Moore1

Appendix e-1. The survey instrument

Think about recent situations when you have been seeing new patients in the out-patient clinic. Suppose you have taken the history and now will examine the patient. If the history suggests that the patient is unlikely to have findings on the neurological exam, and you are using the exam to confirm your impression that the patient is neurologically normal, what would you do?
The components of a reasonably “complete” neurological examination are listed on the next page. Consider your own usual practice in the scenario described above (you want to reassure yourself that the patient is indeed normal), and rate each neurological examination item according to how likely you are to include it. Use the following scale:
I rarely, if ever, include this.
I include sometimes, but less than 80% of the time.
I include this at least 80% of the time.
I will always or almost always include this.

1. What do you do to reassure yourself the patient is normal: Mental Status.

Rarely if ever / Sometimes (<80%) / Often (>80%) / Always or almost always
Folstein mini-mental status test (or equivalent formal test)
Tests of language
Tests of praxis, drawing, executive function

2.What do you do to reassure yourself the patient is normal: Cranial Nerves

Rarely if ever / Sometimes (<80%) / Often (>80%) / Always or almost always
Testing smell
Visual fields
Visual acuity
Fundoscopy
Pupillary reflex
Pursuit eye movements
Saccadic eye movements
Corneal reflex
Facial muscles
Gag reflex
Hearing
Palate movement with phonation
Articulation
Sternocleidomastoids
Tongue

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3. What do you do to reassure yourself the patient is normal: Motor Exam.

Rarely if ever / Sometimes (<80%) / Often (>80%) / Always or almost always
Gait
Heel walking
Toe walking
Tandem gait
Rising from squatting or kneeling
Tone in arms
Tone in legs
Pronator drift
Rapid alternating movements in upper limbs
Rapid alternating movements in lower limbs
Finger-to-nose
Heel-shin
Specific muscle power testing in upper limbs
Specific muscle power testing in lower limbs

4. What do you do to reassure yourself the patient is normal: Reflexes.

Rarely if ever / Sometimes (<80%) / Often (>80%) / Always or almost always
Biceps reflex
Brachioradialis reflex
Triceps reflex
Knee jerk
Ankle reflex
Plantar response
Primitive reflexes (e.g., palmomental, grasp)
Abdominal reflexes

5. What do you do to reassure yourself the patient is normal: Sensation.

Rarely if ever / Sometimes (<80%) / Often (>80%) / Always or almost always
Vibration sensation
Pinprick sensation
Thermal sensation
Proprioception
Romberg

Note: Light touch was added to the survey based on feedback received after the first Delphi round with McGill neurologists. Light touch was included on the survey used in rounds two and three of the Delphi process and on the survey given to Canadian neurologists. McGill medical students received the original version of the survey that did not include light touch. All versions of the survey also included demographic questions (not shown).