Mental Status Exam

1. General Behavior
2. Stream of Talk
3. Mood and Affect
4. Content of Thought
5. Intellectual Capacity
6. Sensorium
a. GCS
i. Eyes (4 open, 3 open to speech, 2 open to pain, 1 closed)
ii. Verbal (5 oriented, 4 confused, 3 inapp words, 2 incomprehensible, 1
none)
iii. Motor (6 obeys, 5 localizes to pain, 4 withdrawal from pain, 3
decorticate, 2 decerebrate, 1 none)
b. Decorticate internal rotation of shoulders, flexion of forearm, wrist and clenched
fists, leg extension, plantarflexion) disinhibition of red nucleus
c. Decerebrate adduction of arm, internal rotation of shoulder, pronation of forearm
and extension of elbow, flexion of wrists and fingers, leg extension, pantarflexion)
below level of red nucleus
Speech
Head and Face
Cranial Nerves
1. Olfactory
a. Coffee beans
2. Optic
a. Visual acuity, visual field, pupillary reflex, fundoscopy
b. Fundoscopy: red-orange reflex, borders of the optic disc, cup-disc ratio, retinal
vessels (a-v ratio, banking, crossing), venous pulsations
c. Confrontation
d. Snellen chart (6 meters)
e. Light reflex, size of pupis
3. Oculomotor, Trochear (SO), Abducens (LR)
a. 2, 3, 4, 6 ptosis, en- or exophthalmos; ocular motility
b. During convergence, check for miosis
4. Branchial group and tongue
a. V: masseter, temporalis
b. VII: forehead wrinkling, eyelid closure, plastysma, Chvostek
c. IX, X: phonation, articulation, swallowing, gag reflex,
d. XI: SCM, Traps (Shrug)
e. XII: midline protrusion, inspect for atrophy
5. Special Sensory
a. VII: Taste
b. VIII: Otoscope, Finger rustling, Rinne, Weber, auditory palpebral reflex for
children
c. Vestibular: Dolls eye maneuver, caloric test

6. Somatic Sensation
a. (V-VII arc): Corneal Reflex cotton wisp
b. V: Light touch, temperature discrimination, pain
c. Buccal mucosal sensation in selected areas

Motor
1. Inspect
a. Posture, general activity, tremors, involuntary movements
b. Gait: free walking, heel and toe walking, tandem walking, deep knee bend
c. Body gestalt
d. Size and contour of muscles: atrophy, fasciculations (twitch), hypertrophy,
asymmetries, joint malalignments
e. Skin lesions, neurocutaneous stigmata like in myelomeningoceles
i. Caf-au-lait neurofibromatosis I
2. Palpate muscles
a. If atrophic, hypertrophic or Hx suggests tenderness or spasms
b. Duchenne Muscular dystrophy pseudohypertrophy of calf and deltoids
i. Dystrophin
ii. X-linked recessive
3. Strength Testing
a. Shoulder girdle: press down on arms at shoulder ht; check for winging of scap
b. Upper extremities: biceps, triceps, wrist dorsiflexors, grip, extensors
c. Abdominal m: do a sit up; check for umbilical migration
d. Lower ex: hip flexors, adductors
e. Grade strength from 0-5; paralysis or severe, moderate, minimal weakness, normal
4. Muscle tone and range of movements
a. Manipulate joints to test for spasticity, clonus, rigidity, hypotonia and range of
movements
5. Muscle stretch (deep) reflexes
a. Grade 0-4 and designate whether clonic
b. Jaw jerk (V aff and eff)
c. Biceps reflex (C5-6)
d. Brachioradialis (C5-6)
e. Triceps (C7-8)
f. Finger flexion reflex (C7-T1)
g. Quadriceps reflex (knee jerk; L2-4)
h. Medial Hamstring (L5-S1)
i. Triceps surae (ankle jerk, S1-2)
j. Toe flexion reflex (S1-2)

6. Percuss muscle
a. Thenar eminence for percussion myotonia
b. Test for myotonic grip for pt with generalized weakness
7. Skin and muscle (superficial) Reflexes
a. Abdominal skin and muscle
i. Upper quadrants T8-9
ii. Lower quad T11-T12
iii. Look for Beevors sign (umbilical migration)
1. For pt with thoracic spinal cord lesion
b. Cremasteric
i. Afferent L1; efferent L2
c. Anal pucker reflex
i. S4-5
ii. Sacral or cauda equina lesions
d. Bulbocavernosus reflex
i. S3-4
ii. Sacral or cauda equina lesions
e. Plantar reflex (Babinski)
i. Aff S1; eff L5-S1-2
8. Cerebellar Gait
a. Finger to nose and rapid alternating hand movements
b. Heel to knee
c. Cerebellar ataxia
9. Nerve root stretching tests
a. Leg raising tests for low back pain or leg pain
i. Straight knee leg raising test (Lasegue)
1. Disc herniation (L5-S1 junction most common)
2. Crossed leg raise can be done to confirm (more specific test)
ii. Bent knee leg raising test (Kernig)
b. Meningeal irritation suspected
i. Nuchal rigidity and concomitant leg flexion (Brudzinski)
ii. Leg raising tests

Sensory
1. Superficial Sensory
a. Light touch of hands, trunk, feet
b. Temp discrimination over hands trunk feet
c. Pain over hands, trunk, feet
2. Deep sensory
a. Vibration
b. Proprioception
c. Stereognosis
d. Directional Scratch Test
e. Romberg
f. Graphesthesia
3. Determine distribution of any sensory loss
a. Dermatomal, peripheral nerves, plexus, central pathway, nonorganic

Cerebral Functions
1. Higher level sensory (if Hx or mental status exam suggest a cerebral lesion)
a. Graphagnosia
b. Finger agnosia
i. Inability to name, recognize, distinguish fingers
c. Two point discrimination
d. Right or left disorientation
i. Gerstmann: Dysgraphia, dyscalculia, finger agnosia
ii. Angular and supramarginal gyri lesions of the dominant hem
e. Topognosia
i. Recognition of location of stimuli on skin
f. Tactile, auditory, visual inattention

Others
Spurlings test
For cervical radiculopathy

Extend neck and rotate to one side, same for other side
Upper motor neuron (pyramidal tract)
Clonus - lift left leg, dorsiflex
Babinski
Spasticity
Pyramidal weakness
Clasp-knife response
Hyperreflexia - Increase deep tendon reflex
Lower motor neuron (ALS, Myasthenia gravis)
Paresis
Fibrillations, fasciculations
Hypotonia, atonia
Hyporeflexia
Asterixis
Test: Wrist extended, doctor extends further
Cirrhosis
Hepatic encephalopathy
Opiate overdose
Wilsons disease
Acute liver failure
Antalgic gait
Spend more time on one leg when walking
Parkinsonian gait
Hypokinesia, small irregular steps, small shuffling steps, stride length reduced
Trendelenburg gait
Gluteus medius
Marcus-Gunn pupil
Swinging light test
Optic neuritis
Argyll-Robertson
Miosis with accommodation but not to light reflex
Horner Syndrome
Miosis, ptosis, hemifacial anhidrosis
Adie
Tonically dilated pupil