GENERAL APPROACH TO HISTORY AND EXAMINATION

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SECTION I GENERAL APPROACH TO HISTORY AND EXAMINATION

NERVOUS SYSTEM – HISTORY

An accurate description of the patient’s neurological symptoms is an important aid in establishing the diagnosis; but this must be taken in conjunction with information from other systems, previous medical history, family and social history and current medication. Often the patient’s history requires confirmation from a relative or friend.

The following outline indicates the relevant information to obtain for each symptom, although some may require further clarification.

NERVOUS SYSTEM – EXAMINATION

Neurological disease may produce systemic signs and systemic disease may affect the nervous system. A complete general examination must therefore accompany that of the central nervous system. In particular, note the following

CNS examination is described systematically from the head downwards and includes:

EXAMINATION – CONSCIOUS LEVEL ASSESSMENT

A wide variety of systemic and intracranial problems produce depression of conscious level. Accurate assessment and recording are essential to determine deterioration or improvement in a patient’s condition. In 1974 Teasdale and Jennett, in Glasgow, developed a system for conscious level assessment. They discarded vague terms such as stupor, semicoma and deep coma, and described conscious level in terms of EYE opening, VERBAL response and MOTOR response.

The Glasgow coma scale is now used widely throughout the world. Results are reproducible irrespective of the status of the observer and can be carried out just as reliably by paramedics as by clinicians

EYE OPENING – 4 categories

MOTOR RESPONSE – 5 categories

Obeys commands

Localising to pain

Apply a painful stimulus to the supraorbital nerve, e.g. rub thumb nail in the supraorbital groove, increasing pressure until a response is obtained. If the patient responds by bringing the hand up beyond the chin = ‘localising to pain’. (Pressure to nail beds or sternum at this stage may not differentiate ‘localising’ from ‘flexing’.)

Flexing to pain

If the patient does not localise to supraorbital pressure, apply pressure with a pen or hard object to the nail bed. Record elbow flexion as ‘flexing to pain’. Spastic wrist flexion may or may not accompany this response.

Extending to pain

If in response to the same stimulus elbow extension occurs, record as ‘extending to pain’. This is always accompanied by spastic flexion of the wrist.

None

Before recording a patient at this level, ensure that the painful stimulus is adequate.

During examination the motor response may vary. Supraorbital pain may produce an extension response, whereas fingernail pressure produces flexion. Alternatively one arm may localise to pain; the other may flex. When this occurs record the best response during the period of examination (this correlates best with final outcome). For the purpose of conscious level assessment use only the arm response. Leg response to pain gives less consistent results, often producing movements arising from spinal rather than cerebral origin.

EXAMINATION – HIGHER CEREBRAL FUNCTION

COGNITIVE SKILL

Dominant hemisphere disorders

Listen to language pattern

Expressive dysphasia

Receptive dysphasia Does the patient understand simple/complex spoken commands?
e.g. ‘Hold up both arms, touch the right ear with the left fifth finger.’ Receptive dysphasia Ask the patient to name objects. Nominal dysphasia Does the patient read correctly? Dyslexia Does the patient write correctly? Dysgraphia Ask the patient to perform a numerical calculation, e.g. serial 7 test, where 7 is subtracted serially from 100. Dyscalculia Can the patient recognise objects? e.g. ask patient to select an object from a group. Agnosia

Non-dominant hemisphere disorders

Note patient’s ability to find his way around the ward or his home.	Geographical agnosia
Can the patient dress himself?	Dressing apraxia
Note the patient’s ability to copy a geometric pattern, e.g. ask patient to form a star with matches or copy a drawing of a cube.	Constructional apraxia

Mini Mental Status Examination (MMSE) is used in the assessment of DEMENTIA (page 127).

MEMORY TEST

Testing requires alertness and is not possible in a confused or dysphasic patient.

REASONING AND PROBLEM SOLVING

Test patient with two-step calculations, e.g. ‘I wish to buy 12 articles at 7 pence each. How much change will I receive from £1?’

Ask patient to reverse 3 or 4 random numbers.

Ask patient to explain proverbs.

Ask patient to sort playing cards into suits.

The examiner must compare patient’s present reasoning ability with expected abilities based on job history and/or school work.

