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Physical Examinations IV

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Mental Status Examination

Overview

Source: Carmen Black, Matthew Goldenberg, and Jaideep Talwalkar; Yale School of Medicine

The mental status exam is a clinical evaluation of emotional, perceptual, and cognitive functioning that spans both the fields of psychiatry and neurology. Developing skill in the psychiatric portions of the examination are important to describe salient aspects of the patient's mental state that may be observed during routine history and/or physical exam. Proficiency in the cognitive portions of this evaluation is vital while caring for patients with suspected cognitive impairment from illnesses like dementia, delirium, and substance intoxication. This video will teach students how to assess both cognitive and psychiatric portions of this examination, including behavior, speech, mood, affect, thought process and content, perception, attention, orientation, registration, and executive function.

The mental status exam is unique in that a variety of non-clinical factors may differentially impact how a patient performs while undergoing this exam in English. Furthermore, the mental status examination differs from other forms of physical examination as it requires a combination of directed questions and passive observation. Due to its reliance upon clinicians' perception and passive observation of diverse patient populations, proper execution and cultural validity of the exam are facilitated by an awareness of how several sociocultural factors may differentially impact patient presentation and clinician interpretation. Additionally, examiners often rely upon tests of verbal fluency and math skills to evaluate cognitive function. However, it is important for examiners to be sensitive to the needs of the patients with a wide diversity of languages and education levels. Therefore, this video will also address how to equitably administer the examination for patients from various socioeconomic, educational, and cultural backgrounds.

Procedure

1. Appearance and Behaviour

  1. Attire, grooming, hygiene— Make observations about the patient's attire. For example, are the patient's clothes well-suited for the weather? Are clothes disheveled? Is there evidence of soiling (e.g., layers of old dirt on skin or body odor suggesting inadequate bathing)? Responses may range from well-groomed to disheveled, good to fair to poor hygiene, and appropriate or inappropriate attire.
  2. Nourishment— Note whether the patient appears well-nourished or malnourished. Signs of malnourishment include muscle wasting in small (temporal, hands) and large (buttocks, quadriceps) muscle groups, loss of subcutaneous fat, sores at the edges of the lips, sunken eyes, and a variety of other features.
  3. Also, note any remarkable aspects of their physical appearance, like dysmorphia, wounds or marks, or scars. Many of these details should be observed passively while conducting various other aspects of the physical exam.
  4. Special Considerations— It is important to remain mindful that patients from various backgrounds may wear attire that differs from our own, but that would still be considered appropriate and well-groomed.
  5. Motor activity— Assess whether the patient appears relaxed, restless (e.g., tapping their leg, fidgeting with hands, pacing the room), or somewhere in between. 
  6. Interpersonal behavior:
    1. Eye contact— Take note of how frequently the patient is making eye contact with you throughout the assessment. Responses include good, fair, and poor eye contact.
    2. Attitude— Observe how the patient relates to the examiner throughout the encounter. Some patients may be engaging, while others may be shy and reserved. Others may be dismissive, irritable, or angry. Some patients may also be uncooperative towards the interview/exam.  
  7. Special Considerations— Patients may demonstrate culturally-normative differences in how they relate to medical providers. For example, patients with past experiences of healthcare discrimination or from cultures where direct eye contact is not the norm, maybe more reserved or make less eye contact during clinical encounters. This should still be observed by the clinician but would not be considered pathological.   

