The Formal Mental Status Examination

The Formal Mental Status Examination

Category

Sample Observations

AppearanceElderly, agitated, disheveled, muscular, well-dressed

BehaviorPolite, cooperative, avoids direct eye contact, restless, moves slowly and rigidly,

Level of consciousnessAlert, drowsy, unresponsive to loud noises or painful stimuli

AttentionReadily distracted, neglects right side, concentrates successfully on serial tasks

Speech and languageRapid, hesitant, incoherent, garbled, uses nonsense words, mute

MoodSad, anxious, agitated, euphoric

AffectDemonstrates wide range or appropriate affect, including anger, sadness, crying, laughter

OrientationKnows person, place, date

MemoryRecalls recent and remote events

Thought contentSuicidal ideas, preoccupied with loss of job, says commentator on TV is talking about him

Thought processesLogical, loose associations, unclear reasoning, sluggish

InsightHas little appreciation of whats wrong, saying he has a liver condition that will improve soon without treatment

JudgmentSays If I reject dialysis, Ill probably die in a few weeks.

Higher cognitive functioningBright, dull

Fund of knowledgeKnows last five presidents, describes recent events in Nicaragua

CalculationSerial subtraction of 7s: 100, 93, 86, 79, 72

AssessmentOverall impression is that his depression and suicidality have resolved, and that he currently shows moderate sadness but an otherwise normal range of affect and no significant cognitive deficits or disorders of sleep, appetite, or energy

Appearance and Behavior-How old does the patient appear to be? Does the patient appear much younger or older than his or her actual age?

-General health

-Cleanliness and self-care (shaven, use of makeup, condition of hair and nails)

-Dress: Care in dressing (neatness, cleanliness vs. disheveled, dirty, stained, neglecting one side of the body). Type of clothing (appropriateness to social setting and season; highly stylized, eccentric, muted)

-Facial expression (tense vs. relaxed, blank, fixed, smiling, staring)

-Posture (erect, slumped, bizarre stance)

-Motor activity: Amount and character (overactive, restless, fidgety, frenzied; motionless, underactive, slow). Abnormal movements (rigid, tremulous, repetitive movements mannerisms, posturing)-Attitude and cooperation (friendly, interested, flirtatious, belligerent,, combative, preoccupied, restless, withdrawn, suspicious)

-Eye contact-response to environment and appropriateness of behaviour (talking to self, becoming hostile when certain subjects are broached, startles when phone rings)Level of consciousnessPerformance of the entire history and portions of the physical examination, including most of the mental status examination, presupposes that the patient has a fair normal level of consciousness ( i.e. the patient is alert rather than lethargic, somnolent, stuporous, or comatose) and exhibits normal arousability (responds to usual speech rather than requiring special maneuvers to gain and maintain attention). The patients attention, concentration, and cooperation are also required. Significant disturbances in these functions would normally be mentioned at the beginning of the history under reliability.-Level of consciousness (alert, drowsy, stuporous, hypervigilant). Rather than using vague labels (e.g. semicomatose) for patients with depressed consciousness, describe the patients response verbal and physical to verbal, visual, and tactile (including, at times, painful) stimuli (e.g., No response to commands, calling his name, or being touched firmly, but moves all four extremities when shaken or pinched)

-Attention is the ability to focus on specific stimuli and screen out irrelevant stimuli, rather than being distracted or attending only to one portion of the body. Apprehensive patients will often have trouble attending to complex tasks, although they have no cognitive deficit when more relaxed

-Concentration (ability to persist with tasks vs. distractibility in many tests in the mental status examination).

Speech and LanguageSpontaneous speech and conversation during the history can be characterized as follows:

-Quality or quantity, including fluency, clarity, speed (e.g., slurred, garbled, stuttering, slowed, rapid, pressured)

-Content and organization: coherence, logic, relevance, redundancy, precision, spontaneity, disordered syntax, loose associations, circumstantial, evasive, perseverating, periods of prolonged silence or seeming distraction

Mood and Affect (Emotional State)The term mood is used to describe a prevailing emotional tine; the term affect refers to moment-to-moment expression of emotion and the range of observable emotion. Mood and affect have qualities such as range, intensity, changeability, and appropriateness. Mood and affect have qualities such as range, intensity, changeability, and appropriateness. A common and important clinical finding is discordance between patients stated feelings and their nonverbal communication.

