Neurology. Charles H. Clarke

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