Neurological examination, semiology and topographic diagnosis
This domain tests the bedside method: whether you can examine systematically, describe findings in accepted terms, and translate them into a lesion localisation. Questions often present a short vignette and ask for the most likely site, not the diagnosis.
Structured examination
- Consciousness and brainstem: Glasgow Coma Scale (E4 V5 M6), pupil size and reactivity, eye position and movements, oculocephalic and corneal reflexes.
- Cranial nerves I–XII: fields, fundoscopy, ptosis, diplopia in nine positions, facial symmetry (central versus peripheral), palate, tongue, hearing.
- Motor: tone, MRC power 0–5, reflexes graded 0–4+, plantar responses, clonus.
- Coordination and gait: finger–nose, heel–shin, rapid alternating movements, Romberg, gait with and without aid.
- Sensation: light touch, pinprick, 128 Hz vibration, joint position, plus cortical tests (graphesthesia, stereognosis, extinction).
- Cognition and speech: MMSE or MoCA, frontal assessment, naming, repetition, comprehension, reading, writing.
Upper versus lower motor neuron signs
UMN: spasticity, hyperreflexia, Babinski, no fasciculations, mild disuse atrophy. LMN: flaccidity, areflexia, fasciculations, marked atrophy. Central facial palsy spares the forehead because the upper face has bilateral cortical innervation.
Aphasia patterns
Broca (non-fluent, repetition impaired, comprehension preserved), Wernicke (fluent, comprehension impaired, repetition impaired, anosognosia), conduction (fluent, comprehension intact, repetition impaired), global, and the transcortical variants in which repetition is spared.
Brainstem syndromes
Weber (ipsilateral III palsy plus contralateral hemiparesis, midbrain), Millard-Gubler (ipsilateral VI and VII plus contralateral hemiparesis, pons), Wallenberg (ipsilateral Horner, ataxia, facial pain loss; contralateral body pain loss; dysphagia, medulla). Internuclear ophthalmoplegia (MLF) indicates a lesion between the abducens and oculomotor nuclei, typically demyelinating in the young and vascular in the elderly.
Worked example
A right-handed patient has sudden non-fluent speech, impaired repetition, preserved comprehension, and right hemiparesis. Impaired repetition with preserved comprehension localises to the left inferior frontal gyrus (Broca area, superior division of the MCA), not to the peripheral speech apparatus. Adding impaired comprehension would make it global aphasia.
Traps
Calling dysarthria aphasia; missing left hemineglect in right hemisphere lesions; testing vibration without confirming the patient understands; diagnosing peripheral facial palsy when the forehead is spared; ignoring hypoglycaemia and postictal states as stroke mimics.