1.-Mental-Status-Examination Guide for Students

MSE

1. Mental Status Examination
(Bates, Chapter 5, page 158)

Components
• Appearance & Behavior
• Speech & Language
• Mood
• Thoughts & Perception
• Cognition (Memory, Attention, Information and Vocabulary, Calculations, Abstract Thinking, and Constructional ability)

The format that follows should help structure your observations, but is not intended as a step-by-step guide. Be flexible, but thorough. In some situations, however, sequence is important. If the
patient’s consciousness, attention, comprehension of words, and ability to speak are impaired, assess these deficits promptly. If the patient cannot give a reliable history, testing most of the
other mental functions will be difficult and merits an evaluation for acute causes.

Component of MSE What to observe Task of Examiner Task of Patient Possible Result
Appearance and Behavior
• Level of
Consciousness












• Is patient alert and
awake
• Does he understand
questions and can
respond










Ask questions.


If the patient does not respond to
questions,
- Speak to the patient by name
and in loud voice
- Shake the patient gently,
wakening a sleeper

If still no response, assess for stupor or
coma.

- Observe patient’s posture and
ability to relax and movement.
Answer questions of
examiner.













N: Awake and alert, response is appropriate and
reasonably quick.
A: Appears sleepy. Unable to respond to the
questions. Lethargic, Obtunded.

2. • Posture and Motor
Behavior















• Dress, Grooming, and
Personal Hygiene















- The patient’s posture
and ability to relax.
Note the pace, range,
and type of movement.













- How the patient is
dressed
- grooming of the
patient’s hair, nails,
teeth, skin, and, if
present, beard.
- Compare one side of
the body with the
other.

























- Observe dress, grooming and
personal hygiene















- none
















- none
















N: Good posture and able to relax. Movements
are voluntary and spontaneous.
A: tense posture, restlessness,
and anxious fidgeting; the crying,
pacing, and hand-wringing of agitated
depression; the hopeless
slumped posture and slowed movements
of depression; the agitated
and expansive movements of a
manic episode.









N: Appropriately dressed. Clean clothing and
presentable. Groomed hair, nails and teeth.
A: Grooming and personal hygiene
may deteriorate in depression,
schizophrenia, and dementia. Excessive
fastidiousness may be seen in
obsessive–compulsive disorder. Onesided
neglect may result from a
lesion in the opposite parietal cortex,
usually the nondominant side.

3. • Facial Expression





• Manner, Affect, and
Relationship to
People and Things
- Observe the face both
at rest and
during conversation.



- Assess the patient’s
affect, or external
expression of the inner
emotional state.
- Observe the patient’s
openness,
approachability, and
reactions to others and
the surroundings.
Watch for changes in expression.
Is expression appropriate for topics
discussed? Is face immobile throughout?


Is affect appropriate to the topics being
discussed?
is the affect labile, blunted, or
flat? Does it seem exaggerated at certain
points?
Does the patient hear or see things not
present, or converse with someone who
is not there?




- none





- none

N: Facial expression is appropriate for topics
Note expressions of anxiety, depression,
apathy, anger, elation, or facial
immobility in parkinsonism.



N: Affect is appropriate to topics discussed.
A: Labile, blunted, flat, exaggerated. Patient hears
or sees things not present.
Speech and Language
• Quantity






• Rate
• Volume
• Articulation of
Words






Observe for patient’s speech
and language. Is the patient
talkative or unusually silent?
Are comments spontaneous, or
limited to direct questions?


Is speech fast or slow?
Is speech loud or soft?
Are the words clear and
distinct? Does the speech
have a nasal quality?






















N: normal rate, volume and clear articulation of
words.




Note the slow speech of depression; the
accelerated louder speech of mania.
Dysarthria refers to defective articulation.
Aphasia is a disorder of language.
Dysphonia results from impaired volume,
quality, or pitch of the voice

4. • Fluency



Rate, flow, and melody of
speech and the content
and use of words.






