THE NEUROLOGIC EXAMINATION

• MENTAL STATUS
• GAIT & STATION
• CRANIAL NERVES
• MOTOR SYSTEM
• COORDINATION
• REFLEXES
• SENSATION
• HEAD & NECK
• SPINE & SKIN
Neurologic examination
MENTAL STATUS EXAM
 Mental Status Exam

AWARENESS
• ORIENTATION
• LEVEL OF CONSCIOUSNESS

DEFINITION: Overall state of arousal, readiness,

alertness; preparedness to respond to
environment

ASSESSMENT: if not alert, try to arouse pt:

speak pt name --> shout name
--> shake --> brief pain
 Mental Status Exam

LEVEL OF CONSCIOUSNESS
"AVPU" mnemonic: pt is Alert --> responds to Voice
--> responds to Pain--> is Unconscious

1 Alert = awake, fully aware and responsive;

normal waking consciousness
2 Lethargic, drowsy = responds when spoken to,
may drift to sleep if no stimulation
3 Obtunded = may awaken to voice but is minimally responsive
when doing so
4 Stuporous = difficult to rouse,
may groan or become restless to brief pain
5 Coma = pt is unresponsive or may show abnormal response to
voice or pain
GLASGOW COMA SCALE

Overview:

The Glasgow coma scale is used to assess patients in coma.

The initial score correlates with the severity of brain injury and
prognosis.

Glasgow coma scale = (score for eye opening) + (score for

best verbal response) + (score for best motor response)
GLASGOW COMA SCALE

Eye Opening Score

spontaneously 4

to verbal stimuli 3
to pain 2
never 1

Best Verbal Response Score

oriented and converses 5
disoriented and converses 4
inappropriate words 3
incomprehensible sounds 2
no response 1
GLASGOW COMA SCALE

Best Motor Response Score

obeys commands 6
localises pain 5
flexion withdrawal 4
abnormal flexion (decorticate rigidity) 3
extension (decerebrate rigidity) 2
no response 1
GLASGOW COMA SCALE

Interpretation:
• maximum score is 15 which has the best prognosis
• minimum score is 3 which has the worst prognosis
• scores of 8 or above have a good chance for recovery
• scores of 3-5 are potentially fatal, especially if
accompanied by fixed pupils or absent oculovestibular
responses
• young children may be nonverbal, requiring a
modification of the coma scale for evaluation.
PHYSICAL EXAMINATION OF THE COMATOSE PATIENT:

• General Inspection
• Color
• Scalp & Skull
• Eyes
• Facial muscles
• Oral cavity
• Breath
• Ears
• Neck
• Limbs
• Sensory Examination
 Mental Status Exam

ORIENTATION

DEFINITION: capacity to identify and recall one's identity and place in

time and space
ASSESSMENT: directed questions

• TIME “Do you know what date it is?”

• PLACE "Can you tell me where you are right now?"
• PERSON “Who is that man standing beside you?”
“Who am I?”
 Mental Status Exam

APPEARANCE
• Gender
• Race
• Apparent age
• State of health
• Position (e.g. supine, sitting, standing)
• Clothing
• Hygiene
• Habitus
• Physical characteristics
(e.g. hair style, amputation)
• Gait
 Mental Status Exam

BEHAVIOR
• Eye contact
• Mannerisms
• Patterns of movement
• Speed of movement (e.g. slowed, hyperactive)
• Stupor = pt is awake but immobile and mute, may or may not have
reduced awareness of environment
• Waxy flexibility, catalepsy = stuporous but takes body positions
physically imposed by examiner
• Echopraxia = pt involuntarily copies others' movements
• Mimicry = pt voluntarily copies others' movements
• Catatonia = alternate between stupor and hyperactivity;
may show catalepsy, echopraxia, echolalia
• Cataplexy = sudden loss of muscle tone, esp. with emotional arousal
• Hyperkinesia = excessive motor activity
• Akisthesia = motor restlessness, uncomfortable if he keeps still
 Mental Status Exam

COOPERATION

• cooperative vs. uncooperative

• guarded
• attentiveness to examiner
• attitude to examiner, to illness
 Mental Status Exam

SPEECH & LANGUAGE

• Volume
• Rate
• Prosody = emotional intonation of speech;
variations in stress, pitch and rhythm
• Amount = quantity of speech produced
poverty = minimal speech, as in monosyllabic and
unelaborated responses to questions
loquacious = excessive speech
• Fluency = ease with which pt appears to produce speech
• Spontaneity = pt initiates speech on his/her own,
not just in response to conversation
• Articulation = phonation;
ASSESS: note pt's speech;
have pt say "pa-pa," "ta-ta," and "ga-ga"
 Mental Status Exam

