SAN BEDA COLLEGE OF MEDICINE

BATCH 2019 A/Y 2015-2016 NEUROSCIENCE I

MINI OSCE REVIEWER

EXAMINATION OF MENTAL STATUS AND HIGHER CEREBRAL FUNCTIONS

MENTAL STATUS EXAMINATION D. Fluency and Rhythm/Articulation
I. General Behavior and Appearance - Slurred, clear, with appropriately placed
II. Stream of Talk inflections, hesitant, with good
III. Mood and Affective Responses articulation, aphasic
IV. Content of Thought - This can already be noted while you are
V. Intellectual Capacity taking the patient’s medical history.
VI. Sensorium Remember yung mga scanning speech etc.
a. Consciousness
b. Attention Span III. Mood and Affect
c. Orientation for time, place and person → Is the patient euphoric, agitated, giggling, silent,weeping,
d. Memory, Recent and Remote orangry?
e. Fund of Information → Is the mood appropriate? Is the patient emotionally
f. Insight, Judgment, and Planning labile?
g. Calculation
A. MOOD
I. General Behavior and Appearance - term used to describe a sustained internal emotion
→ Is the patient normal, hyperactive, agitated, quiet, - has a wide spectrum and gradation but the most
immobile? obvious are sadness, joy, grief and anger
→ Is the patient neat or slovenly? Do the clothes match the - calm, depressed, euthymic(normal), euphoric,
patient’s age, peers, sex, and background? anxious

→ Gives an overall impression of the patient B. AFFECT

→ Appearance (Observed): Gait, posture, clothes, grooming - generally refers to the external expression of
→ Behavior (Observed): Mannerisms, gesture, psychomotor emotional content and maybe at odds with the
activity, expression, eye contact, ability to follow patients mood
commands/requests, compulsions - it is more fluid compared to the mood and can change
from moment to moment
A. General Appearance(is the patient) - Appropriate, inappropriate, giggles a lot
- calm, sad, worried, hostile - constricted (limited variations)
B. Grooming - blunted (minimal variations)
- kempt, unkempt, disheveled - Flat( no affect)
C. Interview behavior - Affective lability
- cooperative, uncooperative, passive - Affective blunting
D. Clothing
- Do the clothes match the patient’s age, peers, sex, AFFECTIVE RESPONE
and background? - Imagine your reaction to a hand grenade thrown onto
- Also are his/her clothes appropriate for the current your table or merely to a cockroach. Your alarm or
weather, situation? aversion differs in the two cases.
- appropriate, inappropriate, with layers of - Affectiveresponses should have the appropriate quality
clothing and quantity
E. Others: hygiene, posture(erect/kyphotic), ability to relax, 1. Assay affective responses not by blunt questions, but
position and activity, eye contact (direct/furtive) by comparing the observed with the expected
reactions. What affect would you expect as a Pt
discusses her paralyzed arm? What affect would you
Note: NEVER use the term “NORMAL” because what is expect if the Pt complains that the “apparatus” plots
normal for you might not apply to everyone. to kill him?
o A blunted, bland, or indifferent affect occurs
Sample reporting for pt’s clothes, say: most commonly with hysteria, schizophrenia,
“The patient’s clothes is appropriate for his/her age, sex, and bifrontal lobe lesions
season,orientation and occasion.” 2. If you have cause to cry or laugh, how much
provocation does it take to make you start and how
II. Stream of Talk
much time does it take you to get over it? If the Pt
→ Does the patient converse normally?
cries for 15 seconds and then starts to laugh when
→ Is the speech rapid, incessant, under great pressure, or is
you ask him to tell you a funny story, the Pt has
it slow and lacking in spontaneity and prosody?
affective lability, the opposite of affective blunting.
→ Is the patient discursive, tangential, and unable to reach
o Affective lability, on-and-off laughing and
the conversational goal
crying, commonly accompanies bilateral upper
motoneuron (UMN) disease, as we have seen in
→ Speech and Language (Observed):
pseudobulbar palsy and diffuse brain diseases.
A. Quantity
- talkative, spontaneous, expansive
B. Rate To test this you can give the patients situational events
- fast, slow, pressured such as: “Kapag po nasusunog itong building ano po ang
C. Volume (Tone) gagawin niyo?
- loud, soft, monotone, weak
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Notice if the pt’s reply is relevant and appropriate for the - Echolalia: abnormal repetition of words, phrases or
situation. sentences previously spoken by another person
(1) Pt may say “Pupunta ako ng bangko.”- obviously it is Example: Student1: Papasa tayo ng 1st yr :)
not appropriate; or Student2: Papasa tayo ng 1st yr :)
(2) Pt may say “I will call for help and run fast. I’m gonna - Flight of ideas: subjective experience of racing
die helppppp!!!” tapos biglang “Hahaha… Mamatay thoughts leading to shifting of ideas; multiple
na ko! Woohoo!” obviously patient has a labile affect thoughts, ideas w/o connection

