School of Nursing

Christopher W. Blackwell, Ph.D., ARNP-CAssistant Professor, School of NursingCollege of Health & Public AffairsUniversity of Central Florida

NGR 5003: Advanced Health Assessment & Diagnostic Reasoning

Unit Three: Mental Status and Neurological System:

Basic assessment of mental status and the neurological system Advanced assessment of mental status and the neurological system Assessment findings of abnormal presentations in mental status and the neurological

system Differential diagnoses of mental status and the neurological system Advanced Clinical reasoning: A case study approach

ADVANCED ASSESSMENT OF MENTAL STATUS

LEARNING OBJECTIVES1. Identify aspects of an interview that facilitate mental status examination.2. Describe techniques to assess mental status in the following areas: physical

appearance, cognitive abilities, emotional stability, speech, and language skills.3. Recognize findings that deviate from expected findings.4. Compare and contrast common conditions affecting mental status.5. Identify conditions affecting mental status in various age groups.

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Outline for Chapter 4: Mental Status

Mental Status Mental status is the total expression of a person’s emotional responses, mood,

cognitive functioning, and personality and is closely linked to the individual’s executive functioning.

The mental status portion of the neurologic examination is performed continuously throughout the entire interaction with a patient and its major focus is identification of the individual’s strengths and capabilities for interaction with the environment.

Anatomy and Physiology The cerebrum is primarily responsible for an individual’s mental status. The gray

outer layer (cerebral cortex) houses higher mental functions, perception, and behavior.

The hemispheres of the cerebrum are divided into several lobes: Frontal: associated with speech, emotions, memory. Parietal: processes sensory data. Temporal: responsible for perception and interpretation of sounds and their

sources; contains the speech area; involved in long-term memory the comprehension of language and the integration of behavior, emotion, and personality. Long-term memory is associated with this area.

Limbic: mediates behavior that determines survival and reactions to emotions; expression of affect is mediated by the connections between the limbic system and the frontal lobes.

Age- and Condition-Related Variations Infants and children. Brain cells are present at birth, but it takes the first years of

life for brain cells to fully develop and myelinize. Insults and environmental influences affect intellectual development.

Adolescents. Intellectual maturation continues. Vocabulary increases, abstract thinking develops, and logical reasoning develops. The child is able to make generalizations, determine future plans, and consider risks and possibilities. Judgment begins to develop. Values are reflected in thinking and action.

Older adults. Problem-solving skills decline; vocabulary skills remain much the same. Remote memory may be better than recent memory. There is a decline in synthesis and metabolism of neurotransmitters. Metabolism is adequate to respond to stress. There is an increased risk of delirium.

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Review of Related History

History of Present Illness Disorientation and confusion. Ask patient to describe onset, duration, associated

problems (e.g., head injury, loss of vision or hearing), associated symptoms (e.g., mood swings, anxiety, change in appetite), and medications taken.

Depression. Explore troubling thoughts or feelings of the patient, as well as energy level, recent cause of grief, change in lifestyle, feelings of harming self, and medications taken.

Anxiety. Assess the patient for sudden, unexplained attacks of intense fear, anxiety, or panic for no apparent reason and for fear of not being able to get help or of not being able to escape in certain situations, difficulty controlling worrying, and spending more time than necessary doing or checking things over and over again. Also assess for the patient’s interactions with others, a recent traumatic event, associated symptoms, and any current medications.

Past Medical and Family History Ask patient about any history of neurologic disorders, brain surgery, psychiatric

counseling or hospitalization, mental retardation, Alzheimer disease, or learning disorders.

Personal and Social History Pertinent data include emotional status, feelings of discouragement, life goals,

relationship with family members, intellectual level, sleeping/eating patterns, weight loss/gain, anxiety, and use of alcohol or street drugs.

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Age- and Condition-Related Variations Children. Areas relevant to children are speech and language, behavior,

performance of self-care activities, personality and behavior patterns, and learning or school difficulties.

Adolescents. Ask adolescents about risk-taking behaviors, school performance, and family interactions. Remember that adolescents may be reluctant to communicate and to speak of attitudes and experiences.

Older adults. Ask patient about any experience with depression or changes in mental functions.

Examination and Findings

Summary of Examination—Mental Status Observe physical appearance and behavior. Investigate cognitive abilities by assessing the following:

State of consciousness Response to questions Reasoning Arithmetic ability Memory Attention span

Evaluate emotional stability from the following: Signs of depression or anxiety Disturbance in thought content Hallucinations

Observe speech and language by the following: Voice quality Articulation Coherence Comprehension Aphasia

Additional ProceduresGlasgow Coma Scale

The Glasgow Coma Scale is often used to quantify consciousness when a patient has an altered level of consciousness because of head trauma or another hypoxic event.

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Three scores are added to produce the Glasgow Coma Score, of which a maximum score of 15 indicates the optimal level of consciousness.

The lower the score, the more severe the impairment in consciousness. The lowest score possible is 3, indicating deepest coma.

Expected Findings in Infants and Children By 2 months, the infant should appear alert, quiet, and content, and should

recognize the face of a significant other. Also, by the time the infant is 2 to 3 months old, the examiner should be able to coax the infant to smile.

Drooling is common in the first year because of teething. By 2 years of age, drooling should disappear.

The infant’s cry should be loud and angry. Cooing and babbling are expected after 3 to 4 months. One or two words should be distinct by 9 to 10 months.

Immediate recall can be tested with repetition exercises: a 4-year-old can repeat three digits; a 5-year-old can repeat four digits; a 6-year-old can repeat five digits.

Older preschoolers are more skilled with remote memory than younger children. The Denver II is a useful tool in determining whether a child is developing fine

and gross motor skills, language, and personal-social skills as expected.

Findings Associated with Disorders in Infants and Children Drooling after 2 years of age could be caused by mental retardation or anomalies

of the teeth or upper gastrointestinal tract. A shrill, whiny, or high-pitched cry suggests a central nervous system deficit. Delayed developmental milestones, an inability to discriminate between two or

more stimuli, impaired short-term memory, and a lack of motivation could be indicative of mental retardation.

A combination of behavior problems that interfere with the child’s ability to learn such as developmentally inappropriate inattention, impulsivity, and hyperactivity could be indicative of attention deficit disorder.

A pervasive developmental disorder that arises before 3 years of age and includes a combination of behavioral traits and communication deficits may be an autistic disorder, which may result from left brain dysfunction.

