CNS PESA

PART I - MENTAL STATUS EXAM

A. Fill in the three required components of the Mental Status Exam (LOL):

Three Required Components of the Mental Status Exam (LOL)

Level of Consciousness

Orientation

Language

. How to Test Each Component

For each domain listed above, briefly describe how you would assess it during a bedside exam.

1. How to test:

2. How to test:

3. How to test:

B. How to Test Each Component

1. Level of Consciousness How to test: Observe patient's alertness, arousal, and responsiveness to verbal stimuli; note ability to maintain attention and interact appropriately with examiner.

2. Orientation How to test: Ask patient to state person, place, time, and situation (e.g., name, location, date, reason for visit).

3. Language How to test: Assess fluency, comprehension, naming, and repetition through conversation and simple commands.

Cranial Nerve

How You Test It

What an Abnormal Finding Might Mean

CN I (Olfactory)*Not routinely tested

CN II (Optic)

CN III (Oculomotor)

CN IV (Trochlear)

CN V (Trigeminal - sensory)

CN V (Trigeminal - motor)

CN VI (Abducens)

CN VII (Facial)

CN VIII (Vestibulocochlear)

CN IX (Glossopharyngeal)

CN X (Vagus)

CN XI (Spinal Accessory)

CN XII (Hypoglossal)

CN I - Olfactory

Not routinely tested in screening exam; may ask about smell if indicated

Anosmia from sinonasal disease, head trauma, or frontal lobe pathology

CN II - Optic

Shine light to assess direct and consensual pupillary response; gross visual screening

Visual pathway abnormality, optic nerve disease, or afferent pupillary defect

CN III - Oculomotor

Assess pupil constriction and extraocular movements

Ptosis, diplopia, dilated pupil; may suggest midbrain lesion or increased ICP

CN IV - Trochlear

Assess downward and inward eye movement during EOM testing

Vertical diplopia; difficulty with stairs or reading

CN V - Trigeminal (Sensory)

CN V - Trigeminal (Motor)

Light touch to forehead, cheeks, and jaw bilaterally

Sensory loss in trigeminal distribution; brainstem or peripheral nerve lesion

Palpate masseter while patient clenches jaw

Weakness suggests trigeminal motor dysfunction

CN VI - Abducens

Assess lateral eye movement during EOM testing

Inability to abduct eye; often affected by increased ICP

CN VII - Facial

Ask patient to raise eyebrows, smile, puff cheeks, close eyes tightly

Central vs peripheral facial weakness (forehead sparing vs involvement)

CN VIII - Vestibulocochlear

Finger rub, whisper test, or tuning fork if available

Hearing loss or vestibular dysfunction

CN IX - Glossopharyngeal

Say "ah" while observing palate rise using light and tongue blade

Asymmetric palate elevation; dysphagia

CN X - Vagus

Voice quality and palate elevation with "ah"

Hoarseness, dysphagia; brainstem or vagal pathology

CN XI - Spinal Accessory

Shrug shoulders or turn head against resistance

Weakness suggests accessory nerve dysfunction

CN XII - Hypoglossal

Stick out tongue and move side to side

Tongue deviation toward side of lesion

Exam Component

How You Perform the Test

What an Abnormal Result Suggests

Rapid Alternating Movements

Finger-to-Nose

Heel-to-Shin

Romberg Test

Gait Testing (three components)

Exam Component

How the Test Is Performed

What an Abnormal Result Suggests

Rapid Alternating Movements (Dysdiadochokinesis)

Patient rapidly pronates and supinates hands on thighs or taps fingers alternately; performed bilaterally

Dysdiadochokinesis indicating cerebellar hemisphere dysfunction

Finger-to-Nose

Patient alternates touching examiner's finger and their own nose; performed bilaterally

Dysmetria (overshoot/undershoot), intention tremor → cerebellar dysfunction

Heel-to-Shin

Patient slides heel of one foot down the opposite shin while supine; performed bilaterally

Ipsilateral cerebellar pathology causing impaired coordination

Romberg Test

Patient stands with feet together, first eyes open then closed; examiner guards patient

Loss of balance with eyes closed suggests proprioceptive or vestibular dysfunction, not primary cerebellar disease

Gait Testing (regular, tandem, heel, toe)

Patient walks normally, heel-to-toe, on heels, and on toes

Wide-based or ataxic gait suggests cerebellar disease; tandem gait is most sensitive for subtle cerebellar dysfunction

1. How is the Babinski reflex performed, and what does a positive result indicate?

1. Babinski reflex: Stroking the lateral sole of the foot and across the sole over the MTP joints; up-going great toe in adults suggests an upper motor neuron lesion.

