| Asking questions about month, date, day of week and place tests ???, which involves not only memory but also attention and language. | Orientation, memory |
| orientation, memory: tests recent memory for which the temporal lobe is important. | Three-word recall tests |
| orientation, memory: naming presidents, tests not only the temporal lobes but also heteromodal association cortices. | Remote memory tasks |
| Digit span, spelling backwards and naming months of the year backward test attention and working memory which are frontal lobe functions | Attention-working memory |
| These frontal lobe functions can be tested by using problem solving, verbal similarities and proverbs | Judgement-abstract reasoning |
| This is a test of verbal fluency and the ability to generate a set of items which are frontal lobe functions. most individuals can give 10 or more words per minute | Set generation |
| Asking the patient to follow commands demonstrates that they understand the meaning of what they have heard or read. It is important to test reception of both spoken and written language | Receptive language |
| In assessing expressive language it is important to note fluency and correctness of content and grammar. This can be accomplished by tasks that require spontaneous speech and writing, naming objects, repetition of sentences, and reading comprehension | Expressive language |
| The patient is asked to perform skilled motor tasks without any nonverbal prompting. Skills tested for should involve the face then the limbs. In order to test for ??? the patient must have normal comprehension and intact voluntary movement. | praxis |
| praxis: is typically seen in lesions of the dominant inferior parietal lobe. | Apraxia |
| is the ability to recognize objects perceived by the senses especially somatosensory sensation. Having the patient (with their eyes closed) identify objects placed in their hand (stereognosis) and numbers written on their hand (graphesthesia) tests parietal lobe sensory perception | Gnosis |
| Tests for this includes right-left orientation, naming fingers, and calculations. | Dominant parietal lobe function |
| This is important for visual spatial sensory tasks such as attending to the contralateral side of the body and space as well as constructional tasks such as drawing a face, clock or geometric figures. | Non-dominant parietal lobe function |
| Recognition of colors and faces tests visual association cortex (inferior occiptotemporal area). Achromatopsia (inability to distinguish colors), visual agnosia (inability to name or point a color) and prosopagnosia (inability to identify a familiar faces) result from lesions in this area. | Visual recognition |
| inability to distinguish colors | achromatopsia |
| inability to name or point to a color | visual agnosia |
| inability to identify a familiar faces | prosopagnosia |
| represent the highest and most complex level of neurological function | cerebral hemispheres |
| are important for attention, executive function, motivation, and behavior.
Tests for this 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 | The frontal 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 this function are those of memory, particularly declarative memory | temporal lobes |
| Language- Temporal and Frontal Lobes: The principle area for receptive language is?
which is located in the posterior part of the superior temporal gyrus of the dominant temporal lobe. | Wenicke's area |
| Language- Temporal and Frontal Lobes: The major region for expressive language is?
located in posterior part of the inferior frontal gyrus of the dominant hemisphere. | Broca's area |
| Are important for the non-verbal contextual and emotional aspects as well as the prosody (rhythm) of language. | Homologous regions of the non-dominant hemisphere |
| Tests for written and spoken receptive and expressive language are used to? | "view" these language centers (wernicke's area, broca's area, and homologous regions of the non-dominant hemisphere). |
| are important for perception and interpretation of sensory information especially somatosensory information. | The parietal lobes |
| Parietal lobes: is particularly important for visual-spatial function. | The non-dominant parietal lobe |
| Parietal lobe: is important for praxis, which is the formation of t he idea of a complex purposeful motor act while the frontal lobes are important for the execution of the act. | The dominant parietal lobe |
| which consists of the constellation of acalculia, finger agnosia, right-left confusion and agraphia, occurs with damage to the dominant inferior parietal lobe. | The Gerstmann syndrome. |
| 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),
constructional apraxia ( inability to draw objects which require use of visual spatial organization); and,
testing for elements of Gerstmann's syndrome |
| inability to identify objects by tactile exploration | agnosia |