VI. Sensorium
IV. Content of Thought A. CONSCIOUSNESS
→ Does the patient have illusions, hallucinations or
- Does the patient make response that proves
delusions, and misinterpretations?
awareness of self and environment?
→ Does the patient suffer delusions ofpersecution and
 Intuitive: awareness of self and
surveillance by malicious persons or forces?
environment/awareness of our sensorium
→ Is the patient preoccupied with bodily complaints, fears
 Operational: measured using practical test by
ofcancer or heart disease, or other phobias?
the physician
→ Content of thought: frontal lobe

 To determine pt’s awareness to self and environment

Perceptual Distortions
1. Inspection
1. ILLUSIONS
 Does the patient appear to adopt
 Is a false sensory perception based on natural
appropriately to the ongoing visual auditory
stimulation of a sensory receptor (response to
and tactile stimuli
stimulus)
2. Verbal stimuli
 Example: may nakasabit na towel, akala mo multo
 Respond appropriately To inquiries or
2. HALLUCINATIONS
request
 Is a false sensory perception not based on natural
3. Pain
stimulation of a sensory receptor (no stimulus)
 Respond appropriately to pain
 no external stimulus but with perception of
imaginary objects
 Pathologic alteration in LOC
 Example: may alien/multo daw na nakatayo sa
 Delirium ( acute confusional state)---------coma
harap mo kahit wala naming kahit ano dun
 Global impairment of sensorium
 A repetitively experienced hallucinations may
 + disorientation, amnesia, misperception,
indicate a lesion of the appropriate sensory cortex
hallucination, agitataion
 Example: A lesion in the:  Demented patient- mostly at night
o Occipital cortex might cause hallucinations of  Delirium tremens
vision - + excitement and seizures , sweating,
o Uncus: hallucinations of smell snake on corner of room , screaming
o Postcentral gyrus: hallucinations of somatic - alcohol withdrawal/ antidepressant drugs
sensation  Mania
3. DELUSIONS
 Expansive mental state
 is a false belief not based on reality/not subject to  Pressure of speech, grandiosity, feeling of
reason/that reason cannot dispel. unlimited power
 *no stimulus and vision is not congruent with reality  + retention of orientation
 Example: may alien na kukuha sayo :D
4. SUICIDAL  Glasgow Coma Scale
 How to ask: “Naisip nyo na po ba magsuicide? Bakit
po? Ano po ang naisip nyong plano (method)?”
5. IDEA OF REFERENCE
 pt’s inaccurate interpretation that general events
are personally directed to him
 iniisip niya siya yung tinutukoy ng isang tao (ex.
reporter sa tv)

In assessing thought content, important na may follow up

questions, don’t settle for one question, make more specific
inquiries to know yung thinking ng patient

V. Intellectual Capacity
→ Is the patient bright, average, dull, or obviously
demented or mentally retarded?
- Bright: quick to learn
- Dementia: a chronic, more or less permanent
change in mentation, often insidious in onset, and
often progressive (Delirium: transient)
- Mentally retarded: delayed or limited intellectual
function

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 Anatomic Basis of Consciousness C. ORIENTATION

