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The Neurologic Examination See Harisson's-Part16 Chap 361
The Neurologic Examination See Harisson's-Part16 Chap 361
The Neurologic Examination See Harisson's-Part16 Chap 361
AWARENESS
• ORIENTATION
• LEVEL OF CONSCIOUSNESS
LEVEL OF CONSCIOUSNESS
"AVPU" mnemonic: pt is Alert --> responds to Voice
--> responds to Pain--> is Unconscious
Overview:
to verbal stimuli 3
to pain 2
never 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.
PHYSICAL EXAMINATION OF THE COMATOSE PATIENT:
• General Inspection
• Color
• Scalp & Skull
• Eyes
• Facial muscles
• Oral cavity
• Breath
• Ears
• Neck
• Limbs
• Sensory Examination
Mental Status Exam
ORIENTATION
APPEARANCE
• Gender
• Race
• Apparent age
• State of health
• Position (e.g. supine, sitting, standing)
• Clothing
• Hygiene
• Habitus
• Physical characteristics
(e.g. hair style, amputation)
• Gait
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
Mental Status Exam
COOPERATION
GENERAL KNOWLEDGE
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.
MEMORY
• 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)
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 them
2. Tactile agnosia - inability to recognize simple objects by
palpation; lesions in the parietal lobe
3. Autotopagnosia - loss of appreciation or identification of a
body part; lesions of the parietal lobe
4. 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
PERCEPTION
DEFINITION: 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?")
PERCEPTION
MOOD
DEFINITION: emotional tone the pt subjectively feels
ASSESSMENT: what the pt says
AFFECT
DEFINITION: emotion displayed, what the interviewer observes
ASSESSMENT: facial expressions, body language, laughter, use of
humor, tearfulness
THOUGHT CONTENT
DEFINITION: the topics one thinks about
ASSESSMENT: observe speech and behavior;
may need to use targeted questions
THOUGHT CONTENT
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 PROCESS
DEFINITION: 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