11BEHAVIOR Appearance appears stated age, uses a cane to walk Attitude cooperative, hostile, detachedActivity normal, increased, agitated, subduedSpeech normal rate/rhythm, dysarthricDress casual, provocative, dirtyGrooming disheveled, meticulousHygiene clean, malodorous
12REASONING LANGUAGE COGNITIVE EXAM (“Mental status”) MEMORY ATTENTION AROUSAL
13REASONING Must know LANGUAGE education Can the patient hear? COGNITIVE EXAM (“Mental status”)MustknoweducationREASONINGLANGUAGEMEMORYATTENTIONAROUSALCan thepatienthear?
14MEMORY Immediate memory = attention Recent memory (episodic) Recall of three words at 5 minutesEnsure that pt has registered the items“Repeat these words after me, I want you to remember them.”Remote memory (semantic & episodic)Tends to overlap with knowledge, most of what we ask is overlearnedPresidents, date of W.W.II, etc..
15REASONING (Higher cognitive fx) Tests problem solving, abstract thinkingFund of knowledge - overlaps with remote memoryHow many weeks in a year?Name four presidents since 1940?What causes rust?CalculationsAdd, subtract, multiple, divideSequences1, 2, 3, ...1, 4, 9, 16, ....2, 3, 5, 7, 11, ...
16REASONING (continued) SimilaritiesApple - orangeCar - airplanePoem - novelProverbsDon’t cry over spilt milkA stitch in time saves ninePeople who live in glass houses shouldn’t throw stones
18EMOTION AFFECT “Affect is to weather as mood is to climate” • predominate sad, euphoric, angry, anxious• intensity unmodulated• range narrow, broad• congruence incongruent with contentMOOD euthymic, dysthymic, elatedSUICIDE Do you ever wish you won’t wake up?Does it ever seem that life isn’t worth it?HOMICIDE Is there someone who deserves to be hurt?
23PersonPlaceTimeSituation“Oriented X 3”“O X3”“Oriented X 4”“OX4”
24ORIENTATION ASSESSES: “Oriented X 3” “O X3” “Oriented X 4” “OX4” PersonPlaceTimeSituation“Oriented X 3”“O X3”“Oriented X 4”“OX4”• language• perception• reasoning• remote memory• recent memoryORIENTATIONASSESSES:
25Mini Mental Status More precise Less precise More comprehensive Less comprehensiveShorterExaminer normsMore preciseMore comprehensiveLongerStatistical normsMini Mental StatusOrientationFull mentalstatusNeuropsychologicalTesting
26MINI MENTAL STATE EXAM ADVANTAGES brief (10 min), systematic bedside instrumentwide recognition among physicianssince it is standardized, the score it yields is meaningful to physicians familiar with itDISADVANTAGESspecific deficits may be ignored if the overall score is not low (less than 25 out of 30)the global score has no localizing valverepeated use with intact patients produces a mechanical transaction
27Examiner uses paper and pencil Total of 30 pointsorientation (10)recent memory (3)attention (3)calculation, spell backward (5)name, read, repeat (4)write (1)constructional ability (1)ideomotor praxis (3)Not timed
28What is the (year) (season) (date) (day) (month)? Where are we? (state) (county) (city) (hospital) (floor)(10)Ask pt to repeat three objects - give one per second.Number repeated first trial = score (3). Present till allrepeated or 6 presentations.Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Scorenumber of correct answers or spell “world” backward,score is number of letters in correct order. “dlorw” is3 points.
29Ask the patient to name a watch and a pencil. (2) Ask the patient to say “No ifs, ands or buts” (1).Ask the patient to recall the three words (3).Ask the pt to read and follow the command:“Close your eyes”. Score (1 ) only if closes eyes.Ask the pt to write a sentence. It must have asubject and a verb and be sensible. Ignoregrammar and punctuation (1).
30Place a piece of paper where the patient can reach it with either hand. Ask him/her to:(1) pick it up, (2) fold it in half, (3) lay it on thefloor. 1 pt for each step executed correctly (3).Ask the patient to copy a drawing of intersectingpentagons. All 10 angles must be present and twomust intersect to create a 4 sided figure. Ignoretremor and rotation (1).
31Normals can be expected to score > 25 However, even with > 25, if 0/3 or 1/3 for recentmemory or problems with naming, repeating,writing or reading suggest focal deficits.It is most sensitive to disturbances whichbroadly effect function, it may miss subtle,focal problems.
32You may not always do a MMS: Too little timePatient becomes agitated at challengeHowever, even without an MMSInteracting with the patient and obtaining ahistory have provided information to writeup a mental status examLesson: YOU DO NOT HAVE TO DOAN MMS TO THOROUGHLY EXAM A PT