2. What is pronator drift, how is it tested, and what does a positive finding suggest?

2. Pronator drift: Arms extended, palms up, eyes closed; downward drift and pronation indicate subtle UMN weakness.

3. How is this different than the Romberg test?

3. Difference between pronator drift and Romberg:

a) Pronator drift assesses upper motor neuron function by revealing subtle weakness in the corticospinal tract.

b) Romberg test assesses proprioceptive and vestibular function, not motor strength, by removing visual input. A positive Romberg (instability only with eyes closed) suggests sensory ataxia due to dorsal column or peripheral nerve pathology, not cerebellar disease. We combine it with the pronator drift test for convenience.

4. Describe how to test for ankle clonus and what it signifies.

4. Ankle clonus: Rapid dorsiflexion of the foot; sustained rhythmic beats indicate UMN hyperexcitability.

5. How is Kernig's sign performed and what does a positive result suggest?

5. Kernig's sign: Pain or resistance with knee extension while hip is flexed; suggests meningeal irritation.

6. How is Brudzinski's sign performed and what pathology is it associated with?

6. Brudzinski's sign: Passive neck flexion causes involuntary hip and knee flexion; suggests meningitis or meningeal irritation.

7. What is nuchal rigidity, and how is it assessed on physical exam?

7. Nuchal rigidity: Resistance to passive neck flexion; indicates meningeal inflammation.

7. What mental status domain is assessed by digit span or spelling a word backward?

7. Attention - commonly impaired in delirium and diffuse cerebral dysfunction.

8. A patient cannot recall three words after five minutes but remembers long-term personal history. Which cognitive domain is impaired?

8. Recent memory impairment with preserved remote memory.

9. What cognitive function is being tested when a patient is asked how two objects are similar?

9. Executive function, specifically abstraction.

10. What type of task is commonly used to assess non-dominant hemisphere function?

10. Constructional/visuospatial tasks, such as clock drawing or figure copying.

11. Which finding is most consistent with an upper motor neuron lesion?

A. Muscle atrophy and fasciculations

B. Hyporeflexia

C. Hyperreflexia and clonus

D. Decreased tone with weakness

11. C - Hyperreflexia and clonus are classic UMN findings.

12. Which special test is most sensitive for detecting subtle unilateral upper extremity weakness?

A. Babinski reflex B. Hoffmann sign C. Pronator drift D. Romberg test

12. C - Pronator drift is the most sensitive test for subtle unilateral weakness.

13. Which combination of findings best suggests meningeal irritation?

A. Hyperreflexia and clonus B. Pronator drift and Babinski C. Kernig and Brudzinski signs D. Hoffmann sign and ankle clonus

13. C - Kernig and Brudzinski signs indicate meningeal irritation.

14. A patient holds both arms extended with palms up and eyes closed. After several seconds, the right arm slowly drifts downward and pronates. What test is being performed, and what does this finding suggest?

14. This is pronator drift, suggesting contralateral upper motor neuron weakness.

15. A febrile patient with headache resists passive neck flexion. When the examiner flexes the neck, the patient's hips and knees involuntarily flex. Name the two exam findings present and what they suggest.

15. Findings are nuchal rigidity and Brudzinski's sign, suggesting meningeal irritation (e.g., meningitis).

16. Absence of Kernig and Brudzinski signs rules out meningitis. (T/F)

16. False - Meningitis may be present even if meningeal signs are absent.

17. Pronator drift is primarily a test of lower motor neuron function. (T/F)

17. False - Pronator drift detects upper motor neuron pathology.

Match the special test with the best description.

a. Babinski b. Pronator drift c. Kernig sign d. Brudzinski sign e. Ankle clonus

1. Subtle upper motor neuron weakness

2. Suggests corticospinal tract dysfunction

3. Involuntary hip and knee flexion with neck flexion

4. Rhythmic muscle contractions after rapid dorsiflexion

5. Pain with knee extension while hip is flexed

a → 2 b → 1 c → 5 d → 3 e → 4