Neurological Skills. A Guide to Examination and Management in Neurology

137 Pages·1987·5.746 MB·English

by  Michael J.G. Harrison (Auth.)

To Heather, John and Iain
Neurological Skills
A Guide to Examination and Management in
Neurology
Michael J.G. Harrison, DM, FRCP
Professor in Clinical Neurology and
Francis and Renee Hock Director of Research,
Reta Lila Weston Institute of Neurological Studies,
University College and Middlesex School of Medicine
Butterworths
London Boston Singapore Sydney Toronto Wellington
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First published 1987
Reprinted 1990
© Butterworth & Co. (Publishers) Ltd, 1987
British Library Cataloguing in Publication Data
Harrison, Michael, 1936-
Neurological skills : a guide to
examination and management in neurology.
1. Neurology
I. Title
616.8 RC346
ISBN 0-407-01360-1
Library of Congress Cataloging in Publication Data
Harrison, M. J. G. (Michael J. G.)
Neurological skills.
Includes bibliographies and index.
1. Nervous system—Diseases—Diagnosis. 2.Nervous
system—Diseases. I. Title. [DNLM: 1. Nervous
System Diseases—diagnosis. 2. Nervous System
Diseases—therapy. 3. Neurologic Examination.
WL 141 H321n]
RC348.H316 1986 616.8Ό475 86-20720
ISBN 0-407-01360-1
Typeset by Scribe Design, Gillingham, Kent
Printed and bound by Butler and Tanner Ltd, Frome and
London
Preface
The ability to make a neurological diagnosis Hopefully, the illustrations and text that
depends above all on the capacity to under- follow will help the student, at whatever
stand the patient's history, to carry out a stage, to gain confidence in his or her ability
reliable examination and to interpret neurolo- to cope with neurological problems; to lessen
gical symptoms and signs. This book the mystery of neurology without losing any
attempts to describe the neurological ex- of its fascination.
amination and its pitfalls and discusses how To simplify the text, the patient has been
physical signs or lack of them can be used to referred to as 'he' throughout, although cases
substantiate or refute the hypothesis gener- occur in both sexes. So that subsections can
ated whilst listening to the patient's own be consulted in isolation, there is some
account of affairs. First steps in the manage- repetition of key points.
ment of neurological conditions are also
described.
Acknowledgements
It is a pleasure to record my gratitude to retinal photographs. Permission to reproduce
Charles Fry and Sue Deeley of Butterworths figures was kindly granted by the Oxford
and to Marie-Louise Autin and Beryl Laatz University Press, the editors of the Oxford
who patiently oversaw the gestation of the Textbook of Medicine and the publishers and
manuscript. I must also express my thanks to editor of the British Journal of Hospital Medi-
the authors of many fine monographs, to all cine, the Physician, and the British Medical
my teachers, and students, and to my patients Bulletin. I am grateful to Dr Ben Aspey and to
who all provided moments of insight. Their the staff of the Department of Medical
sagacity accounts for many useful tips, the Illustration of the University College and
errors are mine. Dr Michael Johnson read the Middlesex School of Medicine for their skilled
text and made many useful suggestions. Mr assistance with the figures and tables.
Peter Hamilton kindly provided some of the
1
History and examination
The history example, if it sounds as though the patient
may have spinal cord disease, one would go
on to ask about back pain and sphincter
Taking a revealing history is a highly skilled disturbance if these had not yet been men-
exercise. Although it is learnt largely by tioned. By showing interest and sympathy at
apprenticeship, some advice can be prof- this stage one is also building a rapport that
fered. will be vital to the patient's compliance with
It is important to secure the patient's trust advice or medication, and trust in the
and allay his nervousness by a friendly diagnosis.
approach and due privacy. A history taken in As well as giving clues about the function
the open ward is unlikely to be given in a or part of the neuraxis at fault, the history
relaxed way, and so may be unreliable. The also reveals most of the information needed
examiner must hide his irritation at vague- to diagnose the nature of the pathological
ness and his hurry. The patient must feel that process responsible for the symptoms. Thus
this doctor will listen, and has time to hear the nature of the onset and the time course of
him out. This means that a mental note must evolution of symptoms reveal whether the
be made of matters that will need clarification patient has a vascular or mechanical lesion
by gentle probing, and the patient initially (sudden onset), an inflammatory disease
allowed to get off his chest those things he (usually subacute onset over days) or a
most wants the doctor to hear. Later it is neoplastic or degenerative disorder (insi-
appropriate to discourage a catalogue of dious onset with progresive deterioration).
second-hand medical opinions from previous Intermittent processes like those in multiple
consultations, and to analyse what the sclerosis, epilepsy and migraine produce a
patient has meant by words like numb, or diagnostically episodic history.