Expected Findings in Older Adults Deterioration of intellectual function should not be found until 70 years of age

unless the patient has a disease of the central nervous system or a disease that affects the central nervous system.

Problem-solving skills that deteriorate with age may be related to disuse. Recent memory deteriorates before remote memory. Ability to perceive spacial relationships and to reason abstractly declines with age.

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Older adults may have problems understanding new concepts by 80 years of age.

Findings Associated with Disorders in Older AdultsDementia of Alzheimer Type

Dementia of Alzheimer type accounts for approximately 60% to 70% of dementia cases, of which there is severe progressive deterioration in mental functions with a subtle, insidious onset.

The duration and rate of progression varies and an impaired ability to learn new information or to recall previously learned information is present.

The disorder leads to profound disintegration of personality and to eventual complete disorientation.

Women, especially those with a positive family history, are at greatest risk.Vascular Dementia (Multi-Infarct Dementia)

Vascular dementia has a rapid onset with deterioration in cognitive ability, often related to a series of infarcts in the cerebral blood vessels.

The patient has impaired memory, leading to an inability to learn new information or to recall previously learned information, in addition to aphasia, apraxia, agnosia, or a disturbance in executive functioning.

Risks include long-standing hypertension and small strokes often without significant loss of muscle strength.

Symptom onset may be sudden or subtle depending upon the location, size, and frequency of the infarct and a stepwise deterioration of cognitive function occurs with plateaus and occasional episodes of improvement.

Disorders of Altered Mental Status Delirium. An acute confusional state accompanied by a disorder of perception. Delirium tremens. The brain’s response to withdrawal of alcohol that had been

consumed in large quantities over time. Dementia. A clinical syndrome of failing memory and impairment of other

intellectual functions, behavioral abnormalities, and personality changes resulting from a chronic progressive deterioration of the brain.

Concussion. A temporary alteration in mental status resulting from brain injury due to sports injuries, motor vehicle crashes, and falls.

Disorders of Mood Depression. A common psychiatric disorder resulting from a lack of important

neurotransmitters that function at the synapses between neurons in the brain. Mania. Caused by a chemical imbalance in the brain. Mania is a persistently

elevated, expansive, or irritable mood lasting longer than a week; it is caused by a biochemical imbalance in the brain.

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Anxiety disorders. A group of disorders with marked anxiety or fear at such a high level that significant interference is noted with personal, social, and occupational functioning. Specific disorders include panic attacks, panic disorders, agoraphobia, specific phobias, obsessive-compulsive disorder, and acute and post-traumatic stress disorder.

Schizophrenia. A severe, persistent, psychotic disorder that is a neuroanatomic and neurochemical abnormality that may be either genetically or environmentally induced. It typically has an adolescent or early adult onset that is characterized by relapses and persists throughout life. Major symptoms include hallucinations, delusions, and disordered thinking, speech, and behavior.

ADVANCED ASSESSMENT OF NEUROLOGICAL SYSTEM

LEARNING OBJECTIVES1. Conduct a history related to the neurologic system.2. Discuss examination techniques for the neurologic system.3. Identify normal age and condition variations of the neurologic system.4. Recognize findings that deviate from expected findings.5. Relate symptoms or clinical findings to common pathologic conditions.

Outline for Chapter 5: Neurologic System

Neurologic System The nervous system, with its central and peripheral divisions, maintains and

controls all body functions by its voluntary and autonomic responses. The evaluation of motor, sensory, autonomic, cognitive, and behavioral elements

makes neurologic assessment one of the most complex portions of the physical examination.

Anatomy and Physiology The central nervous system consists of the brain and the spinal cord. The peripheral nervous system is composed of motor and sensory nerves and

ganglia outside the central nervous system. The autonomic nervous system regulates involuntary body function. The sympathetic division reacts to physiologic and psychologic stress. The parasympathetic division conserves body resources. The brain and spinal cord are protected by the skull and vertebrae, the meninges,

and cerebrospinal fluid.

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Cerebrospinal fluid circulates between an interconnecting system of ventricles in the brain and around the brain and spinal cord, serving as a shock absorber.

Brain The brain receives its blood supply from the two internal carotid and two vertebral

arteries that join to form the basilar artery. Three layers of meninges surround the brain and spinal cord and assist with

producing and draining the cerebrospinal fluid. Blood drains from the brain through venous plexuses and dural sinuses that empty

into the internal jugular veins. The three major units of the brain are the cerebrum, the cerebellum, and the

brainstem.

Cerebrum The cerebral cortex houses higher mental functions and controls general

movement, visceral functions, perception, behavior, and the integration of functions.

The frontal lobe houses the motor cortex, which controls voluntary skeletal movement and fine, repetitive motor movements.

The parietal lobe performs sensory data processing and interpretation of tactile, visual, gustatory, olfactory, and auditory sensations. Comprehension of written words and recognition of body parts and position are dependent on the parietal lobe.

The occipital lobe houses the primary vision center and provides interpretation of visual data.

The temporal lobe controls the perception and interpretation of sounds and determination of their source. It is also involved in the integration of taste, smell, and balance. The reception of speech and interpretation of speech is located in Wernicke area.

The limbic system mediates behavior patterns necessary for survival, such as mating and the sense of fear. Memory functions depend on the limbic system.

Cerebellum The cerebellum aids the motor cortex to coordinate voluntary movement. It also

processes sensory data and controls muscle tone, equilibrium, and posture.

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Brainstem The brainstem is the pathway between the cerebral cortex and the spinal cord. It

controls involuntary functions. The nuclei of the 12 cranial nerves arise from medulla oblongata, pons, midbrain, and diencephalon. The thalamus is the major integrating center for perception of various sensations, such as pain and temperature, and serves as a relay center between the basal ganglia and the cerebellum.

Cranial Nerves Cranial nerves are peripheral nerves that originate from the brain. Each nerve has

sensory or motor functions. Four cranial nerves also have parasympathetic functions.

Basal Ganglia The basal ganglia serve as the pathway between the motor cortex and the upper

brainstem, and they contribute to gross intentional movement without conscious thought.

Spinal Cord and Spinal Tracts The spinal cord runs from the foramen magnum to L1 and L2 of the vertebral

column. Grouped fiber tracts carry sensory, motor, and autonomic impulses between the brain and body. Myelin-coated white matter contains the ascending and descending tracts, which control muscle tone and posture, and the ascending tracts, which mediate sensations.

