What is the recommended approach for a patient presenting with neurological symptoms during a neuro (neurological) exam?

Recommended Approach for Neurological Examination in Patients with Neurological Symptoms

A specialist evaluating a patient with neurological symptoms should perform a comprehensive history and office-based examination of cognitive, neuropsychiatric, and neurologic functions, aiming to diagnose the underlying cause. 1

Core Components of the Neurological Examination

1. Mental Status Assessment

• Evaluate level of consciousness using standardized tools like Glasgow Coma Scale
• Assess cognition with brief validated cognitive tests covering:
  • Orientation
  • Attention
  • Memory (particularly delayed free and cued recall/recognition)
  • Executive function
  • Visuospatial function
  • Language 1

2. Cranial Nerve Examination

• Pupillary light response
• Oculocephalic reflexes
• Corneal reflexes
• Cough/gag reflexes
• Visual fields and acuity
• Facial sensation and movement
• Hearing 1

3. Motor Examination

• Strength assessment in all extremities
• Tone evaluation (hypertonia, rigidity, spasticity)
• Abnormal movements (tremor, dystonia, chorea)
• Coordination testing 1

4. Sensory Examination

• Light touch
• Pain sensation
• Proprioception
• Vibration sense 1

5. Reflexes

• Deep tendon reflexes
• Pathological reflexes (Babinski sign)
• Primitive reflexes when appropriate 1

6. Gait and Station

• Observe for ataxia, asymmetry, or abnormal patterns
• Assess balance and coordination 1

Special Considerations Based on Presenting Symptoms

For Acute Mental Status Changes/Delirium

• Neuroimaging with CT or MRI is usually appropriate if:
  • Clinical suspicion for an acute neurological cause is high
  • The cause of symptoms is not found on initial assessment
  • Symptoms do not respond appropriately to management 1
• CT is usually appropriate for patients presenting with delirium, although yield may be low without trauma or focal deficits 1

For Vertigo/Dizziness

• HINTS examination (Head Impulse, Nystagmus, Test of Skew) should be performed to distinguish central from peripheral causes
• HINTS can be more sensitive than early MRI for detecting stroke (100% versus 46%) 2
• Negative HINTS exam performed by specially trained providers may eliminate the need for neuroimaging 2

For Headache

• Neuroimaging is not usually warranted for patients with migraine and normal neurological examination
• Neuroimaging should be considered in patients with non-acute headache and unexplained abnormal findings on neurological examination 1
• Features that increase probability of finding abnormalities on imaging:
  • Headache worsened by Valsalva maneuver
  • Headache causing wakening from sleep
  • Progressively worsening headache
  • New headache in older people 1

For Movement Disorders

• Evaluate for Parkinsonian characteristics (dystonia, hypertonia, rigidity)
• Assess for tremors, chorea, and dysarthria
• Consider MR imaging of the brain, which may detect structural abnormalities in the basal ganglia 1

Sedation Management During Neurological Assessment

• Sedation should be managed to maximize clinical detection of neurological dysfunction
• Exception: patients with reduced intracranial compliance where withdrawal of sedation may be deleterious 3
• Use standardized sedation protocols with validated scoring systems like the Richmond Agitation Sedation Scale
• Prefer intermittent (as-needed) analgo-sedation over continuous infusion
• Consider short-acting, non-benzodiazepine sedatives
• Implement daily reassessment of sedation goals and stepwise sedation weaning 1

When to Consider Advanced Neurological Assessment

• Neuropsychological evaluation is recommended when office-based cognitive assessment is not sufficiently informative:
  • When a patient reports concerning symptoms but performs normally on basic cognitive examination
  • When there is uncertainty about interpretation of results due to complex clinical profile 1
• Referral to a neurologist/neurointensivist should be considered for:
  • Atypical cognitive abnormalities (aphasia, apraxia, agnosia)
  • Sensorimotor dysfunction
  • Severe mood/behavioral disturbance
  • Rapid progression or fluctuating course 1

Pitfalls to Avoid

• Incomplete documentation of neurological examinations, particularly in non-neuroscience settings 4
• Failing to perform serial examinations to detect changes over time
• Overlooking subtle neurological deficits that may indicate serious pathology
• Inadequate assessment of patients with impaired consciousness due to sedation
• Misinterpreting drug-induced findings (e.g., fixed dilated pupils after epinephrine administration) 1
• Failing to consider neuroimaging in patients with atypical presentations or unexplained abnormal findings 1

By following this structured approach to neurological examination, clinicians can effectively evaluate patients presenting with neurological symptoms and make appropriate decisions regarding further diagnostic testing and management.