2 The neurological examination
Higher centres
The neurological examination is broken down into three components:
Higher centre function testing
1 The patient is given a six-item name and address (for example, William Bourke, 61 Griffith Avenue, Waverley) and asked to repeat it correctly on three consecutive attempts and until it is correctly repeated three times. The number of times the initial material needs to be offered should be scored. The average person should not require more than ten repetitions of the data to repeat it three times correctly. This tests immediate recall and allows transfer from the metaphoric RAM (random accessed memory) to hard drive. Once the material is correctly repeated three times, the patient is advised that an alarm has been set and they will be asked why it was set when it goes off in five minutes. The reason will be to see if the patient can remember that the alarm was set for a reason, what that reason was, and then repeat the six-item name and address. Most people can remember why the alarm was set, and personal experience suggests the average patient will recall three or four out of the six items. This tests immediate memory, five-minute recall, compliance and cooperation. It does contain a cultural element as the name and address is Australian based, but the recall of why the alarm was set does not reflect cultural bias.
2 Once Step 1 has been completed and the backwards timer is set, the remainder of the higher centre function testing can take place. This distracts the patient to allow proper five-minute recall rather than the patient practising and thus only testing immediate recall rather than five-minute recall.
3 Within the Australian context the patient is asked the name of the prime minister, state premier, day and date. This tests orientation in time and place as well as awareness of current affairs with an element of memory testing. Most will know at least day and date, and many will offer politicians’ family names if prompted with given names.
4 The next test is ‘Serial 7s’. Patients are asked to sequentially deduct 7 from 100, 7 from the response (i.e. 93) and 7 from that—until asked to stop. Once the patient reaches ‘30’ the sequence recurs, thus if the patient correctly states 100, 93, 86, 79, 72, 65, 58, 51, 44, 37, 30, it is my practice to stop at 30. The average person loses concentration when the answer is ‘44’. The most common error is 100, 93, 84 but this still shows good arithmetic skills: (a) the patient correctly subtracts 100 – 7 to achieve 93; (b) then subtracts 3 from 93 to achieve the 80s; (c) then subtracts 3 from 7 to get 4; (d) but rather than subtracting 4 from 90 the patient adds 4 to 80, hence the answer 84. This demonstrates anxiety rather than dyscalculia. Serial 7s test calculation (eloquent dominant hemisphere function), visual spatial orientation (spatial non-dominant hemisphere function) and the connections between the hemispheres to coordinate both hemispheres (corpus callosum). It also assesses concentration and anxiety levels. It is important to determine which of these factors has provoked an error if one occurs, as demonstrated above with the ‘84’ response.
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