Neurologic & Mental Status Assessment – Lecture Review

Introduction & Class Logistics

• Session focus: neurological system, normal neuro assessment, and mental-status examination.

• Course housekeeping

  • Pre-class quiz ((5) questions) completed; post-class quiz of (10) questions due by (22{:00}) tonight.

  • Learning Objectives hand-out aligns directly with exam content – review thoroughly.

• “High / Low / Buffalo” feedback board

  • High = positive course element.

  • Low = negative element.

  • Buffalo = point of confusion or unanswered question.

Central Nervous System (CNS) Anatomy Review

• Cerebrum

  • Two hemispheres; each controls the contralateral side of the body.

  • Four lobes – location & primary functions

  • Frontal: personality, behavior, judgment, voluntary movement.

  • Parietal: tactile perception, shape recognition.

  • Occipital (posterior): vision & visual interpretation.

  • Temporal (lateral): hearing, taste, smell, language comprehension.

• Sub-cortical structures

  • Basal ganglia: initiation/coordination of movement.

  • Thalamus: sensory relay station.

  • Hypothalamus: autonomic center regulating temperature, heart rate, BP.

• Brainstem (midbrain, pons, medulla)

  • Houses cranial nerves III – XII.

  • Vital centers for breathing, heart rate, vasomotor control.

• Cerebellum

  • Balance, posture, coordination of voluntary movement.

• Spinal cord

  • Reflex center; ascending (sensory) & descending (motor) tracts.

Peripheral Nervous System & Reflex Arc

• PNS: cranial + spinal nerves.

• Spinal nerves: 31 pairs ((8) cervical, (12) thoracic, (5) lumbar, (5) sacral, (1) coccygeal). Named by exit level.

• Simple reflex arc

  • Afferent (sensory) → integration in spinal cord → Efferent (motor) → muscle contraction.

  • Example: patellar reflex (stimulus → spinal cord → quadriceps contract) – occurs in milliseconds.

• Reflex categories

  • Deep-tendon (myotatic) – patellar, biceps, triceps, etc.

  • Superficial – corneal, abdominal, plantar.

  • Visceral – pupillary light reflex.

Age-Related Neurological Changes (Older Adult)

• General cerebral atrophy → ↓ muscle bulk & strength.

• Diminished vibratory, pain, and temperature sensation.

• Loss of taste buds (sweet is last to disappear).

• Benign essential tremor (head, hands, jaw) – distinguish from Parkinsonism.

• Slower reaction time; recent memory decline while remote memory intact.

Motor Abnormalities & Involuntary Movements

• Muscle tone descriptors

  • Flaccid: hypotonic, limp.

  • Spastic: hypertonic, stiff.

  • Rigidity: constant resistance.

  • Cog-wheel rigidity: ratchet-like – classic in Parkinson’s.

• Involuntary movements

  • Tic: brief repetitive twitch of muscle group (e.g., eye).

  • Myoclonus: sudden jerks (e.g., hiccup, seizure jerk).

  • Fasciculation: continuous fine twitch of resting muscle.

  • Chorea: sudden, rapid, purposeless movement.

  • Athetosis: slow, writhing movements (cerebral palsy).

  • Tremor

  • Resting tremor – present at rest (Parkinson).

  • Intention tremor – worsens with voluntary activity.

• Seizure: time-limited electrical disturbance (seconds → minutes); sub-types covered in Med-Surg.

Coordination & Gait Testing

• Rapid Alternating Movements (RAM)

  • Pat knees with alternating palm/back quickly; or thumb–finger tap.

• Finger-to-Finger / Finger-to-Nose

  • Examiner’s moving target ↔ patient’s nose; tests cerebellar function & vision.

• Gait observation

  • Normal walk ((~20) ft): smooth, balanced, arm swing symmetric.

  • Tandem (heel-to-toe) walk: detects ataxia, sobriety check.

• Romberg test

  • Feet together, arms at side, eyes closed (20\,s); minimal sway = negative/normal.

Sensory System Assessment

Spinothalamic Tract (Anterior/Lateral)

• Pain: sharp (broken tongue depressor) vs dull discrimination.

• Light touch: cotton wisps; patient says “now” when felt.

Posterior (Dorsal) Column

• Vibration: strike tuning fork, place on bony prominence (toe tip, finger); ask when vibration starts & stops.

• Proprioception (Position sense): move distal phalanx up/down; patient identifies direction.

Tactile Discrimination (Cortical Sensory)

• Stereognosis: identify familiar object in hand (coin, key).

• Graphesthesia: recognize number/letter traced on palm.

• Extinction: touch both sides simultaneously; patient states locations.

• Point location: touch skin, withdraw, patient points to spot.

Deep Tendon & Superficial Reflexes

Grading Scale

0 :{ No response}\
1+ :{ Diminished / hypoactive}\
2+ :{ Average / normal}\
3+ :{ Brisk, possibly pathologic}\
4+ :{ Hyperactive, clonus, pathologic}

Key Reflexes & Spinal Levels

Cranial Nerves (CN) Overview

Mnemonics

• Names: “On Old Olympus’s Towering Top A Finn And German Viewed Some Hops.”

• Function (S/M/B): “Some Say Money Matters But My Brother Says Big Brains Matter More.”

Table of Nerves & Bedside Tests

Neurological Documentation Tips

• Combine grade + spinal level + intact/impaired.

  • Example: “Achilles reflex 2+\,(L5-S2) intact bilaterally.”

• Include abnormal findings: “Positive Babinski right foot.”

• Always record mental status, pupil size/reactivity, and vital signs with neuro checks.

Glasgow Coma Scale (GCS)

• Perform on admission and serially for head injury, stroke, altered LOC.

Stroke Recognition & Education (FAST)

• Face droop

• Arm weakness

• Speech difficulty

• Time (call 911) – clot-busting therapy window ≈ 4\,h.

• Personal anecdote: rapid EMS & thrombolytic → near-full recovery; underscores timing.

Mental Status Examination (MSE)

Purpose

• Detect dysfunction & determine impact on daily self-care.

Core Behaviors ((10))

1. Consciousness

2. Language

3. Mood & affect

4. Orientation (person, place, time)

5. Attention & calculation

6. Memory (recent & remote)

7. Abstract reasoning

8. Thought process

9. Thought content

10. Perception (hallucinations/illusions)

Appearance–Behavior–Cognition–Thought (ABCT) Framework

• Appearance: posture, dress, grooming.

• Behavior: LOC, facial expression, speech, mood/affect.

• Cognition: orientation, attention span, memory, new learning.

• Thoughts: process, content, perception; screen for suicidal ideation.

Levels of Consciousness

Delirium vs Dementia

Affect Terminology

• Flat, depressed, elated, euphoric (excessive happiness), anxious, fearful, irritable, blunted/ambivalent, labile (rapid shifts), inappropriate.

Subjective vs Objective Data

• Subjective = patient reports ("pain 10/10", "dizzy").

• Objective = observable/measured (BP, lab values, gait, flinching on movement).

Testing Protocol – Check-off Highlights

• CN testing sequence (smell → vision → EOMs → facial sensory/motor → hearing → gag/swallow → shoulder shrug → tongue midline).

• Motor: RAM, finger-nose, gait, tandem, Romberg.

• Sensory: sharp/dull, cotton, vibration, proprioception, stereognosis, graphesthesia.

• Reflexes: biceps, brachioradialis, triceps, patellar, Achilles, plantar; document with grade & level.

High–Low–Buffalo Reflection Tool

• Provide anonymous written feedback:

  • High – effective teaching moments.

  • Low – areas needing improvement.

  • Buffalo – lingering questions.