Content of Mental Status Exam1. General Presentation.
A. Appearance-apparent age, grooming, state of health, hygiene/cleanliness, physical characteristic {build/weight, physical abnormalities, deformities, etc.), state of health, distress, pain, appropriateness of attire. pride, dignity, Note unilateral neglect of dress, description of appearance should be enough detail for identification. take into consideration the individual’s age, race, sex, educational background, cultural background, socioeconomic status, etc.
B. Motor Activity-posture {slouched, erect), gait {staggering, shuffling, rigid), coordination, speed-activity level, gestures, tremors, tics/grimacing, relaxed, restless, pacing, threatening, hyperactive or under active, disorganized, purposeful, stereotyped movements, repetitive.
C. Interpersonal-rapport with the interviewer. Engaged, interested, cooperative, opposition/resistant, submissive, defensive, fearful, note how they greet examiner.
D. Facial Expression-relaxed, tense, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful.
E. Behavior-distant, indifferent, evasive, negative, irritable, labile, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, somnolent.
2. State of Consciousness-alert, hyperalert, lethargic -reasons for lethargy often organic.
3. Speech.
A. Form-conversational, distractible, rambling, circumstantial, tangential.
B. Quantity-mute, overtalkative, can’t be interupted.
C. Rate-rapid, accelerated, pressured, slow, blocked.
D. Quality-dramatic, histrionic, sarcastic, humorous.
F. Expressive Language-normal, circumstantial, anomia, paraphasia, clanging, echolalia, incoherent, blocking, neologisms, perseveration, flight of ideas, mutism.
G. Receptive Language-normal, comprehends, abnormal.
H. Dysprodia-Flat monotone speech-no emotional expression.
4. Mood and Affect.
A. Mood-a symptom as reported by the individual describing how they feel emotionally, such as: normal, euphoric, elevated, depressed, irritable, anxious, angry.
B. Affect-observed reaction or expressions. Range of affect includes: broad, restricted, blunted, flat, inappropriate, labile, mood congruent, mood incongruent.
5. Orientation and Intellectual Ability.
A. Orientation-time, person, place, and self. The individual should be asked questions such as the day of the week, month, the date, where he lives, where he is now, if he knows who he is.
B. Intellectual Ability-above average, average, below average.
a. General information-the last four presidents, governor, the capitol, what direction does the sun rise, etc.
b. Calculation-serially subtracting 7 from 100 (at least six times). Simple multiplication word problems such as, “if a pencil costs 5 cents, how many pencils can you buy with 45 cents?”.
c. Abstract Reasoning-proverbs. This is the ability to make valid generalizations. Responses may be literal, concrete, personalized, or bizarre. Example, “Still waters run deep”, “ A rolling stone gather no moss”.
d. Opposites-slow/fast, big/small, hard/soft.
6. Attention & Concentration-.
A Concentration-Days of the week backward-serial sevens-serial threes, serial fives.
B. Attention-Non-numeric test-read series of random letters-have patient tap finger or say yes every time hear chosen letter. Numeric-string of digits forward and backward-starting with three digits. Stop when patient misses two of each. Average is 7 digits.
7. Memory-immediate (10 to 30 sec) short term (up to 1hour) recent (2 hours to 4 days) recent past (past few months) remote past (6 months to lifetime).
8. Thought Processes/Content-deals with organization and composition of thought. Examples include: normal, blocking, loose associations, confabulation, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, depersonalization, suicidal ideation, homicidal ideation.
9. Hallucination-none, auditory, visual,olfactory, gustatory.
10. Insight-good, fair, poor. Understanding, thought,feeling, behavior.
11. Impulse Control-good, fair, poor. The ability/tendency to resist or act on impulses.
*This is not exhaustive-mental status questions could go on interminably.
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