73 The Neurological Examination Evan D. Murray, MD, and Bruce H. Price, MD KEY POINTS ered most effective when the clinician has formed a hypothesis that is based on observation and history and is prepared to • Cognitive impairment, behavioral changes, and fluidly adapt both the examination and the hypothesis as new psychiatric symptoms occur frequently in association information and findings appear. A well-rehearsed examina- with neurological conditions. tion prevents omissions and ensures consistency of technique. A well-reasoned examination with an array of alternative • A well-performed mental status and neurological techniques that verify findings ensures greater accuracy and examination are essential for the identification of confidence in those findings. The complexity of planning, medical and neurological conditions that impact performing, and interpreting the neurological examination is cognition, behavior, and mood. a challenge that persists throughout the entirety of a physi- • The objective of the neurological examination is to cian’s career. verify the integrity of the central and peripheral The neurological examination is performed routinely for nervous systems and to achieve neuroanatomical most psychiatric admissions but is uncommonly performed localization of signs and symptoms. Localization is a in outpatient psychiatric settings. In some circumstances, a crucial step for the generation of a rational careful history alone may establish a neurological diagnosis; differential diagnosis. however, this is often not the case. The examination is helpful • The neurological examination can be conceived of as for corroborating the history, establishing the severity of a being conducted along a continuum of complexity condition, and directing treatment. The overall assessment that builds on information acquired during its approach should use a reproducible methodology for obtain- performance. It is fluidly adapted during its ing and interpreting the history, performing the examination, performance with components added, as needed, to and analyzing both. A comprehensive neurological examina- clarify findings. tion is unnecessary in every patient. The clinician must learn to focus or expand the examination as needed. A good exami- • The interpretation of findings requires careful and nation can be instrumental in discerning primary psychiatric effective integration with knowledge of neuroanatomy illness from secondary symptoms that occur in association and the clinical history. with a multitude of neurological conditions (such as stroke, • A well-organized and rehearsed examination Alzheimer’s disease, Huntington’s disease, Parkinson’s disease, promotes consistency and comprehensiveness of and demyelinating disease). (See Box 73-1 for a summary of technique while reducing omissions of elements of major neurological findings and associated conditions that the examination. frequently manifest by psychiatric symptoms.) Malingering and conversion disorder need to be distinguished from deficits that localize to specific neuroanatomy.4 Medication side effects, such as parkinsonism and dystonia, need to be identi- OVERVIEW fied, treated, and followed clinically. General principles include: Proficiency in performing a neurological examination is • Assess for side-to-side symmetry during the neurological advantageous to the psychiatrist. All behavior and perception examination. One side of the body serves as a control for occurs as a result of neural activity. Neural activity arises from the. other Determine if there is focal asymmetry. brain circuitry that is developmentally sculpted through the • Determine if dysfunction originates from the central nervous interaction of environmental factors with human genetic system (CNS), peripheral nervous system (PNS), or both. potential.1 Neural circuitry is susceptible to malfunction and • Consider if the finding (or findings) can be explained by a damage in a host of ways; this results in many recognizable single lesion or whether a multi-focal process is required. patterns of cognitive and behavioral impairments. The neuro- • Establish the lesion’s location. If the process involves the logical examination is of tremendous utility for identifying CNS, clarify if it is cortical, subcortical, or multi-focal. If these patterns and thereby allowing for recognition of neuro- subcortical, clarify if it is in the white matter, basal ganglia, logical processes that may be treated. Neurological conditions brainstem, cerebellum, or spinal cord. are frequently co-morbid with psychiatric symptoms. Such • If the process involves the PNS, determine if it localizes to symptoms may stem from the stress of illness, be a direct func- thee