ORIENTATION Ask for the patients full name, the location, and the date, and note the

exact response
MEMORY It is striking that many patients are able to discuss details of their history reasonably well, and
appear to have intact memory in casual discussion, yet have significant memory deficits when explicitly
tested. There is, therefore, no substitute for specifically testing memory on mental status exam.
Recent memory. Ask the patient to recall three items or a brief story after a delay of 3 to 5 minutes. Be
sure the information has been registered by asking the patient to repeat it immediately before initiating
the delay.
Remote memory. Ask the patient about historical or verifiable personal events.
What Is Being Tested? Memory can be impaired on many different timescales. Impaired ability to
register and recall something within a few seconds after it was said is an abnormality that blends into the
category of impaired attention. If immediate recall is intact, then difficulty with recall after about 1 to 5
minutes usually signifies damage to the limbic memory structures located in the medial temporal lobes
and medial diencephalon.
Dysfunction ofthese structures causes two characteristic forms of amnesia, which usually coexist.
Anterograde amnesia, is difficulty remembering new facts and events occurring after lesion onset, and
Retrograde amnesia, is impaired memory of events for a period of time immediately before lesion onset,
with relative sparing of earlier memories.
LANGUAGE Language, like memory, may seem intact during casual conversation, even when substantial
deficits are present. Explicit testing of language is, therefore, a mandatory part of the mental status exam.
1. Spontaneous speech. note tonal modulation and paraphasic errors (inappropriately substituted
words or syllables), neologisms (nonexistent, invented words), or errors in grammar.
2. Comprehension. Can the patient understand simple questions and commands?
3. Naming. Ask the patient to name some easy objects (e.g., pen, watch, book, etc.)
4. Repetition. Can the patient repeat single words and sentences (a standard is no ifs, ands, or buts)?
5. Reading. Ask the patient to read aloud single words, a brief passage, and the front page of a
newspaper and test for comprehension.
6. Writing. Ask the patient to write their name and write a sentence.
What Is Being Tested? Different kinds of language abnormalities are caused by lesions in the dominant
(usually left) frontal lobe, including Brocas area; the left temporal and parietal lobes, including
Wernickes area; subcortical white matter and gray matter structures, including the thalamus and
caudate nucleus; as well as the nondominant hemisphere.
CALCULATIONS, RIGHTLEFT CONFUSION, FINGER AGNOSIA, AGRAPHIA
Impairment of all four of these functions in an otherwise intact patient is referred to as Gerstmanns
syndrome. Since Gerstmanns syndrome is caused by lesions in the dominant parietal lobe, aphasia is
often (but not always) present as well, which can make the diagnosis difficult or impossible.
1. Calculations. Can the patient do simple addition, subtraction, and so on?
2. Rightleft confusion. Can the patient identify right and left body parts?
3. Finger agnosia. Can the patient name and identify each digit?
4. Agraphia. Can the patient write their name and a sentence?
Rightleft confusion and finger agnosia can both be quickly screened for with the classic command, Touch
your right ear with your left thumb.
What Is Being Tested? abnormality of all four of these functions that is out of proportion to other
cognitive deficits is strongly localizing to the dominant (usually left) parietal lobe.
APRAXIA inability to follow a motor command, when this inability is not due to a primary motor deficit or
a language impairment. You can test for apraxia by asking the patient to do complex tasks, using
commands such as Pretend to comb you hair or Pretend to strike a match and blow it out and so on.
Patients with apraxia perform awkward movements that only minimally resemble those requested, despite
having intact comprehension and an otherwise normal motor exam. Unfortunately, the term apraxia has
also been attached to a variety of other abnormalitiesfor example, constructional apraxia in patients
who have visuospatial difficulty drawing complex figures, ocular apraxia in patients who have difficulty
directing their gaze, dressing apraxia in patients who have difficulty getting dressed, and so on.
NEGLECT AND CONSTRUCTIONS Hemineglect is an abnormality in attention to one side of the universe
that is not due to a primary sensory or motor disturbance. In sensory neglect, patients ignore visual,
somatosensory, or auditory stimuli on the affected side, despite intact primary sensation. This can often be
demonstrated by testing for extinction on double simultaneous stimulation. Thus, patients may
detect a stimulus when the affected side is tested alone, but when stimuli are presented simultaneously on
both sides, only the stimulus on the unaffected side may be detected.
Patients should be asked, Is anything wrong with you right now? because patients with anosognosia
may be strikingly

unaware of severe deficits on the affected side of their body. Construction tasks that involve drawing
complex
figures or manipulating blocks or other objects in space may be abnormal as a result of neglect or other
visuospatial impairments
What Is Being Tested? Hemineglect is most common in lesions of the right (nondominant) parietal lobe,
causing patients to neglect the left side.