STANDARD PSYCHIATRIC HISTORY AND PHYSICAL STANDARD PSYCHIATRIC HISTORY AND PHYSICAL
What follows are
What follows are the essential elements of the essential elements of the initial psychiatric work-up. the initial psychiatric work-up. Although very similar Although very similar to theto the evaluations performed by other fields of medicine, the history and physical (H&P) described below is evaluations performed by other fields of medicine, the history and physical (H&P) described below is modified and expanded
modified and expanded in certain areas to in certain areas to meet the meet the specific needs of specific needs of psychiatry. psychiatry. Medicare also requiresMedicare also requires certain elements
certain elements in a in a work-up. work-up. Most required Most required elements are elements are consistent with routine consistent with routine medical care. medical care. However,However, there are occasional required elements, which
there are occasional required elements, which are not routinely done. are not routinely done. These are bolded.These are bolded. Some general information about the process:
Some general information about the process: -
- The The H&P H&P must must be be dictated at dictated at the the time time of of hospital hospital admission. admission. Use Use the the STAT STAT dictation mdictation mode. ode. Forms Forms areare available to facilitate completion of the examination, document that an examination was performed and available to facilitate completion of the examination, document that an examination was performed and serve as a
serve as a template for dictation - template for dictation - but are not but are not mandatory. mandatory. Evaluations performed in outpatient settingsEvaluations performed in outpatient settings are less urgent and frequently will not include a physical examination but should follow the same format are less urgent and frequently will not include a physical examination but should follow the same format otherwise.
otherwise. -
- If If a a particular aspect particular aspect of of the the examination is examination is not not performed, indicate, performed, indicate, "not done". "not done". Do Do not not write, "defer"write, "defer" unless you plan to
unless you plan to document the examination later. document the examination later. It can be It can be useful to elaborate on the useful to elaborate on the reasons (reasons (e.g.e.g.
“patient too
“patient too somnolent to somnolent to allow testing of allow testing of cognition”). cognition”). These occurrences These occurrences should be should be rare. rare. ExaminationsExaminations of the genitals and breasts may be
of the genitals and breasts may be skipped if the patient has had skipped if the patient has had it done in the it done in the past year. past year. However, thisHowever, this should not
should not be an invariant practice and a sensible plan to address this portion of the physicalbe an invariant practice and a sensible plan to address this portion of the physical examination seems prudent (
examination seems prudent (e.g.e.g. “mammograms one year ago – unremarkable according to patient, she“mammograms one year ago – unremarkable according to patient, she will follow-up with primary care
will follow-up with primary care doctor”). doctor”). If an If an important portion of important portion of the examination is the examination is incomplete,incomplete, attention should be given in the A/P to
attention should be given in the A/P to a sensible plan to complete the a sensible plan to complete the examination at a later date. examination at a later date. If theIf the patient is not admitted to your service, inform the resident about the aspects of the exam that could not patient is not admitted to your service, inform the resident about the aspects of the exam that could not be completed or, in the case of attendings without a resident, inform the admitting attending.
be completed or, in the case of attendings without a resident, inform the admitting attending. -
- Do Do not not use use descriptions such descriptions such as as "within normal "within normal limits". limits". Instead, Instead, indicate indicate the the results.results. -
- Each Each examination needs examination needs to to uniquely reflect uniquely reflect the the person person being being examined. examined. Comments Comments made made by by the the patientpatient should be placed in quotation marks and can be a very effective way to document certain aspects about a should be placed in quotation marks and can be a very effective way to document certain aspects about a patient’s mental status.
patient’s mental status. -
- The The dictation should dictation should be be initiated in initiated in a a standard manner standard manner - - example: "This example: "This is Dr. is Dr. (resident) dictating the(resident) dictating the STAT psychiatric admission note for patient (W), hospital name (X), floor (Y), attending physician (Z)." STAT psychiatric admission note for patient (W), hospital name (X), floor (Y), attending physician (Z)." I. "IDENTIFICATION":
I. "IDENTIFICATION": "This
"This is is the the psychiatric psychiatric admission admission of of this this (age) (age) year year old, old, (marital (marital status, status, race, race, gender)gender) who
who was was brought brought to to the the hospital hospital by by (relatives, police, (relatives, police, self)". self)". If If in in hospital, hospital, "He/she "He/she enters enters as as aa patient
patient on on Dr. Dr. 's 's service service as as a a voluntary/involuntary/involuntary voluntary patient".patient". II. "INFORMANTS":
II. "INFORMANTS":
Estimate the reliability of the source.
Estimate the reliability of the source. Also include the relationship of the Also include the relationship of the source to the source to the patient andpatient and how well the source knows the patient.
how well the source knows the patient. Because of HIPPA one should Because of HIPPA one should also note here that permissionalso note here that permission was obtained to talk with informants.
was obtained to talk with informants. III.
III. "CHIEF "CHIEF COMPLAINT":COMPLAINT":
The chief complaint should always be a quotation of the patient's own complaint, not the relative's or The chief complaint should always be a quotation of the patient's own complaint, not the relative's or doctor's paraphrase.
At the physician's discretion in addition to the patient’s chief complaint a chief complaint of an At the physician's discretion in addition to the patient’s chief complaint a chief complaint of an informant other than
informant other than the patient mthe patient may be ay be added. added. The source The source must be must be clear. clear. Again, it is Again, it is a quotation,a quotation, not a paraphrase.
not a paraphrase. IV.
IV. "HISTORY "HISTORY OF OF PRESENT PRESENT ILLNESS":ILLNESS": The HPI is the
The HPI is the most important part of most important part of the history and physical. the history and physical. Most of the Most of the data, which will aid,data, which will aid, directly or indirectly, in the diagnosis and treatment of the patient's illness, should be included in the directly or indirectly, in the diagnosis and treatment of the patient's illness, should be included in the HPI.
HPI. Most severe psychiatric illnesses are Most severe psychiatric illnesses are chronic and chronic and recurrent and thus recurrent and thus the knowledge of the knowledge of thethe longitudinal course is extremely important in assessing the patient and planning treatment. longitudinal course is extremely important in assessing the patient and planning treatment. Therefore, although certain phases or manifestations of an illness may have existed for years, they Therefore, although certain phases or manifestations of an illness may have existed for years, they are reported in the HPI.
are reported in the HPI. For example, in the For example, in the case of a case of a patient admitted to the hospital with affectivepatient admitted to the hospital with affective symptoms, the
symptoms, the initial affective episode 20 initial affective episode 20 years ago years ago is described in is described in the HPI. the HPI. This approach isThis approach is similar to that taken for other chronic debilitating illnesses in which it is important to have a similar to that taken for other chronic debilitating illnesses in which it is important to have a longitudinal perspective on the illness (
longitudinal perspective on the illness (e.g.e.g. asthma, asthma, CAD, PVD). CAD, PVD). Obviously one Obviously one should not should not listlist verbatim everything that has happened to the patient, but rather consolidate and present the pertinent verbatim everything that has happened to the patient, but rather consolidate and present the pertinent information concisely.
information concisely. In In most most cases, the cases, the data data of the of the HPI are HPI are presented chronologically.presented chronologically. Occasionally, the complexity of the present illness will require separate consideration of part of the Occasionally, the complexity of the present illness will require separate consideration of part of the history or separate consideration of one
history or separate consideration of one informant's report. informant's report. After reading the HPI After reading the HPI one should haveone should have an impression of the course of the patient's illness (
an impression of the course of the patient's illness (e.g.e.g. specific symptoms and their severity,specific symptoms and their severity, response to treatment, compliance
response to treatment, compliance with treatment). with treatment). Doing a Doing a thorough and thorough and complete HPI will complete HPI will resultresult in one including what Medicare considers the essential elements of the HPI (Location of symptom in in one including what Medicare considers the essential elements of the HPI (Location of symptom in the body [usually not an issue for psychiatric patients], Quality, Severity, Duration, Timing, Context, the body [usually not an issue for psychiatric patients], Quality, Severity, Duration, Timing, Context, Modifying Factors and Associated Signs and Symptoms).