Watch for abnormalities of spontaneous
speech such as:
■ Hesitancies and gaps in the flow and
rhythm of words
■ Disturbed inflections, such as a
monotone
■ Circumlocutions, in which phrases or
sentences are substituted for a word
the person cannot think of, such as
“what you write with” for “pen”
■ Paraphasias, in which words are
malformed (“I write with a den”), wrong
(“I write with a bar”), or invented (“I
write with a dar”).




These abnormalities suggest aphasia
from cerebrovascular infarction.
Aphasia may be receptive (impaired
comprehension with fluent speech) or
expressive (with preserved comprehension
and slow nonfluent speech).
MOOD Ask the patient to describe his or her
mood, including usual mood level and
fluctuations related to life events.

“How did you feel about that?” for
example,
or, more generally, “How is your overall
mood?” The reports from family and
friends may be of value.
Moods range from sadness and melancholy;
contentment, joy, euphoria, and
elation; anger and rage; anxiety and
worry; to detachment and indifference.
THOUGHT AND
PERCEPTIONS
• Thought Processes







Assess the logic, relevance,
organization, and coherence
of the patient’s thought
processes throughout the
interview



Ask patient that can be answered easily.
“What can you say about being
hospitalized right now?”


“You mentioned that










A: Circumstantiality, derailment, flight of ideas,
neologisms, blocking, confabulation,
perseveration, echolalla and clanging

Compulsions, obsessions, phobias,
and anxieties often occur in anxiety

5. • Thought Content













• Perceptions












• Insight






assess thought content, follow
the patient’s leads
and cues rather than asking
direct questions.























Some of your first questions to
the patient often yield
important
information about insight:
“What brings you to the
hospital?” “What seems to
a neighbor caused your entire illness.
Can you tell me more about that?”

“What do you think about at times like
these?”
“When people are upset like this,
sometimes they can’t keep certain
thoughts out of their minds,” or “ . . .
things
seem unreal. Have you experienced
anything like this?”


“When you heard the
voice speaking to you, what did it say?
How did it make you feel?”

“Sometimes after major surgery like
yours, people hear peculiar or
frightening
things. Has anything like this happened
to you?”




















disorders.















A: Hallucination, Illusions














Patients with psychotic disorders
often lack insight into their illness.
Denial of impairment may accompany
some neurologic disorders.

6. • Judgment
be the trouble?” “What do you
think is wrong?” Note whether
the patient is
aware that a particular mood,
thought, or perception is
abnormal or part of an
illness.


Assess judgment by noting the
patient’s responses to family
situations, jobs, use of money,
and interpersonal conflicts.

Note whether decisions and
actions are based on reality or
impulse, wish fulfillment,
or disordered thought content.
What insights and values seem
to underlie
the patient’s decisions and
behavior? Allowing for cultural
variations, how do
these compare with a
comparable mature adult?
Because judgment reflects
maturity,
it may be variable and
unpredictable during
adolescence.








“How do you plan
to get help after leaving the hospital?”
“How are you going to manage if you
lose your job?”
“If your husband starts to abuse you
again, what will you do?”
“Who will take care of your financial
affairs while you are in the nursing
home?”










Judgment may be poor in delirium,
dementia, intellectual disability, and
psychotic states. Anxiety, mood disorders,
intelligence, education, income,
and cultural values also influence
judgment.












COGNITIVE FUNCTIONS
• Orientation


assess orientation during the
interview.

Ask the ff:




Disorientation is common when
memory or attention is impaired,
as in delirium.

7. • Attention

































Test of attention
Explain that you would like to
test the patient’s ability to
concentrate,
perhaps adding that this can be
difficult if the patient is in pain
or ill.

















■Person—the patient’s name, and
names of relatives and professional
personnel
■ Time—the time of day, day of the
week, month, season, date and year,
duration
of hospitalization
■ Place—the patient’s residence, the
names of the hospital, city, and state


Digit Span
Recite a series of numbers, ask the
patient to repeat the numbers back to
you.

