Neurological examination: feel the fear, then do it anyway
Gavin Yamey presents a practical approach to a widely feared task Neurology has always had an image problem. It conjures up an arcane world where educated men in bow ties elicit startling diagnoses with a hat pin or a single glance. Lesser mortals can barely pronounce Gerstmann-Sträussler-Scheinker syndrome or Pelizaeus-Merzbacher disease (both true entities, I'm afraid). The result is that when we come to perform a neurological examination ourselves, we feel incompetent and afraid. This article makes only one claim - to give you some guidance through the thorny thicket so that you will hopefully emerge triumphant. Under exam conditions, being polite and courteous to patients will always score highly, so make sure that they are comfortable and always cover them once the exam is over.
Neurological cases are common in finals, because the signs are striking and static. You will not be asked to examine the entire nervous system. Instead, be prepared to assess cranial nerves, limbs, gait, speech, or higher mental functions. Looking hard before acting may reveal a huge amount (obvious facial palsy? Fasciculations? Walking stick?).
Your routine questions should distinguish between dysphonia (poor voice production), dysarthria (a mechanical disorder of articulation) and dysphasia (a language or communication disorder). Remember that we are all temporarily dysarthric, but not dysphasic, after a visit to the dentist or the pub. Examiners are impressed if you can distinguish between a receptive dysphasia, where comprehension is impaired, and an expressive type where it remains intact, although they usually coexist.
Begin a conversation with your patient, perhaps by asking his/her name and address, and listen for clues. If his/her speech sounds dysarthric, this sign can be exaggerated by