Clinical Skills IV

Instructional Book

Neurobehaviour System:

History Taking

Clinical Skills Center

Faculty of Medicine
Pelita Harapan University
Karawaci Tangerang
Semester V
2013
0

CEREBROVASCULAR DISEASE
MUSCLE WEAKNESS
During first part of this semester, the focus will be on aspects of the medical interview and physical
examination that relate to the neurological system. The course material is designed to link with your studies
in the basic sciences of this body system. You will also have the opportunity to develop your
communication skills. This will involve learning how to identify and respond to emotional issues that arise
during a medical interview and to communicate effectively with patients who have hearing or cognitive
impairment.
The first tutorial in this series focuses specifically on muscle weakness as a presenting problem. It also
provides an introduction to the basic examination of the neurological system, with emphasis on testing
motor strength and co-ordination of the lower limbs.
Muscle weakness
There are three components to gathering information from a patient whose presenting problem is
weakness:
(i) Does the patient have true muscle weakness?
Firstly, it is important to clarify whether the patient has true muscle weakness, or whether they are
describing a loss of physical or emotional energy, or another non-neuromuscular problem such as
joint pain or stiffness. People who have motor weakness are not able to perform specific activities,
such as standing up from a squatting position or moving a limb.
(ii) Where is the weakness?
Secondly, the pattern of the weakness needs to be established, in order to help determine the
likely site of the underlying pathology. Muscle weakness can be due to a primary problem involving
muscles or it can be due to conditions affecting the neuromuscular junction, peripheral nerves,
spinal nerve roots, anterior horn cells or the corticospinal tracts. It is therefore important to find out
whether the weakness affects all muscle groups or is confined to a particular area of the body.
If the weakness is generalised, this may indicate a problem such as myasthenia gravis, which
affects the neuromuscular junction. If the weakness is not generalised, the next step is to find out if
it is symmetric or asymmetric. Asymmetric weakness is usually caused by conditions that affect the
central or peripheral nervous systems. If the weakness is symmetric, it can be classified as
proximal or distal or localised. Proximal weakness is usually caused by primary muscle disorders
affecting the axial muscle groups, that is, the deltoids or the muscles responsible for hip flexion.
Distal weakness, in contrast, mainly affects the hands or feet and may be caused by peripheral
neuropathy or motor neuron disease.
(iii) What is the cause of the muscle weakness?
Thirdly, information needs to be gathered to help find out the underlying cause. There are many
causes of muscle weakness, including immunological conditions, malignancy, vascular events,
1

drugs or metabolic disorders. At this level of your training, you are not expected to be able to
determine the underlying cause of a patients muscle weakness.
Applying the cardinal features framework to muscle weakness
Cardinal
feature

Notes

Cardinal
Sitefeature

Where is the weakness? Which muscle groups are weak?

Quality

This cardinal feature is not usually helpful.

Severity

The severity can be quantified by determining what function the patient has in the affected area. Can
the patient move the affected area against gravity or is it paralysed? What cant the patient do
because of the weakness?

Time course

This is an important feature as it can help to point to the underlying cause. Did the weakness come on
suddenly? Does it fluctuate? Is it worse at the end of the day?

Context

Ask the patient if there was anything in particular they noticed at the time the weakness started.

Aggravating
factors

Is there anything that makes the weakness worse? Is there anything that triggers episodes of
weakness?

Relieving
factors

Is there anything that seems to relieve the weakness?

Associated
features

Is the weakness generalised or localised? If localised, is it symmetric or asymmetric? If symmetric, is

it proximal, distal or in another specific pattern?

As you learn more about diseases that cause muscle weakness, you will be able to ask specific
questions that can help point to a diagnosis.
At this stage, you could ask about whether the patient has any pain in their muscles or whether the
weakness is associated with other neurological symptoms, such as sensory changes. You will learn
about sensory symptoms in the next tutorial.

Case Study 4.0

Bill Russell, a 57-year old divorced former house

painter, has been admitted to hospital with muscle weakness for further investigation. He is being
interviewed by Nick Modzrewski, a second year
medical student.
Watch the interview and write down the cardinal
features of Mr Russells presenting problem. Describe the pattern of his muscle weakness.

Building your communication skills

During previous semesters, you learned about basic communication skills, such as active listening,
clarification and effective questioning, which enhance doctor-patient interaction. You also learned how to
build rapport with a patient and conduct an interview. During the next few tutorials, emphasis will be placed
on identifying and responding to a patients physical or emotional discomfort during a medical interview.
Acquiring communication skills at the same time as you learn about the content of clinical medicine has
been shown to augment the application of these skills in real-life practice.
It is important during a medical interview to demonstrate to a patient not only that you are listening
carefully to the information they are conveying, but also that you appreciate the physical or emotional
discomfort or distress that they might be experiencing. This has been shown to be associated with higher
patient satisfaction with the quality of their care. Patients are also more likely to provide further information
if they know that you are interested in their symptoms and willing to understand their experience of illness.
Acknowledging verbal expression of physical discomfort
A patient presenting with a symptom will usually describe some degree of physical discomfort. In Case
Study 4.01, Bill Russell described the discomfort he experienced when he had a fall due to his muscle
weakness. Nick Modzrewski acknowledged this discomfort during his interview with Mr Russell:
MR RUSSELL:

and then yesterday, I had another fall just outside the market I knocked
myself around a bit hurt both knees and scraped my right arm nothing
broken, like but there was a bit of bleedin

NICK:

That doesnt sound too good

MR RUSSELL:

well, it shook me up a bit and I couldnt get up so someone called an

ambulance and they brought me here

Acknowledging non-verbal expression of physical discomfort

A patient may also express physical discomfort in a non-verbal manner. Observe the patients body
language and acknowledge any discomfort it may convey.
It is important to acknowledge the degree of pain that a patient is experiencing. For example:
STUDENT:

Does the pain go anywhere else?

PATIENT:

Not really no

STUDENT:

OK. You do seem to be in a lot of pain .

These communication skills may seem quite straightforward but can be difficult to apply when you are also
concentrating on the content of the interview. It is therefore important that you practice these skills as much
as possible when interviewing patients. It is also important that you apply them in a way that reflects your
personal style of communication.

