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HPIM 21e (Video V7-02) - 12992401
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HPIM 21e (Video V7-02) - 12992401
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Segment:0 .
The first part of the real neurological examination itself is the mental status examination. Now for arbitrary reasons, we have divided the mental status into two subcomponents, what we call the psychiatric mental status and what's called the neurological mental status. Of course, any sophisticated person knows that all behavior comes from the brain, and therefore it's a little bit arbitrary to separate a so-called psychiatric mental status from a so-called neurological mental status.
But the reality is that there are what we think of as psychiatric illnesses, like schizophrenia, and manic depressive illness, and so on. And there are neurological illnesses like Alzheimer's disease, and multiple sclerosis, and so on. So it's true that we separate them in our minds, even though we know that these all come from the brain. Now, I'm not going to talk about the psychiatric mental status examination in a lot of detail today.
This is really about the neurological mental status. But I would say that every doctor, neurologist, internist, emergency physician, OB/GYN, anybody who takes care of patients ought to have some sense of the patient's mental status. Because the truth is, disorders of mental status account for a lot of the reasons for which people come to see doctors. And I would say that for a non-psychiatrist, that is including neurologists like myself, or an internist, primary care doctor, emergency physician, they ought to at least get three bits of information out of the psychiatric mental status.
And I would call those affect, mood and thought. Let me just define those briefly and tell you what I'm talking about there. Affect is the appearance of the person to an outsider. And you can easily learn that by simply looking at the person as you're interviewing them. So you're having a conversation with the patient, taking a history. You ought to be recording in your mind, does this person look happy, sad, neutral, frightened?
What is their affect? An affect, so you can keep it in mind, it really is what an actor does when a director says to behave in a certain way. So if the director says to the actor, look surprised, the actor might go like that. Not necessarily a good actor, but an actor does that. That's a surprised look, or a frightened look, and so on. That's affect-- it's been put on by the person in response to a command.
Mood is the person's real feelings. And the way we monitor mood is something that I call a reflective technique. That means you monitor your own feelings in the presence of the patient as you take the history. This is not something that is taught in most medical schools very well anymore, because it's sort of politically incorrect to have feelings about patients. But the truth is, we're human beings, doctors are.
We have feelings about patients. Some patients make us anxious. Some make us angry. Some make us happy. Some make us sad. That's data, and we're examining the nervous system. It's very important for us to know what we're feeling. It doesn't mean we're going to act on it. It would be unprofessional, of course, to act on it, but we need to know what it is.
So if I'm feeling anxious in the presence of a patient, that generally means that the patient is anxious. And if I'm feeling sad, it usually means the patient is sad. Now, of course, this all depends on you being normal. If you're a normal person and you're feeling anxious, it's probable that that's being transmitted to you in some kind of nonverbal way-- that's useful.
And then what I tell people to do is to compare affect and mood. That is, does the feeling that you're having about the patient match what the person looks like? If you're feeling sad, the person ought to look sad. If you're feeling anxious, they ought to look anxious. If they don't, there is what I would call a mood affect association. Mood affect association means there's something wrong with the nervous system.
It can be a psychiatric illness like depression or schizophrenia, or it can be a neurological illness like multiple sclerosis or motor neuron disease. Remember, in motor neuron disease, some people have what we call pseudobulbar affect. They have inappropriate laughing and crying, so that they're laughing when they're sad and when they're making you sad. That's an affect mood dissociation.
Very important for you to recognize that you're in the presence of somebody who can't match their affect with their mood. All that's done, of course, during the normal interactions with a person that you have after you introduce yourself and you take the history. And then finally, for the psychiatric mental status, I would say that you should get some feeling for the person's thought process and thought content.
The thought is a code. It's used by the nervous system to communicate with itself. It's an internal process. The only way we can really monitor it is to use language. We're going to have to use a code that I can understand. It could be written language, spoken language, but there has to be some sort of language. So as I'm taking the history, I'm thinking to myself, does this story make sense to me?
Is A connected to B connected to C, or is something wrong with this person's thought? Either the thought process is abnormal, or the thought content is abnormal. You should carefully think to yourself, is this story making sense? The story should make sense. If it doesn't, question yourself. Say, I wonder if I'm in the presence or somebody who has a thought disorder.
Remember, thought disorder is an extremely common problem-- it starts in young people. It doesn't go away by and large. So there are lots and lots of patients who will come to your office, no matter what kind of doctor you are, with a complaint, and in fact, they have a thought disorder of some kind. They might be delusional, they might be obsessional, and very important for you to recognize that.
This kind of information is obtained in the ordinary interaction with patients. So Alan, tell me a little bit about your life before you came here to Boston. Where were you before you came to Boston? I was living in Los Angeles, California, for the last 10 years. Wow, it must have been quite a difference coming to the Northeast, huh?
Yes, it's quite a bit colder here. It is, isn't it? What other differences are there that you've noticed? Is it culturally different, do you think? Yes, by and large I think there is a difference between East coast and West coast. So I immediately get a sense of the Boston area being a little bit more focused on education, and obviously sports as well.
Yeah, absolutely. I guess in LA, they still like the Lakers quite a bit though, isn't that right? Yes, they do. But without a football team, I can't really call it a real sports town. That's right. So the point here is we're going to have a conversation. And we ought to have a conversation about something that the patient, the person, has some knowledge.
And what I've learned is that he knows something about sports, has some interest in sports. That's something that I can talk to him about. It might be sports. It might be music. It might be politics. It can be anything. It doesn't make any difference what it is. As long as it's something about which they have interest and knowledge-- not you.
And that, of course, means you have to have a life of some kind as a doctor. Because you're going to have to have some kind of a conversation with people. So having heard that, I might say to him something like, what happened to the football team in LA? Why don't they have a football team? Well, that's a great question. What is the reason?
Their team was moved to St. Louis, and ever since it's been a battle between the league and the local politicians. Where did they play? They played in a big stadium there in LA. What was that called? That's the Coliseum. Coliseum, right. So what I'm testing is his memory, his language, and his thought.
And I'm talking about something that he ought to know about. He's shown an interest in it, and I expect him to actually know something about it. If you're going to pick up a subtle mental status abnormality, you have to expect a lot from your patients within a realm that they understand things. So if he had said to me, I'm very interested in being a French cook, that's what I do, I might have said to him, how do you make hollandaise sauce?
How would you make that? And I would expect him to know how. Whereas in Alan's case, I don't know if he knows how to make hollandaise sauce or not. Do you? I don't think I do. So it wouldn't be a fair question for him. He's not necessarily interested in that. So we find out through our interactions with the person during a history taking what kind of things interest this person, and that's what we talk about.
And what the patient, of course, doesn't really realize is this is a neurological examination. It's also, of course, good for patient-doctor relations. It's the kind of interaction you want to have with your doctor. But for a neurologist, or somebody interested in the nervous system, this is actually part of the exam. That's how we're going to find out. And I'm looking at him-- does he smile in the appropriate time?