nerv root, plexus, peripheral nerve, neuromuscular tion of brain pathology, or result from a combination of the junction, muscle, skin, or if it is multi-focal. two. Psychiatric symptoms and behavioral changes may precede other key physical manifestations of the disorder or Some of this localization, particularly to the PNS, will occury at an time during the disease course.2 eAn effectiv and exceed the expertise of most psychiatrists. These principles are reliable neurological examination may afford opportunities presented as tools to organize thinking. for earlier detection of treatable conditions, anticipation of There is no clear consensus among experts as to the order psychiatric manifestations, and avoidance of adverse events of performing and presenting the neurological examination. (e.g., neuroleptic sensitivity of patients with Lewy body However, there is little dispute about the mental status portion dementia) in persons who are at particular risk. being performed first followed by examination of the cranial By the late nineteenth century the elementary neurological nerves. Thereafter, there are variations in the sequence, selected examination was refined with objective, consistent, and repro- components of the examination, methods of performance, ducible findings.3 The practice of the examination is consid- terminology used to describe findings, and the interpretation 791 Downloaded for Anonymous User (n/a) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 16, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 792 PART XVIII Neuropsychiatry BOX 73-1 Neurological Abnormalities That BOX 73-2 Components of Elemental Neurological Suggest Diseases Associated with Examination Psychiatric Symptoms CRANIAL NERVES EXAMINATION ABNORMALITIES AND THEIR POSSIBLE Olfaction I UNDERLYING ETIOLOGY Vision II Vital signs • Visual fields (VF) • Marked hypertension (hypertensive encephalopathy, • Acuity serotonin syndrome, neuroleptic malignant syndrome, • Optic disks/vessels (performed after VF and acuity) pre-eclampsia) Pupillary reflexes II, III • Tachypnea (delirium caused by systemic infection) Eye movements III, IV, VI • Hypoventilation (hypoxia, alcohol withdrawal, sedative Facial sensation/jaw strength V intoxication) Facial movement VII Cranial nerves Hearing VIII • Hyposmia, anosmia or odor misidentification (traumatic Palate IX, X brain injury, Alzheimer’s and Parkinson’s disease) Speech/dysarthria IX, X, XII • Visual field deficit (stroke, mass, multiple sclerosis, systemic Head rotation XI lupus erythematosus) Shoulder shrug XI Pupils Tongue movement XII • Argyll Robertson (neurosyphilis) MOTOR • Unilateral dilation (brain herniation, porphyria) Involuntary movements/adventitious movements • Horner’s syndrome (stroke, carotid disease, demyelinating Muscle bulk disease) Tone Ophthalmoplegia Strength • Vertical gaze palsy (progressive supranuclear palsy) Hand drift/pronation/posturing • Mixed (Wernicke-Korsakoff syndrome, chronic basilar meningitis) SENSATION Cornea Light touch • Kayser-Fleischer rings (Wilson’s disease) Joint position sense Lens Vibration • Cataracts (chronic steroids, Down’s syndrome) Pinprick (pain)/temperature (pick one of these) Fundi Romberg • Papilledema (intracranial mass lesion, multiple sclerosis) COORDINATION • Optic pallor (multiple sclerosis, porphyria, Tay-Sachs Finger to nose/follow the target disease) Fine motor movements Extrapyramidal (Parkinson’s disease, Lewy body disease, Rapid alternating movements Huntington’s disease, stroke, Wilson’s disease, numerous Heel to shin others) Cerebellar (alcohol, hereditary degenerative ataxias, GAIT paraneoplastic, use of phenytoin) Station Motor neuron (amyotrophic lateral sclerosis, frontotemporal Spontaneous ambulation dementia with motor neuron disease) Toe/heel/tandem Peripheral nerve (adrenomyeloneuropathy, metachromatic Postural reflexes leukodystrophy, vitamin B12 deficiency, porphyria) REFLEXES Gait Deep tendon reflexes • Apraxia (normal pressure hydrocephalus, frontal dementias) Cutaneous reflexes • Spasticity (stroke, multiple sclerosis) Plantar responses • Bradykinesia (multi-infarct dementia, Parkinson’s disease, Atavistic or primitive reflexes progressive supranuclear palsy, Lewy body disease) of various findings. Clinicians should decide on a sequence, receptiveness to evaluation, ability to cooperate, cultural sen- practice and become proficient at it, and then use it consist- sitivities, and mental state should be accomplished at the ently. This improves performance and speed, provides a data- earliest time. If one anticipates that the evaluation will agitate base of variations in responses, and reduces the likelihood of the patient or that conditions are deemed unsafe,