Role-play D: Muscle Weakness

Eddie Bell
You are Eddie Bell, aged 68 years, and you have come to the doctor today because you have been having
weakness in your left arm and leg.
Opening statement:
I think something is going wrong with my brain, Doc. I keep getting these funny turns and I cant move my
arm and leg properly. My father had a stroke and Im worried that I might be having one too.
If asked to elaborate, say: Well, a couple of times Ive lost the power in my arm and leg and they dont
seem to be able to do what I want them to do. I almost fell over the last time it happened.
Site: Its my left arm and left leg that are affected.
Quality: When it happens, my left arm and leg just feel really heavy and dead. Its a real effort to lift them,
or even move them at all.
Severity: Its pretty bad - I feel really weak when it happens. One time I dropped my mug of tea when I
went weak and almost burned myself. Then another time I almost fell over, but luckily I had time to sit down
before my leg gave way completely.
Time Course:
If asked when this first started, say: 2 weeks ago.
If asked about the onset: Each episode has a very sudden onset and offset.
If asked how often the episodes occur: Its happened about 4 times in the last two weeks.
If asked about the duration of an episode, say: It only seems to last for about 10 minutes, but it feels like
forever. Each time I think Im having a stroke.
Context: I cant think of anything different that Ive been doing. I feel pretty good usually.
Aggravating factors: Nothing seems to bring it on
Relieving factors: Nothing helps when it comes on. It just seems to pass of its own accord.
Associated features: One time my wife said that my mouth was drooping a bit when I felt weak. I felt like it
was a bit difficult to talk properly then too, but then everything came back to normal again, thank goodness.
Past History: High blood pressure and Diabetes. You had a heart attack last year
Smoking: Ex-smoker - you smoked for 20 years but you stopped last year when you had the heart attack.
Your doctor told you to stop.

Medical Interview Assessment Form

Opening segment of interview

Yes

No

No

N/A

Greets the patient

Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement
Exploration of the presenting problem

Yes

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features
Communication Skills

Done Well

Adequate

Done well

Adequate

Needs
improvement

Demonstrates active listening skills

Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions
Interview Management

Needs
Improvement

Is systematic with questioning

Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

CRANIAL NERVE DISORDER

HEADACHE
Headache is one of the most common medical problems in the community. Most people will have
experienced a headache at some time in their life. The majority of headaches are benign and self-limiting,
although they can cause significant morbidity and disruption to activities of daily living. When a patient
presents with a headache, the most important step is to assess whether there might be a serious or lifethreatening cause1,2. Conditions such as brain tumours, sub- arachnoid haemorrhage, stroke and
meningitis can present with headache. Associated features such as acute onset, progressive pattern,
associated neurological features, altered conscious state, fever and neck stiffness, or a history of cancer
are warning signs that a serious cause may be present.
The focus of this tutorial is on chronic headaches where a serious underlying cause has been excluded.
There are two main types of chronic headache: (i) tension-type headache (TTH) and (ii) migraine. Other
less common causes of primary chronic headache exist but you do not need to know about these at this
level of your training. You also do not need to know about the details of secondary headaches, that is,
those that are due to another medical problem, such as dysfunction of the temporo-mandibular joint, drugs
or sinusitis.
Tension-type headache is the most common type of chronic headache3. The underlying cause of this type
of headache is not exactly known. They are usually bilateral and of mild to moderate intensity, although
sometimes can be severe. The character of a tension-type headache is typically described as being like a
pressure or a band around the head or a dull ache. There are usually no associated features, apart from
muscle tenderness of the head, neck or shoulders. Tension- type headaches are usually classified
according to how frequently they occur. An infrequent TTH occurs less than one day per month, frequent
episodic TTHs occur during 1 14 days per month, and chronic TTH is used to describe headaches that
occur 15 or more days per month. TTH can be precipitated by stress or certain movements of the head and
neck.
Chronic headache due to migraine is also common, peaking in the fourth decade and occurring more
frequently in women than men4. The underlying cause is not known but it is thought to be due to neuronal
dysfunction that leads to vascular changes, both intra- and extra-cranially. A migraine headache is typically
unilateral in site, but about 30% are bilateral. It is usually throbbing in character, with gradual onset and
slow offset, and is often associated with nausea, vomiting, photophobia and phonophobia. Relief is often
gained by lying down in a dark, quiet room. Premonitory symptoms include fatigue, difficulty with
concentration, nausea, neck stiffness and blurred vision. Migraine headache is often preceded by an aura,
a complex of neurological symptoms probably related to a decrease in cortical blood flow. Symptoms of an
aura include visual or speech disturbance, sensory symptoms or motor weakness.

Cardinal
feature

Migraine

Tension-type headache (TTH)

Site

Unilateral in about 70% of cases

Usually bilateral

Quality

Dull and throbbing

Non-throbbing

Pulsating

Band like, may be described as

a pressure or tightness

Moderate to severe

Mild to moderate, can be severe

May disrupt daily activities

Usually does not stop the person

from going about their normal
activities

Gradual onset with crescendo pattern; slow offset

Waxes and wanes

Often begins in the mornings although can occur at any time of the
day

Variable duration

Severity

Time course

Lasts for up to 3 days

Context

May occur in the context of a stressful life situation

May occur in the context of a

stressful life situation

Aggravating
factors

May be precipitated by routine physical activity

Not precipitated by routine

physical activity

Stress, menstruation, oral contraceptives, fatigue, lack of sleep,

certain foods, additives to wines

Relieving factors Analgesic medication

Stress, certain head and neck

movements may trigger
headaches
Analgesic medication

Usually better if lies down in dark room with minimal noise

Associated
features

Nausea, vomiting, photophobia and phonophobia

No associated features, except for

mild muscle tenderness

May be preceded by aura, consisting of visual or speech

disturbance, motor weakness and sensory changes

Case Study 4.04

Sally Lewis, a 35-year old mother of two young
children who works part-time in customer service, has been referred to Neurology Clinic for assessment of her chronic headaches. She is being
interviewed by Nick Modzrewski, a second year
medical student.
Watch the interview and write down the cardinal
features of Mrs Lewiss presenting problem. Discuss the features of her presentation that help to
differentiate between migraine and tension-type
headache.

Building your communication skills

Identifying and responding to anxiety
The focus of this tutorial is learning how to respond to a patient who demonstrates anxiety during an
interview.
Anxiety is a common emotional response to being unwell or having treatment in the health care system. It
is important that you learn to identify and respond to anxiety in the medical setting. Firstly, it may represent
an organic problem such as an overactive thyroid gland, or a psychiatric or psycho-social problem that
needs intervention. Secondly, dealing with a patients anxiety can help to build rapport and may facilitate
the interview process. Thirdly, it can be therapeutic for the patient to express their anxiety and to have
someone acknowledge their concerns.
Identifying anxiety in a patient may be quite straightforward if he or she verbally communicates this to you
during the interview. Alternatively, you may notice signs of anxiety, such as fidgeting, rapid speech, sighing
frequently, sweating or tremour.
If a patient seems to be anxious, dont ignore it. If you do not address a patients anxiety, it may
unnecessarily prolong the interview process or you may not elicit important information needed to establish
the diagnosis or make a management plan.
Try to establish why the patient is anxious. Sometimes the reason will not be obvious. Encourage the
patient to talk about their anxiety, but dont pry. Do not dismiss the patients concerns as being trivial.
Provide reassurance if this is appropriate.
Do not transmit your own anxiety about the interview to the patient as this may escalate the situation.

