B.  Obtain History, Physical Examination, Mental Status Examination (MSE), Medication Including Over-The Counter (OTC), And Lab Tests As Indicated

 

Note: An assessment may already have been obtained as part of the patient’s initial assessment.

 

OBJECTIVE

 

Obtain clinical background information on the patient.

 

ANNOTATION

 

1.     Interview the patient and other collateral informants, where appropriate, about medical history and use of prescription and non-prescription medications before initiating extensive diagnostic testing.

2.     Note any history of recent head trauma.

3.     Order laboratory tests selectively, aiming to detect potential medical causes for the presenting symptoms, where indicated by:

·         Specific symptoms found on the medical review of systems

·         Evidence of unusual symptom profiles

·         History of atypical illness course

4.     Screen for cognitive status, particularly in the elderly patient.

·         Consider a standardized instrument, such as Folstein’s Mini-Mental State Examination (MMSE) (Folstein et al., 1975) using age and education-adjusted cut-off scores (Crum et al., 1993).

Consider using a standardized procedure, such as the Neurobehavioral Cognitive Status Exam (Kiernan et al., 1987), if the mental status screening is positive.