EMOTIONAL STATE

Anxiety or excitement

Depression or apathy

Emotional behaviour

Uninhibited behaviour

Slowness of movement or responses

Personality type or change.

CRANIAL NERVE EXAMINATION

OLFACTORY NERVE (I)

Test both perception and identification using aromatic non-irritant materials that avoid stimulation of trigeminal nerve fibres in the nasal mucosa, e.g. soap, tobacco.

One nostril is closed while the patient sniffs with the other.

OPTIC NERVE (II)

N.B. Refractive error (i.e. inadequate focussing on the retina, e.g. hyper-metropia, myopia) can be overcome by testing reading acuity through a pinhole. This concentrates a thin beam of vision on the macula.

Visual fields

Gross testing by CONFRONTATION. Compare the patient’s fields of vision by advancing a moving finger or, more accurately, a red 5 mm pin from the extreme periphery towards the fixation point. This maps out ‘cone’ vision. A 2 mm pin will define central field defects which may only manifest as a loss of colour perception.

In the temporal portion of the visual field the physiological blind spot may be detected. A 2 mm object should disappear here.

The patient must fixate on the examiner’s pupil.

Peripheral visual fields are more sensitive to a moving target and are tested with a GOLDMANN PERIMETER.

The patient fixes on a central point. A point of light is moved centrally from the extreme periphery. The position at which the patient observes the target is marked on a chart. Repeated testing from multiple directions provides an accurate record of visual fields.

Central fields are charted with either a Goldmann perimeter using a small light source of lesser intensity or a TANGENT (BJERRUM) SCREEN. The HUMPHREY FIELD ANALYSER provides an alternative and particularly sensitive method of testing central fields. This records the threshold at which the patient observes a static light source of increasing intensity.

Optic fundus (Ophthalmoscopy)

Ask the patient to fixate on a distant object away from any bright light. Use the right eye to examine the patient’s right eye and the left eye to examine the patient’s left eye.

If small pupil size prevents fundal examination, then dilate pupil with a quick acting mydriatic (homatropine). This is contraindicated if either an acute expanding lesion or glaucoma is suspected.

Pupils

Size (small = miosis/large = mydriasis)

Reaction to light: both pupils constrict when light is shone in either eye

Reaction to accommodation and convergence: pupil constriction occurs when gaze is transferred to a near point object.

OCULOMOTOR (III), TROCHLEAR (IV) AND ABDUCENS (VI) NERVES

A lesion of the III nerve produces impairment of eye and lid movement as well as disturbance of pupillary response.

Pupil: The pupil dilates and becomes ‘fixed’ to light.

Ptosis: Ptosis is present if the eyelid droops over the pupil when the eyes are fully open. Since the levator palpebrae muscle contains both skeletal and smooth muscle, ptosis signifies either a III nerve palsy or a sympathetic lesion and is more prominent with the former.

Ocular movement

Steady the patient’s head and ask him to follow an object held at arm’s length. Observe the full range of horizontal and vertical eye movements.

Note any malalignment or limitation of range.

Examine eye movements in the six different directions of gaze representing maximal individual muscle strength.

Question patient about diplopia; the patient is more likely to notice this before the examiner can detect impairment of eye movement. If present:

– note the direction of maximum displacement of the images and determine the pair of muscles involved

– identify the source of the outer image (from the defective eye) using a transparent coloured lens.

e.g.

Conjugate movement: Note the ability of the eyes to move together (conjugately) in horizontal or vertical direction or tendency for gaze to fix in one particular direction.

Nystagmus: This is an upset in the normal balance of eye control. A slow drift in one direction is followed by a fast corrective movement. Nystagmus is maximal when the eyes are turned in the direction of the fast phase. Nystagmus ‘direction’ is usually described in terms of the fast phase and may be horizontal or vertical. Test as for other eye movements, but remember that ‘physiological’ nystagmus can occur when the eyes deviate to the endpoint of gaze.

e.g. Nystagmus to the left maximal on left lateral gaze.

TRIGEMINAL NERVE (V)

Compare each side. Map out the sensory deficit, testing from the abnormal to the normal region.

Corneal reflex

Test corneal sensation by touching with wisp of wet cotton wool. A blink response should occur bilaterally.

