CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]

E. Fund of
information
F. Insight, judgment,
and planning
G. Calculation

SENSORIUM
Outline of mental status examination
General behavior and
appearance

Stream of Talk

Mood and affective

responses

Content of thought

Intellectual Capacity

Sensorium

Is the Pt normal,
hyperactive, agitated,
quiet, immobile? Is the Pt
neat or slovenly? Does the
Pt dress in accordance
with age, peers, sex and
background?
Does the Pt converse
normally? Is the speech
rapid, incessant, under
great pressure, or is it slow
and lacking in
spontaneity? Is the Pt
discursive and unable to
reach the conversational
goal?
Is the Pt euphoric,
agitated, inappropriately
gay, giggling or silent,
weeping and angry? Does
the mood swing in a
direction appropriate to
the subject matter of the
conversation? Is the Pt
emotionally labile?
Does the Pt have illusions,
hallucinations or delusions
and misinterpretations? Is
the Pt preoccupied with
bodily complaints, fears of
cancer or heart disease, or
other phobias? Does the
Pt suffer delusions of
persecution and
surveillance by malicious
persons or forces?
Is the Pt bright, average,
dull, or obviously
demented or mentally
retarded?
A. Consciousness
B. Attention span
C. Orientation for
time, place, and
person
D. Memory, recent
and remote

Concept of Sensorium
A mechanism integrates all of the senses, all of the
memories, all the hopes and desires, into a stream of
consciousness.
Locus of Sensorial Mechanism
Hippocrates brain as the site of the sensorium
Aristotle sensorium in the heart (is the first of all parts
to be formed)
Charaka The heart is the seat of consciousness
Herophilus Sensoriom in the Calamus Scriptorius of
the Fourth Ventricle
- Shifted the cite to cerebellum, and suggested
that the superior intelligence of human kind
resulted from the richness of the cerebral
cortical convolutions
Galen supported the doctrines of Herophilus,
Erasitratus and Hippocrates
Interpretational definition of the sensorium commune
Sensorium commune the mechanism for consciously
perceiving ongoing events, relating them to the past
and to future goals and responding with behavior
appropriate to ones role in life
The sensorium then:
- Receives the ongoing afferent information and
relates it to memory traces of past events and
to future possibilities
- Invests the stream of thought with emotion,
significance, and priority
- Programs behavior appropriate to ones role
and station
- The whole process constitutes perception,
integration, and execution. As such, the
sensorium has no localized residence but
represents the integration of all neural activity
within the brain

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]

The Sensorium as Communal Experience (Common

Sense)
Sound of mind has a common sense of:
1. Who they are and what their role and station in
life is
2. Where they are
3. When it is: morning, afternoon etc
4. What is happening: is it raining?
5. How the wise and prudent person should
respond: to come in out of the rain
Common Sense derives from the intuition that all
normal human beings share a common sense of who,
where, and what they are, what is happening in daily
affairs, and how to respond appropriately to the
exigencies
Quick operational testing of the sensorium

4. Memory
a. Note how well the Pt recalls and relates the
events of the medical history
b. Inquire: Does your memory work all right?
Do you have trouble with your memory? If
you suspect memory disturbances:
Suppose we try out your memory? Provide
Pt with nonsense items that have no special
relationship (53 Broadway, orange and
table) At the end of the NE, ask the Pt to
recite them
c. Determine whether the Pt differs in the
ability to recall recent or remote events.
Can the Pt give his date of birth, but not the
present day, month, and year?
Recent memory suffers most in aging or
brain diseases:

Ex asks a series of who, where, when, what questions

Five sensorial functions:
Consciousness
Attention Span
Orientation of Time, person and place
Recent memory
Detailed Examination of Sensorium
1. Consciousness awareness of self and
environment
2. Attention Span Can the Pt attend to stimuli
long enough to complete it?
- Ask the Pt to recite the months backwards or
spell the world backwards
3. Orientation does the Pt comprehend who he
or she is, and where, and when it is?
As the person: Does the Pt recognize him- or
herself and role as a Pt and recognize other
people, their roles and yours as a doctor?
As the place: Does the Pt understand the nature
and geography of the place? Does the Pt
recognize that he or she is in the hospital, its
name and the name of the city and state?
As to time: Does the Pt know the time of the
day, day of week, month, and year?

