THE NEUROLOGIC EXAMINATION

• MENTAL STATUS• GAIT & STATION• CRANIAL NERVES• MOTOR SYSTEM• COORDINATION• REFLEXES• SENSATION• HEAD & NECK• SPINE & SKIN

Neurologic examinationMENTAL STATUS EXAM

DEFINITION: Overall state of arousal, readiness, alertness; preparedness to respond to environment

ASSESSMENT: if not alert, try to arouse pt: speak pt name --> shout name --> shake --> brief pain

• LEVEL OF CONSCIOUSNESS

Mental Status Exam

AWARENESS

• ORIENTATION

1 Alert = awake, fully aware and responsive; normal waking consciousness

2 Lethargic, drowsy = responds when spoken to, may drift to sleep if no stimulation

3 Obtunded = may awaken to voice but is minimally responsive when doing so

4 Stuporous = difficult to rouse, may groan or become restless to brief pain

5 Coma = pt is unresponsive or may show abnormal response to voice or pain

LEVEL OF CONSCIOUSNESS

Mental Status Exam

"AVPU" mnemonic: pt is Alert --> responds to Voice --> responds to Pain--> is Unconscious

Overview:

The Glasgow coma scale is used to assess patients in coma. The initial score correlates with the severity of brain injury and prognosis.

Glasgow coma scale = (score for eye opening) + (score for best verbal response) + (score for best motor response)

GLASGOW COMA SCALE

Eye Opening Score

spontaneously 4

to verbal stimuli 3

to pain 2

never 1

Best Verbal Response Score

oriented and converses 5

disoriented and converses 4

inappropriate words 3

incomprehensible sounds 2

no response 1

GLASGOW COMA SCALE

GLASGOW COMA SCALE

Best Motor Response Score

obeys commands 6

localises pain 5

flexion withdrawal 4

abnormal flexion (decorticate rigidity) 3

extension (decerebrate rigidity) 2

no response 1

Interpretation: • maximum score is 15 which has the best prognosis • minimum score is 3 which has the worst prognosis • scores of 8 or above have a good chance for recovery

• scores of 3-5 are potentially fatal, especially if accompanied by fixed pupils or absent oculovestibular responses • young children may be nonverbal, requiring a

modification of the coma scale for evaluation.

GLASGOW COMA SCALE

PHYSICAL EXAMINATION OF THE COMATOSE PATIENT:

• General Inspection• Color• Scalp & Skull• Eyes• Facial muscles• Oral cavity• Breath• Ears• Neck• Limbs• Sensory Examination

ORIENTATION

DEFINITION: capacity to identify and recall one's identity and place in time and space

ASSESSMENT: directed questions

• TIME “Do you know what date it is?”• PLACE "Can you tell me where you are right now?" • PERSON “Who is that man standing beside you?”

“Who am I?”

Mental Status Exam

• Gender• Race• Apparent age• State of health• Position (e.g. supine, sitting, standing)• Clothing• Hygiene• Habitus• Physical characteristics

(e.g. hair style, amputation)• Gait

APPEARANCE

Mental Status Exam

Mental Status Exam

BEHAVIOR

• Eye contact• Mannerisms• Patterns of movement• Speed of movement (e.g. slowed, hyperactive)• Stupor = pt is awake but immobile and mute, may or may not have

reduced awareness of environment• Waxy flexibility, catalepsy = stuporous but takes body positions

physically imposed by examiner• Echopraxia = pt involuntarily copies others' movements• Mimicry = pt voluntarily copies others' movements• Catatonia = alternate between stupor and hyperactivity;

may show catalepsy, echopraxia, echolalia• Cataplexy = sudden loss of muscle tone, esp. with emotional arousal• Hyperkinesia = excessive motor activity• Akisthesia = motor restlessness, uncomfortable if he keeps still

COOPERATION

• cooperative vs. uncooperative• guarded• attentiveness to examiner• attitude to examiner, to illness

Mental Status Exam

SPEECH & LANGUAGE

• Volume• Rate• Prosody = emotional intonation of speech;

variations in stress, pitch and rhythm• Amount = quantity of speech produced

poverty = minimal speech, as in monosyllabic and unelaborated responses to questions loquacious = excessive speech

• Fluency = ease with which pt appears to produce speech• Spontaneity = pt initiates speech on his/her own,

not just in response to conversation• Articulation = phonation;

ASSESS: note pt's speech; have pt say "pa-pa," "ta-ta," and "ga-ga"

