Clinical Skills NEURO - History Taking

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Clinical Skills Center

Faculty of Medicine Pelita Harapan University

Karawaci – Tangerang Semester V

2013

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CEREBROVASCULAR DISEASE

MUSCLE WEAKNESS

During first part of this semester, the focus will be on aspects of the medical interview and physical examination that relate to the neurological system. The course material is designed to link with your studies in the basic sciences of this body system. You will also have the opportunity to develop your communication skills. This will involve learning how to identify and respond to emotional issues that arise during a medical interview and to communicate effectively with patients who have hearing or cognitive impairment.

The first tutorial in this series focuses specifically on muscle weakness as a presenting problem. It also provides an introduction to the basic examination of the neurological system, with emphasis on testing motor strength and co-ordination of the lower limbs.

Muscle weakness

There are three components to gathering information from a patient whose presenting problem is weakness:

(i) Does the patient have true muscle weakness? Firstly, it is important to clarify whether the patient has true muscle weakness, or whether they are describing a loss of physical or emotional energy, or another non-neuromuscular problem such as joint pain or stiffness. People who have motor weakness are not able to perform specific activities, such as standing up from a squatting position or moving a limb.

(ii) Where is the weakness?

Secondly, the pattern of the weakness needs to be established, in order to help determine the likely site of the underlying pathology. Muscle weakness can be due to a primary problem involving muscles or it can be due to conditions affecting the neuromuscular junction, peripheral nerves, spinal nerve roots, anterior horn cells or the corticospinal tracts. It is therefore important to find out whether the weakness affects all muscle groups or is confined to a particular area of the body. If the weakness is generalised, this may indicate a problem such as myasthenia gravis, which affects the neuromuscular junction. If the weakness is not generalised, the next step is to find out if it is symmetric or asymmetric. Asymmetric weakness is usually caused by conditions that affect the central or peripheral nervous systems. If the weakness is symmetric, it can be classified as proximal or distal or localised. Proximal weakness is usually caused by primary muscle disorders affecting the axial muscle groups, that is, the deltoids or the muscles responsible for hip flexion. Distal weakness, in contrast, mainly affects the hands or feet and may be caused by peripheral neuropathy or motor neuron disease.

(iii) What is the cause of the muscle weakness?

Thirdly, information needs to be gathered to help find out the underlying cause. There are many

causes of muscle weakness, including immunological conditions, malignancy, vascular events,

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drugs or metabolic disorders. At this level of your training, you are not expected to be able to

determine the underlying cause of a patient’s muscle weakness.

Applying the cardinal features framework to muscle weakness

Cardinal

feature

Cardinal

feature

Notes

Site

Where is the weakness? Which muscle groups are weak?

Is the weakness generalised or localised? If localised, is it symmetric or asymmetric? If symmetric, is

it proximal, distal or in another specific pattern?

Quality This cardinal feature is not usually helpful.

Severity The severity can be quantified by determining what function the patient has in the affected area. Can

the patient move the affected area against gravity or is it paralysed? What can’t the patient do

because of the weakness?

Time course This is an important feature as it can help to point to the underlying cause. Did the weakness come on

suddenly? Does it fluctuate? Is it worse at the end of the day?

Context Ask the patient if there was anything in particular they noticed at the time the weakness started.

Aggravating

factors

Is there anything that makes the weakness worse? Is there anything that triggers episodes of

weakness?

Relieving

factors

Is there anything that seems to relieve the weakness?

Associated

features

As you learn more about diseases that cause muscle weakness, you will be able to ask specific

questions that can help point to a diagnosis.

At this stage, you could ask about whether the patient has any pain in their muscles or whether the

weakness is associated with other neurological symptoms, such as sensory changes. You will learn

about sensory symptoms in the next tutorial.

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Case Study 4.0

Bill Russell, a 57-year old divorced former house painter, has been admitted to hospital with muscle weakness for further investigation. He is being interviewed by Nick Modzrewski, a second year medical student. Watch the interview and write down the cardinal features of Mr Russell’s presenting problem. De-

scribe the pattern of his muscle weakness.

Building your communication skills

During previous semesters, you learned about basic communication skills, such as active listening, clarification and effective questioning, which enhance doctor-patient interaction. You also learned how to build rapport with a patient and conduct an interview. During the next few tutorials, emphasis will be placed on identifying and responding to a patient’s physical or emotional discomfort during a medical interview. Acquiring communication skills at the same time as you learn about the content of clinical medicine has been shown to augment the application of these skills in real-life practice.

It is important during a medical interview to demonstrate to a patient not only that you are listening carefully to the information they are conveying, but also that you appreciate the physical or emotional discomfort or distress that they might be experiencing. This has been shown to be associated with higher patient satisfaction with the quality of their care. Patients are also more likely to provide further information if they know that you are interested in their symptoms and willing to understand their experience of illness.

Acknowledging verbal expression of physical discomfort

A patient presenting with a symptom will usually describe some degree of physical discomfort. In Case Study 4.01, Bill Russell described the discomfort he experienced when he had a fall due to his muscle weakness. Nick Modzrewski acknowledged this discomfort during his interview with Mr Russell:

MR RUSSELL: … and then yesterday, I had another fall … just outside the market … I knocked myself around a bit … hurt both knees … and scraped my right arm … nothing broken, like … but there was a bit of bleedin’ …

NICK: That doesn’t sound too good …

MR RUSSELL: … well, it shook me up a bit … and I couldn’t get up so someone called an ambulance and they brought me here …

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Acknowledging non-verbal expression of physical discomfort

A patient may also express physical discomfort in a non-verbal manner. Observe the patient’s body language and acknowledge any discomfort it may convey.

It is important to acknowledge the degree of pain that a patient is experiencing. For example:

STUDENT: Does the pain go anywhere else?

PATIENT: Not really … no …

STUDENT: OK. You do seem to be in a lot of pain ….

These communication skills may seem quite straightforward but can be difficult to apply when you are also concentrating on the content of the interview. It is therefore important that you practice these skills as much as possible when interviewing patients. It is also important that you apply them in a way that reflects your personal style of communication.

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Role-play D: Muscle Weakness

Eddie Bell

You are Eddie Bell, aged 68 years, and you have come to the doctor today because you have been having weakness in your left arm and leg.

Opening statement: I think something is going wrong with my brain, Doc. I keep getting these funny turns and I can’t move my arm and leg properly. My father had a stroke and I’m worried that I might be having one too.

If asked to elaborate, say: Well, a couple of times I’ve lost the power in my arm and leg and they don’t seem to be able to do what I want them to do. I almost fell over the last time it happened.