When choosing digits, use street
numbers, zip codes, telephone numbers,
and
other numerical sequences that are
familiar to you, but avoid consecutive

Serial 7s
Instruct the patient, “Starting from a
hundred, subtract 7, and
keep subtracting 7.
Note the effort required and the speed
and accuracy of
the responses.

Spelling Backward
This can substitute for serial 7s. Say a
five-letter










Digit Span
- Recite the numbers
back to examiner


























Causes of poor performance include
delirium, dementia, intellectual disability,
and performance anxiety.











Poor performance may result from
delirium, the late stage of dementia,
intellectual disability, anxiety, or
depression. Also consider educational
level.

8. • Remote Memory





• Recent Memory







• New Learning Ability








Higher Cognitive Functions
• Information and
Vocabulary































Note the person’s grasp of
information, complexity of the
ideas, and choice of
vocabulary.
word, spell it, for example, W-O-R-L-D,
and ask the patient to spell it backward.

Inquire about birthdays, anniversaries,
social security
number, names of schools attended, jobs
held, or past historical events such as
wars relevant to the patient’s past.

Events of the day. Ask meal for breakfast







Give the patient three or four words such
as “83,
Water Street, and blue,” or “table,
flower, green, and hamburger.” Ask the
patient to
repeat them so that you know that the
information has been heard and
registered.

Begin assessing fund of
knowledge and vocabulary during the
interview. Ask about work, hobbies,
reading, favorite television programs, or
current events. Start with simple
questions, then move to more difficult
questions.




Remote memory may be impaired in
the late stage of dementia.





Recent memory is impaired in dementia
and delirium. Amnestic disorders
impair memory or new learning ability
and reduce social or occupational
functioning, but lack the global features
of delirium or dementia. Anxiety,
depression, and intellectual disability
may also impair recent memory.


N: pt can remember words








Information and vocabulary are relatively
unaffected by psychiatric disorders
except in severe cases. Testing
helps distinguish adults with life-long
intellectual impairment (whose information
and vocabulary are limited)
from those with mild or moderate
dementia (whose information and
vocabulary are fairly well preserved).

9. • Calculating Ability









• Abstract thinking















■ The name of the president, vice
president, or governor
■ The names of the last four or five
presidents
■ The names of five large cities in the
country


Test the patient’s ability to do
arithmetical calculations,
starting with simple addition and
multiplication

(“What is 4 + 3? . . . 8 + 7?”)
(“What is 5  6? . . . 9  7?”)



Test the capacity to think abstractly in
two ways.

Proverbs. Ask the patient what it means

“A rolling stone gathers no moss.”

Note the relevance of the answers and
their degree of concreteness or
abstractness.
For example, “You should sew a rip
before it gets bigger” is concrete,
whereas “Prompt attention to a problem
prevents trouble” is abstract.











Poor performance suggests dementia
or aphasia, but should be measured
against the patient’s fund of knowledge
and education.







Average
patients should give abstract or semiabstract
responses.

Concrete responses are common in
people with intellectual disability,
delirium, or dementia, but may also
reflect limited education. Patients
with schizophrenia may respond
concretely or with personal and
bizarre interpretations.

10. • Constructional
Ability
Similarities. Ask the patient to tell you
how the following are alike:

An orange and an apple
A church and a theater
A cat and a mouse
A piano and a violin

Note the accuracy and relevance of the
answers and their degree of
concreteness
or abstractness. For example, “A cat and
a mouse are both animals” is abstract,
“They both have tails” is concrete, and
“A cat chases a mouse” is not relevant.

copy figures of increasing
complexity onto a piece of blank unlined
paper. Show each figure one at a time
and ask the patient to copy it as well as
possible


























With intact vision and motor ability,
poor constructional ability suggests
dementia or parietal lobe damage.
Intellectual disability can also impair
performance.