The gray matter contains nerve cell bodies. Upper motor neurons make up descending pathways from the brain to the spinal

cord. Lower motor neurons originate in the anterior horn of the spinal cord and extend into the peripheral nervous system.

Spinal Nerves Sensory and motor fibers of each spinal nerve supply and receive information in a

specific body distribution or dermatome. The anterior branches of spinal nerves form nerve plexi. The spinal nerve may complement the effort of a related nerve or help compensate for some loss of function. Several peripheral nerves originate from the nerve plexi.

Within the spinal cord, each spinal nerve separates into ventral roots, which carry impulses from spinal cord to muscles and glands, and dorsal roots, which carry impulses from sensory receptors to the spinal cord. Impulses may initiate a reflex action when synapsing with the motor fiber after a stimulus. Reflex depends on intact afferent nerve fibers, functional spinal cord synapses, intact motor fibers, functional neuromuscular junctions, and competent muscle fibers.

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Age- and Condition-Related Variations Infants and children. Most brain growth and myelinization of the brain and

nervous system occur in the first year after birth. Damage from infection or trauma during this first year may affect brain function.

Primitive reflexes are present in the newborn; these may become inhibited as cortical function and voluntary control evolve. Motor maturation occurs in a cephalocaudal direction. Development occurs in an orderly sequence, although timing varies among children. Brain growth continues until 12 to 15 years of age.

Pregnant women. Hypothalamic-pituitary neurohormonal changes occur during pregnancy. Physiologic alterations include contraction or tension headaches, and acroparesthesia (numbness and tingling of the hands). Pregnant women increase nap time and sleep time during the first trimester.

Older adults. After 50 years of age, brain cells may decrease 1% a year. Between the ages 30 and 90, the velocity of nerve impulse conduction declines 10%. Touch and pain stimuli sensation may diminish.

Review of Related History

History of Present Illness Seizure or convulsions. Patients with seizures should be asked about the sequence

of events, including character of symptoms, presence of aura, level of consciousness, automatisms, muscle tone, and postictal behavior. Relationship of seizure to time of day, meals, fatigue, emotional stress, or activity before attack should be recorded, as well as frequency of seizure and any medications taken.

Pain. Pertinent data include the onset, quality, intensity, location, and path of the pain. Patients should also be asked about associated manifestations (e.g., crying, sweating, and tremors), as well as efforts to treat and medications taken.

Gait coordination. Areas to assess include balance problems and falling tendencies. Associated problems (e.g., arthritis, stroke, or seizure) should be explored, as well as medications taken.

Weakness or paresthesia. Patients should be asked to describe the onset and character of the problem, as well as any associated symptoms (e.g., tingling, pain, or joint stiffness), concurrent chronic illness, and medications taken.

Tremor. Pertinent data include onset (sudden or gradual) and character (e.g., worse with rest). Also note any associated problems, methods that provide relief, and any medications taken.

Past Medical History Relevant data include past incidence of trauma (e.g., head, spinal cord, or

localized injury), meningitis, congenital anomalies, cardiovascular problems, or neurologic disorders.

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Family History Pertinent data include family history of neurofibromatosis, Huntington’s chorea,

muscular dystrophy, or Tay-Sachs disease. Incidence of mental retardation, seizure disorder, headaches, alcoholism, Alzheimer disease, learning disorders, gait problems, or metabolic problems (e.g., thyroid or hypertensive disease) should also be noted.

Personal and Social History Ask patients about environmental or occupational hazards, use of alcohol or

mood-altering drugs, medications taken, ability to care for self, and sleeping or eating patterns. Hand, eye, and foot dominance should also be assessed.

Age- and Condition-Related Data Infants. Relevant data include prenatal history (e.g., mother’s health), exposure to

TORCH viruses, birth history (e.g., Apgar and gestational age scores), respiratory status at birth (e.g., resuscitative efforts), neonatal problems (e.g., seizures, jaundice, or swallowing difficulty), congenital anomalies, hypotonia or hypertonia in infancy, and any developmental delays.

Children. Document developmental milestones (e.g., age of first smile and achievement of head control), loss of previously achieved function, performance of self-care activities (e.g., dressing, toileting, and feeding), and any health problems (including headaches, seizure activity, or any clumsiness, unsteady gait, or frequent falling).

Pregnant women. Data relevant to pregnant women include weeks of gestation or EDC, as well as any convulsions or headaches.

Older adults. Older patients should be asked about any pattern of increased stumbling, falls, or interference with daily activities. Hearing loss, vision deficit, or anosmia should be noted.

See Risk Factors: Cerebrovascular Accidents (p. 774).

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Examination and Findings

Summary of Examination—Neurologic SystemInspection Observe appearance and behavior. Note state of consciousness and emotional stability. Note communication skills.Proprioception and Cerebellar Function Evaluate coordination and fine motor skills:

Assess rapid, rhythmic, alternating movements. Assess accuracy of movements by performing the following tests: Finger-to-finger test Finger-to-nose test Heel-to-shin test

Evaluate balance: Perform Romberg test to assess equilibrium. Observe and assess gait.

Sensory Function Evaluate primary sensory functions by performing the following tests:

Superficial touch Superficial pain (If superficial pain sensation is not intact, perform temperature and

deep pressure sensation tests.) Vibration Position of joints

Evaluate cortical sensory functions by performing the following tests: Stereognosis Two-point discrimination Extinction phenomenon Graphesthesia Point location

Reflexes Evaluate superficial reflexes. Evaluate deep tendon reflexes by testing biceps, brachioradial, triceps, patellar, and

Achilles reflexes and testing for ankle clonus.Additional Procedures

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Use the 5.07 monofilament to test for protective sensation on the feet of patients with diabetes mellitus or peripheral neuropathy.

Test for the following signs of meningitis: Nuchal rigidity Brudzinski sign Kernig sign

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Summary of Neurologic System Findings

Life Cycle Variations

NormalFindings

TypicalVariations

Findings Associatedwith Disorders

Adults Smoking impairs smell and taste.

Patients who wear contact lenses may have diminished corneal blink reflex.

Unexpected gait patterns may indicate various neurologic disorders. Cranial nerve impairment may indicate local injury or CNS lesion. Motor neuron lesions cause clinical signs, such as muscle spasticity or flaccidity. Positive Romberg sign indicates cerebellar ataxia or vestibular dysfunction. Sustained clonus suggests motor neuron disease.