Site: It’s my left arm and left leg that are affected.

Quality: When it happens, my left arm and leg just feel really heavy and dead. It’s a real effort to lift them, or even move them at all.

Severity: It’s pretty bad - I feel really weak when it happens. One time I dropped my mug of tea when I went weak and almost burned myself. Then another time I almost fell over, but luckily I had time to sit down before my leg gave way completely.

Time Course:

If asked when this first started, say: 2 weeks ago.

If asked about the onset: Each episode has a very sudden onset and offset.

If asked how often the episodes occur: It’s happened about 4 times in the last two weeks.

If asked about the duration of an episode, say: It only seems to last for about 10 minutes, but it feels like forever. Each time I think I’m having a stroke.

Context: I can’t think of anything different that I’ve been doing. I feel pretty good usually.

Aggravating factors: Nothing seems to bring it on

Relieving factors: Nothing helps when it comes on. It just seems to pass of it’s own accord.

Associated features: One time my wife said that my mouth was drooping a bit when I felt weak. I felt like it was a bit difficult to talk properly then too, but then everything came back to normal again, thank goodness.

Past History: High blood pressure and Diabetes. You had a heart attack last year

Smoking: Ex-smoker - you smoked for 20 years but you stopped last year when you had the heart attack. Your doctor told you to stop.

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Medical Interview Assessment Form

Opening segment of interview Yes No

Greets the patient Introduces self Explains status Uses an open-ended question Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site Location Radiation

Quality Severity Time course

Onset Offset Duration Temporal profile Periodicity

Context Relieving factors Aggravating or precipitating factors Associated features

Communication Skills Done Well Adequate Needs

improvement Demonstrates active listening skills Allows patient to speak without interruption Clarifies information with patient Uses questions effectively Does not use jargon or technical language Uses open questions before moving on to more

focussed questions

Interview Management Done well Adequate Needs

Improvement Is systematic with questioning Directs the interview effectively Uses restatement and/or paraphrasing Helps the patient stay relevant Uses internal summaries Conducts interview fluently

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CRANIAL NERVE DISORDER

HEADACHE Headache is one of the most common medical problems in the community. Most people will have experienced a headache at some time in their life. The majority of headaches are benign and self-limiting, although they can cause significant morbidity and disruption to activities of daily living. When a patient presents with a headache, the most important step is to assess whether there might be a serious or life-threatening cause1,2. Conditions such as brain tumours, sub- arachnoid haemorrhage, stroke and meningitis can present with headache. Associated features such as acute onset, progressive pattern, associated neurological features, altered conscious state, fever and neck stiffness, or a history of cancer are warning signs that a serious cause may be present. The focus of this tutorial is on chronic headaches where a serious underlying cause has been excluded. There are two main types of chronic headache: (i) tension-type headache (TTH) and (ii) migraine. Other less common causes of primary chronic headache exist but you do not need to know about these at this level of your training. You also do not need to know about the details of secondary headaches, that is, those that are due to another medical problem, such as dysfunction of the temporo-mandibular joint, drugs or sinusitis. Tension-type headache is the most common type of chronic headache3. The underlying cause of this type of headache is not exactly known. They are usually bilateral and of mild to moderate intensity, although sometimes can be severe. The character of a tension-type headache is typically described as being like a pressure or a band around the head or a dull ache. There are usually no associated features, apart from muscle tenderness of the head, neck or shoulders. Tension- type headaches are usually classified according to how frequently they occur. An infrequent TTH occurs less than one day per month, frequent episodic TTHs occur during 1 – 14 days per month, and chronic TTH is used to describe headaches that occur 15 or more days per month. TTH can be precipitated by stress or certain movements of the head and neck. Chronic headache due to migraine is also common, peaking in the fourth decade and occurring more frequently in women than men4. The underlying cause is not known but it is thought to be due to neuronal dysfunction that leads to vascular changes, both intra- and extra-cranially. A migraine headache is typically unilateral in site, but about 30% are bilateral. It is usually throbbing in character, with gradual onset and slow offset, and is often associated with nausea, vomiting, photophobia and phonophobia. Relief is often gained by lying down in a dark, quiet room. Premonitory symptoms include fatigue, difficulty with concentration, nausea, neck stiffness and blurred vision. Migraine headache is often preceded by an aura, a complex of neurological symptoms probably related to a decrease in cortical blood flow. Symptoms of an aura include visual or speech disturbance, sensory symptoms or motor weakness.

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Cardinal feature

Migraine

Tension-type headache (TTH)

Site Unilateral in about 70% of cases Usually bilateral

Quality Dull and throbbing Pulsating

Non-throbbing Band like, may be described as

a pressure or tightness

Severity Moderate to severe May disrupt daily activities

Mild to moderate, can be severe Usually does not stop the person

from going about their normal

activities

Time course Gradual onset with crescendo pattern; slow offset

Often begins in the mornings although can occur at any time of the

day

Lasts for up to 3 days

Waxes and wanes Variable duration

Context May occur in the context of a stressful life situation May occur in the context of a

stressful life situation

Aggravating factors

May be precipitated by routine physical activity

Stress, menstruation, oral contraceptives, fatigue, lack of sleep,

certain foods, additives to wines

Not precipitated by routine

physical activity

Stress, certain head and neck

movements may trigger

headaches

Relieving factors Analgesic medication Usually better if lies down in dark room with minimal noise

Analgesic medication

Associated features

Nausea, vomiting, photophobia and phonophobia

May be preceded by aura, consisting of visual or speech disturbance, motor weakness and sensory changes

No associated features, except for mild muscle tenderness

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Case Study 4.04

Sally Lewis, a 35-year old mother of two young

children who works part-time in customer serv-

ice, has been referred to Neurology Clinic for as-

sessment of her chronic headaches. She is being

interviewed by Nick Modzrewski, a second year

medical student.

Watch the interview and write down the cardinal

features of Mrs Lewis’s presenting problem. Dis-

cuss the features of her presentation that help to

differentiate between migraine and tension-type

headache.


