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Pharmacotherapy: A Pathophysiologic Approach, 9e >

eChapter 19. Evaluation of

Neurologic Illness
Susan C. Fagan; Ahmed Alhusban; Fenwick T. Nichols

Key Concepts
The clinical neurologic history and examination are the cornerstones of neurologic diagnosis and
management.
Through the patients history, one can determine the main symptoms, the mode of onset (gradual or
sudden), progression over time (maximal at onset or steadily gaining intensity), and associated illnesses and
risk factors.
The neurologic examination is directed at localization of the disease process so that evaluation and
management may be planned appropriately.
The neurologic examination of a specific patient may be adapted to the patients specific deficit. For
example, a patient with double vision may warrant an extensive cranial nerve examination but a less extensive
assessment of finger strength.

Learning Objectives
On completion of the chapter, the reader will be able to:
1. Describe the importance of the neurologic examination in the diagnosis of neurologic diseases.
2. Determine when abbreviation of the neurologic examination is appropriate in a given patient.
3. Apply the results of a neurologic examination, as written in the patients medical record, to the creation and
monitoring of a pharmacotherapy plan.
4. Recognize the importance of lumbar puncture, electroencephalography, evoked potentials, electromyography,
nerve conduction velocities, carotid Doppler, magnetic resonance angiography, computed tomographic
angiography, transcranial Doppler, computed tomography, magnetic resonance imaging, diusion-weighted
imaging, positron-emission tomography, and single-photon-emission computed tomography in the diagnosis
of a patient with a neurologic illness.
5. Comment on the importance of symmetry in the evaluation of a patient with a neurologic illness.
6. Identify when a patient has a focal neurologic deficit by interpreting the results of the neurologic examination.

Introduction
To contribute most eectively to the care of patients with neurologic illness, one must understand the tools used in
the diagnosis and management of these patients. In addition, clinicians must be able to gather their own data
through a targeted neurologic examination and history taking to ensure optimal pharmacotherapy in neurologic
patients.
Despite technologic advances that have led to the development of sensitive diagnostic tests in
neuroscience, the clinical neurologic history and examination are still the cornerstones of neurologic diagnosis and

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management.1

Signs and Symptoms

Adults
As in all of medicine, obtaining an accurate and complete history is of utmost importance in the evaluation of
neurologic diseases. In many instances, the diagnosis can be made on the basis of the history, and the neurologic
examination can be tailored to optimally evaluate the patient and confirm the diagnosis.1 Details obtained from the
family or other observers support and further expand the data obtained from the patient during history taking.1
Care must be taken to avoid leading the patient. Patients own description of the symptoms might help in
identifying the possible etiologies of the presenting illness, but caution should be exercised, as they might give a
wrong impression about the illness.1 Obtaining an accurate history may be dicult because a number of
neurologic diseases may aect patients speech and memory.1
Through the patients history, one can determine
the main symptoms, the mode of onset (gradual or sudden), progression over time (maximal at onset or steadily
gaining intensity), and associated illnesses or risk factors (recent head injury from a motor vehicle accident).1 Each
complaint of the patient should be thoroughly investigated while taking the history.1 Special attention should be
given to the drug and family history because they often help in identifying the etiology of the patient complaint. The
history should also identify factors that might precipitate or ameliorate the symptoms.1 The physical examination is
important because it can reveal evidence of systemic disease that may have aected the nervous system
secondarily (e.g., a seizure in a patient with elevated temperature and sti neck may suggest meningitis).1 The
neurologic examination is only one component of a complete general physical examination.

The Neurologic Examination

An assessment of patient eort is necessary to interpret the results of the neurologic examination. It can
identify any abnormalities, particularly asymmetry of function, and help to localize the lesion within the nervous
system (central vs. peripheral and specific location within the central nervous system [CNS] or the peripheral
nervous system). The neurologic examination consists of six main components: higher cortical function (mental
status), cranial nerves, motor function, reflexes, sensory function, and gait.1eTable 19-1 describes the common
approaches to assessing each of the six domains and includes examples of the diseases in which abnormal
findings are common.
eTable 19-1 The Neurologic Examination

Domain

Tests Performed

Example Diseases with

Abnormal Findings

Mental
status

While obtaining the history: general mental and

emotional status, speech, memory, alertness,
abstract reasoning, ability to follow commands (motor
integration), ability to communicate

Dementias, stroke, metabolic

encephalopathies

Cranial
nerves

Visual acuity, visual fields, eye movements, jaw

strength, corneal reflex, facial symmetry, auditory
acuity, gag reflex, shoulder and neck strength

Myasthenia gravis,
Parkinsons disease, stroke,
amyotrophic lateral sclerosis
(ALS)

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Motor
function

Motor strength with and without resistance,

coordination (rapid alternating movements, finger-tonose test), tremors, atrophy, fasciculations

Stroke, myasthenia gravis,

Parkinsons disease, ALS

Reflexes

Biceps and triceps tendon reflexes, plantar response

(Babinskis sign is an upgoing toe and is abnormal),
superficial cutaneous reflexes (abdominal)

