3-16 The Abnormal Neuro Exam Flashcards
What is the usefulness of the neurological history vs. the exam?
The neurological history, particularly in how the symptoms develop over time (minutes, days, weeks, years, etc.) helps determine the “WHAT” of diagnosis: stroke, infection, demyelination, tumor, seizure, trauma, etc.
The neurological examination helps to determine the “WHERE,” since we know so much about the FUNCTIONS of each segment of the central and peripheral neurological systems
What is the order of the neuro exam?
- Mental status examination
- Cranial nerves
- Cerebellum
- Strengths
- Deep tendon reflexes
- Sensory testing, as needed
- Gait, if possible
What does LOL AMEN mean?
Mental Status Exam
- Level of consciousness
- Orientation
- Language -these may be sufficient in most cases
- Attention
- Memory
- Executive/Intellectual function
- Non-dominant hemisphere
What are the 7 components of the MSE? Quick descriptor for each one?
- Level of consciousness: fully alert, lethargic/sleepy, stuporous, comatose
- Orientation: person, place, time
- Language: spontaneous/fluent/articulation, comprehension/commands, naming, repetition
- Attention: digit span, spelling, months/days forwards/backwards
- Memory: anterograde (recent), retrograde (distant)
- Executive/Intellectual function: verbal fluency, similarities, proverbs, estimates
- Non-dominant hemisphere: visual-spatial and construction skills, neglect, music
Why would you do a mental status exam?
It allows the diagnosis of important medical conditions, and helps in diagnosing and localizing these conditions:
Coma
Aphasia
Delirium
Apraxia and Agnosia
Dementia
Finding these abnormal conditions is far more helpful than simply concluding a patient as “altered mental status,” or as having a “changed mental status.”
Will performing a mental status exam rustle patient’s jimmies?
Generally not, no. (Unless they are standardized patients)
Second and third year medical students may feel most patients will somehow be offended by a mental status examination, or they will feel insulted
In reality, most patients do not have any objections to mental status examinations, unless they are physical uncomfortable or have significant psychiatric problems
Generally, how soon can you start MSE testing when dealing with a patient?
As soon as you start taking history.
it is always good to determine, tactfully, in advance, how much mental status testing can and should be done with each individual patient
Some mental status testing can be done as soon as the history is begun, in reality, as a student gains experience
(Pearl: can also document CN II-XII grossly intact by having a normal patient conversation. This only applies in the real world, though, not PCM.)
What are the various terms to describe LOC? What are the descriptions?
This is the subjective assessment of the physician:
ALERT: fully awake without stimulation, and able to cooperate in a history and physical examination
LETHARGIC: Patient prefers to sleep, but will stay awake with minimal verbal or physical stimulation
STUPOROUS: Patient requires repeated physical stimulation to stay awake
COMATOSE: A sleep like state in which the patient CANNOT be awakened: no further mental status testing is possible!
What is the significance of an abnormal LOC?
A lowered level of consciousness is always significant
Finding a previously alert patient is stuporous or comatose means something is seriously wrong, and is often an early sign of either a new disorder or a worsening of a known one
What problems could be present in a patient with an abnormal LOC?
- The patient has had a new problem such as a decline in the function of an organ system: CNS, heart, lungs, kidneys, liver
- A new medication has produced an adverse effect
- The bacterial infection has spread to the blood: sepsis
- The patient’s hematocrit, glucose or partial pressure of oxygen has declined, or the partial pressure of carbon dioxide has risen
What is the value of testing orientation in the MSE?
Orientation - test for person/name, place, and date/time.
Some physicians add a fourth factor: awareness of their reason for being in the hospital or the doctor’s office
May be affected by any of the medical conditions that cause delirium or dementia
Not always valuable in localizing brain disease, but traditionally tested in virtually all patients
How is orientation documented??
Documentation, if a normal level of consciousness and orientation: AOX3, which is a minimum mental status examination for patients with no apparent neurological disease
What types of abnormal language problems might be picked up on MSE?
Aphasia
Broca’s aphasia
Wernicke’s aphasia
Anomia, (sometimes agraphia too)
Dysarthria
What does aphasia indicate?
Aphasia is ALWAYS an indication that the patient’s DOMINANT HEMISPHERE is impaired:
stroke, hemorrhage, seizure, or trauma, if it is a sudden result,
or a tumor or dementia, if GRADUAL over many months or years
Describe the location and symptoms of Broca’s aphasia.
BROCA’S APHASIA: frontal lobe, usually accompanied by hemiplegia, retained understanding, brief “telegraphic” output
Describe the location and symptoms of Wernicke’s aphasia.
WERNICKE’S APHASIA: less common, superior temporal lobe, fluent, poor understanding
What do Broca’s aphasia and Wernicke’s aphasia have in common?