| inability to perform purposeful motor acts on command | apraxia |
| inability to draw objects which require use of visual spatial organization | constructional apraxia |
| are important for perception of visual information. | The occipital lobes |
| occipital lobes: are important for recognition of color and shape as well as the recognition of faces | Areas in the inferior temporal visual association cortex |
| Are important for perceiving motion of objects. | projections from the occipital lobe to the superior temporal-parietal area are important |
| 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 |
| Traps: 1: There is more variability to the expression of lesions of the cerebral cortex than of? | structures more caudal in the neuroaxis |
| Traps: 2: ??? can affect a patient's performance on the mental status exam. | Time of day, stress, fatigue, and pain |
| Traps: 3: you need to consider the patient's ??? when evaluating the results of the mental status exam | social and educational background |
| pearls: 1: The mental status begins with? | listening and watching the patient during the history part of the examination |
| pearls: 2: The patient must be awake and alert in order to have a "???" to view the cortex. | window |
| pearls: 2: So assessment of the level of alertness and the intactness of the reticular activating system is actually the ??? step in the mental status assessment | first |
| Examination of the cranial nerves allows one to "view" the brainstem all the way from its? | rostal to caudal extent. |
| The brainstem can be divided into 3 levels: | the midbrain, the pons, and the medulla |
| The cranial nerves for midbrain are: | 2 (CN 3&4) |
| The cranial nerves for the pons are: | 4 (CN 5-8) |
| The cranial nerves for the medulla are: | 4 (CN 9-12) |
| The cranial nerves for each of these (3 levels of brainstem) are: | 2 for the midbrain (CN 3&4),
4 for the pons (CN 5-8), and
4 for the medulla (CN 9-12). |
| Cranial nerve findings when combined with ??? are powerful for localizing lesions in the brainstem. | long tract findings (coticospinal and somatosensory) |
| Cranial nerve 1: | Olfactory or olfaction |
| Is the only sensory modality with direct access to cerebral cortex without going through the thalamus. | Olfaction |
| The olfactory tracts project mainly to the? | uncus of the temporal lobes. |
| This cranial nerve has important localizing value because of its "x" axis course from the eye to the occipital cortex. | Cranial nerve 2 |
| The pattern of a visual field deficit indicates whether an anatomical lesion is: | pre- or postchiasmal, optic tract, optic radiation or calcarine cortex. |
| These cranial nerves give or give us a view of the midbrain. | Cranial nerves 3 and 4 |
| The 3rd nerve in particular can give important anatomical localization because? | it exits the midbrain just medial to the cerebral peduncle. |
| Controls eye adduction (medial rectus), elevation (superior rectus), depression (inferior rectus), elevation of the eyelid (levator palpebrae superiors), and parasympathetics for the pupil. | The 3rd (cranial) nerve |
| Supplies the superior oblique muscle, which is important to looking down in (towards the midline) | The 4th Cranial Nerve (CN) |
| Are located in the pons and give us a view of this level of the brainstem. | Cranial nerves 5,6,7,8 or pontine level |
| This cranial nerve innervates the lateral rectus for eye abduction. | Cranial nerve 6 |
| Remember that cranial nerves 3, 4 and 6 must work in concert for? | conjugate eye movements |
| Cranial nerves 3, 4 and 6 must work in concert for conjugate eye movements; if they don't, then what results? | diplopia (double vision) results |
| Connects the 6th nerve nucleus to the 3rd nerve nucleus for conjugate movement. | The medial longitudinal fasciculus (MLF) |
| Eye movements are controlled by ???, which are tested for the neurological exam. | 4 major oculomotor gaze systems:
Saccadic
Smooth Pursuit
Vestibulo-ocular
Vergence |
| 4 major oculomotor gaze systems:
Frontal gaze center to PPRF (paramedian pontine reticular formation) for rapid eye movements to bring new objects being viewed on to the fovea. | Saccadic |
| 4 major oculomotor gaze systems:
Parietal-occipital gaze center via cerebellar and vestibular pathways) for eye movements to keep a moving image centered on the fovea during head movements. | Smooth Pursuit |
| 4 major oculomotor gaze systems:
Keeps image steady on fovea during head movements. | Vestibulo-ocular (Vestibular input) |
| 4 major oculomotor gaze systems:
(optic pathways to oculomotor nuclei) to keep image on fovea predominantly when the viewed object is moved near (near triad- convergence, accommodation and pupillary constriction). | Vergence |
| The entry zone for this cranial nerve is at the mid pons with the motor and main sensory (discriminatory touch) nucleus located at the same level. | Cranial nerve 5 |