 Ascending reticular activating system (ARAS) - the ability to locate oneself in one's environment
o Ascending reticulo thalamo cortical with reference to time, place, and people; position in
pathway relation to true north, to points on the compass, or
o Consist of the groups of the neuronal groups to a specific place or object.
in the pontomesencephalic tegmentum and
diencephalon that increases awareness
Orientation to Orientation to Orientation to
when stimulated and decrease it when
Person Place Time
destroyed.
 Specific Sensory relay Nuclei of the thalamus 1. Ano pong 1. Ano pong 1. Ano pong petsa
Cortical pangalan nyo? pangalan ng ngayon?
Modality Thalamic Nuclei
receptive Area 2. Kilala nyo po ba lugar na ito? 2. Ano pong buwan
Vision Lateral Calcarine cortex kasama nyo? 2. Nasaang ngayon?
geniculate Body Occipital lobe (if the patient has palapag/floor po 3. Ano pong taon
Hearing Medial Superior company, but if tayo ngayon? ngayon?
Geniculate temporal Gyrus none, “Kilala nyo 3. Nasaang kalye po 4. Ano pong araw
Body Temporal Lobe po ba ako?”) ang lugar na ito? ngayon?
Somatic Nucleus Post central 3. Kaano-ano nyo 4. Nasaang 5. Ano pong
sensation ventralis gyrus po sya? siudad/municipio panahon o
posterior Parietal lobe (if the patient has tayo ngayon? “season”
company, but if 5. Nasaang bansa ngayon?
 LEVELS OF CONSCIOUSNESS none, “Ano po po tayo ngayon?
a. Conscious: aware/alert ako para sa
b. Somnolence: May drift off to sleep during inyo?”)
examination but may be awaken by tapping or name
calling
D. MEMORY
c. Stupor: May drift into sleep during interview,awaken
- The process of registering or recording information,
with vigorous shaking or by painful stimuli
d. Coma: cannot be awaken tested by asking for immediate repetition
information, followed by storage or retention of
information.
B. ATTENTION SPAN
o Recent or short-term memory covers minutes,
- Attention to a stimuli long enough to comprehend &
hours, or days
respond to them
o Remote or long term memory refers to interval
- Lesion: Ascending Reticular Activation System
of years.
- Orientation, attention span, and memory intertwine
TAKE NOTE inextricably
(1) Kapag nabigay nyo na yung instruction sa patient, make
sure na naintindihan nya yun. Kasi kapag nagsimula na  Note how well the Pt recalls and relates the events of the
syang sumagot hindi ka na pwedeng magsalita ulit kasi medical history.Inquire,
mawawalan ng purspose yung pagtanong mo. Hindi na 1. “Does your memory work all right?” or more bluntly,
sya magiging attention span kung tanong ka ng tanong sa “Do you have trouble with your memory?”
patient. If you suspect a memory disturbance, say to the Pt,
Example: “Suppose, we try out your memory?”
Doc: Nay ano po ang 100 kapag binawasan ng 7. 2. Ask the Pt to name the presidents backward from
Nay: 93 the present one. This task requires more attention
Doc: Nay e ano naman po ang 93 kapag binawasan ng 7 and memory than reciting the months backward.
Nay: 86 3. Provide the patient with an address, a color, and an
Doc: Okay, e nay ang 86 kapag binawasn ng 7 object to remember, three nonsense items that have
Kapag ganyan ginawa nyo. Devoided na sya sa purpose ng no relation. Have the Pt repeat the items to ensure
test. ONLY ASK THE QUESTION ONCE, then make sure that that they have registered. Then, at the end of NE,
the patient understands! ask the Pt to recite them.
4. Determine whether the Pt differs in the ability to
(2) Also take into consideration yung EDUCATIONAL recall recent or remote event.
ATTAINMENT kasi baka magtanongtanong ka ng mga  RECENT MEMORY – suffers mostly in aging or
subraction na matataas tapos hindi naman pala nakapag brain disease
aral yung patient. o Grandfather cannot remember where she
o Series of 7: ipapasubtract natin sa patient ang 100 ng 7 laid her glasses pero tanda nya yung mga
hanggang makaabot kayo ng 65 sinaunang kwento
o Series of 3: ipapasubtract natin sa patient ang 20 ng 3
o Spell word backwards: ipapaspell na natin ang E. FUND OF INFORMATION
“MUNDO/KARNE/CARNE” backwards - Ask about current events.
o Recite in Reverse: iparecite sa patient ang mga buwan - If unable to discuss the current activities and events,
sa taon ng nagsisimula sa DECEMBER hanggang umabot the Pt has organic brain, cultural deprivation, or is
sa JANUARY withdrawn as to need psychiatric care.

