Neurology

Neurological Assessment
at Bedside

WestNet Medical • Module 08 • Bedside Neuro Assessment & the Whole Person

WestNet Unified Health Platform • WestNet Catalog 731985456628 • ISBN 978-0-XXXXX-XXX-X (Pending)
CE Accreditation Path: ANCC • ACCME • CARNA
Last updated: June 2026

Core Learning Objective

Learners will perform a structured, time-critical bedside neurological assessment — the Glasgow Coma Scale, stroke recognition (BE-FAST), seizure first aid, the focused cranial-nerve and motor exam, and the altered-mental-status workup — and will reliably separate reversible, medical causes from anything reflexively labelled “psychiatric.” The percentile is not the patient; observe the human, not the label.

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WestNet Medical Publications
A division of WestNet North America Inc.
medical.westnet.ca

Co-Published With

WestNet Humanitarian Services (WHS)
UN Supplier • Registered NGO
www.westnet.ngo

WestNet Catalog (UPC-A): 7 31985 45662 8
ISBN 978-0-XXXXX-XXX-X (Pending) • First Edition

7 31985 45662 8

WestNet Medical Publications

Continuing Education Information

Field	Detail
Module	08 of 12 — Neurology
Contact Hours	4.0 (Pending ANCC / ACCME / CARNA approval)
Target Audience	RNs, LPNs, RPNs, Paramedics, ED & ICU Nurses, Stroke-team members, Nurse Practitioners, Physician Assistants, Licensed Clinicians
Publication	WestNet Medical Publications • Catalog 731985456628 • ISBN Pending
Disclosure	Educational content. Does not replace facility policy, physician orders, local stroke / seizure protocols, or jurisdictional scope-of-practice rules.

Perform a structured, head-to-toe focused bedside neurological assessment efficiently and reproducibly
Score the Glasgow Coma Scale accurately across eye, verbal, and motor responses and state the severity band
Recognize acute stroke using BE-FAST and activate the time-critical pathway without delay
Deliver seizure first aid and recognize status epilepticus as a medical emergency
Examine pupils and cranial nerves and interpret lateralizing findings
Work up altered mental status and exclude reversible, medical causes before any “psychiatric” attribution
Interpret head-circumference variation as a measurement, not a diagnosis — and assess faith by function, safety, and distress, never by its content

Program Preface

§ 01

The bedside neurological exam is the most information-dense five minutes in clinical medicine. Long before any scan, the brain tells you what it needs — through the eyes, the words, the strength of a grip, the symmetry of a smile. This module teaches you to read that story under time pressure, in the order that catches the dangerous, reversible things first.

Module 08 is not a substitute for imaging or for the neurologist. It is the structured observation that decides how fast imaging and the specialist are summoned — and that, in stroke and status epilepticus, is the difference that saves brain tissue.

WestNet Position

Neurology rewards the clinician who observes before they label. A GCS of 8 is a measurement, not a person; a wide head is a measurement, not a diagnosis; a patient who prays is describing a practice, not a symptom. Measure precisely — then look up and assess the human in front of you.

The Focused Bedside Neuro Exam

§ 02

A complete neurological exam can take forty minutes. A focused bedside exam takes five, and answers the only questions that matter acutely: Is consciousness intact? Is there a focal deficit? Is this getting worse? Run it in a fixed order so nothing is skipped under pressure.

Step 1

Level of Consciousness

Alertness and orientation first. Use AVPU as a quick gate, then the Glasgow Coma Scale for a reproducible number you can trend across shifts.

Step 2

Pupils & Cranial Nerves

Pupil size, equality, and reaction. A blown unilateral pupil is a herniation alarm. Screen face, eye movements, gag, tongue.

Step 3

Motor & Sensation

Pronator drift, grip and limb power graded 0–5, gross sensation. Asymmetry is the headline — one side weaker than the other localizes the lesion.

Step 4

Coordination & Gait

Finger-to-nose, heel-to-shin, and — if safe — gait. Cerebellar signs and a new ataxia are easily missed and clinically loud.

Always Establish Baseline

The single most useful neurological observation is change from this patient’s own baseline. A fixed GCS of 14 in someone who was 15 an hour ago is an emergency; a stable lifelong finding is not. Ask family, ask the prior chart, document the trend — never just the snapshot.

Level of Consciousness & the Glasgow Coma Scale

§ 03

The Glasgow Coma Scale (GCS)^[1] is the universal, reproducible language for level of consciousness. It scores three responses independently — Eye opening (1–4), Verbal response (1–5), and Motor response (1–6) — for a total from 3 (deep coma) to 15 (fully alert). Always report the components, not just the sum: E3 V4 M5 = 12 tells a clinician far more than “12.”

Severity Bands

Mild 13–15 • Moderate 9–12 • Severe ≤ 8. A GCS of 8 or less means the patient cannot reliably protect their airway — “GCS 8, intubate” is the classic teaching. The motor component carries the most prognostic weight; if you record only one number, record motor.

Scoring Pitfalls

Score the best response observed. Note confounders that cap a score — intubation (verbal not testable, mark “V⊂T”), sedation, intoxication, aphasia, periorbital swelling, or a language barrier. A low GCS from sedation is not the same emergency as a low GCS from a bleed; document why.

Glasgow Coma Scale Calculator

§ 04

Select the best response observed on each axis. The total and severity band update live. Use this to drill scoring until the components are second nature — it is a teaching aid and never replaces a documented clinical assessment.

Interactive Clinical Partner

GCS — Live Calculator

Eye opening (1–4), Verbal response (1–5), and Motor response (1–6) score independently; the total runs 3–15. Always record the components alongside the sum.

15/15

Mild — 13–15

E4 · V5 · M6

Eye Opening

Verbal Response

Motor Response

Interpretation

Severity bands: Mild 13–15 • Moderate 9–12 • Severe ≤ 8. A GCS ≤ 8 raises airway-protection concern. Trend the score — a falling GCS is the warning, not the absolute number.

Pupils & the Cranial Nerve Screen

§ 05

The eyes and face carry an outsized share of the neurological story. A focused cranial-nerve screen takes about ninety seconds and catches brainstem and lateralizing problems early.

Pupils

Size, Equality, Reaction

Note diameter, symmetry, and the direct/consensual light reflex. A new, unilateral fixed and dilated (“blown”) pupil suggests third-nerve compression from rising intracranial pressure — a herniation emergency. Pinpoint pupils suggest opioids or a pontine lesion.

CN II & III/IV/VI

Vision & Eye Movements

Gross visual fields by confrontation; track an “H” pattern for the extraocular muscles. New diplopia, gaze palsy, or a fixed deviation localizes quickly.

CN V & VII

Face: Sensation & Movement

Light touch over the three trigeminal zones; then “raise your eyebrows, screw your eyes shut, show your teeth.” Forehead spared = central (stroke); forehead involved = peripheral (Bell’s palsy).

CN IX/X & XII

Swallow, Voice, Tongue

Check palate elevation and gag, voice quality, and tongue protrusion (deviates toward a weak side). Bulbar signs flag aspiration risk — protect the airway before anything else.

The Forehead Rule

Facial weakness that spares the forehead points to a central lesion (stroke); weakness that involves the forehead points to a peripheral seventh-nerve palsy (Bell’s). This one distinction changes the entire pathway — one is a stroke call, the other usually is not.

Power, Sensation & Coordination

§ 06

The limb exam answers one dominant question: is there asymmetry? A symmetrical finding is usually systemic or chronic; a new one-sided finding localizes a lesion and, until proven otherwise, is a stroke.

Power

MRC Grading 0–5

0 none · 1 flicker · 2 movement with gravity eliminated · 3 against gravity · 4 against resistance · 5 normal. Test major groups side-to-side and compare.

Drift

Pronator Drift

Arms out, palms up, eyes closed for ten seconds. A drifting, pronating arm is a sensitive early sign of subtle upper-limb weakness — often the first visible stroke sign.

