Box 10.

4 Comprehensive screening neurological examination Conscious level and cognitive function (determined during history taking) Is the patient's conscious level clouded? Is the history given accurately, concisely and with insight? Or is the patient concrete, circumlocutory or vague? Is the patient neatly dressed and well cared for? Is the patient's behaviour normal? Is the patient aphasic or dysarthric? Vision Acuity: For each eye, using normal refractive correction, test ability to read small and large print, or use Snellen chart if available. If this fails, test counting of fingers, perception of light. Visual fields: Test all four quadrants for each eye individually. Fundi: Check for papilloedema, optic atrophy, retinopathy. Pupils: Check equality and consensual and direct reactions to light and accommodation. Eye movements Test both eyes together in 'H' pattern for range of movement and diplopia. Test both eyes together in '+' pattern for smooth pursuit and nystagmus. Remainder of cranial nerves Nerve V: Pinprick on left and right in ophthalmic, maxillary and mandibular distributions; clenching of teeth; jaw jerk. Nerve VII: Appearance and symmetry; screwing up eyes against pressure, forcing lips closed against pressure, blink reflexes. Nerve VIII: Hear whispered numbers in each ear. Nerves IX and X: Ask patient to say 'ah' and observe palate. Nerve XI: Ask patient to shrug shoulders and move head to either side and flex against resistance while you observe sternomastoids. Nerve XII: Inspect tongue. Ask patient to protrude tongue and press against inside of cheek on either side. Limbs and trunk Inspection for wasting, fasciculation, skin lesions. Posture of outstretched arms with wrists pronated and supinated, looking for drift, tremor, abnormal movements. Tone at wrist, elbows, knees and ankles, ankle clonus. Power of proximal, axial and distal muscles on both sides. Co-ordination: Finger-nose test; rapid alternating movements; heel-shin test. Reflexes: Deep tendon reflexes of biceps, supinator, triceps, fingers, quadriceps, gastrocnemius; plantar responses. Sensation: Test pinprick distally to proximally up arms and legs medially and laterally; and up trunk bilaterally, anteriorly and posteriorly. Vibration sense or joint position sense at little finger, great toe (moving proximally if failed). Gait and stance Observe walking pattern. Standing still with feet together and eyes closed. Walking heel to toe. Jumping and hopping. The conscious level is best assessed by observation while taking the history. Severe disturbance should be quantified by the GCS score, but delirium can be gauged objectively by the first parts of the MiniMental State Examination (MMSE; see Chapter 3), namely orientation and repetition. Digit span, where the patient must immediately repeat a series of numbers ('a telephone number') called out by the examiner, is a good test for delirium. Even a moderately severely demented patient will be able to repeat a six-digit number successfully. If a wide-awake patient without severe dementia fails this test, he or she may have a specific aphasia in the domain of repetition, or hysterical or depressive pseudodementia. Spelling 'world' forwards (preserved even in severe dementia) and then backwards (requiring concentration, organization and 'internal repetition') is another cognitive test relatively sensitive to mild states of delirium. INTERPRETATION Clouding of consciousness may result from acute diffuse cerebral dysfunction, e.g. in cerebral hypoperfusion, metabolic disease or encephalitis. Focal lesions of the thalamus, especially if medial and bilateral, can also cause delirium, and lesions of the brainstem reticular activating system cause a

markedly impaired conscious level. Altered conscious level makes cognitive assessment largely redundant. There is little point in going through the whole MMSE if the patient cannot hold enough mental focus to repeat a six-digit number.