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F. INSIGHT, JUDGMENT, PLANNING → Other agnosias

- refers to the extent to which the patient realizes that 1. Associative Visual Agnosia
he suffers from an illness or from personal - inability to recognize and name previously
difficulties and to the extent to which he recognizes known objects or pictures or demonstrate its
the need for treatment. It includes the use
understanding of his illness in general and of any 2. Appreceptive Visual Agnosia
psychopathological experiences in particular. The - impaired perception of patterns and inability to
patient's spontaneous suggestions for treatment recognize shapes
should be recorded. The performances of reasoning 3. Color Agnosia
and judgment show the present ability to apply
involved intellectual functions to life situations
which are of importance to the patient. A. AGRAPHOGNOSIA (AGRAPHESTHESIA)
- Lesion in the parietal lobe
- INSIGHT: Awareness of how one’s own personality - vs. Graphanesthesia: sensory pathways are
traits and behaviors contribute to symptoms and destroyed
problems. To understand cause and meaning of a - How to test:
situation. o With the patient’s eyes closed, trace letters
 Insight to illness or numbers (1-10) on the skin of patient’s
o Is the patient Aware that he has disease? palm or fingertips by using the cap end of a
o Insight Concerning present illness pen

- JUDGEMENT: Ability to access situation correctly, In testing for agraphognosia in the left hand, you test the
choose among different options, and act ❒right/❒left?
appropriately within that situation Right Parietal Lobe
 Judgment
o Give a scenario then ask the patient what B. PROSOPAGNOSIA
he will do - Inability to recognize faces in person or in photos
o Ex: What would you do if you found a wallet - Lesion in the inferomedial temporo-occipital region
with money and identification card (usually bilateral; if unilateral, the right side is usually
 Good or poor judgment affected) irrigated by cortical branches of posterior
cerebral artery.
G. CALCULATION - How to test:
- Calculations describes the ability to manipulate o Let a person known to the patient enter the
numbers mentally. Simple addition, subtraction, or room
multiplication questions may be used. Problems of o Present photos of well-known people
money and change are often helpful with patients
with limited educational background. C. AUTOTOPAGNOSIA (ASOMATOGNOSIA)
- How to test: - Agnosia of body scheme (knowing body parts,
o Ask whether the Pt can balance a checkbook boundaries, posture)
o Make a change:“Bumili ako ng bigas na tig - inability to locate, identify, orient one’s body parts
28.75php at ang bigay ko sa tinder ay 50php, - vs. Topagnosia: inability to localize skin stimuli
magkano ag sukli ko?”
o Do formal paper and pencil calculations: simple TWOAUTOPAGNOSIAS:
arithmetic (6+8; 28-12) 1. Tactile Finger Agnosia
o Subtract 7’s serially form 100 - Lesion in the left angular gyrus (posterior
CEREBRAL/HIGHER CORTICAL parasylvian area)
I. Agnosia - How to Test:
a. Agraphognosia o Assign numbers (1-5) to patient’s
b. Prosopognosia fingers. With the patient’s eyes closed,
c. Autotopagnosia randomly touch digits on the patient’s
d. Left Side Hemispatial Inattention right and left hands. Ask patient to
e. Anosognosia identify the digit (i.e. number and if it
f. Inattention to Double Cutaneous Stimuli is right or left).
II. Apraxia - If there is disorientation (right-left
III. Aphasia disorientation)
o Give further commands (e.g. Touch
your left ear using your right hand.).
I. Agnosia
o Ask the patient to point to your right
→ Agnosia: “not knowing”
and left hands and digits by number or
→ inability to understand the meaning, import, or symbolic
name
significance of ordinary sensory stimuli though the
o Place a patient’s body part in one
sensory pathways and sensorium are relatively intact
position then ask him/her to duplicate
→ criteria include:
that position with the opposite
1. relatively intact sensory pathway
extremity while his/her eyes are
2. relatively intact sensorium and mental status
closed.
3. patient previously understood or is familiar with the
symbolic significance of the stimulus
4. due to an organic cerebral lesion