Does his affect and mood match? Do the thoughts connect, one to the other? So I would say in my quick screening of him here that he has normal affect, mood and thought. The feelings he's eliciting in me match his appearance. He tells me a story. Very logically, it makes sense. Now what is the neurological mental status? Well, the neurological mental status could be enormously complex.
And probably many of you have referred patients for neuropsychological tests to a cognitive expert. And these tests could take days, literally. And they can give hundreds of tests of all different kinds of cognition. And in fact, it's so complex that it's intimidating to many doctors. They don't know where to begin. How are we going to test all of these cortical and subcortical functions that make us human beings?
And there's some ways that you can approach this. The way I think about it is to think of the mental status as having four major spheres of activity, and you test these four major spheres in sequence. Here in a moment, why I test them in this sequence. I start with a level of consciousness. How awake is this person? There's somewhere between awake and alert and comatose-- everybody is somewhere on that spectrum.
And the question is, where is this person precisely? And I'll show you how to do that in a minute. Once we decide that this person is awake, or nearly awake, very good and alert, I can then go on and test language. Remember I said a moment ago language was the code that we use to communicate with each other. And it's the only way we can find out about thought. So I'm going to test language, and I'll tell you in a minute how we might test language.
If language is reasonably good, it doesn't have to be perfect, but if it's reasonably good, if there is a language that allows us to communicate with each other I can then go on and I can test memory. Memory is the core cognitive function. Nothing can be learned without memory, and many neurological diseases cause memory deficit. So I'm going to want to test memory. And I'll tell you some ways of testing memory.
I've already given you some clues. And finally, if those three things are pretty good, he's awake and attentive, he's got a language that I can use and he's got a reasonable memory, we can then test so-called visual/spatial skills. That is to say, does he have a map in his head of extra personal space? Does he know what right and left is, up and down? Does he organize things in his brain in a reasonable way with regard to his view of the external world?
And that's what I would do for cognitive testing. Now how am I going to organize that? Well, many years ago, 1975, Marshal Folstein and his wife Susan Folstein and Paul McHugh, Head of Psychiatry at Hopkins, decided that people just weren't doing mental status examinations. They weren't doing them, so they put together what they call the mini mental state examination.
And it became one of the most cited papers in all of medicine, I'd say, used very, very widely throughout medicine to deal with the mental status. And what I thought we would do is actually do the mini mental status examination here on Alan today. I'm going to tell you in a minute that this test is not perfect. It is not perfectly sensitive, and it's not perfectly specific.
But as Marshal Folstein actually once told me in person, they invented it because they wanted to invent something that was a lot better than nothing, which is what people were doing before the mini mental. So I'm going to actually give the mini mental. You can download this from the internet. Very easy to get many versions of this. You take the patient's name and date of birth. How old are you, Alan?
33. How are did go in school? I've got a Bachelor's degree. Bachelor's degree in college. So we'll say four years of college, and we put down the date of our examination. So let's start now. What is today's date? December 12, 2009.
Right, so what I'm doing is I'm just going to check that off. That happens to be correct. That is the correct date today. And what's the month? You've already told me, you can say again. And the year? 2009. What day of the week is this?
This is a Saturday. It's a Saturday. And what season of the year is this? The winter. So that's actually incorrect. It's actually the fall. It feels like the winter, but it's not quite the winter yet. So that's a very tricky question, the 12th of December.
But anyhow, this just shows you some of the potential weaknesses you could have in an exam like this. But at the end I'll show you that it actually works out pretty well. What do you call this place, this building where we are right now? Hospital. Tell me specifically, what hospital is it? Brigham and Women's Hospital.
Yep. And what department are we in in the hospital? Neurology. What city is this? Boston. Do you know what county we're in? I don't know that. So there's another one. It's Suffolk County.
A lot of people don't know that. It's not that easy a question. What state are we in? Massachusetts. Massachusetts, that's great. Now, I'm going to test your memory. Say these three words after me, and then memorize them. Will you do that? OK.
Ball, flag, and tree. Say them again. Ball, flag, and tree. So we've just tested immediate recall, which is a test of attentional ability. So he was able to repeat them immediately. And I want you to memorize those, so keep those in mind, OK? OK.
OK, good. Now, I'd like you to start with 100, and subtract by sevens, go back by sevens until I tell you to stop. Take your time. 93, 86, 79, 72, 65. Good. So we let people go back for five iterations. I get to check for each of the correct answers. It's just another attentional test-- can the person keep the task in mind while going back by sevens?
Some defects in that one. Many, many people who I test can't do that. And they're otherwise normal people, and they might get five points off for that. So it's a problem with it, isn't it? Some people, it's too hard. You sometimes have to adapt this. You have to say, well, I want you to go back by threes, depending on how much education a person might have had.
I would like you to think very carefully, go slowly, and try to spell the word "world" backwards. D, L, R, O, W. Very good. Perfect. Another test of attention. This is by asking the person to do two things at once, basically. Keep the task in mind, picture that thing in your mind's eye, as we like to say, that's probably somewhere in the parietal occipital lobe, and then pull it out, one by one.
Very good. What were those three words that I asked you to memorize? Ball, flag and tree. So he was able to keep those in mind. So that's his ability to actually recall. We tested before his ability to put them into memory, and now we know that he can bring them out. What do you call this item right here? That is a wristwatch.
And this one here? A pencil. So watch and pencil gets him two points. Can you repeat after me, no ifs, ands or buts. No ifs, ands, or buts. That's a very classical neurological question. I don't know if it was invented by, but it was certainly put on the map by Norman Geschwind, the great cognitive behavioral neurologist.
And I remember him telling me that this was a very useful phrase in English. Because it was a phrase that had meaning, no ifs, ands, or buts, but was actually extremely difficult for the nervous system to repeat. So it's a sensitive but not specific test of language disorder. Now I'm going to give you a piece of paper here. And I'd like you to take this piece of paper, fold it in half, and put it on the stretcher next to you.
It's a three-step command-- take the piece of paper, fold it in half, put it on the table next to you which he just did. And now I'd just like you to look at this and do what the card says. And you probably can't see that, but he did close his eyes correctly. This is a simple written command of his ability to read, so he gets a point for that.
And now I'm going to give you this piece of paper and a clipboard. I'd like you to just write a sentence of your own, anything you like, just a complete sentence. I shouldn't be talking when he's doing this. And if I were actually doing the test, I would not be interfering with his thinking about this. But I wanted you to understand what we were trying to do here.
We want a sample of his handwriting. It's not only his handwriting, but of course it's his written language. We've tested his ability to read, now we're testing his ability to write. And what we're looking for here is a sentence that makes sense, that has a subject and an object in a reasonable sentence. We don't hold up to a very high standard.