dizzy. However, care must be taken not to The history also directs the subsequent
'lead the witness' by suggesting answers to examination. At the end of the history it
important questions. should be clear which parts of the neurologic-
As one listens it is important to start al examination are going to be crucial. The
hypothesizing about the meaning of the examination 'digs' where the history has
history taken. What is the anatomical im- marked an 'Χ', or rather a '?'. In addition the
plication of the presenting symptom or group examiner will be intent on ruling out other
of symptoms; does it sound like a disorder of possibilities, as well as confirming the first
consciousness, of the vestibular or visual hypothesis. Alternative diagnoses that re-
system, of motor or sensory function, etc.? quire very different management or treat-
The hypothesis should only be vague but it ment must always be considered, if only to be
will be important in directing the later refuted.
questions aimed at clarification and at con- It should be clear that history taking is an
firming or refuting the initial localization. For active process, the examiner processing the
1
2 History and examination
information, formulating a hypothesis or gives the history without moving his mouth
several hypotheses, rejecting some as further more than a fraction, and who points to the
data appear and planning the examination. site of the pain without daring to touch the
Research has shown that the experienced pointing finger on the face, has trigeminal
clinician makes his first hypothesis, albeit a neuralgia. Such a spot diagnosis is not often
fairly vague one, within seconds of meeting possible, however, and routine questions are
the patient. needed both of nervous system function, and
The clues are not only those of the stated of the health of other systems (Table 1.1).
history. While the patient is being greeted,
Table 1.1 Routine neurological enquiry
seated, and invited to explain his problem,
Have you noticed any change in your mood,
the clinician has an opportunity to start the
memory or concentration?
examination. The patient reveals much of his
Is your sleep disturbed?
personality, mood, intelligence, memory,
Have you had any black-outs or been dizzy?
language, and voice as he tells his story. Have there been any problems with vision,
Body language is also revealing. The patient's hearing or balance?
agitated or depressed mood affects his Have you had difficulty with talking, chewing or
movements. Some neurological conditions swallowing?
may be suspected on first meeting the Have you noticed any numbness or pins and
patient. The walk as the new patient needles in your face, body, arms or legs?
approaches the desk may reveal parkinson- Have you had weakness, heaviness or clumsiness
ism, hemiplegia, ataxia or foot drop. The of your limbs?
Is your walking affected?
difficulty getting out of the chair at the end of
Have you normal control over your bowels and
the interview may alert one to the possibility
waterworks and is sexual function normal?
of proximal muscle weakness. The general
appearance of the face may suggest an Problems may arise because the patient is
endocrine abnormality (hypopituitarism, unintelligent, dementing, deaf, depressed or
acromegaly, hypothyroidism, exophthalmic frightened, or has a language disorder (dys-
goitre) or reveal a rash (adenoma sebaceum, phasia). The doctor may be tired, have a
lupus pernio, disseminated lupus erythema- headache, or be inattentive or interrupt too
tosis, dermatomyositis)—all clues to the often. If not careful he may put words into
neurological condition. A parkinsonian im- his patient's mouth in an attempt to save time
mobility or a weak face may be obvious and and cut corners. The solution may be to start
disorders of the eyelids or eyes can be again on another occasion. All junior doctors
noticeable as the patient is questioned. A tilt know the irritation of hearing a patient
of the head may suggest cervical disc disease, produce a new gem of information when
a posterior fossa tumour, or diplopia due to telling his story to the consultant, which he
weakness of one of the oblique muscles. forgot or was insufficiently encouraged to
Parkinsonian tremor may become obvious in reveal when first encountered. The other aid
the hand resting on the lap. to overcoming these difficulties is to inter-
For all these reasons, and to increase view a relative as well. Besides confirming
rapport, as well as to be polite, the clinician the accuracy of the patient's own story, such
should look at the patient's face while additional history may also reveal the pa-
listening. Note taking should be limited and tient's lack of memory or a change of
saved until later. The patient who is talking personality. Eyewitness accounts of attacks
to a doctor who has his head in the notes of loss of consciousness, for example, are
scribbling furiously is unlikely to relax and worth miles of EEG recording, so patients
fully co-operate, and the doctor will be with black-outs must be asked to bring an
missing some valuable physical signs. eyewitness to the consultation if at all
The act of making a diagnosis is frequently possible. A phone call to a relative, work-
one of pattern recognition. The patient who mate, or doctor may not be a glamorous way
describes sharp stabs of pain in one side of of making a diagnosis but can be very 'cost
the face provoked by eating and talking, who effective'.
