Page 93 Guide to Pain Management in Low-Resource Settings

Physical Examination: Neurology 81

Th e examiner develops a quick plan of the se- a general familiarization with a coma scale (such as the
quence of steps in the examination, which should be famous Glasgow Coma Scale) may be useful.
followed, because otherwise important aspects of the Establish that the patient is fully conscious, able
examination may be missed. A checklist of activities is to understand and follow instructions, and fully orient-
often useful for the non-neurologist who is not yet ex- ed in time, space, and person. Th e patient’s mood and
perienced. For many, it is easy to follow the examina- emotional state (level of anxiety, depression, apathy, dis-
nd other interest, posturing, and behavior) should be assessed. If fition in a rostral caudal direction, but one may
ective. As a bare minimum, the ar- any impairment is noted, a full description should be re- ffmethods equally e
eas listed below must be assessed in an adult patient. corded as precisely as possible.
Cognitive skills can quickly assessed using sim-
What items do I look for in the ple observations during history taking and can then be
c skills. fineurological examination? supplemented by direct examination of speci
uency can easily flAssessment of language pattern and
• Higher functions and general examination: (look pick up those patients with motor dysphasia, while abil-
for level of consciousness, maybe use the Mini- ity to follow instruction in the course of general exami-
Mental State Examination [MMSE] to test cogni- nation may raise the suspicion of receptive dysphasia.
tive function, and check vital functions) Th e MMSE examination of Folstein et al (Mini-
• Examination of the head and neck: (look for men- Mental State Examination) is a quick formal test con-
ness or a posi- sisting of some 30 items which can quickly be car- ffingeal irritation, such as neck sti
tive Kernig’s test, check neck muscle function and ried out in less than 10 minutes, should suspicion of a
cit be raised. With this tool, orientation, fineck movement) cognitive de
• Examination of the cranial nerves memory and recall, abstraction, comprehension, read-
• Examination of the motor and musculoskeletal ing, drawing, and writing ability can be assessed. Where
system (look for deformities, bulk, muscle tone, dysphasia is marked, testing other elements of cognition
cult, if not impossible. ffiand bilateral strength) is di
• Examination of the sensory system (distinguish
cits or pain radia- How do I examine the head firadicular and nonradicular de
exes and the “primi- and neck? fltion; check deep tendon re
exes) fltive” re
• Cerebellar functions (test coordination with rap- Observe and palpate for deformities and tenderness
nger-nose and in the scalp and over the muscles—especially the tem- fiid alternating hand movements,
heel to shin test, tandem walk, one-leg stance, poralis muscles. Tenderness over the insertion of the
and Romberg test) paraspinal and mastoids on the skull may be elicited
• For special diagnostic questions only, certain in patients with neck muscle spasms, while occasional
“technical” testing could be useful (laboratory tenderness at the vertex may be elicited in patients with
uid, electro- tension and depression headaches. fltests, blood tests, cerebrospinal
exing the flphysiology, electroencephalography, electroneu- Check for meningeal irritation by
ness and pain along the ffromyography, testing of autonomic functions, neck and observing for sti
and imaging) spine, and follow this with the Kernig’s test. Brudzin-
ski’s sign is rarely observed in adults. Palpation for the
How do I evaluate “higher functions”? carotid pulse will establish the presence and symme-
cial and deep palpation of fitry of the pulsations. Super
Th e patient’s degree of consciousness should be evalu- the neck muscles may elicit spasticity and tenderness
ated and established as this is probably the most impor- and should then be followed by an assessment of neck
tant point in the evaluation of a patient neurologically. movements in all directions, which may be restrict-
Most patients who will be reviewed outside the emer- ed by pain, spasms, and/or osteoarthritis of the spine.
gency department presenting with pain will not be in a Lhermitte’s sign may occasionally be elicited in patients
coma, and an elaborate description of how to evaluate a with multiple sclerosis and spinal canal stenosis, among
patient in a coma may not be necessary. Nevertheless, other pathologies.