Stroke, spinal cord lesions,

endocrine diseases (e.g.,
diabetes, hypothyroidism),
peripheral neuropathy

Sensory
function

Asymmetry to pinprick, vibration, temperature

Stroke, peripheral
neuropathy, migraine aura,
diabetes, spinal cord lesions

Gait

Walking, standing (Romberg test = eyes closed,

which accentuates disequilibrium)

Stroke, Parkinsons disease,

spinal cord lesions

A targeted neurologic examination can be performed when a specific deficit is suspected. An example of the
quantification of muscle strength is given in eTable 19-2. During the documentation of the examination results, the
clinician should avoid using poorly defined clinical terms to describe the findings.1 The clinician must synthesize
the results of the history and physical examination to arrive at an anatomic localization of the lesion and create a
dierential diagnosis.1 Readers are encouraged to consult other references to better understand the intricacies of
the neurologic examination.
eTable 19-2 Muscle Strength Evaluation

Grade

Description

No movement; no contraction

Barely detected minor contraction, no movement

Body part is actively moving but not against gravity

Body part is actively moving against gravity

Body part is actively moving against gravity and minor resistance

Body part is actively moving against full resistance

Pediatrics
Similar to adults, the chief complaint and history of the presenting illness are very important in the pediatric
neurologic evaluation. They can localize lesions and identify possible etiologies of the presenting illness. Because
of dierent developmental stages of the pediatric population, the history is largely obtained from the family.2
In addition to identifying the temporal and chronological progression of the presenting illness, pediatric history
should address the family history because many of the pediatric illnesses could have an inherited genetic cause.2
A unique aspect of the pediatric evaluation is the developmental history, which is essential to assess the
developmental stage of the patient compared with standard age-related developmental milestones.2 In addition, it

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helps to identify any relation between the current illness and the developmental stage of the patient.2
The neurologic examination of pediatric patients should be adapted to their age and developmental stage. In
addition to the standard domains of the neurologic examination, an assessment of the weight, height, and head
circumference of the patient should be included. These measurements should be evaluated with reference to
special age-adjusted charts to identify any abnormalities.2 The patient should be evaluated for any dysmorphic or
skin color abnormalities. The fontanels should be assessed for size and whether they are open or closed.2
Cerebellar control of ambulation and fine coordination can be assessed by observing the patient during playing
and walking.2 The patients responses to light touch and painful stimuli can be assessed by observing facial
expressions, withdrawal, and avoidance responses to tickling, touching, and finger or toe pinching.2

