We have spoken about the importance of developing a methodical approach to patient care and then using that approach consistently to gain confidence and reliability.  The Mental Status Exam is no different, what is your methodical approach to a mental status exam?  And let's be clear... this is not an exam of the intoxicated patient... this is the methodical MSE of EVERY patient.  Lets take a minute and develop a methodical approach to an MSE.  You walk up and determine what?  LOC?  Awake, alert, oriented? How alert?  How oriented?  Unconscious and unresponsive?  What's their disposition?  Are they easily agitated, erratic, unpredictable, violent, uncooperative?  Calm and cooperative? Are they able to answer all questions appropriately?  How about following commands, and not orders, but is your stroke assessment patient able to understand your requests during examination?  Is the patients cognition intact?  Are they able to COGNITIVELY understand what you're asking them or what you're asking from them?  Do they demonstrate cognition by articulating their own understanding of your concerns and demonstrating an understanding of the consequences and implications of your concerns?  Are they COHERENT?  Do they demonstrate logical and consistent thought process?  Are they able to go from A to B consistently and logically?  Are there any clinical signs of intoxication from drugs or alcohol?  CLINICAL SIGNS.. not number of drinks!  The one who asks, well how many beers is too many beers, has no methodical approach to the MSE!  It's not about how many beers!  It's about your Mental Status Exam!  Does the patient exhibit SIGNS of Intoxication.  Overly paranoid?  Hallucinations?  Delusional? Slurred speech?  Staggered Gait?  Romberg's Test, are they able stand unassisted without swaying or falling while keeping their eyes closed?  Does the patient present with Nystagmus, involuntary movement of the eyes either horizontally or vertically?  These can be used as CLINICAL indications of intoxication.  Which by the way should be evident when assessing for what?  COGNITION and COHERENCY.  Remember... you CAN'T inform the person who's cognition is absent and is incoherent.  So... enough of that!  What does the exam look like?  


MSE: Awake, alert, oriented x4.  Calm and cooperative.  Able to follow commands and answer questions appropriately.  Intact Cognition and understanding.  Coherent with an intact linear thought process.  


Obviously you change points of the exam depending on the patient (unconscious, unresponsive, paranoid and unpredictable with violent disposition, unable to answer questions with absent cognition and incoherent thought).  Use this exam or make up your own.  Just use it consistently!  As always... Own the Day and go out the door with Intent!

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