2. • The history tells you the pathology, the examination tells yo u where the
pathology is. If you are stumped by a patient, go back and take the history
again.
• Like a lawyer, you must obtain the facts (as opposed to your own or the
patient's speculation) without asking ' leading questions’.
• In other words, phrase your questions carefully so they do not suggest an
answer to the patient. The only difference between the doctor and the
lawyer on this occasion is that the doctor must put the patient at ease and
empathize with him or her prior to asking questions.
• It does not pay, however, to let the patient talk in an uncontrolled manner
and it is often advisable to ask questions that have a yes or no answer. For
example, instead of asking a patient to describe his or her bladder function,
one could ask ‘do yo u get a normal feeling of a full bladder or not?' .
3. • In fact, when asking a patient w ith suspected cauda equina compression I
ask three questions . The first is 'do you have a normal feeling of a full
bladder?', the second is 'can you feel the urine passing down the urethra?’
if the answer is no, then one asks how the patient knows when he or she has
finished passing urine and the answer must be 'when the noise of the urine
flowing in t o the receptacle ceases’ .
• The final question relates to the anal canal mucosa! sensi tivity and I 'can
you differentiate if you are going to pass flatus or faeces?'. All these
questions require a yes or no answer and avoid the patient regaling you with
intricate details of how little or how much pushing etc. is required, which is
of little help in elucidating neurological function.
4. • An experienced clinician uses the history to focus his or her
examination .
• Numbness on its own is an unreliable symptom, often meaning
different things to patients and doctors.
• Pins and needles on the other hand, with or without numbness, is a
very reliable symptom, indicating a disorder of the nervous system
from the sensory cortex to the peripheral nerve.
• If the lesion is in the spinal cord, the pins and needles indicate a
posterior column abnormality and is often associated with a tightness
or gripping ('like a bloodpressure cuff') around the chest, abdomen or
legs depending on the level of the lesion.
5. • Spino-thalamic tract involvement produces no pins and needles
whatsoever; these patients notice a lack of appreciation of pain and
temperature and complain of painless injuries.
• had one patient who painlessly nailed his forearm to the workbench.
An absence of pins and needles may make a posterior column disorder
unlikely but one can only exclude a spinothalamic tract disorder by
testing with a pin.
6. • When recording the history of an epileptic attack or similar disorders,
it is best to record what the patient experiences and what an observer
saw. Of course it is essential to obtain a history from the relatives
when there is a possibility of personality or memory change and
similar disorders of 'higher intellectual functioning'.
7. • When investigating pain obtain as precise a description as possible of
the site of the pain as well as the factors increasing or decreasing it,
and whether or not there are periods without pain. Always be aware of
any pain that wakes a patient at night; it is usually a severe pain.
• We know the headache of raised intracranial pressure is worse at night
or on waking (which may be earlier than usual), but did you know that
sciatica waking the patient at night and furthermore forcing the patient
out of bed to pace up and down and eventually spend the night sitting
in a chair, is typical of cauda equina compression due to a
neurofibroma or ependymoma? (Figure 19(a)).
8. • Root pain arising higher in the spinal canal, due to a meningioma or
neurofibroma, may also wake the patient up at night and force him or
her to get out of bed to walk around.
• Any interscapular pain, especially waking the patient at night, should
be considered to be due to a metastatic deposit until proved otherwise,
especially if the patient is known to have a primary lesion elsewhere. I
am continually distressed by the number of paraplegic patients that are
admitted with a long history of interscapular pain which has not been
diagnosed; yet how much better it would be for the patient to have the
diagnosis made at the 'pain stage', and receive irradiation then and so
avoid spinal cord compression. It is said that night pain is typical of an
osteoid osteoma of the spine, which responds dramatically to aspirin.
9. Testing strength
• Weakness of dorsiflexion of the foot is the world's most commonly
missed physical sign! It is extraordinary that probably 90% of
neurologists and neurosurgeons (not to mention orthopaedic surgeons)
do not know how to examine for weakness of dorsiflexion of the foot.
• This is commonly affected with lumbar disc prolap se or lateral recess
stenosis, yet this diagnostically important weakness is missed. Why?
The reason is that doctors are taught to test for this weakness by as
king the patient to ' bend the foot back and keep it there', the doctor
subsequently a ttempting to plantar flex the foot and overcome the
patient's a ttempts to dorsiflex the foot.
10. • This method disguises considerable weakness because the patient can
'lock' the foot in this position. Much more reliable is to start with the
foot plantar flexed and resist the patient's efforts to dorsiflex. In other
words 'go with the movement' (Figure 20)
11. • This indeed is a general principle when testing for strength. If a patient
is reluctant to exert full power, then exert no resistance at all but
encourage the patient to try, and when he or she does then one can
suddenly increase the resistance.
• Do not forget wasting is a feature of a lower motor neurone lesion and
I find it useful to measure limb circumference, especially in the legs .
More than 1 cm difference is significant, although of course there may
be ca uses for wasting other than a lower motor neurone lesion.
12. • Lack of facility as shown by asking the patient to ' play the piano' is a
useful sign of an upper motor neurone lesion affecting the hands. This
is present often before formal weakness is obvious.
• Testing for spasticity by sudden passive pronation-supination
movement is also extremely helpful
13. • Most patients with a footdrop have an LS root lesion, but not all.
• Sometimes a lesion arising from (meningioma) or near (glioma of the
corpus callosum) the falx cerebri may present with a footdrop because
the 'foot' part of the motor homunculus is sited there.
• Such lesions may cause diagnostic errors but there are two clues:
usually the plantar response is extensor and often (but depending on
the exact si te of the lesion) there are no sensory symptoms or signs.
Furthermore there is absolutely no pain, but sometimes one can see a
relatively painless footdrop with an LS root lesion.
• If in doubt scan the head!
14. • The reflexes are particularly important as these do not rely on patient
cooperation, except for the need for the patient to relax and have their
attention diverted. What is often not appreciated is that you can hear
an absent reflex.
15. • One can be too obsessional when it comes to sensory testing and
beginners often find areas of sensory loss that reflect no more than the
natural variation of skin sensitivity, e.g. the lateral thigh is often less
sensitive than other areas.
16. • The dermatomes are important to know. One does not need to
remember the boundaries but the point of maximum sensation for any
particular dermatome, i.e. the thumb for C6. CS is over the point of the
shoulder, C7 the middle finger, C8 the little finger, Tl is along the
ulnar border of the forearm (this is where to look for sensory loss with
a cervical rib) and T3 is in the axilla.
17. • The main tip I pass on concerning the cranial nerves is when
examining for a lower motor neurone facial weakness one must 'look
for blinking'. Many books give long and convoluted advice to help
decide if there is an upper or lower motor neurone facial weakness. It
is really quite simple: look for a lack of or even a delayed blink. If this
is present a lower motor neurone lesion is present and this is the
earliest sign of such a weakness. Get used to watching how people
blink!
18. • Before leaving any patient it is obligatory to stand the patient up 'heel
to toe’ with the eyes open then shut.
• A useful manoeuvre is to ask the patient to hop on either leg as this
often brings out a latent weakness as does asking the patient to walk
on their heels and toes. These tests come into their own if the patient
for any reason is unable to fully cooperate with formal testing of
strength.
19. • This should be a processing of the data collected in the history and
physical exam. For the purpose of this course, you should just
synthesize information regarding the chief complaint and attempt to
construct a differential diagnosis for the chief concern/complaint.
Ultimately as you progress through your training and into clinical
practice, the history and physical will take a more focused form. For
patients who have multiple medical problems, you may need to do
this for each problem.
