Mental Status Exam & Dermatology Transcript Notes

Mood, Affect, and Speech

  • Observations of a patient: sometimes smiles or laughs when someone says something funny, but otherwise has a flat affect and flat speech.
  • Importance of noticing speech abnormalities as part of mental status: stuttering is one example.
  • Other speech variations discussed include:
    • Saying random words (word salad)
    • Repeating words (perseveration)
    • Rhyming words
  • There is a chart in the book that defines the different variations of speech; review that chart for a comprehensive list.
  • Mood and affect: assess whether facial expression matches the stated mood.
  • Documentation tip: always state the mood first when charting, or if not stating it to the patient, chart the mood first before noting affect congruence.
  • Example from lecture: someone saying 3It is just too hot and describing discomfort in hot weather; the expression should align with the mood described.

Cognitive Function: Orientation and Attention

  • Core cognitive domains to assess:
    • Orientation to person
    • Orientation to place
    • Orientation to time
    • Orientation to situation
  • Person: assess by asking for name and birth date. For safety, staff often require knowing a patient’s name and birth date; patients may respond with non-specific answers (e.g., 3I woke up in Texas) but should demonstrate some identifying information.
  • Hospital example: a patient woke up disoriented, thought they had been in the hospital ICU for two weeks. A nurse’s reaction highlighted how easily hospital settings can disrupt time perception.
    • The speaker described feeling disoriented after waking, and the nurse reacting as if the patient’s remarks were irrational, illustrating how easily language can reflect one’s own professional role under stress.
    • Lesson: hospital environments can blur the sense of time; for clear assessment, consider asking about month or year when time tracking is unreliable.
  • Dementia: noted as a potential underlying reason for altered mental status in elderly patients.
  • Attention span: described as variable and sometimes hyperactive in certain contexts (e.g., children with attention difficulties in hospital settings).
  • Remote memory: assess by asking about distant events; example question: 3Tell me about your first job.
  • Confabulation: be aware of the tendency to fill in gaps with invented details. Big fancy term for this is 3confabulation. Intellectually capable people can still confabulate.
  • Aphasia: a language disorder where comprehension may be impaired. Key points:
    • You can point to objects and ask 3What is this? or 3What would you call this?
    • Patients with aphasia may speak fluently but write words that are incomprehensible; they may lose the ability to translate thoughts into written language.
  • Thought processes and content: assess for logical thinking and the presence of perceptions that aren’t aligned with reality. Indicators include hallucinations or talking to people who aren’t there.
  • Anxiety and depression screening: used in clinical practice; tools mentioned include:
    • Generalized Anxiety Disorder scale (GAD-7): 7 questions.
    • Patient Health Questionnaire (PHQ-2 and PHQ-9): PHQ-9 consists of nine questions plus one additional question, totaling 10 items in many implementations.
    • A positive response to thoughts of suicide is taken seriously; many hospitals screen for thoughts of self-harm on admission.
  • Judgment: assess long-term planning and realistic expectations. Example questions could include goals for the end of a semester or for five years from now.
  • Mini-Cognitive Exam: a brief screen consisting of three words, a clock-drawing task, and recall of those three words; used to gauge cognitive status.
  • Anecdotal notes on orientation and perception: some patients spontaneously misidentify time or place; consider verifying orientation with multiple cues.

Language, Thought, and Perception Examples

  • Word/filler usage and errors: the speaker gave examples like 3Aileen? Georgina? as a conversational distractor, illustrating how name recall can fail in informal testing.
  • Pupil observations: some individuals have naturally dilated pupils; such individuals may also experience night blindness due to poor adaptation to low light conditions.
  • Nails and keratin: the discussion included reference to hard keratin plates, pointing to nails as a diagnostic feature in some contexts.

Skin, Pregnancy, and Neonatal Skin Changes

  • Pregnant women: skin changes during pregnancy are linked to estrogen and progesterone; metabolism is increased during pregnancy.
  • A note about melanoma: a mention of metastatic melanoma that originated in the eye appeared in the transcript; this serves as a reminder of potential systemic connections to skin presentations.
  • Family patterns: keloids and hemangiomas often run in families.
  • Mongolian spots vs. Nevus simplex (stork bites):
    • Mongolian spots: more common in darker-skinned individuals; typically appear as dark patches on the back or buttocks.
    • Nevus simplex (stork bites): more common in Caucasians; flat pink/red patches often on the nape of the neck or forehead.
  • Cutis marmorata: a physiologic (benign) mottling pattern seen in newborns in response to cold.
  • Physiologic jaundice of the newborn: seen in about ty percent ( er) of newborns; caused by bilirubin accumulation; the bilirubin is normally excreted in stool, but newborns may have temporary delays.
    • Sunlight exposure can accelerate bilirubin breakdown and clearance; outdoors exposure helps reduce bilirubin.
    • In some cases, more intensive phototherapy may be used when jaundice is severe.
  • Lanugo: fine hair covering the newborn’s body; helps to hold vernix on the skin.
  • Vernix caseosa: waxy coating on newborn skin that protects during gestation.
  • Linea nigra: a darker line along the abdomen in pregnancy, caused by maternal hormones crossing the placenta; typically runs along the midline from the navel down.
  • Linea alba: the central white/skin-colored line along the midline that becomes more pronounced during pregnancy due to hormonal changes.
  • Cholasma (melasma) or mask of pregnancy: darker patches on the face caused by hormones; common in pregnancy.
  • Elderly skin changes (common descriptive terms):
    • Solar lentigines (often miscalled liver spots): pigmented patches due to sun exposure and aging.
    • Sebaceous hyperplasia: enlarged sebaceous glands, commonly seen on the cheeks; can give a bumpy, yellowish appearance.
    • Decreased skin turgor: slower return to normal after pinching the skin; indicates reduced elasticity.
    • Decreased hair growth and brittle nails with aging.
  • Scleral changes: scleral yellowing (scleral icterus) can indicate jaundice.
  • Skin lesions and conditions (general dermatology terms):
    • Contact dermatitis: vesicular eruption often from irritants (e.g., Steri-Strips post-surgery).
    • Gyrate, serpiginous (snake-like) lesions; wheel (hives); scale; fissure (opening in skin); excoriation (abrasion).
    • Normal surgical scar: visible staples or sutures; surrounding scar tissue may appear pale.
    • Hypertrophic scar vs. keloid: overgrowth of scar tissue beyond the wound boundary; keloids can be prominent in some individuals.
    • Common sites for problematic scarring: legs, heels, elbows.

