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.

1- 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.

2- 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?

3- 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?

4- 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.

5- 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.

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.

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Dr Mahmoud Ahmad Fora

Last Updated Feb 18, 2003