Sensation

Gross Screen

Light touch and pinprick, comparing left to right and proximal to distal. Map any level or one-sided loss; full modality testing follows if screen is abnormal.

Coordination

Cerebellar Signs

Finger-to-nose and heel-to-shin for dysmetria; rapid alternating movements for dysdiadochokinesia. New ataxia — especially with vertigo — can be a posterior-circulation stroke.

Asymmetry Is the Signal

Train your eye to compare sides reflexively: face, then arms, then legs, then sensation. The brain is built symmetrically; new asymmetry is the loudest thing the nervous system can say at the bedside.

Stroke Recognition — FAST & BE-FAST

§ 07

In ischemic stroke, roughly 1.9 million neurons are lost every minute reperfusion is delayed. Time is brain. The classic FAST screen (Face, Arm, Speech, Time) catches most anterior-circulation strokes; BE-FAST adds Balance and Eyes to capture the posterior-circulation strokes that FAST misses.^[3] Recognition feeds directly into the time-critical management pathway for acute ischemic stroke.^[2]

Time Is Brain

Record the last-known-well time — not when symptoms were noticed. This single data point determines eligibility for thrombolysis and thrombectomy. “Wake-up” strokes default the clock to when the patient was last seen normal. Do not let a stroke patient wait for routine triage.

Don’t Forget Glucose

Hypoglycemia is the great stroke mimic — it can produce focal weakness and aphasia that resolve completely with dextrose. Check a fingerstick glucose on every suspected stroke before committing to the diagnosis. A reversible cause masquerading as a stroke is exactly the kind of thing a careful bedside clinician catches.

Clinical Pearls

• Score the best response, document the components. Record GCS as its parts — E/V/M — never the total alone; “E3 V4 M5 = 12” localizes and trends in a way that “12” cannot.
• “Worst headache of my life.” A sudden, severe thunderclap headache is subarachnoid hemorrhage until proven otherwise — do not anchor on migraine or “tension”; it is a CT-and-escalate moment.
• A new fixed, dilated pupil is a herniation emergency. Unilateral third-nerve compression from rising intracranial pressure is a call-for-help-now sign, not a finding to chart and revisit on the next round.
• Assess function, safety and distress — not belief. Faith, prayer, and normal human variation are not pathology; ask whether the person is safe and functioning, and let the neurological exam, not the worldview, decide what is medical.

Case Vignette

At 18:40, while eating dinner, a patient suddenly develops a left facial droop, left arm drift, and slurred speech. Onset is abrupt and one-sided.

Resolution: This is BE-FAST positive (Face, Arm, Speech). Fix the last-known-well time at 18:40 — the moment they were last seen normal — and activate the stroke pathway immediately: urgent CT, keep the patient NPO, and check a fingerstick glucose. Time is brain — do not “watch and wait” or re-screen on the next round.

Red Flags — Escalate Now

• Any BE-FAST sign — Balance loss, Eyes (vision loss/diplopia), Face droop, Arm drift, or Speech disturbance.
• Sudden “worst headache of life” (thunderclap) — subarachnoid hemorrhage until proven otherwise.
• New fixed/dilated pupil or a GCS drop ≥ 2 — herniation.
• Seizure > 5 minutes or repeated without recovery — status epilepticus.
• Any new focal deficit.

Activate the stroke/neuro emergency now — note the last-known-well time.

BE-FAST Recognition Tool

§ 08

Check each sign you observe right now. Even one positive finding should prompt the stroke pathway — the tool tallies your findings and gives the time-critical next step live.

0/6

No BE-FAST signs marked

Continue your focused assessment and keep watching. If anything changes, re-screen immediately and note the time.

How to Use It

BE-FAST is a screen, not a diagnosis — its job is speed. A single positive sign is enough to activate the pathway; do not wait to accumulate more. Always pair it with a glucose check and a last-known-well time. The tool supports clinical judgement; it never replaces it.

Seizure Recognition, First Aid & Status Epilepticus

§ 09

Most seizures stop on their own within one to three minutes. Your job during one is to protect, not to restrain — and to start the clock, because a seizure that will not stop is a true emergency.

Do — Seizure First Aid

Note the time it started — duration drives everything
Protect the head; clear hard or sharp objects away
Roll to the recovery position once movements ease
Loosen anything tight around the neck
Stay, observe the pattern, and reassure as awareness returns
Check glucose — hypoglycemia causes seizures

Don’t

Put anything in the mouth — they will not “swallow the tongue”
Restrain or hold the person down
Move them unless they are in danger
Crowd them or let an audience gather
Assume it is over the instant shaking stops — postictal confusion is normal
Reflexively label postictal agitation as “psychiatric”

Status Epilepticus — Emergency

A seizure lasting ≥ 5 minutes, or repeated seizures without full recovery between them, is status epilepticus^[4] — a neurological emergency with rising mortality the longer it runs. Call for help, secure the airway and oxygen, get IV access and glucose, and give a benzodiazepine per protocol without delay. Do not wait for it to “ride out.”

Postictal ≠ Psychiatric

After a seizure, confusion, agitation, and even transient combativeness are expected as the brain reorganizes. This is a recovering nervous system, not a behavioral problem. Orient gently, keep the person safe, and let the postictal state resolve before drawing any conclusion about “agitation.”

Altered Mental Status: A Structured Workup

§ 10

“Altered mental status” is a finding, not a diagnosis. The discipline of the workup is to exhaust the reversible, medical causes before anyone reaches for a behavioral or psychiatric label. The bedside mnemonic AEIOU-TIPS keeps the differential honest.

The Universal First Moves

For any altered patient: check glucose, oxygen saturation, temperature, and vitals immediately; review the medication list and recent changes; consider infection and intoxication. A delirium screen (e.g., CAM) separates the acute, fluctuating, inattentive picture of delirium from a primary psychiatric presentation.

Delirium Is Medical

Delirium — acute onset, fluctuating course, inattention, often with an underlying infection, drug, or metabolic cause — is frequently mislabeled as “agitation” or “dementia” and sedated rather than investigated. Sedation treats the staff’s discomfort, not the patient’s brain. Find and fix the cause. (See Module 11 — Elder Care & Delirium.)

Reversible & Medical, Not “Psychiatric” — The Differentiator

§ 11

The most consequential call in altered mental status is also the easiest to get wrong: is this an acute medical brain problem, or a primary psychiatric presentation? The reflexive default jumps to “psychiatric” the moment behavior is hard to manage — and that default sedates reversible emergencies. Mark what you actually observe; the tool weighs the picture and flags the safe next step.

Points toward a Medical / Reversible Cause

Delirium / organic — treat the cause

Points toward a Primary Psychiatric Picture

Functional — assess in context

MedicalUnclearPsychiatric

Awaiting input

Mark the features you observe

Clinical Safety

When the picture leans medical — or is unclear — do not settle on a psychiatric label. Acute onset, fluctuation, abnormal vitals, abnormal glucose, focal signs, or a recent medication change all point away from “psychiatric” and toward a reversible cause that demands a medical fix. This tool supports — never replaces — clinical assessment.

The Mental-Status Exam: Faith Is Not Pathology

§ 12

The mental-status exam asks about thought content, perception, and belief. Here a careful clinician meets a fork in the road. A patient who says they pray and feel that God responds is not, by that fact, describing a symptom — they are describing a practice shared by billions of people across every culture and continent, and one that scripture itself promises will be answered.^[5]

Two Scriptures, One Promise

“Call upon Me; I will respond to you.” — Qur’an 40:60
“Call to Me, and I will answer you.” — Jeremiah 33:3
The sense that prayer is heard is the lived expectation of mainstream faith, not evidence of disordered cognition. A mental-status framework that cannot tell devotion from delusion has reached the edge of what it can responsibly assess.

