Neurological Assessment 🧠

• 1. Triage urgency first: ABC, capillary glucose, GCS, and sudden focal signs (FAST). Treat time-critical stroke or seizure pathways before a leisurely full exam.
• 2. Decide screen vs focused exam. If the history suggests no neurology, a brief screen is enough. If symptoms or screening findings are abnormal, examine the relevant systems in detail.
• 3. Work systematically: mental status / GCS → cranial nerves → motor (MRC) → tone and reflexes → sensation → coordination → gait.
• 4. Localise the pattern (UMN vs LMN, hemispheric, brainstem, cord, root, nerve, muscle) and document clearly.
• 5. Escalate per red flags below and local stroke / neurology pathways. See NICE NG127 for recognition and referral of suspected neurological conditions.

• Sudden focal neurology (face, arm, speech, vision, neglect): treat as stroke / TIA per local pathway until proven otherwise.
• Rapidly progressive symmetrical limb weakness (hours to days): immediate senior review; assess bulbar and respiratory function (?Guillain–Barré).
• Rapidly progressive gait ataxia (days to weeks): urgent neurology / suspected cancer pathway referral (NICE NG127).
• New seizure features with blackout, meningism, declining GCS, or suspected raised ICP: ABC, senior, imaging as indicated.
• Suspected cauda equina (saddle anaesthesia, new urinary retention / incontinence, bilateral leg signs): urgent MRI and spinal team per local protocol.
• Fever with neck stiffness, photophobia, or rash: meningitis / encephalitis pathway.
• GCS falling or fluctuating: senior review; do not attribute to “sleep” without a documented neuro exam.

• Explain what you are doing and obtain verbal consent. Offer a chaperone for intimate elements if needed.
• Position: ideally sitting or supine with enough space to assess gait. Expose limbs adequately; compare sides.
• Have: tendon hammer, Neurotip or similar, 128 Hz tuning fork if available, pen torch, cotton wool / fingertip.
• Check capillary glucose early if altered consciousness, stroke-like symptoms, or unknown history.
• Tailor depth to the question. Purpose beats ritual (MRCP PACES principle): know why each manoeuvre is included.

• Alertness and orientation to person, place, and time during history-taking.
• Language: fluency, comprehension, naming, repetition. Note dysarthria vs dysphasia.
• GCS if reduced consciousness or head injury: Eyes / Verbal / Motor. Record the three numbers, not only the total. Use the GCS calculator topic.
• If drowsy or confused, also document attention, following commands, and any fluctuation (delirium).

• II: visual acuity (each eye), confrontation fields, pupils (size, reactivity, RAPD), fundoscopy if headache / raised ICP concern.
• III, IV, VI: eye movements in H pattern; nystagmus; ptosis; diplopia.
• V: facial sensation (V1–V3), corneal reflex if indicated, jaw power if needed.
• VII: raise eyebrows, close eyes tightly, show teeth / smile. Upper face spared in UMN facial weakness.
• VIII: hearing (finger rub); Dix–Hallpike / HINTS only if trained and clinically indicated for vertigo.
• IX, X: palate elevation, voice, cough; gag only if indicated.
• XI: shoulder shrug / head turn against resistance.
• XII: tongue protrusion and fasciculations. Lower cranial nerves matter most when there is dysarthria or dysphagia.

• Inspection: wasting, fasciculations, posture, adventitious movements (tremor, myoclonus, chorea).
• Tone: passive movement at elbow, wrist, knee, ankle. Spasticity (clasp-knife) vs rigidity (lead-pipe / cogwheel).
• Pronator drift: arms outstretched, palms up, eyes closed. Drift or pronation suggests UMN lesion.
• Power: grade with MRC scale (table). Test key myotomes side-to-side. Fix the joint and feel the contraction.
• Key upper limb: shoulder abduction (C5), elbow flexion (C5–6), elbow extension (C7), wrist extension (C6–7), finger abduction (T1).
• Key lower limb: hip flexion (L2–3), knee extension (L3–4), ankle dorsiflexion (L4–5), great toe extension (L5), ankle plantarflexion (S1).
• Functional screens: heel and toe walking, deep knee bend, rising from a chair without hands.

• Biceps (C5–6), triceps (C7), brachioradialis (C6), knee (L3–4), ankle (S1). Compare sides.
• Plantars: stroke lateral sole. Extensor (Babinski) suggests UMN lesion after infancy.
• Grade roughly: 0 absent, 1+ reduced, 2+ normal, 3+ brisk, 4+ clonus. Clonus at ankle is abnormal.
• Absent reflexes with weakness: think LMN, neuropathy, or root. Brisk reflexes with weakness: think UMN / cord / brain.

• Modalities: light touch, pinprick (pain), temperature if available, vibration (128 Hz on bony prominence), proprioception.
• Demonstrate each modality on the sternum first. Ask whether sides feel the same, not “is this sharp?”
• Screen fingertips and toes. If abnormal or symptoms suggest a pattern, map dermatomes and major nerve territories.
• Look for patterns: hemisensory, sensory level (cord), glove-and-stocking, single root or peripheral nerve.
• Romberg: stand feet together, then close eyes. Sway or fall with eyes closed suggests proprioceptive (dorsal column / neuropathy) loss, not primary cerebellar disease.

• Finger–nose and heel–shin: look for intention tremor and past-pointing.
• Rapid alternating movements (dysdiadochokinesia).
• Gait: casual walk, tandem (heel–toe), turn. Note base width, arm swing, steppage, festination, circumduction.
• Cerebellar pattern reminder (DANISH): Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Speech, Heel–shin.

• Record GCS as E_ V_ M_ (and total). Note if a component is non-testable (e.g. intubated).
• Cranial nerves: state which were tested and any asymmetry.
• Power: MRC grades by muscle group or myotome, left and right. “Power 5/5 globally” is acceptable only after an adequate screen.
• Sensation: modalities tested and the pattern of any loss (do not invent precision you did not map).
• Reflexes: grade and plantars. Coordination and gait in plain language.
• Impression: localisation and urgency, then plan (imaging, stroke pathway, senior / neurology).

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