Examination of the nervous system

Summary

Speech

1. ▪ Assess the three components of speech production (phonation, articulation and language production).

2. ▪ You will already have heard the patient speak during the historytaking section. Are there any problems with phonation? (Dysphonia – reduced speech volume; aphonia – inability to produce sound.)

3. ▪ Now assess articulation by asking the patient to repeat the following phrases – ‘baby hippopotamus’, ‘West Register Street’ and ‘British Constitution’. Is there any dysarthria?

4. ▪ Assess language production centres by (1) Listening to the patient's spontaneous speech, (2) Assessing comprehension by observing responses to simple commands (for example ‘close your eyes’), (3) Assessing the patient's ability to identify and name simple objects, for example a pen or watch, and (4) Assessing the ability of the patient to repeat sentences (for example ‘no ifs, ands, or buts’). Note whether there is an expressive dysphasia, or a receptive dysphasia.

Mental state and higher cerebral functions

1. Consciousness –is the patient alert, confused, obtunded, stuporous,or comatose. Assess the level of consciousness more objectively using the Glasgow coma scale.

2. ▪ Appearance and behaviour – assess the patient's general demeanour, physical appearance and responses to your questions during history taking. Also look for any obvious evidence of self-neglect, which can often be seen in advanced dementia.

3. ▪ Affect – note the patient's affect.

4. ▪ Cognitive function – assess by using the mini-mental state examination.

5. ▪ Dyspraxia and apraxia – ask the patient to performsimple upper and lower limb tasks, for example for the upper limb, write a sentence, or do up his/her shoelaces).