Role-play C: Headache
Background
Joe Martinelli, a 40year old engineer, has come to see his doctor with new onset headaches.
Opening statement
Ive started getting bad headaches. Theyve been coming for about four weeks now and they are really
starting to get me down.
Site: They are always on the right side. They usually start around my eye.
If asked if the pain goes anywhere else, say: It seems to go deep behind my eye and it often moves over
here.
Rub over your right temple area.
Quality: Im not sure how to describe it.
If you are offered a menu of choices, say: That it is a throbbing pain.
Severity:
It is excruciating when it is present. I have to get up and walk around to try to distract myself from the pain.
It stops me from doing anything.
If asked to say how bad the pain is on a scale of 0 to 10, say: Its probably about a 9 or 10 at its worst.
Time Course:
The headaches usually come on suddenly. I dont get any warning and then bang, suddenly its there it
gets really bad after only a few minutes. It usually lasts a couple of hours and then it dies away. Ive been
getting them about once every day or so. Usually the same time, late in the evening.
Context:
Ive noticed that they seem to come on more often when Ive had a few glasses of wine, so Ive stopped
drinking it with my evening meal.
Relieving Factors: Ive tried taking paracetamol but that does nothing
Aggravating factors:
I havent noticed anything in particular. Alcohol seems to bring them on but once they are present, they are
really bad whatever I do.
Associated features:
When I get the headaches, I also get a watery eye and my nose feels stuffy. Sometimes I feel sweaty and
sick in the stomach.
10

Role-play D: Headache
Background
You are Rebecca/ Rob Damitri, aged 24 years, a PHD student in economics.
Opening statement
Ive been getting a lot of headaches lately and its really getting me down. Ive got a lot going on right now
and I cant afford to be out of action with these headaches.
If asked to elaborate:
They are coming more and more often, I feel like I always have one. Its pretty
wearing.
Site: I feel it right around my head, on both sides, like a tight headband.
Quality: Its like a pressure feeling, right around my head.
If asked: It is not throbbing.
Severity: Its not bad enough to put me to bed - Im still carrying on working on my PHD. But its still pretty
painful.
If asked to rate out of 10: 3-4 out of 10.
Time Course: Ive had a headache from most days for the last month.
If asked about progression over time: They are much the same as they were when they started.
If asked about frequency, say: They come most days, often later in the day.
Context: Ive been working really hard on writing my thesis so Im doing pretty long work hours, more so in
the last month. Im also working on weekends a lot, so dont have much time for relaxation.
Precipitating factors: I sometimes wonder if the headaches are brought on by sitting at my desk, but Im
not sure.
Relieving factors: If I take a couple of Panadol then that usually gives me some relief. But I still feel a dull
ache, even after 2 Panadol tablets.
Associated features: I feel a bit sore around my neck and shoulders, like theres a bit of tension there in
the muscles.

11

Medical Interview Assessment Form

Opening segment of interview

Yes

No

No

N/A

Greets the patient

Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement
Exploration of the presenting problem

Yes

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features
Communication Skills

Done Well

Adequate

Done well

Adequate

Needs
improvement

Demonstrates active listening skills

Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions
Interview Management

Needs
Improvement

Is systematic with questioning

Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

12

SENSORY DISTURBANCE
During the last tutorial, the focus was on muscle weakness and the motor neurological examination of the
lower limbs. During this tutorial, you will learn how to interview a patient presenting with sensory
disturbance and perform a sensory examination of the lower limbs. You will also have an opportunity to
develop your ability to identify and respond to emotional issues that arise during a medical interview.
Sensory disturbance
Sensation is the process by which stimuli are detected by specialised receptors in the skin, muscles or
joints and transmitted to the brain via the peripheral nervous system. The processing of this information
allows the body to maintain its posture, react to pain and other noxious stimuli, and use senses such as
touch and hearing to provide information about the surrounding environment. Sensation is an important part
of the bodys defence system. It is a continuous and usually subconscious process. Disordered sensation,
by way of contrast, can be quite intrusive and can lead to considerable disability and distress. As with other
symptoms, it is helpful to have a framework when interviewing patients who present with sensory
disturbance. There are three components to gathering information about this symptom:
(i) What symptoms of sensory disturbance does the patient describe?
Sensory symptoms are usually divided into two main categories: positive symptoms, which are
caused by heightened activity in sensory pathways, and negative symptoms, which are caused by
loss of sensory function.
a. Positive sensory symptoms
Patients experiencing this type of sensory disturbance may describe symptoms such as
tingling, pins and needles, pricking, burning, tightness, a band-like sensation around their
body, or an electric shock. They may also report pain, which is often sharp or stabbing in
nature. Patients who have positive sensory symptoms often do not have a sensory deficit on
physical examination. There are a number of specific terms that are used to describe positive
sensory disturbances:
Term

Meaning

Paraesthesia

Abnormal sensation perceived without an abnormal stimulus

Hyperaesthesia

Abnormal increase in sensitivity to a stimulus

Dysaesthesia

All positive sensory changes, whether due to a stimulus or not (this covers both of the above
terms)

Hyperalgesia

Heightened response to a noxious stimulus

Allodynia

Normal stimulus felt as pain, for example, clothing brushing against body being felt as pain

b. Negative sensory symptoms

13

Patients experiencing this type of sensory disturbance may describe symptoms such as
numbness, coldness or loss of feeling in a particular distribution. Patients who report negative
sensory symptoms often have a sensory deficit on physical examination. There are a number
of specific terms that are used to describe negative sensory disturbances:
Term

Meaning

Hypoaesthesia

Diminished ability to perceive pain, temperature or touch

Anaesthesia

Complete inability to perceive pain, temperature or touch

Analgesia

Complete insensitivity to pain

Note: If a patient has a sensory disturbance that involves the receptors in the muscles, tendons
and joints that serve proprioception, then the patient may report imbalance, and unsteady gait
or a lack of precision with movements. The term sensory ataxia is used to describe these
symptoms.
(ii) What is the pattern of the sensory disturbance?
Establishing the pattern of the sensory loss is helpful in determining the likely site of the underlying
problem. Having a sound knowledge of the underlying anatomy and physiology of the neurological
system facilitates this process. Find out if the sensory loss affects one side of the body, a whole
limb or part of a limb. Also find out if it is symmetric or asymmetric.
Some common patterns of sensory loss are:
(i) A glove and stocking distribution due to peripheral neuropathy
(ii) A dermatomal pattern due to a spinal cord or nerve root lesion
(iii) An area supplied by a particular nerve
(iii) A hemisensory loss, due to a lesion of the spinal cord, brain stem, thalamus or cortex
(iv) What is the underlying cause of the sensory disturbance?
Sensory changes may be due to medical conditions affecting either the central nervous system or
the peripheral nervous system. Central nervous system conditions that cause sensory disturbance
include cerebrovascular disease, multiple sclerosis and tumours. A wide range of conditions can
affect the peripheral nervous system, including diabetes mellitus and alcohol excess. Nerve
entrapment syndromes are a common cause of peripheral sensory disturbance. As you learn more
about medical conditions, you will be able to ask patients specific questions in order to establish
the underlying cause. You are not expected to be able to do this at this stage of your training.