Pressure Ulcers: Staging and Features

  • Stage 1: nonblanchable erythema (red area that does not blanch with touch).
  • Stage 2: partial-thickness skin loss (epidermis and possibly dermis damaged).
  • Stage 3: full-thickness skin loss (extends through the dermis into deeper tissues).
  • Stage 4: full-thickness skin and tissue loss; may see exposure of bone, tendon, or muscle.
  • Visual cues: left image shows nonblanchable erythema (Stage 1) while the right shows Stage 2 with skin loss; Stage 3 and Stage 4 illustrated with deeper tissue involvement.

Vascular Tumors and Pigmented Lesions

  • Hemangiomas generally run in families; two main types:
    • Strawberry hemangioma: superficial, bright red patch present at birth, grows to about age 2, then typically involutes by age 6 with possible small residual scar.
    • Cavernous hemangioma (deep): a deeper vascular lesion.
  • Telangiectasias (spider angiomas): small, dilated blood vessels near the surface of the skin.
  • Telangiecyte (term often used in teaching): a vascular lesion; the speaker struggled with the term but intended to describe spider angiomas and related vascular patterns.
  • Bruising: a rough color-change guide to bruise evolution is common in pediatric assessments.

Pediatric Conditions and Common Lesions

  • Candidiasis (yeast diaper rash): bright red, very painful diaper rash that can be difficult to clear; antifungal treatment needed until clearance.
  • Impetigo: bacterial skin infection typically caused by Streptococcus (strep) or Staphylococcus; often presents with honey-colored crusts.
  • Ringworm (tinea) pedis: fungal infection of the feet; terminology uses tyle pedis (pedis means feet).
  • Herpes simplex: commonly referred to as labial herpes; presents as cold sores around the mouth.
  • Milia (milk spots): benign, tiny white facial bumps seen in newborns.
  • Lyme disease rash: erythema migrans or other rashes associated with Lyme disease.
  • Hair changes with treatment: toxic alopecia can occur with chemotherapy or systemic toxins; hair cells at rest are less likely to shed than actively growing hair.
  • Traction alopecia: hair loss due to tight braids or hairstyles that pull on the hair shaft.

Additional Notes and Practical Points

  • Interpreting normal variants versus pathology:
    • Some findings (lanugo, linea nigra, physiologic jaundice, milia) are normal in newborns or pregnancy; differentiate from pathologic conditions.
  • Documentation and clinical context:
    • Many observations are context-dependent (hospital setting vs. outpatient, pregnancy, neonatal period).
  • Remember to use evidence-based screening tools and to follow institutional protocols for safety (e.g., suicide risk screening on admission; use of validated scales like GAD-7 and PHQ-9).
  • When in doubt about terminology, refer to standard glossaries for dermatologic terms (e.g., gyrate, serpiginous, wheal, scale, fissure, excoriation).

Quick Reference: Key Numbers and Terms

  • GAD-7: 7 questions
  • PHQ-9: 9 questions + 1 additional question (total often treated as 10 items)
  • Physiologic jaundice affects up to about 70 ext{ percent} of newborns
  • Hemangioma involution timeline: strawberry hemangiomas grow to age ~2, usually resolve by age ~6
  • Pressure ulcer stages: 1 through 4 (as described above)
  • Lines on pregnancy:
    • Linea nigra: midline abdominal darkening
    • Linea alba: midline white line; reference for normal anatomy
  • Common neonatal features:
    • Lanugo: fine fetal hair
    • Vernix caseosa: protective coating
    • Cholasma: facial hyperpigmentation during pregnancy
  • Common dermal patterns/examples to recognize quickly:
    • Contact dermatitis (vesicles)
    • Fissures (opening) and excoriations (abrasions)
    • Scars: normal, hypertrophic, and keloid
    • Pigmented lesions: lentigines (liver spots), Mongolian spots, Nevus simplex
    • Vascular lesions: hemangiomas (strawberry and cavernous), telangiectasias (spider angiomas)
    • Infections: candidiasis, impetigo, ringworm (tediopedis), herpes simplex, Lyme rash
    • Alopecias: toxic alopecia, traction alopecia

Note: The transcript contains several anecdotal and clinical teaching examples (e.g., hospital disorientation, family history patterns, and specific patient anecdotes). Use these as mnemonic anchors when studying, but verify terminology and clinical recommendations against your course textbooks and current guidelines.