Both inquiry and observation are used to examine mood and affect. Pay attention to the four basic affective states: sadness 9indlucing grief and depression), happiness (including elation and mania), anxiety (including panic), and anger.

See the following questions about mood and affect:

-How is your spirits/mood? In general/this moment?

-How are you feeling about the way your life is going/will be going in your future/in the nearest future?

-Have you had any change of feelings come over you?

-Are you nervours/anxious/irritable/frightenend?

-Are there specific situations that make you feel panicked?

-Are you afraid of crowded places/going alone?

-Have you been angry/ out of control?

-Have you been sad?

-Have you felt like crying?

-Have you cried a lot?

-Have you felt discouraged?

-Have you felt like you cannot go on?

-Have you ever thought that life is not worth living?

-What do you do for fun?

-Have you been able to enjoy yourself?

-How is your energy/ambition?

-Are you able to concentrate/to think clearly?

-Has your memory changed?

-How is your sleep/appetite/sexual drive?

-How do these feelings affect your?

Patients may describe themselves or appear in some of the following ways: sad, depressed, lacking energy, apathetic, unable to enjoy life, energetic, happy, euphoric, irritable, angry, furious, anxious, fearful, panicked, or feeling fine ( perhaps despite events that would lead one to expect differently.

The observer may note the following: the affect and its quality and appropriateness, the ability of the patient to describe this emotional life, such behaviors as retardation, agitation, lability, irritability, suspiciousness, defensiveness, impulsiveness, the communication of quilt, shame, worry, self-deprecation, or suspiciousness; and how the patient affects the examiner (e.g., producing fright, boredom, sadness, hopelessness, or anxiety).Orientation and MemoryNow I would like to ask you some routine questions to test your memory. Some of these questions may seem a little sill, but being sick can affect our ability to think clearly, and its important that I check you.-Let me first ask you some simple questions. Do you know todays date?

-What day did you get admitted?

-Can you give me your address and phone number?

The most frequently employed formal tests of the mental status involve examination for the ability to identify person (patients name, age, and birth, date, or the name and occupation or function of the examiner or another familiar person), place (the name of the institution or type of building the patient is in and where it is located), and time (date, day of week, hour and season).

Person

-What is my name/occupation?

-You know who I am, dont you?

Place

-Where are we right now?

-What is the name of this place?

-What kind of place is this?

-What city are we in? What state?

-How long have you been here?

-Have you been here long?

Time

-What is todays date/year, month, date?

-What day of the week is it?

-About what time is it?

-What season of the year is it now?

-What year is it this year? Do you know that?

-Do you remember what day of the week it is?

Memory-Long term, or remote, memory is tested by obtaining either verifiable personal information or widely know historical facts.Birth date, address, phone number, names and birthdays of children or relatives.

Name the last four Presidents of (country) or describe major historical events

-Recent memory is tested by inquiring about orientation or asking the patient to recall verifiable events of the past few days

-How long have you been in hospital?

-Who is the doctor here?

-Did you get any test today? What tests were done yesterday?

-Can you recall any recent news?

-Do you remember when you were born?

-What month were you born in?

-Do you remember what time of the month? What was the date?

-Immediate recall (sometimes called registration, short-term memory, or immediate retention) is tested by digit or phrase repletion, and overlaps with attention.

Thought Content and ProcessThe content of thought includes major concerns (worries, conflicts, interests, feelings of inadequacy, longings, ambition, somatic preoccupations), obsessions, phobias, perseverations, strange experiences, suicidal or homicidal ideation, and various distortions of perception such as disturbances in the sense of self (depersonalization, derealization) or of the control of thinking.Questions about thought content and process:DelusionsDelusions are fixed, false beliefs that are not in keeping with the patients culture and that often contain misinterpretations or a finding of special meaning in events (e.g., a sense of being singled out or being paid special attention, or of being persecuted or influenced).

