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General Survey & Mental Status Assessment

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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  1. General Survey & Mental Status Assessment

  2. 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

  3. 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

  4. 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

  5. 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

  6. Normal “plumb line” Line should be straight up and down through ear, shoulder, and hip

  7. Mobility • Gait Smooth, even well-balanced • Range of motion • Full mobility for each joint • Movement is smooth, even and well-balanced

  8. Mental Status Assessment Appearance Behavior and Psychomotor Activity Attitude Toward Examiner Speech Pattern

  9. Mental Status Assessment Mood and Affect Orientation Level of Consciousness Cognitive Ability Perceptions & Thought Content Insight & Judgment

  10. Appearance • Dress • Neat • Meticulous • Unkempt/disheveled • Revealing, provocative, or outlandish • Grooming/Hygiene • Clean vs. dirty • Body odor • Excessive makeup/perfume

  11. Behavior • Body position/posture • Erect • Slumped • Reclining • Eye contact • Expression • Compulsions

  12. Psychomotor Activity Relaxed, calm Restless/Agitated Pacing Tics /Twitches Gesturing or posturing Yawning

  13. Attitude Toward Examiner Cooperative Friendly Playful Flirtatious/Seductive Open/Frank Guarded Hostile Suspicious

  14. Speech Pattern • Articulation • Fluent and clear • Mumbling • Speech Impediments • Talkative • Excessively loud or soft • Rapid/Pressured • Minimal—answering with “yes,” “no,” or grunting • Mute

  15. Mood Happy Sad Anxious Irritable Angry Depressed Elated/Euphoric Labile

  16. Affect Laughing/smiling Bright Tearful Flat/blunted Detached Labile

  17. Mood & Affect These are sometimes congruent but not always!

  18. 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)

  19. Level of Consciousness Alert Drowsy Lethargic Obtunded Stuporous Comatose

  20. Perceptions & thought content Hallucinations Delusions/Paranoia Suicidal or homicidal Excessive rumination Intrusive thoughts

  21. 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

  22. Teen Depression Irritable or angry mood Unexplained aches and pains Extreme sensitivity to criticism Withdrawing from some, but not all people

  23. 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

  24. 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

  25. The Beginning… 

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