The general examination 3
Some features of the history suggest that suggests open sutures, for example in an
the patient will be unlikely to have any infant with hydrocephalus, and unilateral
evidence of organic disease. The patient may dullness may indicate a subdural collection.
show either exaggerated distress, or demons- The spine too is percussed for focal tender-
trate 'la belle indifférence''. A shopping list of ness suggesting local pathology such as an
medical consultations or symptoms, or a epidural abscess, or vertebral metastasis, and
bizarre symptom, may arouse suspicions in observed and palpated for any hint of
the clinician's mind. Discrepancies may also scoliotic curvature. Such a curve may be
be obvious in the patient's appearance. A congenital or part of a hereditary condition
woman with difficulty in using her hands is such as Friedreich's ataxia, but may also be
unlikely to be accurately made up. Well- acquired from muscle paralysis as in
brushed hair may conflict with a complaint poliomyelitis or with skeletal disease. A tuft
that the arms cannot be lifted above shoulder of hair or dimple in the lumbar region may be
level. a clue to a congenital spinal abnormality such
Finally one should recall probabilities. as spina bifida.
Most headaches will be due to migraine or The size of the two hands and feet should
tension, for example. This does not mean be compared by placing them side by side. A
that other important causes must not be hemiparesis in infancy may be reflected in
considered and excluded but it does mean retarded growth on one side. The length and
that the clinician's 'bias' should be towards girth of thumbs or fingers or the length and
the likely, not the unlikely. width of the foot may reveal a difference. The
patient may know that they need a half size
smaller shoe on one side. A high arched foot
Further reading under which a light can be seen from the side
even when a flat board is pressed up onto the
heel and sole can be a sign of other congenital
BALLA, j.i. (1980) Pathways in Neurological Diagnosis.
Edward Arnold, London. anomalies or hereditary conditions. Such a
pes cavus is found, for example, in some
hereditary neuropathies. The toes tend to be
bunched up.
Examination of the skin may yield useful
The general clues. Many café-au-lait patches are indica-
tive of neurofibromatosis even when there
examination are no obvious fibromas or neuromas. Rashes
about the face may indicate tuberose scler-
osis, or dermatomyositis and the fine pale
texture of the skin of a patient with pituitary
The routine physical examination including failure may prompt a survey of body hair and
obligatory measurement of the blood press- testicular size.
ure may of course reveal the cause of Neck stiffness is sought by passive flexion
neurological problems but will not be consi- of the neck by the examiner's hands under
dered in detail. Clearly a hard prostrate, a the occiput. This is best done from directly in
breast lump, lymphadenopathy, a cardiac front with the elbows flexed. Limitation
source of embolism, or signs of organ failure suggests meningitis or subarachnoid bleed-
may all be crucial. Some aspects of the ing. If lateral flexion of the neck is restricted,
examination are more directly relevant to the cervical spondylosis is the likely cause. A
making of a neurological diagnosis, however, general rigidity is felt in some parkinsonian
and will be discussed. syndromes. Limitation of elevation of the
The skull should be palpated for lumps or extended leg with the examiner's hand under
bulges (over a meningioma), its circumfer- the heel implies root irritation, for example
ence measured if hydrocephalus is sus- by a prolapsed disc, or meningeal irritation. If
pected, and percussed. A cracked-pot note the flexed knee is brought up to the abdomen
4 History and examination
and then the knee is extended, resistance is depressed, thought disordered, confused,
felt again with meningism or root entrapment amnesic or overtly demented. More formal
(Kernig's sign). assessment may need the skills of a clinical
A bruit may be heard over cranial arter- psychologist, but an intermediate level of
iovenous malformations or fistulae; it is best testing at the bedside by the clinician is an
sought by placing the bell of an Old- important part of the neurological
fashioned' stethoscope over the closed eye. examination.
The patient should be asked to open the
other eye and fix his gaze so that movement
Dysphasia
of the eyeball under the stethoscope does not
cause uninvited extraneous noises. Bruits
over the neck commonly arise from the heart. Listening to the patient's speech and observ-
If this is the case they will be recognized over ing his comprehension of what he hears will
the precordium and heard in the sternal give an impression of language capability.
notch and will peter out somewhat as they This is preferable to trying to take a short cut
are conducted up the major vessels. A bruit and testing naming ability, which can be
restricted to the angle of the jaw is likely to be mildly defective in confused patients when it
a marker of atheromatous stenotic disease of does not prove that the dominant hemis-
the carotid artery. Venous hums have a lower phere is damaged. The ability to read, write
frequency, vary with head position and and repeat words and phrases should be
posture, and may be stopped by gentle tested. Lesions in the frontal lobe produce a
pressure on the neck or by a Valsalva non-fluent disturbance of speech. The patient
manoeuvre. A thyrotoxic goitre may also be comprehends normally but produces few
the source of a continuous murmur. Au- words or telegrammatic short sentences. The
scultation over the spine may extremely speech lacks melody and rhythm. Proposi-
rarely reveal the bruit of a spinal angioma, tional speech is lost before expletives. Be-
and is worth carrying out in patients with a cause Broca's area for speech is close to the
spinal lesion. face and mouth area of the motor strip, there
Joint disease may impair movement and may be some difficulty pronouncing some
complicate testing of muscle power so the full syllables due to a 'high level' disturbance of
range of passive movement at joints like the complex muscle activity needed for articula-
shoulder and knee may have to be checked. tion. When there is a temporal lobe lesion
causing dysphasia the speech is fluent
Swelling and abnormal mobility may be
though full of errors (Wernicke's aphasia).
