How do you evaluate and manage a patient with neurological symptoms?

Comprehensive Neurological Examination and Management of Patients with Neurological Symptoms

A comprehensive neurological examination should include assessment of mental status, cranial nerves, motor function, sensory function, reflexes, coordination, and gait, followed by appropriate diagnostic testing based on findings to determine etiology and guide management. 1

Initial Assessment and Examination Components

Mental Status Assessment

• Evaluate level of consciousness, orientation, attention, memory, language, and executive function
• Use validated cognitive assessment tools such as:
  • Glasgow Coma Scale for level of consciousness
  • Confusion Assessment Method for delirium detection
  • Brief standardized cognitive tests for cognitive domains 1

Cranial Nerve Examination

• Assess all 12 cranial nerves systematically:
  • Pupillary light response
  • Extraocular movements
  • Facial sensation and movement
  • Hearing and balance
  • Swallowing and gag reflex
  • Tongue movement 1

Motor Examination

• Evaluate:
  • Muscle tone and bulk
  • Strength in all extremities (grade on 0-5 scale)
  • Abnormal movements (tremor, fasciculations, dyskinesias)
  • Coordination (finger-to-nose, heel-to-shin tests)
  • Gait and station 1

Sensory Examination

• Test:
  • Light touch
  • Pain (pinprick)
  • Temperature
  • Vibration
  • Proprioception
  • Cortical sensations (stereognosis, graphesthesia) 1

Reflex Testing

• Deep tendon reflexes (biceps, triceps, patellar, Achilles)
• Pathological reflexes (Babinski, Hoffman's)
• Frontal release signs if cognitive impairment is suspected 1

Tiered Diagnostic Approach

Tier 1: Initial Workup

1. Laboratory studies:

   • Complete blood count
   • Comprehensive metabolic panel
   • Thyroid function tests
   • Vitamin B12 level
   • Inflammatory markers (ESR, CRP)
   • Toxicology screen if indicated 1

2. Structural brain imaging:

   • MRI brain (preferred) or CT if MRI contraindicated
   • Imaging should be obtained in all patients with new neurological deficits 1, 2

Tier 2: Specialized Testing Based on Initial Findings

• Neuropsychological evaluation when:

  • Office-based cognitive assessment is inconclusive
  • Patient reports symptoms but performs normally on brief testing
  • Complex clinical profile or confounding factors exist 1

• Electrodiagnostic studies (EMG/NCS) when:

  • Peripheral nervous system involvement is suspected
  • Differentiation between axonal and demyelinating processes is needed
  • Motor neuron disease is suspected 3

• Cerebrospinal fluid analysis when:

  • Infection, inflammation, or autoimmune process is suspected
  • Demyelinating disease is considered 1

Management Approach

Acute Management

1. Stabilize vital functions:

   • Ensure adequate oxygenation (maintain O2 saturation >94%)
   • Position head of bed at 15-30° to prevent aspiration
   • Nothing by mouth until swallow assessment if indicated 1

2. Treat reversible causes:

   • Correct metabolic abnormalities
   • Address infections
   • Discontinue offending medications
   • Manage seizures if present 1

Ongoing Management

1. Serial neurological assessments:

   • Frequency based on clinical condition and risk for deterioration
   • Use consistent assessment tools to track changes 1

2. Specialist referral when:

   • Atypical presentation
   • Rapidly progressive symptoms
   • Early-onset cognitive changes
   • Complex neuropsychiatric features
   • Diagnostic uncertainty 1

Special Considerations

Cognitive Impairment

• Include both patient and care partner in evaluation
• Obtain collateral history about functional changes
• Assess impact on activities of daily living
• Consider structured disclosure of diagnosis 1

Critical Care Setting

• Minimize sedation when possible to optimize neurological assessment
• Implement multimodal monitoring for patients with impaired consciousness
• Assess for delirium using validated tools
• Monitor for neurological complications of critical illness 1, 2

Common Pitfalls and Caveats

1. Incomplete examination: Failure to assess all neurological domains can lead to missed diagnoses. Always perform a systematic and complete examination. 2, 4

2. Overreliance on imaging: Neuroimaging may be normal despite significant neurological dysfunction. Clinical examination remains the cornerstone of diagnosis. 1

3. Inadequate follow-up: Neurological conditions may evolve over time. Serial examinations are essential to detect progression or improvement. 1

4. Neglecting cognitive assessment: Cognitive dysfunction is often overlooked but is a critical component of the neurological examination, especially in older adults. 1

5. Failure to obtain collateral history: In patients with cognitive impairment, information from care partners is essential for accurate diagnosis. 1

The neurological examination should be tailored to the presenting symptoms while maintaining a systematic approach. When properly performed and interpreted in the clinical context, it guides further diagnostic testing and management decisions to improve patient outcomes.