Mental Status Exam

• Dysphasia - Two broad categories:1. Sensory dysphasia -- difficulty lies in comprehension

talk in jargon; maybe unaware of his disability2. Motor dysphasia – difficulty lies in production

understands simple questions or requests but finds difficulty in replying

• Dysarthria - defect in articulation of speech- due to disorder of neuromuscular control; maybe lingual,

labial, pharyngeal, laryngeal, or cerebellar- ask pt to repeat “West Register Street”, “Fifty-first Artillery Brigade”

• Dysphonia - condition of disturbed sound, rhythm or tonal quality of speech. Paralysis of one or both vocal cords may produce hoarseness

SPEECH & LANGUAGE

Mental Status Exam

DEFINITION: fund of knowledge and overall assessment of general intelligence

ASSESSMENT: note from pt's speech, ask pt to name last 5 Presidents, 5 large cities, historical events (average, below average, above average)

Reduction of general mental capacity usually implies diffuse damage to the cerebral cortex. If damage occurs after learning process, “dementia” is used.

Mental Status Exam

GENERAL KNOWLEDGE

Vocabulary is the best indicator of a patient’s overall pre morbid intellectual capacity

• Rapid, charged speech - in manic persons• Voluble, inappropriate jargon without apparent goals

- in Wernicke’s aphasia• Self-directed neologisms (words or phrases that have

meaning only to the person using them)- in schizophrenic pts.

• Slow, monotonous speech- in depression, hypothyroidism, and Parkinson’s syndrome

SPEECH & LANGUAGE

Mental Status Exam

MEMORY

Mental Status Exam

• Immediate memory = memory over seconds, minutes: ASSESS by asking pt to repeat three words or

numbers• Recent memory = memory over mins, hours, days; ASSESS by asking about events of the past 48 hours; (e.g. meals, visitors, whereabouts)• Remote memory = memory over years; ASSESS: ask about remote events that should be known to the pt;

(e.g. pt personal history, date of birth, marriage)

In organic disease of the temporal lobe, recent memory usually fails before remote memory.

RETENTION & RECALL

• If this faculty is impaired, no “new” memories will be formed• Test:

1. Have pt repeat a number of digits beginning with 3 digits and increasing until a limit is reached. The test is repeated with the pt reversing the digits. (Average intelligence can repeat 6 digits forward and 5 digits reversed)

2. Ask pt to remember 3 objects (2 similar and 1 dissimilar). After 3 mins, ask pt to repeat. Failure to do so lead to repetition with another 3 objects; repeat after 2 and half mins.

Mental Status Exam

Mental Status Exam

REASONING

• Judgment - pt's ability to make wise decisions, especially in everyday activities and social matters-- self-care, self-welfare, personal relationships; ASSESS: Ask an imaginary scenario. "What would you do if you smelled smoke in a crowded theater?" (good response is "call 911" or "get help"; poor response is "do nothing" or "light a cigarette").

• Insight - pt awareness that he/she has problems, what they are, and their implications;

ASSESS: asking pt why he is in the hospital• Abstraction - use of proverbs

“People in glass houses should not throw stones”“A rolling stone gathers no moss”

OBJECT RECOGNITION

The defect of recognition of simple objects is called agnosia. Five categories:1. Visual agnosia - showing pt simple objects and asking

him to name them2. Tactile agnosia - inability to recognize simple objects by

palpation; lesions in the parietal lobe3. Autotopagnosia - loss of appreciation or identification of a

body part; lesions of the parietal lobe4. Anosognosia - implies denial of disease and is due to

loss of perception of the affected part, usually a paralyzed limb; lesions in frontal and parietal lobes

5. Auditory agnosia - inability to percieve the meaning of sound despite the absence of deafness

 

Mental Status Exam

PRAXIAS

Apraxia - inability to execute a planned motor act in the absence of paralysis

• Ideational apraxia - higher order deficit, cannot sequencing a multi-step task but each elemental step is ok;

- resembles extreme absentmindedness- no impairment of motor movement

• Ideomotor apraxia - cannot perform learned motor acts properly; the most common apraxia; ASSESS: "Show me how to salute, blow out a match, brush your teeth" -->"Mimic me" --> provide real objects

PERCEPTIONDEFINITION: sensory experience and its immediate interpretation ASSESSMENT: pt's speech and behavior, but mostly targeted questions (e.g. "Do you sometimes hear or see things that others do not seem to see or hear?" "Do you ever have any sensations that worry you or seem odd?" "Do you worry

that you senses sometimes 'play tricks' on you?")

