What data are recorded in the treatment plan regarding the workup following a history and Mental Status Examination (MSE)?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Note the following:

  • Routine lab studies - Sequential multiple analysis, CBC count with differential, urinalysis, urine drug screen, thyroid-stimulating hormone and thyroid function test, urine pregnancy test, rapid plasma reagent, and HIV test if indicated

  • Other laboratory tests based on interview and other examinations - Vitamin B-12/folate levels; medication levels, including lithium, imipramine, and digoxin; prothrombin time, activated partial thromboplastin time, and International Normalized Ratio; amylase, lipase, sedimentation rate, luteinizing hormone, follicle-stimulating hormone, hepatitis panel, and copper level

  • Imaging studies - CT scan, MRI, other imaging studies based on interview (eg, positron emission tomography scan, ultrasound)

  • Other tests - Electroencephalogram, ECG

  • Procedures - Dexamethasone-suppression test, catecholamine level, lumbar puncture, Amytal interview, hyperventilation, sodium lactate infusion

  • Histologic findings - Based on final diagnosis (eg, Alzheimer disease amyloid plagues)

  • Staging - Based on final diagnosis

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