Modifying Factors and Associated Signs and Symptoms).
When the relevancy of certain data of the more remote history is indeterminate, such data should be When the relevancy of certain data of the more remote history is indeterminate, such data should be included in the
included in the past medical or past medical or social history as is social history as is appropriate. appropriate. Similarly, certain data about currentSimilarly, certain data about current problems (
problems (e.g.e.g. medical illnesses, drug or alcohol use, sexuality) should be included in the HPI onlymedical illnesses, drug or alcohol use, sexuality) should be included in the HPI only if they are
if they are pertinent to the present pertinent to the present illness. illness. If they If they are not, then are not, then they should be they should be placed in theplaced in the appropriate section below.
appropriate section below. It is improper to em
It is improper to employ flippant language. ploy flippant language. The hospital record is a The hospital record is a formal document that may formal document that may bebe subject to inspection by courts of law.
subject to inspection by courts of law.
An earnest attempt must be made to include all the diagnostic possibilities and to avoid prejudice by An earnest attempt must be made to include all the diagnostic possibilities and to avoid prejudice by presenting data referable to only one of the illnesses requiring differential consideration.
presenting data referable to only one of the illnesses requiring differential consideration. The following specific considerations should be observed in writing the HPI:
The following specific considerations should be observed in writing the HPI: a)
a) What What was was the the mode mode of of onset? onset? Was Was it it insidious insidious or or abrupt? abrupt? Was Was it it first first apparent apparent to to the the patientpatient or to others?
or to others? b)
b) How How did did the the evolving evolving illness illness affect affect the the patient's patient's usual usual life life functions? functions? Were Were his/her his/her marriage,marriage, occupation, or
occupation, or avocations disrupted? avocations disrupted? Did Did his/her his/her relationshirelationships ps with with people people change? change? WereWere there alterations in habits such as those of taking meals or those involving patterns of sleep? there alterations in habits such as those of taking meals or those involving patterns of sleep? If alterations have occurred, indicate when, and how extensively.
If alterations have occurred, indicate when, and how extensively. c)
c) What What are are the the specific specific symptoms, symptoms, which which have have appeared appeared during during the the time time of of the the Present Present Illness?Illness? A psychiatric case history, like histories elsewhere in medicine, is based on patterns of A psychiatric case history, like histories elsewhere in medicine, is based on patterns of symptoms.
these were obtained as a part of the examination.
these were obtained as a part of the examination. However, signs observed by an informantHowever, signs observed by an informant are listed in the
are listed in the HPI. HPI. A diagnosis becomes possible when A diagnosis becomes possible when it is found it is found that a patient hasthat a patient has experienced a pattern of symptoms in content and chronology with the natural history of a experienced a pattern of symptoms in content and chronology with the natural history of a known illness.
known illness. d)
d) Do Do not not forget forget to to include include pertinent pertinent negative negative findings findings as as well well as as positive positive findings.findings.
Obviously a great many questions could be asked of each patient, but certain symptoms have proven Obviously a great many questions could be asked of each patient, but certain symptoms have proven to be
to be particularlparticularly y important in important in psychiatric disorders. psychiatric disorders. These include: These include: symptoms symptoms of of change inchange in physiologic functions (eating, sleeping, elimination, menses, potency), loss or gain in weight, physiologic functions (eating, sleeping, elimination, menses, potency), loss or gain in weight, changes in mood, changes in memory or judgment, changes in behavior suggesting hallucinations or changes in mood, changes in memory or judgment, changes in behavior suggesting hallucinations or delusions, id
delusions, ideas of sin, guilt, peas of sin, guilt, persecution, jeersecution, jealousy or infialousy or infidelity. delity. This list is not cThis list is not complete buomplete butt representative.
representative. IV.
IV. "PAST "PAST MEDICAL MEDICAL HISTORY":HISTORY":
List pertinent childhood illnesses or facts concerning growth and development. List pertinent childhood illnesses or facts concerning growth and development. In chronological order list
In chronological order list operations, other hospitalizations, significant injuries, significant illnessesoperations, other hospitalizations, significant injuries, significant illnesses not resulting in hospitalization.
not resulting in hospitalization.
Specific inquiry should be made concerning head injury and neurological illness. Specific inquiry should be made concerning head injury and neurological illness. V. "ALLERGIES":
V. "ALLERGIES":
Formally speaking, this section should only contain medications that provoke an allergic immune Formally speaking, this section should only contain medications that provoke an allergic immune response in
response in a patient. a patient. Not uncommonly Not uncommonly though, non-allergic responses are though, non-allergic responses are listed here. listed here. In order In order toto avoid confusion one should indicate the specific response for each allergy.
avoid confusion one should indicate the specific response for each allergy. VI. "MEDICATIONS":
VI. "MEDICATIONS": VII.
VII. "FAMILY "FAMILY HISTORY":HISTORY":
Note the presence or absence of psychiatric or neurological illness among first-degree relatives Note the presence or absence of psychiatric or neurological illness among first-degree relatives (parents,
(parents, siblings, siblings, children). children). Inquire Inquire specifically specifically about about "nervous "nervous breakdown", breakdown", depression,depression, schizophrenia, alcoholism, mental deficiency, delinquency, legal difficulties, suicide, suicide schizophrenia, alcoholism, mental deficiency, delinquency, legal difficulties, suicide, suicide attempts, "neuroses",
attempts, "neuroses", epilepsy, syphilis, epilepsy, syphilis, hospital care, hospital care, and and psychotherapy. psychotherapy. When When any any positivepositive material emerges, age of onset, the course of illness, specific symptoms, and treatment are all material emerges, age of onset, the course of illness, specific symptoms, and treatment are all important.
important.
Similar history concerning second-degree relatives (aunts, uncles, grandparents) is also important. Similar history concerning second-degree relatives (aunts, uncles, grandparents) is also important. Finally, questions should be asked concerning family history of the more important and common Finally, questions should be asked concerning family history of the more important and common nonpsychiatric illnesses.
nonpsychiatric illnesses. VIII.
