mental status exam and cranial nerves
DESCRIPTION
poerpoint presentation regarding how to test for the mental status nd cranial nerve function of a patientTRANSCRIPT
The Neurological Examination
Dante P. Bornales, MD, MHPEdFellow of the Philippine Neurological Association
In doing the Neuro. Exam., always bear the following in mind:
1. The purpose of the detailed neurological evaluation is to isolatethe “deficits” so that one could make a neurological localization ,reserve the determination of “what is the lesion” after one has correlatedthe findings with the “temporal profile” of the case;
2. The complexity of the procedures relates to the extensiveness of the
functions of the nervous system, it is necessary for a clinician to master the procedure with constant and regular practice so that onecan vary and even short cut the procedures depending on the neurological complaint of the patient;
The Neurological Examination
The Neurological Examination
In doing the Neuro. Exam., always bear the following in mind:
3. It is necessary to integrate parts of the neurological exam with the other parts of the history and general physical examination
eg.: assess MSE and speech during the interviewevaluate some of the CN exam as one go through the
history and PE
4. During the conduct and in the documentation of the findings, make sure that one’s thinking is organized in the following categories:
I. Cerebral Examination / Mental Status ExaminationII. Cranial Nerve ExaminationIII. Motor System Examination, including CoordinationIV. Sensory System ExaminationV. Muscle Stretch ReflexesVI. Other Significant Neurological Findings
The Neurological Examination
In doing the Neuro. Exam., always bear the following in mind:
5. In each of the categories, make sure that one compares “symmetry” of the findings;
6. What you will document are the findings, and not conclusions! Avoidusing “normal” blatantly, rather describe objectively what youobserve from the patient;
7. It is better to commit rather than to omit the seemingly insignificantneurological findings; and,
8. “If one doesn’t write anything, one did not do anything” , a thoroughand detailed documentation of the neurological findings is betterthan a lacking neurological evaluation.
The neurological history and the neurological exam findingsshould closely be correlated in order for one to determine
the nature of the lesion, as follows:
Major Neurological Disease Categories:(Adams and Victor’s: Principles of Neurology)
1. Cerebrovascular Diseases (Vascular Diseases)2. Infections of the Nervous System3. Neoplasms of the Nervous System4. Traumatic Injury5. Neurodegenerative Diseases6. Demyelinating Diseases7. Inflammatory Diseases / Autoimmune Diseases8. Congenital / Developmental Diseases9. Metabolic Diseases affecting the Nervous System
Cerebral Examination / Mental Status ExaminationSpeech, Level of consciousness, Attention and Orientation,Memory processing, Calculation, Abstract thinking, Fund ofinformation
Cranial Nerve ExaminationCN I to XII
Motor System Examination, including Cerebellar testsInspection of body position, Involuntary movements, muscle bulk,Muscle Tone, Manual Motor Testing, Coordination and Gait
Sensory System ExaminationLight touch, pain and temperature, position and vibration senses,Descrimination modalities
Muscle Stretch ReflexesDeep tendon reflexes
Other Significant FindingsSigns of meningeal irritation, primitive reflexes, superficial reflexes
The Components of the Neurological Examination
Things needed for the neurological examination
Don’t forget: the ophthalmoscope for fundoscopy
Mental Status Examination
1. SpeechPhonationArticulation
Language Production
2. Level of consciousness3. Attention and Orientation4. Memory processing
Immediate recallRecent MemoryRemote Memory
5. Calculation6. Abstract thinking7. Fund of information
Mental Status Examination
Speech
Phonation - is the production of sounds as the air passes through the vocal cords
Disorder: dysphonia
Articulation- is the manipulation of sounds as it passes through the upperairways by the palate, tongue, and the lips to produce phonemes
Disorder: dysarthria
Language production- the organization of phonemes into words and sentences, and is controlled by the speech centers in the dominant hemisphere
Disorder: dysphasia or aphasia
Phonation
Assessment:- could have been observed during the history-taking- if not, simply ask questions and get him to talk
- in dysphonia:the speech volume is reducedthe voice sounds husky
- dysphonia is usually due to lesion of the recurrent laryngeal nervesrespiratory muscle weakness (eg. GBS)
Articulation