Sensory impairment may be from spinal tract, brainstem, or cerebral lesions. Tactile agnosia suggests parietal lobe lesion. Some disorders appear in early and middle-age adulthood.

Multiple sclerosis symptoms occur between ages 20 and 40 years. Myasthenia gravis symptoms appear either between 20 and 30 years of age or in late middle age.

Huntington chorea symptoms appear between 30 and 40 years of age, with death occurring about 15 years later.

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Infants and children

By 2 months of age, infants appear alert, quiet and content, and they recognize significant others.

Social smile develops by 2 or 3 months. Drooling generally disappears by 2 years of age.

Children say 1 to 2 words by 9 or 10 months of age.

Infants can purposefully release objects by 10 months.

Primitive reflexes, such as yawning, sneezing, and blinking, are present.

Young children often have neurologic soft signs, which should resolve by 7 years of age.

Bones fuse by age 6 years.

At birth, anterior fontanel is 4 to 5 cm in diameter and closes by 24 months.

Posterior fontanel closes by age 2 months.

Third fontanel is normal but may suggest Down syndrome.

Transillumination should show a ring of 2 cm or less, except for the occiput, which is less than 1 cm.

Infant neck is short but lengthens by age 3 to 4.

Skull bruits are common up to 5 years of age.

Disorder and disease symptoms beginning in childhood include symptoms of muscular dystrophy, cerebral palsy, Reye syndrome, mental retardation, and attention deficit hyperactivity disorder.

Pregnant women

During first trimester, pregnant women increase nap time and sleep time.

Late in pregnancy, women experience more frequent night awakening and less sleep time.

Contraction or tension headaches may occur.

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Older adults With age, smell and taste senses diminish.

Tactile and vibratory sensation and position recognition are often impaired with age.

The following cranial nerve changes may occur: reduced ability to differentiate colors, reduced upward gaze, slower adjustment to lighting changes, decreased corneal reflex, middle- to high-frequency hearing loss, and a reduced gag reflex.

Older adults have diminished reflexes.

After age 50, brain cells decrease 1% a year.

Parkinson disease is more common in older adults.

Alzheimer disease and senile dementia are disorders of older adults.

See Box 22-1: Procedure for the Neurologic Screening Examination (p. 775); Table 22-3: Procedure for Cranial Nerve Examination (p. 776); Table 22-6: Procedures for Testing the Integrity of Individual Spinal Tracts for Upper and Lower Motor Neuron Disorders (p. 788); and Table 22-8: Scoring Deep Tendon Reflexes (p. 790).

See Table 22-4: Characteristics of Unexpected Gait Patterns (p. 784); Box 22-2: Patterns of Sensory Loss (p. 788); Table 22-7: Superficial and Deep Tendon Reflexes (p. 789); Differential Diagnosis: Characteristics of Upper and Lower Motor Neuron Disorders (p. 790); and Table 22-14: Neurologic Signs Associated with CVA by Location (p. 804).

See Table 22-9: Indirect Cranial Nerve Evaluation in Newborns and Infants (p. 793); Table 22-10: Primitive Reflexes Routinely Evaluated in Infants (p. 796); Table 22-11: Primitive Reflexes Less Commonly Evaluated in Infants (p. 796); Table 22-12: Cranial Nerve Examination Procedures for Young Children (p. 796); and Table 22-13: Activities for Evaluating Neurologic Soft Signs in Children (p. 797).

See cultural differences discussed in the Physical Variations box (p. 767).Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of

Elsevier Inc

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Course Lecture Content:

• Advanced assessment of mental status and the neurological system

• Assessment findings of abnormal presentations in mental status and the neurological system

• Differential diagnoses of mental status and the neurological system

Christopher W. Blackwell, Ph.D., ARNP-CAssistant Professor, School of NursingCollege of Health & Public AffairsUniversity of Central FloridaNGR 5003: Advanced Health Assessment & Diagnostic Reasoning

Advanced Assessment: Mental Status • Total expression of a person’s emotional responses, mood, cognitive functioning, and personality• Performed continuously throughout the interaction• Anatomy & Physiology:– Cerebrum primarily responsible for mental status– Grey outer layer (cortex) houses higher mental functions (perception & behavior)– Frontal lobe associated with speech formation (Broca); also emotions, affect, drive, awareness of self, and autonomic responses to emotions, goal-oriented behavior, and short-term memory– Parietal lobe associated with sensory perceptions– Temporal lobe associated with sound discrimination/localization (Wenicke), integration of behavior, emotion, and personality, long-term memory– Limbic system controls survival mechanisms (mating, aggression, fear, and affection); affect mediated by limbic and frontal areas

Advanced Assessment: Mental Status – All brain cells present at birth; first years of life for development/myelinization– Adolescents begin to develop abstract thinking, judgment, intelligence, and experience; values take greater shape– NO decline in general IQ with older adults

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– Problem-solving skills decline from disuse in old age; remote memory may be more efficient than recent (does not interfere w/ daily life); increased risk of delirium w/ acute illness (UTI) or metabolic derangement

Advanced Assessment: Mental Status • Review of Related Hx:– Hx of Present Illness:• Disorientation/Confusion : – Onset (abrupt, insidious, associated w/ physical condition, time of day)– Duration (hours, days, or persistent)– Associated problems (visual/hearing loss, neurologic disorders, brain injury, systemic infection, ETOGH w/d, metabolic/electrolyte disorder, CVA, emotional crisis)– Associated symptoms (delusions, hallucination, mood swings, anxiety, sadness, lethargy or agitation, insomnia, anorexia, drug toxicity)– Rx: anticholinergics, benzodiazepines, opioid analgesics, TCAs, levodopa/amantadine, diuretics, digoxin, antidysrhhythmics, sedatives, hypnotics, alternative/complimentary Tx• Depression : – Troubling thoughts/feelings, constant worry, change in life outlook, feelings of hopelessness and inability to control feelings– Energy level, agitation, feel best in AM/PM, feels when fatigued when awakened– Recent cause of grief, change in lifestyle, – Thoughts on dying, thinking of harming self or others– Rx Hx