14

Applying the cardinal features framework to sensory disturbance

Cardinal feature

Notes

Site

Where is the sensory disturbance? Does it affect one half of

the body? A whole limb? Part of a limb? Is it symmetric or
asymmetric?

Quality

Establish whether the patient had positive or negative sensory

symptoms or a combination of the two.

Severity

Severity can be quantified by determining the degree to

which the sensory symptoms disrupt the patients life.

Time course

This is an important feature as it can help to point to the

underlying cause. Did the sensory disturbance come on
suddenly or over days to months? Is it worse at night?

Context

Ask the patient if there was anything in particular they

noticed at the time the sensory disturbance started.

Aggravating factors

Is there anything that makes the sensory

disturbance worse?

Relieving factors

Is there anything that seems to relieve the sensory

disturbance?

Associated features

As you learn more about diseases that cause sensory

disturbance, you will be able to ask specific questions that can
help point to a diagnosis.
At this stage, you could ask about whether the patient
has noticed any associated neurological symptoms, such
as muscle weakness or gait disturbance. If they describe
loss of sensation, enquire as to whether they have
sustained any injuries, such as ulcers or burns, as a
result.

15

Case Study 4.02

Julie Davidson, a 55-year old office worker with
a history of palpitations, syncope, rectal bleeding
and oesophageal reflux, has developed sensory
symptoms in her feet. She is being interviewed by
Jane Lee, a second year medical student.
Watch the interview and record the cardinal fea-tures of Ms
Davidsons presenting problem. Iden-tify the positive and
negative symptoms and list them below. Describe the
distribution of her sen-sory disturbance.

Positive sensory symptoms

Negative sensory symptoms

16

Building your communication skills

In the last tutorial, the importance of acknowledging a patients physical discomfort was discussed.
Identifying and responding to a patients emotional discomfort or distress is an equally important skill in
medicine. It is, however, a skill that many medical students find confronting. During this
semester, the basic principles of this skill will be integrated into your clinical skills training.
Identifying emotional distress or discomfort
Many people express some type of emotion, such as anxiety, sadness, anger or happiness, when talking
about their health. They may be worried about their medical disorder, have a psychological problem or be
experiencing social problems at home or at work. Furthermore, emotional responses can be a sign of an
organic brain disorder, such as a brain tumour.
It is important that you learn to identify and respond to such emotional responses. Firstly, the emotional
response may represent a serious organic, psychiatric or psycho-social problem that needs urgent
intervention. Secondly, responding to a patients emotions can help to build rapport and may make him or
her more comfortable in revealing important information about their physical symptoms or psycho-social
circumstances. Thirdly, it can be therapeutic for the patient to express their emotions and to have someone
acknowledge the distress that they are experiencing.
Identifying a patients emotional distress will often be straightforward. He or she may tell you about their
emotions or demonstrate them in an obvious non-verbal way, such as by crying, being angry or appearing
anxious. Sometimes the signs that a patient is distressed are more subtle. Reduced eye contact or a
change in posture, for example, may be the only indication that the patient is experiencing emotional
distress. Psychological problems can also present as physical symptoms, such as headaches or fatigue. It
is important, however, that you do not assume that a patients symptom is due to a psychological cause
without thorough evaluation. With experience, you will become more alert to subtle presentations of
emotional or psychological problems.
Many of the generic communication skills that you have learned so far are helpful when
responding to a patients emotional distress. Active listening skills such as reflecting, restatement and
paraphrasing, in particular, can be very effective. It is important to reflect not only the patients words, but
also their emotions. There are also specific skills that can be applied to particular situations. During this
tutorial, the focus will be on the patient who is crying. Responding to a patient who is anxious or angry will
be addressed in subsequent tutorials.
Responding to a patient who is crying
In Case Study 4.02, Julie Davidson started crying while talking with Jane Lee. Discuss how Jane
responded to this situation as you go through the following notes with your tutor.

17

Crying is a common response to emotional distress. If a patient starts to cry while you are interviewing
them, dont ignore it. Acknowledge that he or she is upset, and convey to them that crying is a legitimate
response to a difficult situation. If you have been writing notes during the interview, stop and put your pen
down.
Try to establish why the patient is distressed. Sometimes the reason will not be obvious or what it seems.
Crying, for example, may mask the fact that the patient is angry about something. Encourage the patient to
express their feelings, however if they dont want to talk about what is making them distressed, dont pry. It
is important to respect patients privacy.
Offer practical help. Provide the patient with a box of tissues if possible. Ask what you can do for the
patient. Also ask if they would prefer that you stay or if they would prefer that you left them alone. If the
patient seems significantly distressed, it is best to advise someone such as the nurse who is looking after
the patient on the ward or the doctor who is supervising you.
Use silence effectively. You may feel it is best to keep talking with the patient but often it is appropriate to
give them time to compose themselves.
Dont offer false hope. Dont say, for example, Im sure everything will turn out OK, as this might not be
the case.
Use touch prudently. It may be of comfort to the patient but take care that it is not interpreted the wrong
way. If you judge that touching a patient is appropriate, placing your hand between their wrist and their
elbow is usually acceptable. It is rarely appropriate to hug a patient. The important thing to remember is
that if you dont feel comfortable touching a patient, dont do it.
Finally, it is important to review your own response when a patient cries. Your reaction to the situation may
be influenced by your own emotions at the time or how closely you identify with the patients situation. Dont
project your own feelings on to the patient. If you feel distressed by a situation on the wards, please contact
the appropriate person from your clinical school.

