Many complaints call for an examination of the nervous system. For example, you will want to perform some sort of neurological examination in patients with common complaints such as headache and low back pain. A neurological examination is also required if the patient has any sort of weakness, disorders of sensation, or problems with movement or posture.

Simple examination procedures, when performed properly, can give very valuable information leading to the correct diagnosis and treatment. It is therefore essential that the neurological examination be performed correctly. As with other physical examination techniques, this requires the understanding and cooperation of the patient. Be sure to explain clearly whatever procedures you are about to carry out, and make sure that the patient understands and can follow your instructions.

The nervous system has such widespread effects, that there is little point in a general screening. Neurological examination is most often directed at diagnosing a specific complaint. Therefore, you will have to choose your tests based on the patient's history and the results of previous examinations. You cannot afford to waste time performing tests which are unlikely to be related to the patient's chief complaint.

Disorders of the central nervous system, such as stroke, Alzheimer disease and Parkinsonism tend to effect older people and so will probably become more common in the future. Each of these disorders has quite characteristic symptoms which you will soon learn to recognize. Your examination will help you to determine the level of the patient's disability, and so determine what kind of support they require.

Younger people most often suffer neurological disease due to accidents, especially motor vehicle and sporting accidents. Their injuries may be quite devastating. However, the treatment of such injuries and the rehabilitation of disabled patients is improving rapidly. Neurological testing is important not just in diagnosing an injury, but also in monitoring improvements in response to treatment.

Situation 1: A doctor is examining a junior high school student who has just been brought into the emergency room of a hospital following an accident. The young man fell off of his bicycle and struck his head. He was not wearing a bicycle helmet. He is conscious and lucid.

Doctor: Ben, I need to perform a few tests to see how badly you are hurt. None of this will hurt and it won't take long, but I need you to follow my instructions and do what I ask. Can you do that?

Ben: I think so. Okay.

Doctor: Ben, I need to look in your eyes for just a second. Can you look at this light? (The doctor checks for pupillary reflexes.) This only takes a second. How does your head feel now?

Ben: It hurts a little, but I guess I'm okay.

Doctor: Good. Now, I want you to look at this pen. Can you follow it with your eyes. (The doctor moves the pen about, checking eye movements.) How was that? Easy?

Ben: Sure.

Doctor: Ben, I want to touch both sides of your face with my fingers. (The doctor checks sensation on the left and right side of the face.) I need to know if it feels normal and the same on both sides. How does that feel?

Ben: Yeah, that feels normal, I guess.

Doctor: Now I need you to close your eyes really tight, and don't let me open them. Can you keep your eyes closed? (The doctor tries to raise the young man's upper eyelids against resistance.) Okay, can you open your eyes now? How are you feeling? This won't take much longer.

Ben: I'm fine. My head just hurts a bit.

Doctor: Okay, now I want you to stick out your tongue and say "Ah". (The doctor checks for asymmetry of the tongue and uvula.) Good. And now can you just swallow for me? (The patient swallows.) Ben, you look fine, but from now on I want you to wear your bicycle helmet. What do you think?

Ben: I guess you're right.

Patterns:

* I need to perform a few tests
... to look in your eyes
... to know if it feels normal

* I need you
... to follow my instructions
... to close your eyes

* Can you
... do that
... at this light
... follow it with your eyes
... open your eyes now
... just swallow for me

* I want you
...to look at this pen
... to touch both sides of your face
... to stick out your tongue
... to wear your bicycle helmet

* How
... does your head feel
... does that feel
... are you feeling ...

* It won't take long
* This only takes a second
* This won't take much longer ...

Situation 2: A chiropractor is examining a 35 year-old man who appears to have a herniated lumbar disc. The man is sitting on the edge of an examination table in obvious pain.

Doctor: Mr. Roberts, I am going to run my hands down both of your legs, and I want to know if both sides feel normal. (The doctor checks the dermatomes of the leg for sensation.) Were the two sides the same?

Mr. Roberts: The top and outside of my left foot feels numb compared to the right side.

Doctor: Okay, now I am going to hold down your knee, and I want you to push up into my hand. (The doctor tests the strength of the hip flexors on the right and left.)

Mr. Roberts: It is hard to push very hard because of the pain.

Doctor: I understand, but your strength actually seems pretty good. Now I am going to hold your knee bent and I want you to push out against my hand. (The doctor tests the strength of the knee extensors.)

Mr. Roberts: That`s not so bad.

Doctor: And now I want you to hold your big toe up and hold it there. I am going to push down. (The doctor tests the strength of the extensors of the great toe.) That seems a little weak on the left.

Mr. Roberts: There was no extra pain with that, but I don`t seem to have much strength.

Doctor: Next, I want you to hold your foot in this position and don`t let me push it down. (The doctor puts the patient`s feet in inversion, and then tries to push them back to the neutral position.) Again, you appear to be somewhat weaker on the left side.

Mr. Roberts: That wasn`t painful, but I feel as if I have no strength.

Doctor: I understand. Now, I want to check your reflexes, but I think I will get you to lie on your back for that. Do you think you can lie down?

Mr. Roberts: This is going to be pretty painful. Can you lift my feet up for me? (With the doctor`s assistance, Mr. Roberts slowly lies down on his side, and then slowly rolls onto his back.) Wow, that always hurts.

Doctor: I`ll give you just a minute to relax. Are you okay?

Discussion:

1. In the first situation, the young boy does not seem especially concerned about or afraid of the examination. Why do you think that normally children have a different attitude from adults towards examination?

2. At the end of the examination, in situation 1, the doctor warns the young boy about wearing a bicycle helmet. Do you think that this is the doctor`s responsibility? Why?

3. In the second situation, the patient is in a lot of pain. How might you modify your examination for such a patient?

4. In the second situation, even though the patient has serious pain, the doctor doesn't appear to be especially concerned. Why do you think the doctor doesn`t show great concern for the patient`s pain?

5. In the first situation, the boy hit his head, but the doctor examined his face (eyes, facial skin etc.). In the second situation, the man had back pain, but the doctor examined his legs. Why aren`t these doctors looking at the site of the pain or injury?