Advanced Assessment: Mental Status • Anxiety:– Sudden, unexplainable attacks of intense fear, panic for no reason, fear of not receiving needed help/escape, more time spent in verifying things over and over– Avoids situations with other people– PTSD from previous horrifying/traumatic/horrible event– Associated symptoms (panic attacks, obsessions, compulsions)– Rx Hx– PMH:• Neurological disorder, brain injury (residual effects), chronic disease, debilitating conditions, psychiatric Tx/ hospitalizations– Family Hx:

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• Psychiatric disorders, mental illness, ETOHism, mental retardation, autism, Alzheimer’s disease, learning disorders– Personal and Social Hx:• Emotional Status : Self concept, ability to cope with and level of current life stressors, irritabilty/restlessness, decreased libido/activity, problems with $, family, job• Discouragement : Life goals, frustrations, attitudes• Intellectuality : Education, cognitive changes, communication abilities (understand/execute speech), change in memory/thought process• Sleeping/ eating patterns : Anorexia, wt. loss/gain, anxiety; ETOH/Drug use

Advanced Assessment: Mental Status – Children : first words (intelligiblity, quality of enunciation, progression to words/phrases), behavior (temper tantrums, breath-holding, hyperactivity/limited attention span, separation anxieties), ADLs (dressing/toileting/feeding), personality/behavioral changes (related to event/trauma, FUO), learning/school problems (attention, interest, activity level, concentration)– Adolescents : risk-taking, school performance, quality of family interactions– Older Adults : change in: mental/cognitive function, thought process, memory; confusion (sudden/gradual), hopelessness, helplessness, suicidal ideation, withdrawal from self-care and others

Advanced Assessment: Mental Status • Examination and Findings:– Physical Appearance and Behavior:• Grooming : poor hygiene, concern w/ appearance, inappropriate dress (season/gender/occasion), sudden change may indicate depression, psychiatric disturbance, dementia• Emotional Status : concern appropriate for content discussed (consider cultural variations), carelessness, apathy, inability to sense others’ emotions, loss of sympathy, docilility, rage, excessive irritability• Body Language : posture should be erect, eye contact consistent; slumping may be depression or neurologic condition (PD), excessively energetic movts./watchful eyes could indicate tension, anxiety, or metabolic disorder– Cognitive Abilities:• Assess using MMSE: lower scales NORMAL with advancing age and lower education

• Analogies: Ask pt.:

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– What is similar about peaches and lemons; oceans and lakes; trumpet and clarinet?– Complete the comparison: An engine is to an airplane as an oar is to a _____?– What is different about these 2 objects: Magazine: Telephone Book; Bush: Tree”– Inability to answer common knowledge could indicate lesion of L dominant cerebral hemisphere

Advanced Assessment: Mental Status • Abstract Thinking: What is the meaning of a common metaphor?:– Bird in the hand worth 2 in bush– Rolling stone gathers no moss– Inability to answer may indicate dementia, brain damage, schizophrenia, low IQ• Arithmetic Ability: Use paper and pencil:– 50 – 7 = ? Continue to subtract 7 until pt. arrives to 8– 50 + 8 = ? Continue to add 8 until pt. arrives to 98– Inability associated with depression/ diffuse brain disease• Writing Ability: – Write-out personal address» Omission/addition of #s, letters, words, etc. indicates aphasia– Draw complex figures (face of a clock, house, flower)» Inability indicates dementia, parietal lobe damage, celebellar lesion, or peripheral neuropathy• Execution of Motor Skills:– Put on lipstick (F) or comb hair (M/F)» Inability termed Apraxia, indicates cerebral disorder• Memory:– Immediate Recall: 5-8 numbers forward; 4-6 numbers backward– Recent: Show pt. 4-5 objects and ask to write these down 10 minutes later– Remote: Verifiable events about past life (mom’s maiden name, HS attended, etc.)– Memory loss can result from disease, infection, temporal lobe trauma, loss of immediate and recent: Dementia

Advanced Assessment: Mental Status • Attention Span:– Ask pt. to perform tasks or complete arithmetic

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– Easy distraction, confusion, negativism, and impairment of recent/remote memory indicates fatigue, anxiety, Rx• Judgment:– How is the pt. meeting familial obligations– What are future plans? Are they appropriate?– Ask: “What would you do if you found a stamped envelope?” Explain meaning of metaphors– Impaired judgment indicates mental retardation, emotional disturbance, frontal lobe injury, or psychosis– Emotional Stability:• Observe mood and emotional expressions (verbal/non-verbal); note mood swings, anxiety, depression, anger hostility, or hypralertness• What is current affect? Is this usual? Are feelings a problem in daily life? Times or experiences more difficult?• Unresponsiveness, hopelessness, agitation, aggression, anger, euphoria, irritability, or wide mood swings indicate mood/affect/feelings disturbance• Observe for appropriateness of sequence, logic, coherence to topics discussed; ideas should be logical and goal directed• Illogical/unrealistic thought process, disturbance in thinking stream indicates emotional/psychiatric disturbance• Obsessive thoughts in making decisions, fears, guilt. Feel like you’re being watched or followed? Compulsively repeat actions? Phobias/compulsions interfere with life? Often indicative of mental dysfunction/psychiatric disorder

Advanced Assessment: Mental Status • Auditory/visual/tactile hallucinations? A/V associated w/ psychiatric disorder and drug use; Tactile: ETOH W/D– Speech and Language Skills:• Pt. voice should be clear and strong; speech fluent and articulate w/ clear expression of thought• Dysphonia?: Problems in voice volume/ quality, or pitch (R/O laryngeal innervation problem or larynx disease)• Dysarthria is associated with motor deficit of the lips, pharynx, tongue, or palate; cerebellar dysarthria (poorly coordinated, irregular speech with unnatural separation of syllables) associated with MS• Patient should be able to follow two-step directions• Patient intentions/ perceptions: Word salad, flight of ideas/ loose associations, neologisms, echolalia, clang association all could indicate psychiatric disorder

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• Aphasia can result from neurological brain damage to regions controlling speech (Brocas/ Wernicke)

Advanced Assessment: Mental Status • GCS:

Advanced Assessment: Mental Status • Posturing

Advanced Assessment: Mental Status – Infants and children:• Level of activity and response to environmental stimuli• Watch for drowsiness, stupor, active, or irritable• At 2 mos, infant should be quiet and content, recognizing similar faces• At 2-3 mos, examiner can coax smile; inability is immediate alarm regarding physiologic/neurologic health• Drooling lessens by 1, disappears by 2 (if persists, look for anomalies in mentation [retarded], teeth, upper GI)• Crying should be loud and angry (not high-pitched/hoarse); shrill or whiny/catlike cry/screeching suggests CNS deficit (Cri Du Chat)• 1-2 verbalizations (mama, papa) by 9-10 mos• Screen with DDST• Observe for expressive language milestones (Table 4-3)• Is the child able of playing and having fun?• Memory:– Immediate recall: 4-year olds can repeat 3 digits/words; 5=4; 6= 5 – Recent: Not done– Remote: Assess what was eaten for dinner the night before

Advanced Assessment: Mental Status • Cocaine Addicted Neonate:

Advanced Assessment: Mental Status – Older Adults:• Personality doesn’t change over time with absence of illness• Interpersonal skills should be consistent

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• Existing personality traits may be exaggerated (paranoia)• W/O CNS disease, intellectual function declines after age 70• > 2 errors in drawing a clock indicates cognitive dysfunction• Must consider possible roles of cardiovascular, pulmonary, hepatic, renal, metabolic disease• Screen with Geriatric Depression Scale (4-14)• Review ability to perform ADLs to assess mental status functioning• Rx can cause slow reaction time, disorientation, loss of memory, tremors, and anxiety• Problem-solving skills deteriorate from disuse• Recent memory usually not impaired; but will impair before remote• Family members more concerned than memory loss than pt. could indicate dementia• Problems in understanding new concepts > 80• Set Test good evaluation tool: assesses motivation, alertness, concentration, short-term memory, and problem solving; 15-25 = investigate further; < 15 = dementia• Faces should not appear masklike; stance should not be stooped (advanced disease states)

Abnormal Presentations in Mental Status • Disorders of Altered Mental Status:– Delirium: Acute confusional state accompanied by disorder of perception• Pt. unable to orient x 4l orients only to person• Hallucinations common• Could result from w/d from ETOH, Rx, drugs, age-related/neurological impairment, neoplasm, infection, or crisis– Delirium Tremens (DT): W/D from ETOH (elevated VS, irritability, anxiety, restlessness); agitation, confusion, combativeness, panic, seizure, hallucination– Dementia: Failing memory and cognitive impairment. Chronic personality changes resulting from CNS deterioration (memory impairment, aphasia, apraxia, agnosia; social impairment); Alzheimer’s type 60-%70% of older adult cases– Concussion: Temporary alteration in mental status resulting from brain injury (HA, dizziness, dazed look, aphasia, N/V, tinnitus, amnesia); symptoms from 15 min – weeks (LOC serious)

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Abnormal Presentations in Mental Status • Disorders of Mood:– Depression: Lack of neurotransmitters in brain• Feelings of hopelessness, helplessness, suicidal ideation• Anorexia, insomnia, constipation, HA, fatigue• Poor memory/concentration; lack of motivation• Etiology: Rx, grief, neurological diseases, lifestyle change– Mania: Persistent, expansive, elevated mood, • > 1 week• Decreased need for sleep; hyperactivity; poor judgment• Look for problems in social, occupational, interpersonal functioning• Anxiety Disorders: Worries interfere with personal, social, and occupational functioning; PTSD, OCD, panic attack, phobias. Palpitations, tachycardia, N/V/D, dizziness, faintness, paresthesias; MOST COMMON psychiatric disorders• Schizophrenia: Severe, persitent psychotic disorder onset in early 20s; marked by severe hallucinations, delusions, and disordered thought, speech, and behavior• Infants and Children: Mental retardation (look for delayed/missed milestones, inability to discriminate between stimuli; lack of short-term memory); ADHD (inattentiveness, impulsivity, poor self-esteem/ school performance; onset < 7); Autism (left brain dysfunction; onset < 3; deficit in social interaction, language, or imaginative play; lack of awareness of others, preoccupation with certain objects; most are mentally retarded and only 1%-2% progress as functional adults)• Older Adults: Alxheimer’s (disintegration of function to complete disorientation); Vascular Infarct (CVA: longstanding Hx of HTN/ mini-CVA)

Differential Diagnosis: Mental Status • Delirium vs. Dementia

Advanced Neurological Assessment • Anatomy and Physiology:– CNS/PNS– Autonomic (Sympathetic/Parasympathetic)– CSF, made by ependymal cells, line ventricles within the dural sinuses– 3 major units: Cerebrum (higher mental functions; visceral function, perception, behavior– Frontal/ Parietal/ Occipital/ Temporal/ Limbic system); cerebellum (motor cortex for voluntary movts/ equilibrium), brainstem (nuclei of 12 cranial nerves originate, vital centers; thalamus for sensations of pain/temp)

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– Basal ganglia integrates cerebral motor cortex and brainstem (gross movt without intentional thought) – Brain receives 20% of total cardiac output• Anterior: Carotid arteries; • Posterior: Posterior vertebral arteries• Join in midbrain as circle of Willis

Advanced Neurological Assessment – Cord: Foramen Magnum L2– Descending/ascending tracts; upper motor neurons– Sensory and motor fibers supply information in a distribution called dermatomes– Ventral root of spinal nerves carry impulses to muscles and gland; dorsal root to carry sensory impulses– Intruding (trauma, infection, biochemical injuries), events in 1st 2 years of life very detrimental to brain growth and development– Reflexes at birth: yawn, sneeze, hiccup, blink at bright light/sound, PERRL; w/d from pain—development in cephalocaudal direction– Few changes during pregnancy: inc. in tension HAs, acroparestesias; due to postural vessel kinking

Advanced Neurological Assessment • Dermatomes

Advanced Neurological Assessment• Review of Related Hx:– Hx of Present Illness:• Seizure Hx (independent observer report): aura, fall to ground, shrill cry, motor activity, transition phase, changes in face/lips color, LOC, postictal, length• Character of aura (irritability, tension, confusion, blurred vision, focal activity; GI impairment)• LOC (loss, impairment, duration)• Automatism: eyelid flutter; chewing/smacking of lips• Muscle tone: flaccid, stiff, tense, twitching, direction of spasm over body• Postictal Status: weakness, paralysis, confusion, dizziness, HA, muscle aches, fatigue/sleepiness• Timing: Dday, meals, w/ fatigue, emotional stress, excitement, menses, Rx role; Hx is epilepsy—when did it start?• Rx: anticonvulsants (interactions w/ other Rx), alternative agents