2. Speech

  1. Volume— Take note of the volume of the patient's voice throughout the encounter. Assess whether it is normal, loud, or soft.
  2. Rate— Take note of the speed at which the patient is talking. Observations range between slow, normal, rapid  (which is faster than normal but still possesses natural pauses), and pressured speech (which is characterized by speaking that is nearly nonstop and difficult to interrupt due to lack of natural pauses).
  3. Rhythm— Gauge the fluency of a patient's speech: does it flow freely or not? Patients are said to demonstrate speech latency if there is a significant delay in initiating speech. Patients may stutter or have other dysrhythmias. 
  4. Tone— Does the patient's tone of speech demonstrate normal inflection or monotony?
  5. Articulation— Take note of whether the patient's speech is clear or not. Dysarthria, also known as slurred speech, occurs when a patient has motor difficulty articulating speech because of a functional abnormality that causes muscle weakness or paralysis, like a stroke or prior injury.
  6. Special Considerations: Substance intoxication is a common cause of slurred speech. Use the context and other clues throughout the clinical exam to determine if a patient's slurred speech might be a result of substance intoxication. For example, emergency room visits might have a urine drug screen available for review.
  7. When interviewing patients who are non-native speakers of English, it is important to appreciate that the patient's mechanics of speech (for example, rate, rhythm, articulation) may be due to their late English language acquisition, and findings should not necessarily be interpreted as pathologic. 

3. Mood and Affect

  1. Mood refers to the emotional state that a patient specifies during an examination. Many patients spontaneously reveal their emotional state via relationship-centered medical interviewing, such as Smith's patient-centered interviewing method.
  2. If you have not been able to gauge how the patient is feeling through conversation, simply ask, "How are you feeling today?" Common responses include "fine" or "good" (often referred to as euthymic), depressed, angry, or anxious. It is acceptable to directly quote how a patient responds to this question, if desired.
  3. Affect refers to the emotional state that examiners infer based upon observing a patient's appearance, behavior, and manner of engagement. Patients may appear dysphoric, euthymic, anxious, irritable, scared, or more.
  4. Congruence of affect is when a patient's observed affect matches what they say their mood is, such as a patient expressing that they feel worried and visibly appear anxious. 
  5. An incongruent affect might also be notable. For example, if a patient is smiling while talking about how depressed he is. 
  6. Appropriateness of affect is when a patient's observed affect matches the situational content they are describing. For example, a patient who is smiling and laughing while describing a funeral would be said to have an inappropriate affect. 
  7. Appropriateness may be distinguished from the congruence of affect. Imagine a patient who reports feeling "good" and is physically smiling and laughing while describing a tragic event. This patient demonstrates congruence of affect given that their reported "good" mood matches their smiles and laughs. However, this patient would have an inappropriate affect, given that the "good" mood and demonstrated behavior do not match the circumstances they are describing.
  8. Range of affect describes the spectrum and intensity of a patient's emotional expression. Observations span from flat when there is no emotional expressivity, to restricted affect when there is subdued emotional expression, to the full range when there is a moderate expression of both happy and sad emotional expression, to labile when patients may suddenly vacillate from one emotional extreme to the other within the same encounter.
  9. Remain mindful that certain cultures have a different range of acceptable emotional content and intensity than others, with some cultures accepting more reserved behavior and others accepting more intensity of affect. Caution against misinterpreting culturally normative emotional affect.        

4. Thought Content

  1. This is the "what" people think and can include important elements like suicidal or homicidal thoughts, obsessions (recurrent, persistent thoughts that cause distress), and/or delusions (fixed false beliefs). Paying attention to how and what the patient is talking about is the best way to glean their thought content. Unless spontaneously volunteered, there is often some specific content that the examiner wants to ask about.
  2. Suicidal Ideation— Ask the patient about thoughts of wanting to be dead or harming themselves with questions like, "Have you ever wished that you could go to sleep and not wake up?" or "Have you ever had thoughts about hurting yourself? If yes, did you ever think about how you would do it? A positive response during any portion of this subsection or on a related question on a screening instrument, like the Patient Health Questionnaire-9 (PHQ-9), requires additional immediate medical attention.
  3. Obsessions— In certain circumstances, screening for obsessive thoughts may be helpful. "Do you have unwanted thoughts that seem to be difficult to get rid of or that cause you particular worry?"
  4. Delusions— In certain circumstances, it is appropriate to ask about the presence of certain types of delusions (fixed false beliefs): 
    1. Paranoia: "Do you have the feeling that anyone is out to get you or harm you in some way?"
    2. Grandiosity: "Do you have a sense that you have special powers or particular importance?"

