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MENTAL STATUS EXAMINATION. Outline Operational definition Purposes Components –Behavior –Cognition –Emotion Cognitive examination Mini Mental Status.

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Presentation on theme: "MENTAL STATUS EXAMINATION. Outline Operational definition Purposes Components –Behavior –Cognition –Emotion Cognitive examination Mini Mental Status."— Presentation transcript:

1 MENTAL STATUS EXAMINATION

2 Outline Operational definition Purposes Components –Behavior –Cognition –Emotion Cognitive examination Mini Mental Status

3 MENTAL STATUS EXAMINATION : What is it? ASSESSMENT of the: Behavior (see it all) Emotion (see some of it) Cognition (see none of it) Exhibited by the patient during the entire medical encounter

4 PURPOSES Detect Describe Neuroanatomical localization Assess functional implications of Abnormalities/deficits in : Behavior Emotion Cognition

5 ABNORMALITIES & DEFICITS Require diagnostic explanation May compromise capacity to coherently and reliably describe medical state to give informed consent to adhere to a therapeutic plan

6 MEDICAL ENCOUNTER Comprehensive global assessment

7 BEHAVIOR Appearance Attitude Activity Speech Dress Grooming Hygiene

8 BEHAVIOR Appearance Attitude Activity Speech Dress Grooming Hygiene COGNITION Thought content Thought progression Insight/judgment

9 BEHAVIOR Appearance Attitude Activity Speech Dress Grooming Hygiene COGNITION Thought content Coherence Goal directedness Insight/judgment Operations Arousal Attention Memory Emotion Language Reasoning

10 BEHAVIOR Appearance Attitude Activity Speech Dress Grooming Hygiene EMOTION Affect Mood Suicide Homicide COGNITION Thought content Coherence Goal directedness Insight/judgment Operations Arousal Attention Memory Emotion Language Reasoning

11 BEHAVIOR Appearanceappears stated age, uses a cane to walk Attitudecooperative, hostile, detached Activitynormal, increased, agitated, subdued Speechnormal rate/rhythm, dysarthric Dresscasual, provocative, dirty Groomingdisheveled, meticulous Hygieneclean, malodorous

12 COGNITIVE EXAM (“Mental status”) REASONING LANGUAGE MEMORY ATTENTION AROUSAL

13 COGNITIVE EXAM (“Mental status”) REASONING LANGUAGE MEMORY ATTENTION AROUSAL Must know education Can the patient hear?

14 MEMORY Immediate memory = attention Recent memory (episodic) Recall of three words at 5 minutes Ensure 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 overlearned Presidents, date of W.W.II, etc..

15 REASONING (Higher cognitive fx) Tests problem solving, abstract thinking Fund of knowledge - overlaps with remote memory How many weeks in a year? Name four presidents since 1940? What causes rust? Calculations Add, subtract, multiple, divide Sequences 1, 2, 3,... 1, 4, 9, 16,.... 2, 3, 5, 7, 11,...

16 REASONING (continued) Similarities Apple - orange Car - airplane Poem - novel Proverbs Don’t cry over spilt milk A stitch in time saves nine People who live in glass houses shouldn’t throw stones

17 BEHAVIOR Appearance Attitude Activity Speech Dress Grooming Hygiene COGNITION Thought content Thought progression Insight/judgment Arousal Attention Memory Language Reasoning EMOTION Affect Mood Suicide Homicide

18 EMOTION AFFECT “Affect is to weather as mood is to climate” predominate sad, euphoric, angry, anxious intensityunmodulated rangenarrow, broad congruenceincongruent with content MOODeuthymic, dysthymic, elated SUICIDEDo you ever wish you won’t wake up? Does it ever seem that life isn’t worth it? HOMICIDEIs there someone who deserves to be hurt?

19 MEDICAL ENCOUNTER Comprehensive global assessment Focused selected assessment

20 IN PRACTICE, MOST ENCOUNTERS ARE FOCUSED Accordingly the formal mental status exam is often limited to an assessment of COGNITION Further cognition is often assessed solely using: ORIENTATION

21 TO ORIENT To understand one’s relationship to the environment

22 Person Place Time Situation “Oriented X 3” “O X3”

23 Person Place Time Situation “Oriented X 3” “O X3” “Oriented X 4” “OX4”

24 Person Place Time Situation “Oriented X 3” “O X3” “Oriented X 4” “OX4” ORIENTATION ASSESSES: language perception reasoning remote memory recent memory

25 More precise More comprehensive Longer Statistical norms Less precise Less comprehensive Shorter Examiner norms Orientation Full mental status Mini Mental Status Neuropsychological Testing

26 MINI MENTAL STATE EXAM ADVANTAGES brief (10 min), systematic bedside instrument wide recognition among physicians since it is standardized, the score it yields is meaningful to physicians familiar with it DISADVANTAGES specific deficits may be ignored if the overall score is not low (less than 25 out of 30) the global score has no localizing valve repeated use with intact patients produces a mechanical transaction

27 Examiner uses paper and pencil Total of 30 points orientation (10) recent memory (3) attention (3) calculation, spell backward (5) name, read, repeat (4) write (1) constructional ability (1) ideomotor praxis (3) Not timed

28 What 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 all repeated or 6 presentations. Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Score number of correct answers or spell “world” backward, score is number of letters in correct order. “dlorw” is 3 points.

29 Ask 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 a subject and a verb and be sensible. Ignore grammar and punctuation (1).

30 Place 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 the floor. 1 pt for each step executed correctly (3). Ask the patient to copy a drawing of intersecting pentagons. All 10 angles must be present and two must intersect to create a 4 sided figure. Ignore tremor and rotation (1).

31 Normals can be expected to score > 25 However, even with > 25, if 0/3 or 1/3 for recent memory or problems with naming, repeating, writing or reading suggest focal deficits. It is most sensitive to disturbances which broadly effect function, it may miss subtle, focal problems.

32 You may not always do a MMS: Too little time Patient becomes agitated at challenge However, even without an MMS Interacting with the patient and obtaining a history have provided information to write up a mental status exam Lesson: YOU DO NOT HAVE TO DO AN MMS TO THOROUGHLY EXAM A PT


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