Box 2.

A suggested approach for a screening neurological examination

• General features: make a note of dress, foetor, level of arousal (Glasgow Coma Scale), insight into presenting problem, ease of communication, recall of personal information, speech (slurred speech or dysarthria / expressive or receptive dysphasia / hypophonia) – if affected, perform a bedside swallow test to assess aspiration risk
• Cranial nerves: gross acuity (able to read your ID badge), fundi, fields, eye movements, pupil size and light responses, facial strength
• Tone: normal, flaccid, spastic or rigid
• Power:
  • Pronator drift

  • Characterise the pattern of weakness: pyramidal (brain/spinal cord), proximal>distal (muscle/radiculopathy), distal>proximal (neuropathy, rarer myopathies). Is it lateralising (ie hemiplegia) or localising (paraplegia as seen in cord lesions)

• Neck flexion: this is of particular importance in cases of suspected acute neuromuscular weakness (in extreme cases, patients may present with ‘head-drop’) and should be regarded as a harbinger of diaphragmatic failure
• Reflexes: absent, normal or brisk. Remember reflexes are frequently reduced in diabetic patients
• Sensory: distal light touch sensation, double simultaneous stimulation (the presence of sensory hemi-neglect indicating higher cortical sensory impairment, as may commonly occur with right parietal strokes). Characterise the pattern of light touch sensory loss where possible but bear in mind that the sinister causes of sensory impairment are usually associated with other signs. Organic patterns of isolated light touch sensory impairment include: unilateral (either mononeuropathy or monoradiculopathy), ‘glove and stocking’ (toxic-metabolic axonal polyneuropathies) and dense hemisensory (rare instances of lacunar stroke, more likely to indicate a functional neurological disorder). The initial stages of GBS and inflammatory transverse myelopathy may be predominantly sensory; the presence of a truncal level usually indicates cord pathology)
• Coordination: finger–nose, heel–shin
• Gait including walking on toes and tandem gait
• Blood pressure and pulse (including postural responses) Postural blood pressure measurements should be obtained after lying down for at least 5 minutes of rest and repeated after standing for 3 minutes. Postural hypotension is defined as a reduction of greater than 20 mmHg systolic or 10 mmHg diastolic. Any symptoms that develop during the standing phase of the assessment should be clearly documented