18

Role-play A: Sensory disturbance

Background
You are James/Jane McDonald, a 26 year old graduate university student, who has had type 1 diabetes
mellitus for 19 years. You are presenting to your general practitioner with a burn on the right foot and a
history of numbness.
Opening statement
Last night I was resting my feet near a small radiator while I was studying. My feet have been numb for the
past three months and I didnt notice how hot my feet were. Ive burnt the skin on the sole of my right foot
and Im very worried about it, although strangely enough, I dont seem to be getting any pain from it.
Cardinal features
Site: Ive noticed the numbness on the soles over my feet and over the top of my feet too. The rest of my
legs seem to be OK.
Quality: The main problem is numbness.
If asked: I have not had any tingling or pins and needles. But sometimes Ive had shooting pains in my feet.
Severity: The shooting pains seem to be worse at night and sometimes they stop me from sleeping. Its
making me feel pretty tired now.
If asked to score the pain out of 10: say 5
Time Course: Its been about 3 months since I first noted the numb feeling. The pains have only just
started in the last 4 weeks.
If asked how the symptoms are progressing over time: They are getting worse
Context: I guess all this started when my sugars started going a bit haywire. The readings have been a lot
higher than they are supposed to beI havent seen my diabetes specialist for a while now.
Aggravating factors: Nothing particular seems to make it worse
Relieving factors: My GP put me on a medication called Amitriptyline, but this didnt really help. It makes
me feel pretty terrible in the mornings, so Ive stopped taking it.
Associated features: Sometimes it feels like Im walking on cotton wool - its really weird, sort of hard to
describe. But I cant think of anything else different.

19

Role-play B: Sensory Disturbance

Joanne Andrews
Background
Joanne Andrews, aged 42 years, has come to see the doctor about numbness in her
hands.
Opening statement:
Ive been waking up at night with a really weird feeling in my hands. When I get it I have to wake up and
shake my hands about before I can get back to sleep. Im really over it now. I just want a good nights
sleep!
Site: Its in both handsmainly around my thumbs and also in some of my fingers.
(If asked exactly where you feel this - indicate your thumb, index and middle fingers)
Quality: It feels sort of numb and also tingly. Its like when your foot goes to sleep except its your
hand!It feels really weird
Severity: Its bad enough to wake me up. Sometimes it even feels painful.
If asked to score the pain out of 10, say: 6
Time Course: Its been happening for a couple of months now.
If asked how often: It probably started as a few times a week, now it is most nights - at least once,
sometimes twice a night it wakes me.
If asked about the duration of an episode, say: It usually wakes me up and then lasts about 10 minutes.
Then it fades to a dull ache and I usually manage to get back to sleep.
Context: It just gradually started happeningI have been pretty busy with work and have been doing long
hours at the computer but Im not sure that its related
Aggravating factors: Sometimes Ive had a similar feeling throughout the day after Ive
been on the computer keyboard. I was finishing a big project off last week and I noticed my hands ached
after working for a long stretch.
Relieving factors: Shaking and rubbing my hands seems to help. Ive tried taking a
painkiller before I go to sleep but that hasnt stopped the pain coming at all.
Associated features: Im not sure if I am imagining it, but I think that my hands are a bit weaker. I keep
having to ask my husband to open bottles and jars for me...but then Ive never been very strong

20

Medical Interview Assessment Form

Opening segment of interview

Yes

No

No

N/A

Greets the patient

Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement
Exploration of the presenting problem

Yes

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features
Communication Skills

Done Well

Adequate

Done well

Adequate

Needs
improvement

Demonstrates active listening skills

Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions
Interview Management

Needs
Improvement

Is systematic with questioning

Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

21

TRANSIENT LOSS OF CONSCIOUSNESS

During this tutorial, you will learn how to interview a patient who has had transient loss of consciousness.
You will also have an opportunity to build on your ability to identify and respond to emotional issues that
arise during a medical interview, as well as to practise the neurological examination of the upper and lower
limbs.
Transient loss of consciousness
Transient loss of consciousness is a common symptom, affecting up to 50% of the population at some
stage. There are many causes of transient loss of consciousness but most fall into one of two major
categories: (i) syncope or (ii) seizure. It is important to differentiate between syncope and seizure, as these
conditions have very different underlying causes and treatments.
(i) Syncope
Syncope is defined as a sudden loss of consciousness and postural tone, with spontaneous and
complete recovery. It is caused by a global fall in blood flow, which leads to a reduction in the
oxygen supply to the brain and inactivity of the cerebral cortex. There are many causes of syncope,
most of which are benign. Vasovagal syncope is the most common benign cause of syncope.
Other benign causes include postural hypotension and situational syncope (e.g. syncope during
cough, micturition, defecation). These benign causes must be differentiated, however, from
cardiovascular aetiologies, which are associated with an increased risk of sudden death. Cardiac
syncope can be caused by arrhythmias, such as tachycardias and bradycardias, or, less
commonly, organic heart disease, such as aortic stenosis or myocardial ischaemia.
(ii) Seizure
A seizure is caused by sudden uncontrolled electrical neuronal activity in the brain. During a
seizure, in contrast to syncope, the cerebral cortex is overactive, with increased blood flow
secondary to the surge in electrical activity. If this electrical activity begins in both hemispheres of
the brain at once, a generalised seizure will result. The most common type of generalised seizure
is called a tonic-clonic seizure. This type of seizure is characterised by sudden loss of
consciousness associated with stiffening of the body and followed by convulsive or repetitive
jerking movements of the limbs. There are other less common types of generalised seizures but
you do not need to know about these at this level of your training.
Not all seizures cause loss of consciousness. In some instances, the abnormal electrical activity is
confined to a focal area of the brain, with the resulting symptoms depending on the function of the
affected area of the brain. This is called a simple partial seizure. Sometimes, however, abnormal
electrical activity that starts in a focal area spreads to the whole brain, leading to an altered state of
consciousness after the seizure has started, although not necessarily a change in postural tone.
This is called a complex partial seizure.
Seizures can be caused by a wide range of underlying conditions, including genetic
disorders, focal brain lesions due to stroke, tumour or head injury, infectious diseases and
metabolic disorders. For many patients, no underlying cause can be established. The term epilepsy
is used when a person has recurrent unprovoked seizures. Thus not all people who have
experienced a seizure have epilepsy.
22

Interviewing a patient who has had transient loss of consciousness

A thorough assessment is required when a patient presents with suspected transient loss of
consciousness, as there may be a serious underlying cause. Often the patient will use a term such as
collapse, funny turn, spell or blackout to describe what has happened to them, so you will need to clarify
the nature of the presenting problem. You may need to establish whether the person has actually lost
consciousness or, if instead, they have experienced a related type of problem, such as light-headedness,
dizziness, vertigo, loss of balance, muscle weakness or a psychiatric disturbance.
The next step is to try to determine the cause of the transient loss of consciousness. At this stage of your
training, you are expected to know about the typical features of vasovagal syncope, cardiac syncope and
tonic-clonic seizures. You are not expected to know about the less common benign causes of syncope or
about other types of seizures.
Find out about the cardinal features of the patients presenting problem. A table is included in these notes
that contains information about the typical features of each of the main causes of transient loss of
consciousness. Apart from the cardinal features, it is also important to find out about the prodrome and the
period just after the event.
A witness account will be vital for obtaining information about the time when the patient was unconscious. It
is important to find out about the duration of the loss of consciousness, as this can assist in differentiating
seizure from syncope. Many people who witness such an event will describe it as lasting a minute or so,
when they really mean ten seconds. It can be helpful to illustrate to the witness the duration of one to two
minutes by counting it out using your watch. If the duration of the loss of consciousness was prolonged,
other causes must be considered. You are not expected to be able to assess a patient with prolonged loss
of consciousness at this level of your training.

