A QUICK NEUROPSYCHIATRIC EXAMINATION

Volume 2 Issue 3 March, 2012

Consultation Liaison Psychiatry -Focus: Neurology

The neuropsychiatric examination is one of the most unique exercises in all of clinical medicine, and is performed to localize a lesion in the central or peripheral nervous system, diagnose neurological and psychiatric disorders. The statement has been made, “History tells you what it is, and the examination tells you where it is.” Reflex hammer, tuning forks are essential, but don’t miss to carry an ophthalmoscope, gloves, tongue depressor and sterile pins. And never forget to observe and listen.

Examination begins as soon as we see patient, an observation is vital for various reasons; a dull face, without arm swing can indicate Depression or Parkinsonism. Listening to patient can be crucial in diagnosing many psychiatric disorders. Where there is no complaint of cognitive problems and the patient appears to behave normally and give a consistent history, detailed cognitive examination is usually not indicated. Features suggestive of cognitive impairment include evidence of abnormal behaviour, inability to give a history, and concern from relatives. Mental status examination which includes assessment of concentration, attention, mood, thoughts, perception, and speech output can help in making diagnosis of psychiatric disorders. Formal assessment of attention is assessed by asking the patient to count backwards from 20 to zero.

If dementia is suspected, MMSE should be done. A score of 28/30 or more effectively rules out Alzheimer’s disease. In assessment of speech, don’t overlook comprehension deficits and naming problems. Visual field examination is very important and often neglected. In routine practice test both eyes together, in four quadrants. A common abnormality is homonymous hemianopia. Most hemianopias are caused by stroke. Eye movements are important and must not be overlooked. Cranial nerves involvement is common; VI nerve involvement is usually vascular; III nerve affection is urgent, if painful and the pupil is dilated which can be due to aneurysms and tumors compression.

Test facial movement by asking patients to screw up their eyes and grin, eye closure weakness should not be missed as it suggests lower motor type of facial palsy. Impairment of corneal reflex can be very early sign of trigeminal neuropathy and need to be always performed. Look at the tongue; it should protrude centrally, and not be wasted. Tendon reflexes are normally absent (or diminished) in cases of neuropathy. Before labelling a reflex is absent, never forget to do Jendrssik maneuver for reinforcement.

There are some neurological signs that mean very little in isolation. Isolated sensory signs are rarely relevant. Sensory examination is really important in excluding possible motor neuron disease. Muscle power is actually more difficult to assess than it might seem. It should be done to demonstrate a pattern of weakness such as pyramidal, radicular, specific peripheral nerve, proximal, distal. Only repetitive practice makes you o do quick and proper neuropsychiatric evaluation.