Identifying and responding to anxiety

The focus of this tutorial is learning how to respond to a patient who demonstrates anxiety during an interview. Anxiety is a common emotional response to being unwell or having treatment in the health care system. It is important that you learn to identify and respond to anxiety in the medical setting. Firstly, it may represent an organic problem such as an overactive thyroid gland, or a psychiatric or psycho-social problem that needs intervention. Secondly, dealing with a patient’s anxiety can help to build rapport and may facilitate the interview process. Thirdly, it can be therapeutic for the patient to express their anxiety and to have someone acknowledge their concerns. Identifying anxiety in a patient may be quite straightforward if he or she verbally communicates this to you during the interview. Alternatively, you may notice signs of anxiety, such as fidgeting, rapid speech, sighing frequently, sweating or tremour. If a patient seems to be anxious, don’t ignore it. If you do not address a patient’s anxiety, it may unnecessarily prolong the interview process or you may not elicit important information needed to establish the diagnosis or make a management plan. Try to establish why the patient is anxious. Sometimes the reason will not be obvious. Encourage the patient to talk about their anxiety, but don’t pry. Do not dismiss the patient’s concerns as being trivial. Provide reassurance if this is appropriate. Do not transmit your own anxiety about the interview to the patient as this may escalate the situation.

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Role-play C: Headache Background Joe Martinelli, a 40year old engineer, has come to see his doctor with new onset headaches. Opening statement I’ve started getting bad headaches. They’ve been coming for about four weeks now and they are really starting to get me down. Site: They are always on the right side. They usually start around my eye. If asked if the pain goes anywhere else, say: It seems to go deep behind my eye and it often moves over here. Rub over your right temple area. Quality: I’m not sure how to describe it. If you are offered a menu of choices, say: That it is a throbbing pain. Severity: It is excruciating when it is present. I have to get up and walk around to try to distract myself from the pain. It stops me from doing anything. If asked to say how bad the pain is on a scale of 0 to 10, say: It’s probably about a 9 or 10 at its worst. Time Course: The headaches usually come on suddenly. I don’t get any warning and then bang, suddenly it’s there… it gets really bad after only a few minutes. It usually lasts a couple of hours and then it dies away. I’ve been getting them about once every day or so. Usually the same time, late in the evening. Context: I’ve noticed that they seem to come on more often when I’ve had a few glasses of wine, so I’ve stopped drinking it with my evening meal. Relieving Factors: I’ve tried taking paracetamol but that does nothing … Aggravating factors: I haven’t noticed anything in particular. Alcohol seems to bring them on but once they are present, they are really bad whatever I do. Associated features: When I get the headaches, I also get a watery eye and my nose feels stuffy. Sometimes I feel sweaty and sick in the stomach.

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Role-play D: Headache Background You are Rebecca/ Rob Damitri, aged 24 years, a PHD student in economics. Opening statement I’ve been getting a lot of headaches lately and it’s really getting me down. I’ve got a lot going on right now and I can’t afford to be out of action with these headaches. If asked to elaborate: They are coming more and more often, I feel like I always have one. It’s pretty wearing. Site: I feel it right around my head, on both sides, like a tight headband. Quality: It’s like a pressure feeling, right around my head. If asked: It is not throbbing. Severity: It’s not bad enough to put me to bed - I’m still carrying on working on my PHD. But it’s still pretty painful. If asked to rate out of 10: 3-4 out of 10. Time Course: I’ve had a headache from most days for the last month. If asked about progression over time: They are much the same as they were when they started. If asked about frequency, say: They come most days, often later in the day. Context: I’ve been working really hard on writing my thesis so I’m doing pretty long work hours, more so in the last month. I’m also working on weekends a lot, so don’t have much time for relaxation. Precipitating factors: I sometimes wonder if the headaches are brought on by sitting at my desk, but I’m not sure. Relieving factors: If I take a couple of Panadol then that usually gives me some relief. But I still feel a dull ache, even after 2 Panadol tablets. Associated features: I feel a bit sore around my neck and shoulders, like there’s a bit of tension there in the muscles.

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focussed questions



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SENSORY DISTURBANCE During the last tutorial, the focus was on muscle weakness and the motor neurological examination of the lower limbs. During this tutorial, you will learn how to interview a patient presenting with sensory disturbance and perform a sensory examination of the lower limbs. You will also have an opportunity to develop your ability to identify and respond to emotional issues that arise during a medical interview. Sensory disturbance Sensation is the process by which stimuli are detected by specialised receptors in the skin, muscles or joints and transmitted to the brain via the peripheral nervous system. The processing of this information allows the body to maintain its posture, react to pain and other noxious stimuli, and use senses such as touch and hearing to provide information about the surrounding environment. Sensation is an important part of the body’s defence system. It is a continuous and usually subconscious process. Disordered sensation, by way of contrast, can be quite intrusive and can lead to considerable disability and distress. As with other symptoms, it is helpful to have a framework when interviewing patients who present with sensory disturbance. There are three components to gathering information about this symptom:

(i) What symptoms of sensory disturbance does the patient describe? Sensory symptoms are usually divided into two main categories: positive symptoms, which are caused by heightened activity in sensory pathways, and negative symptoms, which are caused by loss of sensory function.

a. Positive sensory symptoms Patients experiencing this type of sensory disturbance may describe symptoms such as tingling, pins and needles, pricking, burning, tightness, a band-like sensation around their body, or an electric shock. They may also report pain, which is often sharp or stabbing in nature. Patients who have positive sensory symptoms often do not have a sensory deficit on physical examination. There are a number of specific terms that are used to describe positive sensory disturbances:

Term Meaning

Paraesthesia Abnormal sensation perceived without an abnormal stimulus

Hyperaesthesia Abnormal increase in sensitivity to a stimulus

Dysaesthesia All positive sensory changes, whether due to a stimulus or not (this covers both of the above

terms)

Hyperalgesia Heightened response to a noxious stimulus

Allodynia Normal stimulus felt as pain, for example, clothing brushing against body being felt as pain

b. Negative sensory symptoms

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Patients experiencing this type of sensory disturbance may describe symptoms such as numbness, coldness or loss of feeling in a particular distribution. Patients who report negative sensory symptoms often have a sensory deficit on physical examination. There are a number of specific terms that are used to describe negative sensory disturbances:

Term

Meaning

Hypoaesthesia Diminished ability to perceive pain, temperature or touch

Anaesthesia Complete inability to perceive pain, temperature or touch

Analgesia Complete insensitivity to pain

Note: If a patient has a sensory disturbance that involves the receptors in the muscles, tendons and joints that serve proprioception, then the patient may report imbalance, and unsteady gait or a lack of precision with movements. The term sensory ataxia is used to describe these symptoms.

