The medical assistant's role in the neurologic examination

As with other physical examinations, a careful history provides the physician with valuable clues in diagnosing neurologic conditions. Such clues may include a record of seizures, syncope, diplopia, incontinence, or any of the previously mentioned subjective symptoms. The patient’s general health often complicates a neurologic diagnosis.

The purposes of a neurologic examination are to determine whether a nervous system problem is present, to discover its location (or locations), and to identify the type and extent of the malfunction. During the examination, the physician may determine the effect of the symptoms on the patient’s emotional status, intellectual performance, cognitive ability, and general behavior. The patient’s grooming and mannerisms are carefully observed, as is his or her ability to communicate effectively, including the appropriate use of speech, language, and writing skills. The medical assistant should listen carefully for difficulty putting words together, slurred speech, and whether the conversation makes sense. Sudden slurred speech, facial drooping, or numbness on one side of the body are stroke red flags - notify the physician immediately rather than simply charting them for later review. For other inappropriate changes in the patient, note them on the patient’s record for the physician’s attention and evaluation.

The physical examination of the neurologic system includes evaluation of the cranial nerves. You can assist by helping the patient assume the proper position necessary for each test and by having the instruments the physician needs ready for use. For example, cranial nerve I (the olfactory nerve) is tested by determining the patient’s ability to identify familiar odors, such as coffee, tobacco, or cloves. Cranial nerve V (the trigeminal nerve) is checked by having the patient differentiate between warm and cold objects held against the right and left cheeks.

Peripheral nerve function is evaluated by examining the motor system, including muscular strength, gait, and movements. The diameters of the upper arms and the calves of the legs may be measured and compared to diagnose muscle atrophy. Motor functioning can be assessed through Romberg’s test, in which the patient is asked to stand with the feet together, arms horizontal to the body, and eyes closed. The sensory system is examined by noting the patient’s ability to perceive superficial sensations, such as a wisp of cotton brushed on the skin, a light pinprick, or hot and cold touching certain areas. Several deep tendon reflexes (DTRs), such as the patellar and Achilles reflexes, are checked. Babinski’s reflex is tested by stroking the lateral aspect of the sole of the foot with a dull instrument (e.g., the handle of a reflex hammer or a tongue blade). For a positive Babinski’s sign, the great toe dorsiflexes while the other toes fan out. This may indicate a possible stroke or brain lesion. Other diagnostic tests may include a skull radiograph, carotid arteriogram, EEG, and MRI and CT studies.

Diagnostic testing

Several tests are used to help the physician accurately diagnose conditions and diseases of the neurologic system. The most common diagnostic procedures are the lumbar puncture and various radiographic studies.

Electroencephalography

Electroencephalography is used to record the brain wave activity of a patient suspected of having a seizure disorder or to determine the effectiveness of pharmaceutical treatment to control the brain’s abnormal electrical activity. The particular pattern of brainwave activity helps diagnose the seizure disorder type. EEGs are also used to help localize the area of the brain that is causing a partial seizure disorder. To prepare for the test, the patient may be told to stop taking certain medicines (sedatives, muscle relaxants, sleeping aids, or antiseizure drugs) and to avoid all caffeine for 12 hours before the test. During an EEG, 16 to 25 electrodes are placed on the patient’s scalp with either paste or an elastic cap to record the electrical activity of the brain. The patient must remain very still during the examination, even sleep if possible, so that the electrodes can pick up the electrical impulses of the brain without interference. Once the electrodes are in place, an EEG typically takes up to 60 minutes; sedation may be required for patients who cannot remain still, such as young children. Every individual has a unique EEG pattern. In a healthy brain, most of the recorded waves are the occipital alpha waves coming from the back of the head. Irregular slow waves are called delta waves, which are normally found in people deeply asleep and in infants and young children. A delta wave pattern is abnormal in an awake adult. Rhythmic slow waves, called theta waves, show a decrease in brain activity. Electrical silence (flatline EEG) indicates no evidence of brain activity and is one of the criteria used to determine brain death. EEG is valuable for diagnosing epilepsy, brain tumors, and other brain conditions.

Lumbar puncture

If the physician suspects that an infection or inflammation of the CNS is present, a lumbar puncture (spinal tap) is ordered to collect a CSF sample for culture and analysis of glucose and protein, or to detect increased intracranial pressure or an area of intracranial bleeding. The patient is placed on the left side in the fetal position; using sterile technique, the physician injects the lumbar puncture site with a local anesthetic, and the puncture is performed by inserting a special needle into the subarachnoid space, usually between the L4 and L5 vertebrae. The pressure in the subarachnoid space is recorded, and at least four tubes of CSF are collected for laboratory analysis. The most common complaint after the procedure is a severe headache. Extended bed rest once was recommended to prevent a spinal headache, but research no longer supports this approach. After the procedure, the patient is encouraged to drink fluids to rehydrate so that the CSF that was withdrawn during the spinal tap is replaced as quickly as possible. Medical practices usually have a specially equipped room where this procedure is performed. If you are working in such an office, you may be responsible both for assisting with the procedure and for monitoring the patient afterward - exactly which tasks you may perform is delegated by the supervising physician and governed by your state’s medical practice act, not a single national rule. You also will have particular office protocols to follow regarding the frequency of vital signs, liquid intake, urine output, and visitors. Lumbar punctures usually are performed in hospitals, outpatient clinics, or surgical centers. On discharge, patients should be told to notify the physician immediately if they experience visual disturbances; numbness and tingling of the legs; drainage of blood or liquid from the puncture site; inability to urinate; or a persistent headache.

Legal and ethical issues

In neurology you will be faced with a variety of behaviors and personality changes that frequently are a part of neurologic conditions. Often a patient is not aware of these changes and may appear as though nothing is wrong. You must treat this patient with the same dignity and respect as you would all other patients, despite how the patient may treat you. Some patients are concerned that loved ones have turned against them and are treating them in an abusive manner. A patient’s family may be experiencing severe emotional stress in coping with the patient’s behavior. You must remember the medical assistant’s code of ethics and the need for total confidentiality. Whatever is discussed in the examination room cannot be repeated to other staff members in the office and can never be discussed outside the office. Confidentiality must be strictly maintained.

HIPAA applications

Under HIPAA, patients generally have the right to obtain a copy of their health information, but psychotherapy notes - a mental health professional’s documentation and analysis of counseling conversations - receive special protection: they’re kept separate from the general chart, they can’t be released to a third-party payer or insurer without the patient’s specific authorization, and under federal law the treating therapist (not the patient) decides whether to release them to the patient, with no right of appeal. State law can grant patients broader access to these notes, in which case the stricter state law controls.

Professional behaviors

Thinking critically is central to acting professionally in a neurologic practice, since patients present with a wide range of signs, symptoms, and mental health states - including the ability to question patients logically and separate relevant from irrelevant information. Stay alert to personal bias that could affect the respectful care you provide, especially with patients who have a mental illness diagnosis. Conducting a professional, respectful patient history and using strong interpersonal communication skills lays the groundwork for the patient’s care in the neurology office.