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D. LEFT SIDE HEMISPATIAL INATTENTION DISTINCTION BETWEEN APRAXIA AND OTHER MOTOR
- Unilateral neglect due to a right parietal lesion DEFICITS
- How to test:  Apraxic patients are often unaware of their deficits and
o Let the patient draw any symmetrical figure may do an act automatically that they cannot do on
(e.g. cross, bike, wheel). command
o Line Bisection Test (a better test): Draw a 20 o Example: Apraxic patients may fail to stick out
cm straight line then ask the patient to their tongue and lick their lips on command but
mark the center of the line. may then lick their lips automatically. The patient
may fail to make a fist when asked in close the
E. ANOSOGNOSIA fingers but may automatically grasp an object,
- Lack of awareness of any bodily defect, such as a spoon.
- Usually affecting the left side due to a right parietal
lesion WITH PYRAMIDAL LESIONS
- How to test:  The paralysis precludes doing the act voluntarily or
o Ask the patient whether there is anything automatically, thus violating a necessary condition that
wrong with the affected side (patient with the motor system be fairly intact. The paralyzed patient
anosognosia would reply “no”). Ask the may also have apraxia, but the paralysis prevents its
patient if he/she can move the affected recognition.
arm.
o Stand on the patient’s affected side. Place PATIENT WITH A CEREBELLAR LESION
the patient’s affected arm alongside  Retains the ability to perform an act but cannot perform
him/her. Place your own arm (same side) it smoothly.
on patient’s waist. Ask patient to get
his/her own arm (patient with anosognosia WITHBASALMOTORNUCLEILESION
would get the examiner’s arm).  Involuntary movements or rigidity impede down the
act,but the sequence of the act remains possible.
F. INATTENTION TO DOUBLE CUTANEOUS STIMULI
- Synonyms: sensory suppression, sensory extinction, TECHNIQUESTOTESTFORCOMMONAPRAXIAS
sensory inattention 1. The Examiner tests for apraxia almost inadvertently in
- Lesion in the association cortex giving routine commands such as:
o “Stick out your tongue.” “Make a fist.” “Walk
i. Tactile Inattention to Simultaneous Bilateral Stimuli across the room.”
(Double Simultaneous Stimulation) o These commands disclose tongue, hand, and
- Lesion usually in the right parietal lobe gait apraxias, respectively.
- How to test: 2. For formal testing, the Examiner makes special verbal
o Inform the patient you may touch one or requests and, if that fails, demonstrates acts for the
both sides. With the patient’s eyes closed, patient to pantomime.
apply light pressure or brush the patient’s 3. Face-tongue (bucco-facial) apraxia
face (cheeks), dorsum of the hands, o Ask the patient to protrude the tongue and
dorsum of the feet) using your index finger move it up, down, right, and left and lick the
or a cotton wisp. lips. Ask the patient to act as if blowing out a
match or sucking on a straw. If verbal
ii. Inattention to Simultaneous Unilateral Stimuli instruction fails, try miming.
- Lesion in the parietal lobe 4. Arm (ideomotor) apraxia
- Can also be manifested in learning-disabled o More complicated apraxias such as ideomotor
children, due to a gross structural lesion, apraxia require sequential actions. Ask the
wherein they tend to suppress hand stimulation patient to demonstrate a sequence: how to use
- How to test silverware, thread a needle, strike a match and
o Simultaneously touch on one side: face- light a candle, and use a key to lock and unlock
hand; foot-hand; face-foot a lock, or use scissors or other tool. The
Examiner may provide the actual materials or
II. Apraxia tools or may have the patient imitate gestures
→ Inability to perform a voluntary act even though the and hand positions.
motor system, sensory system, and mental status are o Ideomotor apraxias occur with lesions of the
relatively intact language-dominant hemisphere, almost
→ Patient must comprehend the act, cooperate in always the left. Patient with ideomotor
attempting it, and have a motor system sufficiently intact apraxia also has aphasia. Both hands are
to execute the act. These requisites exclude patients with usually affected, although the lesion is
paralysis or functional mental illnesses, such as hysteria unilateral.
or negativism, profound dementia, and mental 5. Constructional apraxia
retardation, to whom apraxia is not meant to apply o Ask the patient to copy geometric figures (a
→ If the definition and conditions for diagnosing apraxia cross, interlocking pentagons, or clock face) or
causes the strange feeling of repeating a previous construct them out of matchsticks.
experience (the déjà vu of anterior temporal lobe 6. Dressing apraxia
lesions), we are on the right track o Watch the patient try to get dressed. The
apraxic patient cannot orient the clothes to put
them on and gets the shoes on the wrong foot.