Afferent route – ophthalmic division V (light touch – main sensory nucleus)

Efferent route – facial nerve VII

This test is the most sensitive indicator of trigeminal nerve damage

Motor examination

Observe for wasting and thinning of temporalis muscle – ‘hollowing out’ the temporalis fossa.

Ask the patient to clamp jaws together. Feel temporalis and masseter muscles. Attempt to open patient’s jaws by applying pressure to chin. Ask patient to open mouth. If pterygoid muscles are weak the jaw will deviate to the weak side, being pushed over by the unopposed pterygoid muscles of the good side.

Jaw jerk

Ask patient to open mouth and relax jaw. Place finger on the chin and tap with hammer:

Slight jerk – normal

Increased jerk – bilateral upper neuron lesion.

AUDITORY NERVE (VIII)

Cochlear component

Test by whispering numbers into one ear while masking hearing in the other ear by occluding and rubbing the external meatus. If hearing is impaired, examine external meatus and the tympanic membrane with auroscope to exclude wax or infection.

Differentiate conductive (middle ear) deafness from perceptive (nerve) deafness by:

1. Weber’s test: Hold base of tuning fork (512 Hz) against the vertex. Ask patient if sound is heard more loudly in one ear.

2. Rinne’s test: Hold the base of a vibrating tuning fork against the mastoid bone. Ask the patient if note is heard. When note disappears – hold tuning fork near the external meatus. Patient should hear sound again since air conduction via the ossicles is better than bone conduction.

In conductive deafness, bone conduction is better than air conduction.

In nerve deafness, both bone and air conduction are impaired.

Further auditory testing and examination of the vestibular component requires specialised investigation (see pages 62–65).

GLOSSOPHARYNGEAL NERVE (IX): VAGUS NERVE (X)

These nerves are considered jointly since they are examined together and their actions are seldom individually impaired.

Note patient’s voice – if there is vocal cord paresis (X nerve palsy), voice may be high pitched. (Vocal cord examination is best left to an ENT specialist.)

Note any swallowing difficulty or nasal regurgitation of fluids.

Ask patient to open mouth and say ‘Ah’. Note any asymmetry of palatal movements (X nerve palsy).

Gag reflex

Depress patient’s tongue and touch palate, pharynx or tonsil on one side until the patient ‘gags’. Compare sensitivity on each side (afferent route – IX nerve) and observe symmetry of palatal contraction (efferent route – X nerve).

Absent gag reflex = loss of sensation and/or loss of motor power. (Taste in the posterior third of the tongue (IX) is impractical to test).

ACCESSORY NERVE (XI)

Sternomastoid

Ask patient to rotate head against resistance. Compare power and muscle bulk on each side. Also compare each side with the patient pulling head forward against resistance.

N.B. The left sternomastoid turns the head to the right and vice versa.

Trapezius

Ask patient to ‘shrug’ shoulders and to hold them in this position against resistance. Compare power on each side. Patient should manage to resist any effort to depress shoulders.

HYPOGLOSSAL NERVE (XII)

Ask patient to open mouth; inspect tongue.

– evidence of atrophy (increased folds, wasting)

– fibrillation (small wriggling movements).

Ask patient to protrude tongue. Note any difficulty or deviation. (N.B. apparent deviation may occur with facial weakness – if present, assess tongue in relation to teeth.)

Protruded tongue deviates towards side of weakness.

Non protruded tongue cannot move to the opposite side.

Dysarthria and dysphagia are minimal.

EXAMINATION – UPPER LIMBS

MOTOR SYSTEM

Appearance

Tone

Ensure that the patient is relaxed, and assess tone by alternately flexing and extending the elbow or wrist.

Power

Muscle weakness. The degree of weakness is ‘scored’ using the MRC (Medical Research Council) scale.

Score 0 – No contraction

Score 1 – Flicker

Score 2 – Active movement/gravity eliminated

Score 3 – Active movement against gravity

Score 4 – Active movement against gravity and resistance

Score 5 – Normal power

If a pyramidal weakness is suspect (i.e. a weakness arising from damage to the motor cortex or descending motor tracts (see pages 193–198) the following test is simple, quick, yet sensitive.

