The neurologic examination for the busy small animal veterinarian (Proceedings)
A complete neurologic examination is an essential component of the physical examination for patients with suspected neurologic disorders, but is sometimes not performed because of the time constraints of a busy practice. At other times, patients with symptoms of neurologic disease can seem intimidating for those not accustomed to performing the neurologic examination. However, with practice, a basic understanding of neurology and a few tips, the neurologic examination can easily be incorporated into all physical examinations.
Before the neurologic examination
The patient's signalment (age, breed, sex) and history should be obtained before the neurologic examination. The following list of questions is important for all patients in whom neurologic symptoms are present or suspected, but is by no means complete. It is easy to incorporate these questions when obtaining a history, or they may asked in a questionnaire that is filled out by a client prior to examination. For others, having a trusted technician obtain answers to these questions prior to the veterinarian entering the examination room may be possible.
The neurologic examination should cover all areas of the nervous system, including the brain, spinal cord and neuromuscular system. The component parts of the neurologic examination include 1) evaluation of mentation, 2) observation of gait and posture, 3) postural reactions, 4) spinal cord reflexes, 5) cranial nerve examination, 6) palpation of the vertebral column, skull and muscles and 7) sensory testing. In most instances it is preferable to begin with the least threatening components of the examination and work towards those areas of the examination which may be resented most or painful to the patient. Whenever possible, all components of the examination should be covered, however there are situations in which an abbreviated examination is necessary. One such instance is with aggressive patients. Often the patient's response to a stimulus on the neurologic examination is subtle and requires some degree of cooperation from the patient. If a animal does not allow examination with light restraint, increasing physical restraint rarely provides useful information from the neurologic examination. Similarly, accurate neurologic assessment can not be obtained in patients given chemical restraint. The safety of the investigator, pet owner and pet should be taken into consideration when deciding upon the components of the neurologic examination for each individual patient.
Observation of gait and posture
Put the patient on the floor. This seems simple but often pet owners have the patient waiting for the veterinarian on the examination table before the examination begins. If possible, observe the patient while walking on and off leash in a area with good traction. If necessary take the patient outside on a leash. Often weakness or gait changes will be apparent within just a few steps. If deficits are not readily observable, having a patient go up and down stairs, an incline or turning quickly may make more subtle deficits apparent. It is preferable to have an assistant or the pet owner to walk the pet so the veterinarian can observe the gait more accurately.
When observing a patient off a leash note the direction in which they turn. While circling is readily apparent to most pet owners, turning predominantly to one direction is a more subtle clue to possible neurologic disease that will often not be noticed at home. The pet owner may be a tremendous help at motivating the pet to move during this phase of examination. Placing the patient on the floor in an enclosed room while the history is being obtained is a good time to begin observing gait and posture.