General survey mental status assessment
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General Survey & Mental Status Assessment. General Survey. Study of the whole person, including their general health state and any obvious physical characteristics Physical appearance Body structure Mobility Behavior Sensory perception. Physical Appearance. Age Appears stated age Sex

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General Survey & Mental Status Assessment

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General Survey & Mental Status Assessment


General Survey

Study of the whole person, including their general health state and any obvious physical characteristics

Physical appearance

Body structure

Mobility

Behavior

Sensory perception


Physical Appearance

  • Age

    Appears stated age

  • Sex

    Sexual development appropriate for gender and age

  • Level of consciousness

    Alert and oriented to time, place, person and situation


Physical Appearance

  • Skin color and appearance

    Even, uniform, presence of rashes , lesions, or jaundice

  • Facial features/expression

    relaxed, symmetric with movement

  • Signs of acute distress/appears well or ill


Body Structure

  • Stature

    Height within normal range for age and genetic heritage

  • Nutrition

    Weight within normal range

  • Symmetry

    Body parts equal bilaterally

  • Posture

    Normal “plumb line”

  • Position

    Comfortably erect

  • Body build/contour

    proportions even


Normal “plumb line”

Line should be straight up and down through ear, shoulder, and hip


Mobility

  • Gait

    Smooth, even well-balanced

  • Range of motion

    • Full mobility for each joint

    • Movement is smooth, even and well-balanced


Mental Status Assessment

Appearance

Behavior and Psychomotor Activity

Attitude Toward Examiner

Speech Pattern


Mental Status Assessment

Mood and Affect

Orientation

Level of Consciousness

Cognitive Ability

Perceptions & Thought Content

Insight & Judgment


Appearance

  • Dress

    • Neat

    • Meticulous

    • Unkempt/disheveled

    • Revealing, provocative, or outlandish

  • Grooming/Hygiene

    • Clean vs. dirty

    • Body odor

    • Excessive makeup/perfume


Behavior

  • Body position/posture

    • Erect

    • Slumped

    • Reclining

  • Eye contact

  • Expression

  • Compulsions


Psychomotor Activity

Relaxed, calm

Restless/Agitated

Pacing

Tics /Twitches

Gesturing or posturing

Yawning


Attitude Toward Examiner

Cooperative

Friendly

Playful

Flirtatious/Seductive

Open/Frank

Guarded

Hostile

Suspicious


Speech Pattern

  • Articulation

    • Fluent and clear

    • Mumbling

    • Speech Impediments

  • Talkative

  • Excessively loud or soft

  • Rapid/Pressured

  • Minimal—answering with “yes,” “no,” or grunting

  • Mute


Mood

Happy

Sad

Anxious

Irritable

Angry

Depressed

Elated/Euphoric

Labile


Affect

Laughing/smiling

Bright

Tearful

Flat/blunted

Detached

Labile


Mood & Affect

These are sometimes congruent but not always!


Orientation

  • Person—ask their name

  • Place—do they know where they are?

    • Country/state/city

    • Building/floor

  • Time

    • Month, day and year

    • Season

  • Situation

    • Current circumstance

    • General (life/work/family, etc)


Level of Consciousness

Alert

Drowsy

Lethargic

Obtunded

Stuporous

Comatose


Perceptions & thought content

Hallucinations

Delusions/Paranoia

Suicidal or homicidal

Excessive rumination

Intrusive thoughts


Assessing for Depression

Depressed mood most of the day

Loss of interest or pleasure in activities

Insomnia/hypersomnia

Psychomotor agitation/retardation

Fatigue/loss of energy

Diminished ability to think/concentrate, indecisiveness

Recurrent thoughts of death/suicidal ideation


Teen Depression

Irritable or angry mood

Unexplained aches and pains

Extreme sensitivity to criticism

Withdrawing from some, but not all people


Depression and Anxiety Matter!

Overuse of health care services

Impaired functional and cognitive ability, especially in older adults

Longer hospital stays

Decreased wound healing/recovery

Increased mortality

Risk for suicide


Insight & Judgment

  • Insight into:

    • Cause of illness/problem

    • Role in situation

  • Judgment—past or future

    • What patient did in previous situation

    • How patient plans to act or get help in the future


The Beginning… 


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