5. Thought Process

  1. This is the "how" people think— the organization, formulation, and flow of thoughts—and is determined by paying attention to a patient's conversation and flow of logic throughout the clinical exam.
  2. Organized, Linear, Logical— A coherent thought process is clear, logical, and easy to follow. Other ways of describing a thought process that is organized and makes sense are "linear" and/or "goal-directed." For example, many patient encounters begin with the clinician asking, "What brings you in today?" A patient with a linear, logical thought process would be able to describe the circumstances bringing them to the clinic today in a concise manner where ideas naturally flow from one to the other.  
  3. Tangential— A tangential thought process begins with one topic. However, the patient will often use the end of the preceding idea to pivot into a slightly related but different idea without ever returning to answer the original question. 
  4. Circumferential— A circumferential thought process is exactly as the word describes, circles around the topic before completing. That is, patients include a lot of extra details that are not particularly related to your question, but they do eventually answer your specific question.
  5. Perseveration— A perseverative thought process means that a patient gives the same response to a number of different questions. The patient often has a difficult time changing topics or ideas to provide clear answers to the doctor's questions.  
  6. Disorganized— A disorganized thought process is one that lacks cohesion. The conversation might bounce from topic to topic without any real relation between topics. Responses to questions may be poorly related to the question. Disorganized thought processes are typically observed in patients with psychosis who are having difficulty expressing their thoughts in a way that clearly communicates their concerns. Meaningful communication, however, is impaired by their difficulties in organizing their thoughts. There are a variety of terms that describe types of disorganized thought processes, including a flight of ideas, loose associations, and thought blocking.

6. Insight, Judgment, and Perceptions

  1. Insight refers to how well a patient has self-reflection and an understanding of their own medical illness. Insight also refers to how well a patient can see how their own behavior is contributing to the better or to the worse for their health. This information will most often be gathered passively during the history and physical examination. Answers range from "good" to "fair" to "poor."
  2. Judgment refers to the soundness of choices a patient makes while navigating their physical health. Like insight, assessments of judgment will be inferred by listening to a patient's decision-making process during the history and physical examination. Answers range from "good" to "fair" to "poor."
  3. Special considerations— Please note that cultural beliefs and education level may impact how a patient relates their understanding of their current clinical scenario. Note that a patient does not need to demonstrate mastery of the technical jargon to have robust insight into their medical course. Additionally, personal and cultural beliefs may also impact how a patient conducts their choices while navigating their healthcare treatment options. Caution is warranted not to project one's own values onto a diverse patient population.
  4. Perceptions— This aspect of the mental status exam evaluates how a patient is experiencing their environment. Assess whether a patient is experiencing auditory or visual hallucinations (sensory experiences in the absence of external stimuli). Patients may also experience hallucinatory experiences in other sensory systems (for example, touch, taste, smell), though these are much less common and not routinely screened for.
  5. Begin by asking the patient if they are seeing things that others cannot see or hearing things that other people cannot hear. If the answer is yes, follow up by asking what the content of the hallucinations is. Of particular importance is any auditory hallucination that is instructing the patient to do something, so-called "command hallucinations."
  6. Sometimes a doctor may notice that a patient seems to be responding to stimuli that the doctor does not perceive. A doctor can voice this observation to the patient to discover more information.