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Usually this is associated with right parietal large, acute lesions, such as infarcts, than when lesions
lesions and is part of the neglect syndrome. evolve relatively slowly, as with neoplasms.
o Dressing apraxia and constructional apraxia,
in which the patient fails to complete the left III. Aphasia
side of figures, occur most frequently with a → The inability to understand or express words as symbols
right posterior parietal lesion. for communication, even though the primary
7. Gait apraxia (Bruns ataxia): Ask the patient to rise and sensorimotor pathways to receive and express language
walk. and the mental status are relatively intact.
8. Writing and speaking apraxia (aphasia): Explained in
the next section. CLINICAL TESTING FOR APHASIA
9. Global apraxia in children: The child lags in motor skills  Detecting Aphasia during the History: Aphasia testing
such as chewing, swallowing, dressing, tying shoelaces, begins with the history. You will readily detect gross
buttoning, and the use of cutting tools such as a knife defects in language reception or expression.
and fork and scissors.  Mildy Aphasic Patient: Produces less than the expected
amount of written and spoken language. Patient’s
conversation remains goal directed but fails to hit the
THE PRINCIPLE OF PARSIMONY nail on the head with crisp, logical statements.
 called Occam’srazor  Aphasic Patient: Becomes wordy, as if by preempting
 this principle requires us to seek the simplest the conversation. The patient can prevent the other
explanation: a single lesion and a single diagnosis. In person from saying something that the patient cannot
other words, we seek the simplest, the most understand, or the patient may show redundancy in
parsimonious, explanation. Thus, if a single lesion searching for just the right word.
caused the hemiparesis, hemihypesthesia, and agnosia-
apraxia, it involves the dorsolateral cerebral wall. CLUES TO DYSPHASIA ARE AS FOLLOWS
 Searching for words, pauses, and hesitations
o The preservation of a bit of the superior visual field  Substitution of the wrong words or phonemes
indicates that the most inferior axons of the  Poverty of speech or the converse, excessive production
geniculocalcarine tract are intact. The lesion that causes of sounds that resemble words but fail to communicate
the partial hemianopia involves the superior part of the
 Puzzlement and hesitations in response to ordinary
geniculocalcarine tract, which runs through the parietal
statements made in the course of conversation
lobe and adjacent temporal and occipital lobes.
 Loss of intonation and prosody (rhythm and pattern of
o In addition to the agnostic-apraxic and visual field
sounds)
deficits, implicating the posterior inferior parietal area,
 Frequent dysarthria
the slight hemihypalgesia and hemihypesthesia
 Irritation or distress at the inability to communicate
implicate the primary somesthetic receptive region of
the postcentral gyrus of the right parietal lobe.
USUAL OPERATIONAL STEPS IN EXAMINING PATIENT FOR
o The mild left hemiparesis implicates the motor area
APHASIA
located in the right precentral gyrus.
o The left-side auditory inattention implicates the  During the give and take of the history, listen for word
auditory association area in the posterior part of the choice, in particular word substitutions, a searching for
right temporoparietal region. words, articulations, hesitations, prosody, and the
quantity of speech
NEUROPATHOLOGIC CONSIDERATIONS:  Test the ability of the patient to repeat words spoken by
1. By causing edema and compressing vessels, focal lesions the examiner
may impair the function of surrounding brain tissue. The  Test word comprehension by questions and commands
severest signs usually reflect the site of maximum tissue  Show the patient common objects to name
damage and, therefore, best predict the lesion site. The  Have the patient write a sentence to dictation
patient’s severest defects, the hemianopia and dressing  Have the patient read and interpret a sentence, a
and constructional apraxia, suggest maximum damage paragraph or symbols
to the right posterior parasylvian area, with less
involvement of the sensorimotor cortex of the GENERAL CLASSIFICATION OF APHASIA
paracentral region. (see last page for summary)
2. Radiographic examination showed a mass in the 1. Expressive and receptive aphasia
predicted right parieto-occipital region. Craniotomy and o classified as receptive, expressive or mixed(global)
biopsy disclosed a large, expanding neoplasm, a 2. Fluent and non-fluent aphasia
glioblastoma multiforme, causing pressure on the
surrounding brain. The surgeon removed the right General localization of Lesions causing Aphasia
occipital lobe, providing internal decompression.  The lesion that causes aphasia occupies the LEFT
Postoperatively, the left hemiparesis disappeared, CEREBRAL HEMISPHERE in almost all right-handed and
suggesting that pressure and edema from the neoplasm most left-handed patients.
had caused it, rather than direct extension of the  therefore we designate the left hemisphere as usually
neoplasm to the paracentral area. dominant for the language.
3. Ordinarily, a patient with a lesion in the right posterior
parasylvian area might also have anosognosia. The Localization within the Dominant Hemisphere
patient failed to show it before the operation, but  The lesion usually involves the parasylvian region of the
afterward he failed to recognize that he had a left left hemisphere
hemianopia. Anosognosia occurs more commonly with