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Advanced Neurological Assessment • Neurological-Specific Pain:– HA from meningitis/ encephalitis, neck pain, sciatica, trigeminal neuralgia, herpetic– Onset: sudden/progressive, injury associated– Quality: deep/superficial; aching, throbbing, stabbing, boring, sharp, stabbing, burning, etc.– Location: specific site; radiation/distribution between body parts– Associated symptoms: crying, decreased activity, diaphoresis, rigidity, impaired mentation– Efforts to Tx/ Rx (opioids, NSAID, prescriptions, alternative agents)• Gait Coordination:– Balance: unsteadiness; feeling is listing; – Falling: backwards/forward/consistent; legs simply give way– Associated symptoms: RA of C-Spine, ataxia, CVA, seizure, joint/sensory problems– Rx: phenytoin, pyrimethamine, etopside, vinblastine, prescription/ complementary agents

Advanced Neurological Assessment • Weakness/Paresthesias:– Onset: sudden; w/ sustained activity; timing and activity during intervals between symptoms; rapid/slow– Character: generalized/ specific body system (face/ext); ascending/transient; proximal/distal ext; uni/bilateral, asymmetric; ataxia, loss of balance; hypersensitivity to touch– Associated symptoms: tingling/numbness, confusion, dysphasia, HA, visual disturbance, pain, SOB, limb tightness, joint stiffness/spasm, incontinence– Chronic Diseases: HIV, nutritional deficiency, recent acute illness– Rx: zidovudine, diamenodiphenylsulfone, dideoxyinosine, Amphotericin C, Rx/complimentary agents• Tremor:– Onset (sudden/gradual); character (worse w/ rest, intentional movt, anxiety, uni/bilateral, precise location (ext/head), interference w/ ADLs; associated symptoms (hyperthyroidism, PD, familial tremor, hepatic/renal disorder, ETOH, caffeiene, MS); relieved by rest/activity, ETOH; Rx (neuroleptics, valproate, phenytoin, albuterol, pseudophedrine, antidysrhythmics, corticosteroid)

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Advanced Neurological Assessment – Past Medical Hx: head/spinal trauma, CVA, birth trauma, meningitis, encephalitis, plumbism/ polio, deformities, congenital anomalies, CV problems (HTN, aneurysm); brain surgery, neurological deficit– Family Hx: Hereditary disorders (neurofibromatosis, Huntington chorea, MD, Tay-Sachs disease), ETOHism, MR, epilepsy, HA, Alzheimer, learning disabled, weakness/gait disorder, thyroid disease, HTN, ID/NIDDM– Personal/Social Hx: Environment/occupational hazards (exposure to heavy metals, organic solvents, work w/ heavy-dangerous equipment, work a heights/ in water); hand dominance, ability to perform ADLs; sleeping/eating patterns, wt. loss/gain; anxiety, ETOH, use of Rx/drugs– Infants: Prenatal Hx (mother’s health, Rx taken, infection/TORCH, bleeding, trauma Hx, HTN, ETOH/Rx); Birth Hx (Apgar, gestational age, birth weight, presentation/use of instruments, fetal distress, need for resp. assistance, O2); congenital anomalies; hypo/hypertonia, developmental delay

Advanced Neurological Assessment – Children: Developmental milestones (age of smiling, head control, grasping, transfer of objects between hands, sitting, crawling, walking, toileting); loss of previous achieved function (change in rate of development, age at which expected development slowed); performance of ADLs; impulsive behavior (problems in school, sitting for meals, organizational skills, unable to follow directions/tasks); health problems (HA, unexplained vomiting, lethargy, personality changes, seizure activity); clumsiness, gait, progressive weakness, trouble falling, going-up stairs– Pregnant Women: weeks of gestation/ estimated delivery date, convulsions, seizure activity (PIH), HA, nutritional status– Older Adults: patterns of stumbling/falls, gait problems, safety in home; social w/d, problems in ADLs; hearing/visual deficit, anosmia; transient neurological deficits (TIA)

Advanced Neurological Assessment • Examination and Findings:– Begins with first patient interaction– Consists of assessment of cranial nerves, proprioception/cerebellar function, sensory function, DTRs– See previous table for cranial nerves assessment– Proprioception and Cerebellar Function:• Coordination/ Fine Motor: RRAM, thumb-to-fingers

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• Accuracy: touch patient finger to examiner, changing location; finger to nose (w/ increasing speed); heel-to-shin• Balance: Romberg: close eyes, arms straight to sides, balance each foot for 5 seconds (ensure safety; slight sway normal)• Gait: Watch for shuffling, wide spacing of feet, foot flop, leg lag, scissoring, loss of arm swing, staggering– Sensory Function:• Test hands, lower arms, ABD, feet, and lower legs w/ eyes closed• Compare strength of sensation from side-to-side• Superficial Touch: Cotton lightly to body areas, pt. ID when felt• Superficial Pain: 2 seconds between sharp and dull; ID where felt and type• Temp: ID hot/cold bottles on skin• Vibration: ID tuning fork sensation to sternum, wrist, finger joints, shins, ankle, toes• Position of Joints: Levate-Midline-Depress joints; verify ID of placement

Advanced Neurological Assessment • Assessment of Fine Motor Function

Advanced Neurological Assessment• Romberg

Advanced Neurological Assessment • Cortical Sensory Functions– Stereognosis (place key in pt. hand—verify ID)– 2-Point Discrimination (ID when 2 points become 1)– Extinction (touch cheek, hand, and one other area—ask pt. to ID where felt)– Graphesthesia (draw letter or number on palm—pt. ID)– Point location (touch area of skin, release, pt. ID)– Reflexes: Pt. either sits or lies down; position limb with slight tension on tendon to be tapped• Absence of DTRs could indicate neuropathy/lower motor neuron disorder• Hyperreflexive suggests upper motor neuron disorder

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• DTRs should be symmetric and/or palpable:– 0 = absent– 1+ = sluggish/diminshed– 2+ = expected– 3+ = slightly hyperactive– 4+ = hyperactive with clonus