Procedures Used in the Diagnosis

In addition to the neurologic examination, certain imaging techniques and procedures may be essential in the
diagnosis of neurologic disorders. Lumbar puncture (LP) is used to obtain cerebrospinal fluid (CSF) for further
evaluation. It is used most often as an evaluation for markers of CNS infections, such as meningitis and
encephalitis, but it is also useful in diagnosing subarachnoid hemorrhage, multiple sclerosis, and dementia.1
Opening pressure, cell count and dierential, glucose concentration, total protein concentration, and culture and
sensitivity are measured routinely.1 A space-occupying lesion in the brain with mass eect is a relative
contraindication to LP because herniation could result. Before performing an LP, the patient should be checked for
papilledema, which may indicate increased intracranial pressure.1 The opening CSF pressure is usually less than
18 mmHg.1 Normal CSF is clear and colorless and should not contain any red blood cells or polymorphonuclear
cells.1 The presence of up to five mononuclear cells is considered normal. Total protein in the CSF usually is 45
mg/dL or less. Protein may increase with infection, breakdown of the bloodbrain barrier (e.g., tumors, stroke, and
trauma), and diabetes.1
Electroencephalography (EEG) records the electrical activity of the brain. The record is interpreted by observing the
basic rhythms and waveforms, the symmetry of the recording, and abnormal electrical discharges.1 It also may be
used to assess the response to photic stimulation or hyperventilation. It is used primarily in the diagnosis of
seizures and may be helpful in the evaluation of patients with altered mental status. EEG also may be used to
measure evoked potentials.1 The evoked potentials are the EEG response to repetitive stimuli (visual, auditory, or
tactile) and provide information about the presence of abnormalities and disturbances (but not the cause) in the
specific pathways tested.1
Electromyography (EMG) and nerve conduction velocities (NCVs) are used to assess the function of the peripheral
nerves, neuromuscular junction, and muscles.1 NCVs are measured by stimulating the nerve and recording the
speed of conduction of the impulse. NCVs can be used to detect the presence of localized peripheral nerve injuries
(e.g., carpal tunnel) or diuse symmetric neuropathies (which may be inherited or acquired).1 EMG assesses
muscle dysfunction as a result of primary muscle disease or secondary to nerve injury.1 This test is used to
diagnose peripheral neuropathies (inherited and acquired), Guillain-Barr syndrome, myasthenia gravis,
amyotrophic lateral sclerosis, radiculopathies, and muscle diseases.1
The cerebral circulatory system can be imaged or evaluated in a number of ways, depending on the type and
location of the abnormality suspected. Imaging techniques can be used to identify local arterial stenosis,
aneurysms, and arteriovenous malformations.1 Atherosclerosis of the extracranial arteries, a frequent cause of
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stroke, can be evaluated using ultrasonography (referred to as duplex sonography, carotid Doppler, or color-flow
Doppler), magnetic resonance angiography (MRA), spiral computed tomographic angiography (CTA), or intraarterial
angiography.1 The intracranial arterial circulation can be evaluated using transcranial Doppler, MRA, CTA, or
intraarterial angiography.1 Each technique has its own advantages and disadvantages. Intraarterial angiography
provides the best imaging of the smaller arteries of the cerebral circulation but is more invasive than the other
measures.1
Computed tomography (CT) uses x-rays to produce images of slices of the brain that are 1 to 10 mm in
thickness.1 CT revolutionized the practice of neurology by allowing direct imaging of brain anatomy. It is currently
available in most communities and is used to evaluate patients with intracranial disease. CT scans are used to
identify tumors, hemorrhages, infarctions, hydrocephalus, and atrophy, among other intracranial pathologies.1 IV
contrast agents (a contrast-enhanced scan) can provide imaging of vessel structure; they may also be used to
identify areas of breakdown of the bloodbrain barrier as the result of abscesses, other inflammatory conditions,
tumors, or stroke.1
Magnetic resonance imaging (MRI) uses the magnetic properties of the hydrogen atom nucleus and proton to
produce computer-processed scans that provide improved anatomic detail compared with CT scans.1 MRI oers
the advantages of better dierentiating between white and gray matter and delineating lesions close to bone
(brainstem and cerebellum) and has no radiation risk; however, it is not as readily available as CT and is more
expensive.1 MRI has a proven advantage over CT in evaluating lesions in the posterior fossa and in detecting
lesions in the white matter, such as plaques in multiple sclerosis.1 MRI is also useful in the diagnosis of tumors and
very early ischemic stroke (diusion-weighted imaging). Imaging of the spinal canal and its contents can be
accomplished either by MRI myelography or CT myelography. Myelography refers to injecting a contrast agent into
the CSF, so myelography outlines the spinal cord and provides indirect information about the spinal cord; MRI
provides direct imaging of the soft tissue of the spinal cord, providing direct information about injury to the cord.
Compressive lesions can be identified by myelography or MRI; the consequences of the injury (e.g., edema,
infarction) are better seen on MRI.1

Special Procedures Used in Diagnosis

Other imaging techniques, such as positron emission tomography (PET) and single-photon emission computed
tomography (SPECT), are considered tests of brain function. These tests are being studied extensively in epilepsy
as well as in cerebrovascular disorders, cerebral tumors, movement disorders, and dementia.1 PET scans use a
positron-emitting isotope to display chemical activity and the rates of biologic processes within the brain. This
method can assess regional metabolic changes in the brain.1 The isotopes used in this application have very short
half-lives, necessitating the presence of a cyclotron to produce them on site. This is in contrast to the long half-life
isotopes used in conventional PET scanning that can be produced and then shipped to the hospital.1 The
expense, technical complexity (a cyclotron is needed), and limited availability of this technique limit its clinical
usefulness.
SPECT scans measure radiotracer uptake by tissues and provide cross-sectional images of the brain. This
technique has been used extensively to assess cerebral blood flow. Although the resolution of SPECT is not as
good as PET, the greater availability has led to wide clinical use in disorders such as stroke, dementia, and
epilepsy.1

Conclusion
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Assessment of the patient with neurologic disease is challenging. The patient, by virtue of the neurologic deficit,
may or may not be able to provide reliable information regarding medication history or extent of illness. In these
situations, the clinician must develop alternate strategies to obtain a complete data set and develop a
pharmacotherapy plan. The ability to interpret and synthesize the results of the neurologic examination and other
diagnostic tests will help a great deal in this quest.

Abbreviations
ALS

amyotrophic lateral sclerosis

CNS

central nervous system

CSF

cerebrospinal fluid

CT

computed tomography

CTA

computed tomography angiography

EEG

electroencephalography

EMG

electromyography

LP

lumbar puncture

MRA

magnetic resonance angiography

MRI

magnetic resonance imaging

NCVs

nerve conduction velocities

PET

positron emission tomography

SPECT

single-photon emission computed tomography

References
1. Lowenstein DH, Martin JB, Hauser SL. Approach to the patient with neurologic disease. In: Longo DL, Fauci AS,
Kasper DL, et al. eds. Harrisons Principles of Internal Medicine, 18th ed. New York: McGraw Hill, 2012: 3233
3239.
2. Bernard TJ. Neurologic & muscular disorders. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR, eds.
CURRENT Diagnosis & Treatment: Pediatrics, 20th ed. New York: McGraw-Hill, 2011,
http://www.accessmedicine.com/.

Copyright McGraw-Hill Global Education Holdings, LLC.

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