Introduction

There is little point in having a sound theoretical knowledge of the constituent features comprising drug-related extrapyramidal disorders and the issues surrounding them, if one is a novice in their clinical evaluation. Hands-on expertise is an essential clinical skill.

Of all the components of medical evaluation, the neurological examination is the one about which general clinicians are invariably least confident. Even those junior doctors who can wield a stethoscope with at least a semblance of confidence turn into quivering wrecks when presented with a tendon hammer. If asked to evaluate extrapyramidal status, most would barely get past a tentative tweaking of the wrists as a token evaluation of rigidity. While some might view neurological skills as some sort of medical astrophysics, the routine neurological examination is, in fact, less taxing intellectually than it is physically.

The key to gaining useful information is to approach the examination systematically. Too often, non-neurologists ‘do’ a cranial nerve or two, test for a bit of weakness, tap a couple of tendons, check a few more cranial nerves and so on – ending with the plantars, the international neurological ‘full-stop’! Such a confused approach to examination produces understandably confused results. This is the major reason why neurologicals performed by non-neurologists are often sorry affairs – this and, of course, ignorance.

Ignorance must not be underestimated. At an MRCP exam, the author recalls a cocky candidate being asked by a neurologist of international repute to exam infraspinatus.