SPEECH & LANGUAGE

• Dysphasia - Two broad categories:
1. Sensory dysphasia -- difficulty lies in comprehension
talk in jargon; maybe unaware of his disability
2. Motor dysphasia – difficulty lies in production
understands simple questions or requests but finds difficulty
in replying
• Dysarthria - defect in articulation of speech
- due to disorder of neuromuscular control; maybe lingual, labial,
pharyngeal, laryngeal, or cerebellar
- ask pt to repeat “West Register Street”, “Fifty-first Artillery
Brigade”
• Dysphonia - condition of disturbed sound, rhythm or tonal quality of
speech. Paralysis of one or both vocal cords may produce
hoarseness
 Mental Status Exam

GENERAL KNOWLEDGE
DEFINITION: fund of knowledge and overall assessment
of general intelligence
ASSESSMENT: note from pt's speech, ask pt to name last
5 Presidents, 5 large cities, historical events
(average, below average, above average)
Reduction of general mental capacity usually implies
diffuse damage to the cerebral cortex. If damage occurs
after learning process, “dementia” is used.

Vocabulary is the best indicator of a patient’s overall pre

morbid intellectual capacity
 Mental Status Exam

SPEECH & LANGUAGE

• Rapid, charged speech - in manic persons

• Voluble, inappropriate jargon without apparent goals
- in Wernicke’s aphasia
• Self-directed neologisms (words or phrases that have
meaning only to the person using them)
- in schizophrenic pts.
• Slow, monotonous speech
- in depression, hypothyroidism, and
Parkinson’s syndrome
 Mental Status Exam

MEMORY
• Immediate memory = memory over seconds, minutes:
ASSESS by asking pt to repeat three words or
numbers
• Recent memory = memory over mins, hours, days;
ASSESS by asking about events of the past 48 hours; (e.g.
meals, visitors, whereabouts)
• Remote memory = memory over years;
ASSESS: ask about remote events that should be known to
the pt;
(e.g. pt personal history, date of birth, marriage)

In organic disease of the temporal lobe, recent memory

usually fails before remote memory.
 Mental Status Exam

RETENTION & RECALL

• If this faculty is impaired, no “new” memories will be formed

• Test:
• Have pt repeat a number of digits beginning with 3 digits
and increasing until a limit is reached. The test is repeated
with the pt reversing the digits. (Average intelligence can
repeat 6 digits forward and 5 digits reversed)
• Ask pt to remember 3 objects (2 similar and 1 dissimilar).
After 3 mins, ask pt to repeat. Failure to do so lead to
repetition with another 3 objects; repeat after 2 and half
mins.
 Mental Status Exam

REASONING
• Judgment - pt's ability to make wise decisions,
especially in everyday activities and social matters-- self-
care, self-welfare, personal relationships; ASSESS:
Ask an imaginary scenario. "What would you do if you
smelled smoke in a crowded theater?" (good
response is "call 911" or "get help"; poor
response is "do nothing" or "light a cigarette").
• Insight - pt awareness that he/she has problems,
what they are, and their implications;
ASSESS: asking pt why he is in the hospital
• Abstraction - use of proverbs
“People in glass houses should not throw stones”
“A rolling stone gathers no moss”
OBJECT RECOGNITION
The defect of recognition of simple objects is called agnosia.

Five categories:
4. Visual agnosia - showing pt simple objects and asking
him to name them
5. Tactile agnosia - inability to recognize simple objects by
palpation; lesions in the parietal lobe
6. Autotopagnosia - loss of appreciation or identification of a
body part; lesions of the parietal lobe
7. Anosognosia - implies denial of disease and is due to
loss of perception of the affected part, usually a paralyzed
limb; lesions in frontal and parietal lobes
8. Auditory agnosia - inability to percieve the meaning of
sound despite the absence of deafness
 Mental Status Exam

PRAXIAS
Apraxia - inability to execute a planned motor act in the
absence of paralysis
  

• Ideational apraxia - higher order deficit, cannot

sequencing a multi-step task but each elemental
step is ok;
- resembles extreme absentmindedness
- no impairment of motor movement
• Ideomotor apraxia - cannot perform learned motor
acts properly; the most common apraxia; ASSESS:
"Show me how to salute, blow out a match, brush
your teeth" -->"Mimic me" --> provide real objects
 Mental Status Exam

PERCEPTION
DEFINITION: sensory experience and its immediate interpretation
ASSESSMENT: pt's speech and behavior, but mostly targeted
questions (e.g. "Do you sometimes hear or see things that others
do not seem to see or hear?" "Do you ever
have any sensations that worry you or seem odd?" "Do you worry
that you senses sometimes 'play tricks' on you?")