Assessment:
- ask patient to recite tongue-twisting words “Baby hippopotamus”“kapakipakinabang”
- causes of dysarthria:1. Cerebellar dysarthria - speech is slurred (“drunk”)
with scanning quality
2. Extrapyramidal dysarthria - speech is soft and monotonous
3. Pseudobulbar dysarthria - high pitch with a strangulatedquality; sounds like “Donald Duck”
4. Bulbar dysarthria - nasal quality that may worsen as patient continues to talk
Language production
Assessment:
• establish patient’s handedness (dominant hemisphere dysfunction)• listen to the patient’s spontaneous speech, assess the fluency
and content• assess comprehension by observing his or her response to simple
questions
“open your mouth”; “look up to the ceiling”; “protrude yourtongue”
• assess the patient’s ability to name objectseg: show your wristwatch
• assess the patient’s ability to repeat sentences“no ifs, ands, or buts”
• if any of these features is abnormal, consider aphasia/dysphasia
TYPE OF
APHASIA
LESION SPEECH FLUENCY
SPEECH CONTENT
COMPRE-
HENSION
REPE-TITION
Expressive Broca’s area
Non-fluent normal normal Variable
Anomic Angular gyrus
Fluent normal normal normal
Receptive Wernicke’s area
Fluent Impaired Impaired Variable
Conductive Arcuate fasciculus
Fluent normal normal Impaired
Global parietal Non-fluent Impaired impaired Impaired
Classification of Aphasia
Your task: determine the clinical differences of the different typesof aphasia
Level of Consciousness
components: level of arousal (wakefulness)content of consciousness (awareness)
Level of arousal:
AlertObtundedStuporComa
Your task: define the different levels of consciousness
Level of Consciousness
level of arousal (wakefulness)
• alternatively, can be assessed clinically using the“Glasgow Coma Scale”
content of consciousness (awareness)
• alternatively, can be assessed using the “Mini-MentalState Scale”
Appearance and behaviour
- assessment begins as soon as one meet the patient - look for evidences of self-neglect- observe the patient’s responses to questions during
the history-taking- assess the level of comprehension and insights into
his or her problem
Remember: these questions can be incorporated or are alreadyImplied during the “history-taking”!!!
Attention and Orientation
Attention:
First! Assess that the pt’s comprehension is normal Formal assessment is done using serial reversals:
• spell “WORLD” backwards for me, please• can you name the months of the year backwards • can you count backwards from 10
Attention and Orientation
Orientation:
assess the patient’s orientation to time, place, and personask:
• What day of the week is it today?• How long have you been in the hospital?• Can you tell me where are you now?• What city are we in now?• Who is this person? (point to a family member, or nurse)
Remember: these questions can be incorporated or are alreadyImplied during the “history-taking”!!!
Memory Processing
assess: immediate memory recallrecent memory recallremote memory recall
Immediate memory recall
• establish patient’s comprehension and attention
• test for digit span:
“can you repeat these numbers after me (eg. 293, 9785)please”
- start with 2 or 3 figures- avoid recognizable numbers- a normal person can repeat a five- to seven-digitsequence
Memory Processing
assess: immediate memory recallrecent memory recallremote memory recall
Recent memory recall
• ask to recall about politics, social events, sporting events,taking into account his previous premorbid conditionand socioeconomic status
• ask to memorize a short address (ask the patient back to be
assured that it has been registered); distract pt. for about10 min. by continuing with the other parameters of the MSE,then ask him to repeat the statement
Pearl: most individuals can recall all data in 10 min
Memory Processing
assess: immediate memory recallrecent memory recallremote memory recall
Remote memory recall
• ask about childhood, schooling, work history, or marriage/s(you need a third party to confirm/verify information!!!)
Remember: - the questions in the remote memory processing are alreadyimplied during the interview
- immediate and recent memory are usually affected early in dementing diseases, eg. Alzheimer’s disease
- remote memory is relatively sparred in pts. With minordegrees of brain damage, however always affectedin advanced dementia
Calculation
- should be done in the light of pt’s education
Assessment:• give simple addition and subtraction• do – serial of sevens or threes ( subtracting sevens or
threes serially from 100)
• give simple daily-living-problem solving scenarios, eg. “If a kilo of mangoes cost 75 pesos, how muchwill 5 kilos cost?”
