Neurological Examination - Cognition

Related Subjects: |Neurological History taking |Cortical functions |Motor System |Sensory System |Mental state Examination |Speech and Language Exam |Cranial nerves and examination |Assessing Cogniton

Introduction

• The approach varies greatly be it in the outpatient clinic, the acute assessment unit or the HDU or ITU. The neurological exam has to be matched and appropriate to answer the questions that are asked either by the clinical case or by the examiner. In the clinical case, these are typical - where is the lesion, what is the cause and how do I treat it ? You, therefore, need to have learned the basic building blocks of the neurological exam and be able to improvise as needed.
• Talking sense about findings is also important. You will not win points for suggesting that a bilateral leg weakness is a stroke as your first differential. Having a basic understanding of neurological pathways and some basic anatomy will go a long way to success.

Introduction

• It is, therefore, important to be able to extract as much neurological information that one can be it from a confused patient, a comatose patient or a very compliant and helpful patient. The neurological exam is often too large and time-consuming to do even for most fastidious neurologists who focus instead on the questions mentioned and extract exactly the examinations that will answer these questions they wish to answer. In exams, you might be asked to do small snippets of an exam or be asked to address a single question.

Break it up into its constituent parts.

• Higher functions
• Motor
• Sensory
• Visual
• Cerebellar
• Cranial nerves
• Peripheral nerves

Higher level

• The approach is general initial observational
• Alert, sitting still, nervous, drowsy, somnolescent, eye contact
• Dress - clean, unkempt, soiled, unshaven
• Mannerism - anxious, tics, labile emotions, bewildered, mania, depression, restless
• Behaviour - inappropriate e.g. violence, urinating/defaecating inappropriately

Comatose patient - Glasgow coma scale

• This was initially produced by neurosurgeons in Glasgow in the early 1970s before CT scanning was invented in order to pick those patients who needed urgent neurosurgical intervention.
• It has survived the test of time thanks to its usefulness and provides a useful framework to think about patients with suspected intracranial pathology and coma.
• Changes are important as well as absolute values and can suggest urgent action or referral needed. Do not just give a number but be able to describe the scores themselves.
• Even the dead get 3 points. Stroke patients with aphasia lose 5 points automatically but otherwise maybe awake, even mobile but non verbally communicable.

Confusion

This is where one should start if one is presented a patient where there is a problem with memory or confusion is suspected. Try if the patient is rousable with a GCS > 12. Remember that many misinterpret the dysphasic patient with the delirious patient. As you work your way through the MTS you will soon get an idea if the issue is language or cognition. Start with a few questions on the patient's name, age and date of birth, what time it is, day, month and year. A basic "abbreviated" MTS is fine generally. It may seem superfluous when clerking an 80-year-old in for heart failure but if they are confused several nights later one can compare to see if it is new or that was the admission baseline. Delirium is a bad prognostic indicator.

Mental Test Score

• What is your age? (1 point)
• What is the time to the nearest hour? (1 point)
• Give the patient an address, and ask him or her to repeat it at the end of the test. (1 point) e.g. 42 West Street
• What is the year? (1 point)
• What is the name of the hospital or number of the residence where the patient is situated? (1 point)
• Can the patient recognize two persons (the doctor, nurse, home help, etc.)? (1 point)
• What is your date of birth? (day and month sufficient) (1 point)
• In what year did World War 1 begin? (1 point) (other dates can be used, with a preference for dates sometime in the past.)
• Name the present monarch/dictator/prime minister/president. (1 point) (Alternatively, the question "When did you come to [this country]? " has been suggested)
• Count backwards from 20 down to 1. (1 point)

A more reproducible way is to use the MMSE