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The Mental Status Examination in Primary Care by the Natural Medicine Physician (DC/ND) - Alan...
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Transcript of The Mental Status Examination in Primary Care by the Natural Medicine Physician (DC/ND) - Alan...
Alan B. Korbett, DC, DO DABCO, DACAN
Adult, Child & Adolescent Psychiatrist [email protected]
The Mental Status Examination in Primary Care by the Natural Medicine Physician (DC/ND)
Altered Mental Status Manifestation of
• Trauma
• Medical Emergencies
• Medication or drug uses
• Exposure to toxins
Altered Mental Status Manifestation of Neurological Disorders:
• posttraumatic syndromes • degenerative processes• organic deliriums • vascular abnormalities • Infections• neoplasm • organic psychoses • toxic states
Neurological Examination: 6 Components
• Mental Status Examination
Cranial NervesMotor SystemReflexesSensationCerebellar System
Mental Status Examination 8 Components Hierarchically arranged:
Behavior Observation
Levels of Consciousness
Attention and Concentration
Language
Memory
Constructional Ability
Higher Cognitive Function
Related Cortical Function
Mental Status Examination Components #1 Behavioral Observation
• Behavioral Observation: Observation of :– Orientation – Appearance– Attire– Hygiene – Attitude– Demeanor– Conduct– Reactions
Mental Status Examination Components #2 Consciousness
• Consciousness is a reflection of :- Arousal (Continuum)- Content of Consciousness (higher cognitive
and emotional function )
5 Principle Levels of Consciousness:
Coma: completely unarousable
Alert : awake and cognizant of stimuli
Lethargic or Somnolent : not fully alert, requires active stimuli to maintain alertness, attention impaired, spontaneous movement decrease
Obtundation: difficult to arouse; requires constant stimuli; confusedStupor or Semicomatose: does not respond
spontaneously
Mental Status Examination Components #3 Attention/Concentration
• Attention : the ability to attend to a specific stimuli without distraction from extraneous internal / external stimuli.
• Complex interaction of limbic, neo-cortical and reticular activating system
Attention presupposes alertness but alertness does not necessarily imply attentiveness
Assessment of Attention:
• Digital Repetition: begin with two digits sequence and continue adding an additional digit until patient fails.
Normal digital span is 6 + 1 pending age and general intellectual abilities Inability to repeat five or ≤ suggest defective attention
Concentration (Vigilance): the ability to sustain attention over an extended period.
• Assessment of Vigilance:– Serial Seven Subtraction: count
backwards from 100 by sevens
– Months of the Year Backwards– Common Words Spelled Backwards:
WORLD - DLROW
Mental Status Examination Components #4 Language
• Handedness and language are closely allied, 90% of population definitely right handed of which 99% are strongly left hemisphere dominate
3 Components of Language: Phonology, Semantic (Lexic), Syntactic
• Phonology: refers to the sound patterns of human speech
• Semantics: refers to the assignment of meaning to words and the production of linguistically appropriate individual words
• Syntax: refers to the assembly of words into sentences using pronouns, prepositions, tenses etc. in complex ways which obey strict grammatical rules
6 Assessment of Language Function:
• Fluency of Speech • Reading• Writing• Comprehension • Repetition• Naming
Assessment of Language Function: # 1 Verbal Fluency: Verbal Fluency: the ability to produce spontaneous speech reflective of word finding efficiency
• Fluency is assessed by noting spontaneous speech:
• Substantive content • Clarity of articulation• Grammatical integrity • Evidence of latency • Paucity / excess of words
Aphasia: loss or impairment of language function
Fluent Speech: speech produced at a normal rate, preserved rhythm, melody, good articulation and normal phrase length vs
Non-Fluent Speech: slow, laborious, abnormal rhythm and melody, poor articulation, shortened phrase length.
• Assessment of Verbal Fluency: – Letter Fluency (FAS)– Category Fluency: Animals, Fruits …
• Animal Naming Test: patient asked to generate as many animal names as possible in 60 seconds.
Assessment of Language Function: #2 Comprehension
• Comprehension the ability to perceive, correctly interpret and understand the meaning of visual, auditory and other sensory stimuli, together with interpretation and grasp of the total situation.
Assessment of Comprehension:
• Single-word Comprehension: using everyday objects of differing familiarity and parts of objects.
• Sentence (syntactic) Comprehension: using 3 common objects, test comprehension using a range of syntactic structures. The Pen - Watch-Key Test
• Conceptual Comprehension: using the same array of objects and asking conceptual questions. i.e.: Point to the item used for writing?
Other more formal test: Token Test, Peabody Picture Vocabulary Test
Assessment of Language Function: #3 Repetition
• Repetition: the ability to reproduce with precision devoid of errors.
Assessment of Repetition: tested with series of words and sentences of progressively increasing complexity.
No ifs, ands or buts
The orchestra played and the audience applauded
Assessment of Language Function: #4 NamingNaming: the ability to identify by name objects or drawings of objects.