Pearl: dyscalculia is a prominent fetaure of Gerstmann’s syndrome (dyscalculia, R-L disorientation and finger agnosia) caused bya dominant hemisphere lesions like stroke
Abstract thinking
- this is tested by asking the patient to interpret commonproverbs:
“ A bird in the hand is worth two in the bush”“ Ang lumakad ng matulin, kung matinik ay malalim”“ Ang hindi lumingon sa pinanggalingan ay di makararating
sa paroroonan”
- this can also be tested by assessing the patient’s abilityto identify similarities between pairs of objects,eg. “cow and dog”, “air and water”
Your tasks: Define and differentiate the following1. apraxia from agnosia2. cortical and subcortical dementia
Cranial Nerve I – Olfactory Nerve
Assessment:
• Ask patients about any recent change in their sense of smell(eg. Anosmia, parosmia)
2. Check for the patency of the nostrils
3. Examine each nostril in turn, using tobacco, coffee, or cinnamon(use colored vials so that patient will not be able to identify thetest agents even before the procedure)
Tip: avoid using irritating substances (ammonia, alcohol) for thesesubstances could stimulate the trigeminal nerve endings, evenin anosmic patients!
Cranial Nerve I – Olfactory Nerve
Checking for the patency of each nostrils
Cranial Nerve I – Olfactory Nerve
Examine each nostril with the test agent, preferably with the examinerclosing each of the patient’s nostrils
Cranial Nerve I – Olfactory Nerve
• Unilateral loss of smell is usually asymptomatic
• Bilateral loss of smell is always associated with an alteredsense of taste
• Always examine the CN I in all patients with persosnality changes,disinhibition, or dementia (frontal lobe involvement), and in all cases of head trauma
Cranial Nerve I – Olfactory Nerve
Causes of olfactory symptoms:
Anosmiacongenital
nasal sinuses infections/tumorshead injury/cranial injuryfrontal lobe tumorssubfrontal meningiomas
Parosmias (persistent unpleasant smells)nasal infectionshead injurydepression
Olfactory hallucinationstemporal lobe epileptic seizures
Paroxysmal unpleasant smell (burning rubber, gas)psychosis
Cranial Nerve II – Optic Nerve
Examine:
• Visual acuity using the Snellen chartor a near chart
2. Peripheral field of vision by doing the GrossConfrontational Test
3. Do the fundoscopy using the ophthalmoscope
4. Check for reaction of pupils (for CN II and III)
Cranial Nerve II – Optic Nerve
Assessment using the Snellen chart:
• Position the patient 20 ft away from the chart
2. Ask the patient to read the smallest line of print possible,coaxing him to read the next line may improve performance
Ask the patient to cover one eye during the tests for eacheye
3. Determine the smallest line of print from which the patient can identify more than half the letters
4. For those with refractive errors, use a pinhole to correctthe patient’s vision, and record the findings
Cranial Nerve II – Optic Nerve
Assessment using the near chart:
If the Snellen chart is not available, use the near chart. Hold the hand held chart 14 inches away, and do much the same procedure as using a Snellen chart
Cranial Nerve II – Optic Nerve
If the patient is unable to read the largest character, assess his ability to count your fingers at 1 m (report as VA:CF)
If the patient cannot see your fingers, ask him to identify your moving hands (report as VA:HM)
If the patient cannot see hand movements, flash light in front of his eyes (report as VA:LP). If patient is unable to perceive light (VA:NLP), then the patient is medically blind!
Cranial Nerve II – Optic Nerve
The Gross Confrontational Test
1. Sit or stand about 1 m from the patient with your eyes at the same horizontal level
2. Ask the patient to look directly into your eyes and hold your hands halfway between you and the patient
3. Ask the patient to point at your moving finger/s for you to assess his visual fields (Make sure that the examiner’s visual field is normal before the procedure!)
4. The patient’s visual field will match the examiner’s if the head positions are exactly halfway between the examiner and the patient (this is seldom the case)
If a visual defect is detected, test one eye at a time.
In a right temporal field defect, ask the patient to cover the left eye, and with the right eye, to look into your eye directly opposite. Then slowly move a wriggling / moving finger from the defective area toward the better vision, noting where the patient first responds.
Repeat this at several levels to determine the borders.