The clinical task is not to adjudicate whether the belief is true — that is outside medicine entirely. The task is to assess three things, and only these three:

Assess I

Function

Is the person working, relating, caring for themselves, meeting their responsibilities? Faith that supports a coherent, functioning life is not pathology — for many it is the scaffold of resilience.

Assess II

Safety

Is anyone — the patient or another — at risk? Safety is assessed by behavior and intent, never by the religious content of a belief.

Assess III

Distress

Is the belief a source of comfort or of torment? Distress, not faith, is the clinical signal. A practice that brings peace is not a target for treatment.

The Limit of the Label

Reflexive labeling fails most quietly when it pathologizes the ordinary. Chart what the patient does and how they function — not the content of their faith. Respect here is not a courtesy; it is clinical accuracy. (See Module 07 — De-escalation & observing the human.)

Human Variation: When the Head Is Larger Than Average

§ 13

Head circumference is one of the most commonly measured neurological data points — and one of the most commonly over-read. A larger-than-average head, formally macrocephaly^[6] (occipitofrontal circumference above roughly the 97th percentile), is frequently a benign, familial trait in a healthy, high-functioning person. The measurement is the start of a question, never the answer.

Benign Familial Macrocephaly

The most common cause of a big head in a well child or adult is simply a big head that runs in the family. Plot the trajectory: a head that has tracked steadily along its own (high) curve, in a person who is developing and functioning normally, with normal exam and normal parental head size for comparison, is reassuring — not a diagnosis in search of imaging.

The clinician’s job is to distinguish this benign variant from the rare situations that do warrant a closer look — and to do so without alarming a healthy person over a number on a chart.

Reassuring — observe the human

Head has followed its own curve over time (steady percentile)
Normal development, cognition, and neurological exam
Large head sizes elsewhere in the family
Well, thriving, high-functioning person
No headache, vomiting, or new focal signs

Warrants closer evaluation

Crossing percentiles upward — accelerating growth
Developmental regression or new deficits
Signs of raised intracranial pressure
Bulging fontanelle (infant) or abnormal exam
Persistent morning headache with vomiting

The Percentile Is Not the Patient

A head circumference at the 98th percentile describes a measurement, not a verdict. Most people who carry a larger head are entirely healthy — often strikingly capable. Measured carefully and placed in context, head size joins height and shoe size as ordinary human variation. Observe the human, not the label: a number on a growth chart has never, by itself, made anyone unwell.

The Acute Bedside Neuro Ladder

§ 14

When a patient’s neurological state changes, run the rungs in order. The early rungs are fast and protect life; the later rungs localize and direct treatment.

Rung 1

Airway, Breathing, Circulation

A neuro patient is a whole patient. Secure the airway (GCS ≤ 8 is a red flag), give oxygen, support circulation. Brain rescue starts with the basics.

Rung 2

Glucose & Vitals

Fingerstick glucose, temperature, SpO⊂2, BP, heart rate. Hypoglycemia and hypoxia mimic strokes, seizures, and “psych” presentations — and are instantly reversible.

Rung 3

Level of Consciousness & GCS

Score E, V, M and the total. Establish baseline and the trend. A falling GCS escalates urgency regardless of the absolute number.

Rung 4

Focal Screen: BE-FAST, Pupils, Power

Pupils, face, arm drift, speech, balance, eyes. Any positive sign → activate the stroke pathway and note last-known-well time.

Rung 5

Reversible Differential (AEIOU-TIPS)

Work the reversible causes of altered mental status. Exclude medical and medication causes before any behavioral or psychiatric attribution.

Escalate

Activate Pathway & Specialist

Stroke team, seizure / status protocol, urgent imaging, neurology. Document the timeline and components. Hand off the trend, not just the snapshot.

The Cranial Nerves I–XII in Detail

§ 15

Section 05 introduced the ninety-second cranial-nerve screen. This section is the reference behind it: the twelve cranial nerves, what each one does, and the single most useful bedside test for each. You will not test all twelve on every patient — but knowing what each nerve carries lets you localize a deficit to the brainstem, the nerve, or the muscle in seconds.

Nerve	Chief Function	Fast Bedside Test & What a Deficit Suggests
I — Olfactory	Smell	Identify a familiar scent per nostril. New anosmia after head trauma, or a frontal mass; rarely tested acutely.
II — Optic	Vision, afferent pupil light reflex	Acuity, confrontation fields, fundoscopy. A relative afferent pupillary defect (swinging-light test) localizes to the optic nerve.
III — Oculomotor	Most eye movement, eyelid, pupil constriction	“Down-and-out” eye, ptosis, blown pupil. A fixed dilated pupil with these signs is a herniation alarm.
IV — Trochlear	Superior oblique (eye down & in)	Vertical diplopia worse on reading/stairs; head tilt away from the lesion.
V — Trigeminal	Facial sensation, muscles of chewing	Light touch over three zones; clench the jaw; corneal reflex (afferent). Loss maps a sensory level on the face.
VI — Abducens	Lateral rectus (eye abduction)	Cannot abduct the eye; horizontal diplopia. A “false-localizing” sign in raised intracranial pressure.
VII — Facial	Facial expression, taste (anterior tongue)	Eyebrow raise, eye closure, smile. Forehead spared = central (stroke); forehead involved = peripheral (Bell’s).
VIII — Vestibulocochlear	Hearing & balance	Finger rub, Weber/Rinne; vertigo and nystagmus point here or to its central connections (see HINTS, §25).
IX — Glossopharyngeal	Taste/sensation posterior tongue, swallow	Gag reflex (afferent), palate sensation. Bulbar signs flag aspiration risk.
X — Vagus	Palate, larynx, viscera	“Say ahh” — uvula deviates away from the weak side; hoarse voice; gag (efferent).
XI — Accessory	Sternocleidomastoid & trapezius	Shrug shoulders against resistance; turn head against resistance.
XII — Hypoglossal	Tongue movement	Protrude the tongue — it deviates toward the weak side. Fasciculations suggest a lower-motor-neuron lesion.

A Memory Hook

Generations of clinicians order the twelve nerves with a mnemonic — the classic being “On Old Olympus’ Towering Tops, A Finn And German Viewed Some Hops” for the names, and “Some Say Marry Money, But My Brother Says Big Brains Matter Most” for whether each is Sensory, Motor, or Both. Use whichever sticks — the point is never to skip a nerve under pressure.

Use the flip cards below to drill the deviation rules — the ones most often confused at the bedside. Click any card to reveal the answer.

Localize, Then Escalate

A single cranial-nerve deficit can be benign (an isolated Bell’s palsy) or catastrophic (a third nerve heralding herniation). The discriminators are company and tempo: a deficit that arrives suddenly, with other signs, or with a falling level of consciousness, is an emergency. One isolated, slowly-evolving deficit in a well patient is worked up — not panicked over.

Motor Patterns: Upper vs Lower Motor Neuron & Reflexes

§ 16

Where a motor lesion sits — in the brain and cord (upper motor neuron) or in the nerve root, peripheral nerve, junction, or muscle (lower motor neuron) — produces two opposite patterns. Recognizing which pattern you are looking at narrows the differential before any test is ordered.

Upper Motor Neuron (UMN)

Brain & spinal cord

Increased tone (spasticity), “clasp-knife”
Brisk, hyperactive reflexes
Up-going plantar (Babinski present)
Little or no muscle wasting; no fasciculation
Weakness in a “pyramidal” pattern (extensors weak in arms, flexors weak in legs)

Lower Motor Neuron (LMN)

Root, nerve, junction, muscle

Decreased tone (flaccid)
Reduced or absent reflexes
Down-going / absent plantar
Marked wasting; fasciculations may be visible
Weakness maps to a single root or nerve distribution

Deep-tendon reflexes are graded on a standard scale. Compare side-to-side — an asymmetry is more telling than an absolute value, and a healthy person can sit anywhere from 1+ to 3+ symmetrically.

