint: double vision – two images side by side
Evident convergent squint
Double vision disappears on looking away from the weak lateral rectus and vice versa; worse towards it – the squinting eye
No pupil abnormality.
Remember: a lateral rectus palsy can be caused by a VIth nerve lesion, by muscle or neuromuscular