History
- • Weakness, sensory change, paraesthesia (distribution, onset)
- • Bladder/bowel, sphincter, sexual function
- • Headache, fits, faints, falls, cognition
- • PMH: stroke, MS, DM, alcohol, B12
Examination sequence
- • WIPE — expose limbs fully, compare sides
- • Inspection: posture, wasting, fasciculations, scars, tremor, involuntary movements
- • Tone: rigidity, spasticity, clonus (3+ beats abnormal)
- • Power: MRC 0–5, all major movements proximal to distal
- • Reflexes: biceps/triceps/supinator (C5-T1); knee/ankle/plantars (L3-S1)
- • Coordination: finger-nose, dysdiadochokinesia, heel-shin
- • Sensation: pinprick, light touch, vibration, proprioception, temperature
- • Gait: normal, heel-toe, Romberg
Positive findings
- • UMN: spasticity, hyperreflexia, upgoing plantars, weakness in pyramidal pattern
- • LMN: wasting, fasciculations, hypotonia, hyporeflexia
- • Cerebellar: DANISH (dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia)
Differentials
- • Sudden hemiparesis → stroke (TACS/PACS/LACS)
- • Distal + sensory loss + absent reflexes → peripheral neuropathy
- • Mixed UMN/LMN signs → MND
Viva questions
Q. How to distinguish stroke from Bell's palsy?
A. Bell's involves forehead (LMN); stroke spares forehead (UMN).
Q. Top differentials for spastic paraparesis?
A. Cord compression, MS, transverse myelitis, hereditary spastic paraparesis, B12 deficiency.
Common mistakes
- • Forgetting to test gait
- • Not comparing sides
- • Skipping cranial nerves when asked for full CNS
