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Mini-Mental State Examination (MMSE). This brief test is useful in screening for cognitive dysfunction or dementia and following their course over time. For more detailed information regarding the MMSE, contact the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549.

Asterixis. Asterixis helps identify a metabolic encephalopathy in patients Sudden, brief, nonrhythmic flexion whose mental functions are impaired. Ask the patient to "stop traffic" by ex- of the hands and fingers indicates tending both arms, with hands cocked up and fingers spread. Watch for 1 to asterixis.

2 minutes, coaxing the patient as necessary to maintain this position.

Winging of the Scapula. When the shoulder muscles seem weak or atrophic, look for winging. Ask the patient to extend both arms and push against your hand or against a wall. Observe the scapulae. Normally they lie close to the thorax.

In winging, shown below, the medial border of the scapula juts backward. It suggests weakness of the serratus anterior muscle, as in muscular dystrophy or injury to the long thoracic nerve.


In very thin but normal people, the scapulae may appear "winged" even when the musculature is intact.

Meningeal Signs. Testing for these signs is important if you suspect meningeal inflammation from infection or subarachnoid hemorrhage.

Neck Mobility. First make sure there is no injury to the cervical vertebrae or cervical cord. (In settings of trauma, this may require evaluation by x-ray.) Then, with the patient supine, place your hands behind the patient's head and flex the neck forward, until the chin touches the chest if possible. Normally the neck is supple and the patient can easily bend the head and neck forward.

Brudzinski's Sign. As you flex the neck, watch the hips and knees in reaction to your maneuver. Normally they should remain relaxed and motionless.

Kernig's Sign. Flex the patient's leg at both the hip and the knee, and then straighten the knee. Discomfort behind the knee during full extension occurs in many normal people, but this maneuver should not produce pain.

Pain in the neck and resistance to flexion can arise from meningeal inflammation, arthritis, or neck injury.

Flexion of the hips and knees is a positive Brudzinski's sign and suggests meningeal inflammation.

Pain and increased resistance to extending the knee are a positive Kernig's sign. When bilateral, it suggests meningeal irritation.

Compression of a lumbosacral nerve root may also cause resistance, together with pain in the low back and the posterior thigh. Only one leg is usually involved.

Anal Reflex. Using a dull object, such as a cotton swab, stroke outward Loss of the anal reflex suggests a in the four quadrants from the anus. Watch for reflex contraction of the anal lesion in the S2-3-4 reflex arc, as musculature. in a cauda equina lesion.

The Stuporous or Comatose Patient. Coma signals a potentially life-threatening event affecting the two hemispheres, the brainstem, or both. The usual sequence of history, physical examination, and laboratory evaluation does not apply. Instead, you must:

■ First assess the ABCs (airway, breathing, and circulation)

■ Establish the patient's level of consciousness

■ Examine the patient neurologically. Look for focal or asymmetric findings, See Table 16-14, Metabolic and and determine whether impaired consciousness arises from a metabolic or Structural Coma (p. 620).

a structural cause.

Interview relatives, friends, or witnesses to establish the speed of onset and duration of unconsciousness, any warning symptoms, precipitating factors, or previous episodes, and the prior appearance and behavior of the patient. Any history of past medical and psychiatric illnesses is also useful.

As you proceed to the examination, remember two cardinal DON'T s:

1. Don't dilate the pupils, the single most important clue to the underlying cause of coma (structural vs. metabolic), and

2. Don't flex the neck if there is any question of trauma to the head or neck. Immobilize the cervical spine and get an x-ray first to rule out fractures of the cervical vertebrae that could compress and damage the spinal cord.

Airway, Breathing, and Circulation. Quickly check the patient's color and pattern of breathing. Inspect the posterior pharynx and listen over the trachea for stridor to make sure the airway is clear. If respirations are slowed or shallow, or if the airway is obstructed by secretions, consider intubating the patient as soon as possible while stabilizing the cervical spine.

Assess the remaining vital signs: pulse, blood pressure, and rectal temperature. If hypotension or hemorrhage is present, establish intravenous access and begin intravenous fluids. (Further emergency management and laboratory studies are beyond the scope of this text.)

Level of Consciousness. Level of consciousness primarily reflects the patient's capacity for arousal, or wakefulness. It is determined by the level of activity that the patient can be aroused to perform in response to escalating stimuli from the examiner.

Five clinical levels of consciousness are described in the table below, together with the techniques that may be used to elicit their characteristics. Increase your stimuli in a stepwise manner, depending on the patient's response.

When you examine patients with an altered level of consciousness, describe and record exactly what you see and hear. Summary terms such as lethargy, obtundation, stupor, or coma may have different meanings for other examiners.

Level of Consciousness (Arousal): Techniques and Patient Response

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