| The axons for the descending tract of the 5th nerve (pain and temperature) descend to the level of the ??? before they synapse with neurons of the nucleus of the descending tract of the 5th nerve. | upper cervical spinal cord |
| Cranial nerve 5:
Second neurons then cross over and ascend to the? | VPM of the thalamus |
| This cranial nerve has a motor component for muscles of facial expression (and, don't forget, the stapedius muscle which is important for the acoustic reflex), parasympathetics for tear and salivary glands, and sensory for taste (anterior two-thirds of the tongue). | Cranial nerve 7 |
| Central (upper motor neuron-UMN) versus Peripheral (lower motor neuron-LMN) 7th nerve weakness: With what lesion all of the muscles ipsilateral to the affected nerve will be weak? | peripheral 7th nerve (lesion) |
| Central (upper motor neuron-UMN) versus Peripheral (lower motor neuron-LMN) 7th nerve weakness: Only the muscles of the lower half of the face contralateral to the lesion will be weak because the portion of the 7th nerve nucleus that supplies the upper face receives bilateral corticobulbar (UMN) input. | central 7th |
| This nerve is a sensory nerve with two divisions- acoustic and vestibular. | Cranial nerve 8 |
| Cranial nerve 8: The acoustic division is tested by checking? | auditory acuity and with Rinne and Weber tests. |
| Cranial nerve 8: The vestibular division of this nerve (CN 8) is important for? | balance |
| Cranial nerve 8: The vestibular division of the 8th CN or CN 8 can clinically be tested with the? | oculocephalic reflex (Doll's eye maneuver) and oculovestibular reflex (ice water calorics). |
| Are located in the medulla and have localizing value for lesions in this most caudal part of the brainstem. | Medullary level Cranial nerves 9, 10, 11, 12 |
| These two nerves are clinically lumped together. | Cranial Nerves 9 and 10 |
| CN 9 and 10: Motor wise, they innervate? | pharyngeal and laryngeal muscles. |
| CN 9 and 10: Their sensory component is sensation for the? | pharynx and taste for the posterior one-third of the tongue |
| This nerve is a motor nerve for the sternocleidomastoid and trapezius muscles. | Cranial Nerve 11 |
| Cranial nerve 11: The UMN control for the sternocleidomastoid (SCM) is an exception to the rule of the? | ipsilateral cerebral hemisphere controls the movement of the contralateral side of the body. |
| Cranial nerve 11: The ipsilateral cerebral hemisphere controls the ipsilateral SCM muscle because? | of the crossing then recrossing of the corticobulbar tracts at the high cervical level. |
| This cranial nerve makes sense as far as coordinating head movement with body movement if you think about it (remember that the SCM turns the head to the opposite side). | Cranial nerve 11 |
| Cranial nerve 11: So if I want to work with the left side of my body I would want to turn my head to the left so the ??? would be activated | right SCM |
| The last of the cranial nerves, supplies motor innervation for the tongue | Cranial nerve 12 |
| A 6th nerve palsy may be a "false localizing sign; The reason for this is that: | it has the longest intracranial route of the cranial nerves, therefore it is the most susceptible to pressure that can occur with any cause of increased intracranial pressure. |
| Rules of Diplopia: 1: Diplopia is maximum in the direction of action of the? | paretic muscle |
| Rules of Diplopia: 2: The most peripherally seen image is the? | false image and comes from the eye with the paretic muscle. |
| Rules of Diplopia: 3: The diplopia is horizontal if the ??? are involved; and
vertical if ??? are involved. | horizontal if the medial or lateral recti are involved; and
vertical if the elevator or depressor muscles are involved |
| Intranuclear ophthalmoplegia (INO): A lesion of the MLF causes ??? of the abducting eye with absent adduction of the other eye. | nystagmus |
| Intranuclear ophthalmoplegia (INO): The lesion is on the ??? that should be adducting. | on the side of the eye |
| Intranuclear ophthalmoplegia (INO): There can be a bilateral INO in which case? | neither eye adducts with horizontal gaze. |
| This CN is tested one nostril at a time by using a nonirritating smell such as tobacco, orange, vanilla, coffee, etc. Detection of the smell is more important than the actual identification. | Cranial Nerve 1- Olfaction |
| Cranial Nerve 2: The first step in assessing the optic nerve is testing? | visual acuity. |
| Cranial Nerve 2- Visual acuity: The first step in assessing the optic nerve which is testing the visual acuity can be done with? | a standard Snellen chart or with a pocket chart (Rosenbaum).
note: have the patient use their glasses if needed to obtain best-corrected vision. |
| Cranial Nerve 2- Visual acuity: Cranial Nerve 2- Visual acuity: The first step in assessing the optic nerve which is testing the visual acuity can be done by: | having the patient to hold the pocket chart at the focal length that is best for them which is usually 14 inches.