VIII. "SOCIAL "SOCIAL HISTORY":HISTORY": Upbringing (family
Upbringing (family constellaticonstellation, socioeconomic on, socioeconomic status, religion). status, religion). School and School and occupational historyoccupational history (grade completed and age when stopped, for what reason, ability, performance, and behavior in (grade completed and age when stopped, for what reason, ability, performance, and behavior in school).
school). Types of Types of work and work and job history, if job history, if pertinent. pertinent. Military service (record and Military service (record and type of type of discharge).discharge). Sexual and marital history (details not only of sexual experience, but also the family dynamics with Sexual and marital history (details not only of sexual experience, but also the family dynamics with patient's role may
patient's role may be of be of importance. importance. Premorbid personality (personality of Premorbid personality (personality of patient before the patient before the onsetonset of an acute psychiatric illness).
patient's personality in order to
patient's personality in order to appreciate the changes subsequent to appreciate the changes subsequent to illness. illness. Describe briefly his/herDescribe briefly his/her premorbid activities, interests, general
premorbid activities, interests, general mood mood and social and social patterns. patterns. Also detail Also detail the patient's the patient's drug,drug, alcohol and tobacco history if it is not part of
alcohol and tobacco history if it is not part of the HPI. the HPI. Finally, mention here if the patient is legallyFinally, mention here if the patient is legally incompetent or has somebody legally qualified to make health decisions.
incompetent or has somebody legally qualified to make health decisions. IX.
IX. "ASSETS":"ASSETS":
Medicare requires statements regarding the patient's assets. Briefly mention patient's positive Medicare requires statements regarding the patient's assets. Briefly mention patient's positive attributes, such as talents, compliance, supportive people in the patient's life, insurance status, attributes, such as talents, compliance, supportive people in the patient's life, insurance status, education, job status, housing, wealth that may contribute to the patient's treatment.
education, job status, housing, wealth that may contribute to the patient's treatment.
X.
X. "REVIEW "REVIEW OF OF SYSTEMS":SYSTEMS":
The chief function of the ROS in a psychiatric case history is to provide a systematic investigation of The chief function of the ROS in a psychiatric case history is to provide a systematic investigation of symptoms of nonpsychiatric illnesses.
symptoms of nonpsychiatric illnesses. The ROS does The ROS does not serve to not serve to extend the HPI (extend the HPI (i.e.i.e. filling in gapsfilling in gaps which may have been left in the HPI).
which may have been left in the HPI).
Report positive findings here, not usually seen in psychiatric illness (hemoptysis, melena, orthopnea, Report positive findings here, not usually seen in psychiatric illness (hemoptysis, melena, orthopnea, etc.).
etc.). It should It should be noted be noted that when that when the patient's psychiatric the patient's psychiatric diagnosis is hysteria diagnosis is hysteria ((i.e.i.e. Briquet’sBriquet’s Syndrome, Conversion Disorder), the special symptom review for that illness becomes part of the Syndrome, Conversion Disorder), the special symptom review for that illness becomes part of the HPI.
HPI. It is It is incorrect to say incorrect to say "within normal limits" "within normal limits" or “non-contributory.” or “non-contributory.” Instead one Instead one should list should list thethe specific symptoms
specific symptoms that were that were evaluated. evaluated. At a At a minimum minimum one should one should evaluate functions in evaluate functions in thethe following systems to be compliant with Medicare regulations:
following systems to be compliant with Medicare regulations:
Constitutional Constitutional Eyes
Eyes
Ears, Nose, Throat, and Mouth Ears, Nose, Throat, and Mouth Cardiovascular Cardiovascular Respiratory Respiratory Gastrointestinal Gastrointestinal Genitourinary Genitourinary Musculoskeletal Musculoskeletal
Integumentary (skin and/or breast) Integumentary (skin and/or breast) Neurological Neurological Endocrine Endocrine Hematological/Lymphatic Hematological/Lymphatic Allergic/Immunologic Allergic/Immunologic XI.
XI. "PHYSICAL "PHYSICAL EXAMINATIOEXAMINATION"(with N"(with complete complete neurological neurological examination):examination): For
For inpatient admissions inpatient admissions patients need patients need a a complete complete physical examination. physical examination. The The Mental StatusMental Status Examination (MSE) is an
Examination (MSE) is an amplification of the examination of amplification of the examination of neurological function. neurological function. As amplified, itAs amplified, it is rendered separately and
is rendered separately and placed after the placed after the Physical Examination. Physical Examination. In both In both the physical and the physical and thethe mental status exam, be
mental status exam, be specific with your findings. specific with your findings. For instance, don't simply For instance, don't simply say that something issay that something is "normal" or "within normal limits", state what
"normal" or "within normal limits", state what you found. you found. You cannot state You cannot state "CN II-XII intact.” You"CN II-XII intact.” You must list each cranial nerve and
must list each cranial nerve and what the results of the exam what the results of the exam were. were. Do not state deferred unless thatDo not state deferred unless that part of the exam is
part of the exam is in fact deferred and you intend to in fact deferred and you intend to complete it later. complete it later. If you cannot or are unable toIf you cannot or are unable to do a portion of the exam, state that it was "not done" and indicate the reason why it was not done. do a portion of the exam, state that it was "not done" and indicate the reason why it was not done. Similarly, in the mental status exam, when you assess memory, you need to state exactly which tests Similarly, in the mental status exam, when you assess memory, you need to state exactly which tests you performed.
you performed. For example: "three simple For example: "three simple items recalled immediately and items recalled immediately and at five mat five minutes" wouldinutes" would be adequate.
be adequate. For 'fund For 'fund of of knowledge' testing, state knowledge' testing, state what you what you tested and tested and the specific the specific answer. answer. ForFor example: “presidents were: Bush, Clinton, Bush, Reagan, Nixon.”
NOTE: Medicare considers certain elements of the physical examination to be critical to the NOTE: Medicare considers certain elements of the physical examination to be critical to the “Psychiatric Examination.” These include the Constitutional Elements (Vital Signs: BP, pulse, “Psychiatric Examination.” These include the Constitutional Elements (Vital Signs: BP, pulse, RR, temperature, height, and weight – MDs
RR, temperature, height, and weight – MDs are not required to obtain their own vitare not required to obtain their own vitals. als. TheyThey may use those obtained by the ancillary staff.), General Appearance Elements ( may use those obtained by the ancillary staff.), General Appearance Elements (e.g.e.g.
development, nutrition, body habitus, deformities, and grooming), and Musculoskeletal development, nutrition, body habitus, deformities, and grooming), and Musculoskeletal Elements (muscle tone, stati
Elements (muscle tone, station, and gait). on, and gait). In the inpatient setting lIn the inpatient setting listing these elements in tisting these elements in thehe physical examination
physical examination is appropriate is appropriate and meets and meets Medicare requirements. Medicare requirements. Some prefer to Some prefer to listlist some of these elements in the MSE (
some of these elements in the MSE (e.g.e.g.General Appearance Elements General Appearance Elements in GAB). in GAB). Either way Either way isis
fine.
fine. When examining When examining a patient a patient in tin the outpatient he outpatient setting setting where a where a complete physicalcomplete physical examination is usually not conducted make sure you include these non-MSE elements in your examination is usually not conducted make sure you include these non-MSE elements in your work-up.
work-up.
XII.
