Directed Neurological Examination

The directed neurological examination should begin with a mental status evaluation, which includes a psychiatric assessment. This part of the examination actually begins during the history and may be expanded in a more formal fashion. The mental status examination should include assessments of level of alertness, orientation, and attention. Stupor may be organic in origin or psychiatric. Hypervigilant states may develop with delirium tremens as well as with drug overdoses, such as amphetamine, phencyclidine, and cocaine, or with paranoid states in general. A fluctuating level of consciousness is more likely to be associated with an organic cause, and the presence of stupor will interfere with the remaining aspects of the cognitive examination. Sudden alterations in behavior, especially behavior with automatisms, may also suggest a seizure disorder; seizures of frontal lobe origin may be extremely bizarre, and sudden behavioral changes are often mistaken for psychogenic displays.

To assess mood one must ask how the patient feels, yet the affect is also directly displayed. The patient may appear sad and tearful or ebullient and inappropriately expansive. The way the patient is dressed and presents herself or himself is important but is often overlooked. A slovenly

appearance in a recently high-performing individual is a cause for concern, even if the subject scores well on tests of memory and the simple routine tasks demanded in an office cognitive examination. The way questions are answered is a significant aspect of the emotional evaluation. The examiner should notice whether the patient volunteers information or conceals it. Additionally, it should be noted whether questions are answered in a normal time frame or if there are delays that require several prompts to obtain an answer. Furthermore, the answers may be incomplete or minimally helpful, and the prosody of the speech may convey emotions or the lack of them.

The presence of a thought disorder will be conveyed during conversation and is independent of mood. When taking the history and examining patients, the clinician should look for "loose associations of thought" and the practice of skipping illogically from one idea to another seemingly unrelated idea. It should be observed whether a word with two meanings is used correctly the first time and then used incorrectly to develop an unrelated thought. A formal language examination may be helpful in distinguishing a thought disorder from an aphasia. But when the speech disorder is profound, the difference may be difficult to discern. There are certain features of psychotic speech that may be helpful and should be sought. Clanging, the use of similar sounding words together regardless of their meaning, is never present in aphasia, whereas dysarthria is not a feature of psychosis. Naming should not be impaired in thought disorder but is usually affected in aphasias. The examiner should note that many patients with thought disorders are either noncompliant and refuse to answer or may seem to purposefully misname things, requiring interpretation of the incorrect answers. Writing specimens of a psychotic subject should be obtained; they may be agrammatical or may contain neologisms, simulating aphasia. As in patients with some aphasias, the content of the speech of a patient with a thought disorder may be empty, and often, after a few minutes of monologue, the examiner may have no idea what information was conveyed. Thought-disordered speech may also be pressured and may be highly distractible. The clinician should note any figures of speech that may contain unusual allusions and references to bizarre or macabre things.

The examiner should also ask whether the patient is hearing or seeing things that aren't there and assess whether these hallucinations are interfering with complete cooperation. Delusions should be probed but not countered. Since the delusion is an irrational belief, argument over its logic is fruitless, but the examiner should not agree with it. Depending on the situation, either an explanation that the belief is a delusion but appears real to the patient can be given, or the clinician can simply take note of it and pass on to other subjects. In the case of drug-induced psychosis in Parkinson's disease, the most common delusion is of spousal infidelity, a problem that is often not shared with the neurologist owing to embarrassment by both the patient and the spouse. In this situation and occasionally in others, specific delusions should be asked about.

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