MENTAL STATUS EXAMINATION

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Mental status examination2

Structured way of observing and describing a patient’s current state of mind

Purpose is to obtain a comprehensive cross-sectional description of the patient's mental state

When combined with the biographical and information of the history, allows for an accurate diagnosis, and hence, for treatment

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The data is collected through a combination of direct and indirect means:

• unstructured observation while obtaining the biographical and social information,

• focused questions about current symptoms, and

• formalized psychological tests

Integration of History and MSE

History MSE

Identifying data

Chief complaint

Appearance, behaviour, orientation, level of consciousness

HOPI Co-operation, speech, thought form, content

Exploration of symptoms from HOPI

Affect, Mood, suicidal ideations

Direct testing Knowledge base, cognitive functions, insight, judgment

Overview

General appearance and behaviour Attitude towards examiner Language functions Memory Orientation Abstraction Judgment General Knowledge

Mood and affect Speech Thought form, thought content, thought

stream Perception Insight

Consciousness-7

State of awareness of self and environment

Intensity of stimulation needed to arouse the patient and duration of time patient can maintain attention

5 levels of consciousness on a continuum-alert, clouding, obtundation, stupor, coma

Alertness: awake, fully aware of normal stimuli, capable of meaningful interaction with examiner.

Clouding/Lethargy: not fully alert, drifts off to sleep when not stimulated, cannot pay close attention to examiner, loses train of thought, valid MSE difficult

Obtundation: transitional state, difficult to arouse and when aroused is confusional (quiet delirium), constant stimulation for marginal co-operation, meaningful MSE not possible.

Stupor: respond to vigorous and persistent stimulation, does not rouse but when aroused groans/mumbles/moves restlessly. Indicative of extensive brain dysfunction; no MSE.

Coma: un-arousable, no evidence of behavioural response to stimulation. Deep coma/light coma (reflex actions).

Glasgow coma scale – eye opening, verbal and motor response (Teasedale and Jennett,1974)

–Numeric score for actual level.

–Three response categories: eye opening, verbal, motor.

–Does not take into account level of stimulation.

Score from 3 to 15, with 3 being the most severe head injury and 15 being the least severe head injury.

Rapport12

Spontaneous feeling of harmonious responsiveness that promotes development of a constructive therapeutic alliance.

Implies an understanding and trust between the doctor and the patient

How do you establish rapport???

1. General appearance13

Appearance and appropriateness to situation

AttireHygiene and groomingBody typePhysical abnormalitiesJewelry and cosmetic use

Handedness

Eye contact (fleeting, unwavering)

Facial expression and posture

Manner of relating (relaxed, tense, guarded)

Attitude towards examiner (co-operative, seductive, over-familiar, suspicious, guarded)

2. Motor behavior15

Rate or speed (over-activity, fidgety, restless, retardation)

Purposive and goal directedness (mannerisms, stereotypies)

Response to external stimuli

Involuntary movements (tics) and catatonic features

Attention-16

Patients ability to attend to a specific stimulus without being distracted by internal or external stimuli

Evaluation- Digit span test- digit forward and

backward 5-7 digits is normal

Concentration-17

Is the ability to maintain attention to a specific stimulus over an extended period

Evaluation- Serial subtraction tests- 100-7, 40-3,

20-1 Month and days of the week

backwards

Language functions-18

Phonation

Articulation (slurring, mumbling, unclear)

Fluency- ability to produce spontaneous speech - animal naming test, words beginning with a letter

Comprehension- pointing commands, yes or no questions

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Repetition- sentences with 19 syllables

Naming- body parts, objects, colors

Reading- reading comprehension and reading aloud; education

Writing

Prosody- tonal intonations

Orientation-20

Time (time of the day, day of the week, date, month, year, season)

Place (hospital/clinic, town, state, country) Person (identity of the person, family members,

friends, hospital staff) Sense of passage of time

Sequence of loss of orientation: Time > place>person

Memory-

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Recent- Address test

Object test

Recall of events

Remote- personal and impersonal events

Topographic memory

Memory of skills

Abstract ability-22

Abstract thinking is the ability to grasp the essentials of a whole, to break it into parts, and to discern common properties

Tests- Proverb interpretation

Test of similarity and dissimilarity

Concrete, semi-abstract, abstract

Judgment-23

Ability to assess situation correctly and act appropriately with in that situation

Test judgment- response in test situation

Social- history and observation

Personal- about present and future

General Information and Calculation

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General information- Based on educational, social background

Calculation- Verbal and written- 1 or 2 step problem

Intelligence25

Capacity to solve problems, cope with new situations, acquire skills through learning and experiences, establish logical deductions, and to form abstract concepts

Next Class…

Thought o Streamo Formo Possessiono Content

Mood and Affect

Perception

Other psychotic phenomena

Insight