Previous Lesson | Home | Next Lesson

General Appearance
Have the patient sit facing you on the examining table. Take a few seconds to actively observe the patient, and continue to actively observe the patient during the exam.

Level of consciousness.
Always begin the exam by introducing yourself to the patient as a tool to evaluate the patient's gross level of consciousness. Is the patient awake, alert and responsive? If not, then the exam may have to be abbreviated or urgent actions may have to be taken.

Personal Hygiene and Dress.
Note the patient's dress. Is it appropriate for the environment, temperature, age or social status of the patient? Is the patient malodorous or disheveled?

Posture and Motor Activity.
What posture does the patient assume when instructed to sit on the table? Are there signs of involuntary motor activity, including tremors (resting versus intention, also note the frequency in hertz of the tremor), choreoathetotic movements, fasciculations, muscle rigidity, restlessness, dystonia or early signs of tardive dyskinesia?

Chorea refers to sudden, ballistic movements, and athetosis refers to writhing, repetitive movements. Fasciculations are fine twitching of individual muscle bundles, most easily noted on the tongue. Dystonia refers to sudden tonic contractions of the muscles of the tongue, neck (torticollis), back (opisthotonos), mouth, or eyes (oculogyric crisis). Early signs of tardive dyskinesia are lip smacking, chewing, or teeth grinding.

Damage to the substantia nigra may produce a resting tremor. This tremor is prominent at rest and characteristically abates during volitional movement and sleep. Damage to the cerebellum may produce a volitional or action tremor that usually worsens with movement of the affected limb. Spinal cord damage may also produce a tremor, but these tremors do not follow a typical pattern and are not useful in localizing lesions to the spinal cord.

Height, Build and Weight.
Is the patient obese or cachectic? If cachectic, note any wasting of the temporalis muscles. Note the general body proportions and look for any gross deformities. Also check for dysmorphic features, including low set ears, wide set eyes, small mandible, mongoloid facies, etc.

Vital Signs.
These include temperature, pulse, respiratory rate and blood pressure. It is essential that the vitals always be taken as an initial assessment of a patient. Emergency measures may have to be taken for drastically abnormal vital signs.

Follow this vital sign acquisition routine:
Place the thermometer under the patient's tongue and instruct the patient to keep it there. Wait 20-30 seconds for the results.
Next, find the radial pulse in the patient's right arm with your first two fingertips of your right hand. Look at your watch and count the pulses over 15 seconds and then multiply by 4. Note the quality of the pulse. Is it bounding or thready, weak or prominent, regular or irregular, slow or rapid?. Once you are finished with the pulse measurement, keep your fingers on the pulse and secretly look at the patient's chest and count respirations for 15 seconds and also multiply this number by 4. Keeping your hand on the patient's pulse prevents the patient from becoming conscious of you watching them breath, preventing a likely adjustment in their respiratory rate.
Next, take the blood pressure. If it is high repeat the measurement later in the examination.
Finally, if a high temperature is present, or a previous history was taken suggesting meningeal irritation, test the patient for meningismus. Ask the patient to touch their chin to their chest to evaluate neck stiffness (a person with meningeal inflammation can only do this with pain). A positive Brudzinski's test is when the patient lifts their legs off the table in an effort to releave pain felt when the neck is flexed.
Next, have the patient lie flat on the examining table. Keeping the lower leg flexed, raise the upper leg until it is perpendicular to the floor. Slowly extend the lower leg while keeping the upper leg stationary. If meningeal irritation is present, this maneuver will be painful for the patient. Sometimes the patient will raise their head off the table and/or scream if pain is present, this is considered a positive Kernig's test.

Meningismus consists of fever, clouding of consciousness, photophobia (bright light being painful to look at), nuchal rigidity, a positive Brudzinski's test, and possibly a positive Kernig's test.

Special Topic: Classic Cerebrospinal Fluid Characteristics
Idiopathic Seizures Clear CSF with normal protein, normal glucose, no WBC's, no RBC's, normal opening pressure and normal % Gamma globulin.
Bacterial Meningitis: Milky CSF with increased protein, decreased glucose, high WBC's (PMN predominate), few RBC's, mildly increased opening pressure and normal % Gamma globulin.
Guillain-Barre Syndrome: Yellow CSF with very high protein (up to a gram), normal glucose, no WBC's, no RBC's, normal opening pressure and normal % Gamma globulin.
Subarachnoid Hemorrhage: Yellow CSF with increased protein, normal glucose, few WBC's, inumerable RBC's, mildly increased opening pressure and normal % Gamma globulin.
Herpes Simplex Encephalitis: Cloudy CSF with increased protein, normal glucose, increased WBC's (lymphocyte predominate), few RBC's, increase in opening pressure and normal % Gamma globulin.
Viral Meningitis: Cloudy CSF with increased protein, normal glucose, increased WBC's (lymphocyte predominate), no RBC's, normal opening pressure and normal % Gamma globulin.
Multiple Sclerosis: Clear CSF with mild increase in protein, normal glucose, few WBC's (lymphocytic predominate), no RBC's, normal opening pressure, increased % Gamma globulin.
Benign Intracranial Hypertension: Clear CSF with normal protein, normal glucose, no WBC's, no RBC's, increased opening pressure and normal % Gamma globulin.



Previous Lesson | Home | Next Lesson