Grade 0

Absent

No response even with reinforcement (Jendrassik maneuver). Points to an LMN or sensory-arc problem.

1+ to 2+

Normal range

1+ diminished but present; 2+ normal. Symmetry is what reassures.

Brisk

Brisker than average; may be normal or early UMN — read in context with tone and plantars.

Clonus

Repeating beats; sustained clonus is pathological and an UMN sign. Check ankle clonus directly.

The Plantar Response

Stroke the lateral sole firmly from heel to little toe and across the ball. Down-going (toes curl) is the normal adult response. Up-going (great toe extends, others fan) is Babinski-positive — a reliable upper-motor-neuron sign at any age beyond infancy. It is one of the few truly objective neurological findings.

Why the Pattern Matters

A patient with brisk reflexes, spasticity, and an up-going toe has a problem in the brain or cord — think stroke, mass, or myelopathy. A patient with flaccid weakness, absent reflexes, and wasting has a problem in the nerve or muscle — think neuropathy, radiculopathy, or a neuromuscular disorder. Same weakness, opposite workup. (Mixed UMN and LMN signs together is its own red flag — see §27.)

The Sensory & Coordination Exam in Depth

§ 17

Sensation travels to the brain along two separated highways, and knowing which one is involved localizes a lesion the way no imaging request can. Test both systems when a sensory complaint is the headline.

Tract 1

Spinothalamic — Pain & Temperature

Crosses to the opposite side within a segment or two of entering the cord. Tested with pinprick and a cold tuning fork. Loss here is contralateral below a spinal lesion.

Tract 2

Dorsal Columns — Vibration, Proprioception, Fine Touch

Ascends same-side to the brainstem before crossing. Tested with a 128 Hz tuning fork and joint-position sense. Loss is ipsilateral below a cord lesion.

Because the two systems cross at different places, a single cord lesion can produce a striking split — the basis of the Brown-Séquard pattern in §26. Map sensory loss in one of four shapes; each points to a different level of the nervous system:

Pattern of loss	Where the lesion most likely is
Glove-and-stocking (distal, symmetric)	Peripheral — a length-dependent polyneuropathy (e.g., diabetic). See §27.
Dermatomal stripe (a band on a limb/trunk)	A single nerve root — radiculopathy.
A sensory level across the trunk	The spinal cord — find the level, then escalate. See §26.
One whole side of the body	The brain — thalamus or cortex; think stroke.

Coordination: Cerebellar Signs (DANISH)

The cerebellum makes movement smooth; when it fails, movement becomes clumsy without being weak. Remember DANISH: Dysdiadochokinesia (clumsy rapid alternating movement), Ataxia (broad-based gait), Nystagmus, Intention tremor, Slurred/scanning speech, and Hypotonia. Finger-to-nose past-pointing and heel-to-shin dysmetria are the two fastest bedside tests.

Acute Cerebellar Signs Are a Stroke Until Proven Otherwise

New ataxia, vertigo, and nystagmus together — especially in a patient with vascular risk factors — can be a posterior-circulation (cerebellar) stroke, which FAST routinely misses. The cerebellum sits in a tight posterior space; swelling there compresses the brainstem fast. Do not dismiss “just dizziness and unsteadiness.” Run BE-FAST and the HINTS exam (§25).

Romberg Is a Proprioception Test, Not a Cerebellar One

Ask the patient to stand with feet together and then close their eyes. Falling only once the eyes shut is a positive Romberg — it means the dorsal columns (position sense) or vestibular input, not the cerebellum, are doing the failing. A cerebellar patient is unsteady with eyes open and closed alike. The distinction is small and frequently mis-taught.

Stroke Syndromes & Vascular Territories

§ 18

BE-FAST gets the stroke patient into the pathway; recognizing the syndrome tells the team which vessel and how big the threat. Each cerebral artery supplies a defined territory, and occluding it produces a recognizable cluster of deficits. You are not expected to read the angiogram — only to describe the pattern accurately so the right call is made.

Dominant vs Not

Aphasia or Neglect

A dominant (usually left) hemisphere stroke produces aphasia — language fails. A non-dominant stroke produces neglect — the patient ignores one side of the world. Both are major-territory red flags.

Lacunar

Small-Vessel Strokes

Deep, small infarcts give “pure” syndromes — pure motor, pure sensory — without aphasia or visual loss. Easy to under-call; still a stroke.

Posterior

The Dangerous Misses

Brainstem and cerebellar strokes bring vertigo, double vision, crossed signs, and ataxia. Often mistaken for a labyrinth or “medical” problem — the costliest error in stroke care.

Bleed vs Clot

You Cannot Tell Without a Scan

Ischemic and hemorrhagic strokes can look identical at the bedside. The CT decides — which is exactly why imaging is urgent and why no antiplatelet/thrombolytic is given on clinical impression alone.

Crossed Signs Mean Brainstem

Weakness or numbness of the face on one side and the body on the other localizes to the brainstem — a posterior-circulation stroke until proven otherwise. This “crossed” pattern is pathognomonic and routinely missed because each individual sign looks minor. Escalate it like any other stroke.

Describe, Don’t Diagnose the Vessel

Your bedside job is an accurate description — which side, which parts, how sudden, last-known-well — not naming the artery. But recognizing that “face and arm weak with aphasia” is a large-vessel pattern, while “vertigo with crossed numbness” is posterior, sharpens the urgency you communicate and may flag a thrombectomy candidate. Verify every step against your local stroke protocol.

Stroke Severity: NIHSS-Lite Estimator

§ 19

The National Institutes of Health Stroke Scale (NIHSS)^[8] quantifies stroke severity from 0 to 42 across fifteen items. The full, certified scale governs treatment decisions; the simplified six-item estimator below is a teaching aid to build intuition for how deficits add up into a severity band. It is not the certified NIHSS and must never be charted as one — use your facility’s validated tool for real scoring.

Interactive Clinical Partner

NIHSS-Lite — Severity Estimator

Pick the best description for each of six representative items. The estimate and band update live. This is a learning aid, not the certified 15-item NIH Stroke Scale.

0/ est.

No deficit marked

Select each item below

Interpretation

Indicative bands only: 0 none • 1–4 minor • 5–15 moderate • 16–20 moderate–severe • 21+ severe. The certified NIHSS has fifteen items and required training; this estimator omits most of them. Verify against current local stroke protocols.

Why Severity Matters

A higher score signals a larger territory and, often, a large-vessel occlusion that may be a thrombectomy candidate. But a low score never means “safe to wait” — a disabling deficit (isolated aphasia, a dense hemianopia) can score modestly yet still demand urgent treatment. Severity informs the pathway; it does not gate the urgency.

Transient Ischemic Attack & Transient Deficits

§ 20

A transient ischemic attack (TIA) is a brief episode of focal neurological dysfunction from temporary ischemia, without permanent infarction — classically minutes, almost always resolving within an hour. The danger is not the episode itself but what it announces: a TIA is a warning shot, and the risk of a completed, disabling stroke is highest in the first 48 hours.

“It Resolved” Is Not Reassurance

The single most dangerous reflex with a transient deficit is relief. A face that drooped and recovered, an arm that went weak and came back, speech that garbled and cleared — these are not “nothing happened.” They are a stroke that has not finished. A TIA is a medical emergency that warrants urgent, same-day assessment, not a routine follow-up.

Distinguish the vascular event from its common mimics — the distinction changes the entire pathway:

Feature	TIA (vascular)	Common mimics
Onset	Sudden, maximal at onset	Migraine aura & seizure: spreading/marching over minutes
Symptom quality	Negative — loss of function (weakness, loss of vision/speech)	Positive — flashing lights, tingling that marches, jerking
Duration	Minutes, typically < 1 hour	Migraine 20–60 min aura; seizure seconds–minutes + postictal
Always check	Glucose — hypoglycemia mimics a TIA perfectly and is instantly reversible.

