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MENTAL STATUS EXAMINATION
Outline• Operational definition
• Purposes
• Components– Behavior– Cognition– Emotion
• Cognitive examination
• Mini Mental Status
MENTAL STATUS EXAMINATION: What is it?
ASSESSMENT of the:• Behavior (see it all)• Emotion (see some of it)• Cognition (see none of it)Exhibited by the patient during the
entire medical encounter
PURPOSES• Detect• Describe• Neuroanatomical localization• Assess functional implications of
Abnormalities/deficits in:• Behavior• Emotion• Cognition
ABNORMALITIES & DEFICITS
Require diagnostic explanation
May compromise capacity • to coherently and reliably describe
medical state• to give informed consent• to adhere to a therapeutic plan
MEDICALENCOUNTER
Comprehensiveglobal assessment
BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene
BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene
COGNITIONThought contentThought progressionInsight/judgment
BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene
COGNITIONThought contentCoherenceGoal directednessInsight/judgment
OperationsArousalAttentionMemoryEmotionLanguageReasoning
BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene
EMOTIONAffectMoodSuicideHomicide
COGNITIONThought contentCoherenceGoal directednessInsight/judgment
OperationsArousalAttentionMemoryEmotionLanguageReasoning
BEHAVIORAppearance appears stated age, uses a cane to walk
Attitude cooperative, hostile, detached
Activity normal, increased, agitated, subdued
Speech normal rate/rhythm, dysarthric
Dress casual, provocative, dirty
Grooming disheveled, meticulous
Hygiene clean, malodorous
COGNITIVE EXAM (“Mental status”)
REASONING
LANGUAGE
MEMORY
ATTENTION
AROUSAL
COGNITIVE EXAM (“Mental status”)
REASONING
LANGUAGE
MEMORY
ATTENTION
AROUSAL
Must know education Can the
patienthear?
MEMORY
Immediate memory = attentionRecent memory (episodic)
Recall of three words at 5 minutesEnsure that pt has registered the items“Repeat these words after me, I want you to remember them.”
Remote memory (semantic & episodic)Tends to overlap with knowledge, most of what we ask is overlearnedPresidents, date of W.W.II, etc..
REASONING (Higher cognitive fx)Tests problem solving, abstract thinkingFund of knowledge - overlaps with remote memory
How many weeks in a year?Name four presidents since 1940?What causes rust?
CalculationsAdd, subtract, multiple, divideSequences
1, 2, 3, ...1, 4, 9, 16, ....2, 3, 5, 7, 11, ...
REASONING (continued)
SimilaritiesApple - orangeCar - airplanePoem - novel
ProverbsDon’t cry over spilt milkA stitch in time saves ninePeople who live in glass houses shouldn’t throw stones
BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene
COGNITIONThought contentThought progressionInsight/judgmentArousalAttentionMemoryLanguageReasoning
EMOTIONAffectMoodSuicideHomicide
EMOTIONAFFECT “Affect is to weather as mood is to climate”• predominate sad, euphoric, angry, anxious• intensity unmodulated• range narrow, broad• congruence incongruent with contentMOOD euthymic, dysthymic, elatedSUICIDE Do you ever wish you won’t wake up?
Does it ever seem that life isn’t worth it?
HOMICIDE Is there someone who deserves to be hurt?
MEDICALENCOUNTER
Comprehensiveglobal assessment
Focusedselected assessment
IN PRACTICE, MOST ENCOUNTERSARE FOCUSED
• Accordingly the formal mental status exam is often limited to an assessment of COGNITION
• Further cognition is often assessed solely using:
• ORIENTATION
TO ORIENTTo understand
one’srelationship to the
environment
PersonPlaceTime
Situation
“Oriented X 3”“O X3”
PersonPlaceTime
Situation
“Oriented X 3”“O X3”
“Oriented X 4”“OX4”
PersonPlaceTime
Situation
“Oriented X 3”“O X3”
“Oriented X 4”“OX4”
ORIENTATION ASSESSES:
• language• perception• reasoning • remote memory• recent memory
More preciseMore comprehensiveLonger Statistical norms
Less preciseLess comprehensiveShorterExaminer norms
Orientation Full mentalstatus
Mini Mental Status
NeuropsychologicalTesting
MINI MENTAL STATE EXAMADVANTAGES• brief (10 min), systematic bedside instrument• wide recognition among physicians• since it is standardized, the score it yields is meaningful to
physicians familiar with itDISADVANTAGES• specific deficits may be ignored if the overall score is not low
(less than 25 out of 30)• the global score has no localizing valve• repeated use with intact patients produces a mechanical
transaction
• Examiner uses paper and pencil• Total of 30 points
orientation (10)
recent memory (3)
attention (3)
calculation, spell backward (5)
name, read, repeat (4)
write (1)
constructional ability (1)
ideomotor praxis (3)• Not timed
What is the (year) (season) (date) (day) (month)?Where are we? (state) (county) (city) (hospital) (floor)(10)
Ask pt to repeat three objects - give one per second.Number repeated first trial = score (3). Present till allrepeated or 6 presentations.
Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Scorenumber of correct answers or spell “world” backward, score is number of letters in correct order. “dlorw” is3 points.
What is the (year) (season) (date) (day) (month)?Where are we? (state) (county) (city) (hospital) (floor)(10)
Ask pt to repeat three objects - give one per second.Number repeated first trial = score (3). Present till allrepeated or 6 presentations.
Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Scorenumber of correct answers or spell “world” backward, score is number of letters in correct order. “dlorw” is3 points.
Ask the patient to name a watch and a pencil. (2)
Ask the patient to say “No ifs, ands or buts” (1).
Ask the patient to recall the three words (3).
Ask the pt to read and follow the command:“Close your eyes”. Score (1 ) only if closes eyes.
Ask the pt to write a sentence. It must have asubject and a verb and be sensible. Ignore grammar and punctuation (1).
Ask the patient to name a watch and a pencil. (2)
Ask the patient to say “No ifs, ands or buts” (1).
Ask the patient to recall the three words (3).
Ask the pt to read and follow the command:“Close your eyes”. Score (1 ) only if closes eyes.
Ask the pt to write a sentence. It must have asubject and a verb and be sensible. Ignore grammar and punctuation (1).
Place a piece of paper where the patient can reach it with either hand. Ask him/her to:(1) pick it up, (2) fold it in half, (3) lay it on the floor. 1 pt for each step executed correctly (3).
Ask the patient to copy a drawing of intersectingpentagons. All 10 angles must be present and twomust intersect to create a 4 sided figure. Ignoretremor and rotation (1).
Place a piece of paper where the patient can reach it with either hand. Ask him/her to:(1) pick it up, (2) fold it in half, (3) lay it on the floor. 1 pt for each step executed correctly (3).
Ask the patient to copy a drawing of intersectingpentagons. All 10 angles must be present and twomust intersect to create a 4 sided figure. Ignoretremor and rotation (1).
Normals can be expected to score > 25
However, even with > 25, if 0/3 or 1/3 for recentmemory or problems with naming, repeating, writing or reading suggest focal deficits.
It is most sensitive to disturbances which broadly effect function, it may miss subtle,focal problems.
You may not always do a MMS:
•Too little time
•Patient becomes agitated at challenge
However, even without an MMS
Interacting with the patient and obtaining a
history have provided information to write
up a mental status exam
Lesson: YOU DO NOT HAVE TO DO
AN MMS TO THOROUGHLY EXAM A PT