found in a Charcot joint, disorganized by loss
Many words are incorrect (paralogisms) and
of pain sensibility as in syringomyelia, tabes
some are apparently newly invented ones
dorsalis or diabetes mellitus.
(neologisms). The normal cadence of speech
is preserved (prosody) and the patient
sounds as though he is talking in an
unfamiliar language. To add to this impress-
The neurological
ion he fails to understand the spoken word.
Extensive lesions of the dominant hemis-
examination
phere may affect both the temporal and
frontal areas involved in language function.
The resultant global dysphasia is non-fluent
Mental state and language and the patient is also unable to understand.
Rare disconnections of these two speech
areas, for example by lesions in the parietal
The patient's appearance, demeanour and
lobe, produce a fluent dysphasia with re-
performance during history taking are them-
latively preserved comprehension but a great
selves good tests of intelligence, memory and
difficulty in repeating phrases (conduction
behaviour. Whilst the history is given it may
aphasia) (Table 1.2).
become clear that the patient is anxious,
The neurological examination 5
Table 1.2 Types of dysphasia
Type Site of Features
lesion
Output Comprehension Other
1. Broca Frontal Non-fluent Good Hemiplegia
2. Wernicke Temporal Fluent Bad Field defect
3. Conduction Parietal Fluent Good Cannot repeat
4. Global Combined Non-fluent Bad Hemiplegia
Hemisensory loss
Field defect
Other faculties
dominant side a special difficulty with dres-
sing may occur and denial and neglect of the
The detection of dysphasia of whatever type opposite limbs are likely. On the dominant
defines a lesion in the dominant hemisphere side difficulty with calculations, right-left
which is on the left in some 95 per cent of the orientation and writing are seen (Ger-
population. Other neuropsychological de- stmann's syndrome). A lesion of the left
ficits that implicate the left hemisphere angular gyrus causes striking difficulty with
include difficulties with calculation and ver- reading. Contralateral sensory disturbance is
bal memory. Right-sided lesions should be usually detectable.
suspected if the patient has lost visual Occipital lobe lesions, as well as causing
memory, has difficulty with visuospatial field defects, impair colour recognition and
tasks such as dressing and finding his way, the identification of objects from their visual
or shows striking neglect or denial of the left image. Bilateral damage to the visual cortex
side (anosognosia). causes blindness with loss of optokinetic
Frontal lobe lesions cause personality nystagmus. The patient may deny blindness
change with apathy or disinhibited silliness. (Anton's syndrome).
The patient may be incontinent and may Table 1.3 sets out the neuropsychological
have a grasp reflex—when the examiner 'scan' which provides localizing evidence.
draws his fingertips down the palm and on to Global impairment of such functions, espe-
the palmar aspect of the patient's fingers they cially of learning and memory, imply demen-
curl to grip his hand against an adducted tia. Simple tests of general knowledge, the
straight thumb. A subfrontal tumour such as ability to calculate, learn a name and address
a meningioma may cause tell-tale anosmia, or and recall it at 3 minutes, and learn and
optic atrophy on one side (the side of the reproduce an abstract Binet figure will reveal
mass) and papilloedema on the other—the modest impairment. Severe degrees of de-
Foster-Kennedy syndrome. Seizures are mentia are obvious when the patient cannot
common and often versive in type with head name the day and date, identify where they
and eyes turning away from the side of the are, or give an account of themselves. Formal
irritative lesion. Status epilepticus in a patient psychometry is necessary when there is any
who has never had a fit before is often due to uncertainty, especially when there is a
a frontal lobe lesion. problem in distinguishing depression from
Temporal lobe lesions are characterized by dementia. A mini-mental state examination
memory problems, Wernicke's aphasia, visual can be used to quantitate moderate dementia
field defects and seizures affecting smell, at the bedside (Table 1.4).
taste, visual, auditory or bodily sensations. Confusion superficially resembles demen-
Parietal lobe lesions cause difficulties with tia but the history is short and the patient is
performance of complex acts (praxis) such as agitated and hallucinated. His attention span
striking a match despite adequate muscular is short, and consciousness level mildly
power and co-ordination. On the non- impaired. There is rich detail in confused