(ii) What is the pattern of the sensory disturbance? Establishing the pattern of the sensory loss is helpful in determining the likely site of the underlying problem. Having a sound knowledge of the underlying anatomy and physiology of the neurological system facilitates this process. Find out if the sensory loss affects one side of the body, a whole limb or part of a limb. Also find out if it is symmetric or asymmetric. Some common patterns of sensory loss are: (i) A “glove and stocking” distribution due to peripheral neuropathy (ii) A dermatomal pattern due to a spinal cord or nerve root lesion (iii) An area supplied by a particular nerve (iii) A hemisensory loss, due to a lesion of the spinal cord, brain stem, thalamus or cortex

(iv) What is the underlying cause of the sensory disturbance?

Sensory changes may be due to medical conditions affecting either the central nervous system or the peripheral nervous system. Central nervous system conditions that cause sensory disturbance include cerebrovascular disease, multiple sclerosis and tumours. A wide range of conditions can affect the peripheral nervous system, including diabetes mellitus and alcohol excess. Nerve entrapment syndromes are a common cause of peripheral sensory disturbance. As you learn more about medical conditions, you will be able to ask patients specific questions in order to establish the underlying cause. You are not expected to be able to do this at this stage of your training.

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Applying the cardinal features framework to sensory disturbance

Cardinal feature

Notes

Site Where is the sensory disturbance? Does it affect one half of

the body? A whole limb? Part of a limb? Is it symmetric or

asymmetric?

Quality Establish whether the patient had positive or negative sensory

symptoms or a combination of the two.

Severity Severity can be quantified by determining the degree to

which the sensory symptoms disrupt the patient’s life.

Time course This is an important feature as it can help to point to the

underlying cause. Did the sensory disturbance come on

suddenly or over days to months? Is it worse at night?

Context Ask the patient if there was anything in particular they

noticed at the time the sensory disturbance started.

Aggravating factors Is there anything that makes the sensory

disturbance worse?

Relieving factors Is there anything that seems to relieve the sensory

disturbance?

Associated features As you learn more about diseases that cause sensory

disturbance, you will be able to ask specific questions that can

help point to a diagnosis.

At this stage, you could ask about whether the patient

has noticed any associated neurological symptoms, such

as muscle weakness or gait disturbance. If they describe

loss of sensation, enquire as to whether they have

sustained any injuries, such as ulcers or burns, as a

result.

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Case Study 4.02

Julie Davidson, a 55-year old office worker with a history of palpitations, syncope, rectal bleeding and oesophageal reflux, has developed sensory symptoms in her feet. She is being interviewed by Jane Lee, a second year medical student.

Watch the interview and record the cardinal fea-tures of Ms Davidson’s presenting problem. Iden-tify the positive and negative symptoms and list them below. Describe the distribution of her sen-sory disturbance.

Positive sensory symptoms

Negative sensory symptoms

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Building your communication skills In the last tutorial, the importance of acknowledging a patient’s physical discomfort was discussed. Identifying and responding to a patient’s emotional discomfort or distress is an equally important skill in medicine. It is, however, a skill that many medical students find confronting. During this semester, the basic principles of this skill will be integrated into your clinical skills training. Identifying emotional distress or discomfort Many people express some type of emotion, such as anxiety, sadness, anger or happiness, when talking about their health. They may be worried about their medical disorder, have a psychological problem or be experiencing social problems at home or at work. Furthermore, emotional responses can be a sign of an organic brain disorder, such as a brain tumour. It is important that you learn to identify and respond to such emotional responses. Firstly, the emotional response may represent a serious organic, psychiatric or psycho-social problem that needs urgent intervention. Secondly, responding to a patient’s emotions can help to build rapport and may make him or her more comfortable in revealing important information about their physical symptoms or psycho-social circumstances. Thirdly, it can be therapeutic for the patient to express their emotions and to have someone acknowledge the distress that they are experiencing. Identifying a patient’s emotional distress will often be straightforward. He or she may tell you about their emotions or demonstrate them in an obvious non-verbal way, such as by crying, being angry or appearing anxious. Sometimes the signs that a patient is distressed are more subtle. Reduced eye contact or a change in posture, for example, may be the only indication that the patient is experiencing emotional distress. Psychological problems can also present as physical symptoms, such as headaches or fatigue. It is important, however, that you do not assume that a patient’s symptom is due to a psychological cause without thorough evaluation. With experience, you will become more alert to subtle presentations of emotional or psychological problems. Many of the generic communication skills that you have learned so far are helpful when responding to a patient’s emotional distress. Active listening skills such as reflecting, restatement and paraphrasing, in particular, can be very effective. It is important to reflect not only the patient’s words, but also their emotions. There are also specific skills that can be applied to particular situations. During this tutorial, the focus will be on the patient who is crying. Responding to a patient who is anxious or angry will be addressed in subsequent tutorials. Responding to a patient who is crying In Case Study 4.02, Julie Davidson started crying while talking with Jane Lee. Discuss how Jane responded to this situation as you go through the following notes with your tutor.

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Crying is a common response to emotional distress. If a patient starts to cry while you are interviewing them, don’t ignore it. Acknowledge that he or she is upset, and convey to them that crying is a legitimate response to a difficult situation. If you have been writing notes during the interview, stop and put your pen down. Try to establish why the patient is distressed. Sometimes the reason will not be obvious or what it seems. Crying, for example, may mask the fact that the patient is angry about something. Encourage the patient to express their feelings, however if they don’t want to talk about what is making them distressed, don’t pry. It is important to respect patients’ privacy. Offer practical help. Provide the patient with a box of tissues if possible. Ask what you can do for the patient. Also ask if they would prefer that you stay or if they would prefer that you left them alone. If the patient seems significantly distressed, it is best to advise someone such as the nurse who is looking after the patient on the ward or the doctor who is supervising you. Use silence effectively. You may feel it is best to keep talking with the patient but often it is appropriate to give them time to compose themselves. Don’t offer false hope. Don’t say, for example, “I’m sure everything will turn out OK”, as this might not be the case. Use touch prudently. It may be of comfort to the patient but take care that it is not interpreted the wrong way. If you judge that touching a patient is appropriate, placing your hand between their wrist and their elbow is usually acceptable. It is rarely appropriate to hug a patient. The important thing to remember is that if you don’t feel comfortable touching a patient, don’t do it. Finally, it is important to review your own response when a patient cries. Your reaction to the situation may be influenced by your own emotions at the time or how closely you identify with the patient’s situation. Don’t project your own feelings on to the patient. If you feel distressed by a situation on the wards, please contact the appropriate person from your clinical school.