-Have you felt that people have been taking special notice of you?

-have you noticed that the television or newspapers have had messages especially for you?

-Have other people been able to control your thoughts or read your mind?

HallucinationsHallucinations are false sensory impressions, either auditory, gustatory, olfactory, or tactile.

-Have you heard voices?

-Have you heard your thoughts out loud, as if they were spoken?

-Have you seen anything unusual, perhaps things that do not really exist?

IllusionsIllusions are misinterpretations of real experiences (e.g., a delirious patient thinks the doctor in the white coat is an ice cream vendor).

Bizarre, paranoid, or grandiose thinking

-Are there thoughts that continually run through your mind/frighten you?

-Do you ever have a feeling that people are talking about your or watching you?

Homicidality and suicidality-Have you had thoughts about harming others/yourself/about taking life?

-Have you ever considered suicide in the past?

-Have you attempted suicide? If yes, tell me more.

-How serious are you?

-How would you do it?

-Do you have any plans for doing it?

-Do you have the means (pills, gun other) to hurt yourself?

-Could you stop yourself?

-What keeps you from doing it?

-Would you be able to call for help before you did anything serious?

-Sometimes people who are upset (or very ill) have unusual (or frightening) thoughts. Has this happened to you?

-have you heard or seen things that turned out not to really be there or that others could not hear or see?

Insight and JudgmentThe term insight refers to the patients ability to understand that he or she is suffering from an illness.-Why are you here today? Did you want to come?

-Do you think anything is wrong with your? Why?

-Do you have a physical illness?

-Do you have trouble with your thinking/emotions?

-Have you changed?

-What do the doctors (or family, or others) make of it?

-What do the tests show?

-Do you believe you are thinking clearly?

-Do you think you need any help? What kind?

-Do you think you will get better?

-What are your plans for the future?

Judgment is best described in medicolegal terms: Does the patient appreciate the consequences of various actions? For example, what if treatment were foregone?-Is the patient able to reason about actions and their consequences?

-Does the patient act impulsively?

-Would the patient act on the basis of delusional beliefs or hallucinatory perceptions/ on wishful thinking?

-What is his or her capacity for homicidal or suicidal behavior?

-What is the basis for the patients reasoning? Is such judgment appropriate to the patients age and cultural background?

Higher Cognitive FunctionFund of Knowledge

Calculation

Cognitive or intellectual function may be conceptualized as involving either basic levels, such as consciousness, attention, concentration, orientation, and memory (and, in some schemes, language and thought) or higher functions, such as fund of information, calculations, and abstraction 9 and, in some schemes, insight and judgment). Tests of visual perception and constructional ability may also be included under higher cognitive function or higher intellectual function.

For patients with intact basic cognitive abilities, you should learn to characterize the higher- level functions, especially fund of information and calculation. Tests of such higher intellectual functions can also be used to screen for defects of basic cognitive function, since, for instance, calculations are dependent of attention as well as arithmetic ability.

You need to inquire about the patients level of education, type of employment, and cultural background in order to estimate his or her optimal level of cognitive functioning.

-How are you at figures?

-How would you do in subtracting 7 from 100? Try it?-Simple addition, subtraction, multiplication: What would you get in change if you bought a 15- ruble juice with a fifty ruble bill?

-In order to test your concentration, I would like to ask you to try the following: Repeat this number, 1 6 7 4 3 Thats fine. Now lets try a longer number.

-You moved to (the domicile) in 1986. So about how many years have you been living there?

-Who is the President? Who was President before him?

-Do you recall any recent important news?

-What have you read in the paper or heard on the news?

-Do you know anything about what is going on in the United States, for example?

-Name four large cities in Russia.

-Why are these people famous? (name some famous people)

-What is the similarity between a plum and a peach/a plane and a boat?

-Red and blue are colors. A chair and a table are both what?

Proverb interpretation:

-Tell me what people mean when they say:

-People in glass houses should not throw stones.-Dont cry over spilled milk.

-A rolling stone gathers no moss.

-Write your name/draw a clock with the correct time/ copy this figure (give a person a picture with a figure)