23

Was there true loss

of consciousness?

NO

YES

Vertigo
Disequilibrium
Pre-syncope
Non-specific
Dizziness

Was the loss of

consciousness
transient?

NO

YES

Coma
Stupor

Syncope

Vasovagal syncope

Seizure

Cardiac syncope

Suspected Transient Loss of Consciousness

24

Differentiating between the major causes of transient loss of consciousness

Syncope
Cardinal feature
Prodrome

Faints (vasovagal
syncope)
Usually present,
includes feeling of
light-headedness and
wobbly legs, vision going
dim, noises sounding
distant

Blackouts (cardiac
sycnope )
Usually not present

Seizure
Primary generalised
seizures usually
begin without warning
Complex partial or
secondary generalised
seizures may have a
prodrome (aura), the
nature of which depends
where the seizure
originates in the brain; dj
vu may occur

May remember start of

collapse

Site

Not relevant

Not relevant

Not relevant

Quality

Loss of postural tone

Loss of postural tone

Convulsive movements can

occur, although usually only
a few jerks

Convulsive
movements can occur,
although usually only
a few jerks

(i) Tonic phase

Stiffening of limbs with
extension of
back and limbs, eyes
deviate upwards, may cry
out involuntarily
(ii) Clonic phase
Generalised flexion
contractions of muscles
alternating with
relaxation
Not usually quantified

Severity

Not usually quantified

Not usually quantified

Time course

Usually less than 30

seconds

Usually less than 30

seconds

Usually 1 2 minutes

25

Syncope
Cardinal feature

Faints (vasovagal
syncope)

Blackouts (cardiac
sycnope )

Seizure

Context

Usually doesnt occur

when sitting or lying

Can occur when

sitting or lying

Can occur when

sitting or lying Can
occur during sleep

Precipitating factors

Vasovagal syncope
often has specific
precipitating factors,
such as fasting, pain,
emotional events or
prolonged standing

Cardiac syncope usually

does not have a clear
precipitating factor

Usually spontaneous but

can be triggered by sleep
deprivation or stress

Relieving factors

Lying flat assists

recovery

Self-limiting

Self-limiting

Associated features

Tongue biting unusual

Head turning unusual
Sweaty
Pallor
No cry or moan
No frothing at mouth
Incontinence of urine may
occur,
although
not
common

Tongue biting unusual

Head turning unusual
Sweaty
Pallor
No cry or moan
No frothing at mouth
Incontinence of urine may
occur,
although
not
common

Tongue biting
common Head
turning common
Usually not sweaty
Cyanosis
Cry or moan at onset
Frothing at mouth
Incontinence of urine may
occur

Period after the

event

Rapid recovery of
consciousness

Rapid recovery of
consciousness

Rarely confused
afterwards

Rarely confused
afterwards

Injury not common

as protective reflexes
preserved

Injury may occur

Slow recovery
Period of confusion >
2 minutes
May feel exhausted
and sleepy Muscle
aches Injury
common

26

Case Study 4.05

James Nicholls, a 66-year old man with a history
of ischaemic heart disease, has been admitted to
hospital after a second episode of transient loss
of consciousness in less than a week.
He is being interviewed by Nick Modzrewski, a
second year medical student. The witness account is provided by Mr Nicholls daughter, Sarah.
Watch the interview and write down the cardinal features of Mr Nicholls presenting problem.
Discuss the features that differentiate between
syncope and seizure as a cause for his presentation.

27

Building your communication skills

Identifying and responding to anger
In Case Study 4.05, Sarah Nicholls expressed anger about aspects of her fathers medical management.
Using the following notes, discuss with your tutor why she might have been angry and how Nick
Modzrewski responded to this.
Anger is a common emotion in a medical setting. It can be a natural response by a patient to their illness or
to having to deal with the health care system. As a medical student, it is important that you learn how to
respond professionally to tense and difficult situations on the wards and in clinics. Reacting with anger or by
walking away will only escalate the situation.
Start by establishing why the patient or their relative is angry. There may be an obvious and legitimate
reason for it. The underlying problem, however, may be unrelated to the current situation, and the person
may be just displacing their frustration about something else onto you.
Often the person merely wants someone to hear them out, so allow them time to do so. Listen carefully to
what the person is saying. Convey in words and by your manner that you are trying to understand their
point of view and that you acknowledge the difficulty of the situation. Do not disagree with the person, even
if what they are saying is incorrect, as this is unlikely to be helpful and may ignite an argument. Dont be
defensive. Do not criticise another health professional as you may not be in possession of all the facts
about the situation.
Offer to find someone who can assist the patient or relative with their concerns. If the situation escalates
and you feel verbally or physically threatened, remove yourself from the location and inform a senior
person.
Always check your own response to an emotionally charged situation. You may not have control over
difficult situations, but you do have control over the way you react. Be aware that your ability to respond in a
measured way will be affected by fatigue, hunger or background personal stress. If you find that you have a
short fuse when dealing with difficult situations, explore ways of learning how to manage this better.
Finally, dont internalise the other persons anger or take it personally. There may, however, be situations
later on where you have contributed to a persons anger, such as by making a medical error. You will be
taught later in the course how to respond to this type of situation.
Practice with role-plays
In pairs, use role-plays to practise interviewing a patient about the neurological symptoms. Give each other
feedback using the Medical Interview Assessment forms at the back of this workbook.