XII. "MENTAL "MENTAL STATUS STATUS EXAMINATIONEXAMINATION":": As its name
As its name and location imply it and location imply it is intended to be is intended to be an objective description of signs. an objective description of signs. It covers thoseIt covers those aspects of CNS
aspects of CNS functioning that tend to functioning that tend to be abnormal in be abnormal in psychiatric disorderspsychiatric disorders. . We have We have attempted toattempted to use generally accepted terms.
use generally accepted terms. Their formal definitions are given Their formal definitions are given in the glossary at in the glossary at the end of the end of thisthis document.
document. Since the Since the CNS is CNS is not divided into not divided into neurological and psychiatric parts, several items neurological and psychiatric parts, several items thatthat other services place in neurological section are placed in the MSE when conducted by a psychiatrist. other services place in neurological section are placed in the MSE when conducted by a psychiatrist.
NOTE: Medicare compliant exams must include a description of Thought Processes. NOTE: Medicare compliant exams must include a description of Thought Processes. As defined by Medicare, this includes “rate of thoughts, content of thoughts (e.g. logical As defined by Medicare, this includes “rate of thoughts, content of thoughts (e.g. logical vs. illogical,
vs. illogical, tangential); abstract tangential); abstract reasoning and computatireasoning and computation.” on.” The Flow The Flow of Thoughtof Thought and Thought Content categories of a traditional mental status exam include most of and Thought Content categories of a traditional mental status exam include most of these elements.
these elements. For logical For logical reasons and ease reasons and ease of remembering, tof remembering, this document his document listslists abstract reasoning and computation under Sensorium and Intellect.
abstract reasoning and computation under Sensorium and Intellect.
Medicare compliant exams also require a Description of Associations (defined by Medicare compliant exams also require a Description of Associations (defined by Medicare as “loose, tangential,
Medicare as “loose, tangential, circumstantial, intact”). circumstantial, intact”). The Flow of The Flow of Thought categoryThought category described involves a detailed description of associations (how ideas are connected to described involves a detailed description of associations (how ideas are connected to each other).
each other). For descriptive purposes, For descriptive purposes, this document this document uses the uses the better-defined terms better-defined terms of of “derailment”, “tangentiality” and “flight of ideas” to describe what has sometimes been “derailment”, “tangentiality” and “flight of ideas” to describe what has sometimes been called “loose associations” (see the Mental Status Glossary at the end of the document called “loose associations” (see the Mental Status Glossary at the end of the document for standard definitions of these terms).
for standard definitions of these terms).
Ordinarily the MSE is divided into eight parts. Ordinarily the MSE is divided into eight parts. 1.
1. "General "General Appearance Appearance and and Behavior" Behavior" (GAB): (GAB): Does Does the the patient patient appear appear his/her his/her stated stated age?age? Describe facial expression as well as
Describe facial expression as well as condition, dress and grooming. condition, dress and grooming. Is the Is the patient unkempt,patient unkempt, or m
or malnourished? alnourished? Does he/she Does he/she smell? smell? Evidence for Evidence for tattoos, scars, and tattoos, scars, and lacerations should lacerations should bebe recorded here or in
recorded here or in the dermatological parts of the the dermatological parts of the PE. PE. Does the patient use Does the patient use a wheelchair, aa wheelchair, a cane, glasses
cane, glasses or or a a hearing aid? hearing aid? Describe the Describe the observed motor observed motor activity (overactive,activity (overactive, underactive, give
underactive, give evidence of evidence of neurologic disturbance). neurologic disturbance). Evidence Evidence for for tardive dyskinetictardive dyskinetic movements and
movements and cogwheel rigidity are cogwheel rigidity are listed here. listed here. Is the Is the patient cooperative, calm, patient cooperative, calm, oror agitated?
agitated? Does he/she Does he/she regard the regard the examiner during examiner during the interview, does the interview, does he/she avert he/she avert eyeeye contact, or are his/her eyes fixated in space (on
contact, or are his/her eyes fixated in space (on an apparent object that is an apparent object that is not present)? not present)? DoesDoes his/her mouth move when he/she is not talking?
2.
2. "Speech": "Speech": This This section section is is concerned concerned only only with with the the mechanics mechanics of of talking. talking. What What is is the the rate rate andand volume?
volume? Is Is it it monotone? monotone? What What is is the the rhythm? rhythm? Is Is there there dysarthria? dysarthria? Is Is there there an an increase inincrease in latency (normal time to respond is 3-5
latency (normal time to respond is 3-5 secs)? secs)? Is the amount Is the amount of speech increased or decreasedof speech increased or decreased ((e.g.e.g. mute, poverty of mute, poverty of speech)? speech)? Is it Is it spontaneous or does spontaneous or does the patient the patient only talk only talk when awhen a question is
question is asked? asked? Is Is the the speech speech stilted? stilted? What What is is the the level level of of the the vocabulary? vocabulary? Are Are therethere neologisms, word approximations, phonemic or semantic paraphasias?
neologisms, word approximations, phonemic or semantic paraphasias? 3.
3. "Flow "Flow of of Thought" Thought" (FOT): (FOT): This This section section describes describes how how thoughts thoughts are are connected connected to to each each other.other. When normal, thoughts are logical, sequential and goal directed (
When normal, thoughts are logical, sequential and goal directed ( i.e.i.e. one can answerone can answer questions directly).
questions directly). This area This area of the of the MSE is MSE is difficult and difficult and requires constant work. requires constant work. It involvesIt involves observations about verbal patterns, which
observations about verbal patterns, which one does one does not ordinarily make. not ordinarily make. This area This area of theof the MSE is the least precise but can be done well with the use of verbatim examples from the MSE is the least precise but can be done well with the use of verbatim examples from the patient.
patient. A general rule of thumb A general rule of thumb is that if you have is that if you have to ask the patient to to ask the patient to explain himself or if explain himself or if you find yourself saying, "I think he means this" then the patient probably has a thought you find yourself saying, "I think he means this" then the patient probably has a thought disorder and is
disorder and is having difficulties in explaining himself. having difficulties in explaining himself. Also describe the Also describe the rate at which rate at which oneone thought follows the previous thought.
thought follows the previous thought. Several patterns of thought Several patterns of thought flow have been flow have been noted tonoted to occur in patients and are described below.
occur in patients and are described below.
- Circumstantial speech involves inclusion of too many trivial details.
- Circumstantial speech involves inclusion of too many trivial details. For the most For the most part it ispart it is logical and
logical and sequential. sequential. Thus the Thus the connection between connection between ideas is ideas is easily understood. easily understood. In In additionaddition if the patient is given enough time he/she will also reach the goal (usually the answer to your if the patient is given enough time he/she will also reach the goal (usually the answer to your question). Circumstantial speech is
question). Circumstantial speech is not necessarily pathological. not necessarily pathological. It tends It tends to be to be seen moreseen more commonly in the elderly (
commonly in the elderly (e.g.e.g.a patient starting back in 1914 and going through his/her wholea patient starting back in 1914 and going through his/her whole life story to tell you why he/she looks both ways when crossing the street.)
life story to tell you why he/she looks both ways when crossing the street.)