It doesn't have to be poetry, but we'd like it to be something meaningful. My son Casey is two and a half years old. So he gets full credit for that sentence. That's a sentence that makes sense. It's written correctly, the language in it is correctly. And finally, I'd like you to copy this figure. So you see these pentagons overlapping pentagons, and I'm going to just ask him to copy right to the right of it this diagram.
Now we're testing extra personal space, his ability to see the shape, to have his parietal lobe work. And then his motor system, his right hand, is working to reproduce this diagram. Again, we don't expect artistic talent. All we want is the basic shape, the concept that one of these figures is behind the other one. And he gets full credit for that. So he's going to get two points off.
He thought it was winter, it's actually fall. It's darn close to winter, but there's no partial credit for that. So out of a total of 30, he gets a 28. Got to write a 28 down here. Now the point I wanted to make about this is that in many, many studies that have been done validating this test, it's been shown that until the score goes down to about 20, it really doesn't have any meaning at all.
So even though he missed a couple of these, clearly he doesn't have an abnormal mental status. Now, you might say, we knew he didn't have an abnormal mental status before we started giving this test. Well, we already talked to him. I talked to him about the football situation in LA. He was able to tell me a good story. The truth is that if you take a good history like that and you have a reasonable conversation with people, you can be pretty certain that their mental state is all right.
But there are certain things that you could miss. For example, a person could have a nice conversation with you and not be able to copy these diagrams. They can have a big problem with their parietal lobe, which you wouldn't pick up by just having a casual conversation with them. So the point that the Folstein's and Paul McHugh made I think is a very good one. You have to do this in a rigorous fashion, it can't be casual.
It doesn't have to be the mini mental. You could think in your own mind through the four spheres that are tested by the mini mental, which just to remind you, is level of consciousness, language, memory, and visual spatial skills. And you can give your own test if you wish, as long as you state clearly that you've done all of these things and you're sure about them. Now, let me give you a couple of other little tricks that you might use in people who can't do the mini mental for one reason or another.
Maybe you're in a hurry. Maybe the person has seen the mini mental recently and it wouldn't be fair to give it to them again. They would already know what the mini mental was testing. With regard to level of consciousness, we're all somewhere between alert, awake and comatose. The people who are very bad off with regard to level of consciousness, it's very obvious-- their eyes are closed, they look asleep.
These are people who are mainly in the hospital, not in the office. And basically we have definitions for the degrees of unconsciousness that we use. And these definitions don't have important physiological meaning, they're just a way of communicating with each other. So we define coma as a state of apparent sleep which cannot be overcome, even with a noxious stimulus. If you pinched the person, you can't get a meaningful response out of them.
They might make a reflex movement, like pull away or internally rotate their limbs, but they won't do anything meaningful. If a noxious stimulus does awake the person up, even if it's temporary, we call that stupor. If you can wake a person up from a state of apparent sleep just with a verbal command, wake up, and they open their eyes-- even if they go back to sleep, we'll call that drowsiness.
So drowsiness, stupor and coma are very easy to recognize, because they have in common that the eyes are closed. It's only the degree of stimulus that it takes to make the eyes open. The tricky thing, and the problem that you face in the office and in many consultations, is a person who is not normal from a mental status standpoint, but is not bad enough to close their eyes. So by looking at them, you can't see anything's wrong with them.
So I look at Alan, and he looks fine. His eyes are open and he's paying attention to me. But the question is, is there a subtle abnormality in his level of consciousness? Now, in the mini mental, they tested that in many different ways. They gave him three words to repeat immediately. They asked him to spell world backwards. They ask him to go back by sevens, that takes quite a bit of attention.
And people who couldn't do this, I might give them a motoric command. So let's do this together. We can clap. When I clap once, you clap twice. OK. And when I click twice, don't clap. OK. This is called the go-no go protocol.
It's not that easy. So let's try to do it, and try not to make a mistake. Ready? OK. Here we go. OK, that's very good. So he did that perfectly. You could see it requires a fair amount of attention to do this.
This has the advantage of being sort of a game-like phenomena. If somebody is a little off and they can't do the detailed mini mental, you can sometimes do the go-no go protocol and find out whether the person is attentive or not. A person who can do that is probably attentive. And you can now move on to the next stage, which is language. Language I tested, didn't I, just in taking my history. He understood my questions.
His responses were perfectly reasonable. The trick comes in when somebody can't speak to you, but they still might have normal language. Now, when would that occur? Well, the simple thing would be somebody intubated in the hospital with a tube in their mouth, they can't speak. But there are neurological diseases that could do that as well. So if somebody were paralyzed, or very dysarthric because of cerebellar ataxia, and they're so bad off that you couldn't understand their speech, that doesn't mean they don't have normal language.
And we would have to then go to written language, which of course is much more tedious to test, but we could do it. And in the mini mental, there was a test of written language. I asked him to write a sentence. He created a sentence in his mind and he also read some commands for me, so I tested those. And if that didn't work, what would you do then? A person in the intensive care unit, their limbs are tied down, there's wires and tubes everywhere, they can't speak to you-- can you test language?
You might be able to. You could use computer language which is just yes and no. That's how computers work, and you can test people that way. It's very tedious and slow, but it can be done. For example, I can do this with Alan here. What I'd like you to do is raise your left hand if you mean yes, and raise your right hand if you mean no. Is Nixon president?
Is Johnson president? Is Obama president? Good. Is it spring? Summer? Fall? Very good. So he's learned that it's fall, and you can see that I can test him with yes or no questions.
And I can do that with people who can just blink, who can just look up or just look down. I can say one blink is yes, two blinks are no. Looking up is yes, looking down is no. And sometimes you're shocked to find that a person who's very bad off looking actually has a normal language. They are awake, they are alert, they have a normal language. So you want to make sure you test language.
If there is speech, it's often very easy to test language just by talking to the person. And what you're listening for is the cadence and musical quality of the language, what we call prosody. Does it sound like language? And the thing I tell people to try to remember is make believe you don't speak this person's language. Let's say they're speaking Spanish. Would you recognize it as a language anyway?
Would you or not? And if it sounds like a language, then you'd probably say that the prosody, or musical quality, is normal. If it doesn't sound like a language, then there's something wrong with prosody, the brain's ability to make it sound like a normal language. Let me give you an example of that. I can't test this really on Alan because he's normal. But if I said to somebody how are you, Mr. Jones, and Mr.
Jones looked me in the eye and said, MADE-UP LANGUAGE, what would you say? Does that sound like a language to you? It does, doesn't it? It has the prosody of language, has the musical quality of the language, but you don't understand it. So your first thought, of course, is that it's another language. What language is it?
And I wonder if any of you looking at this could think of what language is that. What language is that that I just gave you?