Advanced Neurological Assessment • DTRs

Advanced Neurological Assessment • Additional Procedures:– Auscultate for carotid bruit– 5.07 Filament: Test for peripheral neuropathy in feet of pt.’s w/ DM and peripheral neuropathy; apply adequate pressure for 1.5 seconds and assess for sensation at all sites– Meningeal Signs:• Brudzinski Sign: Involuntary flexion of the hips and knees w/ nexk flexion• Kernig Sign: Flex leg at knee and hip while pt. supine, then strengthen leg. + if pain and resistance in lower leg to straightening• Nuchal Rigidity: Neck stiffness in meningitis/ICH– Test by having pt. relax head, you raise slowly; should be no pain or resistance– Infants: Observe for spontaneity and symmetry/smoothness in activities; purposeful movt occurs by 2 months; by 10 months-transferring objects hand-to-hand (7) and releasing (10); patellar DTR present at birth; Achilles/brachioradialus at 6 months (test w/ finger); + Babinski through 2 years; facial, EXT, trunk twitching could be signs of epilepsy

Advanced Neurological Assessment • 5.07 Filament Testing

Advanced Neurological Assessment• Brudzinski (A); Kernig’s (B)

Advanced Neurological Assessment• Primitive DTRs• Palmar• Plantar• Moro

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• Placing• Stepping• Tonic Neck

Advanced Neurological Assessment – Children: Done through DDST. Observe child at play, watching gait (wide at first, then closer together) and fine motor coordination; DTRs not tested. Soft signs (22-13) good indicator of developmental delay

Advanced Neurological Assessment– Pregnant Women: DTRs may be accenuated– Older Adults: CNS responses can be delayed; temors and anxiety is common; Rxs often interact; sense of smell and taste diminshed; ability to differentiate color, reduce upward gaze, tactile/vibratory sense decreased; DTRs less brisk; Achille’s/Plantar often absent; Assess with Tinetti Balance and Gait Assessment Tool (22-3)

Abnormal Neurological Presentations • Disorders of the CNS:– HIV-Encephalopathy: HIV-infection of brain tissue leading to progressive dementia (PML); HA, short/long--term memory losses; inability to follow instructions; eventual global impairment (hyperreflexia, increased tonia, chorea-like movts)– MS: Breakdown of blood-brain barrier; immune depletion of myelin sheaths (incontinence, fatigue, muscle weakness, ataxia, visual disturbance, 20-40 years of age)– Generalized Seizure Disorder: Excessive DC of neurons results in involuntary muscle contractions (r/o systemic disease, trauma, infection, CVA)– Encephalitis: Often viral in-origin, inflammation of brian/spinal cord; vector often responsible (fever, malaise, nuchal rigidity)– Meningitis: Inflammation of dura, arachnoid, or pia maters; bacteria or virus (fevers, sweats, chills, HA, seizure, N/V, nuchal rigidity); children protected through Hib/Pneumococcal, college/residential patient inc. risk– Lyme Disease: Caused by ticks carrying Borrelia b.; begins as rash which spreads to bulls-eye appearance (HA, meningitis, encephalitis, ataxia, facial paralysis—early; arthritis later)– Intracranial Tumors: Primary/METS CA; typical s/s include HA, papilledema, N/V, change in LOC, unsteady gait (peak onset 3-12; 50-70)– CVA

Abnormal Neurological Presentations • CT Scan of MS

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Abnormal Neurological Presentations• CT Scan of HIV Encephalopathy

Abnormal Neurological Presentations• Disorders of the PNS:– Myasthenia Gravis: Insidious muscular fatigue caused by acethycholinesterase; initial weakness of face, mouth, throat, neck, ptosis; verified through Tensilon Test– Guillain-Barre Syndrome: Follows non-specific infection; MS of the PNS only temporary; ascending symmetric weakness; 85% recovery—VDRF common– Trigeminal Neuralgia: Sharp pain arising from inflammation of CN V; usually results from artery wearing away myelin (triggers are talking, chewing, swallowing, face washing, etc.—onset 40-60 years)– Peripheral Neuropathy: Motor/sensory loss—most common in hands and feet (DM most common cause; kerosene toxicity and B12 deficiency also causes)—loss of sensation of pain below patella (watch for skin ulceration/deformities)

Abnormal Neurological Presentations • Children:– CP: Syndromes of the brain resulting from hypoxia at birth—significant delays in motor/ sensory function—MR in 60%– Shaken Baby Syndrome: Most common in <1 year; severe coup-counter-coup injuries; assess retinal hemorrhaging and subdural/arachnoid hemorrhage; altered LOC—unresponsive to arousal– HIV-Encephalopathy: Similar to adults, but missed rather than eroded developmental functions– Rett Syndrome: Unknown etiology of progressive encephalopathy in girls between 6-18 months of age; loss of voluntary hand movts, hand-wringing movts/loss of acquired hand skills, ataxia/rigidity of legs, growth retardation, loss of facial expression—autistic behavior; Pictured:

Abnormal Neurological Presentations • CT Scan of Shaken Baby Syndrome

Abnormal Neurological Presentations• CT Scan of Rett Syndrome

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Abnormal Neurological Presentations • Pregnancy: Maternal obstetric palsy results in weakness in lower EXTs due to nerve compression; usually reversible s/p delivery• Older Adults: – PD: Deficiency in dopamine results in poor communication between coordination/ muscle control centers of brain; Hx of encephalitis, drug (cocaine) use, CV disease; usually affects those > 50; intitial symptoms are unilateral tremors which end w/ rest; progresses to head tic, bradykinesia, pillrolling, masked faces, shuffling gait—assess dopamine levels– Normal Pressure Hydrocephalus: Caused by noncommunicating hydrocephalus (sinuses, ventricle, etc.)—ICP is normal (0-15 mmHg); triad marked by gait disorder, psychomotor slowing, and incontinence; usually corrected via ventriculoperitoneal shunt– Postpolio Syndrome: Original disease state results in eventual inability of neurons to sprout new axons; s/s similar to myasthenia gravis but also w/ cold intolerance, joint pain, dyspnea, and dysphagia

Abnormal Neurological Presentations • PET Scan: Pre and Post PD Tx

Differential Diagnosis• S/S of neurological diseases are very similar• Must look at the minor details, usually obtained from Hx:– Onset of S/S– Associated factors (Rx, injury, infection, etc.)– Relieving factors (rest, activity, etc.)– Constitutional: Fever (VS), Malaise, current functional status (ADLs)• Diagnostic Testing:– General Labs: CMP, CBC c Diff, UA, UDS, TSH, Free T4

– General Rad: CXR, CT Scan, MRI– Specific Labs: Dopamine level, Tensilon Test, cardiac markers, EEG– Specific Rad: PET, carotid US

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