Recall that grandfather cannot remember

where he just laid his glasses, but can wax
eloquent about events of long ago.
5. Fund of information current events
6. Insight, judgment and planning ask the Pt
plans to do
7. Calculations Pt can balance a checkbook,
make change, do formal paper-and-pencil
calculations, and subtract sevens serially from
100
SEE TABLE 11-2 ATTACHED
Neurologic implications of sensorial defects
Memory loss: Bilateral lesions of the medial temporal
lobe and hippocampal-fornix-mammillary body circuit
Dyscalculia left posterior hemisphere lesion

Affective Responses person reacts emotionally to

ongoing events
- Assay affective responses not by direct inquiry,
but by comparing the observed with the
expected reactions

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]
-

Affective lability commonly accompanies

bilateral UMN disease, as seen in pseudobulbar
palsy or diffuse brain diseases

AGNOSIA, APRAXIA, APHASIA

Agnosia not knowing ; inability to understand the
meaning (import or symbolic significance) of ordinary
sensory stimuli even though the sensory pathway and
sensorium are relatively intact
- Astereognosia
- Agraphognosia
- Finger agnosia
- Astatognosia
- Atopagnosia
- Anosognosia
- Prosopagnosia
Apraxia is the inability to perform a willed act even
though the motor system and mental status are
relatively intact
Tests for apraxia
Give various commands: Stick out your tongue,
make a fist, walk across the room
Principle of Parsimony (Occams Razor)
- Single lesion, single diagnosis
Common Apraxias tested in the NE

Perceptual distortions, illusions, hallucinations and

delusions
Illusions a false sensory perception based on natural
stimulation of a sensory receptor
Hallucinations a false sensory perception not based on
natural stimulation of a sensory receptor
-

Woman with schizophrenia

Delusions a false belief that reason cannot dispel

-

1. Gait apraxia Ask the Pt to walk

2. Tongue apraxia ask the Pt to protrude tongue
and move it up, down, right and left
3. Everyday activity (ideomotor) apraxia Ask the
Pt to demonstrate how to use silverware, strike
a match and light the candle and use a key. Etc
4. Constructional apraxia ask the Pt to copy
geometric figures or construct them out of
match sticks
5. Dressing apraxia Watch the Pt try to put on an
article of clothing
6. Writing and speaking apraxia (aphasia)

Nurse tried to poison the Pt

Localizing significance of hallucination

Hallucinations may indicate a lesion of the appropriate
sensory cortex
Lesions in occipital cortex hallucinations of vision
Uncus smell
Post-central gyrus somatic sensation

APHASIA inability to understand or express words as

symbols for communication, even though the primary
sensorimotor pathways receive and express language
and the mental status are relatively intact
4 avenues of Language
- Speaking
- Writing
- Reading
- Listening

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]
Exclamatory Speech serves to communicate the
emotional states of the instant, rather than ideas
- OUCH!
Prepositions/Representations simple declaration;
states something for analysis that was, is or could be; a
preeminently willful, planned and often crafty
- Fire engines ought to be red
Clinical Testing for Aphasia
1. Detecting early aphasia during the interview
2. Formal aphasia screening test
To test the Pts ability to read, write, name
things, repeat words and sentences and copy
them to dictation, and to follow written and
verbal commands

Technique for administering the Halstead-ReitanWepman Test for cerebral dysfunction

1. Instruct patient I have several things for you to
do. Please do them carefully, and be sure to do
your best. First write your name, address and
date on the page

SEE TABLE 11-3

General Classification of Aphasia
1. Expressive/receptive aphasia
- Mixed expressive-receptive aphasia
- Asphasics comprehend language better that
they express it
2. Fluent and non fluent aphasia
- Depending on the amount of retained language,
rather than following the traditional expressivereceptive scheme
General Localization of lesions causing aphasia
1. Localization to the dominant hemisphere
a. Lesion that causes aphasia Is in the LEFT
Cerebral Hemisphere in most all right
handed and most left handed Pts.
LEFT HEMISPHERE dominant for Language
2. Localization within the dominant hemisphere
a. Lesions usually involve the parasylvian
region of the left hemisphere, subjacent
deel white matter, caudate putamen or the
thalamus, interrupting the corticocortical