MADE-UP LANGUAGE: . I've given talks on the subject all over the place, and some people say it's Russian, it's Polish. Well, the fact is that it's actually from a very important episode of The Three Stooges, that language called "Three Little Pirates" in which they talk gibberish like this. And it's a lovely example of what we call effluent aphasia. It sounds like a language, but it doesn't have the function of a language, doesn't transmit information from one person to another.
MADE-UP LANGUAGE: That's effluent aphasia. Other aphasias, language disorders, don't sound anything like a language. I wouldn't have to speak the person's language to know that something was wrong. How are you Mr. Jones, and Mr. Jones says to me, MUMBLING:. Clearly something is wrong with language. He's pointing at this paralyzed right hand. That is a non-fluent kind of aphasia.
MADE-UP LANGUAGE: Then if we have people repeat, as we did in the mini mental status examination, no ifs, ands or buts, you've done a pretty darn good language exam. You've tested comprehension, you've listened for fluency, and you've tested repetition. And in fact, if you can say about somebody's language that it was normal or abnormal comprehension, with normal or abnormal fluency, with normal or abnormal repetition, you've actually characterized the aphasia, if there is an aphasia, very accurately.
MADE-UP LANGUAGE: So that's language. Then memory, of course, we've tested in the mini mental by giving those three objects and asking a few minutes later what they were. That's a fairly crude test. If you needed to know more about memory, it's best to have a conversation with people about some subject that they know about. And we did that with Alan.
MADE-UP LANGUAGE: We talked a little bit about football, and what happened to the LA Rams. And he was able to tell us that story very accurately. So that's a pretty good test of memory, and language, and fluency, just having that conversation. And I think it's actually more sensitive to have a conversation like that than it is to give one of these kinds of tests, or to give people a story that has no meaning to them and no importance to them.
MADE-UP LANGUAGE: There's a famous neurological story called The Tom and Bill Story. Tom and Bill went fishing, and Bill caught three black bass. Remember that, you say to the person. And then you come back 20 minutes later and you ask about this story, provided you yourself remember to ask. And if you ask, a lot of people will have forgotten details of that story. The story is not very interesting, it has no importance to the patient.
MADE-UP LANGUAGE: Isn't a very good test really to give people an unimportant story. Finally, this visual/spatial skill business which we tested in the mini mental by having him draw those two pentagons, one in front of the other. There are other ways of testing this. I could say to you, Alan, can you picture in your mind a map of the United States? You're watching me.
MADE-UP LANGUAGE: You can do that, can't you? You can conjure that up in your mind's eye. That's back in your parietal occipital lobe, be lighting up on a PET scan right now, metabolically active. And I said, do you see Boston on that map? Uh huh. Can you see LA on the map? Which way would you go to get from Boston to LA? What direction?
MADE-UP LANGUAGE: West. Right. Directly West, or Northwest, Southwest, where is it? Southwest. It's somewhat South, isn't it? Yes. So you see, he's pictured that in his mind. He knows which way is right and left, north and south, up and down.
MADE-UP LANGUAGE: We all have this map of extra personal space. And finally, when I'm in this stage of the examination, I test something called praxis. Praxis is very closely related to language. Praxis has the ability to carry out learned motor activities. And apraxia is analogous to an aphasia. It's the inability to carry out a learned motor activity, despite the fact that you've got enough motor power to do it, you have enough sensory function to do it, and enough cerebellar function to do it.
MADE-UP LANGUAGE: You can do it, but you are unable to do it for some reason. And so you have to give a person a learned task. For example, make believe that you're going to hang a picture on the wall and just show me how you do it. Take the hammer and nail and just act it out. OK. Let's see you do it. All right.
MADE-UP LANGUAGE: Very good. So you see what he's done here, he's holding this imaginary nail here. He's holding an imaginary hammer in his hand. That's all conjured up in his head, and he's using both hemispheres. He used his right hemisphere to do this one. He used his left hemisphere to do this one. He got the language idea, he distributed it to both hemispheres.
MADE-UP LANGUAGE: So if you couldn't do that, there would be something wrong with either his language, or the ability to get that language to the motor systems in one or the other hemisphere. Do you smoke? No. Did you ever smoke? No No.
MADE-UP LANGUAGE: Watch this. Make believe you smoke. Take out a pack of cigarettes. Take a cigarette out, put it in your mouth like you would do it normally, and light it. Let's see how you do it. OK, um-- Just make believe you have a pack of cigarettes. OK, I'd open them up, take one out, put the box down.
MADE-UP LANGUAGE: Got to light it, right? Yep, looking for his lighter. He's got an electric lighter, lights the cigarette. So there you see, never smoked, has a program in his brain from watching television, whatever, watching other people smoke. To do this, he can conjure that up out of language into both hemispheres in a very complicated way. There's two kinds of apraxias.
MADE-UP LANGUAGE: There's a kind of apraxia that looks like awkwardness. So if I said to you, let's see you hammer in a nail, the person might do this. Or they might use their hand for the object. Instead of having the imaginary hammer, they would hit with their hand. Hand for object-- it's awkward. And if I said to them, no, no, do it like this, that wouldn't help.
MADE-UP LANGUAGE: They would still do it like this, or do some other thing that wouldn't be right. That's called an ideomotor apraxia. They have the right idea, but they can't do it normally. It looks awkward, and showing them doesn't help. And then there's something called an ideational apraxia, which is more of a real apraxia where the idea is wrong. So you say to the person, I want you to hang a picture on the wall, make believe how you'd do it.
MADE-UP LANGUAGE: And the person does this. That's not close. It's completely off. So you say, well, no, no, this is what you do, and the person does it. So if you give them the idea they can do it, but they don't have the idea for doing it. The idea has been lost. By and large, these ideomotor apraxias are more anterior in the brain, and these ideational apraxias are more posterior in the brain.
MADE-UP LANGUAGE: It's just a little idea of how to think about apraxia. Apraxia is very important, because it can imitate paralysis. A person can't seem to do things, and it actually is because they've lost this program. It isn't that the limb is paralyzed, and in fact, we wouldn't call it an apraxia if the limb were paralyzed. Final point about this is, you can't have an apraxia for something that isn't learned.
MADE-UP LANGUAGE: So for example, gait. Gait is not learned. We are born unable to walk. We don't have enough myelin. Our nervous system is not mature enough. But by year one or so, plus or minus a few months, babies stand up and start walking, don't they? They don't have to see other people walking. They don't have to be taught how to walk, they just walk.
MADE-UP LANGUAGE: When the nervous system is ready to walk, it walks. So if you lose the ability to walk, we wouldn't call that an apraxia. Now, you'll hear a lot of people say this-- apraxia of gait. This is probably an incorrect use of the term. And the reason I'm so fastidious about this is that if these terms are going to have any use, we've got to use them in a certain way.
MADE-UP LANGUAGE: There's no sense talking about apraxia of gait when we mean by apraxia the loss of the ability to do a learned function despite good motor sensory and coordination functions. So I hope this gives you an approach to the mental status examination which will be practical in the office.