Have them recite the line with the smallest letters that they can read and record acuity. |
| Cranial Nerve 2: There are several different screening test that can be used to assess visual fields at the bedside: First is to: | hold up both hands superiorly and inferiorly and ask the patient if they can see both hands and do they look symmetric.
Then test each eye individually using your fingers in the four quadrants of the visual field and ask the patient to count fingers help up or point to the hand when a finger wiggles using yourself as a control. |
| Cranial Nerve 2: There are several different screening test that can be used to assess visual fields at the bedside: The second test is to use: | A second screening test is to use a grid card. |
| Cranial Nerve 2: There are several different screening test that can be used to assess visual fields at the bedside: The second one is: | with the help of a grid card, have the patient focus on the dot in the center of the grid then ask if any part of the grid is missing or looks different. |
| Cranial Nerve 2: There are several different screening test that can be used to assess visual fields at the bedside: the third is: | to use a cotton tip applicator. Testing one eye at a time ask the patient to say "now" as soon as they see the applicator come into their side vision as they focus on the examiner's nose. |
| Is the most accurate way of assessing visual fields | Formal perimetry |
| Cranial Nerve 2- Fundoscopy: Direct visualization of the optic nerve head is an important and valuable part of assessing CN 2. Systematically look at the optic disc, vessels, retinal background and fovea. | Fundoscopy |
| Cranial Nerves 2 & 3 - The afferent or sensory limb of 'what' is CN 2 while the efferent or motor limb is the parasympathetics of CN 3. | pupillary light reflex |
| Cranial Nerves 2 & 3: Is used to test for a relative afferent pupillary defect or a Marcus Gunn Pupil. | Swinging flashlight test. |
| Cranial Nerves 2 & 3: Swinging flashlight test is done by: | swinging the flashlight back and forth between the two eyes identifies if one pupil has less light perception than the other.
Shine the flashlight at one eye noting the size of both pupils.
Then swing the flashlight to the other eye.
If both pupils now dilate then that eye has perceived less light stimulus ( a defect in the sensory or afferent pathway) than the opposite eye. |
| Cranial Nerves 3, 4 & 6- Inspection and Ocular Alignment: Before checking ocular movements it is important to: | inspect the eyes
Look for ptosis.
Note the appearance of the eyes and check for ocular alignment ( the reflection of your light source should fall on the same location of each eyeball). |
| Cranial Nerves 3, 4 & 6: Testing extraocular range of motion with both eyes open and following the target (conjugate gaze) is called: | versions |
| Cranial Nerves 3, 4 & 6: Versions is done by: | asking the patient to follow a target through the six principle positions of gaze.
Note any misalignment of the eyes or complaint of diplopia (double vision). |
| Cranial Nerves 3, 4 & 6: If there is any misalignment of the eyes or diplopia on versions it is important to then examine each eye with the other covered... this is called? | ductions |
| Cranial Nerves 3, 4 & 6: in doing ductions, what and how it should be done? | The patient should follow an object through the six principle positions of gaze so each extraocular muscle's function is tested. |
| Its purpose is to insure that the image that is being looked at is centered or maintained on the fovea of the retina. | Supranuclear control of gaze |
| Supranuclear gaze systems: Are tested by holding up your two hands about three feet apart and instructing the patient to look at the finger that is wiggling without moving their head. The patient's eyes should be able to quickly, smoothly and accurately jump from target to target. | Saccades |
| Supranuclear gaze systems: To test 'this', ask the patient to keep watching the target without moving their head. Then move the target slowly from side to side and up and down.
The eyes should be able to follow the target smoothly without lagging behind or jerking to catch up with the target. | Smooth pursuit. |
| Supranuclear gaze systems: Is a test of smooth pursuit with quick resetting saccades. | Optokinetic Nystagmus |
| Supranuclear gaze systems: Optokinetic Nystagmus can be done by: | using a tape with repeating shapes on it and ask the patient to look at each new object as it appears as you run the tape between your fingers to the right, left, up, and down.
the patient will have brief pursuit eye movements in the direction of the tape movement with quick saccades or jerks in the opposite direction.
The resetting saccades are easier to observe than the brief pursuit movement. |
| Supranuclear gaze systems: Is obtained by having the patient visually fixate on an object straight ahead, then rapidly turning the patient's head from side to side and up and down.
The eyes should stay fixed on the object and turn in the opposite direction of the head movement. | Vestibulo-ocular reflex |
| Supranuclear gaze systems: Eye movements occur when the eyes move simultaneously inward (convergence) or outward (divergence) in order to maintain the image on the fovea that is close up or far away. | Vergence |