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Role-play A: Sensory disturbance Background You are James/Jane McDonald, a 26 year old graduate university student, who has had type 1 diabetes mellitus for 19 years. You are presenting to your general practitioner with a burn on the right foot and a history of numbness. Opening statement Last night I was resting my feet near a small radiator while I was studying. My feet have been numb for the past three months and I didn’t notice how hot my feet were. I’ve burnt the skin on the sole of my right foot and I’m very worried about it, although strangely enough, I don’t seem to be getting any pain from it. Cardinal features Site: I’ve noticed the numbness on the soles over my feet and over the top of my feet too. The rest of my legs seem to be OK. Quality: The main problem is numbness. If asked: I have not had any tingling or pins and needles. But sometimes I’ve had shooting pains in my feet. Severity: The shooting pains seem to be worse at night and sometimes they stop me from sleeping. It’s making me feel pretty tired now. If asked to score the pain out of 10: say 5 Time Course: It’s been about 3 months since I first noted the numb feeling. The pains have only just started in the last 4 weeks. If asked how the symptoms are progressing over time: They are getting worse Context: I guess all this started when my sugars started going a bit haywire. The readings have been a lot higher than they are supposed to be…I haven’t seen my diabetes specialist for a while now. Aggravating factors: Nothing particular seems to make it worse Relieving factors: My GP put me on a medication called Amitriptyline, but this didn’t really help. It makes me feel pretty terrible in the mornings, so I’ve stopped taking it. Associated features: Sometimes it feels like I’m walking on cotton wool - it’s really weird, sort of hard to describe. But I can’t think of anything else different.

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Role-play B: Sensory Disturbance Joanne Andrews Background Joanne Andrews, aged 42 years, has come to see the doctor about numbness in her hands. Opening statement: I’ve been waking up at night with a really weird feeling in my hands. When I get it I have to wake up and shake my hands about before I can get back to sleep. I’m really over it now. I just want a good night’s sleep! Site: It’s in both hands…mainly around my thumbs and also in some of my fingers. (If asked exactly where you feel this - indicate your thumb, index and middle fingers) Quality: It feels sort of numb and also tingly. It’s like when your foot goes to sleep – except it’s your hand!…It feels really weird… Severity: It’s bad enough to wake me up. Sometimes it even feels painful. If asked to score the pain out of 10, say: 6 Time Course: It’s been happening for a couple of months now. If asked how often: It probably started as a few times a week, now it is most nights - at least once, sometimes twice a night it wakes me. If asked about the duration of an episode, say: It usually wakes me up and then lasts about 10 minutes. Then it fades to a dull ache and I usually manage to get back to sleep. Context: It just gradually started happening…I have been pretty busy with work and have been doing long hours at the computer but I’m not sure that it’s related Aggravating factors: Sometimes I’ve had a similar feeling throughout the day after I’ve been on the computer keyboard. I was finishing a big project off last week and I noticed my hands ached after working for a long stretch. Relieving factors: Shaking and rubbing my hands seems to help. I’ve tried taking a painkiller before I go to sleep but that hasn’t stopped the pain coming at all. Associated features: I’m not sure if I am imagining it, but I think that my hands are a bit weaker. I keep having to ask my husband to open bottles and jars for me...but then I’ve never been very strong…

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focussed questions



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TRANSIENT LOSS OF CONSCIOUSNESS During this tutorial, you will learn how to interview a patient who has had transient loss of consciousness. You will also have an opportunity to build on your ability to identify and respond to emotional issues that arise during a medical interview, as well as to practise the neurological examination of the upper and lower limbs. Transient loss of consciousness Transient loss of consciousness is a common symptom, affecting up to 50% of the population at some stage. There are many causes of transient loss of consciousness but most fall into one of two major categories: (i) syncope or (ii) seizure. It is important to differentiate between syncope and seizure, as these conditions have very different underlying causes and treatments.

(i) Syncope Syncope is defined as a sudden loss of consciousness and postural tone, with spontaneous and complete recovery. It is caused by a global fall in blood flow, which leads to a reduction in the oxygen supply to the brain and inactivity of the cerebral cortex. There are many causes of syncope, most of which are benign. Vasovagal syncope is the most common benign cause of syncope. Other benign causes include postural hypotension and situational syncope (e.g. syncope during cough, micturition, defecation). These benign causes must be differentiated, however, from cardiovascular aetiologies, which are associated with an increased risk of sudden death. Cardiac syncope can be caused by arrhythmias, such as tachycardias and bradycardias, or, less commonly, organic heart disease, such as aortic stenosis or myocardial ischaemia.

(ii) Seizure

A seizure is caused by sudden uncontrolled electrical neuronal activity in the brain. During a seizure, in contrast to syncope, the cerebral cortex is overactive, with increased blood flow secondary to the surge in electrical activity. If this electrical activity begins in both hemispheres of the brain at once, a generalised seizure will result. The most common type of generalised seizure is called a tonic-clonic seizure. This type of seizure is characterised by sudden loss of consciousness associated with stiffening of the body and followed by convulsive or repetitive jerking movements of the limbs. There are other less common types of generalised seizures but you do not need to know about these at this level of your training.

Not all seizures cause loss of consciousness. In some instances, the abnormal electrical activity is confined to a focal area of the brain, with the resulting symptoms depending on the function of the affected area of the brain. This is called a simple partial seizure. Sometimes, however, abnormal electrical activity that starts in a focal area spreads to the whole brain, leading to an altered state of consciousness after the seizure has started, although not necessarily a change in postural tone. This is called a complex partial seizure. Seizures can be caused by a wide range of underlying conditions, including genetic disorders, focal brain lesions due to stroke, tumour or head injury, infectious diseases and metabolic disorders. For many patients, no underlying cause can be established. The term epilepsy is used when a person has recurrent unprovoked seizures. Thus not all people who have experienced a seizure have epilepsy.

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Interviewing a patient who has had transient loss of consciousness A thorough assessment is required when a patient presents with suspected transient loss of consciousness, as there may be a serious underlying cause. Often the patient will use a term such as collapse, funny turn, spell or blackout to describe what has happened to them, so you will need to clarify the nature of the presenting problem. You may need to establish whether the person has actually lost consciousness or, if instead, they have experienced a related type of problem, such as light-headedness, dizziness, vertigo, loss of balance, muscle weakness or a psychiatric disturbance. The next step is to try to determine the cause of the transient loss of consciousness. At this stage of your training, you are expected to know about the typical features of vasovagal syncope, cardiac syncope and tonic-clonic seizures. You are not expected to know about the less common benign causes of syncope or about other types of seizures. Find out about the cardinal features of the patient’s presenting problem. A table is included in these notes that contains information about the typical features of each of the main causes of transient loss of consciousness. Apart from the cardinal features, it is also important to find out about the prodrome and the period just after the event. A witness account will be vital for obtaining information about the time when the patient was unconscious. It is important to find out about the duration of the loss of consciousness, as this can assist in differentiating seizure from syncope. Many people who witness such an event will describe it as lasting a “minute or so”, when they really mean “ten seconds”. It can be helpful to illustrate to the witness the duration of one to two minutes by counting it out using your watch. If the duration of the loss of consciousness was prolonged, other causes must be considered. You are not expected to be able to assess a patient with prolonged loss of consciousness at this level of your training.

