TABLE 2811 Mental Status in the Emergency Department An Outline

Important components of the mental status examination include level of consciousness, spontaneous speech, behavioral observation, physical appearance, the relaying of history information, attention, and language comprehension. This information is usually easily obtained during history taking. The more traditional mental status examination relies on specific assessment of orientation, memory, intellect, judgment, and affect.

The physician should compare his or her own direct observations of the patient's behavior with reports from the patient's family and friends. Documentation of the patient's orientation should include an assessment of attention, ability to concentrate on a specific task, and the traditional evaluation of person, place, and time. The patient should be asked the day, month, and year and place where he or she is presently being examined. Impaired language performance, including difficulty with speech, reading, writing, and word finding, may indicate a neurologic disorder. Memory is often divided into three categories: immediate, recent, and remote. Immediate memory is tested by asking a patient to repeat a series of digits (usually five) forward and backward. Recent memory can be tested by asking the patient to repeat three unrelated words immediately and then again after 3 to 5 min. The patient should be able to restate these after 3 to 5 min. The patient may also be asked about events that have occurred in the last few hours. Remote memory can be tested by asking about previous addresses, occupations, or historical events from an early period in the patient's life. Tests of memory should include details of significant personal, national, and international historical events. All history should be corroborated.

Investigation of higher cognitive functions includes assessment of a patient's general command of information; mental calculation, especially subtraction, such as serial sevens; and spelling of words forward and backward (such as world). Patients with organic disease often have difficulty spelling backward or performing serial calculation. The patient's affect or outward display of emotion should be evaluated for sadness, euphoria, and anxiety. This may help distinguish between cognitive disturbance induced by depressive disorders and dementia due to significant cerebral pathology. An examiner can draw some conclusions regarding a patient's thought processes during the patient's own telling of his or her history.

Disordered thought processes include paranoid or grandiose delusions, fixed false beliefs, and delusional denial of illness. Such beliefs should be compared with reports from family and friends.

Visual hallucinations do occur in functional psychotic illnesses (schizophrenia or affective disorder), but most often result from organic disease. A patient with visual hallucinations should always be assumed to have organic pathology until proven otherwise.

Judgment may be impaired in organic disease, and historical evidence of faulty judgment should be elicited. Insight about judgment can be gained by asking a patient how he or she would deal with day-to-day problems, such as finding the way home from the hospital.

Finally, the examiner should test for specific focal neurologic deficits, including apraxias, agnosias, right-left disorientation, aphasias, and inability to follow complex spoken and written commands. Such signs may or may not occur in association with other localizing neurologic signs, such as asymmetric reflexes, paresthesia, or hemiparesis.

Ask the patient to "draw a clock face." The physician can draw a circle on a piece of paper and ask the patient to fill in the numbers on the paper to look like a clock face. If the patient can put in the numbers correctly in a clock face, he or she should then be asked to put the hands at the position to read a specific time. If the patient cannot do these tasks, organic disease is present.

Accurately diagnosing and understanding behavioral emergencies in the elderly is difficult but important. Syndromes include confusion, agitation, psychosis, and behavioral regression. Diagnoses that cause emergency syndromes such as this in the elderly are listed in Tab!ei281-2.

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