Mental Status Exam
If the history of present illness is viewed as a timeline of what the patient experienced up until the presentation to the ED, the mental status exam (MSE) should be viewed as a snapshot of what the patient looks like in front of you at that moment in time.
While the history of present illness theoretically shouldn’t change, the MSE is the key element during reassessments of patients to determine if they are responding to treatment or not.
This should be a brief description of the patient’s outer presentation, including clothing, level of grooming and hygiene, weight, height, whether or not they appear their stated age, dentition, presence of tattoos or bodily markings, piercings, scars, evidence of past physical trauma, missing or deformation of limbs, posture, presence of accessories including prosthetics, walker, wheelchair, cane, or eye glasses.
This should describe any observed behaviors of the patient. Descriptors can include level of calmness, whether they are cooperative with the interview, their level of engagement, including if they are withdrawn or aloof. Mention if the patient appears internally preoccupied, if they are talking to themselves, or if they are responding to internal stimuli.
Displayed episodes of aggression (verbal or physical), posturing, or tearfulness should be noted. Emotional lability, including laughing, is also an important descriptor to document. The clinician should identify whether or not these observed behaviors are appropriate for the context of the interview.