CNS Examination For MD Residents

Attention - Ability to maintain/select information (working memory vs distractibility).

Immediate recall - Memory for information just presented (often attention/working memory dependent).

Delayed recall - Recall after a delay (more related to storage/retrieval processes).

Aphasia - Language impairment due to cortical dysfunction (e.g., comprehension, naming, repetition, fluency).

Executive dysfunction - Impairment in planning, abstraction, set-shifting, and self-monitoring.

Cued recall - Recall after a hint/category cue; useful for separating encoding vs retrieval problems.

Active Recall

Orientation - _________________________________________________

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Attention - _________________________________________________

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Immediate recall - _________________________________________________

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Delayed recall - _________________________________________________

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Aphasia - _________________________________________________

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Executive dysfunction - _________________________________________________

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Cued recall - _________________________________________________

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Worked Examples

Example 1 (Orientation + Attention, straightforward)

A patient says the correct name, knows they are in hospital, but gives the wrong date. Digit span is 4 forward, 2 forward after distraction.

• Orientation:

• Person: correct

• Place: correct

• Time: disoriented (date)

• Attention:

• Digit span 4 forward = impaired/low-normal depending on your reference

• Drop to 2 after distraction suggests poor sustained attention

Now you try:

Document orientation and attention in one-line MSE style.

• Person: _________________________________________________

• Place: _________________________________________________

• Time: _________________________________________________

• Attention task result: _________________________________________________

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Example 2 (Memory with cued vs uncued recall)

Given 3-word learning, immediate recall is 3/3. After 5 minutes: delayed recall is 1/3 uncued, 3/3 with category cue.

• Immediate recall: 3/3 → encoding/attention adequate

• Delayed recall uncued: 1/3 → retrieval difficulty or storage/encoding vulnerability

• Cued recall: 3/3 → cue restores access → more consistent with retrieval/strategy issue than complete storage failure

Now you try:

Write a brief interpretation of uncued vs cued delayed recall.

• Immediate recall: _________________________________________________

• Delayed uncued: _________________________________________________

• Delayed cued: _________________________________________________

• Likely interpretation: _________________________________________________

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Example 3 (Language + Executive function, pattern recognition)

Patient speaks fluently but naming is impaired; comprehension is intact; repetition is poor. On similarities, responses are concrete; on a sequencing task they perseverate.

• Language:

• Fluent speech + poor repetition → consider impaired repetition component (patterning vs dysarthria)

• Naming impaired → anomia component

• Executive function:

• Concrete similarities → impaired abstraction

• Perseveration on sequencing → set-shifting/executive control impairment

Now you try:

Assign domain-level deficits and describe each in exam language.

• Language: _________________________________________________

• Executive function: _________________________________________________

• Pattern note (e.g., fluency/repetition/comprehension): _________________________________________________

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Practice Questions

• (Easy, 4-mark) Describe how you would score orientation in the MSE.

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• (Medium, 8-mark) A patient has digit span 3 forward, serial 7s errors after the first correct subtraction, and is distractible during testing. Explain what this implies for attention, and how you would document it.

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• (Medium, 8-mark) Immediate recall is 5/5; delayed recall is 0/5 uncued

is 0/5 uncued; provide a 1-2 sentence interpretation linking encoding vs retrieval for memory, and state what additional MSE step you would use to test the difference.

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• (Hard, 12-mark) “Executive dysfunction is the most useful domain to explain poor performance on every other MSE domain.” How far do you agree? Structure your answer using orientation, attention, memory, language, and executive function, and include at least one reason you would score each domain separately.

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• (Easy, 4-mark) A patient can repeat a phrase but has impaired naming to confrontation. Which language subdomains does this suggest, and why?

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• (Hard, 12-mark) A patient shows fluent speech, impaired comprehension of multi-step commands, and makes semantic paraphasias on description tasks. Explain which language domains are most likely affected and how you would reflect uncertainty in your scoring.

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• (Medium, 8-mark) Serial 7s: patient starts correctly, then progressively skips steps. During attention testing they are distractible but can complete a simple digits-forward task. Explain what this pattern most likely indicates for attention vs executive function, and how you would document it.

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Answer Key

• Orientation scoring: name/person/place/time with “correct/incorrect” per item; document partial orientation and any inconsistencies.

• Attention: initial subtraction works then breakdown with distraction → reduced sustained attention/working attention; document digit span, serial 7s error pattern, and distractibility during testing.

• Delayed recall 0/5 uncued after perfect immediate recall → retrieval failure or encoding that is cue-dependent; test with category cues (e.g., semantic cue) and/or recognition.

• Executive dysfunction claim: disagree/partly agree; justify that separate domain scoring is needed because orientation/attention/language can fail independently; executive deficits can contribute to many domains but domain separation improves diagnostic clarity.

• Repeat preserved + naming impaired → suggests anomia/confrontation naming impairment with relatively intact phonological repetition; document “repetition intact, naming impaired.”

• Impaired comprehension + semantic paraphasias + fluent output → suggests receptive language impairment (semantic processing/comprehension) rather than isolated motor speech; score with “fluent speech,” “impaired comprehension,” “semantic errors,” and note differential (e.g., Wernicke’s-type picture) if needed.

• Attention vs

End of chapter one. 4 more chapters in the full book.