Subscribe Now/Learn More
PsychiatryOnline subscription options offer access to the
DSM-5 library, books,
journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists
and mental health professionals with key resources for diagnosis, treatment, research,
and professional development.
Need more help? PsychiatryOnline Customer Service may be reached by emailing PsychiatryOnline@psych.org
or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).
How engaged and oriented is the patient to the presenting
concern? Is he or she able to articulate and speak coherently? Does
the speech have regular rate and prosody? Do there appear to be
any language comprehension difficulties? What is the mood and affect
of the patient? Does he or she make good eye contact?
Is the face symmetric, and is the patient able to demonstrate
a good range of facial expression? Is there any eyelid or facial
What is the sitting posture of the patient? If the
patient moves around during the interview, does there appear to
be any asymmetry? Are there any extraneous movements, such as tics
or choreiform movements? Can he or she get up and down from the
chair without using the armrests (i.e., good proximal muscle strength)?
Does the patient have a high-stepping gait, sometimes
seen in sensory neuropathies (Friedrich's ataxia, vitamin
Are there any tremors or clumsiness noted during the
Is there any toe walking (a potential sign of lower
extremity spasticity) or asymmetry of arm swing while walking (a
potential sign of mild limb paresis)?
Character of weakness
Spastic paralysis with hypertonia
Flaccid paralysis with hypotonia
Accompanying encephalopathy, developmental delay, intellectual disability,
Asymmetric if due to cortical lesion
Decreased or absent
Babinski reflex positive
Babinski reflex not present
Fasciculations and fibrillations
Note. DTR = deep
Background rhythm slowing
Brain lesion may be located in the region where background
is slowed (if focal) and may reflect state of arousal if generalized,
such as in certain coma states.
Polymorphic delta slowing may be related to structural
lesions, a recent seizure, encephalopathy, migraine; rhythmic delta
activity may be associated with structural lesions, metabolic disorders, trauma,
Periodic lateralized epileptiform discharges
These reflect acute or subacute process such as infection,
vascular insult, or trauma and may be an interictal phenomenon.
Spike and slow-wave discharges
These commonly reflect primary generalized epilepsy
(e.g., absence and/or generalized tonic-clonic) and may
be elicited by hyperventilation or photic stimulation in such patients.
Sharp and slow-wave complex discharges
These may be seen in patients with tonic seizures;
patients may have accompanying developmental delay or mental retardation
(as seen in Lennox-Gastaut syndrome).
Focal epileptiform discharges (e.g., spikes or sharp
These may be seen in patients with partial-onset seizures
and may also be an incidental and clinically nonsignificant finding
in normal children.
Migraine and equivalents
Falling with unresponsiveness
Syncope (vasovagal or neurocardiogenic)
Craniocervical junction disorders
Chiari type I malformation
Organized repetitive movements
Psychogenic nonepileptic seizures
Chorea (Sydenham's, toxic, stroke related)
Head banging, sleepwalking, and sleeptalking
Night terrors and nightmares
Narcolepsy and cataplexy
Periodic leg movements