circuits of the parasylvian cortex or its

connections with the deep nuclear masses
b. Left handers, the lesion occupies the
homologous regions of the right
hemisphere.
Nonfluent (Brocas) motor aphasia (expressive
aphasia)
1. Clinical Features
a. Pt speaks telegraphically and sparsely. Pt
uses some nouns and verbs but omits the
small connecting words, conjunctions such
as but, or and and, and the articles such as
a, an, or the.
- I go house instead of I go to the house
Pt shows poverty of associations, such as
naming all the makes of automobiles or all
objects in red
b. Difficulty in writing, suggesting that the
posterior inferior part of the frontal part of
frontal lobe contains executive centers for
language expression, consisting of the
funnel through which plays on the motor
cortex to express speech by speaking or
writing.
c. Pt retains the ability to audit language and
to read.
2. Lesion site
Pure expressive or nonfluent aphasia indicates a lesion
of the anterior part of the aphasic zone, in the posterior
inferior part of the frontal lobe. An upper motor neuron
palsy (right side of face) accompanies expressive
aphasia
Fluent (Wernickes) receptive aphasia
1. Clinical Features
a. Produces plentiful or even an excessive number
of words, but the words are often wrong or
assembled in wrong sounds (phonemes)
b. The substitution of erroneous phrases, words,
or parts of the word in called paraphasia
c. The Pt crams in numerous words substitutions,
circumlocutions, and neologisms
d. They cannot use their auditory feedback to
correct their own errors in word production

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]
2. Lesion site
Region around the posterior end of the sylvian
fissure at the parieto-occipito-temporal confluence
Lesion affects the aphasic zone more posteriorly
and temporally than in nonfluent aphasia
It disconnects the auditory cortex in the superior
temporal gyrus from the rest of the posterior
parasylvian area, the word association area
Dyslexia, or visual word agnosia
1. Clinical Features
a. Pure agnosia for the meaning of written words,
inspite of adequate intelligence and exposure to
conventional methods of instruction
b. Cannot name colors
c. Give paragraphs to read and ask the Pt to
explain the material
2. Lesion site
Posterior end of the aphasic zone. It damages word
association cortex of the occipital lobe or
disconnects it from afferents that arrive via corpus
callosum, or from the lingual and fusiform gyri.
Lesions of dominant frontal love that may be
associated with Brocas aphasia
Auditory Agnosia
1. Clinical Features
- Fails to understand spoken words but can write
and speak

2. Lesion Site
Lesion destroys virtually all of the left
parasylvian cortex or its connections with
the caudate-putamen, or thalamus.
-Common infaction
Role of the right hemisphere in language
1. The right hemisphere can interpret words as
symbols for verbal communication only to a
limited extent, after the brain reaches
developmental maturity
2. The right hemisphere has to deliver the
language stimuli it receives to the left
hemisphere via corpus callosum for
interpretation and motor expression
3. The parasylvian zone of the right hemisphere
interprets and modulates the prosody of
emotional expression, the rhythm, melody and
inflections that add emotions to speech
4. Pts with lesions in the right parasylvian zone or
its subcortical connections cannot invest their
own speech with its emotional coloring nor
interpret the emotional connotation or gestures
of others
5. Pt whose speech lacks emotional inflection has
expressive aprosody
6. Pt who cannot differentiate the emotional
inflections of language spoken by others have
receptive aprosody or Global aprosody
Testing for right hemisphere aprosody
- The Ex listens for flat emotionless speech during
medical history
- Ex says a test phrase in different emotional
inflections and ask the Pt to interpret the
emotion conveyed.
The levels and types of speech disturbances

2. Lesions
- Lesion occupy posterior part of the superior
temporal gyrus next to the primary auditory
receptive area in the transverse gyri, in the floor
of the sylvian fissure
Global Aphasia
1. Clinical Features
Pt has severe expressive and receptive
dysphasia, virtually eliminating all receptive and
expressive communication by words.