- Tangential speech is used to refer to the situation in which a patient’s response to specific - Tangential speech is used to refer to the situation in which a patient’s response to specific questions is oblique
questions is oblique or irrelevant. or irrelevant. It should It should not be not be used to used to refer to refer to abnormalities inabnormalities in spontaneous speech.
spontaneous speech.
- Derailment (a.k.a. LOA) is used to describe spontaneous speech in which ideas slip off the - Derailment (a.k.a. LOA) is used to describe spontaneous speech in which ideas slip off the track and
track and onto another one onto another one that is that is obliquely related. obliquely related. Thus, it is Thus, it is comparable to comparable to tangentialtangential speech, but tangential is used to describe the phenomenon when it occurs as the immediate speech, but tangential is used to describe the phenomenon when it occurs as the immediate response to a
response to a question. question. Loosening of Associations is an Loosening of Associations is an older term for older term for derailment, but is noderailment, but is no longer recommended.
longer recommended.
- Flight of Ideas describes derailment in which one idea is quickly followed by another ( - Flight of Ideas describes derailment in which one idea is quickly followed by another ( e.g.e.g.
in the context of
in the context of pressured speech). pressured speech). Use of this Use of this term, historically, is used to term, historically, is used to indicate the FOTindicate the FOT in a manic and thus one should be careful in its use in non-manics, lest it be misinterpreted in a manic and thus one should be careful in its use in non-manics, lest it be misinterpreted by others.
by others.
- Incoherence (a.k.a. word salad, jargon aphasia, schizophasia, paragrammatism) denotes a - Incoherence (a.k.a. word salad, jargon aphasia, schizophasia, paragrammatism) denotes a pattern of speech
pattern of speech that is that is more severely more severely affected than derailment. affected than derailment. In contrast to In contrast to derailment,derailment, where the slippage occurs between ideas or sentences, the slippage in incoherence occurs where the slippage occurs between ideas or sentences, the slippage in incoherence occurs between words or
between words or phrases. phrases. At times At times it can it can be difficult to be difficult to differentiate incoherence fromdifferentiate incoherence from Wernicke’s aphasia.
Wernicke’s aphasia.
- Clanging (choice of words based on their sounds), rhyming, puns may be present. - Clanging (choice of words based on their sounds), rhyming, puns may be present. - Echolalia (repeating what is said by others in an echoing fashion).
- Perseveration (repeating the same word, phrase, or idea over and over again). - Perseveration (repeating the same word, phrase, or idea over and over again). 4.
4. "Content "Content of of Thought" Thought" (COT) (COT) or or Thought Thought Content Content (TC): (TC): This This section section describes describes predominantpredominant ideas and thoughts that the
ideas and thoughts that the patient is discussing or is patient is discussing or is occupied by. occupied by. One should not One should not simplysimply record patient complaints (
record patient complaints (e.g.e.g. "I am "I am seeing things" or seeing things" or “I want “I want to kill to kill myself”). myself”). SuchSuch statements are subjective and
statements are subjective and are symptoms are symptoms and thus and thus belong in belong in the HPI. the HPI. Instead whenInstead when evaluating a patient's COT one should be probing and examining several aspects of a belief, evaluating a patient's COT one should be probing and examining several aspects of a belief, for example, in
for example, in order to order to offer evidence for offer evidence for or against it or against it being a being a delusion. delusion. COT can COT can bebe subdivided into 4
subdivided into 4 components. components. Each should be Each should be commented on.commented on. a) Suicidal and homicidal thoughts
a) Suicidal and homicidal thoughts
Every patient must be evaluated for the presence of suicidal or homicidal ideas. Every patient must be evaluated for the presence of suicidal or homicidal ideas. Ideation should
Ideation should be delineated be delineated from from intent and intent and plan. plan. Findings should Findings should be explicitlybe explicitly recorded in the note.
recorded in the note. It is not adequate or appropriate to just take It is not adequate or appropriate to just take at face value what aat face value what a patient says (
patient says (e.g.e.g. I’m I’m suicidal”) and suicidal”) and list the list the patient as patient as suicidal or suicidal or homicidal. homicidal. SuchSuch statements are symptoms and by themselves do not belong in the MSE but instead statements are symptoms and by themselves do not belong in the MSE but instead should be placed
should be placed in the in the HPI or listed HPI or listed as a as a chief complaint. chief complaint. Not uncommonly Not uncommonly suchsuch statements by patients are just attempts at inducing somebody to do something ( statements by patients are just attempts at inducing somebody to do something ( i.e.i.e.
manipulative).
manipulative). Suicidal or homicidal Suicidal or homicidal statements should be statements should be explored to explored to determine thedetermine the degree of intent.
degree of intent. For example, is For example, is the patient planning for the patient planning for the future, is the the future, is the statementstatement conditional (
conditional (e.g.e.g. “I will only kill myself “I will only kill myself if you if you discharge me”). discharge me”). Also include in Also include in thisthis section any statements about the patient doing harm to him/herself or others that would section any statements about the patient doing harm to him/herself or others that would not result in death (
not result in death (i.e.i.e.any form of violence to self or others).any form of violence to self or others). b) Thoughts associated with psychosis
b) Thoughts associated with psychosis
Delusions, ideas of reference, feelings of derealization and depersonalization are Delusions, ideas of reference, feelings of derealization and depersonalization are reported in this section of the
reported in this section of the mental status examination. mental status examination. They are reported here if They are reported here if theythey were found
were found to to occur on occur on examination. examination. Past experiences Past experiences would be would be in the in the HPI.HPI. Traditionally, hallucinations are also recorded here since they occur frequently with Traditionally, hallucinations are also recorded here since they occur frequently with other
other psychotic psychotic phenomena phenomena like like delusions. delusions. However, the However, the observable observable signs signs of of hallucinati
hallucinations are ons are usually behavioral and usually behavioral and should be should be recorded in recorded in GAB. GAB. All this All this said,said, almost all psychiatrist record hallucinations here.
almost all psychiatrist record hallucinations here. Hallucinat
Hallucinations are ions are false sensory false sensory perceptions. perceptions. Sometimes an Sometimes an attempt is attempt is made made toto distinguish between illusions (the misinterpretation of real sensory stimuli) as opposed distinguish between illusions (the misinterpretation of real sensory stimuli) as opposed to hallucinations, which occur
to hallucinations, which occur in the in the absence of absence of real, external, sensory real, external, sensory stimuli. stimuli. ForFor practical purposes, one cannot always distinguish between illusions and hallucinations. practical purposes, one cannot always distinguish between illusions and hallucinations. It is
It is likely that mlikely that most patients with ost patients with delirium are delirium are experiencing illusions. experiencing illusions. HallucinatiHallucinationsons can occur
can occur in any in any of the of the five sensory mfive sensory modalities. odalities. Auditory hallucinations are the mAuditory hallucinations are the mostost common.
common. Visual hallucinations are Visual hallucinations are also also common. common. Tactile hallucinations are Tactile hallucinations are sometimessometimes called haptic hallucinations (not to be confused with hypnagogic hallucinations which called haptic hallucinations (not to be confused with hypnagogic hallucinations which occur
occur in in the the state state between wakefulness between wakefulness and and sleep). sleep). Olfactory and Olfactory and gustatorygustatory hallucinations may sometimes occur.