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The first part of the real neurological examination itself is the mental status examination. Now for arbitrary reasons, we have divided the mental status into two subcomponents, what we call the psychiatric mental status and what's called the neurological mental status. Of course, any sophisticated person knows that all behavior comes from the brain, and therefore it's a little bit arbitrary to separate a so-called psychiatric mental status from a so-called neurological mental status.
But the reality is that there are what we think of as psychiatric illnesses, like schizophrenia, and manic depressive illness, and so on. And there are neurological illnesses like Alzheimer's disease, and multiple sclerosis, and so on. So it's true that we separate them in our minds, even though we know that these all come from the brain. Now, I'm not going to talk about the psychiatric mental status examination in a lot of detail today.
This is really about the neurological mental status. But I would say that every doctor, neurologist, internist, emergency physician, OB/GYN, anybody who takes care of patients ought to have some sense of the patient's mental status. Because the truth is, disorders of mental status account for a lot of the reasons for which people come to see doctors. And I would say that for a non-psychiatrist, that is including neurologists like myself, or an internist, primary care doctor, emergency physician, they ought to at least get three bits of information out of the psychiatric mental status.
And I would call those affect, mood and thought. Let me just define those briefly and tell you what I'm talking about there. Affect is the appearance of the person to an outsider. And you can easily learn that by simply looking at the person as you're interviewing them. So you're having a conversation with the patient, taking a history. You ought to be recording in your mind, does this person look happy, sad, neutral, frightened?
What is their affect? An affect, so you can keep it in mind, it really is what an actor does when a director says to behave in a certain way. So if the director says to the actor, look surprised, the actor might go like that. Not necessarily a good actor, but an actor does that. That's a surprised look, or a frightened look, and so on. That's affect-- it's been put on by the person in response to a command.
Mood is the person's real feelings. And the way we monitor mood is something that I call a reflective technique. That means you monitor your own feelings in the presence of the patient as you take the history. This is not something that is taught in most medical schools very well anymore, because it's sort of politically incorrect to have feelings about patients. But the truth is, we're human beings, doctors are.
We have feelings about patients. Some patients make us anxious. Some make us angry. Some make us happy. Some make us sad. That's data, and we're examining the nervous system. It's very important for us to know what we're feeling. It doesn't mean we're going to act on it. It would be unprofessional, of course, to act on it, but we need to know what it is.
So if I'm feeling anxious in the presence of a patient, that generally means that the patient is anxious. And if I'm feeling sad, it usually means the patient is sad. Now, of course, this all depends on you being normal. If you're a normal person and you're feeling anxious, it's probable that that's being transmitted to you in some kind of nonverbal way-- that's useful.
And then what I tell people to do is to compare affect and mood. That is, does the feeling that you're having about the patient match what the person looks like? If you're feeling sad, the person ought to look sad. If you're feeling anxious, they ought to look anxious. If they don't, there is what I would call a mood affect association. Mood affect association means there's something wrong with the nervous system.
It can be a psychiatric illness like depression or schizophrenia, or it can be a neurological illness like multiple sclerosis or motor neuron disease. Remember, in motor neuron disease, some people have what we call pseudobulbar affect. They have inappropriate laughing and crying, so that they're laughing when they're sad and when they're making you sad. That's an affect mood dissociation.
Very important for you to recognize that you're in the presence of somebody who can't match their affect with their mood. All that's done, of course, during the normal interactions with a person that you have after you introduce yourself and you take the history. And then finally, for the psychiatric mental status, I would say that you should get some feeling for the person's thought process and thought content.
The thought is a code. It's used by the nervous system to communicate with itself. It's an internal process. The only way we can really monitor it is to use language. We're going to have to use a code that I can understand. It could be written language, spoken language, but there has to be some sort of language. So as I'm taking the history, I'm thinking to myself, does this story make sense to me?
Is A connected to B connected to C, or is something wrong with this person's thought? Either the thought process is abnormal, or the thought content is abnormal. You should carefully think to yourself, is this story making sense? The story should make sense. If it doesn't, question yourself. Say, I wonder if I'm in the presence or somebody who has a thought disorder.
Remember, thought disorder is an extremely common problem-- it starts in young people. It doesn't go away by and large. So there are lots and lots of patients who will come to your office, no matter what kind of doctor you are, with a complaint, and in fact, they have a thought disorder of some kind. They might be delusional, they might be obsessional, and very important for you to recognize that.
This kind of information is obtained in the ordinary interaction with patients. So Alan, tell me a little bit about your life before you came here to Boston. Where were you before you came to Boston? I was living in Los Angeles, California, for the last 10 years. Wow, it must have been quite a difference coming to the Northeast, huh?
Yes, it's quite a bit colder here. It is, isn't it? What other differences are there that you've noticed? Is it culturally different, do you think? Yes, by and large I think there is a difference between East coast and West coast. So I immediately get a sense of the Boston area being a little bit more focused on education, and obviously sports as well.
Yeah, absolutely. I guess in LA, they still like the Lakers quite a bit though, isn't that right? Yes, they do. But without a football team, I can't really call it a real sports town. That's right. So the point here is we're going to have a conversation. And we ought to have a conversation about something that the patient, the person, has some knowledge.
And what I've learned is that he knows something about sports, has some interest in sports. That's something that I can talk to him about. It might be sports. It might be music. It might be politics. It can be anything. It doesn't make any difference what it is. As long as it's something about which they have interest and knowledge-- not you.
And that, of course, means you have to have a life of some kind as a doctor. Because you're going to have to have some kind of a conversation with people. So having heard that, I might say to him something like, what happened to the football team in LA? Why don't they have a football team? Well, that's a great question. What is the reason?
Their team was moved to St. Louis, and ever since it's been a battle between the league and the local politicians. Where did they play? They played in a big stadium there in LA. What was that called? That's the Coliseum. Coliseum, right. So what I'm testing is his memory, his language, and his thought.
And I'm talking about something that he ought to know about. He's shown an interest in it, and I expect him to actually know something about it. If you're going to pick up a subtle mental status abnormality, you have to expect a lot from your patients within a realm that they understand things. So if he had said to me, I'm very interested in being a French cook, that's what I do, I might have said to him, how do you make hollandaise sauce?
How would you make that? And I would expect him to know how. Whereas in Alan's case, I don't know if he knows how to make hollandaise sauce or not. Do you? I don't think I do. So it wouldn't be a fair question for him. He's not necessarily interested in that. So we find out through our interactions with the person during a history taking what kind of things interest this person, and that's what we talk about.
And what the patient, of course, doesn't really realize is this is a neurological examination. It's also, of course, good for patient-doctor relations. It's the kind of interaction you want to have with your doctor. But for a neurologist, or somebody interested in the nervous system, this is actually part of the exam. That's how we're going to find out. And I'm looking at him-- does he smile in the appropriate time?
