Before touching the patient, it is important and good practice to stand back and spend some time in performing a thorough general examination of the patient. Unfortunately, students often rush into touching the patient, hence often neglecting crucial signs which may lead to the diagnosis.
An approach to the general examination of a patient presenting with neurological complaints is outlined as follow:
- What is the age and sex of the patient? Certain neurological disorders are more common in certain age groups and genders compared to others. For example, in a young woman presenting with recurrent episodes of sudden onset of limb weakness and numbness, one may suspect demyelinating disease such as multiple sclerosis. However, in an elderly man with a similar presentation, recurrent stroke would be more likely than multiple sclerosis which is more common in young women.
- What is the conscious state of the patient? Is he or she fully alert, confused, drowsy or comatosed?
- What is the body habitus of the patient? Are there any abnormal body proportions?
- Are there any dysmorphic features or cutaneous lesions which may suggest an underlying syndromal disorder (e.g. Down syndrome) or neuro-cutaneous disorder (e.g. neurofibromatosis or tuberous sclerosis)?
- Is there any abnormal posturing of the patient? For example, a hemiplegic posture of the patient (e.g. flexion of the upper limbs and extension of the lower limbs) would suggest that the patient has an upper motor neuron lesion. Patients with inattention due to a parietal lesion in the non-dominant hemisphere may also show abnormal positioning.
- Are there any abnormal movements of the patient? For example, resting tremor noted on general inspection may suggest that the patient has parkinsonism.
- Are there any obvious abnormal facial features? For example ptosis (in patients with myasthenia gravis, third nerve palsy and Horner’s syndrome), facial weakness or asymmetry, and masked facies (in patients with parkinsonism).
- Is the gaze of the patient abnormally deviated, e.g. in cortical or brainstem lesions?
- Does the patient require tube feeding or ventilatory support due to bulbar dysfunction (e.g. in patients with stroke, motor neuron disease, neuromuscular disorders etc.) or weakness of the respiratory muscles (e.g. in patients with a high cervical cord lesion, motor neuron disease, Guillain Barré syndrome or neuromuscular junction disorders such as myasthenia gravis etc.)?
- If the patient is coming in through the examination room, what is the mobility of the patient like? Is he or she bedbound, or does he or she require a wheelchair or walking aid? And why might that be the case? Is it because of significant weakness, gait ataxia or injury due to underlying neurological deficits?
- If the patient is walking into the examination room, is there any abnormal gait? For example, hemiplegic gait in a patient with a stroke, wide-based ataxic gait in a patient with cerebellar dysfunction and shuffling, festinating gait with a stooped posture and lack of arm swing in a patient with parkinsonism?
- After the general examination of the patient, one should also look around the patient which may also give important clues. For example, does the patient require a foley catheter? This may be due to dysfunction along the micturition pathway (e.g. due to cord and brainstem lesions) resulting in bladder dysfunction. Are there any monitors attached to the patient e.g. cardiac monitor (is there any arrhythmia such as atrial fibrillation), oximeter etc.?
Whilst asking the patient for consent for further examination, one should also note whether the patient has any abnormalities in language (e.g. expressive or receptive dysphasia) or speech (e.g. dysarthria, hoarseness).