Step Four Neurological Examination and Confirmatory Testing

Check for mental status changes, seizure-like presentations, brainstem signs (e.g., nystagmus), motor and sensory neuropathies, and changes in reflexes. If appropriate, identify soft neurological signs for the purposes of later monitoring. Separately address cerebellar signs (ataxia, dystaxia, or dysmetria), as they may shed light on the identity of certain toxic agents. Exclude common diagnoses and differentiate between possible contributing factors such as peripheral neuropathy in patients with both chemical exposure and diabetes or alcoholism.

Neurophysiological testing provides irreplaceable data useful for assessment of the current condition and for neurological monitoring. Additional information should be obtained from imaging and neuropsychological tests, as appropriate. Industrial hygiene tests may be necessary, especially if legal issues are anticipated.

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