Does his affect and mood match? Do the thoughts connect, one to the other? So I would say in my quick screening of him here that he has normal affect, mood and thought. The feelings he's eliciting in me match his appearance. He tells me a story. Very logically, it makes sense. Now what is the neurological mental status? Well, the neurological mental status could be enormously complex.
And probably many of you have referred patients for neuropsychological tests to a cognitive expert. And these tests could take days, literally. And they can give hundreds of tests of all different kinds of cognition. And in fact, it's so complex that it's intimidating to many doctors. They don't know where to begin. How are we going to test all of these cortical and subcortical functions that make us human beings?
And there's some ways that you can approach this. The way I think about it is to think of the mental status as having four major spheres of activity, and you test these four major spheres in sequence. Here in a moment, why I test them in this sequence. I start with a level of consciousness. How awake is this person? There's somewhere between awake and alert and comatose-- everybody is somewhere on that spectrum.
And the question is, where is this person precisely? And I'll show you how to do that in a minute. Once we decide that this person is awake, or nearly awake, very good and alert, I can then go on and test language. Remember I said a moment ago language was the code that we use to communicate with each other. And it's the only way we can find out about thought. So I'm going to test language, and I'll tell you in a minute how we might test language.
If language is reasonably good, it doesn't have to be perfect, but if it's reasonably good, if there is a language that allows us to communicate with each other I can then go on and I can test memory. Memory is the core cognitive function. Nothing can be learned without memory, and many neurological diseases cause memory deficit. So I'm going to want to test memory. And I'll tell you some ways of testing memory.
I've already given you some clues. And finally, if those three things are pretty good, he's awake and attentive, he's got a language that I can use and he's got a reasonable memory, we can then test so-called visual/spatial skills. That is to say, does he have a map in his head of extra personal space? Does he know what right and left is, up and down? Does he organize things in his brain in a reasonable way with regard to his view of the external world?
And that's what I would do for cognitive testing. Now how am I going to organize that? Well, many years ago, 1975, Marshal Folstein and his wife Susan Folstein and Paul McHugh, Head of Psychiatry at Hopkins, decided that people just weren't doing mental status examinations. They weren't doing them, so they put together what they call the mini mental state examination.
And it became one of the most cited papers in all of medicine, I'd say, used very, very widely throughout medicine to deal with the mental status. And what I thought we would do is actually do the mini mental status examination here on Alan today. I'm going to tell you in a minute that this test is not perfect. It is not perfectly sensitive, and it's not perfectly specific.
But as Marshal Folstein actually once told me in person, they invented it because they wanted to invent something that was a lot better than nothing, which is what people were doing before the mini mental. So I'm going to actually give the mini mental. You can download this from the internet. Very easy to get many versions of this. You take the patient's name and date of birth. How old are you, Alan?
33. How are did go in school? I've got a Bachelor's degree. Bachelor's degree in college. So we'll say four years of college, and we put down the date of our examination. So let's start now. What is today's date? December 12, 2009.
Right, so what I'm doing is I'm just going to check that off. That happens to be correct. That is the correct date today. And what's the month? You've already told me, you can say again. And the year? 2009. What day of the week is this?
This is a Saturday. It's a Saturday. And what season of the year is this? The winter. So that's actually incorrect. It's actually the fall. It feels like the winter, but it's not quite the winter yet. So that's a very tricky question, the 12th of December.
But anyhow, this just shows you some of the potential weaknesses you could have in an exam like this. But at the end I'll show you that it actually works out pretty well. What do you call this place, this building where we are right now? Hospital. Tell me specifically, what hospital is it? Brigham and Women's Hospital.
Yep. And what department are we in in the hospital? Neurology. What city is this? Boston. Do you know what county we're in? I don't know that. So there's another one. It's Suffolk County.
A lot of people don't know that. It's not that easy a question. What state are we in? Massachusetts. Massachusetts, that's great. Now, I'm going to test your memory. Say these three words after me, and then memorize them. Will you do that? OK.
Ball, flag, and tree. Say them again. Ball, flag, and tree. So we've just tested immediate recall, which is a test of attentional ability. So he was able to repeat them immediately. And I want you to memorize those, so keep those in mind, OK? OK.
OK, good. Now, I'd like you to start with 100, and subtract by sevens, go back by sevens until I tell you to stop. Take your time. 93, 86, 79, 72, 65. Good. So we let people go back for five iterations. I get to check for each of the correct answers. It's just another attentional test-- can the person keep the task in mind while going back by sevens?
Some defects in that one. Many, many people who I test can't do that. And they're otherwise normal people, and they might get five points off for that. So it's a problem with it, isn't it? Some people, it's too hard. You sometimes have to adapt this. You have to say, well, I want you to go back by threes, depending on how much education a person might have had.
I would like you to think very carefully, go slowly, and try to spell the word "world" backwards. D, L, R, O, W. Very good. Perfect. Another test of attention. This is by asking the person to do two things at once, basically. Keep the task in mind, picture that thing in your mind's eye, as we like to say, that's probably somewhere in the parietal occipital lobe, and then pull it out, one by one.
Very good. What were those three words that I asked you to memorize? Ball, flag and tree. So he was able to keep those in mind. So that's his ability to actually recall. We tested before his ability to put them into memory, and now we know that he can bring them out. What do you call this item right here? That is a wristwatch.
And this one here? A pencil. So watch and pencil gets him two points. Can you repeat after me, no ifs, ands or buts. No ifs, ands, or buts. That's a very classical neurological question. I don't know if it was invented by, but it was certainly put on the map by Norman Geschwind, the great cognitive behavioral neurologist.
And I remember him telling me that this was a very useful phrase in English. Because it was a phrase that had meaning, no ifs, ands, or buts, but was actually extremely difficult for the nervous system to repeat. So it's a sensitive but not specific test of language disorder. Now I'm going to give you a piece of paper here. And I'd like you to take this piece of paper, fold it in half, and put it on the stretcher next to you.
It's a three-step command-- take the piece of paper, fold it in half, put it on the table next to you which he just did. And now I'd just like you to look at this and do what the card says. And you probably can't see that, but he did close his eyes correctly. This is a simple written command of his ability to read, so he gets a point for that.
And now I'm going to give you this piece of paper and a clipboard. I'd like you to just write a sentence of your own, anything you like, just a complete sentence. I shouldn't be talking when he's doing this. And if I were actually doing the test, I would not be interfering with his thinking about this. But I wanted you to understand what we were trying to do here.
We want a sample of his handwriting. It's not only his handwriting, but of course it's his written language. We've tested his ability to read, now we're testing his ability to write. And what we're looking for here is a sentence that makes sense, that has a subject and an object in a reasonable sentence. We don't hold up to a very high standard.
