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  <head>
    <title>031-02 Bedside localisation, examination reliability, and test selection</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Bedside localisation and test selection">
      <outline text="Narrative to anatomical model">
        <outline text="Summary: failed function, distribution, onset">
          <outline text="More localising than a diagnostic label"/>
        </outline>
        <outline text="Identify instability first">
          <outline text="Airway, respiratory weakness, status, cord compression"/>
          <outline text="Changes order and speed of assessment"/>
        </outline>
      </outline>
      <outline text="History and episodes">
        <outline text="History may localise better than hurried exam"/>
        <outline text="Positive phenomena: excess or spreading activity"/>
        <outline text="Negative phenomena: loss of function">
          <outline text="Distinction helpful but not absolute"/>
        </outline>
        <outline text="Migraine aura spreads over minutes"/>
        <outline text="Embolic ischaemia starts abruptly"/>
        <outline text="Presyncope: warmth, sweating, recovery supine"/>
        <outline text="Convulsive movements can occur in syncope"/>
        <outline text="Confusion, tongue injury, rhythmic activity: seizure"/>
      </outline>
      <outline text="Reliability and mental status">
        <outline text="Ensure hearing, vision, language, wakefulness"/>
        <outline text="Record pain, fear, sedation, effort limits"/>
        <outline text="Repeat after repositioning or distraction"/>
        <outline text="Serial examination reveals change"/>
        <outline text="Orientation relatively insensitive"/>
        <outline text="Attention before delayed recall"/>
        <outline text="Cues and recognition: retrieval versus encoding"/>
      </outline>
      <outline text="Vision and eye movements">
        <outline text="Monocular loss: anterior to chiasm"/>
        <outline text="Bitemporal loss: chiasm"/>
        <outline text="Homonymous defect: contralateral retrochiasmal"/>
        <outline text="Red desaturation and afferent pupillary defect"/>
        <outline text="Anisocoria in light and dark identifies pathway"/>
        <outline text="Binocular diplopia means misalignment"/>
        <outline text="Third nerve with pupil: compression concern"/>
        <outline text="Sixth nerve may be non-localising"/>
        <outline text="Internuclear ophthalmoplegia: medial fasciculus"/>
      </outline>
      <outline text="Face, bulbar, and ventilation">
        <outline text="Forehead sparing not infallible"/>
        <outline text="Taste, tears, hyperacusis refine facial level"/>
        <outline text="Wet voice, weak cough, drooling: aspiration risk"/>
        <outline text="Tongue wasting, fasciculation: LMN"/>
        <outline text="Spastic tongue, brisk jaw: corticobulbar"/>
        <outline text="Ventilatory failure without breathlessness">
          <outline text="Saturation normal until CO2 retention advanced"/>
          <outline text="Measure forced vital capacity serially"/>
        </outline>
      </outline>
      <outline text="Motor and reflexes">
        <outline text="Pronator drift detects subtle pyramidal weakness"/>
        <outline text="Position joint, stabilise, then grade"/>
        <outline text="Proximal symmetric weakness: muscle, many mimics"/>
        <outline text="Fatigable ptosis, diplopia: junction failure"/>
        <outline text="Reflexes read as a pattern">
          <outline text="Asymmetry beats absolute briskness"/>
          <outline text="Absent ankle with distal loss: neuropathy"/>
        </outline>
        <outline text="Acute cord injury may be flaccid first"/>
        <outline text="Brisk jaw with limb UMN: above cervical cord"/>
      </outline>
      <outline text="Sensory testing">
        <outline text="Answer an anatomical question"/>
        <outline text="Move from normal toward abnormal"/>
        <outline text="Pinprick small fibre, vibration dorsal column"/>
        <outline text="Sensory level may lie below lesion">
          <outline text="Check from both directions"/>
        </outline>
        <outline text="Irregular stimuli, non-leading choices"/>
        <outline text="Reproducible boundary over single error"/>
      </outline>
      <outline text="Gait">
        <outline text="Hemiparetic circumduction, spastic scissoring"/>
        <outline text="Foot drop: high-stepping gait"/>
        <outline text="Cerebellar broad base, sensory ataxia without vision"/>
        <outline text="Parkinsonism: short stride, poor turning"/>
        <outline text="Frontal: initiation failure despite strength"/>
      </outline>
      <outline text="Localisation and negative findings">
        <outline text="Built from concordant findings"/>
        <outline text="Plexus spans nerves, not length-dependent"/>
        <outline text="Mononeuropathy may need electrodiagnosis"/>
        <outline text="Normal early reflexes or imaging do not exclude"/>
        <outline text="Consider multiple lesions or systemic process"/>
      </outline>
      <outline text="Investigations and synthesis">
        <outline text="Diffusion detects acute infarction"/>
        <outline text="Imaging causal only when anatomy aligns"/>
        <outline text="Choose CSF tests before the puncture"/>
        <outline text="Do not delay antimicrobials"/>
        <outline text="Prolonged EEG raises yield"/>
        <outline text="Early electromyography may miss denervation"/>
        <outline text="State best localisation and dangerous alternatives"/>
        <outline text="Record conditions so others can compare"/>
      </outline>
    </outline>
  </body>
</opml>