• Assessment of Naming:
Confrontational Naming: using items from several categories and varying frequency of common to uncommon items
• Generate a List: items from a particular category or items beginning with a particular letter “t”
Assessment of Language Function: #5 Reading
Reading: Assessed by: Single Letter Identification Single word reading using words with regular and
exceptional spelling to sound correspondence, and
plausible non words Text Reading
Disorders of Reading:
• Peripheral Dyslexias: defect in the early
visual components of decoding written script
Central Dyslexias: defect in the normal linguistic processes involved in the deriving of meaning from words
Assessment of Language Function: #6 Writing
• Writing: depends upon integration of
motor control, visual spacial and
kinaesthetic function and symbolic
aspects of the language system. Angular Gyrus associated with writing ability
• Assessment of Writing:– Copying of words and single letters – Writing words with regular and exceptional spelling to sound correspondence, and plausible non words– Spontaneous writing of sentences
Mental Status Examination Components #5 :Memory
• Memory: mental process to store
experiences and perceptions for recall
at a later time.
Memory is a hierarchi process that may provide clinical and anatomic diagnostic data.
• 3 Stages: Stage I : information received and
registered by particular sensory modalities, held in short term (working)
memory temporarily Stage II: storing or retaining of information on
a more permanent basis Stage III: recall or retrieval of stored information
• Clinical Subdivisions of Memory: – Immediate Memory: recall after an
interval of a few seconds
i.e.: Digital recall
Recent Memory: ability to learn and retrieve new material after an interval of minutes, hours or days
Remote Memory: recollection of very early events
Mental Status Examination Components #5 Memory: Explicit Memory: that which is available to conscious access.Implicit (Procedural) Memory: refers to the forms of memory that do not have conscious access• Explicit Memory:
Short Term (Working) Memory: Verbal Spatial Long Term Memory:
Semantic (Fact) Memory Episodic (Event) Memory
Short Term (Working) Memory: responsible for immediate repetition of words, numbers, melodies (aka phonologic or articular loops)
Mental Status Examination Components #5 Long Term Memory (Explicit Memory):
1. Semantic (Fact) Memory - responsible for the permanent store of representational
knowledge of facts and concepts , words and their meanings
• Disorders of Semantic Memory: – Selective Impairments: (sparing of other
cognitive
abilities) • HSV encephalopathies• Major Head Injures• Vascular Lesions• Focal Temporal lobe atrophy
– As part of more diffuse dementing illnesses
Assessment for Semantic Memory Long Term Memory (Explicit Memory):
• Test of General Knowledge – Information; Similarities and Vocabulary– Category Fluency– Object Naming to Confrontation
Mental Status Examination Components #5 Long Term Memory (Explicit Memory) : 2. Episodic (Event) Memory:
• Disorders of Episodic (Event) Memory: 1. Amnestic Syndromes - restricted to individuals with pure disorders of memory, sparing global intellectual function
a. Anterograde Amnesia - inability to learn new material after the brain insult b. Retrograde Amnesia - amnesia for events that occurred before the brain insult
2. Transient Amnesia
Mental Status Examination Components #5 Long Term Memory: Test for Anterograde Amnesia:
• Verbal: – recall of complex verbal information– Word-List Learning – Three Unrelated Words
Non-Verbal: recall of geometric figures Rey-Osterrieth Figure Test Visual Design Reproduction
Mental Status Examination Components #5 Long Term Memory: Test for Retrograde Amnesia:
1. Personal Autobiographical
2. Public Events: Famous Faces Test, Famous Events Test
Mental Status Examination Components #5 Implicit (Procedural) Memory
Conditioning
Priming
Motor Skills
Mental Status Examination Components #6 Constructional Ability
Constructional Ability: refers to the ability to draw or construct two or three dimensional
figures or shapes• Constructional Ability Impairments:
– Apraxia: inability to execute complex motor tasks despite intact sensory and motor systems, coordination, good comprehension and full co-operation. Parietal lobe posterior to the Rolandic Fissure.
Apraxia Assessment: Drawing to Command: patient is instructed to draw a picture of a clock, flowerpot and a house (in perspective)
Mental Status Examination Components #7 Higher Cognitive Function Higher cognitive Function: are built upon the basic processes of attention, language and memory. • Cognitive Functions attributed to the Frontal lobes:
– Adaptive Behavior – Problem Solving– Abstract Conceptional Ability – Planning– Set Shift / Mental Flexibility – Initiation– Sequencing behavior – Social behavior– Personality (drive, motivation, inhibition) – Temporal order judgements
Related Cortical Function
• Right - Left Disorientation• Agnosia - • Denial & Neglect • Apraxia
Thank YOUThe Mental Status Examination in Primary Care by the Natural Medicine Physician (DC/ND)
Alan B. Korbett, DC, DO
DABCO, DACAN
Adult, Child & Adolescent Psychiatrist