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Was there true loss of consciousness?

NO YES

Vertigo Was the loss of Disequilibrium consciousness Pre-syncope transient? Non-specific Dizziness

NO YES

Coma Stupor

Syncope Seizure

Vasovagal syncope Cardiac syncope

Suspected Transient Loss of Consciousness

25

Differentiating between the major causes of transient loss of consciousness

Cardinal feature

Syncope

Seizure

Faints (vasovagal

syncope)

Blackouts (cardiac

sycnope )

Prodrome Usually present,

includes feeling of

light-headedness and

“wobbly” legs, vision going

dim, noises sounding

distant

May remember start of

collapse

Usually not present Primary generalised

seizures usually

begin without warning Complex partial or

secondary generalised

seizures may have a

prodrome (“aura”), the

nature of which depends

where the seizure

originates in the brain; déjà

vu may occur

Site Not relevant Not relevant Not relevant

Quality Loss of postural tone Convulsive movements can

occur, although usually only

a few jerks

Loss of postural tone Convulsive

movements can occur,

although usually only

a few jerks

(i) Tonic phase

Stiffening of limbs with

extension of

back and limbs, eyes

deviate upwards, may cry

out involuntarily

(ii) Clonic phase

Generalised flexion

contractions of muscles

alternating with

relaxation

Severity Not usually quantified Not usually quantified Not usually quantified

Time course Usually less than 30

seconds

Usually less than 30

seconds

Usually 1 – 2 minutes

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Cardinal feature

Syncope

Seizure

Faints (vasovagal

syncope)

Blackouts (cardiac

sycnope )

Context Usually doesn’t occur

when sitting or lying

Can occur when

sitting or lying

Can occur when

sitting or lying Can

occur during sleep

Precipitating factors Vasovagal syncope

often has specific

precipitating factors,

such as fasting, pain,

emotional events or

prolonged standing

Cardiac syncope usually

does not have a clear

precipitating factor

Usually spontaneous but

can be triggered by sleep

deprivation or stress

Relieving factors Lying flat assists

recovery

Self-limiting Self-limiting

Associated features Tongue biting unusual

Head turning unusual

Sweaty

Pallor

No cry or moan

No frothing at mouth

Incontinence of urine may

occur, although not

common

Tongue biting unusual

Head turning unusual

Sweaty

Pallor

No cry or moan

No frothing at mouth


occur, although not

common

Tongue biting

common Head

turning common

Usually not sweaty

Cyanosis

Cry or moan at onset

Frothing at mouth


occur

Period after the

event

Rapid recovery of

consciousness

Rarely confused

afterwards Injury not common

as protective reflexes

preserved

Rapid recovery of

consciousness

Rarely confused

afterwards Injury may occur

Slow recovery

Period of confusion >

2 minutes

May feel exhausted

and sleepy Muscle

aches Injury

common

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Case Study 4.05

James Nicholls, a 66-year old man with a history

of ischaemic heart disease, has been admitted to

hospital after a second episode of transient loss

of consciousness in less than a week.

He is being interviewed by Nick Modzrewski, a

second year medical student. The witness ac-

count is provided by Mr Nicholls’ daughter, Sa-

rah.

Watch the interview and write down the cardi-

nal features of Mr Nicholl’s presenting problem.

Discuss the features that differentiate between

syncope and seizure as a cause for his presenta-

tion.

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Identifying and responding to anger

In Case Study 4.05, Sarah Nicholls expressed anger about aspects of her father’s medical management. Using the following notes, discuss with your tutor why she might have been angry and how Nick Modzrewski responded to this. Anger is a common emotion in a medical setting. It can be a natural response by a patient to their illness or to having to deal with the health care system. As a medical student, it is important that you learn how to respond professionally to tense and difficult situations on the wards and in clinics. Reacting with anger or by walking away will only escalate the situation.

Start by establishing why the patient or their relative is angry. There may be an obvious and legitimate

reason for it. The underlying problem, however, may be unrelated to the current situation, and the person

may be just displacing their frustration about something else onto you.

Often the person merely wants someone to hear them out, so allow them time to do so. Listen carefully to

what the person is saying. Convey in words and by your manner that you are trying to understand their

point of view and that you acknowledge the difficulty of the situation. Do not disagree with the person, even

if what they are saying is incorrect, as this is unlikely to be helpful and may ignite an argument. Don’t be

defensive. Do not criticise another health professional as you may not be in possession of all the facts

about the situation.

Offer to find someone who can assist the patient or relative with their concerns. If the situation escalates

and you feel verbally or physically threatened, remove yourself from the location and inform a senior

person.

Always check your own response to an emotionally charged situation. You may not have control over

difficult situations, but you do have control over the way you react. Be aware that your ability to respond in a

measured way will be affected by fatigue, hunger or background personal stress. If you find that you have a

short fuse when dealing with difficult situations, explore ways of learning how to manage this better.

Finally, don’t internalise the other person’s anger or take it personally. There may, however, be situations

later on where you have contributed to a person’s anger, such as by making a medical error. You will be

taught later in the course how to respond to this type of situation.

Practice with role-plays

In pairs, use role-plays to practise interviewing a patient about the neurological symptoms. Give each other

feedback using the Medical Interview Assessment forms at the back of this workbook.

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Role-play A: TLOC

Background

You are Aaron Schukraft, a 36 year old lawyer. You are presenting to your general practitioner after an

episode of collapse.

Opening statement

I gave my girlfriend a bit of a scare last night. I collapsed in the bathroom in the middle of the night and she

was really worried about me. I feel fine now.

If asked to elaborate: We’d had a pretty big day - I’d just been out of town for my brother’s wedding and

we’d gone pretty hard. We got home really late and I was a still pretty tipsy I suppose. I just got up from bed

to go to the toilet about 3am and that’s when it happened.

Cardinal features

Site: N/A

Quality: I don’t know what I did - no one saw it happening. I was just standing up at the toilet, about to take

a piss, and then the next minute I woke up on the floor.

