Level of Alertness, Attention, and Cooperation

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Be as specific as possible in documenting the level of alertness, noting what the patient can or cannot do in response to which stimuli (see the section "Coma Exam" in Neuroanatomy Through Clinical Cases 3e, Chapter 3). One can test attention by tasks such as spelling a short word forward and backward (W-O-R-L-D/D-L-R-O-W is a standard), repeating a string of integers forward and backward (digit span), or naming the months forward and backward. Normal digit span is six or more forward and four or more backward, depending slightly on the patient’s age and education. It normally takes up to twice as long to recite months backward as forward. Note that these tests of attention depend on language, memory, and some logic functions as well. Degree of cooperation should be noted, especially if it is abnormal, since this will influence many aspects of the exam.

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