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Medical Examination in Neurologic Patients
Many specialists, including neurologists, are first trained in general medicine. As such, they interpret their findings in the context of the entire body. For this reason, they must remain facile in performance and interpretation of the general medical examination. However, they do not perform the entire examination on every patient but rather select specific portions for focus that are appropriate to their study. For example, if a neurologist is seeing a stroke patient in the emergency department, the general medical examination segment of greatest interest is cardiovascular. However, if they are examining a patient in the clinic with worsening myasthenia gravis, they may pay special attention to the pulmonary examination with concern for respiratory drive and the possibility of aspiration.
Therefore, this chapter will consider both the basic general medical examination that might be performed on most patients and the focused examination that is indicated for specific entities.
Basic Medical Examination
The basic medical examination usually includes cardiac, pulmonary, musculoskeletal, and vascular examinations. These are the most important for correlation with neurologic conditions, especially in the acute care environment.
Cardiac examination is probably the most important. This is where the return on investment of the time of examination is the greatest. The examination might reveal a heart murmur or an irregularity that would have implications, especially in a patient in whom cardiovascular or cerebrovascular disease is considered.
Vascular examination goes hand in hand with the cardiac examination. Carotid bruits can be reflective of previously undetected disease. In addition, peripheral pulses are important because their absence or association with other findings suggesting vascular disease can indicate the possibility of nonvascular pathology.
Musculoskeletal examination is performed largely by observation during history taking. However, when gait is tested as part of the neurologic examination, the examiner watches the patient walk and observes how the limbs and body move. Abnormalities can be manifested that may suggest spinal pathology, peripheral nerve pathology, or myopathy.
Skin examination is mainly for rash or edema. Rash is a rare accompaniment to several diseases involving the nervous system, such as dermatomyositis, but edema is quite important, as it can be a sign of peripheral vascular disease, renal disease, or cardiac disease. Any of these may be important contributors to the neurologic presentation.
Focused Medical Examination
In select instances, there is a focused examination that is specific to the problem under consideration. We will discuss some general guidelines and then some specific scenarios.
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