Dysponia disturbances in or a lack of production of

sounds in the larynx
Dysarthria disorder in articulating speech sounds
Dysprosodies consists of scanning speech (cerebellar),
plateau speech (basal motor nuclei/parkinsonian) and
stuttering, cluttering, and absence of emotional
inflections (cerebral)
Dysphasia highest level

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]
-

Disturbances in the understanding or

expression of words as symbols for
communication

Mutism or Aphonia
- Little or no speech
- Deaf mutism, elective mustism, hysterical
mutism, akinetic mutism, autism, and other
retardation syndromes, catatonia, depression,
postictal confusion, and the mutism or
bradylalalia after bilateral lesions of thalamus or
basal motor nuclei
Too much speech an increase in the amount and
rate of speech, of logorrhea, fluent aphasia,
cluttering, echolalia, and pressure of speech
Gerstmanns Syndrome
1. Clinical Features
Dysgraphia cannot copy
Dyscalculia
Finger agnosia
Right left disorientation
2. Lesion site
Left angular gyrus, at the
parietooccipitotemporal junction may cause the
4 core components, one or all of the
components can occur with lesions of more
distant sites

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]
Table 11.2 Outline of sample questions to screen the Patients
Sensorium
Questions
Questions in Filipino
Area of
sensorium
tested
What is your name?
Ano po ang pangalan
Orientation
How old are you?
niyo?
to person,
When is your
Ilang taon na po kayo?
time and
birthday?
Kailan po ang inyong
place; recent
kaarawan?
and remote
memory;
What is your address?
Saan po kayo nakatira,
consciousnes
Are you staying there
dun po ba kayo
s of self and
now?
namamalagi?
environment
What kind of work do
you do?

Ano po ang inyong

trabaho?

Do you have a
family/wife/husband
or children?
What are their
names/occupations/ag
es/addresses?
Where are they now?
Do you happen to
know the time of the
day?
Have you been waiting
long to see me?

Mayroon po ba kayong
pamilya, asawa o mga
anak?
Ano ano po ang kanilang
mga pangalan at edad?
Saan po sila nakatira?

What is the
day/date/month/year
?

Alam niyo po ba anong

petsa ngayon?

What is the season

/weather?

Alam niyo po ba kung

anong panahon meron
ngayong araw na ito?

What did you do

yesterday?
What have you come
to see me about?
How does it come
about that youre
seeing me?
Do you feel that you
need any medical
help?

Ano po ang ginawa niyo

kahapon?
Mayroon po ba kayong
nararamdaman na sakit?

What are your plans

for the future?

Ano po ang mga plano

niyo sa mga susunod na
araw?
(If still working)
Gaano po kayo katagal
pang magttrabaho o
magreretire na ho ba
kayo?
Ano po ang inyong
reaction o palagay sa
(magbanggit ng nasa
news . . impeachment..

How long do you

expect you will be
off work?

What do you think of ..

(mention some items
in the news.)

Alam niyo po ba anong

oras na ngayon?
Gaano po kayo katagal
naghintay para sa
examination na ito?

Orientation
to time,
recent
memory

Doctor/Patie
nt role
recognition,
insight as to
presence of
an illness or
need for
medical
attention and
judgment
Judgment
and
planning?

Recent
memory,
fund of
information,

How has your memory

been?
Are you worried about
it?

etc)
Kamusta naman po ang
inyong memorya,
madalas po ba kayong
nakakalimot?

Suppose we test it. See

whether you can
remember. . (give a
name, color, address)

Magbigay ng pangalan,
kulay at address

Can you name the last

several presidents?
Subtract 7 from 100,
then take off seven
more and continue
subtracting 7s. Spell
world or other word
backward.

attention
span

Naalala pa niyo po ba ang

mga nakaraan nating
presidente?
Ano po ang sagot sa
100-7 (93)
93-7 (86)
86-7 (79)
79-7 (72)
72-7 (65)
65-7 (58)