hallucinations may sometimes occur. A delusion is
A delusion is a fixed false a fixed false belief outside of the belief outside of the norm of norm of the patient’s culture. the patient’s culture. WhenWhen evaluating whether a particular false belief is delusional or not, one needs to determine evaluating whether a particular false belief is delusional or not, one needs to determine whether the thought is fixed (
whether the thought is fixed (i.e.i.e. in the face of evidence that the belief is false thein the face of evidence that the belief is false the patient persists in believing it.).
patient persists in believing it.). Also determine whether the Also determine whether the fixed false belief fixed false belief is ais a normal for the patient’s culture (
not necessarily an
not necessarily an indication of psychosis. indication of psychosis. Persecutory delusions are Persecutory delusions are obviously thoseobviously those of persecution (note that they
of persecution (note that they should NOT be should NOT be referred to as paranoid. referred to as paranoid. Paranoid meansParanoid means delusional).
delusional). Delusions of Delusions of megalomania are megalomania are those of those of being a being a great person. great person. One kind One kind of of delusion, which has its own name because it occurs so frequently, is the delusion of delusion, which has its own name because it occurs so frequently, is the delusion of passivity (see First Rank Sym
passivity (see First Rank Symptoms below). ptoms below). This is the This is the belief that one's belief that one's thoughts orthoughts or one's motor behavior is under the
one's motor behavior is under the control of an outside agent. control of an outside agent. The outside agent mayThe outside agent may be either animate
be either animate or inanimate. or inanimate. It may It may be close be close at hand at hand or at or at a distance. a distance. The patientThe patient may believe that his mind is being controlled, that thoughts are being put in his mind, may believe that his mind is being controlled, that thoughts are being put in his mind, taken out of his mind, being broadcasted, or somehow molded (thought taken out of his mind, being broadcasted, or somehow molded (thought insertion/w
insertion/withdrawal/ithdrawal/broadcasting). broadcasting). He mHe may ay believe that believe that his his body is body is being controlled,being controlled, marionette-lik
marionette-like. e. This experience of This experience of passivity is often accompanied by passivity is often accompanied by a complex a complex arrayarray of other delusions and hallucinations so that it can be difficult to determine at what of other delusions and hallucinations so that it can be difficult to determine at what point one pathological phenomenon ends and another begins.
point one pathological phenomenon ends and another begins. ‘Delusion of reference’.
‘Delusion of reference’. This term This term is source is source of confusion of confusion because it because it covers such covers such aa variety of
variety of experiences. experiences. Normal Normal people people havehave ideasideas of reference in embarrassing socialof reference in embarrassing social situations (feeling that somebody
situations (feeling that somebody is talking is talking about you). about you). These beliefs These beliefs are short-livedare short-lived and are
and are quickly recognized as lacking quickly recognized as lacking veracity. veracity. On the On the other hand, patients other hand, patients who arewho are psychotic may experience
psychotic may experience delusionsdelusions of reference in a bizarre and pronounced fashion.of reference in a bizarre and pronounced fashion. A delusion of reference is the unwarranted idea based upon a trivial occurrence ( A delusion of reference is the unwarranted idea based upon a trivial occurrence (e.g.e.g.
the person at the next table looked at the patient) that a person is talking about you, the person at the next table looked at the patient) that a person is talking about you, watching you, or
watching you, or noticing you. noticing you. The belief continues The belief continues in spite of in spite of no evidence supportingno evidence supporting the belief.
the belief. It also is used It also is used to describe the phenomenon to describe the phenomenon where a patient reports that where a patient reports that anan event was meant as a special message to the patient (
event was meant as a special message to the patient (e.g.e.g. the death of the horse in Thethe death of the horse in The Godfather had a hidden message for the patient from God -- that horses should be killed Godfather had a hidden message for the patient from God -- that horses should be killed because they are the messengers of Satan).
because they are the messengers of Satan).
‘Derealization’ is the feeling that the world has changed, usually in some alien way. ‘Derealization’ is the feeling that the world has changed, usually in some alien way. The patient may
The patient may or may or may not know that not know that this feeling is this feeling is abnormal. abnormal. ‘Depersonal‘Depersonalization’ isization’ is a similar feeling, however
a similar feeling, however it applies to it applies to the patient's own the patient's own body. body. The patient feels The patient feels thatthat his/her body is somehow changed or that his/her identity has somehow changed or his/her body is somehow changed or that his/her identity has somehow changed or become lost.
become lost. The patient may The patient may or may not or may not believe the feeling is abnormal.believe the feeling is abnormal. ‘Schneiderian First Rank
‘Schneiderian First Rank Symptoms’. Symptoms’. Kurt Schneider Kurt Schneider believed that believed that several psychoticseveral psychotic symptoms only occurred in patients with schizophrenia (
symptoms only occurred in patients with schizophrenia (i.e.i.e. are pathognomonic) andare pathognomonic) and thus argued that their presence always indicated the presence of schizophrenia. thus argued that their presence always indicated the presence of schizophrenia. Schneider called these symptoms, First Rank Symptoms (Second Rank Symptoms were Schneider called these symptoms, First Rank Symptoms (Second Rank Symptoms were symptoms that
symptoms that occur frequently in occur frequently in schizophrenia and in schizophrenia and in other illnesses). other illnesses). SubsequentSubsequent work has shown that while First Rank Symptoms are seen frequently in schizophrenia work has shown that while First Rank Symptoms are seen frequently in schizophrenia they can occur in patients whose course of illness is not consistent with schizophrenia. they can occur in patients whose course of illness is not consistent with schizophrenia. Thus, their presence suggests a high likelihood that a patient may have schizophrenia Thus, their presence suggests a high likelihood that a patient may have schizophrenia but this likelihood is
but this likelihood is not 100%. not 100%. This fact accounts for This fact accounts for why the why the presence of certainpresence of certain psychotic symptoms qualify outright for the A criterion of schizophrenia whereas other psychotic symptoms qualify outright for the A criterion of schizophrenia whereas other psychotic symptoms must occur in the presence of other symptoms in order for the A psychotic symptoms must occur in the presence of other symptoms in order for the A criterion of schizophrenia to
criterion of schizophrenia to be met. be met. Psychotic patients should be Psychotic patients should be evaluated for theseevaluated for these specific symptoms.
specific symptoms. Schneiderian symptoms revolve around Schneiderian symptoms revolve around the concept that the the concept that the patientpatient has lost control of
has lost control of his body and his body and is being controlled by is being controlled by others. others. First Rank SymptomsFirst Rank Symptoms are:
- Hearing one’s own thoughts out loud - Hearing one’s own thoughts out loud - 3
- 3rdrd person voices commenting on the actions of the patientperson voices commenting on the actions of the patient - Voices arguing among themselves
- Voices arguing among themselves
- Thought insertion – insertion of a thought into ones mind by an outside agent - Thought insertion – insertion of a thought into ones mind by an outside agent - Thought withdrawal – having one’s thought withdrawn from one’s mind - Thought withdrawal – having one’s thought withdrawn from one’s mind - Thought broadcasting – being able to broadcast one’s thoughts
- Thought broadcasting – being able to broadcast one’s thoughts - Attributing one’s feelings to others (delusion of passivity – feelings) - Attributing one’s feelings to others (delusion of passivity – feelings) - One’s drive is controlled from outside (delusion of passivity – impulses) - One’s drive is controlled from outside (delusion of passivity – impulses) - Experiencing one’s actions as controlled from outside (volitional passivity) - Experiencing one’s actions as controlled from outside (volitional passivity) - Having bodily sensations imposed from outside (somatic passivity)
- Having bodily sensations imposed from outside (somatic passivity)
- Attributing special delusional significance to one’s perceptions (delusional - Attributing special delusional significance to one’s perceptions (delusional
perceptions).