28

Role-play A: TLOC
Background
You are Aaron Schukraft, a 36 year old lawyer. You are presenting to your general practitioner after an
episode of collapse.
Opening statement
I gave my girlfriend a bit of a scare last night. I collapsed in the bathroom in the middle of the night and she
was really worried about me. I feel fine now.
If asked to elaborate: Wed had a pretty big day - Id just been out of town for my brothers wedding and
wed gone pretty hard. We got home really late and I was a still pretty tipsy I suppose. I just got up from bed
to go to the toilet about 3am and thats when it happened.
Cardinal features
Site: N/A
Quality: I dont know what I did - no one saw it happening. I was just standing up at the toilet, about to take
a piss, and then the next minute I woke up on the floor.
If asked specifically about prodrome: I felt a bit light-headed when I walked through to the toilet and then
and my vision went a bit funny - like tunnel vision. Thats the last thing I remember.
Severity: N/A
Time Course: Im not sure how long I was out for, but my girlfriend thinks it was only a minute, or less
If asked how long it was until you felt back to normal: Only a few minutes. Then I was fine. My girlfriend was
keen for me to go to the emergency department, but I didnt see what the fuss was about. But she made
me come here today to get checked out.
Context: Wed had a couple of pretty full-on days before the wedding and then on the wedding day itself.
Wed been drinking a fair bit of wine and dancing, and I guess I hadnt really been drinking much water.
Precipitating factors: Well, I guess the big day wed had and the alcohol didnt help. I think I might have
been a bit dehydrated.
Relieving factors: I felt OK after a few minutes of lying on the bathroom floor.
Associated features: My girlfriend said I was a bit pale when I woke up, and a little clammy.
If asked specifically: You had no tongue biting, no moaning/crying/ no frothing at the mouth/ no incontinence
of urine.
29

Role-play B: TLOC
Background
You are Jasmine Lee, a 16 year student. You are presenting to your general practitioner for review after an
episode of collapse.
Opening statement
I had a weird black-out thing today when I was at hockey practice. My coach thought I had a fit and called
my Mum to bring me straight here.
If asked to elaborate:
I was just sitting on the ground with the rest of the team and our coach was talking to us and then the next
thing I know is Im lying on my side with everyone crowded around me, looking worried. It was pretty
embarrassing.
Cardinal features
Site: N/A
Quality: My coach said that I went all stiff and rigid and fell backwards onto the ground, arching my back.
Then he said I started shaking, like I was having a fit.
If asked specifically about prodrome:
I didnt get any warning. I felt fine before I blacked out. Im pretty fit and was ready for training.
Severity: N/A
Time Course: My coach was pretty switched on and timed me with his stopwatch. He said I was out of it for
2 minutes.
If asked how long it was until you felt back to normal: I was a bit groggy for about 10 minutes - I just felt
spaced out. But then after 15 minutes I felt pretty good.
Context: I didnt do anything different today.
Precipitating factors: I guess Ive been up late a few nights doing an assignment for school, so Ive been a
bit tired, but thats pretty normal for me.
Relieving factors: Nil
Associated features: Ive got a sore tongue now - maybe I bit it, I dont know.
If asked specifically: You had no moaning/crying/ no frothing at the mouth/ no incontinence of urine.
30

Medical Interview Assessment Form

Opening segment of interview

Yes

No

No

N/A

Greets the patient

Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement
Exploration of the presenting problem

Yes

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features
Communication Skills

Done Well

Adequate

Done well

Adequate

Needs
improvement

Demonstrates active listening skills

Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions
Interview Management

Needs
Improvement

Is systematic with questioning

Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

31

COGNITION
This tutorial focuses on the assessment of the higher level functions of the brain, specifically memory, which
is an important component of cognition. It also covers the principles of interviewing a patient who has
cognitive impairment and introduces an instrument that is widely used in clinical practice to screen for
cognitive impairment.
Cognition
During your studies in the neurosciences, you have learned how the brain, spinal cord and peripheral
nervous system form a complex, integrated processing and control system. In particular you have learned
about the sensory and motor functions of the body and how to make a basic clinical assessment of these
functions.
During this tutorial, the focus will be on the assessment of the higher functions of the brain, specifically
cognition. The term cognition broadly refers to the mental processes involved in knowledge acquisition,
comprehension and application. The major domains of cognition are:
(i) Memory
Memory refers to the ability to store, retain and retrieve information from the brain. A key
component of memory is attention, which is the ability to selectively concentrate on one element of
the surrounding environment to the exclusion of the other elements.
(ii) Language
Language refers to the ability to comprehend and use expressions in order to communicate. It
incorporates the skills of listening, speaking, reading and writing.
(iii) Executive function
Executive or frontal lobe function refers to the ability to think in an abstract fashion. It involves being
able to organise information, plan ahead and use judgement and reasoning.
Memory and memory loss
The medical interview component of this tutorial is focused on history taking with respect to the memory
component of cognition, specifically memory loss. To start with, it is helpful to have an understanding of the
types of memory in order to effectively gather information about this symptom. There are three types of
memory:
(i) Sensory memory
Sensory memory or attention is the reception and processing of information from a persons
surrounding environment. It involves selection and screening of information by the cerebral cortex.
This process relies on the integrity of a number of brain regions from the brain stem arousal
systems, through to the sensory cortex and the frontal lobes, particularly in the right hemisphere.
(ii) Working memory
Information that is filtered by the attentional systems is transmitted to the pre-frontal cortex. Here it
is held in working or short term memory. Information in working memory can be temporarily stored
for short term use, such as remembering a telephone number in order to make a call.
(iii) Long term memory
Information that has been transmitted to working memory undergoes a process called long-term
32

potentiation. This is the process by which memories are stored in a more permanent form. It
predominantly takes place in the hippocampus. Information is more readily archived in long term
memory if it is stored with other related information or if it is augmented by practice or by using
mnemonic devices. This passes information through the hippocampus several times and
strengthens associations.
There are two major types of long term memory. The first is episodic memory, which refers to
memory of personally experienced events. The second is semantic memory, which refers to a
persons store of facts and concepts, as well as words and their meanings. An example of a
semantic memory would be your knowledge of the cardinal features framework for gathering
information about a symptom. An episodic memory, by way of contrast, would be your memory of
interviewing a particular patient about the cardinal features of, for example, their memory loss
during a clinical skills tutorial on a particular day.
There are many types of memory disorders that you will encounter in clinical practice. Disorders of
attention or sensory memory lead to problems in filtering out background noise from the
environment. The most common cause of this type of problem is delirium, which can be caused by
a range of medical problems, such as infections or hypoxia, or certain medications.
Conditions which affect the memory areas of the hippocampus can lead to problems with storing
information from working or short term memory into long term memory. This can be caused by
disorders such as Alzheimers disease, which can affect not only memory but other components of
cognition. Alzheimers disease especially affects episodic memory, especially the retention of
information about day-to-day experiences. Long term memory is often intact in the early stages of
this disease but becomes affected as the disease progresses.
Eliciting the cardinal features of memory loss
When interviewing a patient about memory loss, find out about which type of memory is affected. This can
be difficult as many patients will want to cover up their loss of memory, often for fear of losing their
independence. A supplementary history will usually need to be obtained from another person, such as a
family member or other carer. The time course of the memory loss is also very important. In conditions such
as Alzheimers disease, the progression is usually very slow. Memory loss that occurs acutely is almost
always due to other causes.
Asking about associated features of memory loss is important. At this stage of your training, you do not
need to be able to ask specific questions in order to establish the underlying cause of a persons memory
loss, but you should be able to recognise if the person has other related cognitive problems. They may
report problems with language, such as difficulty with word finding ability (nominal aphasia), or impaired
ability to carry out motor activities despite intact muscle and nerve function (apraxia). They may also have
problems recognising or identifying objects despite intact sensory function (agnosia). A family member or
carer may report that the patient has had a change in personality or behaviour, such as disinhibition or
apathy. Changes in executive function such as planning, judgement and organisation may also be
described.
33

Case Study 4.06

Dorothy Fitzgerald, 78, has been brought by her
daughter, Judith, to see her general practitioner,
Dr Eleanor Flynn. Judith is concerned about her
mothers memory.
Watch the interview and write down the cardinal
features of Mrs Fitzgeralds presenting problem.