Mental Status Exam

• Hallucinations = a sensory perception despite no physical external stimulus• Sensory modality (e.g. visual, auditory, olfactory, tactile, gustatory)• Formication = tactile hallucination of insects crawling over the skin• Derealization = parts of environment feel unreal, somehow altered• Depersonalization = pt feels detached, unreal, physically altered;

e.g. out of body, body part altered, cut off from other people• Deja vu = feeling that an event has already been lived through• Jamais vu = feeling unfamiliar in a situation the pt. knows should be familiar

 

Mental Status Exam

• Hypnogogic = while one is falling asleep• Hypnopompic = while one is waking up• Illusions = a wrong perception of a real physical external stimulus; e.g. mistaking a shadow for a man• Astereognosis = inability to identify objects based on tactile sensations • Agraphesthesia = inability to use tactile sensations alone to identify

letters or numbers "drawn" on palm• Visuospatial function = visual perceive and reconstruction of spatial

relationships; ASSESS: copy overlapping polygons, draw-a-clock

PERCEPTION

MOODDEFINITION: emotional tone the pt subjectively feelsASSESSMENT: what the pt says

Mental Status Exam

e.g. depressed, sad, happy, neutral, angry, apathetic, fearful, pleasant, irritable, euphoric, anxious

AFFECTDEFINITION: emotion displayed, what the interviewer observes ASSESSMENT: facial expressions, body language, laughter, use of

humor, tearfulness

Mental Status Exam

• Concordance = expressed emotion fit what patient is saying, doing• Appropriateness, responsiveness = expressed emotion sensibly follows

from the precipitating stimuli• Full range = normal variation of emotions during exam• Restricted, constricted range = limited variability of emotion• Stable = normal movement between emotions• Labile = type or intensity shifts suddenly, rapidly• Blunted = few emotions expressed, low intensity• Flat = affect is even less intense than blunted; pt may appear inanimate• Exaggerated intensity

THOUGHT CONTENTDEFINITION: the topics one thinks about ASSESSMENT: observe speech and behavior;

may need to use targeted questions

Delusions = strongly-believed idea, others would clearly see as false; Assess: note in pt's speech; ask targeted questions,

ask "Are you bothered by thoughts that disturb you?"

• Erotic delusions = pt believes that another person, often of higher social status, is in love with him/her

• Grandiosity = pt believes that he/she has unusual talent, virtue, insight, identity

• Delusions of reference = pt believes that ordinary external events (bystander conversations, radio, TV) have special significance secretly intended for the pt

• Ideas of reference = same as above, but pt questions whether or not it is true

Mental Status Exam

• Magical ideation = pt believes in magic cause-and-effect, (e.g. thinking a thing makes it so)• Nihilism = pt believes that a person, part of the pt's body, part of the world does not exist; "I lost my body in my childhood and now I do not have a body“• Paranoia = pt believes others are working against him/her; often secretly, conspiratorially• Persecution = pt sees life events as punishments for previous misdeeds, real or imagined• Somatic = pt believes he/she has a defect or disease• Thought broadcasting = pt believes that his/her thoughts are audible by

others• Thought insertion = pt believes that he/she is thinking thoughts that are

actually someone else's thoughts, somehow physically places into the patient's head

THOUGHT CONTENTMental Status Exam

THOUGHT CONTENT

• Thought blocking = pt believes that he/she would like to think a thought in his/her head, but someone else is physically

preventing him/her from doing so• Thought withdrawal = pt believes that he/she would like to think a

thought in his/her head, but someone has physically removed the thought

• Preoccupations = ideas which dominate pt's thought, more voluntary than obsessions

• Obsessions = involuntary, unwelcome ideas persistently intrude on thinking, demand pt's attention even though pt may recognizes ideas as irrational

• Repeating themes (e.g. guilt, worthlessness, hopelessness, death themes, fears, worries)

Mental Status Exam

THOUGHT PROCESSDEFINITION: the movement of thought, the dynamics of how one thought connects to the next ASSESSMENT: observe pt's speech, some behavior; may need a few

targeted questions

• Goal-directed = thinking stays on target• Logical = analysis is well founded, makes sense• Coherent = thought process is apparent and understandable• Echolalia = pt merely repeats what is said to him/her• Neologisms = nonsense words or real words nonsensically;

e.g. "I fribish the cot," "I table the stairs“• Tight associations = one thought sensibly leads to another reasonable thought• Loose associations = one thought leads to another somewhat less

reasonable thought• Clang association = where one word follows next based only on

rhyming; e.g. "I want to say the play of the day, ray, stay, may I pay"