perceptions). Delusional perceptions combine Delusional perceptions combine a real a real perception with a perception with a delusionaldelusional idea about its m
idea about its meaning. eaning. It, thus, is similar to It, thus, is similar to a delusion of a delusion of reference,reference, e.g.e.g., “when, “when the doctor rubbed his nose, it meant I should leave the room.”
the doctor rubbed his nose, it meant I should leave the room.” c) Non-psychotic thoughts
c) Non-psychotic thoughts
Phobias and obsessions are included here if patient speaks of these phenomena as Phobias and obsessions are included here if patient speaks of these phenomena as occurring at the present time (they are
occurring at the present time (they are otherwise described in the HPI). otherwise described in the HPI). A phobia is A phobia is anan intense, unreasonable fear associated with some situation or object;
intense, unreasonable fear associated with some situation or object; i.e.i.e. fear of heights,fear of heights, closed places, etc.
closed places, etc. An obsession is a An obsession is a recurrent or persistent idea or recurrent or persistent idea or thought which isthought which is recognized as foreign or alien to the individual and which is accompanied by the desire recognized as foreign or alien to the individual and which is accompanied by the desire to resist it.
to resist it. A compulsion is A compulsion is a recurrent act a recurrent act recognized as foreign recognized as foreign or alien or alien to theto the individual and which is
individual and which is accompanied by accompanied by the desire to the desire to resist it. resist it. As such As such compulsionscompulsions should not be placed in COT and if observed should be in GAB and if reported as a should not be placed in COT and if observed should be in GAB and if reported as a symptom in the
symptom in the HPI. HPI. However, some do record However, some do record compulsions here since they compulsions here since they are seenare seen with
with obsessionobsessions.s.
d) Paucity/abundance of thoughts d) Paucity/abundance of thoughts
Finally one should be
Finally one should be evaluating whether there is Poverty of evaluating whether there is Poverty of Content. Content. This is differentThis is different than Poverty of
than Poverty of Speech, which is Speech, which is recorded in recorded in the speech section. the speech section. Poverty of Poverty of SpeechSpeech describes a decrease in the
describes a decrease in the amount of words. amount of words. A patient who only A patient who only answers yes or noanswers yes or no would be
would be an example. an example. Poverty of Poverty of Content describes a Content describes a decrease in decrease in the informationalthe informational content.
content. This This sign sign is is seen seen frequently frequently in in patients patients suffering suffering from from schizophrenia. schizophrenia. AA patient may have Poverty of Speech, Poverty of Content, both, or neither.
patient may have Poverty of Speech, Poverty of Content, both, or neither. 5.
5. "Mood”: "Mood”: As As defined defined by by DSM-IV DSM-IV mood mood is is “a “a pervasive pervasive and and sustained sustained emotion emotion that that colors colors thethe perception of the world.” This is usually accomplished by asking the patient how he/she is perception of the world.” This is usually accomplished by asking the patient how he/she is (or has been) feeling, the goal being to have the patient “average” his/her mood over a (or has been) feeling, the goal being to have the patient “average” his/her mood over a certain amount of time.
certain amount of time. Strictly speaking, since the patient is providing a Strictly speaking, since the patient is providing a subjective report of subjective report of his emotional state, mood is really a symptom and it should be recorded in the HPI section of his emotional state, mood is really a symptom and it should be recorded in the HPI section of the H&P (or in the
the H&P (or in the subjective section of the SOAP note). subjective section of the SOAP note). It is recorded here in It is recorded here in order to alloworder to allow comparison with the
comparison with the observed affect. observed affect. For clinical For clinical utility (especially on utility (especially on the inpatient unit)the inpatient unit) “sustained” is usually interpreted to mean what the predominant emotion has been on the day “sustained” is usually interpreted to mean what the predominant emotion has been on the day of the exam.
of the exam. Not uncommonly the Not uncommonly the patient’s stated mood is patient’s stated mood is given between quotation marksgiven between quotation marks ((e.g.e.g. “angry,” “sad,” “angry,” “sad,” “depressed,” “happy”). “depressed,” “happy”). In In addition for addition for patients with patients with an an affectiveaffective
disorder, a Likert scale is used (0 to 10; 0=suicidal/worse mood imaginable, 5=normal, disorder, a Likert scale is used (0 to 10; 0=suicidal/worse mood imaginable, 5=normal, 10=high as a kite), since this allows one to chart over time changes in the reported mood. 10=high as a kite), since this allows one to chart over time changes in the reported mood. 6.
6. “Affect”: “Affect”: As As defined defined by by DSM-IV DSM-IV affect affect is is “a “a pattern pattern of of observable observable behaviors behaviors that that is is thethe expression of a subjectively experienced feeling state (emotion).” Affect, thus, is a sign expression of a subjectively experienced feeling state (emotion).” Affect, thus, is a sign (“observable”) and describes a person’s emotional state at
(“observable”) and describes a person’s emotional state at the time of the time of the exam. the exam. There areThere are four basic qualities that should be detailed about a person’s affect.
four basic qualities that should be detailed about a person’s affect. a) Type of affect
a) Type of affect Is
Is it it depressed, normal depressed, normal or or elevated/euphelevated/euphoric/happy? oric/happy? What What is is its its range? range? Can Can it it bebe evoked with prompting (
evoked with prompting (e.g.e.g. laughs after laughs after a a joke)? joke)? An An appropriate description of appropriate description of aa patient suffering from depression might be: "Affect is depressed and restricted to the patient suffering from depression might be: "Affect is depressed and restricted to the lower range
lower range though the though the patient will laugh patient will laugh to jokes." to jokes." Other possible Other possible descriptors aredescriptors are anxious and irritable.
anxious and irritable. b) Stability of affect
b) Stability of affect
Is the patient's affect
Is the patient's affect labile? labile? Does it remDoes it remain stable, or ain stable, or does it does it change noticeably andchange noticeably and quickly in response to small changes in the conversation?
quickly in response to small changes in the conversation? c) Appropriateness of affect
c) Appropriateness of affect Is the
Is the patient's affect appropriate to patient's affect appropriate to the conversation? the conversation? Is it Is it congruent to congruent to his statedhis stated mood?
mood? A patient's affect may A patient's affect may be judged to be judged to be inappropriate for a be inappropriate for a number of reasons.number of reasons. Examples should be given.
