Comprehensive Patient Assessment

Introduction to Assessment

The American Academy of Pediatrics recommends combining interviews with the patient alone and accompanied by family members/caregivers to obtain complementary information and identify discrepancies 1
The American Academy of Pediatrics suggests establishing clear confidentiality boundaries before starting the interview to facilitate an open and honest conversation 1
The American College of Radiology recommends using a calm and accessible language, avoiding complex technical terms that may confuse the patient 7

The Alzheimer's Association recommends realizing a mental state assessment that includes appearance, behavior, thought process, thought content, mood and affect, insight, and judgment 1
The Alzheimer's Association suggests using validated brief cognitive assessment tools, such as the Mini-Mental State Examination, even in patients without evident cognitive complaints 3
The Alzheimer's Association recommends evaluating attention, level of consciousness, and thought organization to detect subtle signs of cognitive alteration 3

The American Academy of Pediatrics recommends obtaining information about the onset, course, and trajectory of behavioral or cognitive changes, even if subtle 3
The Annals of Emergency Medicine suggests investigating comorbid medical conditions, medication use, and substance use that may affect mental status 4, 6
The Journal of the National Comprehensive Cancer Network recommends documenting prior psychiatric history, including previous treatments and response to them 5

The Annals of Emergency Medicine recommends investigating abnormal vital signs or physical examination changes that may indicate underlying medical causes of subtle behavioral changes 4, 6
The American College of Radiology suggests evaluating pain and discomfort as possible causes of behavioral changes, often underestimated 7
The Annals of Emergency Medicine recommends considering selective laboratory tests (not routine) based on specific clinical findings 4, 6

The Journal of the National Comprehensive Cancer Network recommends evaluating anxiety, which is common in all patients, differentiating between generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder 5
The Journal of the National Comprehensive Cancer Network suggests investigating suicidal ideation, even in patients without evident depressive symptoms, as the risk may be present 5
The Journal of the American College of Radiology recommends documenting substance use and medication that may affect mental status 7

The Alzheimer's Association recommends realizing a more detailed assessment in elderly patients to differentiate between delirium (reversible medical emergency) and dementia (chronic condition) 3
The Alzheimer's Association suggests considering referral to a specialist for patients with atypical symptoms or complex cognitive-behavioral syndromes 8
The Journal of the American College of Radiology recommends considering neuroimaging assessment in patients with anticoagulant use, coagulopathy, or suspected intracranial infection 7