Cerebral. The presence of accompanying cortical signs other than memory loss helps to localize the anatomical basis of an amnestic syndrome. Accompanying dyspraxia, aphasia, or agnosia indicates that the cortex is involved in the pathological process. An assessment of affect is also important, since depression can produce a picture of seeming dementia (pseudodementia). Emotional lability or poor voluntary control over emotional expression (pseudobulbar affect) can occur in patients with conditions that affect both cortices or with progressive supranuclear palsy.
Cranial Nerves. In the context of compromised cognition, cranial nerve abnormalities are valuable in elucidating the underlying location and cause. Increased intracranial pressure is suggested by papilledema and sixth nerve paresis, and progressive supranuclear palsy often produces distinctive defects in volitional conjugate vertical gaze. A variety of extraocular muscle pareses and nystagmus may accompany Wernicke-Korsakoff syndrome, and visual field defects of a homonymous hemianopia pattern suggest the presence of deep lesions of the white matter pathways, which are seen in patients with thalamic and temporal lobe disorders. Multiple cranial nerve deficits are seen in patients with chronic meningitis.
Motor/Reflexes/Cerebellar/Gait. Chorea and dystonia suggest the possibility of Huntington's disease. Bradykinesia, tremor, rigidity, and postural reflex impairment are seen in Parkinson's disease, and myoclonus typifies postanoxia syndromes and spongiform encephalopathies, among other conditions. Primitive reflexes like snout, plantar extension, and palmomental reflexes, such as rooting responses, suggest the presence of bilateral cortical, subcortical, or brain stem disease. Ataxia and other cerebellar signs may occur in patients with Wernicke-Korsakoff syndrome. Asymmetrical reflexes and mixed areas of weakness (for example, a slight facial paresis on one side and a mild weakness of a leg or arm on the other side) suggest multiple strokes, often subcortical in location.
Sensory. Primary sensory function is difficult to test in patients with memory or cognitive impairment because they are often inattentive and inconsistent in their responses. If primary sensation is normal and a deficit in higher cortical sensory processing is present, such as astereognosis, extinction, or neglect, a cortical disorder should be suspected. Preferential vibration and position sensory loss in combination with memory problems may suggest vitamin B 12 deficiency, whereas severe, painful crises and loss of pin and temperature sensation are more typical of syphilitic illness.
Autonomic Nervous System. In patients with diffuse sympathetic hyperactivity that can occur in the presence of hypothalamic lesions, bilaterally dilated pupils can occur, along with cardiac dysrhythmias and blood pressure instability.
Neurovascular. In the context of possible strokes, the neck vessels should be examined, and evidence of orthostatic hypotension should be sought. Associated Medical Findings
Impaired memory and cognitive functioning are characteristic of drug intoxication or withdrawal as well as of several systemic diseases such as vitamin deficiencies, endocrine disorders, chronic infections, and carcinomas. A general physical examination, therefore, is necessary to identify the precipitating cause. Typically, in disorders of memory such as dementia and amnesic syndromes, the patient does not appear to be acutely ill unless a systemic disorder is also present.
The general physical examination may reveal reversible memory disturbances, the most common causes of which are intracranial masses, normal pressure hydrocephalus, thyroid dysfunction, and vitamin B12 deficiency. Examination of the patient's general appearance, vital signs, skin and mucous membranes, head, neck, chest, and abdomen should reveal clinical signs that will aid in the differential diagnoses of dementia and amnesic syndromes. Fever, tachycardia, hypertension or hypotension, sweating, hypothermia, and impaired level of consciousness should suggest a systemic disease, anticholinergic intoxication, or withdrawal from ethanol or sedative drugs rather than an isolated memory disorder. Jaundice suggests hepatic disease; glossitis, intestinal problems, and yellowish skin suggest a vitamin B12 deficiency; hot, dry skin is often characteristic of anticholinergic drug intoxication. Hypothermia, hypotension, bradycardia, coarse dry skin, brittle hair, and subcutaneous edema are characteristic of hypothyroidism. Recent trauma to the head may be evidenced by scalp lacerations or contusions and pain. Positive Kernig's and Brudzinski's signs are found in cases of meningitis and subarachnoid hemorrhage.
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