Pm Mental Status

Front 1

fasciculations

Back 1

(spontaneous quivering movements caused by firing of muscle motor units)

Front 2

Mental Status consists of?

Back 2

Level of Alertness, Attention & Cooperation
Orientation
Memory
Language
Calculations, Right-Left Confusion, Finger Agnosia, Agraphia
Apraxia
Neglect & Constructions
Sequencing Tasks & Frontal Release Signs
Logic & Abstraction
Delusions & Hallucinations
Mood

Front 3

How is attention tested?

Back 3

W-O-R-L-D / D-L-R-O-W

We can test attention by seeing if the patient can remain focused on a simple task, such as spelling a short word forward and backward (W-O-R-L-D / D-L-R-O-W is a standard), repeating a string of integers forward and backward (digit span), or naming the months forward and then backward. Normal digit span is 6 or more forward, and 4 or more backward, depending slightly on age and education. It normally takes up to twice as long to recite months backward as forward.

Front 4

What's being tested, when testing attention?

Back 4

Level of consciousness is severely impaired in damage to the brainstem reticular formation, and in bilateral lesions of the thalami or cerebral hemispheres (see Neuroanatomy through Clinical Cases Figure 2.23). It may also be mildly impaired in unilateral cortical or thalamic lesions. Toxic or metabolic factors are also common causes of impaired consciousness because of their effects on the structures mentioned here. Generalized impaired attention and cooperation are relatively nonspecific abnormalities that can occur in many different focal brain lesions, in diffuse abnormalities such as dementia or encephalitis, and in behavioral or mood disorder

Front 5

How is orientation tested?

Back 5

Ask for the patient's full name, the location, and the date, and note the exact response

Name: "Harry Smith"
Location: "Hospital," but does not know which one
Date: "1942," and does not know month, date, or season

for pt's w/o mental status prob A&Ox3 will do.

Front 6

What's being tested when orientation's being tested?

Back 6

tests mainly recent and longer-term memory

Front 7

2 Types of memory?

Back 7

Recent & Remote

Front 8

How is recent memory tested?

Back 8

Ask the patient to recall 3 items or a brief story after a delay of 3 to 5 minutes. Be sure the information has been registered by asking the patient to repeat it immediately before initiating the delay.

Provide distracters during the delay to prevent the patient from rehearsing the items repeatedly. A timer, such as a digital watch alarm should be used to provide a consistent interval from patient to patient, and to prevent the examiner from forgetting to ask for the test items!

Front 9

How is remote memory tested?

Back 9

Ask the patient about historical or verifiable personal events.

Presidents: Obama, Clinton, Bush, Ronald Regan, James Carter, Ford

Front 10

When testing remote memory, what's being tested?

Back 10

Memory can be impaired on many different timescales. Impaired ability to register and recall something within a few seconds after it was said is an abnormality that blends into the category of impaired attention discussed earlier. If immediate recall is intact, then difficulty with recall after about 1 to 5 minutes usually signifies damage to the limbic memory structures located in the medial temporal lobes and medial diencephalon (see Neuroanatomy through Clinical Cases Chapter 18). Dysfunction of these structures characteristically causes anterograde amnesia, meaning difficulty remembering new facts and events occurring after lesion onset, and retrograde amnesia, meaning impaired memory of events for a period of time immediately before lesion onset, with relative sparing of earlier memories. Loss of memory without these time characteristics may signify damage to areas other than the medial temporal and medial diencephalic structures.

Front 11

How is Language tested?

Back 11

1. Spontaneous Speech
2. Comprehension
3. Naming
4. Repetition
5. Reading and Writing

Front 12

How is spontaneous speech tested?

Back 12

Note the patient's fluency, including phrase length, rate, and abundance of spontaneous speech. Also note tonal modulation and whether paraphasic errors (inappropriately substituted words or syllables), neologisms (nonexistent words), or errors in grammar are present.

8. Spontaneous Speech

Front 13

How is comprehension tested?

Back 13

Can the patient understand simple questions and commands? Comprehension of grammatical structure should be tested as well; for example, "Mike was shot by John. Is John dead?"

Front 14

How is Naming tested?

Back 14

Ask the patient to name some easy (pen, watch, tie, etc.) and some more difficult (fingernail, belt buckle, stethoscope, etc.) objects. Naming parts of objects is often more difficult. Write down what was said to enable follow-up comparisons.

Front 15

How is Repetition tested?

Back 15

Can the patient repeat single words and sentences (a standard is "no ifs ands or buts")? Again, titrate function using a range of easy to difficult tests, and write down what the patient says.

Front 16

How is Reading and Writing Tested?