A Note on Risk Stratification

Tools such as the ABCD² score (Age, Blood pressure, Clinical features, Duration, Diabetes) have historically been used to estimate early stroke risk after TIA. Scoring tools guide triage but do not replace urgent specialist assessment — current guidance treats most TIAs as requiring rapid workup regardless of score. Follow your local TIA pathway for thresholds and timing.

Amaurosis Fugax

A transient, painless, “curtain coming down” loss of vision in one eye is amaurosis fugax — a TIA of the retinal circulation, often from carotid disease. Treat it with the same urgency as a limb or speech TIA: it is the eye’s version of a warning stroke, and the carotid that supplied it may be about to occlude the brain.

Seizure Types & Classification

§ 21

Section 09 covered seizure first aid. This section covers seizure recognition — because what you call a spell shapes the workup, and many seizures look nothing like the dramatic convulsion most people picture. The modern classification asks two questions first: where did it start, and was awareness kept or lost?

Onset

Focal vs Generalized

Focal seizures begin in one part of one hemisphere; generalized seizures engage both hemispheres from the start. A focal seizure can spread and become bilateral (“focal to bilateral tonic-clonic”).

Awareness

Aware vs Impaired

In a focal aware seizure the person stays conscious (the old “simple partial”); in a focal impaired-awareness seizure consciousness is altered (the old “complex partial”).

Click each card below to flip between what you might see and what it is most likely called. Recognizing the non-convulsive types is where careful clinicians earn their keep.

Two Quiet Emergencies

Non-convulsive status epilepticus can present as prolonged confusion, staring, or “altered mental status” with no convulsion — it is a frequent missed cause of unexplained, persistent obtundation and needs an EEG to catch. And a first-ever seizure in an adult is never “just a seizure”: it demands a search for a cause (stroke, mass, infection, metabolic, drug/withdrawal).

Seizure or Faint? Or Neither?

Convulsive syncope (a few jerks during a faint) is commonly mislabeled as a seizure; true seizures usually bring a longer postictal confusion, tongue-biting (especially lateral), and incontinence. Psychogenic non-epileptic events are real distress and deserve respect — never derision — but they are not treated with escalating anti-seizure drugs. When unsure, protect the patient, time the event, and get expert review rather than guessing.

Headache: Red Flags & Primary Types

§ 22

Headache is one of the most common presentations and one of the few where a single sentence from the patient can change everything. The clinical task is binary at first: is this a primary headache (migraine, tension, cluster — benign, if miserable) or a secondary headache (a symptom of something dangerous)? The red flags — remembered as SNNOOP — are how you tell.

Red-flag screen. Check every feature present. Any single red flag shifts this from “primary headache” toward an urgent secondary-cause workup.

0/8

No red flags marked

No red flags marked. A benign primary headache (migraine, tension, cluster) is more likely — but reassess if anything changes or the pattern is new.

When the red-flag screen is clear, characterize the primary headache — the management differs sharply:

Type	Typical picture
Migraine	Hours to a day; one-sided, throbbing, moderate-severe; nausea, light/sound sensitivity; may have a preceding aura. Worsened by activity.
Tension-type	Bilateral, pressing/“band-like,” mild-moderate; no nausea; not worsened by routine activity. The most common headache.
Cluster	Strictly one-sided, around the eye; excruciating; with tearing, red eye, nasal congestion, restlessness. Short attacks in “clusters.”

The Headaches That Kill

Five secondary headaches must never be missed: thunderclap (subarachnoid hemorrhage), headache with fever and neck stiffness (meningitis — §23), headache with focal deficit or seizure (mass, bleed, stroke), headache worse lying flat / with morning vomiting (raised intracranial pressure — §24), and new headache over age 50 with scalp tenderness / jaw claudication (giant cell arteritis — threatens vision). Each is an escalate-now situation.

“Worst Headache of My Life”

A headache that reaches maximum intensity within seconds to a minute — a thunderclap — is subarachnoid hemorrhage until imaging and, if needed, a lumbar puncture prove otherwise. Do not be reassured because the patient is talking, walking, or has had headaches before. This single descriptor outranks a reassuring appearance every time.

CNS Infection: Meningitis & Encephalitis

§ 23

Infection of the central nervous system is one of the few diagnoses where hours genuinely change survival and disability. Bacterial meningitis can kill a previously well person in under a day; recognition and time-to-antibiotics are the levers that matter most. It belongs squarely in the altered-mental-status differential (the “I” of AEIOU-TIPS).

Meningitis — the classic triad & more

Fever
Neck stiffness (meningismus)
Altered mental status / severe headache
Photophobia; nausea and vomiting
A non-blanching petechial/purpuric rash — meningococcal alarm
The full triad is often absent — do not wait for it

Encephalitis — the brain itself inflamed

Fever with altered behaviour, confusion, or personality change
New seizures in a febrile patient
Focal neurological signs (it affects brain tissue, not just the lining)
Often viral (herpes simplex is the treatable must-not-miss)
Overlaps with meningitis as “meningoencephalitis”
Confusion + fever = think brain, not “behaviour”

Time-to-Antibiotics Saves Lives

When bacterial meningitis is suspected, the priority is not to delay treatment for a perfect workup. Blood cultures and empiric antimicrobial therapy per protocol should not wait for imaging or lumbar puncture when the patient is sick — every hour of delay worsens outcome. Recognize it, escalate it, and let the team start treatment. Verify the specific regimen and sequence against current local protocols.

Two Bedside Signs (Helpful When Present)

Kernig’s (resistance/pain extending the knee with the hip flexed) and Brudzinski’s (involuntary hip/knee flexion when the neck is flexed) support meningeal irritation. They are useful when positive but poorly sensitive — a negative sign never rules meningitis out. Nuchal rigidity and the overall picture carry more weight.

Public-Health & Protection

Suspected meningococcal disease is a notifiable emergency with implications for staff and close contacts — institute droplet precautions early and involve infection control. Protecting the patient and protecting the people around them are the same clinical act here.

Raised Intracranial Pressure & Herniation

§ 24

The skull is a fixed box containing brain, blood, and cerebrospinal fluid. When one component grows — a bleed, a tumour, swelling — pressure rises, and beyond a point the brain is forced through the only openings available. This is herniation, and it is among the fastest-moving emergencies in medicine. Recognizing rising pressure before herniation is the whole game.

Early

The Warnings That Buy Time

Headache worse lying flat or in the morning, vomiting (often without nausea), drowsiness, and a falling GCS. Papilledema if the fundus is examined. These are the signs to escalate on.

Pupil

The Blown Pupil

A new, unilateral fixed and dilated pupil signals third-nerve compression from uncal herniation — the brain pushing against the nerve. This is a call-for-neurosurgery-now sign.

Posture

Abnormal Posturing

Decorticate (arms flexed to the core) is bad; decerebrate (arms extended) is worse and more caudal. Either in a deteriorating patient is a brainstem alarm.

Late

Cushing’s Triad

Hypertension, bradycardia, irregular respiration. By the time the triad appears, herniation is advanced — it confirms, it does not give you lead time.

A Falling GCS Is the Alarm

The most reliable early marker of rising intracranial pressure at the bedside is a declining level of consciousness — a GCS drop of 2 or more points. Do not chart it and move on. Pair it with pupils and a focused exam, escalate to senior/neurosurgical help immediately, and treat as a herniation threat. Specific measures (head-of-bed positioning, osmotic therapy, airway management) are undertaken per protocol by the responding team.

Why the Bedside Nurse Is the Sensor

Imaging is a snapshot; the bedside observer is the continuous monitor. The trend — this patient, more drowsy than an hour ago, with a pupil now sluggish — is information no single scan holds. Trust a deteriorating trend over a reassuring earlier scan, and escalate on the change. Hand off the trajectory, not just the latest number.