• Hallucinations = a sensory perception despite no physical external

stimulus
• Sensory modality (e.g. visual, auditory, olfactory, tactile, gustatory)
• Formication = tactile hallucination of insects crawling over the skin
• Derealization = parts of environment feel unreal, somehow altered
• Depersonalization = pt feels detached, unreal, physically altered;
e.g. out of body, body part altered, cut off from other people
• Deja vu = feeling that an event has already been lived through
• Jamais vu = feeling unfamiliar in a situation the pt. knows should be
familiar
 Mental Status Exam

PERCEPTION
  

• Hypnogogic = while one is falling asleep

• Hypnopompic = while one is waking up
• Illusions = a wrong perception of a real physical external stimulus;
e.g. mistaking a shadow for a man
• Astereognosis = inability to identify objects based on tactile sensations
• Agraphesthesia = inability to use tactile sensations alone to identify
letters or numbers "drawn" on palm
• Visuospatial function = visual perceive and reconstruction of spatial
relationships;
ASSESS: copy overlapping polygons, draw-a-clock
 Mental Status Exam

MOOD
DEFINITION: emotional tone the pt subjectively feels
ASSESSMENT: what the pt says

e.g. depressed, sad, happy, neutral, angry, apathetic,

fearful, pleasant, irritable, euphoric, anxious
 Mental Status Exam

AFFECT
DEFINITION: emotion displayed, what the interviewer observes
ASSESSMENT: facial expressions, body language, laughter, use of
humor, tearfulness

• Concordance = expressed emotion fit what patient is saying, doing

• Appropriateness, responsiveness = expressed emotion sensibly follows
from the precipitating stimuli
• Full range = normal variation of emotions during exam
• Restricted, constricted range = limited variability of emotion
• Stable = normal movement between emotions
• Labile = type or intensity shifts suddenly, rapidly
• Blunted = few emotions expressed, low intensity
• Flat = affect is even less intense than blunted;
pt may appear inanimate
• Exaggerated intensity
 Mental Status Exam

THOUGHT CONTENT
DEFINITION: the topics one thinks about
ASSESSMENT: observe speech and behavior;
may need to use targeted questions

Delusions = strongly-believed idea, others would clearly see as false;

Assess: note in pt's speech; ask targeted questions,
ask "Are you bothered by thoughts that disturb you?"

• Erotic delusions = pt believes that another person, often of higher

social status, is in love with him/her
• Grandiosity = pt believes that he/she has unusual talent, virtue,
insight, identity
• Delusions of reference = pt believes that ordinary external events
(bystander conversations, radio, TV) have special significance
secretly intended for the pt
• Ideas of reference = same as above, but pt questions whether or
not it is true
 Mental Status Exam

THOUGHT CONTENT

• Magical ideation = pt believes in magic cause-and-effect,

(e.g. thinking a thing makes it so)
• Nihilism = pt believes that a person, part of the pt's body, part of the
world does not exist; "I lost my body in my childhood and now I do
not have a body“
• Paranoia = pt believes others are working against him/her;
often secretly, conspiratorially
• Persecution = pt sees life events as punishments for previous
misdeeds, real or imagined
• Somatic = pt believes he/she has a defect or disease
• Thought broadcasting = pt believes that his/her thoughts are audible by
others
• Thought insertion = pt believes that he/she is thinking thoughts that are
actually someone else's thoughts, somehow physically places into
the patient's head
 Mental Status Exam

THOUGHT CONTENT
• Thought blocking = pt believes that he/she would like to think a
thought in his/her head, but someone else is physically
preventing him/her from doing so
• Thought withdrawal = pt believes that he/she would like to think a
thought in his/her head, but someone has physically removed
the thought
• Preoccupations = ideas which dominate pt's thought,
more voluntary than obsessions
• Obsessions = involuntary, unwelcome ideas persistently
intrude on thinking, demand pt's attention even though pt may
recognizes ideas as irrational
• Repeating themes (e.g. guilt, worthlessness, hopelessness, death
themes, fears, worries)
 Mental Status Exam
THOUGHT PROCESS
DEFINITION: the movement of thought, the dynamics of how one thought
connects to the next
ASSESSMENT: observe pt's speech, some behavior; may need a few
targeted questions