Back 16

Ask the patient to read single words, a brief passage, and the front page of the newspaper aloud and test for comprehension. Writing. Ask the patient to write their name and write a sentence.

Front 17

When reading and writing is being tested, what is being tested?

Back 17

What is being tested?

Different kinds of language abnormalities are caused by lesions in the dominant (usually left) frontal lobe, including Broca's area; the left temporal and parietal lobes, including Wernicke's area (see Neuroanatomy through Clinical Cases Figure 2.25); subcortical white matter and gray matter structures, including thalamus and caudate nucleus; as well as the nondominant hemisphere. For further details regarding the neuroanatomy of specific language disorders, see Neuroanatomy through Clinical Cases, Chapter 19.

Front 18

How is Calculation tested?

Back 18

Calculations. Can the patient do simple addition, subtraction, and so on?

Front 19

How is Right–left confusion tested?

Back 19

Can the patient identify right and left body parts?

Right–left confusion and finger agnosia can both be quickly screened for with the classic command, "Touch your right ear with your left thumb."

Front 20

How is Finger agnosia tested?

Back 20

Can the patient name and identify each digit?

Front 21

How is Agraphia tested?

Back 21

Can the patient write their name and a sentence?

Front 22

When testing Calculations, Right-Left Confusion, Finger Agnosia, Agraphia, what is being tested?

Back 22

As we have noted, abnormality of all four of these functions that is out of proportion to other cognitive deficits is strongly localizing to the dominant (usually left) parietal lobe. Otherwise, each of the individual abnormalities can be seen in many different lesions and may be present in individuals with impaired attention, language, praxis (see the next section), constructions, logic and abstraction, and so on.

Front 23

Gerstmann's syndrome?

Back 23

Impairment of all four of these functions in an otherwise intact patient is referred to as Gerstmann's syndrome. Since Gerstmann's syndrome is caused by lesions in the dominant parietal lobe, aphasia is often (but not always) present as well, which can make the diagnosis difficult or impossible. Each of the individual components of Gerstmann's syndrome is poorly localizing on its own, but they are worth documenting as part of the assessment of overall cognitive function:

Front 24

Definition of apraxia?

Back 24

will be used here to mean inability to follow a motor command that is not due to a primary motor deficit or a language impairment. It is apparently caused by a deficit in higher-order planning or conceptualization of the motor task.

Front 25

You can test for apraxia by asking the patient to?

Back 25

do complex tasks, using commands such as "Pretend to comb you hair" or "Pretend to strike a match and blow it out" and so on. Patients with apraxia perform awkward movements that only minimally resemble those requested, despite having intact comprehension and an otherwise normal motor exam. This kind of apraxia is sometimes called ideomotor apraxia. In some patients, rather than affecting the distal extremities, apraxia can involve primarily the mouth and face, or movements of the whole body, such as walking or turning around.

Front 26

When testing for apraxia, what is being tested?

Back 26

Although apraxia indicates brain dysfunction, it can be caused by lesions in many different regions, so exact localization is often difficult. Apraxia is commonly present in lesions affecting the language areas and adjacent structures of the dominant hemisphere. This can make it challenging to prove that the deficit is apraxia rather than impaired language comprehension. Often we can make the distinction by asking the patient to perform a task and, if he fails, demonstrating several tasks and asking him to choose the correct one.

Front 27

Hemineglect?

Back 27

Hemineglect is an abnormality in attention to one side of the universe that is not due to a primary sensory or motor disturbance. In sensory neglect, patients ignore visual, somatosensory, or auditory stimuli on the affected side, despite intact primary sensation (see Neuroanatomy through Clinical Cases, Chapter 19). This can often be demonstrated by testing for extinction on double simultaneous stimulation.

Front 28

anosognosia

Back 28

During the mental status exam, certain other aspects of neglect should be screened for. Patients should be asked, "Is anything wrong with you right now?" because patients with anosognosia may be strikingly unaware of severe deficits on the affected side. For example, some patients with acute stroke who are completely paralyzed on the left side believe there is nothing wrong and may even be perplexed about why they are in the hospital.

Front 29

hemi-asomatognosia

Back 29

Some patients do not even comprehend that affected limbs belong to them

Front 30

What are Construction tasks?

Back 30

Construction tasks involving drawing complex figures or manipulating blocks or other objects in space may be abnormal as a result of neglect or other visuospatial impairments. However, constructional abilities can also be abnormal because of other cognitive difficulties, such as impaired sequencing (see next section) or apraxia.

Front 31

When testing for hemineglect, what is being tested?

Back 31

What is Being Tested?

