Mental state exam and cranial nerves lecture

Neurological Examination

Daniel Eshetu

Mental State Exam

• General appearance and behavior • Orientation• Language• Affect and mood • Thought• Memory • Attention and Calculation• Cognition • Judgment

General Appearance and Behavior

• Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well groomed?

• Level of alertness: Is the patient conscious? If not, can they be aroused? Can they remain focused on your questions and conversation? What is their attention span?

• Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?

Orientation

• Awareness of environment, also referred to as

orientation: – Do they know where they are and what they are

doing here? – Do they know who you are? – Can they tell you the day, date and year?

Language

• Comprehension• Repetition • Naming• Reading • Writ• Speech: Is it normal in tone, volume and

quantity?

Mood

• How do they feel? – You may ask this directly (e.g. "Are you happy,

sad, depressed, angry?").

• Is it appropriate for their current situation?

Affect

• How do they appear to you( to theExaminer)? – Do they make eye contact? – Are they excitable? Does the tone of their voice

change? – Common assessments include • flat (unchanging throughout) • excitable • appropriate

Thought Process

• This is a description of the way in which they think.

• Are their comments logical and presented in an organized fashion? – If not, how off base are they? – Do they tend to stray quickly to related topics?– Are their thoughts appropriately linked or simply

all over the map?

Thought Content

• A description of what the patient is thinking about. • Are they paranoid? • Delusional (i.e. hold beliefs that are untrue)? • If so, about what? – Phobic? – Hallucinating (you need to ask if they see or hear things

that others do not)? – Fixated on a single idea? If so, about what. – Is the thought content consistent with their affect?

• If there is any concern regarding possible interest in committing suicide or homicide

Memory

• Immediate memory – is assessed by listing three objects, asking the patient

to repeat them to you to insure that they were heard correctly. and then checking.

• Short Term Memory – recall at 5 minutes the three objects

• Long term memory – can be evaluated by asking about the patients job

history, where they were born and raised, family history, etc

Attention and Calculations

• Can they perform simple addition, multiplication?

• Are the responses appropriate for their level of education?

• Have they noticed any problems balancing their check books or calculating correct change when making purchases?

Cognition

• Higher cortical functioning and reasoning: Involves interpretation of complex ideas. – For example, you may ask them the meaning of

the phrase, "People in glass houses should not throw stones." • A few common interpretations include

– concrete (e.g. "Don't throw stones because it will break the glass")

– abstract (e.g. "Don't judge others")– bizarre

Judgment

• Provide a common scenario and ask what they would do (e.g. "If you found a letter on the ground in front of a mailbox, what would you do with it?").

Cranial Nerves

Cranial Nerves

Olfactory Nerve - CNI

Optic Nerve- CNII

• Visual Acuity• Visual Field • Color• Pupillary light Reflex• Retina

Visual Acuity

Snellen’s Chart Hand Held Visual Chart

Without Pinhole With Pinhole

Visual Field

Visual Field test

Visual Field Defects

Color Test

Color Blind

Types of Color Blindness Test for Color Blindness

Pupillary light Refelex

Anisocoria With Normal Light Reflex

Anisocoria Greater in the dark Physiologic Vs Horner’s

AnisocoriaAbnormal Light reaction and anisocorea greater at bright light

Algorithm to impaired light Reflex

Pilocarpine Test

Retina ExaminationOphthalmoscope facing the examiner Ophthalmoscope facing patient

Examination of RetinaTechnique of examination

Red Reflex

Normal Fundus

Papilledema

Extra ocular Eye movement CN III,IV&VI

Cardinal Fields of Gaze

Occulmotor Nerve-CN III Palsy

Abducent Nerve-CN VI Palsy

Trigeminal Nerve-CN V

Trigeminal Nucleus

Clinical Exam of CN V

Trigeminal Sensory Trigeminal Motor

Corneal Reflex

Facial Nerve-CN VII

Facial Nerve-CN VII

Lower Motor Facial Palsy

Closing Eyes Frowning

Vestibulochoclear Nerve-CN VIII

Tunning Fork 512 HZ Weber Test

Rinne Test

Bone Conduction Air Conduction

Hallpike Manuever

Glossoparyngeal and Vagus-CN IX&X

Parasympathetic and Sympathetic Nervous System

Gag Reflex

Normal Left side palsy

Spinal Accessory-CN XITesting Sternocledomastoid Muscle Testing Trapezius Muscle

Hpoglossal Nerve-CN XII

Left Hpoglossal Palsy

Left Hpoglossal Nerve palsy

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