The neurological examination ought to be primarily hypothesis-driven, i.e. its function is to increase or decrease the likelihoods of hypotheses generated during history-taking. For example, performing the Dix-Hallpike examination is of interest when the history suggests benign paroxysmal positional vertigo but of highly dubious value in all other circumstances.

Notwithstanding the above, it is sometimes difficult to obtain a good history in the emergency setting. For this reason, one can justify carrying out a ”screening” neurological examination for patients presenting with suspected neurological deficits for which a reliable history cannot be obtained. Which tests ought to be part of this screening neurological examination is debatable. To fulfil their function, screening tests out to be sensitive. Many tests that are traditionally included in the neurological examination have poor sensitivity, e.g. the plantar response test (Babinski).  Other tests, such as the pronator drift test to detect subtle weakness, may be difficult to carry out on a patient that cannot provide a reliable history, e.g. because of decreased level of consciousness.

We propose here a Screening Neurological Examination tailored to the emergency setting where the focus is on identifying time-sensitive conditions (i.e. not on diagnosing Parkinson’s disease). Assessing level of consciousness, orientation and language/articulation do not feature in this proposed examination since abnormal level of consciousness, disorientation and dysphasia/dysarthria will have been identified during the history-taking or resuscitation phase. Items between parentheses related to situations where the patient has a decreased level of consciousness.

 

  1. Cranial Nerves
  • Simultaneous bilateral visual field stimulation (or blink-to-threat response for the patient with altered level of consciousness)
  • Pupillary size and reactivity to light
  • Eye movements
  • Facial movements (or corneal reflex for the patient with altered level of consciousness)
  • Soft palate elevation while saying ”Aah” and simultaneously protruding the tongue

 

2. Motor

  • Arm abduction at shoulder
  • Finger spreading
  • Rising from sitting or hip flexion for the patient who cannot stand
  • Walking on toes and heels or foot dorsiflexion and plantar flexion for the patient who cannot stand

In the setting of altered level of consciousness, testing for focal motor deficits is carried out by applying fingernail or toenail pressure to all four extremities

 

3. Coordination

  • Finger-nose test
  • Heel-shin test
  • Romberg