First Encounter with a Patient: Examination and Formulation

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Chapter 1 First Encounter with a Patient

Examination and Formulation

Despite the ready availability of sophisticated tests, the “hands on” neurologic examination remains the fundamental aspect of the specialty. Beloved by neurologists, this examination provides a vivid portrayal of both function and illness. When neurologists say they have seen a case of a particular illness, they mean that they have really seen it.

When a patient’s history suggests a neurologic illness, the neurologic examination may unequivocally demonstrate it. Even if psychiatrists themselves do not perform the examination, they should be able to appreciate neurologic signs and assess a neurologist’s conclusion.

Physicians should systematically examine patients. They should test interesting areas in detail during a sequential evaluation of the nervous system’s major components. Physicians should try to adhere to the routine while avoiding omissions and duplications. Despite obvious dysfunction of one part of the nervous system, physicians should evaluate all major areas. A physician can complete an initial or screening neurologic examination in about 20 minutes and return to perform special testing of particular areas, such as the mental status.

Examination

Physicians should note the patient’s age, sex, and handedness, and then review the primary symptom, present illness, medical history, family history, and social history. They should include detailed questions about the primary symptom, associated symptoms, and possible etiologic factors. If a patient cannot relate the history, the physician might interrupt the process to look for language, memory, or other cognitive deficits. Many chapters in Section 2 of this book contain outlines of standard questions related to common symptoms.

After obtaining the history, physicians should anticipate the patient’s neurologic deficits and be prepared to look for disease, primarily of the central nervous system (CNS) or the peripheral nervous system (PNS). At this point, without yielding to rigid preconceptions, the physician should have developed some insight about the problem at hand.

Then physicians should look for the site of involvement (i.e., “localize the lesion”). Localization, one of the initial goals of most neurologic examinations, is valuable in most cases. However, it is often somewhat of an art and often inapplicable in several important neurologic illnesses, such as dementia and migraine headaches.

The examination, which overall remains irreplaceable in diagnosis, consists of a functional neuroanatomy demonstration: mental status, cranial nerves, motor system, reflexes, sensation, and cerebellar system, and gait (Box 1-1). This format should be followed during every examination. Until it is memorized, a copy should be taken to the patient’s bedside to serve both as a reminder and as a place to record neurologic findings.

Box 1-1

Neurologic Examination

Mental Status

Orientation (to month, year, place, and any physical or mental deficits)

Memory for immediate, recent, and past events

Higher intellectual functions: arithmetic, similarities/differences

Motor System

Spasticity, flaccidity, or fasciculations

Abnormal movements (e.g., tremor, chorea)

Reflexes

Deep Tendon Reflexes

Biceps, triceps, brachioradialis, quadriceps/patellar, Achilles

Pathologic Reflexes

Extensor plantar response (Babinski sign), frontal release

Sensation

Position, vibration, stereognosis

Cerebellar System

Finger-to-nose and heel-to-shin tests

Rapid alternating movements

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