The Patient with Neurological Disease

Abstract

As no other examination, the neurological exam varies in both its goals and structure depending whether the patient is co-operative or not. While the focus of the examination of the responsive patient is to identify potential focal neurological deficits, the examination of the unresponsive patient targets to identify the cause of the unresponsiveness and localize the underlying lesion(s) in the brain. The clinical method to determine brain(stem) death is a classic example of a structured physical examination (Tables 15.1, 15.2 and 15.3).

Clinical Practices

Box 1 Checklist Patient History: The Unresponsive Patient

Yes	No	Onset of coma?
□	□	Hyperacute (within seconds)?If yes, consider subarachnoid haemorrhage, intracerebral haemorrhage, traumatic brain injury, epilepsy, cerebral hypoperfusion (e.g. cardiac arrest, pulmonary embolism)
□	□	Acute (within minutes)? If yes, consider ischemic (brainstem) stroke, hypoxia/hypercapnia, intoxication, secondary brain injury (head injury)
□	□	Subacute (within hours)? If yes, consider CNS infection, intoxication, metabolic encephalopathy, hydrocephalus, secondary brain injury (head injury)
□	□	Delayed (within days)? If yes, consider (non-infectious) encephalitis, hydrocephalus, metabolic or endocrinologic encephalopathy, chronic subdural haematoma, demyelinating diseases
Yes	No	Preceding symptoms?
□	□	Headache? If yes, consider subarachnoid haemorrhage, intracranial haemorrhage, meningitis, traumatic brain injury
□	□	Unilateral facial weakness (“droop”) or numbness? If yes, consider stroke, chronic subdural haematoma
□	□	Unilateral arm or leg weakness or numbness? If yes, consider stroke, chronic subdural haematoma
□	□	Speech disturbance? If yes, consider stroke, CNS infection, tumour, chronic subdural haematoma, hydrocephalus
□	□	Nausea or vomiting? If yes, consider increased intracranial pressure (e.g. trauma, tumour), cerebellar disease
□	□	Vertigo? If yes, consider cerebellar/brainstem pathology
□	□	Vision impairment/loss? If yes, consider stroke, cerebral hypoperfusion, posterior reversible encephalopathy syndrome, pituitary pathology
□	□	Acoustic or olfactory impairment? If yes, consider epilepsy, tumour
□	□	Personality change and/or confusion? If yes, consider (non-infectious) encephalitis, stroke, metabolic or endocrinologic encephalopathy, epilepsy, tumour, intoxication, chronic subdural haematoma, hydrocephalus
□	□	Stiffening with or without (prolonged, more than several seconds) muscle contractions? If yes, consider epilepsy with postictal depressed mental state or non-convulsive status epilepticus
□	□	Short (few seconds) muscle contractions preceding collapse? If yes, consider cerebral hypoperfusion, hypoxia
□	□	Fever, flulike symptoms, otitis, sinusitis and/or rash? If yes, consider meningitis
Yes	No	Past medical history?
□	□	Previous loss of consciousness or known CNS disease? If yes, review previous medical records
□	□	(Valvular) heart disease (e.g. aortic stenosis?) If yes, consider cerebral hypoperfusion
□	□	COPD, muscular or spinal cord disease? If yes, consider hypercapnia
□	□	Liver or kidney disease? If yes, consider hepatic or uremic encephalopathy
□	□	Thyroid, adrenal or pituitary disease? If yes, consider endocrinologic encephalopathy
□	□	Anxiety disorder/depression? If yes, consider intoxication, psychogenic stupor, hysterical coma
□	□	HIV infection or severe immunosuppression? If yes, specifically consider (opportunistic) CNS infection (e.g. tuberculosis meningitis, cryptococcal meningitis with increased intracranial pressure)
Yes	No	Social history?
□	□	Smoker? If yes, consider stroke
□	□	Alcohol abuse? If yes, consider intoxication, hepatic encephalopathy, epilepsy, vitamin B deficiency, meningitis
□	□	Drug abuse? If yes, consider intoxication
Yes	No	Drug history and compliance?
□	□	Anticoagulation or antiplatelet drugs? If yes, consider intracranial haemorrhage
□	□	Antiepileptic drugs? If yes, consider epilepsy, drug overdose
□	□	Hormone (e.g. thyroid hormones, steroids) therapy? If yes, consider endocrinologic encephalopathy
□	□	Anxiolytics or sedatives? If yes, consider overdose/intoxication

If a CNS infection is suspected, additionally go through the “Checklist Patient History: The Patient with a Suspected Infection”

Box 2 Think of Encephalitis if Two of the Three “Cs” Are Present in the Patient History!

• Coma

• Cephalea

• Changed personality

Box 3 Clinical Findings Which Do Not Preclude the Diagnosis of Brain(Stem) Death

• Stereotypical movements (extremity and/or trunk) to peripheral painful stimuli (spinal reflex)

• Spontaneous movements of extremities other than pathologic posturing (flexion or extension response) (Lazarus sign)

• Sweating, flushing

• Tachycardia

• Absence of diabetes insipidus

• Muscular stretch reflexes

• Abdominal wall or triple flexion response

• Positive plantar reflex