Neurological examination

The following headings summarize the essential elements of the clinical examination:
1 State of consciousness, arousal
2 Appearance, attitude, insight
3 Mental state
4 Orientation in time and place
5 Recall of recent and distant events/memory
6 Level of intellect
7 Language and speech/cerebral dominance
8 Disorders of higher function (e.g. apraxia)
9 Gait
10 Romberg’s test
11 The skull-shape, circumference, bruits
12 The neck-stiffness, palpation and auscultation of carotid arteries
l3 The cranial nerves-see individual nerves
14 The motor system
(a) Upper limbs:
(i) Wasting and fasciculation
(ii) Posture of the outstretched arms-drift, rebound, tremor
(iii) Tone-if increased, is it spasticity or ‘extrapyramidal’ rigidity?
(iv) Power-weakness may be graded roughly into ‘slight’, ‘moderate’ or ‘severe’ or numerically (0-5)
(v) Tendon reflexes: + or ++, normal; +++, increased; 0, absent even with reinforcement
(b) Thorax and abdomen:
(i) Respiration
(ii) Abdominal reflexes and muscles
(c) The lower limbs:
(i) Wasting and fasciculation
(ii) Tone, power and tendon reflexes
(iii) Plantar responses
15 Coordination and fine movements
16 The sensory system. First, the patient is asked whether or not the feeling in the limbs, face and trunk is entirely normal .
(a) Posterior columns:
(i) Light touch
(ii) Vibration (using a 128 Hz tuning fork)
(iii) Joint position
(iv) Two-point discrimination (normal: 0.5 cm on fingertips, 2 cm on soles)
(b) Spinothalamic tracts:
(i) Pain (pin prick) – using a split orangestick
(ii) Temperature
Chart areas of abnormal sensation Short neurological examination A detailed neurological examination is time-consuming and is not necessary in all patients, particularly those without symptoms suggestive of neurological disease. A short examination will detect the majority of defects.

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