7. Cognition

  1. Begin by introducing yourself.
  2. Make sure the patient is seated comfortably. Ensure that there is a pen, paper, and hard surface available for writing.
  3. Next, assess for barriers to communication. Ask the patient what language they speak most regularly and fluently in. Offer to provide services with a certified interpreter if appropriate. Ensure that the patient has hearing aids, if necessary.
  4. Short-term memory: For short-term memory assessment, tell the patient 3 words that you would like them to remember: for example, rainbow, ball, and theater. Make sure that they understood the three words you were saying by asking them to repeat them back to you. Ask the patient to repeat those 3 words again after 5 minutes.
  5. Long-term memory: Ask the patient something about their childhood, like "What was the name of your best friend growing up?" or "What was the name of the street where you grew up as a child?"
  6. Attention and concentration:
    1. Serial 7's— Ask the patient to start at 100 and count backward by 7 and stop once the patient reaches 65 or 72. 
    2. Spelling— Ask the patient to spell a common word that is about 5 letters long and have the patient spell it forwards and backward.
  7. Orientation:
    1. Person— Ask the patient their full name and year of birth.
    2. Place— Ask the patient what city, state, and building they are in.
    3. Situation— Ask the patient why they are seeing you today.
    4. Time— Ask the patient the month, the day of the week, the date of the month, and the year.
      Make sure that patients are not obtaining clues from calendars or clocks that may coincidentally be in the room. Of note, many patients with moderate dementia may not be oriented to date and time, but they often retain sufficient insight to compensate for their decline by checking for clues in their environment.
  8. Object recognition:
    1. Point to three common objects and ask the patient to name each one. In this example, we will be using "clock, table, ring."
    2. Make sure that the objects are not related to each other in form or function. For example, do not use "clock and watch" or "table and chair."
  9. Writing:
    1. Ask the patient to write a sentence.
    2. Be sure the sentence includes a subject and a verb.
  10. Spatial orientation:
    1. Draw a 3-D shape or design on a piece of paper, like a cube. 
    2. Ask the patient to copy that design.
    3. Provide the patient with suitable hard backing, like a clipboard, to make writing easier.
  11. Executive Function 
    1. Ask the patient to draw a clock with hands set to a specific time. 
    2. For example, the Mini-Cognitive Assessment, another standardized cognition screening tool available in multiple languages, instructs patients with the following:
      1. "Next, I want you to draw a clock for me. First, put in all the numbers where they go.' When that is completed, say: 'Now, set the hands to 10 past 11."
  12. Abstract Reasoning
    1. Ask the patient to explain a common proverb, such as "Actions speak louder than words" or "Two wrongs don't make a right."
    2. Alternatively, you may also ask the patient to name similarities between related objects. For example, you may ask, "What do a car, train, and bicycle have in common?" The answer would be that they are all forms of transportation.
  13. Short Term Memory (continued): It should now be approximately 2-5 minutes from the beginning of this exam. Ask the patient to recall the three words from earlier.
  14. Special Considerations 
    1. Language Fluency:
      1. The mental status exam is most commonly administered in English in American healthcare settings; however, there are a significant number of patients who are most fluent in a language other than English.    
      2. Certain portions of the cognitive evaluation may be difficult to perform when the provider and patient are language-discordant, like the word-finding task or writing tests. 
      3. Popular written cognitive assessments like the Montreal Cognitive Assessment (MOCA) are available in a variety of languages and can be administered with the help of a certified interpreter.
      4. Testing abstract reasoning using proverbs may also be problematic, as many proverbs do not have direct translations in other languages. Testing abstract thinking with the technique of asking for similarities may be more useful for patients most fluent in a language other than English.
    2. Math Proficiency:
      1. Counting backward by 7 is not a commonly performed task, thereby making it require more concentration and attention than counting backward by more common increments, like counting backward by 5. This unusual task may certainly be a reasonable method of evaluating concentration and attention for persons who had the opportunity to be exposed to higher-level math through school. However, this task may not be an equitable or valid assessment of cognitive function in persons who may have been unable to complete this task at cognitive baseline.
      2. Substitute less complex methods of assessing attention and concentration as indicated, such as reciting the days of the week backward or counting backward by a more common increment, like 5 or 1.

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Disclosures

No conflicts of interest declared.

Transcript

Tags

Mental Status Exam MSE Clinical Evaluation Mental Capacity Psychiatric Abilities Cognitive Abilities Mental Illness Diagnosis Mood Disorders Thought Disorders Cognitive Impairment Behavior Assessment Speech Assessment Mood Assessment Affect Assessment Thought Process Assessment Thought Content Assessment Insight Assessment Judgment Assessment Cognitive Abilities Assessment Appearance Observation Behavior Observation Mood Observation Speech Observation Affect Inference Thought Content Evaluation Thought Process Evaluation Suicidal Thoughts Evaluation Homicidal Thoughts Evaluation Obsessions Evaluation Delusions Evaluation Insight Evaluation Judgment Evaluation

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