Hemineglect is most common in lesions of the right (nondominant) parietal lobe, causing patients to neglect the left side. Left-sided neglect can also occasionally be seen in right frontal lesions, right thalamic or basal ganglia lesions, and, rarely, in lesions of the right midbrain. In left parietal lesions a much milder neglect is usually seen affecting the patient's right side. Abnormal constructions demonstrating neglect can occur with right parietal lesions. In addition, other abnormalities in constructions can occur as well, as a result of lesions in many other parts of the brain. Generally, however, impaired visuospatial function is more severe with damage to the nondominant (right) hemisphere.

Front 32

Examples of construction tasks?

Back 32

Draw a clock and draw numbers in?
Cross all of these lines on this paper?
Please dissect this line in half?

Front 33

How is logic and abstraction tested?

Back 33

Can the patients solve simple problems such as the following: "If Mary is taller than Jane, and Jane is taller than Ann, who's the tallest?" How do they interpret proverbs such as "Don't cry over spilled milk"? How well can they comprehend similarities such as "How are a car and an airplane alike?" How well can they generalize and complete a series—for example, "Continue the following: AZ BY CX D_"? A more detailed evaluation can be done, when indicated, using formal neuropsychological testing batteries. Educational background must always be taken into account in interpretations of these tests.

Front 34

How are delusions and hallucinations tested?

Back 34

Does the patient have any delusional thought processes? Does he have auditory or visual hallucinations? Ask questions such as, "Do you ever hear things that other people don't hear or see things that other people don't see?" "Do you feel that someone is watching you or trying to hurt you?" "Do you have any special abilities or powers?"

Front 35

When testing for delusions and hallucinations , what is being tested?

Back 35

What is Being Tested?

These abnormalities can be seen in toxic or metabolic abnormalities and other causes of diffuse brain dysfunction, and in primary psychiatric disorders. In addition, abnormal sensory phenomena can be caused by focal lesions or seizures in visual, somatosensory, or auditory cortex, and thought disorders can be caused by lesions in the association cortex and limbic system.

Front 36

How is mood tested?

Back 36

Does the patient have signs of depression, anxiety, or mania? Signs of major depression include depressed mood, changes in eating and sleeping patterns, loss of energy and initiative, low self-esteem, poor concentration, lack of enjoyment of previously pleasurable activities, and self-destructive or suicidal thoughts and behavior. Anxiety disorders are characterized by preoccupation with worrisome thoughts. Mania causes patients to be abnormally active and cognitively disorganized

Front 37

The best muscles to look at for fasciculations in generalized LMN disorders?

Back 37

are the intrinsic hand muscles, shoulder girdle, and thigh. In cases of suspected myositis, palpate the muscles to see if there is tenderness.

Front 38

Involuntary movements and tremors are commonly associated with lesions of the

Back 38

Involuntary movements and tremors are commonly associated with lesions of the basal ganglia or cerebellum (see Neuroanatomy Through Clinical Cases, Key Clinical Concepts 15.2, and 16.1). Tremors can also occasionally be seen with peripheral nerve lesions.

Front 39

Signs of lower motor neuron lesions include

Back 39

Signs of lower motor neuron lesions include
1 weakness
2 atrophy
3 fasciculations
4 hyporeflexia (reduced reflexes)

Front 40

Signs of upper motor neuron lesions include?

Back 40

Signs of upper motor neuron lesions include
1 weakness
2 hyperreflexia (increased reflexes)
3 increased tone

Front 41

The hyperreflexia and increased tone seen with corticospinal lesions is apparently caused by?

Back 41

The hyperreflexia and increased tone seen with corticospinal lesions is apparently caused by damage to pathways that travel in close association with the corticospinal tract rather than directly by damage to the corticospinal tract itself. Note that with acute upper motor neuron lesions there is often flaccid paralysis with decreased tone and decreased reflexes. With time (hours to weeks), increased tone and hyperreflexia usually develop

Front 42

Parts of the Motor Exam?

Back 42

1 Check for atrophy? Fasciculations?
Next test muscle tone.
2 Upper Extremity Tone
3 Lower Extremity Tone


Before formally testing strength in each muscle, it is useful to do a few general functional tests that help detect subtle abnormalities.
Check for drift by having the patient hold up both arms or both legs and close their eyes.

Check fine movements by testing rapid finger tapping, rapid hand pronation—supination (as in screwing in a light bulb), rapid hand tapping, and rapid foot tapping against the floor or other object.

Tests for subtle weakness

Front 43

How is muscle tone assessed?

Back 43

Ask the patient to relax, and then passively move each limb at several joints to get a feeling for any resistance or rigidity that may be present.