Ask the patient to hold arms outstretched with the hands supinated for up to one minute. The eyes are closed (otherwise visual compensation occurs). The weak arm gradually pronates and drifts downwards.

With possible involvement at the spinal root or nerve level (lower motor neuron), it is essential to test individual muscle groups to help localise the lesion.

When testing muscle groups, think of root and nerve supply.

[Note: not all muscle groups are included in the foregoing, but only those required to identify and differentiate nerve and root lesions.]

SENSATION

Pain

Pin prick with a sterile pin provides a simple method of testing this important modality. Firstly, check that the patient detects the pin as ‘sharp’, i.e. painful, then rapidly test each dermatome in turn.

Memorising the dermatome distribution is simplified by noting that ‘C7’ extends down the middle finger.

If pin prick is impaired, then more carefully map out the extent of the abnormality, moving from the abnormal to the normal areas.

Light touch

This is tested in a similar manner, using a wisp of cotton wool.

Temperature

Temperature testing seldom provides any additional information. If required, use a cold object or hot and cold test tubes.

Joint position sense

Hold the sides of the patient’s finger or thumb and demonstrate ‘up and down’ movements.

Repeat with the patient’s eyes closed. Ask patient to specify the direction of movement.

Ask the patient, with eyes closed, to touch his nose with his forefinger or to bring forefingers together with the arms outstretched.

Vibration

Place a vibrating tuning fork (usually 128 c/s) on a bony prominence, e.g. radius. Ask the patient to indicate when the vibration, if felt, ceases. If impaired, move more proximally and repeat. Vibration testing is of value in the early detection of demyelinating disease and peripheral neuropathy, but otherwise is of limited benefit.

If the above sensory functions are normal and a cortical lesion is suspected, it is useful to test for the following:

Two point discrimination: the ability to discriminate two blunt points when simultaneously applied to the finger, 5 mm apart (cf, 4 cm in the legs).

Sensory inattention (perceptual rivalry): the ability to detect stimuli (pin prick or touch) in both limbs, when applied to both limbs simultaneously.

Stereognosis: the ability to recognise objects placed in the hand.

Graphaesthesia: the ability to recognise numbers or letters traced out on the palm.

REFLEXES

Reflex enhancement

When reflexes are difficult to elicit, enhancement occurs if the patient is asked to ‘clench the teeth’.

EXAMINATION – TRUNK

Test pin prick and light touch in dermatome distribution as for the upper limbs.

Levels to remember:

T5 – at nipple

T10 – at umbilicus

T12 – at inguinal ligament.

Abdominal reflexes: T7 – T12 roots. Stroke or lightly scratch the skin towards the umbilicus in each quadrant in turn. Look for abdominal muscle contraction and note if absent or impaired. (N.B. Reflexes may normally be absent in obesity, after pregnancy, or after abdominal operations.)

Cremasteric reflex: L1, L2 root. Scratch inner thigh. Observe contraction of cremasteric muscle causing testicular elevation.

SPHINCTERS

Examine abdomen for distended bladder.

Note evidence of urinary or faecal incontinence.

Note tone of anal sphincter during rectal examination.

Anal reflex: S4, S5 roots. A scratch on the skin beside the anus causes a reflex contraction of the anal sphincter.

EXAMINATION – LOWER LIMBS

SENSATION

Joint position sense

Firstly, demonstrate flexion and extension movements of the big toe. Then ask patient to specify the direction with the eyes closed.

If deficient, test ankle joint sense in the same way.

Vibration

Test vibration perception by placing a tuning fork on the malleolus. If deficient, move up to the head of the fibula or to the anterior superior iliac spine.

REFLEXES

Knee jerk: L2, L3, L4 roots.

Ensure that the patient’s leg is relaxed by resting it over examiner’s arm or by hanging it over the edge of the bed. Tap the patellar tendon with the hammer and observe quadriceps contraction. Note impairment or exaggeration.

Ankle jerk: S1, S2 roots.

Externally rotate the patient’s leg. Hold the foot in slight dorsiflexion. Ensure the foot is relaxed by palpating the tendon of tibialis anterior. If this is taut, then no ankle jerk will be elicited.

Tap the Achilles tendon and watch for calf muscle contraction and plantarflexion.

