American family physician
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The mental status examination relies on the physician's clinical judgment for observation and interpretation. When concerns about a patient's cognitive functioning arise in a clinical encounter, further evaluation is indicated. This can include evaluation of a targeted cognitive domain or the use of a brief cognitive screening tool that evaluates multiple domains. ⋯ Louis University Mental Status Examination, can be used; the tools vary in sensitivity and specificity for detecting mild cognitive impairment and dementia. There is emerging evidence for the validity of cognitive screening performed during telemedicine visits, but it should not replace in-person evaluation of patients who have comorbidities that would preclude reliable testing via telephone or video. The workup after abnormal results of a mental status examination or cognitive screening tool is based on clinical judgment and primarily focuses on ruling out reversible causes of impairment and considering the need for further neuropsychiatric evaluation.
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Acute coronary syndrome (ACS) is defined as reduced blood flow to the coronary myocardium manifesting as ST-segment elevation myocardial infarction or non-ST-segment elevation ACS, which includes unstable angina and non-ST-segment elevation myocardial infarction. Common risk factors include being at least 65 years of age or a current smoker or having hypertension, diabetes mellitus, hyperlipidemia, a body mass index greater than 25 kg per m2, or a family history of premature coronary artery disease. Symptoms most predictive of ACS include chest discomfort that is substernal or spreading to the arms or jaw. ⋯ Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization. Other important management considerations include initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy. Additional interventions shown to reduce mortality in patients who have had a recent myocardial infarction include smoking cessation, annual influenza vaccination, and cardiac rehabilitation.