Dizziness & Vertigo: The HINTS Exam

§ 25

“Dizziness” is one of the hardest complaints in medicine because one word covers four different problems. The first move is to ask what the patient actually means: a spinning vertigo, a faint-feeling presyncope, an unsteady disequilibrium, or a vague light-headedness. For true continuous vertigo, the critical question is the one that scares clinicians: is it a benign inner-ear problem, or a posterior-circulation stroke?

Peripheral vs Central — the Core Split

A peripheral cause (inner ear — vestibular neuritis, BPPV) is benign but miserable. A central cause (brainstem or cerebellar stroke) is dangerous and easily missed because the patient may have no limb weakness — only vertigo. In the acute vestibular syndrome, the eye exam discriminates the two better than imaging does in the first hours.

The HINTS exam^[9] is a three-part eye examination, validated in the acute, continuous, spontaneous vestibular syndrome (not for brief positional spins, and not as a screen in someone without ongoing vertigo). Crucially, it is the reassuring peripheral pattern that requires all three to line up — any central feature points to stroke.

HINTS decision aid. For each of the three components, choose the finding. The tool indicates whether the pattern is reassuringly peripheral or points central (stroke). Teaching aid only — HINTS requires trained examination.

⋯

Select each of the three components

HINTS is interpreted as a whole: the peripheral (reassuring) pattern requires all three benign findings together. Any single central feature outweighs the rest.

“INFARCT” — the Central Pattern

The dangerous (central / stroke) HINTS pattern is remembered as INFARCT: Impulse Normal (a normal head-impulse test — counter-intuitively the worrying one in continuous vertigo), Fast-phase Alternating (direction-changing nystagmus), and Refixation on Cover Test (vertical skew deviation). Any one of these three points to a posterior stroke. A reassuring exam needs all three benign findings together — and even then, persistent or evolving symptoms still warrant escalation.

Don’t Forget the Simple Things

Sudden unilateral hearing loss with vertigo can be a stroke of a specific artery (AICA), not just a labyrinth. New vertigo with any other neurological sign — dysarthria, diplopia, facial numbness, limb ataxia — is a posterior stroke until proven otherwise, no HINTS needed. And in the elderly or vasculopath, keep the threshold to escalate low. Verify against current local stroke protocols.

Spinal Cord Syndromes

§ 26

The spinal cord is the one place in the nervous system where a small lesion produces a catastrophic, often-reversible-if-caught deficit. Acute cord compression is a time-critical emergency — the window to preserve function is measured in hours. The two questions are always: is there a sensory level, and is this getting worse?

The Cord Emergency: Compression

New bilateral leg weakness, a sensory level across the trunk, and especially bladder or bowel dysfunction with saddle (perineal) numbness point to acute cord or cauda equina compression. This is a same-hour MRI-and-neurosurgery situation. Urinary retention with overflow is the classic late, do-not-miss sign — ask about it and check a post-void residual.

The pattern of loss localizes the lesion within the cord, because the sensory tracts (§17) cross at different places:

Syndrome	Characteristic pattern
Complete transection	Loss of all modalities and motor below the level; areflexia then spasticity. A defined sensory level is the hallmark.
Brown-Séquard (hemicord)	Ipsilateral motor & dorsal-column (vibration/position) loss; contralateral pain & temperature loss. The split that only the cord can produce.
Central cord	Arms weaker than legs (“cape” distribution); often in older patients after a hyperextension neck injury.
Anterior cord	Motor and pain/temperature lost below the level; vibration/position spared (dorsal columns survive). Often a vascular (anterior spinal artery) cause.
Cauda equina	Below the cord proper: asymmetric leg weakness, saddle anaesthesia, sphincter loss. A surgical emergency.

Spinal Shock Is Not Septic Shock

Acute cord injury can cause neurogenic shock — hypotension with a paradoxically slow heart rate (loss of sympathetic tone), distinct from the fast, clamped-down picture of hypovolemic or septic shock. Mislabeling it leads to the wrong resuscitation. The combination of hypotension, bradycardia, and a sensory level should redirect your thinking to the cord.

Examine, Immobilize, Escalate

If trauma or compression is possible, protect the spine while you assess, document the highest intact level precisely (it is the baseline everyone will trend against), and escalate urgently. The deficit you record now is the line that tells the team whether the patient is improving or declining — precision here directly serves the human.

Peripheral Neuropathy & the Neuromuscular Junction

§ 27

Beyond the cord lie the nerve roots, the peripheral nerves, the neuromuscular junction, and the muscle — the lower-motor-neuron territory of §16. Most peripheral problems are chronic and benign to triage; a few are emergencies because they climb toward the muscles of breathing.

Pattern

Polyneuropathy

Symmetric, distal, “glove-and-stocking” sensory loss ± weakness, worse in the feet first. Diabetes is the commonest cause worldwide; also alcohol, B⊂1⊂2 deficiency, and drugs.

Pattern

Mononeuropathy

One nerve — carpal tunnel (median), foot-drop (peroneal), wrist-drop (radial). Maps to that nerve’s territory; usually compressive and not an emergency.

Pattern

Radiculopathy

A single nerve root — dermatomal pain/numbness and myotomal weakness, often with a lost reflex (e.g., absent ankle jerk in S1).

Junction

Neuromuscular Junction

Fatigable weakness that worsens with use — classically myasthenia gravis with ptosis, diplopia, and bulbar fatigue late in the day.

The Ascending Emergency: Guillain-Barré

An ascending, symmetric weakness with lost reflexes — often days after a gastrointestinal or respiratory illness — is Guillain-Barré syndrome until proven otherwise. The danger is upward march to the diaphragm: respiratory failure and autonomic instability. Serial vital capacity and a low threshold to escalate are the safeguards. Do not be reassured that “it’s only the legs so far.”

Myasthenic Crisis

In myasthenia gravis, weakness that spreads to swallowing and breathing is a myasthenic crisis — a respiratory emergency. Bulbar fatigue (a weak, nasal voice late in the day; difficulty clearing secretions) is the warning the airway is next. Monitor respiratory function and escalate early; the crisis can outpace expectations.

Watch the Diaphragm, Not Just the Limbs

The unifying lesson of neuromuscular emergencies is that the visible weakness (legs, eyelids, grip) is a distraction from the weakness that kills — the muscles of respiration. A rising respiratory rate, a weakening cough, a softening voice, and breathlessness when lying flat are the signs that matter. Trend breathing, and escalate before the numbers crash.

The Older Adult, Delirium & Brain-Death Basics

§ 28

Two clinical situations sit at opposite ends of the neurological exam yet share one principle: the assessment must be precise, humane, and never reduced to a reflex. The first is the older brain, where presentations are atypical and the stakes of mislabeling are high. The second is the determination of death by neurological criteria — the most consequential assessment a team ever performs.

The Neurological Exam in the Older Adult

§ 28.1

Aging changes the baseline: reflexes may be diminished, vibration sense reduced at the toes, pupils smaller, and reserve thinner. The danger is twofold — ascribing a new, treatable problem to “old age,” or ascribing reversible delirium to “dementia.”

Delirium

Acute — a medical emergency

Onset over hours to days
Attention markedly impaired; fluctuates
Consciousness/alertness altered
Reversible — find and fix the cause

Dementia

Chronic — a baseline, not an event

Onset over months to years
Attention relatively preserved early
Alertness usually normal
A new change in dementia is usually superimposed delirium

Atypical Is Typical in the Old

The older adult with a serious illness may present with only confusion or a fall — no fever with sepsis, no chest pain with a cardiac event, no headache with a bleed. “Off legs,” new confusion, or a fall is a presentation of physical illness until proven otherwise. Screen for the reversible drivers (§10) before anyone says “baseline dementia” or “just old age.” (See Module 11 — Elder Care & Delirium.)

Brain-Death Basics — Death by Neurological Criteria

§ 28.2

Death determined by neurological criteria (“brain death”) is the irreversible loss of all function of the entire brain, including the brainstem. It is a legal and clinical determination made by qualified clinicians under a strict protocol; the material here is orientation only and confers no authority to perform it.