Your task: review the visual pathway and the visual field defectsthat can be assessed using the Gross Confrontational test
The Fundoscopic examination using the ophthalmoscope
Your task: practice the procedure after the demonstration; makesure that you know how to handle the instrument
before the session ends
This is the area that you will be able to see using your ophthalmoscope
Cranial Nerve II, III – Optic and Oculomotor Nerves
Pupillary Light Reflexes
Ask the patient to fixate on a distant target and shine the light in each eye in turnfrom the lateral side. Observe for the direct and consensual light reflexes
Accomodation Reflex
Accomodation Reflex
Cranial Nerve III, IV, VI – Oculomotor Nerve Trochlear Nerve, Abducens Nerve
Inspect the eyes and note for the position of the eyelids and the presence of any strabismus and ptosis
Strabismus is concomitant if it remains constant all throughout the range of eye movement. It is inconcomitant (paralytic) if it varies
Do pursuit and saccadic movements to assess whether the eye movements are conjugate, and to detect diplopia and nystagmus
Pursuit eye movements
Steady the pt’s. head and hold an object (eg. pen) 4-5 cm in front of the eye
Ask the pt. to follow the moving object throughout the range of the binocular vision in the horizontal and vertical planes in an “H” pattern
Assess the smoothness, speed and magnitude of the movements
Saccadic eye movements
Steady the pt’s. head and to look in all directions as quickly as possible. Assess the velocity and the accuracy of the movements
Describe this patient’s EOM paralysis. (The patient was instructed to look downwards!)
Describe this patient’s EOM paralysis. (The patient was instructed to look to the left!)
Describe this patient’s EOM paralysis. (The patient was instructed to look to the right!)
Describe each of the images and discuss the EOM findings
Cranial Nerve V – Trigeminal Nerve
Motor functions of the CN V
Inspect for wasting of temporalis muscle, which produces hollowing above the zygoma
Ask the patient to clench his teeth together and palpate the temporalis and masseter muscles
The pterygoids are assessed by resisting the pt’s. attempts to open his mouth
In unilateral trigeminal lesions, the lower jaw deviates to the paralytic side as the mouth is opened
Sensory functions of the trigeminal nerve
Using light touch, test for the presence and symmetry of the facial sensation
Test for pain sensation using a pin (with blunt end) in the same fashion as you have tested for fine touch
Reserve the tests for temperature and proprioception if there’s an abnormal finding with pain sensation
Sensory testing of the face
Always:
• instruct the patient on what to do before proceeding with test• show the test objects to be used• ask the patient to close his eyes throughout the procedure
Sensory testing of the face – fine touch
Note for symmetry of the sensation by comparing symmetrical dermatomal segments on the face
Sensory testing of the face – pain sensation
Note for symmetry of the sensation by comparing symmetrical dermatomal segments on the face
Sensory testing of the face – temperature sensation
Note for symmetry of the sensation by comparing symmetrical dermatomal segments on the face
Corneal Reflex (CN V and VII)
Reserve this procedure if one cannot test for the separate functions of the V and VII cranial nerves!
Cranial Nerve VII – Facial Nerve
Sensory testing for the taste (anterior 2/3 of the tongue has less clinical benefit, thus, it is reserved for special cases
Motor functions of the CN VII
Always check for symmetry!!!
Your task: review the facial muscle innervation and differentiate peripheral from central facial paralysis
Describe the facial paralysis of this patient.
Does he has peripheral or central facial palsy?
Cranial Nerve VIII – Vestibulocochlear Nerve
Clinical bedside assessment of hearing is not sensitive, and can detect only gross hearing loss!
Reserve the oculovestibular reflex (Doll’s eye) in unresponsive patients!
Grossly assess hearing in each ear while masking the hearing in the other ear by occluding the external meatus with your index finger
Test the pt’s. sensitivity by whispering numbers into his ears and asking him to repeat it
Weber testCheck for lateralization of sounds conducted through the bones
Rinne test
Compare air conduction and bone conduction
Cranial Nerve IX, X - Glossopharyngeal Nerve, Vagus Nerve
This is the normal palatal arches as the patient opens his mouth and when he says “ahhhhh”
Note for gag reflex by touching the soft palate or the pharyngeal walls separately
sensory: IXmotor: X
Observe for the patient’s voluntary swallowing
Describe the direction of the uvula
Cranial Nerve XI – Spinal Accesory Nerve
The function of the trapezius is assessed by asking the pt. to elevate his shoulders, first without, then with resistance
The function of the sternocleidomastoids is assessed by asking the patient to turn his head and applying resistance, note for the bulk and strength of the muscles
Always check for symmetry of the bulk and strength
Cranial Nerve XII – Hypoglossal Nerve
Describe the findings in this patient when you ask him to protrude his tongue
End of segmentEnd of segment