If asked specifically about prodrome: I felt a bit light-headed when I walked through to the toilet and then

and my vision went a bit funny - like tunnel vision. That’s the last thing I remember.

Severity: N/A

Time Course: I’m not sure how long I was out for, but my girlfriend thinks it was only a minute, or less

If asked how long it was until you felt back to normal: Only a few minutes. Then I was fine. My girlfriend was

keen for me to go to the emergency department, but I didn’t see what the fuss was about. But she made

me come here today to get checked out.

Context: We’d had a couple of pretty full-on days before the wedding and then on the wedding day itself.

We’d been drinking a fair bit of wine and dancing, and I guess I hadn’t really been drinking much water.

Precipitating factors: Well, I guess the big day we’d had and the alcohol didn’t help. I think I might have

been a bit dehydrated.

Relieving factors: I felt OK after a few minutes of lying on the bathroom floor.

Associated features: My girlfriend said I was a bit pale when I woke up, and a little clammy.

If asked specifically: You had no tongue biting, no moaning/crying/ no frothing at the mouth/ no incontinence

of urine.

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Role-play B: TLOC

Background

You are Jasmine Lee, a 16 year student. You are presenting to your general practitioner for review after an

episode of collapse.

Opening statement

I had a weird black-out thing today when I was at hockey practice. My coach thought I had a fit and called

my Mum to bring me straight here.

If asked to elaborate:

I was just sitting on the ground with the rest of the team and our coach was talking to us and then the next

thing I know is I’m lying on my side with everyone crowded around me, looking worried. It was pretty

embarrassing.

Cardinal features

Site: N/A

Quality: My coach said that I went all stiff and rigid and fell backwards onto the ground, arching my back.

Then he said I started shaking, like I was having a fit.

If asked specifically about prodrome:

I didn’t get any warning. I felt fine before I blacked out. I’m pretty fit and was ready for training.

Severity: N/A

Time Course: My coach was pretty switched on and timed me with his stopwatch. He said I was out of it for

2 minutes.

If asked how long it was until you felt back to normal: I was a bit groggy for about 10 minutes - I just felt

spaced out. But then after 15 minutes I felt pretty good.

Context: I didn’t do anything different today.

Precipitating factors: I guess I’ve been up late a few nights doing an assignment for school, so I’ve been a

bit tired, but that’s pretty normal for me.

Relieving factors: Nil

Associated features: I’ve got a sore tongue now - maybe I bit it, I don’t know.

If asked specifically: You had no moaning/crying/ no frothing at the mouth/ no incontinence of urine.

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focussed questions



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COGNITION

This tutorial focuses on the assessment of the higher level functions of the brain, specifically memory, which

is an important component of cognition. It also covers the principles of interviewing a patient who has

cognitive impairment and introduces an instrument that is widely used in clinical practice to screen for

cognitive impairment.

Cognition

During your studies in the neurosciences, you have learned how the brain, spinal cord and peripheral

nervous system form a complex, integrated processing and control system. In particular you have learned

about the sensory and motor functions of the body and how to make a basic clinical assessment of these

functions.

During this tutorial, the focus will be on the assessment of the higher functions of the brain, specifically

cognition. The term cognition broadly refers to the mental processes involved in knowledge acquisition,

comprehension and application. The major domains of cognition are:

(i) Memory

Memory refers to the ability to store, retain and retrieve information from the brain. A key

component of memory is attention, which is the ability to selectively concentrate on one element of

the surrounding environment to the exclusion of the other elements.

(ii) Language

Language refers to the ability to comprehend and use expressions in order to communicate. It

incorporates the skills of listening, speaking, reading and writing.

(iii) Executive function

Executive or frontal lobe function refers to the ability to think in an abstract fashion. It involves being

able to organise information, plan ahead and use judgement and reasoning.

Memory and memory loss

The medical interview component of this tutorial is focused on history taking with respect to the memory

component of cognition, specifically memory loss. To start with, it is helpful to have an understanding of the

types of memory in order to effectively gather information about this symptom. There are three types of

memory:

(i) Sensory memory

Sensory memory or attention is the reception and processing of information from a person’s

surrounding environment. It involves selection and screening of information by the cerebral cortex.

This process relies on the integrity of a number of brain regions from the brain stem arousal

systems, through to the sensory cortex and the frontal lobes, particularly in the right hemisphere.

(ii) Working memory

Information that is filtered by the attentional systems is transmitted to the pre-frontal cortex. Here it

is held in working or short term memory. Information in working memory can be temporarily stored

for short term use, such as remembering a telephone number in order to make a call.

(iii) Long term memory

Information that has been transmitted to working memory undergoes a process called long-term

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potentiation. This is the process by which memories are stored in a more permanent form. It

predominantly takes place in the hippocampus. Information is more readily archived in long term

memory if it is stored with other related information or if it is augmented by practice or by using

mnemonic devices. This passes information through the hippocampus several times and

strengthens associations.

There are two major types of long term memory. The first is episodic memory, which refers to

memory of personally experienced events. The second is semantic memory, which refers to a

person’s store of facts and concepts, as well as words and their meanings. An example of a

semantic memory would be your knowledge of the cardinal features framework for gathering

information about a symptom. An episodic memory, by way of contrast, would be your memory of

interviewing a particular patient about the cardinal features of, for example, their memory loss

during a clinical skills tutorial on a particular day.

There are many types of memory disorders that you will encounter in clinical practice. Disorders of

attention or sensory memory lead to problems in filtering out “background noise” from the

environment. The most common cause of this type of problem is delirium, which can be caused by

a range of medical problems, such as infections or hypoxia, or certain medications.

Conditions which affect the memory areas of the hippocampus can lead to problems with storing

information from working or short term memory into long term memory. This can be caused by

disorders such as Alzheimer’s disease, which can affect not only memory but other components of

cognition. Alzheimer’s disease especially affects episodic memory, especially the retention of

information about day-to-day experiences. Long term memory is often intact in the early stages of

this disease but becomes affected as the disease progresses.

Eliciting the cardinal features of memory loss

When interviewing a patient about memory loss, find out about which type of memory is affected. This can

be difficult as many patients will want to cover up their loss of memory, often for fear of losing their

independence. A supplementary history will usually need to be obtained from another person, such as a

family member or other carer. The time course of the memory loss is also very important. In conditions such

as Alzheimer’s disease, the progression is usually very slow. Memory loss that occurs acutely is almost

always due to other causes.