Calculation,
attention
span

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]
Table 11-3 Instructions for use with stimuli of Fig 11-6 to test
for cerebral dysfunction
Patients Task
Examiners
Examiners
Instructions to
Instruction to
the patient
patient (in
Tagalog)
1. Copy
First, draw this on Paki guhi/gaya
Square/Parisu your paper (point po ito (point to
kat (A)
to square) I want
square, dont
you to do it
mention its
without lifting
name) Wag
your pencil from
niyo pong
the paper. Make
itataas ang
it about this same lapis. Gayahin
size
niyo po ang
saktong sukat.
2. Name
What is that
Ano po ang
SQUARE/PARI shape called?
tawag sa hugis
SUKAT
na ito?
3. Spell
Would you spell
Puwede nito
SQUARE/PARI that word for me? ho bang
SUKAT
banggitin ang
mga letrang
bumubuo sa
salita/ paki
spell po ang
salita?
4. Copy
Draw this on your Paki guhit din
CROSS/EKIS
paper. Go around po ito (point to
(B)
the outside like
B)
this until you get
back to where
you started.
5. Name
What is that
Ano po ang
CROSS/EKIS
shape called?
tawag sa hugis
na ito?
6. Spell CROSS
Would you spell
Pwede niyo ho
that word for me? bang i-spell
ang salitang
iyon?
7. Copy
Same with 1 and
TRIANGE/TAL 4 above
SULOK
8. Name
Same as above
TRIANGLE/TA
TSULOK
9. Spell
Same as above
TRIANGLE
10. Name
What is this?
Ano itong nasa
BABY/SANGG
larawan?
OL (D)
11. Write CLOCK
Now I am going to Magpapakita
(E)
show you another po ako ng
picture but dont
larawan pero
tell me the name
wag niyo pong
of it. Just write
sasabihin kung

12. Name FORK

(F)
13. Read 7 SIX 22
(G)
14. Read M G W
(H)
15. Reading I (I)
16. Reading II (J)
17. Repeat
TRIANGLE

18. Repeat
___________
______

19. Repeat
___________
_______
20. Write
SQUARE (K)

the name of the

picture on your
paper.
What is this?

ano ito,
isusulat niyo
po.
Ano po ito?

I want you to read

this.
Read this

Paki basa po
ito.
Paki basa rin
po ito.
Paki basa po
ito.
Nababasa niyo
po ba ito?
Magbabanggit
po ako ng
salita at
gayahin niyo
po pagkatapos
ko.

Now I want you to

read this
Can you read
this?
Now I am going to
say some words. I
want you to listen
carefully and say
them after me as
carefully as you
can. Say this
word: TRIANGLE
The next word is a
little harder but
do your best. Say
this word:
______________
_
Now repeat this
one:
______________
_________
Dont say this
word out loud.
Just write it on
your paper

21. Read SEVEN

(L)

Can you read this

word out loud

22. Repeat SEVEN

Now, I want you

to say this after
me: SEVEN
I am going to say
something that I
want you to say
after me so listen
carefully: HE
SHOUTED THE
WARNING: What
does it mean?
Now I want you to
write the
sentence on the

23. Repeat
explain HE
SHOUTED
THE
WARNING/SI
NIGAW NIYA
ANG BABALA
24. Write HE
SHOUTED
THE

Paki banggit
po ang
sasabihin kong
salita:
____________
__
Paki ulit po ang
salitang ito:
____________
_________
Huwag niyo
pong
babanggitin
ang nakasulat
dito, isulat
niyo pos a
inyong papel.
Paki basa po
ng malakas
itong
nakasulat
Paki ulit po ang
sasabihin ko:
SEVEN
Gayahin niyo
po ang
sasabihin ko at
ipaliwanag ang
ibig sabihin
nito.

Paki sulat po
yung aking
sinabi

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]
WARNING/SI
NIGAW NIYA
ANG BABALA
25. Compute 8520 (M)
26. Compute 7 x
3

paper

27. Name KEY (N)

28. Demonstrate
use of KEY (N)

What is this?
If you had one of
this in your hand,
how would you
use it?
I want you to
draw a picture
that looks like this
Would you read
this?
Now would you
do what I said?

29. Draw KEY

30. Read (O)

31. Place LEFT
HAND TO
RIGHT EAR

32. Place LEFT

HAND TO
LEFT ELBOW

Copy it down and

try to work it out
Now do this one
in your head

Now I want you to

put your left hand
to you left elbow.
(Impossible)

Paki-calculate
po ito.
Paki sabi po
ang sagot
gamit ang inyo
lamang isip
Ano poi to?
Paano niyo po
ba ginagamit
ito?
Paki guhit po
ang larawang
ito
Paki basa po
ito
Paki hawakan
po ang inyong
kanang tenga
gamit ang
inyong
kaliwang
kamay
Paki hawakan
po ang inyong
kaliwang siko
gamit ang
inyong
kaliwang
kamay

CRUZ 1-B [THE PATIENTS MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS]

7 SIX 2 M G W
SQUARE
85-20=

SEVEN