Prerequisite

Known, Irreversible Cause

An established catastrophic cause, with reversible confounders excluded — no sedation/paralysis, normal temperature, normal electrolytes and blood pressure. Without this foundation, no exam is valid.

Coma

Unresponsive Coma

No response to noxious stimulus, no cerebral motor response. The patient is in the deepest coma, off confounders.

Brainstem

Absent Brainstem Reflexes

Absent pupillary, corneal, oculocephalic/oculovestibular, and gag/cough reflexes — the brainstem is silent throughout.

Apnoea

Formal Apnoea Test

No respiratory effort despite a documented rise in CO⊂2, performed under strict, protocolized conditions by qualified clinicians.

Dignity Is Part of the Determination

This is the most solemn assessment in medicine, and it is done with the family, not merely about the patient. Clear, compassionate communication, respect for the person’s faith and wishes, and meticulous adherence to protocol are inseparable here. The rigor protects the patient; the humanity honours them. Determination is governed entirely by jurisdictional law and institutional policy — follow them exactly.

Mimics That Must Be Excluded

Severe hypothermia, deep sedative or neuromuscular-blockade effect, profound metabolic derangement, and conditions such as locked-in syndrome can imitate the picture and must be excluded before any determination. The entire safeguard of the protocol exists to ensure the irreversible is never confused with the recoverable.

Interactive Knowledge Check

§ 29

Ten rapid single-best-answer questions spanning the module. Pick an option for each — the tool marks it immediately and explains why. This is formative self-testing to consolidate the material; the graded competency check follows in §32.

Interactive Clinical Partner

Module 08 — Self-Test

Choose the best answer for each item. Correct answers turn green with a brief explanation; try again on any you miss. Your running score updates live.

0/10

Begin the self-test

0 of 10 answered

Formative self-assessment only. It does not record a grade and does not confer CE credit; the graded Competency Assessment is in §32. Verify all clinical thresholds against current local protocols.

At-a-Glance: Time-Critical Neuro Reference

§ 30

One table to anchor the bedside. Each row pairs a finding with the immediate concern and the first move — built to be read in seconds when the clock is running. Confirm every management step against your current local stroke, seizure, and escalation protocols.

Finding at the bedside	Think first	Immediate move
Any one BE-FAST sign (Balance, Eyes, Face, Arm, Speech)	Acute stroke until proven otherwise	Activate stroke pathway; fix last-known-well time; check glucose; keep NPO^[2]
Focal deficit that fully resolves with dextrose	Hypoglycemia — the great stroke mimic	Treat per protocol; re-examine; a resolved deficit still needs a cause
GCS ≤ 8, or a drop of ≥ 2	Airway at risk / possible herniation	Call senior help now; protect airway; oxygen; urgent imaging^[1]
New fixed, dilated pupil	Third-nerve compression / rising ICP	Herniation emergency — escalate immediately, do not chart-and-wait
Facial weakness, forehead spared	Central lesion (stroke)	Treat as stroke call; run BE-FAST and the pathway
Facial weakness, forehead involved	Peripheral VII (Bell’s palsy)	Usually not a stroke call; examine fully and document
Seizure ≥ 5 min, or repeated without recovery	Status epilepticus	Emergency: airway, oxygen, IV access, glucose, benzodiazepine per protocol^[4]
Sudden “worst headache of life” (thunderclap)	Subarachnoid hemorrhage	Do not anchor on migraine; urgent CT and escalate
Acute, fluctuating confusion + inattention	Delirium — a medical emergency, not “agitation”	Work AEIOU-TIPS; find and fix the cause before any label

How to Read This Table

It is a screen, not a substitute for judgement. Any single “immediate move” here is the start of a pathway your facility defines — verify thresholds, drugs, and contacts against current local protocols, physician orders, and your scope of practice.

Myth vs Evidence: “It’s Probably Behavioural”

§ 30.1

The most expensive error in neuro assessment is reaching for a behavioural or “psychiatric” explanation before the reversible, metabolic causes are excluded. This is rarely malice — it is a busy reflex. Naming the reflex out loud is how careful clinicians disarm it.

The Myth

“He’s just agitated — sedate him and he’ll settle.”
“Sudden confusion in an older patient is dementia.”
“She has a psych history, so this is psychiatric.”
“The weakness resolved, so it was nothing.”
“He prays and feels heard — that belongs in the mental-status problem list.”

The Evidence

Acute, fluctuating confusion is delirium — an organic emergency; sedation hides the cause, it does not treat it^[7]
New confusion is medical until proven otherwise — glucose, oxygen, infection, drugs, electrolytes first
A prior diagnosis does not immunize a patient against stroke, hypoglycemia, or sepsis — re-examine on its own merits
A deficit that resolved (hypoglycemia, TIA, postictal) still demands a cause and a plan
Function, safety, and distress are assessed — belief content is not pathology^[5]

Root Cause, Not Label

Altered mental status is a finding, not a verdict. Reversible drivers — hypoglycemia, hypoxia, electrolyte and metabolic derangements, medications and withdrawal, infection, seizure, and stroke — come first, every time. Treat the person, not the label; find the cause and you make the human human again. (See Module 11 — Elder Care & Delirium and Module 07 — De-escalation.)

At the Bedside: What to Say During a Neuro Event

§ 30.2

A stroke, seizure, or sudden confusion is terrifying for the patient and family — and fear narrows everyone’s thinking. Calm, plain, honest words are part of the clinical intervention. Speak in short sentences; the frightened brain cannot hold long ones.

Possible stroke

Naming Urgency Without Panic

Move fast and say why — speed reassures more than false calm. Keep the patient oriented even if they cannot answer.

Say: “I think you may be having a stroke. We act quickly because fast treatment protects the brain. You are in the right place and we are with you.”Not: “Don’t worry, it’s probably nothing” — it delays the pathway and erodes trust.

During a seizure

Talking to the Family

Most of your words here are for the people watching. Narrate what you are doing and why you are not restraining.

Say: “I’m timing the seizure and keeping them safe. We don’t hold them down or put anything in the mouth — that can cause harm. Most seizures stop on their own.”Not: “Hold him still!” — restraint causes injury and helps nothing.

Postictal / confused

Orienting a Frightened Patient

Postictal or delirious patients may be scared and combative. Lower your voice, give one instruction at a time, reintroduce yourself often.

Say: “You’re safe. You had a seizure and you’re waking up. I’m your nurse. You’re in the hospital and I’m staying right here.”Not: “Calm down” or “You’re being difficult” — it reads as threat to a recovering brain.

Faith & the person

Respecting Belief and Practice

If a patient draws on prayer or faith, meet it with respect — it is often the scaffold of their resilience, not a symptom to correct.

Say: “Would it help to take a moment for your prayer? Tell me what matters to you so we can care for the whole person.”Not: Charting a sincere belief as a finding, or debating whether it is “true.”

Communication Is Clinical

What you say shapes cooperation, consent, and how much history you can gather — and it lowers the agitation that gets mislabeled. Honesty, brevity, and respect are not bedside manner alone; they are part of a safe neurological assessment.

References & Evidence Base

§ 31

The clinical guidance in this module is drawn from peer-reviewed literature indexed by the U.S. National Library of Medicine (PubMed / PMC) and from the published guidelines of major clinical-guideline bodies. Each citation links to the source: journal articles open a PubMed title search; guideline and reference bodies link to their official pages.

Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale (Glasgow Coma Scale). Lancet. 1974. View on PubMedNLM • PubMed
Powers WJ, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke (AHA/ASA). Stroke. 2019. View on PubMedAHA/ASA Guideline • PubMed
Aroor S, et al. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke. 2017. View on PubMedNLM • PubMed
Glauser T, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults (American Epilepsy Society). Epilepsy Currents. 2016. View on PubMedAES Guideline • PubMed
Koenig HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012. View on PubMedNLM • PubMed
U.S. National Library of Medicine — MedlinePlus / StatPearls (NCBI Bookshelf). Macrocephaly. NCBI BookshelfNLM • NCBI Bookshelf
Inouye SK, et al. Clarifying confusion: the Confusion Assessment Method (CAM). A new method for detection of delirium. Ann Intern Med. 1990. View on PubMedNLM • PubMed
National Institute of Neurological Disorders and Stroke (NINDS), NIH. NIH Stroke Scale & Stroke Information. ninds.nih.govNIH / NINDS
Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009. View on PubMedNLM • PubMed

On Evidence

These sources frame the module’s practice points; they do not override your facility policy, physician orders, or local stroke and seizure protocols. Where guidelines are updated, follow the most current version published by the responsible body.

Competency Assessment

§ 32

Fifteen questions. Pass threshold: 11/15 (73%) for CE credit (upon accreditation approval). For rapid formative practice, see the interactive self-test in §29.

Name the three components of the Glasgow Coma Scale and the point range of each. What total defines severe?

Why should you always report GCS components (E, V, M) rather than just the total?

What does BE-FAST stand for, and what does it add over the original FAST screen?

Why is the last-known-well time more important than the time symptoms were noticed?

Define status epilepticus and state the first emergency steps.

A patient has facial weakness. How does forehead sparing change your interpretation and pathway?

List four reversible causes of altered mental status you must exclude before a “psychiatric” label.

A patient says they pray and feel God answers. What three things do you assess — and what do you not assess?

What features make a larger-than-average head reassuring rather than concerning?

Q10

Why is a single fingerstick glucose mandatory in every suspected stroke and every seizure?

Q11

Contrast upper- and lower-motor-neuron weakness across tone, reflexes, the plantar response, and wasting. Which pattern includes a Babinski sign?

Q12

A patient has a dense MCA-territory deficit with global aphasia. Which hemisphere is most likely involved, and why does “the deficit resolved” after a transient version still demand urgent assessment?

Q13

List four SNNOOP-type headache red flags, and name the diagnosis each is screening for.

Q14

A patient with continuous vertigo has a normal head-impulse test, direction-changing nystagmus, and skew deviation. Is this HINTS pattern reassuring or concerning, and what does it suggest?

Q15

Name the cauda-equina red flags that mandate an emergency MRI, and state why determination of death by neurological criteria must exclude hypothermia, sedation, and metabolic derangement first.

Accreditation & Faculty

§ 33

Accreditor	Status
ANCC (American Nurses Credentialing Center)	Application pending
ACCME (Accreditation Council for Continuing Medical Education)	Application pending
CARNA (College of Registered Nurses of Alberta)	Application pending
CPSA (College of Physicians & Surgeons of Alberta)	Planned

Course Director: WestNet Medical Clinical Education Division
Publication: WestNet Medical Publications • WestNet Catalog 731985456628 • ISBN 978-0-XXXXX-XXX-X (Pending)
Platform: WestNet Unified Health Platform / HealthOS v3.6

Glossary

Ref

AEIOU-TIPS	Bedside mnemonic for the reversible causes of altered mental status: Alcohol, Electrolytes/Endocrine, Insulin, Oxygen/Opioids, Uremia, Trauma/Temperature, Infection, Poisons, Stroke/Seizure/Structural.
AVPU	Rapid level-of-consciousness gate: Alert, responds to Voice, responds to Pain, Unresponsive. A quick screen before formal GCS.
BE-FAST	Stroke recognition screen: Balance, Eyes, Face, Arm, Speech, Time. Adds Balance and Eyes to FAST to catch posterior-circulation strokes.
Delirium	Acute, fluctuating disturbance of attention and awareness from an underlying medical cause. A medical emergency, frequently mislabeled as agitation or dementia.
Dysmetria	Inaccurate, over- or under-shooting movement on finger-to-nose or heel-to-shin testing; a cerebellar sign.
Glasgow Coma Scale (GCS)	Reproducible measure of consciousness scoring Eye (1–4), Verbal (1–5), and Motor (1–6), total 3–15. Always report components.
HealthOS	WestNet’s unified clinical platform for ER, inpatient, pharmacy, labs, and mental health across Canada and the USA.
Last-known-well	The last time the patient was confirmed at their neurological baseline; sets the treatment window for stroke therapies.
Macrocephaly	Head circumference above roughly the 97th percentile. Most often a benign, familial trait in a healthy person — a measurement, not a diagnosis.
Pronator drift	Drifting and pronation of an outstretched arm with eyes closed; a sensitive early sign of subtle upper-limb weakness.
Status epilepticus	A seizure lasting ≥ 5 minutes, or repeated seizures without recovery between them. A neurological emergency requiring immediate treatment.
Time is brain	The principle that neurons are lost every minute reperfusion is delayed in ischemic stroke — speed of recognition and treatment determines outcome.

Related WestNet Medical Modules

This module is part of a 12-title series. See also: Module 02 — Cardiovascular Physiology, Module 07 — De-escalating Aggression / Observe the Human, and Module 11 — Elder Care & Delirium.

Neurological Assessmentat Bedside

Continuing Education Information

Program Preface

The Focused Bedside Neuro Exam

Level of Consciousness

Pupils & Cranial Nerves

Motor & Sensation

Coordination & Gait

Level of Consciousness & the Glasgow Coma Scale

Glasgow Coma Scale Calculator

Pupils & the Cranial Nerve Screen

Size, Equality, Reaction

Vision & Eye Movements

Face: Sensation & Movement

Swallow, Voice, Tongue

Power, Sensation & Coordination

MRC Grading 0–5

Pronator Drift

Gross Screen

Cerebellar Signs

Stroke Recognition — FAST & BE-FAST

BE-FAST Recognition Tool

Seizure Recognition, First Aid & Status Epilepticus

Altered Mental Status: A Structured Workup

Reversible & Medical, Not “Psychiatric” — The Differentiator

Points toward a Medical / Reversible Cause

Points toward a Primary Psychiatric Picture

The Mental-Status Exam: Faith Is Not Pathology

Function

Safety

Distress

Human Variation: When the Head Is Larger Than Average

The Acute Bedside Neuro Ladder

The Cranial Nerves I–XII in Detail

Motor Patterns: Upper vs Lower Motor Neuron & Reflexes

Upper Motor Neuron (UMN)

Lower Motor Neuron (LMN)

Absent

Normal range

Brisk

Clonus

The Sensory & Coordination Exam in Depth

Spinothalamic — Pain & Temperature

Dorsal Columns — Vibration, Proprioception, Fine Touch

Stroke Syndromes & Vascular Territories

Aphasia or Neglect

Small-Vessel Strokes

The Dangerous Misses

You Cannot Tell Without a Scan

Stroke Severity: NIHSS-Lite Estimator

Transient Ischemic Attack & Transient Deficits

Seizure Types & Classification

Focal vs Generalized

Aware vs Impaired

Headache: Red Flags & Primary Types

CNS Infection: Meningitis & Encephalitis

Raised Intracranial Pressure & Herniation

The Warnings That Buy Time

The Blown Pupil

Abnormal Posturing

Cushing’s Triad

Dizziness & Vertigo: The HINTS Exam

Spinal Cord Syndromes

Peripheral Neuropathy & the Neuromuscular Junction

Polyneuropathy

Mononeuropathy

Radiculopathy

Neuromuscular Junction

The Older Adult, Delirium & Brain-Death Basics

The Neurological Exam in the Older Adult

Delirium

Dementia

Brain-Death Basics — Death by Neurological Criteria

Known, Irreversible Cause

Unresponsive Coma

Absent Brainstem Reflexes

Formal Apnoea Test

Interactive Knowledge Check

At-a-Glance: Time-Critical Neuro Reference

Myth vs Evidence: “It’s Probably Behavioural”

Neurological Assessment
at Bedside