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 Lesion may extend into the subjacent deep white o Test for the ability to copy sentences from print
matter and into the caudate-putamen or the thalamus, and dictation ( even though the patient can write a
thus interrupting the connections of the parasylvian dictated sentence, he cannot then read it)
cortex with the deep nuclear masses o Test for the elements of Gertmann’s syndrome
o the lesions that cause expressive aphasia are more o Test for other visual agnosias such as inability to
forward, toward the anterior inferior frontal region name colors
o the lesions causing receptive aphasia are more  LESION SITE:
posterior, toward the parieto-occipito-temporal o Congenital Dyslexia : Patient usually has no gross
junction lesion but may show microdysgenesia of the
cortex. Locating the critical area in the parieto-
BROCA’S APHASIA (motoraphasia or nonfluent aphasia) occipito-temporal confluence, centering on the
 Nonfluent aphasic patient : speaks telegraphically, angular gyrus. Dyscalculia oftens accompanies
sparsely, and slowly. Has difficulty in word finding and dyslexia
naming. Uses some nouns but omits conjunctions such o Acquired Dyslexia: usually occupies the posterior
as but, or, and and articles such as a, an, or the. end of the aphasic zone or somewhat more
Example: Patient says “I go house” instead of “ I go to posteriorly. Lesion damages the word association
the house”. As an excellent test sentence, ask the cortex of the parieto-occipito-temporal confluence
patient to repeat “No, ifs, ands, buts, fors, or or’s.” or disconnects it from afferents that arrive from
 Patient fails to make associations, such as naming the the corpus callosum or from the lingual gyrus of
makes of automobiles or naming a number of objects the occipital lobe and fusiform gyri of the
that are red temporal lobe
 Fails to inflect and modulate the normal rhythms of
speech and thus displays one form of dysprosody AUDITORY AGNOSIA (word deafness)
 Has difficulty writing (suggesting that the posterior  Patient with relatively pure auditory aphasia fails to
inferior part of the frontal love mediates speaking and understand spoken words but can read, write, and
writing) speak
 Patient retains the ability to audit language and to read,  LESION SITE: Occupies the posterior part of the left
but lacks the ability to repeat sentences superior temporal gyrus, next to the primary auditory
 LESION SITE: the lesion occupies the anterior part of the receptive area in the transverse gyri, in the floor of the
aphasic zone, in the posterior inferior part of the frontal sylvian fissure.Temporal lobe lesions cause other
lobe auditory agnosias such as interpreting the meaning of
diverse sounds other than language
WERNICKE’S APHASIA (receptive aphasia, fluent aphasia)
 Fluent aphasic patient:produces plentiful but garbled GLOBAL APHASIA
sounds, perhaps best described as a “word salad”.  Patient has expressive and receptive dysphasia that may
Substitution of erroneous words or parts of words and eliminate all receptive and expressive communication
phenomes (paraphasia) robs the speech of meaning. by words. Initially after the lesion, patient may be
 Lose the ability to audit their own words and the words entirely mute. Any speech retained is mainly
of others and often fail to realize the severity of their exclamatory or severely telegraphic
deficit in expression  LESION SITE: lesion destroy most of the left parasylvian
 LESION SITE: occupies the region around the posterior cortex or its connection with the caudate-putamen or
end of the Sylvian fissure at the parieto-occipito- thalamus.
temporal confluence, in the auditory and visual word
association area GERSTMANN’S SYNDROME
 Lesion affects the aphasic zone more posteriorly and  The core signs of Gertmann’s syndrome consist of
temporally than on expressive aphasia dysgraphia, dyscalculia, finger agnosia, and right-left
 Wernicke’s arc ( Arcuate Fasciculus) disorientation, but most patients also have some degree
of aphasia or dyslexia
DYSLEXIA AND ALEXIA (word agnosia and word blindness)  LESION SITE: lesion of the left angular gyrus, at the
 Dyslexia:means agnosia for the meaning of written parieto-occipito-temporal junction. Even though the
words despite adequate intelligence and exposure to lesion is unilateral, the finger agnosia and the right-left
conventional methods of instruction. Hence, the Patient disorientation affect both sides of the body, thus
cannot read. Dyslexia can be classified as congenital or representing bilateral autotopagnosia
acquired.
 Clinical examination for dyslexia:
o If the patient is a child, review the history for
accompanying language and behavioral problems.
Delay in acquiring speech, difficulty in naming
letters, letter reversals such as d for b. Abnormal
sequencing such as was for saw. The child has
attention deficits and the inability to organize,
plan, and carry out actions such as completing
homework assignments.
o Test for the ability to recognize individual letters,
small words, and long words and the ability to
sound out long words, to read phrases, sentences,
and paragraphs, and to explain them

