Lekcja 3: Badanie i Ocena Stanu Pacjenta | Patient Examination and Assessment

1. Patient History

Purpose: Gathering a comprehensive patient history is crucial for contextualizing the neurological examination. This information helps in forming a differential diagnosis and guiding further investigations. A thorough history provides insights into the nature, onset, and progression of neurological symptoms, as well as identifying any underlying or associated conditions.

• Symptom Onset and Duration: Identifies when symptoms began, their progression, and any episodic nature. Details to assess include:
  • Onset: Determine if the onset was acute (sudden) or insidious (gradual).
  • Duration: Establish how long symptoms have persisted, whether they are continuous or intermittent.
  • Progression: Evaluate changes over time, such as worsening, improvement, or fluctuation of symptoms.
• Symptom Description: Provides a detailed understanding of the patient’s complaints. Details to gather include:
  • Headaches: Note the location (e.g., frontal, occipital), nature (e.g., throbbing, stabbing), frequency, and any associated symptoms (e.g., nausea, aura).
  • Dizziness: Determine the type (e.g., vertigo, lightheadedness), triggers, and duration.
  • Sensory Changes: Identify the type (e.g., numbness, tingling), location, and any changes in sensory perception.
  • Motor Function Changes: Assess for weakness, tremors, or involuntary movements.
• Past Medical History: Identifies previous health issues relevant to the current neurological presentation. Details to gather include:
  • Neurological Conditions: Document any previous diagnoses such as stroke, epilepsy, or multiple sclerosis.
  • Comorbid Conditions: Include chronic diseases that may influence neurological health, such as diabetes or hypertension.
• Medication and Allergies: Reviews current and past medications to identify potential side effects or interactions. Details to gather include:
  • Medications: Record all prescription, over-the-counter drugs, and supplements, including dosage and duration.
  • Allergies: Document any known drug allergies, particularly those that could affect neurological health or treatment.

2. General Inspection

Purpose: General inspection involves observing the patient’s overall appearance, behavior, and mobility to identify any obvious signs of neurological dysfunction and gain clues about the nature of the neurological problem.

• Gait and Posture: Evaluates the patient’s ability to walk and maintain posture. Details to observe include:
  • Gait Abnormalities: Look for shuffling, limping, unsteady gait, or difficulty with balance, which may suggest conditions like Parkinson’s disease or cerebellar dysfunction.
  • Posture: Note any abnormalities such as stooped posture, uneven shoulder height, or difficulty maintaining an upright position.
• Facial Symmetry: Detects asymmetry that may indicate neurological issues affecting facial muscles or nerves. Details to observe include:
  • Facial Asymmetry: Look for drooping or weakness on one side of the face, which could suggest conditions like Bell’s palsy or a stroke.
  • Expressions: Assess for difficulties with facial expressions, such as smiling or frowning, which can provide clues to neurological deficits.

3. Neurological Examination

Purpose: The neurological examination involves systematically assessing various aspects of the nervous system to identify dysfunction and guide diagnosis and management.

• Mental Status Examination: Evaluates the patient’s overall cognitive and emotional function. Key details to assess include:
  • Level of Consciousness: Determine the patient’s alertness and responsiveness, ranging from fully alert and oriented to drowsy, stupor, or coma.
  • Cognitive Function: Assess various cognitive abilities, including:
    • Orientation: Awareness of person, place, time, and situation.
    • Memory: Recall of short-term and long-term memory, such as remembering a list of words or recent events.
    • Attention and Concentration: Ability to focus on tasks or follow instructions.
    • Language Abilities: Evaluate speaking, understanding, reading, and writing. Look for signs of aphasia or dysarthria.
  • Mood and Behavior: Observe for changes in emotional state and behavior, including mood swings, agitation, depression, or inappropriate behavior.
• Cranial Nerve Examination: 

• Motor System Examination: Assesses various aspects of motor function. Key details include:
  • Muscle Strength: Test strength in major muscle groups using manual resistance.
  • Muscle Tone: Evaluate resistance to passive movement for increased (spasticity) or decreased (flaccidity) muscle tone.
  • Coordination: Test the smoothness and accuracy of voluntary movements with tasks like the finger-to-nose test and heel-to-shin test.
• Sensory System Examination: Assesses different types of sensory input. Key details include:
  • Light Touch, Pain, and Temperature Sensation: Use a cotton wisp for light touch, pinprick for pain, and a cold or warm object for temperature.
  • Proprioception: Test the ability to sense body position and movement by assessing limb position with eyes closed.
• Reflexes: Evaluates the integrity of reflex pathways. Key details include:
  • Deep Tendon Reflexes: Test reflexes such as the knee jerk (patellar reflex) and ankle jerk (Achilles reflex).
  • Superficial Reflexes: Assess reflexes involving the skin, such as the abdominal reflex and plantar reflex.
  • Pathological Reflexes: Identify abnormal reflexes like the Babinski sign, which can indicate damage to the corticospinal tract.