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MENTAL STATUS EXAM - Coggle Diagram
MENTAL STATUS EXAM
Appearance
What do you see? How is the patient dressed? What about the patient's grooming, hygiene, and body language? Often the first things you notice about a patient are significant.
• Build, posture, dress, grooming, prominent physical abnormalities
• Level of alertness: Somnolent, alert
• Emotional facial expression
• Attitude toward the examiner: Cooperative, uncooperative
Attitude
Observation on client that is reflected to his behavior. Possible descriptors: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive.
LOC
A a measurement of a person's arousability and responsiveness to stimuli from the environment.
Orientation
Orientation: There are four general elements to orientation: person; place; time; and situation. Orientation to person is simply the ability to identify one's name and is the last element of orientation to be lost, usually only in very severe dementia or in psychotic states.
Thought Content
• Refers to the themes that occupy the patients thoughts and perceptual disturbances
• Examples include preoccupations, illusions, ideas of reference, hallucinations, derealization, depersonalization, delusions
Suicidality
can be described as a fatal act of self-harm initiated with the intention of ending one's own life. Intent refers to whether the patient is simply thinking about or even wishing her own death or has an intent to actively do something to bring it about. This is also a judgment call; you aren't responsible for reading the patient's mind, but you are responsible for asking and documenting the patient's response.
Homicidality
The only element unique to homicidal ideation is target: you have a medicolegal obligation to report and protect any intended victim of assault or homicide. If a patient tells you he is thinking of killing his wife, he cannot leave the emergency room until he either reassures you that he has no intent or plan or until you have called her and made every reasonable step (including commitment or incarceration) to prevent him from harming her.
Insight & Judgement
• Insight: awareness of one’s own illness and/or situation
• Judgment: the ability to anticipate the consequences of one’s behavior and make decisions to safeguard your well being and that of others
Attention
Sufficient, deficient, easily distractible, short span of attention, poor or adequate concentration, preoccupation. Serial 7s test. Months of year backwards
Memory
Memory: Short term memory is assessed by listing three objects, asking the patient to repeat them to you to insure that they were heard correctly, and then checking recall at 5 minutes. Long term memory can be evaluated by asking about the patients job history, where they were born and raised, family history, etc.
Intellectual
a description of level of intelligence and of recent and remote memory functions. This is Inquired or observed: Information and vocabulary, abstraction (using similarities and proverbs)
Behavior
• Eye contact: ex. poor, good, piercing
• Psychomotor activity: ex. retardation or agitation i.e.. hand wringing
• Movements: tremor, abnormal movements i.e.. sterotypies, gait
Mood
The prevalent emotional state the patient tells you they feel
• Often placed in quotes since it is what the patient tells you
• Examples “Fantastic, elated, depressed, anxious, sad, angry, irritable, good”
Affect
The emotional state we observe
• Type: euthymic (normal mood), dysphoric (depressed, irritable, angry),
euphoric (elevated, elated) anxious
• Range: full (normal) vs. restricted, blunted or flat, labile
• Congruency: does it match the mood- (mood congruent vs. mood incongruent)
• Stability: stable vs. labile
Speech & Language
• Rate: increased/pressured, decreased/monosyllabic, latency
• Rhythm: articulation, prosody, dysarthria, monotone, slurred
• Volume: loud, soft, mute
• Content: fluent, loquacious, paucity, impoverished
Thought Process
• Describes the rate of thoughts, how they flow and are connected.
• Normal: tight, logical and linear, coherent and goal directed
• Abnormal: associations are not clear, organized, coherent.
Examples include circumstantial, tangential, loose, flight of ideas,
word salad, clanging, thought blocking.