SURVIVAL GUIDE TO THE HISTORY, EXAM, and ORAL PRESENTATION
Rob Naismith, M.D.
The Neurological Exam
The neurological exam is one of the best aspects of neurology. Many patients have physical findings with tremendous utility for understanding how a disease functionally affects a person, for localizing, and for prioritizing the differential. Almost everyone with a neurological disease (except seizures and headaches) will have some abnormalities on their exam. Some of these are quite striking, and some can be very subtle. You cannot learn these in a book or a single lecture, so we learn this by seeing patients together with those who are more experienced. When you round with attendings, they will point out the subtle findings. Watch carefully how your attending does the exam.
You should do a complete neuro exam on all your patients, at least for the initial work-up. The chief or the attending might do a more focused exam, but that’s not the goal for you at this time. You need to have a firm grasp of what is normal and what is abnormal, and that takes much practice.
Mental status can be a large or short part of the exam. On every patient, you should specifically check orientation (person, place, time, situation), recall, short-term memory, attention, calculations, and long-term memory. You should take the persons educational level into context here. These can be expanded upon depending on the story and other findings. Language consists of 6 components. These include comprehension, fluency, naming, repetition, reading, and writing.
Cranial nerves should include visual acuity and funduscopic exam. You need to be able to readily see the optic nerve before the end of the rotation.
For the motor exam, you need to be able to pick-up subtle weakness. This would include having people do fine finger movements, toe tapping, walking on heels and toes, and hopping on each foot if safe to do so. When you check power, be sure that you have the mechanical advantage so that you will know if they have mild weakness.
Remember that for reflexes, you are trying to detect subtle differences, not just whether they are present or absent. The exam is much like an experiment where you are hypothesis testing. After you obtain the history, go wash your hands and use that time to create your hypotheses. Think about the localization(s), and the possible diagnoses on your differential. Do not bias the exam too much by leading the patient. You can conduct it as an objective experiment, and be convinced that the abnormality is really there. If you are not sure, repeat the test until you are convinced. Do more detailed testing when indicated by the history. For example, it may take 15 seconds to elicit the reflexes if they have no symptoms referable to that system, or it may take 2-3 minutes if you are really trying to discern a difference.