Reflex enhancement

When reflexes are difficult to elicit, they may be enhanced by asking the patient to clench the teeth or to try to pull clasped hands apart (Jendrassik’s manoeuvre).

Plantar response

Check that the big toe is relaxed. Stroke the lateral aspect of the sole and across the ball of the foot. Note the first movement of the big toe. Flexion should occur. Extension due to contraction of extensor hallucis longus (a ‘Babinski’ reflex) indicates an upper motor neuron lesion. This is usually accompanied by synchronous contraction of the knee flexors and tensor fasciae latae.

Elicit Chaddock’s sign by stimulating the lateral border of the foot. The big toe extends with upper motor neuron lesions.

To avoid ambiguity do not touch the innermost aspect of the sole or the toes themselves.

EXAMINATION OF THE UNCONSCIOUS PATIENT

HISTORY

Questioning relatives, friends or the ambulance team is an essential part of the assessment of the unconscious or the unco-operative patient.

Has the patient sustained a head injury – leading to admission, or in the preceding weeks?

Did the patient collapse suddenly?

Did limb twitching occur?

Have symptoms occurred in the preceding weeks?

Has the patient suffered a previous illness?

Does the patient take medication?

GENERAL EXAMINATION

Lack of patient co-operation does not limit general examination and this may reveal important diagnostic signs. In addition to those features described on page 4, also look for signs of head injury, needle marks on the arm and evidence of tongue biting. Also note the smell of alcohol, but beware of attributing the patient’s clinical state solely to alcohol excess.

NEUROLOGICAL EXAMINATION

Conscious level: This assessment is of major importance. It not only serves as an immediate prognostic guide, but also provides a baseline with which future examinations may be compared. Assess conscious level as described previously (page 5) in terms of eye opening, verbal response and motor response.

For research purposes, a score was applied for each response, with ‘flexion’ subdivided into ‘normal’ and ‘spastic flexion’, giving a total coma score of ‘15 points’. Many coma observation charts (page 31) still use a ‘14 point scale’ with 5 points on the motor score. The ‘14 point’ scale records less observer variability, but most guidelines for head injury management use the ‘15 point’ scale.

It is important to avoid the tendency to simply quote the patient’s total score. This can be misleading. Describing the conscious level in terms of the actual responses i.e. ‘no eye opening, no verbal response and extending’, avoids any confusion over numbers.

Eye movements

Observe any spontaneous eye movements.

Elicit the oculocephalic (doll’s eye) reflex.

Rotation or flexion/extension of the head in a comatose patient produces transient eye movements in a direction opposite to that of the movement.

Note whether the movements, if present, are conjugate (i.e. the eyes move in parallel) or dysconjugate (i.e. the eyes do not move in parallel). These ocular movements assess midbrain and pontine function.

Elicit the oculovestibular reflex (caloric testing, see page 65).

Visual fields

In the unco-operative patient, the examiner may detect a hemianopic field defect when ‘menacing’ from one side fails to produce a ‘blink’.

Facial weakness

Failure to ‘grimace’ on one side in response to bilateral supraorbital pain indicates a facial weakness.

Limb weakness

Detect by comparing the response in the limbs to painful stimuli. If pain produces an asymmetric response, then limb weakness is present. (If the patient ‘localises’ with one arm, hold this down and retest to ensure that a similar response cannot be elicited from the other limb.)

Pain stimulus applied to the toe nails or Achilles tendon similarly tests power in the lower limbs. Variation in tone, reflexes or plantar responses between each side also indicates a focal deficit. In practice, if the examiner fails to detect a difference in response to painful stimuli, these additional features seldom provide convincing evidence.

THE NEUROLOGICAL OBSERVATION CHART

Despite major advances in intracranial investigative techniques, none has replaced clinical assessment for monitoring the patient’s neurological state. The neurological observation chart produced by Teasdale and Jennett incorporates the most relevant clinical features, i.e. coma scale (eye opening, verbal and motor response), pupil size and reaction to light, limb responses and vital signs. The frequency of observation (normally 2-hourly) depends on the individual patient’s needs. The chart enables immediate evaluation of the trend in the patient’s clinical state.

By permission of the Nursing Times

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