• Goal-directed = thinking stays on target

• Logical = analysis is well founded, makes sense
• Coherent = thought process is apparent and understandable
• Echolalia = pt merely repeats what is said to him/her
• Neologisms = nonsense words or real words nonsensically;
e.g. "I fribish the cot," "I table the stairs“
• Tight associations = one thought sensibly leads to another
reasonable thought
• Loose associations = one thought leads to another somewhat less
reasonable thought
• Clang association = where one word follows next based only on
rhyming; e.g. "I want to say the play of the day, ray, stay, may I
pay"
 Mental Status Exam
THOUGHT PROCESS
• Rambling = thoughts appear nonsensical, unrelated to one another;
complete loosening of associations
• Word salad = totally incomprehensible, gibberish, real words may be
admixed with neologisms
• Circumstantiality = unnecessary digression, wanders from point, with
unreasonably excessive detail, but eventually returns to the
main "stream" of thought
• Tangentiality = same as above, but does not return to the original
main "stream" of thought
• Perseveration = pt continues to repeat idea, phrase, or word;
trouble shifting to a new idea
• Flight of ideas = rapid shifting between usually related thoughts;
speech may be pressured
• Blocking = stream of processing seems to stop suddenly, pt may
suddenly stop speaking; can be an arrest in thought, or
hallucinatory material grabbing pt's attention
Frontal Lobes i
The frontal lobes are important for attention,
executive function, motivation, and behavior. Tests
for frontal lobe function include working memory
(digit span, spelling backward), judgment, fund of
knowledge, task organization and set generation
such as naming lists of things in a certain category.
Temporal Lobes i

The temporal lobes are important for emotional response

(amygdala and its connections to the hypothalamus and
frontal lobes) and memory (hippocampus and limbic
connections). Clinically the main tests for temporal lobe
function are those of memory, particularly declarative
memory.
Language- Temporal and Frontal i Lobes
The principle area for receptive language is Wernicke's
area, which is located in the posterior part of the superior
temporal gyrus of the dominant temporal lobe. The major
region for expressive language is Broca's area located in
posterior part of the inferior frontal gyrus of the dominant
hemisphere. Homologous regions of the non-dominant
hemisphere are important for the non-verbal contextual
and emotional aspects as well as the prosody (rhythm) of
language. Tests for written and spoken receptive and
expressive language are used to "view" these language
centers.
Parietal Lobes i

The parietal lobes are important for perception and

interpretation of sensory information especially
somatosensory information. The non-dominant parietal lobe
is particularly important for visual-spatial function. The
dominant parietal lobe is important for praxis, which is the
formation of the idea of a complex purposeful motor act
while the frontal lobes are important for the execution of the
act. Clinical tests for parietal lobe function include tests for
agnosia (such as inability to identify objects by tactile
exploration), apraxia (inability to perform purposeful motor
acts on command) and constructional apraxia (inability to
draw objects which require use of visual spatial
organization).
Occipital Lobes
The occipital lobes are important
i for perception of visual
information. Areas in the inferior temporal visual
association cortex are important for recognition of color
and shape as well as the recognition of faces. Projections
from the occipital lobe to the superior temporal-parietal
area are important for perceiving motion of objects. Tests
that are used to examine the occipital lobes and its
connections include visual fields (see Cranial Nerve 2),
naming of objects, naming of colors and recognition of
faces.
 Mental Status Exam
The Neurologic Examination
Mentation
• Awareness
Orientation (oriented to time, place, and person)
Level of consciousness (awake, obtunded, stuporous,
semi-comatose, comatose)
• Speech Normal, dysphasia, dysarthria, dysphonia
• General knowledge
Knowledge of current events, vocabulary
• Memory Intact, recent memory impaired,
remote memory impaired
• Retention and recall
Recall of objects, digits forward and reversed
• Reasoning
Judgment insight, abstraction (interpretation of proverbs,
similarities, and differences)
 Mental Status Exam
The Neurologic Examination

• Object recognition Normal, agnosia

• Praxis Ideational and ideomotor apraxia
• Perception Delusions, illusions, hallucinations
• Mood Normal, euphoric, depressed, anxious, agitated
• Affect Normal, flat, inappropriate
 Mental Status Exam

Here is an example of some terms to use in your MSE.

Appearance:
Age (chronological age and whether the person looks this age)
Sex, Race
Body build (thin, obese, cachectic, muscular, frail, medium)
Position (lying, sitting, standing, kneeling)
Posture (rigid, slumped, cross-legged, slouched, comfortable,
threatening)
Eye contact
Dress (what individual is wearing, cleanliness, condition of
clothes, neatness, appropriateness of garments)
Grooming (malodorous, highly perfumed, dirty, unshaven,
smelling of alcohol, hairstyle, makeup)
Manner (cooperativeness, guarded, pleasant, suspicious, glib,
angry, seductive, ingratiating, evasive, friendly, inappropriately
familiar, hostile)
THE END