Examples should be given. d) Amount of affect
d) Amount of affect
Blunted and flat affect is used to describe patients in whom the amount of affect is Blunted and flat affect is used to describe patients in whom the amount of affect is decreased (blunted) or
decreased (blunted) or non-existent (flat). non-existent (flat). This phenomenon This phenomenon is frequently is frequently seen inseen in patients with
patients with schizophrenia. schizophrenia. Usually patients Usually patients with depression with depression do do have have affect. affect. It It is is justjust restricted to the negative emotions.
restricted to the negative emotions. In such In such instances a depressed instances a depressed patients should notpatients should not be described as having a blunted or flat affect.
be described as having a blunted or flat affect. 7.
7. Sensorium Sensorium and and Intellect: Intellect: (( N.B. N.B. In evaluating the following tests of intellectual functioning,In evaluating the following tests of intellectual functioning, factors such as the patient's educational level, ability to concentrate, anxiety, and willingness factors such as the patient's educational level, ability to concentrate, anxiety, and willingness to cooperate should be considered.)
to cooperate should be considered.) Most of these tests are included in Most of these tests are included in the 30 point MMSE.the 30 point MMSE. a) "Sensorium":
a) "Sensorium":
- Orientation to person, place and time (day of month, month, year, day of week, - Orientation to person, place and time (day of month, month, year, day of week, season).
season). If not If not oriented, give patient's answers oriented, give patient's answers and correct and correct information.information. b) "Recent and Remote Memory":
b) "Recent and Remote Memory":
- Retention and immediate recall - give three
- Retention and immediate recall - give three items and test in items and test in five minutes. five minutes. If patientIf patient is unable to actively recall all
is unable to actively recall all three items at three items at 5 minutes, provide hints. 5 minutes, provide hints. Recorded at 3/3Recorded at 3/3 at 0 minutes and x/3 at 5 minutes without prompting and y/3 with prompting.
at 0 minutes and x/3 at 5 minutes without prompting and y/3 with prompting. - Recent memory - date of admission, brought to hospital by whom.
- Recent memory - date of admission, brought to hospital by whom.
- Remote memory - when and where born, date of marriage, names and ages of - Remote memory - when and where born, date of marriage, names and ages of children.
children.
c) "Attention Span and Concentration": c) "Attention Span and Concentration":
- Serial Subtractions - subtract 7 from 100 and 7 from the answer and each succeeding - Serial Subtractions - subtract 7 from 100 and 7 from the answer and each succeeding answer (average adult has
answer (average adult has less than four less than four errors and finishes errors and finishes within 60 seconds). within 60 seconds). If tooIf too difficult, use serial 3s starting at 20. Easiest is counting from 20 backwards to 1.
difficult, use serial 3s starting at 20. Easiest is counting from 20 backwards to 1. - Other -
- Other - If the patient If the patient cannot do the cannot do the mathematical tasks, try verbal ones. mathematical tasks, try verbal ones. Saying theSaying the months of the year in reverse order is a reasonably difficult task that is sensitive to months of the year in reverse order is a reasonably difficult task that is sensitive to abnormalities in
abnormalities in attention. attention. Other possibilities are: Other possibilities are: spelling WORLD spelling WORLD backwards, listingbackwards, listing days of the week backwards, and citing strings of numbers forwards and backwards. days of the week backwards, and citing strings of numbers forwards and backwards. d) “Language”:
d) “Language”:
- Naming objects, ability to repeat phrases and overall vocabulary are examples of - Naming objects, ability to repeat phrases and overall vocabulary are examples of language function.
language function. Reading the paper Reading the paper or other or other material intended for the material intended for the general publicgeneral public is another way
is another way to evaluate language. to evaluate language. NOTE: Assessment of NOTE: Assessment of “Language” is NOT “Language” is NOT thethe same as assessment of “Speech” and must be listed separately in the Mental Status same as assessment of “Speech” and must be listed separately in the Mental Status Exam.
Exam.
e) “Computation”: e) “Computation”:
- Simple mathematical skills: multiply 7 x
- Simple mathematical skills: multiply 7 x 8, divide 75 by 8, divide 75 by 3. 3. If too easy, try If too easy, try moremore difficult skills like
difficult skills like square and square and square roots. square roots. If too If too difficult, test subtraction anddifficult, test subtraction and addition skills.
addition skills.
f) "Fundamentals of Knowledge": f) "Fundamentals of Knowledge":
- Is patient
- Is patient aware of current events, past aware of current events, past history and vocabulary? history and vocabulary? Can he/she name Can he/she name fivefive large cities and the last five
large cities and the last five presidents?presidents? g) “Abstract Reasoning”
g) “Abstract Reasoning”
- Ask the patient to describe the meaning of proverbs - "Don't cry over spilled milk"; - Ask the patient to describe the meaning of proverbs - "Don't cry over spilled milk"; "All that glitte
"All that glitters is not grs is not gold"; old"; "A bird in t"A bird in the hand he hand is worth tis worth two in the wo in the bush"; bush"; "A rolling"A rolling stone gathers no m
stone gathers no moss". oss". Is the patient Is the patient able to identify able to identify the abstractions involved in the abstractions involved in thethe proverbs?
proverbs? Contrasts and comparisons like, “How are Contrasts and comparisons like, “How are an apple and an apple and an orange alike? oran orange alike? or “What is the difference between a cow and a pig?” can also be used to evaluate abstract “What is the difference between a cow and a pig?” can also be used to evaluate abstract reasoning.
reasoning.
h) “Constructional Ability” h) “Constructional Ability”
- Ask the
- Ask the patient to draw a patient to draw a clock face or clock face or to copy intersecting pentagons. to copy intersecting pentagons. This can detectThis can detect constructional apraxia, hemineglect and perseveration.
constructional apraxia, hemineglect and perseveration. 8. "Insight and Judgment":
8. "Insight and Judgment":
Insight and judgment are important components to determine not only in patients with psychiatric Insight and judgment are important components to determine not only in patients with psychiatric disorders but also in
disorders but also in patients with “medical” illnesses. patients with “medical” illnesses. Studies have shown Studies have shown that good insight that good insight andand judgment correlates with improved long-term outcome.
judgment correlates with improved long-term outcome.
-- Insight signifies that the patient realizes that he/she is ill and understands something of theInsight signifies that the patient realizes that he/she is ill and understands something of the nature of his/her illness.
nature of his/her illness. In addition it In addition it also refers to also refers to a patient’s ability to a patient’s ability to recognize his/herrecognize his/her symptoms.
symptoms. It does It does not refer not refer to etiology to etiology or psychodynamic or psychodynamic aspects of aspects of the illness. the illness. EvaluatingEvaluating the patient’s responses to the following questions may
the patient’s responses to the following questions may assess insight: assess insight: What kind of What kind of problemsproblems are you
are you currently having? currently having? Are you Are you sick in sick in any any way? way? What What sort of sort of sickness? sickness? Do Do you needyou need help?
help? What sort What sort of sickness of sickness do people do people have here? have here? In describing In describing their insight one their insight one should beshould be specific about the object of their insight.
specific about the object of their insight. For example a For example a patient might have good insight intopatient might have good insight into the fact that he/she has a major depressive disorder and is having problems with sleep and the fact that he/she has a major depressive disorder and is having problems with sleep and
