Synopsis
Perform and communicate a hypothesis-led but sufficiently complete neurological examination that detects emergencies, establishes a reproducible baseline and supports anatomical localisation.
- Begin before touch: note alertness, interaction, speech, posture, spontaneous movement, asymmetry, involuntary movements, respiratory effort, walking aids and how the patient transfers.
- Confirm identity, explain the purpose, seek consent, offer a chaperone where appropriate, expose only what is necessary and adapt positioning, hearing, vision and communication support to the patient.
- Use a fixed core sequence—mental status, cranial nerves, upper limbs, lower limbs, coordination, gait and relevant special tests—but expand or reorder it when physiology or the presenting problem demands.
- Compare sides and test from an expected normal area toward abnormal. Recheck surprising findings and distinguish 'not tested', 'unable because of pain' and a genuine neurological deficit.
- For each limb record inspection, tone, power by named movement, reflexes, plantar responses and sensation by modality; the phrase 'neurology normal' is not a defensible examination record.
- Power grading requires maximal voluntary effort, good positioning and pain control. Look for drift, fatigability, pyramidal distribution and functional inconsistency rather than relying on a single MRC number.
- Reflexes are interpreted as a pattern. Reinforcement can reveal a present reflex; clonus and an extensor plantar response add central evidence, while absent reflexes require intact technique and relaxation.
- Cranial assessment should include fields, pupils and eye movements as well as face, hearing, palate, tongue and speech; visual acuity and fundoscopy are added when symptoms or raised-pressure risk justify them.
- Never omit gait merely because limb testing on the couch is normal. Observe initiation, base, stride, arm swing, turning and tandem or heel-toe tasks only when safe.
- Finish by summarising positive and important negative findings, localising them, stating limitations and arranging repeat examination or escalation rather than simply listing every manoeuvre.
Key red flags
Impaired attention, orientation, language, memory, praxis, visuospatial awareness or behaviour can be diffuse or focal. Establish whether the patient can engage before interpreting complex commands, cortical sensation or apparent limb weakness.
Pronator drift, weakness following a pyramidal distribution, velocity-dependent increased tone, brisk reflexes, clonus and an extensor plantar response support corticospinal dysfunction, although not every component is present early.
Headache, photophobia, fever and neck stiffness raise meningitis or subarachnoid haemorrhage concern. Absence of classic meningism, especially in older, immunocompromised or obtunded patients, does not safely exclude either emergency.
Wet or nasal voice, weak palatal movement, poor cough, pooling secretions, fatigable counting, neck flexion weakness or paradoxical breathing can precede gas-exchange abnormalities and needs urgent respiratory assessment.
Investigation priorities
Quantify arousal, attention and focal higher-function abnormalities before interpreting the remainder of the examination.
Management branches
New face, arm, leg, speech, visual, neglect, gaze, balance or brainstem dysfunction of sudden or uncertain onset.
- Perform ABCDE and glucose, document last known well and rapidly test conscious level, language, gaze, fields, face, all limbs, sensation, coordination and neglect using a stroke-pathway framework.
- Activate local stroke imaging and specialist review immediately; do not extend the bedside examination with low-yield manoeuvres when this would delay CT, angiography or transfer.
- Time-stamp and repeat the core deficit after imaging, treatment or deterioration, including swallow safety and any posterior-circulation features that a brief screen may miss.