1. It’s not uncommon to meet circumstances where a full neurological examination is recommended. But a really thorough exploration of the nervous system takes hours. What can be done in the real world to screen quickly for neurological problems? Quite a lot, if you eliminate the nonessential.

2. The key is to let symptoms point out the relevant areas of investigation. It’s usually unproductive to test cognition unless the patient reports a problem. Even then, mild self-reported memory loss is unlikely to stem from a neurological condition, but is usually age or stress-related. It’s only if daily life is being affected, or if friends and family report a decline, or if the patient seems newly incoherent, that a neurological diagnosis is likely and a cognition test necessary.

3. Cognition is the most time-consuming part of neurological examination, and also the most subjective. Both of these problems can be minimized by the use of written questionnaires. Keep some validated depression questionnaires (i.e. Beck) and a few MMSEs or GPCOGs (General Practitioner assessment of cognition) handy.

4. Remember, the MMSE can miss some forms of dementia, including Lewy body (relapsing-remitting, sleep disturbance, hallucination, delusion), and frontotemporal dementia (behavioural changes, possible aphasia, few physical signs).

5. It’s useful before testing cognition to test attention and look for dysphasia. If a patient can count down from 20 to zero, attention issues are excluded. Acute confusional states (in the absence of stroke warning signs) are usually related to drug toxicity (i.e. anticholinergic), metabolic disturbance or infection. Screen for dysphasia by asking the patient to name the outer parts of a complex machine like a computer.

6. Many neurological signs are relative. What’s a diminished reflex? The only way to know is to test lots of normal reflexes. It helps to create your own standard package of the quickest and most useful neurological tests (i.e. fundoscopy, straight leg raise, ankle jerk, eye movement, tongue exam, gait) and apply it to all patients with possible neurological symptoms. This practice will quickly build up a mental reference library of what’s normal and what isn’t.

7. Eye movements are important, especially those caused by the third (oculomotor) and sixth (abducens) cranial nerves. In 3^rd nerve palsy the affected eye looks outward, causing double vision in straight ahead gaze. It can’t move inward past “centred,” nor up and down. Eyelid may droop and pupil may not respond to light. Any accompanying pain or worsening is likely a sign of urgent problem, i.e. trauma, tumour, aneurysm or hemorrhage.

8. In 6^th nerve palsy the affected eye can’t look outward, and diplopia results if the patient looks to that side. The possible causes are many, but most cases are vascular. Look for visual field defects — hemianopia often signifies a stroke, and may have implications for driving safety. Slowness in eye adduction (medial rectus palsy) is suggestive of multiple sclerosis. Jerky eye movement with nystagmus suggests brainstem disease. Inability to look up is predictive of a neurological diagnosis.

9. Tongue exam: it should protrude centrally, without fasciculation or wasting. Fasciculation is a possible sign of motor neuron disease, though it can also be due to fatigue, Lyme disease, benzodiazepine withdrawal, or dehydration. But almost any tongue may seem to writhe if the patient knows you’re looking at it. Tell them you’re examining the palate instead.

10. Don’t rely on the MRI to replace a neurological exam. This increasing practice generates time-consuming “incidentalomas” that rarely bear any relation to symptoms.