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Level of consciousness
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Mental status examination
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Cranial nerves
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Motor system
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Sensory system
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Cerebellar system
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Reflexes
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Other special tests
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Note: Abnormal findings or specific symptoms may require an extended evaluation. |
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Ophthalmoscope
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Reflex hammer
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Tuning fork (128 Hz for vibration on bony prominences and 512 Hz for hearing)
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Stethoscope
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Tongue blade
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Pointed instrument: which will not puncture the skin; for instance, the picky end of a broken wooden applicator is often used to apply noxious stimuli
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Wisp of cotton or fluffed cotton swab to test corneal reflex and light touch sensation
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Flashlight
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Tape measure
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Snellen or Rosenbaum eye chart
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General impression of awareness and mental function
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Level of alertness
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General appearance and behavior
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Mood and emotional state
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General thinking processes
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Content of thought
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Reception and interpretation of sensory stimuli (general cognitive function)
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Orientation
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Personal identification
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Attention
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Comprehension
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Higher-level cognitive functions
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Memory (immediate, short-term, long-term)
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Calculations
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General fund of information
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Abstract thinking, reasoning, and judgment
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Language and speech
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Constructional ability
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Motor integrative function
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TABLE 7-1 VARIATIONS/ABNORMALITIES IN THOUGHT PROCESSES | ||||||||||||||||||||||||||||||||||||
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Memory (immediate, short-term, long-term)
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Calculations
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General fund of information
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Abstract thinking, reasoning, and judgment
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Language and speech
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Constructional ability
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Motor integrative function
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Date/place of birth:When were you born?Where were you born?
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School information:Where did you go to school?TABLE 7-2 CLASSIFICATION OF MEMORY
TYPES OF MEMORY
PRIMARY PURPOSE
ACCESSIBILITY/CAPACITY
DURATION
ANATOMIC SITE
TESTING METHOD
CLINICAL PRESENTATION
Immediate (primary)
Register new information
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Rapid accessibility
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Limited capacity
Seconds to minutes
Reticular activating system (RAS)
Immediately repeat a series of numbers
Lack of any memory
Recent (short-term)
Retention and recall of information that has been previously registered
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Slow accessibility
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Much larger capacity
Minutes to years
Limbic system
Repeat names of three objects after being distracted for 3-5 min
Inability to recall information previously registered
Remote (long-term)
Permanently retain information
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Slower accessibility
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Unlimited capacity
Years
Association cortex
Correctly recall important personal events of the past
Cannot recall highly significant past material
Adapted from Tasman, A., & First, M. B. (2004). DSM-IV-TR mental disorders: Diagnosis, etiology, and treatment (pp. 276-277). Hoboken, NJ: Wiley.
When did you attend school?Where is your school located? -
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Vocational history:What do you do for work?Where do you work?How long have you worked there?
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Family history:What are your spouse’s and children’s names?How old are they?What was your mother’s maiden name?
TABLE 7-3 EVALUATION OF LANGUAGE AND SPEECH | ||||||||||||||
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Disorders of central language processing result in aphasia.
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Disorders of motor programming of language symbols result in apraxia of speech.
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Disorders of the motor mechanism of speech result in dysarthria.
TABLE 7-4 CLASSIFICATION OF APHASIAS WITH ANATOMIC CORRELATIONS | |||||||||||||||||||||||||||
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TABLE 7-5 CLASSIFICATION OF APHASIA AND IMPACT ON LANGUAGE FUNCTION | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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TABLE 7-6 PURPOSEFUL MOTOR ACTS AND APRAXIA | ||||||||||||||||
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Figure 7-2 Examples of impaired performance on a test for copying given to a patient with unilateral neglect. |
CHART 7-1 Visual Field Defects Produced by Selected Lesions in the Visual Pathways | |||||||||||||
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Figure 7-5 Technique for the proper use of the ophthalmoscope. Turn on the ophthalmoscope light and adjust the output to the small round beam of white light. Use your index finger to adjust the lens for proper focus; begin by adjusting the lens to zero diopters. Red lens numbers indicate minus diopters (turn the lens control counterclockwise) and are used with a myopic (nearsighted) patient. Black lens numbers indicate plus diopters (turn the lens control clockwise) and are used for a hyperopic (farsighted) patient or for one who has undergone surgical lens removal. Instruct the patient to look straight ahead. Hold the ophthalmoscope with your right hand and use your right eye to look into the patient’s right eye. Hold the thumb of the opposite hand on the patient’s eyebrow above the eye that you are examining.
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