Abstract
After finishing the history, the neurologist should have a distinct anatomical hypothesis that can be confirmed (or rejected) during the bedside examination. Specifically, the neurologist seeks to elicit the signs compatible with this hypothesis, to confirm the absence of signs irreconcilable with it, and to verify that the rest of the examination is normal. A standard bedside examination includes evaluation of consciousness and cognition, cranial nerves, sensorimotor and cerebellar function, and gait and a general medical assessment. In cooperative patients, this can often be done in less than 5 min. In addition, tactful observation of the patient before, during, and after the consultation can reveal a wealth of information regarding neurological function. In this chapter, the reader will find in-depth information and practice tips concerning the examination of neurological patients, including those with decreased consciousness, epileptic seizures, and functional deficits.
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Notes
- 1.
Pica is an abnormal appetite for substances not suitable as food, e.g., bricks, clay, soil, and laundry starch.
- 2.
It is advisable to buy an ophthalmoscope and to use it routinely during the neurological examination. Ophthalmoscopy is undoubtedly the most difficult of all neurological bedside techniques. Considerable practice is needed to master this technique—it has been said that no other bedside examination is associated with as many lies as ophthalmoscopy.
- 3.
When testing for compensatory saccades, it is advisable to strictly focus on one eye at a time as the compensatory saccades are much easier to observe this way. Alternatively, focusing on the patient’s nose permits the examiner to see the compensatory saccades in his own peripheral vision.
- 4.
A patient with a complete spastic hemiparesis has the arm adducted and the elbow, wrist, and finger joints maximally flexed, whereas the joints of the leg (hip, knee, ankle, and phalangeal joints) are fully extended. This leads to the characteristic “short arm, long leg posturing” and is due to increased activity of the antigravity muscles that arise with central spasticity. (That the antigravity muscles remain strong is an evolutionary safety mechanism to ensure continued upright posture.) The result is the typical gait disorder in which the hemiparetic patient has to circumduct the foot in order to clear it from the ground (Wernicke-Mann gait). A mild central palsy will therefore be best detected by testing the anti-antigravity muscles, or, in other words, by long arm, short leg posturing (extension of the arm and flexion of the ipsilateral leg).
- 5.
Decreased muscle tone can be revealed by larger amplitude of arm pendulating on passive shoulder shrug or the Stewart-Holmes test. However, this rarely offers additional significant information.
- 6.
In very long-standing camptocormia, secondary hip and trunk contractures may prevent disappearance of trunk flexion in the supine position.
- 7.
C3, 4, 5 keeps the diaphragm alive.
- 8.
When flushing the ear canal in a conscious patient, the fast phase of the nystagmus will be to the opposite side with cold water and to the same side with warm water. The acronym COWS (Cold Opposite, Warm Same) has been taught for generations as a mnemonic. However, as stated above, this denotes the fast phase of the nystagmus, which is seen typically in conscious patients. In unconscious patients who lack supranuclear gaze control but who have an intact brainstem, there may only be gaze deviation in the other direction (CSWO (Cold Same, Warm Opposite)).
- 9.
Occasionally, hemiparesis and Babinski sign are ipsilateral to the hemispherical lesion. This is the so-called Kernohan’s notch phenomenon and occurs when the mass lesion leads to lateral brain displacement pressing the opposite cerebral peduncle, and thus the opposite corticospinal tract, against the tentorium.
- 10.
Please observe that the diagnostic procedures in children are significantly different due to the immaturity of the brain; these procedures will not be reviewed here.
- 11.
For discussion of SSEP and other evoked potentials, see Chap. 5.
- 12.
Developing a functional disorder out of the blue in later life would be unusual. In the elderly without a history of a psychological condition of any kind, vague complaints about physical symptoms often mask a depressive disorder or a beginning dementia.
- 13.
Alexithymia (Greek, “not being able to read emotions”) is impaired processing of emotions at the cognitive level; e.g., patients report physical signs of panic or anxiety, but they are not aware of any stressful feelings.
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Kondziella, D., Waldemar, G. (2023). Neurological Bedside Examination: “Can I Confirm My Anatomical Hypothesis?”. In: Neurology at the Bedside. Springer, Cham. https://doi.org/10.1007/978-3-031-43335-1_3
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