It doesn't have to be poetry, but we'd like it to be something meaningful. My son Casey is two and a half years old. So he gets full credit for that sentence. That's a sentence that makes sense. It's written correctly, the language in it is correctly. And finally, I'd like you to copy this figure. So you see these pentagons overlapping pentagons, and I'm going to just ask him to copy right to the right of it this diagram.
Now we're testing extra personal space, his ability to see the shape, to have his parietal lobe work. And then his motor system, his right hand, is working to reproduce this diagram. Again, we don't expect artistic talent. All we want is the basic shape, the concept that one of these figures is behind the other one. And he gets full credit for that. So he's going to get two points off.
He thought it was winter, it's actually fall. It's darn close to winter, but there's no partial credit for that. So out of a total of 30, he gets a 28. Got to write a 28 down here. Now the point I wanted to make about this is that in many, many studies that have been done validating this test, it's been shown that until the score goes down to about 20, it really doesn't have any meaning at all.
So even though he missed a couple of these, clearly he doesn't have an abnormal mental status. Now, you might say, we knew he didn't have an abnormal mental status before we started giving this test. Well, we already talked to him. I talked to him about the football situation in LA. He was able to tell me a good story. The truth is that if you take a good history like that and you have a reasonable conversation with people, you can be pretty certain that their mental state is all right.
But there are certain things that you could miss. For example, a person could have a nice conversation with you and not be able to copy these diagrams. They can have a big problem with their parietal lobe, which you wouldn't pick up by just having a casual conversation with them. So the point that the Folstein's and Paul McHugh made I think is a very good one. You have to do this in a rigorous fashion, it can't be casual.
It doesn't have to be the mini mental. You could think in your own mind through the four spheres that are tested by the mini mental, which just to remind you, is level of consciousness, language, memory, and visual spatial skills. And you can give your own test if you wish, as long as you state clearly that you've done all of these things and you're sure about them. Now, let me give you a couple of other little tricks that you might use in people who can't do the mini mental for one reason or another.
Maybe you're in a hurry. Maybe the person has seen the mini mental recently and it wouldn't be fair to give it to them again. They would already know what the mini mental was testing. With regard to level of consciousness, we're all somewhere between alert, awake and comatose. The people who are very bad off with regard to level of consciousness, it's very obvious-- their eyes are closed, they look asleep.
These are people who are mainly in the hospital, not in the office. And basically we have definitions for the degrees of unconsciousness that we use. And these definitions don't have important physiological meaning, they're just a way of communicating with each other. So we define coma as a state of apparent sleep which cannot be overcome, even with a noxious stimulus. If you pinched the person, you can't get a meaningful response out of them.
They might make a reflex movement, like pull away or internally rotate their limbs, but they won't do anything meaningful. If a noxious stimulus does awake the person up, even if it's temporary, we call that stupor. If you can wake a person up from a state of apparent sleep just with a verbal command, wake up, and they open their eyes-- even if they go back to sleep, we'll call that drowsiness.
So drowsiness, stupor and coma are very easy to recognize, because they have in common that the eyes are closed. It's only the degree of stimulus that it takes to make the eyes open. The tricky thing, and the problem that you face in the office and in many consultations, is a person who is not normal from a mental status standpoint, but is not bad enough to close their eyes. So by looking at them, you can't see anything's wrong with them.
So I look at Alan, and he looks fine. His eyes are open and he's paying attention to me. But the question is, is there a subtle abnormality in his level of consciousness? Now, in the mini mental, they tested that in many different ways. They gave him three words to repeat immediately. They asked him to spell world backwards. They ask him to go back by sevens, that takes quite a bit of attention.
And people who couldn't do this, I might give them a motoric command. So let's do this together. We can clap. When I clap once, you clap twice. OK. And when I click twice, don't clap. OK. This is called the go-no go protocol.
It's not that easy. So let's try to do it, and try not to make a mistake. Ready? OK. Here we go. OK, that's very good. So he did that perfectly. You could see it requires a fair amount of attention to do this.
This has the advantage of being sort of a game-like phenomena. If somebody is a little off and they can't do the detailed mini mental, you can sometimes do the go-no go protocol and find out whether the person is attentive or not. A person who can do that is probably attentive. And you can now move on to the next stage, which is language. Language I tested, didn't I, just in taking my history. He understood my questions.
His responses were perfectly reasonable. The trick comes in when somebody can't speak to you, but they still might have normal language. Now, when would that occur? Well, the simple thing would be somebody intubated in the hospital with a tube in their mouth, they can't speak. But there are neurological diseases that could do that as well. So if somebody were paralyzed, or very dysarthric because of cerebellar ataxia, and they're so bad off that you couldn't understand their speech, that doesn't mean they don't have normal language.
And we would have to then go to written language, which of course is much more tedious to test, but we could do it. And in the mini mental, there was a test of written language. I asked him to write a sentence. He created a sentence in his mind and he also read some commands for me, so I tested those. And if that didn't work, what would you do then? A person in the intensive care unit, their limbs are tied down, there's wires and tubes everywhere, they can't speak to you-- can you test language?
You might be able to. You could use computer language which is just yes and no. That's how computers work, and you can test people that way. It's very tedious and slow, but it can be done. For example, I can do this with Alan here. What I'd like you to do is raise your left hand if you mean yes, and raise your right hand if you mean no. Is Nixon president?
Is Johnson president? Is Obama president? Good. Is it spring? Summer? Fall? Very good. So he's learned that it's fall, and you can see that I can test him with yes or no questions.
And I can do that with people who can just blink, who can just look up or just look down. I can say one blink is yes, two blinks are no. Looking up is yes, looking down is no. And sometimes you're shocked to find that a person who's very bad off looking actually has a normal language. They are awake, they are alert, they have a normal language. So you want to make sure you test language.
If there is speech, it's often very easy to test language just by talking to the person. And what you're listening for is the cadence and musical quality of the language, what we call prosody. Does it sound like language? And the thing I tell people to try to remember is make believe you don't speak this person's language. Let's say they're speaking Spanish. Would you recognize it as a language anyway?
Would you or not? And if it sounds like a language, then you'd probably say that the prosody, or musical quality, is normal. If it doesn't sound like a language, then there's something wrong with prosody, the brain's ability to make it sound like a normal language. Let me give you an example of that. I can't test this really on Alan because he's normal. But if I said to somebody how are you, Mr. Jones, and Mr.
Jones looked me in the eye and said, MADE-UP LANGUAGE, what would you say? Does that sound like a language to you? It does, doesn't it? It has the prosody of language, has the musical quality of the language, but you don't understand it. So your first thought, of course, is that it's another language. What language is it?
And I wonder if any of you looking at this could think of what language is that. What language is that that I just gave you?
MADE-UP LANGUAGE: . I've given talks on the subject all over the place, and some people say it's Russian, it's Polish. Well, the fact is that it's actually from a very important episode of The Three Stooges, that language called "Three Little Pirates" in which they talk gibberish like this. And it's a lovely example of what we call effluent aphasia. It sounds like a language, but it doesn't have the function of a language, doesn't transmit information from one person to another.
