Delayed orthostatic hypotension

Every neurologist will recall the humbling experience during training of having presented a patient’s neurologic examination as unremarkable, only to return to the bedside with the professor, who adroitly elicits the cardinal localizing sign that makes sense out of the patient’s narrative. Such experiences inspire us to continue learning and to cultivate the same keen attention to detail that Dr. Watson admired in Sherlock Holmes. “The world is full of obvious things,” said Holmes, “which nobody by any chance ever observes.”¹

The art of eliciting the cardinal neurologic sign is a matter not only of knowledge but also of patience. It may be asking the patient to gaze upward a little while longer to uncover the fatigable ptosis of myasthenia gravis. It may be having the patient extend the arms a minute longer until asterixis appears as a hallmark of hepatic encephalopathy. It may be watching the muscles a while longer to visualize the slight fasciculations of early ALS. It may be observing the stuporous patient a few minutes longer to notice the oral automatisms that signal nonconvulsive status epilepticus. It may be listening to the patient a little while longer to allow opportunity for a hesitantly …