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Thread: Altered Mental Status and Mental Status Examination

  1. #1
    PharmD Year 1 TomHsiung's Avatar
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    Default Altered Mental Status and Mental Status Examination

    Clock-Drawing Test
    The clock-drawing test was originally developed in the early 1900s to evaluate soldiers who had suffered head wounds to the occipital or parietal lobes, injuries that often led to difficulty composing images correct with the appropriate number of parts of correct size and orientation (i.e., constructional apraxia). To depict a clock, patients must be able to follow directions, comprehend language, visualize the proper orientation of an object, and execute normal movements, all tasks that may be disturbed in dementia.

    How to execute a clock-drawing test could be found on webpage of http://references.tomhsiung.com/?dir=Psychiatrics

    Clinical Significance
    In patient without other known causes of constructional apraxia, a positive clock-drawing test increases the probability of dementia (LR = 5.3). A normal clock-draw test is a less useful result, being elicited from many patients with dementia as defined by other measures.
    Last edited by admin; Tue 23rd May '17 at 9:40pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    PharmD Year 1 TomHsiung's Avatar
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    Default Re: [Physical Exam] Mental Status Examination

    Mini-Cog Test
    The Mini-Cog test combines a clock-drawing test with tests of recall to provide a brief screening tool suitable for primary care patients, even those who do not speak English as their native language. To perform the test, the clinician asks the patient to register three unrelated words and then asks the patient to draw the clock, stating, "Draw a large circle, fill in the numbers on a clock face, and set hands at 8:20." The patient is allowed 3 minutes to draw the clock, and instructions may be repeated if necessary. After drawing the clock (or after 3 minutes has elapsed), the patient is asked to recall the three words. The Mini-Cog test is scored by assigning one point for each word recalled and two points for a "normal" clock, which should have the correct orientation and spacing of numbers and hands. An "abnormal" clock receives no points, thus creating possible total scores of 0 to 5.

    Clinical Significance
    A Mini-Cog score of 2 or less increases the probability of dementia (LR = 9.5).
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    PharmD Year 1 TomHsiung's Avatar
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    Default Re: [Physical Exam] Mental Status Examination

    MMSE (Mini-Mental Status Examination)
    The MMSE was introduced by Folstein in 1975 as an 11-part beside test requiring only 5 to 10 minutes to administer, a much briefer time compared with the 1 to 2 hours required by more formal tests of dementia.

    Altered Mental Status and Mental Status Examination-screen-shot-2016-12-24-at-2-52-34-pm-png

    Clinical Significance
    EBM Box 5-1 illustrates that assuming there is no evidence of delirium, a MMSE score of 23 or less increases the probability of dementia greatly (LR = 8.9), whereas a score of 24 to 30 decreases it (LR = 0.2). Nonetheless, because false-positive results become a concern when applying this threshold to large populations with a low incidence of dementia, such as persons living independently in the community, some experts prefer interpreting the MMSE score in three ranges: A score of 20 or less rules in dementia (LR = 14.4); one of 26 or more rules out dementia (LR = 0.1); and one of 21 to 25 is regarded as less conclusive (LR = 2.1), thus prompting further investigation.

    Altered Mental Status and Mental Status Examination-screen-shot-2016-12-22-at-6-49-00-pm-png
    Last edited by TomHsiung; Sat 24th December '16 at 2:56pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    PharmD Year 1 TomHsiung's Avatar
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    Default Re: [Physical Exam] Mental Status Examination

    Diagnosis of Delirium (Confusion Assessment Method)
    Delirium is an acute and reversible confusional state that affects up to 20% of elderly patients hospitalized with acute medical illnesses. Of the several screening tools available to diagnose delirium, one simple and well-investigated one is the Confusion Assessment Method.

    A.Scoring
    The clinician looks for the following four clinical features: 1) change in mental status (compared with the patient's baseline status) that is acute and fluctuating; 2) difficulty in focusing attention or trouble keeping track of what is being said; 3) disorganized thinking (e.g., rambling or irrelevant conversation, unpredictable switching between subjects, illogical flow of ideas); and 4) altered level of consciousness (e.g., lethargic, stuporous, or hyperalert).

    A positive test requires both features 1 and 2 and either 3 or 4.

    B.Clinical Significance
    As illustrated in EBM Box 5-1, a positive test argues strongly for delirium (LR = 10.7) and a negative test argues against delirium (LR = 0.2). Another version of this test, adapted for use in mechanically ventilated patients who cannot talk, has similar accuracy. In any patient with delirium, positive beside tests for dementia are inaccurate because of a high false-positive rate.
    Last edited by TomHsiung; Sat 24th December '16 at 3:02pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    Default Differential Diagnosis of Altered Mental Status

    Differential Diagnosis of Altered Mental Status

    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

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