What does a neurologist do

The neurologist will want to know why you came, your medical history, your family history (especially a history of PD or tremor), and what, if anything, in your social and work history may have contributed to your symptoms. Bring a summary of your medical history, including serious and chronic illness, hospitalizations, surgeries, allergies, medications taken, family and personal background, occupational risks, and lifestyle risks. If what you have to talk about is difficult to discuss, practice how to bring it up. If you expect bad news, bring someone supportive with you.

The doctor or his assistant may ask you about your activities of daily living. These include questions about your speech, salivation, swallowing, handwriting, cutting food and handling utensils, dressing, hygiene, turning in bed, falling, freezing, walking, tremor, and sensory symptoms. This review of your daily activities is not a laundry list. Careful and imaginative questioning is very helpful.

You should be asked whether there has been a change in your voice. Voice implies difficulty with the mechanical rather than the linguistic aspects of speech. An answer such as "yes, my voice seems to fade out at times and people are always asking me to speak up" is almost always diagnostic of PD. You should be asked whether you have recently noticed saliva escaping from the corner of your mouth. This is a private symptom often apparent only to you. The question usually elicits a reply such as "Yes, my pillow is wet at night, but I didn't mention it." Although drooling may be a relatively minor complaint, this symptom is associated with dementia in the minds of many patients and families (see Question 54). You should be reassured that your drooling does not mean you will "lose your mind." Prominent swallowing difficulty early in PD disease usually implies a PD-like disorder. Difficulty with handwriting, cutting food, handling utensils, dressing, and hygiene to some extent depends on whether your dominant hand is affected. If you appear to be unaware of any difficulty with these tasks, the doctor may ask you if you are slower in performing them. This question usually elicits a response such as "Yes, but that isn't anything, is it?"

It's helpful for the doctor to obtain specimens of your handwriting and compare them with past samples. This may show when your disease actually began. In some people it's reassuring to know they had PD for several years before they were aware of their symptoms. This implies their PD is progressing more slowly than they thought.

If your non-dominant hand is primarily affected, the questions should be directed to include those activities you usually performed with that hand. Thus if you're right-handed with left-sided PD, you may be asked how you button your shirt sleeves on your right side or how you wash your right shoulder.

People rarely associate difficulty with turning in bed with a disease, so they do not mention it and are surprised when asked. Such questions provide you with insight into the scope of your disease; you realize that symptoms as different as tremor, drooling, and difficulty turning in bed are part of the same process. During the question-and-answer time, the neurologist will observe your facial expression, your speech, your gestures, and your movements. The neurologist will observe you standing up, walking, and sitting. He or she will see how you rise from your chair and how you take your first step. Walking is a complex act, and a careful examination can provide many insights into your posture, the length of your stride, the way you move your feet, and how you turn. Because such observations require more space than is available in the neurologist's office, you may be asked to walk in the hallway outside.

The neurological examination has several parts. Rigidity is examined by testing muscle tone at your wrists, elbows, shoulders, and knees (and sometimes your hips) by holding the limb and moving it both slowly and rapidly. The testing of reflexes reveals much to a skilled examiner. Testing of strength or power provides more insight into how your nervous system works. Rapid movements are tested by asking you to tap your fingers to your thumb, to turn the palms of your hands up and down, to turn your wrists from side to side as though you're screwing in a light bulb, and to move your feet up and down as though you're walking. The examiner will be look at the amplitude, speed, and rhythm of your movements and compare your left with your right side. Tests of coordination are carried out by asking you to touch your finger to your nose and then to the tip of the examiner's finger. Another test involves running the heel of one foot up and down the shin of the opposite leg. This provides information on a region of your brain called the cerebellum. Eye

Cerebellum the coordinating center in the brain.

movements and speech are also evaluated. The examiner may ask you to say "mama" or "papa" to test your lips. The examiner may ask you to say "Lulu" to test your tongue. The examiner may ask to say, "Ahh." This tests your pharynx. The sensory examination includes an evaluation of your ability to perceive a light touch, a pin prick, and your ability to tell (with your eyes closed) whether your thumb or great toe is being moved up or down. Testing for PD requires skill and practice on the part of the examiner.

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