Once your history has been completed, a detailed general physical examination is done, followed by a neurological examination. Mental status or neurobehavioral testing may also be required. The extent of the examination will depend on whether you are being seen for the first time, whether your clinical situation has changed, and other factors. These examinations are summarized and described in the paragraphs that follow.
Typically, the physical assessment begins with a general medical examination. This includes measuring vital signs, such as blood pressure, respiratory rate, heart rate and temperature. Subsequently, the examination may proceed to include virtually all organ systems. Typically, neurologists will focus attention on the head, eyes, ears, nose and throat (HEENT), cardiovascular, peripheral vascular, and musculoskeletal systems. Obviously, the pulmonary and integumentary (skin and connective tissues) systems are also important. Basically, your doctor will check you out from your head to your toes, hitting the parts of the examination that are most relevant to neurological problems. For example, pressing on your sinuses may produce severe pain if you have an acute sinus infection. This can be a cause of headache and facial pain. Listening to the arteries in your neck can tell your doctor about narrowing in those arteries that may require surgery or blood thinners. A rash on your skin might indicate Lyme disease, meningitis, Rocky Mountain spotted fever, or some other serious neurological condition. By listening to your heart, your doctor may be able to detect valve problems that might put you at risk for stroke. Your doctor might identify an irregular heartbeat that could be a cause for passing out spells or stroke. These are just a few of the many important physical findings that your doctor may look for during your initial evaluation.
Follow-up visits may include only a limited subset of the aspects of the general medical examination. Typically, you will also be followed up by your primary care physician. It is ideal if your primary care physician focuses the most attention on your general medical health, and your neurologist focuses on the neurological issues. Nevertheless, if you have a general medical problem that you want your doctor to look at when you come into the office, make sure that your neurologist knows to perform the relevant parts of the examination. We are not equipped to do pelvic examinations, and rarely have a need for any genital, gynecologic or breast examinations in the neurology setting. If such an examination is ever required, there will be a nurse in the examining room with you with your physician to help you feel more comfortable.
A. CRANIAL NERVE ASSESSMENT
There are twelve nerves that originate from the base of your brain, or brainstem, and the very top part of your spinal cord. These nerves control your eye movements, speech and swallowing movements, sensation in your mouth, nose, eyes and head, special senses, such as hearing and taste, vision and smell, inner ear function such as balance and motion detection, eyesight and pupil size, and other bodily functions, such as heart rate, blood pressure, stomach and intestinal movements. Your neurologist will probably check most or all of these cranial nerves during your initial assessment, in order to determine if there are any problems. A droopy face on one side, double vision, a change in pupil responsiveness, inability to swallow, or facial numbness, might all be signs of cranial nerve deficits.
B. MOTOR EXAMINATION
There are four key aspects to a detailed motor examination. First, the size of your muscles (bulk) is important. Diseased muscles will sometimes shrink, or they may even swell. Second, your muscle strength or power will be examined by assessing your ability to bend your various joints against resistance, or to hold your arms up in the air. Squatting, standing, pinching or other motor tasks may also be employed to get a sense of whether you have full strength, or whether there is a motor deficit. Muscle fatigue is assessed by repeating such tasks. Both muscle strength and fatigue are important components of your motor examination. Third, muscle tone must be assessed. The stiffness of limpness of your muscles when you relax completely is called muscle tone. There are a variety of conditions that can make your muscles more stiff, or excessively limp. Part of your motor examination will involve checking your muscle tone to look for such abnormalities. Fourth, unwanted or inappropriate movements are a critical part of the motor examination. For example, you might have a tremor. Your neurologist will want to characterize the tremor by looking at it while you are at rest and while you are performing various activities. You may also have uncontrollable jerking or shaking movements. You may have muscle twitches or writhing/twisting movements of your head or extremities. At the opposite extreme, you may find yourself stiff to such an extent that your movements are markedly diminished. Patients with Parkinson’s disease, for example, may have both types of movement problems: exaggerated movements such as tremor and dyskinesia are common, and a lack of movement (akinesia) or markedly slowed movements (bradykinesia) are typical of Parkinson’s disease. Your doctor will want to examine all four aspects of your motor system during your examination.
C. MUSCLE STRETCH REFLEXES
Your examination includes typical reflex tests that you have probably had performed many times. For example, your doctor will want to tap on your knees and watch your leg suddenly straighten. There are many other such muscle stretch reflexes that your doctor will want to check. These muscle stretch reflexes tell your doctor about important connections between your muscles and your spinal cord, and also between your spinal cord and your brain. In addition to muscle stretch reflexes, there are “cutaneous” or skin reflexes that may be checked. The most often tested is the “plantar response”. This involves scratching the sole of your foot to watch what happens with your leg and toes. Other cutaneous reflexes may be used to examine your abdomen or perineum (i.e., “your bottom”). These important reflexes, and others, help your doctor to understand some of the responses that you are capable of making, even without your conscious control.
