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The Psychiatric Mental Status Examination Paula Trzepacz Pdf Free
the physical examination should begin with a careful inspection of the patient’s general appearance. any abnormalities in physical examination should be documented in the patient’s chart. if the patient is unable to answer questions about how he or she is feeling or if there is no reliable history of behavior or mood changes, then the examiner should conduct a mental status examination.
the mental status examination begins with a very thorough visual examination of the patient. the examiner should look for evidence of visual acuity, ocular movement, and eye alignment. the patient should be asked about any changes in his or her vision since the last visit. if the patient answers that there has been no change, then the examination is complete.
because inpatients are often more severely ill, the mse is best suited to patients with acute and chronic disorders. the mse is a broad screening tool, and should be completed with a complete medical history, physical examination, and laboratory test results. in addition, it is useful for assessing subtle changes in cognition, behavior, or mood over time or comparing the effects of different treatments. the mse is especially useful for monitoring responses to treatment. after recording a patient’s baseline mse, a repeat mse can be performed within a day of starting treatment and at discharge. repeat testing is useful for monitoring changes in mental status as part of the ongoing care of patients with disorders such as delirium, dementia, or substance use disorder.
the history and physical examination are the foundation of diagnosis, and the mse is the foundation of all mental status assessments. the mse is brief (6–10 minutes), easy to do, and can be administered by medical students and residents in training who lack expertise with psychiatric disorders. with appropriate training, the mse can be learned by medical students and residents in training who lack expertise with psychiatric disorders. the mse is similar to other standardized assessment tools, such as the mini mental status examination (mmse).
the ideal psychiatric assessment is comprehensive. prior to this edition of the apa manual, there was some discussion of a best practice approach to assessing cognitive function in older adults. due to the relative lack of developed standards for this population, the apa manual counseled for targeting a small number of key functions with attention to key informant input. hence, careful and detailed assessment of functional and cognitive domains is recommended. the mmse is the standard psychiatric examination for assessing cognitive function. additional cognitive measures are recommended based on the evaluation finding.
the mpr was developed to assist in the diagnosis of acute mania. it comprises six items that are rated on a four-point scale. scores of two or more should prompt further clinical evaluation of mania as they are highly suggestive of this diagnosis. although the mpr is designed for use in clinical settings, the validity of this instrument has been demonstrated in non-clinic settings.
this new edition of the apa manual features two new tools for diagnosing dementia – the geriatric depression scale and the memory complaint questionnaire. the gds is composed of 15 items, and the score is computed by adding the scores of each item. higher scores are indicative of greater depression. a score of 6 or greater is suggestive of depression. when the gds is right assessed for appropriate patients, they should receive care to address depression. with the memory complaint questionnaire, an informant can describe the patient’s memory function. answers are coded to four categories of forgetfulness and three categories for deficits in verbalization, orientation, or problem solving. patients with impairment in these areas should be assessed to determine the extent of memory complaint.