Orientation is central to the mental status exam. A person’s awareness of their surroundings, their location temporally, and their own identity is primary to general functioning. Of course, everyone occasionally loses track of the date, but when an individual that you are interviewing believes it is 1983- or that it is summer, when the coat rack in the corner is full, this is a significant finding that must be explored further. Assessment of orientation always includes person, place and time (Oriented x 3). Questions of person generally include the identity of the patient and who you are (Dr or counselor, etc.). Orientation to place may include the city, state, or town- where he lives and where he is now. For some patients, it may be appropriate to ask “what planet is this”. If they say Jupiter, then you may have an alien (or a psychotic individual) on your hands. Time orientation include day of the week, date, month, year, etc. (The interviewer may also ask about the current situation, why a person is in your office, etc. This would be oriented x 4.) As a rule, confusion about person is more significant than is confusion about time, place, or situation. If the patient says he is the boogieman and you are Jethro Tull, the patient is exhibiting significant problems (since Jethro Tull was not an individual, but the name of a group). Problems in orientation are often the result of organicity. However, some very depressed individuals may lose tack of time, by several days or even weeks. Further, there is a difference between confusion and delusion about person, place and time. Both schizophrenic and dementia patients may exhibit either delusions or confusion in their orientation.It is often important to quickly evaluate a person’s intelligence. This can be difficult (as well as unimportant) if other more acute issues are primary (prominent suicide ideation with a plan, acute psychosis, or the person is very distressed and tearful). However, in a routine MSE, intelligence is an important aspect of treatment planning.
Quick and easy intellectual capacity can be obtained through asking the person to perform some simple calculations in their head (serial 7s, multiplication word problems). It is also important to know if an individual is able to reason abstractly. Proverbs are one of the simplest and best ways of getting information about concrete versus abstract reasoning ability. The responses may be literal, concrete, personalized, or bizarre. An example of proverbs that may be used is: “still waters run deep”; “a rolling stone gathers no moss”.
Orientation and Intellectual functioning is extremely important in the hospital setting. Delirious patients will often be quite disoriented. The MSE can be used for baseline functioning and tracking of the symptom pattern. In delirium, there is often a fluctuation of consciousness throughout the day. In this case, the MSE can quite useful. Further, it can be used to narrow down medications that might be negatively or positively affecting a patient’s mental status.
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