Mental Status Exam

• Rambling = thoughts appear nonsensical, unrelated to one another; complete loosening of associations

• Word salad = totally incomprehensible, gibberish, real words may be admixed with neologisms

• Circumstantiality = unnecessary digression, wanders from point, with unreasonably excessive detail, but eventually returns to the main "stream" of thought

• Tangentiality = same as above, but does not return to the original main "stream" of thought

• Perseveration = pt continues to repeat idea, phrase, or word; trouble shifting to a new idea• Flight of ideas = rapid shifting between usually related thoughts;

speech may be pressured• Blocking = stream of processing seems to stop suddenly, pt may

suddenly stop speaking; can be an arrest in thought, or hallucinatory material grabbing pt's attention

THOUGHT PROCESSMental Status Exam

iiFrontal LobesThe frontal lobes are important for attention, executive function, motivation, and behavior. Tests for frontal lobe function include working memory (digit span, spelling backward), judgment, fund of knowledge, task organization and set generation such as naming lists of things in a certain category.

iiTemporal LobesThe temporal lobes are important for emotional response (amygdala and its connections to the hypothalamus and frontal lobes) and memory (hippocampus and limbic connections). Clinically the main tests for temporal lobe function are those of memory, particularly declarative memory.

iiLanguage- Temporal and Frontal LobesThe principle area for receptive language is Wernicke's area, which is located in the posterior part of the superior temporal gyrus of the dominant temporal lobe. The major region for expressive language is Broca's area located in posterior part of the inferior frontal gyrus of the dominant hemisphere. Homologous regions of the non-dominant hemisphere are important for the non-verbal contextual and emotional aspects as well as the prosody (rhythm) of language. Tests for written and spoken receptive and expressive language are used to "view" these language centers.

iiParietal LobesThe parietal lobes are important for perception and interpretation of sensory information especially somatosensory information. The non-dominant parietal lobe is particularly important for visual-spatial function. The dominant parietal lobe is important for praxis, which is the formation of the idea of a complex purposeful motor act while the frontal lobes are important for the execution of the act. Clinical tests for parietal lobe function include tests for agnosia (such as inability to identify objects by tactile exploration), apraxia (inability to perform purposeful motor acts on command) and constructional apraxia (inability to draw objects which require use of visual spatial organization).

ii

Occipital LobesThe occipital lobes are important for perception of visual information. Areas in the inferior temporal visual association cortex are important for recognition of color and shape as well as the recognition of faces. Projections from the occipital lobe to the superior temporal-parietal area are important for perceiving motion of objects. Tests that are used to examine the occipital lobes and its connections include visual fields (see Cranial Nerve 2), naming of objects, naming of colors and recognition of faces.

Mentation• Awareness

Orientation (oriented to time, place, and person)Level of consciousness (awake, obtunded, stuporous,

semi-comatose, comatose)• Speech Normal, dysphasia, dysarthria, dysphonia• General knowledge

Knowledge of current events, vocabulary• Memory Intact, recent memory impaired,

remote memory impaired• Retention and recall

Recall of objects, digits forward and reversed• ReasoningJudgment insight, abstraction (interpretation of proverbs, similarities, and differences)

The Neurologic ExaminationMental Status Exam

• Object recognition Normal, agnosia • Praxis Ideational and ideomotor apraxia • Perception Delusions, illusions, hallucinations• Mood Normal, euphoric, depressed, anxious, agitated• Affect Normal, flat, inappropriate

The Neurologic ExaminationMental Status Exam

Here is an example of some terms to use in your MSE. Appearance:

Age (chronological age and whether the person looks this age) Sex, Race Body build (thin, obese, cachectic, muscular, frail, medium) Position (lying, sitting, standing, kneeling) Posture (rigid, slumped, cross-legged, slouched, comfortable, threatening) Eye contact Dress (what individual is wearing, cleanliness, condition of clothes, neatness, appropriateness of garments) Grooming (malodorous, highly perfumed, dirty, unshaven, smelling of alcohol, hairstyle, makeup) Manner (cooperativeness, guarded, pleasant, suspicious, glib, angry, seductive, ingratiating, evasive, friendly, inappropriately familiar, hostile)

Mental Status Exam

THE END