The neurologic exam as a diagnostic tool gained mythical proportions in the pre-CT/MRI era when great clinicians could pinpoint a lesion in the nervous system with often astounding accuracy. Today, with the availability of modern imaging techniques, the neurologic exam remains a critical way station in the clinical decision-making process. Does the patient who just collapsed on the street have cardiac disease or an intracranial bleed? Is the patient with leg weakness and numbness suffering from degenerative joint disease or from impending spinal cord compression? Does the patient with nausea and vomiting need a gastroenterology consult, a head CT, or emergency interventions to lower dangerously elevated intracranial pressure? These, and many similar questions that frequently arise for health care providers in all subspecialties can quickly be answered by a carefully performed neurologic exam.
In this website, we outline the main components of the neurologic exam. The goal will be to demonstrate through streaming video segments how each step of the neurologic exam is performed. In addition, we will briefly discuss which neuroanatomic systems are tested by each part of the neurologic exam, so that its functional and practical relevance will be better appreciated. For a more detailed discussion of the neurologic exam, as well as a clinically oriented approach to neuroanatomy with over 100 real clinical cases presented in an interactive format, please see Neuroanatomy Through Clinical Cases Second Edition, Sinauer Associates, Inc., Publishers.
The neurologic exam is part of the general physical examination. Thus, the neurologic exam should always be preceded by and interpreted in the context of a more general examination including vital signs, heart, lungs, abdomen, etc.
Most clinicians include certain important tests in the neurologic exam, although there are variations in personal style, emphasis and order of the tests. Here, we will adopt a fairly widely accepted format for the neurologic exam, consisting of the following six subdivisions:
Each of these subdivisions can be explored in greater detail through the links above, through the Contents, or Search function.
It is important to emphasize that the neurologic exam tests function. Therefore, for each part of the exam, the patient's level of functioning must be titrated using several tests ranging from easy to difficult. The tests the patient can and cannot perform on a given day should be recorded for comparison with follow-up examinations so that changes in the patient's status can be determined accurately.
Finally, a note about order of the exam and efficiency. Depending on the clinical situation, certain parts of the exam should be performed in greater or less detail. For example, an emergency neurologic exam in a comatose patient can be performed in under two minutes (see Neuroanatomy Through Clinical Cases, Chapter 3). In contrast, a patient with unusual findings seen in the office may require detailed testing for up to an hour for accurate diagnosis. Sometimes certain parts of the exam can be combined, or performed in a slightly different order to minimize the number of times the patient has to change positions. Understanding how to best tailor the exam to the clinical situation comes with experience and practice.