MADE-UP LANGUAGE: That's effluent aphasia. Other aphasias, language disorders, don't sound anything like a language. I wouldn't have to speak the person's language to know that something was wrong. How are you Mr. Jones, and Mr. Jones says to me, MUMBLING:. Clearly something is wrong with language. He's pointing at this paralyzed right hand. That is a non-fluent kind of aphasia.
MADE-UP LANGUAGE: Then if we have people repeat, as we did in the mini mental status examination, no ifs, ands or buts, you've done a pretty darn good language exam. You've tested comprehension, you've listened for fluency, and you've tested repetition. And in fact, if you can say about somebody's language that it was normal or abnormal comprehension, with normal or abnormal fluency, with normal or abnormal repetition, you've actually characterized the aphasia, if there is an aphasia, very accurately.
MADE-UP LANGUAGE: So that's language. Then memory, of course, we've tested in the mini mental by giving those three objects and asking a few minutes later what they were. That's a fairly crude test. If you needed to know more about memory, it's best to have a conversation with people about some subject that they know about. And we did that with Alan.
MADE-UP LANGUAGE: We talked a little bit about football, and what happened to the LA Rams. And he was able to tell us that story very accurately. So that's a pretty good test of memory, and language, and fluency, just having that conversation. And I think it's actually more sensitive to have a conversation like that than it is to give one of these kinds of tests, or to give people a story that has no meaning to them and no importance to them.
MADE-UP LANGUAGE: There's a famous neurological story called The Tom and Bill Story. Tom and Bill went fishing, and Bill caught three black bass. Remember that, you say to the person. And then you come back 20 minutes later and you ask about this story, provided you yourself remember to ask. And if you ask, a lot of people will have forgotten details of that story. The story is not very interesting, it has no importance to the patient.
MADE-UP LANGUAGE: Isn't a very good test really to give people an unimportant story. Finally, this visual/spatial skill business which we tested in the mini mental by having him draw those two pentagons, one in front of the other. There are other ways of testing this. I could say to you, Alan, can you picture in your mind a map of the United States? You're watching me.
MADE-UP LANGUAGE: You can do that, can't you? You can conjure that up in your mind's eye. That's back in your parietal occipital lobe, be lighting up on a PET scan right now, metabolically active. And I said, do you see Boston on that map? Uh huh. Can you see LA on the map? Which way would you go to get from Boston to LA? What direction?
MADE-UP LANGUAGE: West. Right. Directly West, or Northwest, Southwest, where is it? Southwest. It's somewhat South, isn't it? Yes. So you see, he's pictured that in his mind. He knows which way is right and left, north and south, up and down.
MADE-UP LANGUAGE: We all have this map of extra personal space. And finally, when I'm in this stage of the examination, I test something called praxis. Praxis is very closely related to language. Praxis has the ability to carry out learned motor activities. And apraxia is analogous to an aphasia. It's the inability to carry out a learned motor activity, despite the fact that you've got enough motor power to do it, you have enough sensory function to do it, and enough cerebellar function to do it.
MADE-UP LANGUAGE: You can do it, but you are unable to do it for some reason. And so you have to give a person a learned task. For example, make believe that you're going to hang a picture on the wall and just show me how you do it. Take the hammer and nail and just act it out. OK. Let's see you do it. All right.
MADE-UP LANGUAGE: Very good. So you see what he's done here, he's holding this imaginary nail here. He's holding an imaginary hammer in his hand. That's all conjured up in his head, and he's using both hemispheres. He used his right hemisphere to do this one. He used his left hemisphere to do this one. He got the language idea, he distributed it to both hemispheres.
MADE-UP LANGUAGE: So if you couldn't do that, there would be something wrong with either his language, or the ability to get that language to the motor systems in one or the other hemisphere. Do you smoke? No. Did you ever smoke? No No.
MADE-UP LANGUAGE: Watch this. Make believe you smoke. Take out a pack of cigarettes. Take a cigarette out, put it in your mouth like you would do it normally, and light it. Let's see how you do it. OK, um-- Just make believe you have a pack of cigarettes. OK, I'd open them up, take one out, put the box down.
MADE-UP LANGUAGE: Got to light it, right? Yep, looking for his lighter. He's got an electric lighter, lights the cigarette. So there you see, never smoked, has a program in his brain from watching television, whatever, watching other people smoke. To do this, he can conjure that up out of language into both hemispheres in a very complicated way. There's two kinds of apraxias.
MADE-UP LANGUAGE: There's a kind of apraxia that looks like awkwardness. So if I said to you, let's see you hammer in a nail, the person might do this. Or they might use their hand for the object. Instead of having the imaginary hammer, they would hit with their hand. Hand for object-- it's awkward. And if I said to them, no, no, do it like this, that wouldn't help.
MADE-UP LANGUAGE: They would still do it like this, or do some other thing that wouldn't be right. That's called an ideomotor apraxia. They have the right idea, but they can't do it normally. It looks awkward, and showing them doesn't help. And then there's something called an ideational apraxia, which is more of a real apraxia where the idea is wrong. So you say to the person, I want you to hang a picture on the wall, make believe how you'd do it.
MADE-UP LANGUAGE: And the person does this. That's not close. It's completely off. So you say, well, no, no, this is what you do, and the person does it. So if you give them the idea they can do it, but they don't have the idea for doing it. The idea has been lost. By and large, these ideomotor apraxias are more anterior in the brain, and these ideational apraxias are more posterior in the brain.
MADE-UP LANGUAGE: It's just a little idea of how to think about apraxia. Apraxia is very important, because it can imitate paralysis. A person can't seem to do things, and it actually is because they've lost this program. It isn't that the limb is paralyzed, and in fact, we wouldn't call it an apraxia if the limb were paralyzed. Final point about this is, you can't have an apraxia for something that isn't learned.
MADE-UP LANGUAGE: So for example, gait. Gait is not learned. We are born unable to walk. We don't have enough myelin. Our nervous system is not mature enough. But by year one or so, plus or minus a few months, babies stand up and start walking, don't they? They don't have to see other people walking. They don't have to be taught how to walk, they just walk.
MADE-UP LANGUAGE: When the nervous system is ready to walk, it walks. So if you lose the ability to walk, we wouldn't call that an apraxia. Now, you'll hear a lot of people say this-- apraxia of gait. This is probably an incorrect use of the term. And the reason I'm so fastidious about this is that if these terms are going to have any use, we've got to use them in a certain way.
MADE-UP LANGUAGE: There's no sense talking about apraxia of gait when we mean by apraxia the loss of the ability to do a learned function despite good motor sensory and coordination functions. So I hope this gives you an approach to the mental status examination which will be practical in the office.
Language: ES.
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La primera parte un verdadero examen neurológico
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