The coordination examination includes testing of your arms and your legs, in most cases. You may be asked to perform rapid movements, accurate movements, or slow and steady movements. Coordination is simply the ability to control the finer aspects of movement. There may be deficit in coordination due to weakness, tremor, mental or cognitive disturbances, sensory abnormalities, or other disturbances of the systems in your brain that help to coordinate your movements. Coordination is a complex ability. Just look at the most complicated gymnastic maneuvers or other human feats and realize how many years it takes these athletes to learn the maneuvers. As with most other parts of the physical examination, the assessment of your coordination is necessarily limited to a few simple tests that we can perform in the office setting.
Your sensory system includes light touch, pain, vibration, position sense and temperature perception. There are also more complicated types of sensory perception, such as telling how far apart two pins are when they are simultaneously touching your skin, being able to tell what kind of object you are holding in your hand without looking at it, or discerning what letter or number has been written on the palm of your hand, with your eyes closed. Basic sensory abilities, such as pain and touch perception, are just the beginning. Your spinal cord, brainstem and other parts of your brain then take this crude sensory information and translate it into meaningful interpretations of your sensory experience. These perceptual abilities are fundamental to your ability to make sense of your world. Thus, it is possible for the sensory examination to blend right into the cognitive and neurobehavioral examination. The same is true for the motor and coordination exams. These nuances are discussed further under the appropriate sections below.
F. STATION AND GAIT
Your “station” is your ability to keep your body in a particular position, whether sitting or standing. Even the simple task of maintaining your current position is an important neurological ability. It may seem like there is not much happening in your brain, but just watch how fast someone falls over when there is a brain problem. Your gait is also an important window into your motor system, sensory system, and coordination. The act of walking is tremendously complex. Even now, it is difficult for robots to simulate the simple act of walking. Consequently, your doctor can look at you walk, and learn many things about your nervous system. For example, you may be stiff or almost paralyzed on one side. This is obvious when you walk. You may have gross problems with coordination, and this may cause you to stagger back and forth like a drunk. You may have severe slowing and stiffness, which causes you to shuffle, and causes your body to be hunched over when you walk. These are but a few of the many examples of gait disorders that may come to light during your examination.
A. ORIENTATION, ATTENTION AND CONCENTRATION
Your ability to devote mental power on the things happening around you is called your attention. This is a complex subject. The neurobehavioral examination will typically assess your attention span by asking you to perform simple mental tasks. For example, your ability to count or to recite the alphabet are very rudimentary skills requiring attention. The digit span task requires that you repeat the numbers after your examiner calls out a short list. A more complex skill, involving a great deal of concentration, is to recite a series of numbers or letters in reverse order (e.g., spelling a word backwards or reciting the days of the week or months of the year in reverse order). Your ability to pay attention is critical for gathering information about the day of the week, month of the year, current year, present location, and the current situation in which you find yourself. These latter pieces of data are all lumped under the heading “Orientation”. Your ability to orient yourself in the world, and to be able to pay attention to it are fundamental skills required for virtually all other aspects of your mental and cognitive life.
B. SPEECH AND LANGUAGE ASSESSMENT
Your ability to communicate with others is perhaps one of the most important human attributes. There are mechanical aspects of speech, such as being able to make sounds, and holding your mouth in the proper position to form those sounds into meaningful parts of speech. Once there is some evidence of speech output, the appropriateness of this output can be judged in terms of content, speed, clarity, and other factors. Your reading and writing ability may also need to be assessed. Your ability to name objects in your environment, to repeat words, phrases, or sentences, to comprehend and answer questions, and to use reasonable grammar and syntax are all important components of the language assessment. Your doctor may elect to check only a few of these items, or you may have a complete and thorough language evaluation. It all depends on the nature of your problem when you present to Absher Neurology.
Your memory ability is very complex. It includes the ability to store and retrieve information of all types. This can include pictures, movies, sounds, or other images in your brain. It can also include events and situations, all in the appropriate time-sequenced order. It might involve material that you learned when you first began to speak (“ma-ma”), or material that you learned just a few minutes ago (like the day of the week, or your present location). The neurobehavioral examination will attempt to understand your memory system in terms of its storage of new information, retrieval of information from memory stores, and ability to recognize information that has not been retrieved properly. You will sometimes feel quite challenged by the memory tests you are asked to complete during your evaluation. This is fine, because we want to make sure that your memory system is adequately challenged for us to understand whether there are areas of weakness.
D. VISUOSPATIAL ABILITIES
Your ability to perceive images, using your visual system, and to understand the spatial relationships of objects in your environment is also a very complex neurobehavioral skill. There are well over 50 or 60 separate types of visual abilities at work in our brains. This can include such things as color and shape detection, motor perception, depth perception, etc. Anyone who has ever been temporarily disoriented by an optic illusion, or frustrated by a new pair of glasses, can understand just how complex the human visual system is. Necessarily, the visuospatial assessment that we do in the office is quite limited. We can assess such things as your color and depth perception, visual acuity (how sharp your eyes are), ability to recognize and identify objects visually, your ability to copy drawings, and to remember the things that you have seen. The visual system is one of the areas of brain function for which we have accumulated the most knowledge. It is quite likely that your visual assessment, and particularly your visuospatial and perceptual abilities, will be assessed in increasingly complex ways as these new understandings reach the clinical arena.