Asking about associated features of memory loss is important. At this stage of your training, you do not

need to be able to ask specific questions in order to establish the underlying cause of a person’s memory

loss, but you should be able to recognise if the person has other related cognitive problems. They may

report problems with language, such as difficulty with word finding ability (nominal aphasia), or impaired

ability to carry out motor activities despite intact muscle and nerve function (apraxia). They may also have

problems recognising or identifying objects despite intact sensory function (agnosia). A family member or

carer may report that the patient has had a change in personality or behaviour, such as disinhibition or

apathy. Changes in executive function such as planning, judgement and organisation may also be

described.

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Case Study 4.06

Dorothy Fitzgerald, 78, has been brought by her daughter, Judith, to see her general practitioner, Dr Eleanor Flynn. Judith is concerned about her mother’s memory. Watch the interview and write down the cardinal features of Mrs Fitzgerald’s presenting problem.

Building your communication skills Communicating with a patient who has cognitive impairment Many of the patients that you encounter during your medical training will have some degree of cognitive impairment. This can make the interview more challenging but there are many techniques that you can use to optimise communication. Simple environmental measures, such as reducing background noise and other distractions, can make a significant difference to how well the person can attend to what you are saying. Be aware of the possibility of associated visual or hearing impairment. Speak clearly and slowly to the patient but make sure that you do not “talk down” to them. Avoid using a high-pitched voice. Maintain eye contact as much as possible. Optimise your use of basic communication skills such as sign-posting, non-verbal communication and checking understanding. Rephrase questions if you have not made yourself understood by the patient. Allow plenty of time for the patient to reply to your enquiries. Recognise that the interview may take longer than usual. Be aware of the sensitivities associated with asking a person about their cognitive abilities. Do not challenge them unnecessarily, as many people with cognitive impairment are anxious about the implications of their disability. If you are interviewing the patient with a carer, it may be helpful to ask the carer how the person can be helped to communicate with you. Be sensitive to the feelings of both parties during the interview and be aware that you might not be obtaining the whole picture as the carer may be uncomfortable discussing the patient’s memory and behavioural problems in front of them. Obtaining information from a carer is often best undertaken separately from the patient, but do not overlook your duty of confidentiality to a patient who has cognitive impairment. Later in the course you will learn more about how to balance the person’s right to confidentiality with their ability to make decisions for themselves.

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Examination of higher centres The examination of higher brain function can be quite complex. It involves assessing domains such as language, orientation, memory and executive function, as well as noting the patient’s affect and behaviour. You may have observed features of the patient’s higher brain function during the medical interview but it is important to have a systematic way of assessing this. There are a number of instruments available to help screen for cognitive impairment. One of the most commonly used of these is the Folstein Mini-Mental State Examination (MMSE). It is a convenient way of detecting changes in brain function and the magnitude of these changes. Using the MMSE is similar in many ways to, for example, using peak expiratory flow to monitor respiratory function. The Folstein MMSE is administered by asking the patient a set of standard questions. It is important to follow these questions as written and not prompt the patient. It is also important to adopt a neutral standpoint during the administration of the instrument by not challenging incorrect answers or giving positive responses to correct answers. When giving instructions to the patient, also make sure that you speak at the same rate for consistency. All of these help to produce a more reliable result for the assessment. Be aware that there are a number of factors that can influence the result of a mental status examination. These include baseline intelligence, education level and sensory deficits, such as hearing or visual impairment. Cultural factors may also influence how the test is completed by the patient. Also be aware that depression, performance anxiety and drugs or alcohol may also influence how a person performs. With your tutor, go through the items on the Folstein MMSE. Then use the instrument to score the patient in the audio-visual clip provided. You do not need to be able to test other aspects of higher brain function at this level of your training.

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Mini Mental State Examination

1. Orientation (Maximum score 10)

Ask “What is today’s date?” Then ask specifically for parts omitted, “Can you also tell

me what season it is?”

Ask:

“Can you tell me the name of this hospital/ house number?” “What ward/

street name are we on?”

“What suburb are we in?” “What

city are we in?” “What state are

we in?”

Date (e.g. September 2) Year

Month

Day (e.g. Monday)

Season

Hospital/ House no.

Ward/ Street name

Suburb

City

State

2. Registration (Maximum score 3)

Ask the subject if you may test his/ her memory. Then say “ball”,”flag”,”tree” clearly and slowly, about one second for

each. After you have said all three words, ask the subject to repeat them. This first repetition determines the score

(0-3) but keep saying them (up to 6 trials) until the subject can repeat all 3 words. If (s)he does not eventually learn

all three, recall cannot be meaningfully tested

Ball

Flag

Tree

Number of trials

3. Attention and Calculation (Maximum score 5)

Ask the subject to begin at 100 and count backward by 7. Stop after 5 subtractions. Score one point for

each correct number.

If the subject cannot or will not perform this task, ask him/her to spell the word “world” backwards

(D,L,R,O,W). The score is one point for each correctly placed letter, e.g. DLROW= 5, DLORW= 3. Record

response

93

86

79

72

65

OR

number of correctly

placed letters

4. Recall (Maximum score 3)

Ask the subject to recall the three words you previously asked him/ her to remember

(learned in Registration)

Ball

Flag

Tree

5. Language (Maximum score 9)

Naming: Show the subject a wrist watch and ask “What is this?” Repeat for pencil. Score one point for

each item named correctly.

Repetition: Ask the subject, “No ifs, ands, or buts.” Score one point for correct repetition.

3 stage command: Give the subject a piece of blank paper and say,”Take the paper in your right hand, fold it in

half and put it on the floor.” Score one point for each action performed correctly.

Reading: On a blank piece of paper, print the sentence “Close your eyes” in letters large enough for the subject to

see clearly. Ask the subject to read it and do what it says. Score correct only if the subject closes his/her eyes.

Writing: Give the subject a blank piece of paper, and ask him/ her to write a sentence.

It is to be written spontaneously. It must contain a subject and a verb, and make sense. Correct grammar and

punctuation are not necessary.

Copying: On a clean piece of paper, draw intersecting pentagons, each side about 1 inch, and ask the subject

to copy it exactly as it is. All 10 angles must be present, and two must intersect to score 1 point. Tremor and

rotation are ignored:

E.g.

Watch

Pencil

Repetition

Takes in right hand Folds

in half Puts on

floor

Closes eyes

Writes sentence

Draws Pentagons

* In section 3 score number of correct responses items 14-18, or item 19, not both. Rate subject’s level of

consciousness: (a) coma,(b) stupor,(c) drowsy, (d) alert Comments:

Total Score (maximum= 30)

Clinical Skills NEURO - History Taking

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Transcript of Clinical Skills NEURO - History Taking