Building your communication skills

Communicating with a patient who has cognitive impairment
Many of the patients that you encounter during your medical training will have some degree of cognitive
impairment. This can make the interview more challenging but there are many techniques that you can use
to optimise communication.
Simple environmental measures, such as reducing background noise and other distractions, can make a
significant difference to how well the person can attend to what you are saying. Be aware of the possibility
of associated visual or hearing impairment.
Speak clearly and slowly to the patient but make sure that you do not talk down to them. Avoid using a
high-pitched voice. Maintain eye contact as much as possible. Optimise your use of basic communication
skills such as sign-posting, non-verbal communication and checking understanding. Rephrase questions if
you have not made yourself understood by the patient.
Allow plenty of time for the patient to reply to your enquiries. Recognise that the interview may take longer
than usual. Be aware of the sensitivities associated with asking a person about their cognitive abilities. Do
not challenge them unnecessarily, as many people with cognitive impairment are anxious about the
implications of their disability.
If you are interviewing the patient with a carer, it may be helpful to ask the carer how the person can be
helped to communicate with you. Be sensitive to the feelings of both parties during the interview and be
aware that you might not be obtaining the whole picture as the carer may be uncomfortable discussing the
patients memory and behavioural problems in front of them. Obtaining information from a carer is often
best undertaken separately from the patient, but do not overlook your duty of confidentiality to a patient who
has cognitive impairment. Later in the course you will learn more about how to balance the persons right to
confidentiality with their ability to make decisions for themselves.

34

Examination of higher centres

The examination of higher brain function can be quite complex. It involves assessing domains such as
language, orientation, memory and executive function, as well as noting the patients affect and behaviour.
You may have observed features of the patients higher brain function during the medical interview but it is
important to have a systematic way of assessing this.
There are a number of instruments available to help screen for cognitive impairment. One of the most
commonly used of these is the Folstein Mini-Mental State Examination (MMSE). It is a convenient way of
detecting changes in brain function and the magnitude of these changes. Using the MMSE is similar in
many ways to, for example, using peak expiratory flow to monitor respiratory function.
The Folstein MMSE is administered by asking the patient a set of standard questions. It is important to
follow these questions as written and not prompt the patient. It is also important to adopt a neutral
standpoint during the administration of the instrument by not challenging incorrect answers or giving
positive responses to correct answers. When giving instructions to the patient, also make sure that you
speak at the same rate for consistency. All of these help to produce a more reliable result for the
assessment.
Be aware that there are a number of factors that can influence the result of a mental status examination.
These include baseline intelligence, education level and sensory deficits, such as hearing or visual
impairment. Cultural factors may also influence how the test is completed by the patient. Also be aware that
depression, performance anxiety and drugs or alcohol may also influence how a person performs.
With your tutor, go through the items on the Folstein MMSE. Then use the instrument to score the patient in
the audio-visual clip provided. You do not need to be able to test other aspects of higher brain function at
this level of your training.

35

Mini Mental State Examination

1.

Orientation (Maximum score 10)

Ask What is todays date? Then ask specifically for parts omitted, Can you also tell
me what season it is?

Ask:
Can you tell me the name of this hospital/ house number? What ward/
street name are we on?
What suburb are we in? What
city are we in? What state are
we in?
2.

Date (e.g. September 2) Year

Month
Day (e.g. Monday)
Season
Hospital/ House no.
Ward/ Street name
Suburb
City
State

Registration (Maximum score 3)

Ask the subject if you may test his/ her memory. Then say ball,flag,tree clearly and slowly, about one second for
each. After you have said all three words, ask the subject to repeat them. This first repetition determines the score
(0-3) but keep saying them (up to 6 trials) until the subject can repeat all 3 words. If (s)he does not eventually learn
all three, recall cannot be meaningfully tested

Ball
Flag
Tree
Number of trials

3.

Attention and Calculation (Maximum score 5)

Ask the subject to begin at 100 and count backward by 7. Stop after 5 subtractions. Score one point for
each correct number.
If the subject cannot or will not perform this task, ask him/her to spell the word world backwards
(D,L,R,O,W). The score is one point for each correctly placed letter, e.g. DLROW= 5, DLORW= 3. Record
response

4.

Recall (Maximum score 3)

Ask the subject to recall the three words you previously asked him/ her to remember
(learned in Registration)

5.

Language (Maximum score 9)

Naming: Show the subject a wrist watch and ask What is this? Repeat for pencil. Score one point for
each item named correctly.
Repetition: Ask the subject, No ifs, ands, or buts. Score one point for correct repetition.
3 stage command: Give the subject a piece of blank paper and say,Take the paper in your right hand, fold it in
half and put it on the floor. Score one point for each action performed correctly.
Reading: On a blank piece of paper, print the sentence Close your eyes in letters large enough for the subject to
see clearly. Ask the subject to read it and do what it says. Score correct only if the subject closes his/her eyes.
Writing: Give the subject a blank piece of paper, and ask him/ her to write a sentence.
It is to be written spontaneously. It must contain a subject and a verb, and make sense. Correct grammar and
punctuation are not necessary.
Copying: On a clean piece of paper, draw intersecting pentagons, each side about 1 inch, and ask the subject
to copy it exactly as it is. All 10 angles must be present, and two must intersect to score 1 point. Tremor and
rotation are ignored:

E.g.

93
86
79
72
65
OR
number of correctly
placed letters
Ball
Flag
Tree

Watch
Pencil
Repetition

Takes in right hand Folds

in half Puts on
floor
Closes eyes

Writes sentence

Draws Pentagons
* In section 3 score number of correct responses items 14-18, or item 19, not both. Rate subjects level of
consciousness:
(a) coma,(b) stupor,(c) drowsy, (d) alert Comments:

Total Score (maximum= 30)

36