Both have ANOMIA, or inability to name objects, and inability to repeat
Both usually have limitations in writing, AGRAPHIA
Describe dysarthria, and what causes it.
DYSARTHRIA
slurred or thick speech
may be due to disease of either hemisphere, and sometimes the brainstem, or may be due to a decline in consciousness or medication effect,
or diseases of the larynx or mouth
How do you test language function in patients?
§First of all, listen to patients, beginning with your history taking
§Have patients REPEAT words or simple phrases
§Have patients READ a paragraph
§Have patients WRITE a sentence
§Have patients carry out two or three step functions you read to them: “Close your eyes, stick out your tongue, and raise your right arm”
§Have patients NAME some simple objects, such as a pen, a comb, a cup, etc.
What is apraxia?
Apraxia: Loss of skilled movements and gestures (procedural memory)
loss of complex, multi-step actions, such as combing the hair, brushing the teeth, shaving or putting on makeup, or even getting dressed
Patients cannot carry out these tasks, even though they have sufficient motor and sensory functions to do them
Why does apraxia happen?
Partial damage to the dominant lobe
Likely due to damage to connections between different sites in the cerebral cortex
Common in stroke survivors and in severely demented people
What is Gerstmann Syndrome?
a syndrome specifically caused by damage to the angular gyrus of the dominant PARIETAL lobe
What are the symptoms of Gerstmann syndrome?
- ACALCULIA: Inability to understand numbers or to calculate
- AGRAPHIA: Inability to write
- Inability to distinguish the left and right sides of the patient (or of the examiner)
- Inability to distinguish the individual fingers
What does the loss of attention suggest?
MSE: Attention (Concentration)
may suggest the beginning of delirium
How can attention be evaluated?
- Do the months (or the days of the week) forward and then backwards
- Serial sevens, subtracting seven starting from 100
- Read a series of letters, asking the patient to raise his hand when he hears the letter “A”
- Have the patient spell “WORLD” forwards and backwards
What is delirium? What are the symptoms?
Delirium: the acute confusional state
May be referred to also as ENCEPHALOPATHY
There may be agitation (aggressive and dangerous behavior), sometimes hallucinations, tremors, wide fluctuations in blood pressure and pulse rate suggesting autonomic nervous system involvement
Usually there is hyper-reactivity to environmental stimulation, or at other times, extreme sleepiness
What does delirium suggest, clinically? What is it often due to?
Delirium suggests in most cases a diffuse systemic problem is affecting large sections of the brain, such as both hemispheres or the entire brainstem
Often due to INFECTIONS INCLUDING SEPSIS, NEW MEDICATIONS (especially opioids), decline of respiratory, hepatic or renal function, meningitis or encephalitis, or ALCOHOL WITHDRAWAL
§Localizes to widespread dysfunction of the entire brain
How do you do MSE testing in a patient with delirium?
Patients with delirium can not reliably be tested for any later parts of the MSE beyond attention, and even their language function may be partially impaired
They are too inattentive to do memory testing, and executive and nondominant hemisphere functions are also damaged
The physician cannot conclude that a delirious patient has these other MSE abnormalities until the delirium clears
What is delirium likely to be comorbid with?
DEMENTED PATIENTS ARE MORE PRONE TO DELIRIUM THAN NONDEMENTED PATIENTS, and sometimes the diagnosis of dementia is first considered in an older patient who has had a first episode of delirium
What regions of the brain does memory testing in the MSE highlight?
Localizes to BILATERAL medial temporal lobe damage, particularly the HIPPOCAMPUS, but the amygdala and the frontal lobes are essential for good memory function
How does Alzheimer’s disease affect memory?
Alzheimer’s disease almost always begins as a progressive loss of memory; first recent, and then distant memory
What is the difference between anterograde and retrograde memory?
ANTEROGRADE: recent memory, or the ability to store new information, up to a few days
RETROGRADE: more distant memories, including autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.)
How is anterograde memory tested?
Testing recent memory: “Please listen to these 3 words, and then repeat them. I will ask you to remember them soon.” Memorize your OWN 3 words, and ask them in approximately 3 – 10 minutes. Some patients deserve a second try.
Occasionally a normal patient will recall only 2/3, but recalling 0, or 1 words on two attempts is pathologic
In addition to recalling 3 words, what are some other methods of testing anterograde memory?
Also tested by:
- “How long have you been in the hospital?”
- Giving a patient a brief story to remember, perhaps three or four sentences long
- “What did you have for breakfast (or lunch, dinner)?”
- Hide three objects in your examining room as the patient watches, and then ask the patient where they were hidden
How and why is retrograde memory tested?
Less often tested, mostly for confirming a diagnosis of dementia
Examples:
- When did you graduate from high school?
- When did you get married?
- How many children do you have?*
- When did you retire?
- When did the Vietnam War (or World War II) occur?
- Can you name some recent presidents?