E. EXECUTIVE FUNCTION
There are certain parts of the brain that do not have a single job or function. They may have several. Executive abilities can be thought of as the ability of certain parts of your brain to coordinate and organize the efforts of other parts of your brain. For example, you may have excellent strength, good coordination, and perfectly normal sensory and higher-level perceptual abilities. At the same time, you may have lost the ability to drive a car, to dress yourself, or to perform other complex motor tasks. In order to carry out such a complex task, your executive system needs to be able to coordinate all the components such as your motor system, coordination system, etc. Such a complex system also can only be checked in a limited way during a routine neurobehavioral examination. Sometimes it may be necessary to undergo more extensive testing in order to further explore these so-called “higher order” types of mental and cognitive abilities.
It only makes sense that there would be a wastebasket category for your cognitive abilities. For example, if you can correctly perceive an object, can name it, but do not know what it is, and cannot describe its use, what do you call such a cognitive problem? It is not a memory problem, because you can remember the object and how it is used. It is not a perceptual problem, because you can look at it and describe it perfectly. You may even be able to pick out the picture of such an object from a whole group of pictures that are almost identical. You cannot simply call this a visuospatial problem, because the same types of deficits may occur in your sensory system related to the touch and feel of objects. Thus, gnosis, as it is called, is only one of many other complex cognitive abilities that may need to be checked when you have a thorough neurobehavioral examination.
Your neurologist is not the most skilled person in performing a psychiatric assessment and interview. On the other hand, every neurologist has probably had some training in psychiatry. Dr. Absher, for example, completed approximately six months of psychiatric training during medical school, three months during neurology residency, and one year training at a psychiatric hospital during his two year neuropsychiatry and behavioral neurology fellowship at the University of California at Los Angeles. Part of this time was spent seeing some of the most complex psychiatric cases, including refractory schizophrenics seen at the William A. White Building at St. Elizabeth’s Mental Hospital in Washington, D.C., or institutionalized neuropsychiatric patients seen at the Brentwood VA Hospital in Los Angeles in response to a psychiatrist’s request for assistance. Despite these experiences, there is no substitute for the expertise and attention of a skilled psychiatrist.
The basic elements of the psychiatric assessment and interview include observation of general behavioral mannerisms, appearance, and other observable attributes. This can include anything from noting whether someone has brushed his teeth or clipped his fingernails, to paying attention to the cleanliness and style of his clothing. Fidgeting, twitching or other mannerisms are important parts of this assessment. The patient’s ability to engage and participate in conversation is also important. The degree of eye contact, emotional responsiveness, and the motivation that they exhibit while the interview is conducted are all important features of the psychiatric examination. The ability to think in logical and goal-directed ways, to stay on track during a conversation, and to provide honest responses to tough questions are also important parts of the psychiatric evaluation. The presence of hallucinations, or false beliefs (delusions), also needs to be checked.
Most patients will not need a psychiatric assessment, and only a rare patient will need this type of detailed psychiatric interview. Most of the time, your neurologist will simply turn you over to a psychiatrist, so that you can have these things checked by someone who “does this every day.” Just as your heart doctor is a better judge of your heart condition, your psychiatrist is going to be a better judge of the results of your psychiatric assessment. Your neurologist prefers to work along with your other doctors to manage your medical care when at all possible. Sometimes (e.g., if you refuse to see other physicians, are between doctors, or have a new problem that we are assessing for the first time), we will simply need to do the best we can do, regardless of our limitations. You should be aware that we cannot be experts at everything, and you may need to see a psychiatrist.
You should also realize that there are many neurological conditions that can cause psychiatric problems. Your psychiatrist needs to be just as willing to consult a neurologist when problems develop that might be related to neurologic disease. To list a few examples, you should be aware that about half of patients with Parkinson’s disease have a dementia syndrome or a depressive disorder. Almost one-third to one-half of patients with Huntington’s disease have attempted suicide. Stroke patients may develop bipolar disorder, including both mania and depression. These and many other types of “psychiatric” illnesses may directly result from neurological problems. If there is ever a question about whether you need a neurologist, it is a good idea to be checked out by a neurologist.
The above description is a very general outline of the important parts of the physical, neurological, neurobehavioral and psychiatric assessments. To complete a thorough examination in any one of these areas could take at least an hour. Obviously, we cannot spend four hours with every patient. Part of the art of medicine is deciding which parts of the examination and history to perform. You will have to trust our judgment in making these decisions, or seek out a second opinion from another physician. As mentioned, only a very small subset of these assessments may be needed during follow-up evaluations. In fact, only a “focused” assessment may be needed during your new patient examination. Your neurologist constantly makes decisions about which of these parts of the examination to perform, which to delete completely, and which to save for another day. We look forward to helping you understand this important part of your evaluation at Absher Neurology. Please feel free to contact us if you have any questions about your upcoming evaluation, or a previous encounter.