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 Failure of of mentally intact pt with intact sensory

pathways to understand the meaning of the stimulus?
AGNOSIA
 Failure of mentally intact, non paralysed pt to execute
voluntary acts? APRAXIA
 We call apraxia for writing or speaking EXPRESSIVEor
MOTOR APHASIA.
 Four ordinary avenues for receiving and expressing
language?READING, LISTENING AND SPEAKING
 A lesion in the anterior part of parasylvian zone may
extend to motor area, while more posteriorly may extend
to into optic radiation (genicucalcarine tract)
 Pt with non fluent broca’ s aphasia would more likely
have- hemiparesis d/t lesion anteriorly in the aphasic
zone next to motor area
 Fluent aphasic would likely have hemianopsia d/t lesion
posteriorly in the aphasic zone, overlying the
geniculocalcarine tract.
 Type of aphasic that most likely have a severe receptive
aphasia? FLUENT, because lesion is more posterior,
toward the auditory and visual word association region

REFERENCES/LEGEND

Black – from DeMyer’s The Neurologic Examination

Red – own notes from precepts
Blue – other sources

AUTHORS

Climacosa; Bugayong ; Cortez; Gomez; Castillo G; de la Rosa E;

Germise ; Caton ; Bitao; Ilagan; Abolencia; Estrella; Hernandez
Z; Castro; Dickson; Boñula; Engcoy; Hernandezz N; Espiritu;
Guina; Aragones; Barba; Aquino

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 SAN BEDA COLLEGE OF MEDICINE NEUROLOGY:
BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

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