Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 2. Mental Status

EQUIPMENT

image Familiar objects (coins, keys, paper clips)

image Paper and pencil

EXAMINATION

Perform the mental status examination throughout the patient interaction. Focus on the individual’s alertness, orientation, mood, and cognition or complex mental processes (learning, perceiving, decision-making, and memory). Interview a family member or friend if you have any concerns about the patient’s responses or behaviors.

Use a mental status screening examination for health visits when no cognitive, emotional, or behavioral problems are apparent. Information is generally observed during the history in the following areas:

Appearance and behavior

Emotional stability

Grooming

Mood and feelings

Emotional status

Thought process and content

Body language

 

Cognitive abilities

Speech and language

State of consciousness

Voice quality

Memory

Articulation

Attention span

Comprehension

Judgment

Coherence

 

Ability to communicate

TECHNIQUE

FINDINGS

MENTAL STATUS AND SPEECH PATTERNS

Observe physical appearance and behavior

imageGrooming

UNEXPECTED:Poor hygiene; lack of concern with appearance; or inappropriate dress for season, gender, or occasion in previously well-groomed patient.

imageEmotional status

EXPECTED:Patient expresses concern appropriate for emotional content of topics discussed.

UNEXPECTED:Behavior conveys carelessness, apathy, loss of sympathetic reactions, unusual docility, rage reactions, agitation, or excessive irritability.

imageBody language

EXPECTED:Erect posture and eye contact (if culturally appropriate).

UNEXPECTED:Slumped posture, lack of facial expression, excessively energetic movements, or constantly watchful eyes.

imageState of consciousness

EXPECTED:Oriented to person, place, and time; appropriate responses to questions and environmental stimuli.

UNEXPECTED:Disoriented to time, place, or person. Verbal response is confused, incoherent, or inappropriate, or there is no verbal response.

Investigate cognitive abilities

imageMini-Cog

Ask patient to remember and immediately repeat three unrelated words (e.g., red, plate, and milk). Ask patient to draw a clock face with numbers, then to place hands pointing to a specific time requested. Ask the patient to repeat the three words. (Borson et al, 2000)

EXPECTED:All three words are remembered, and the clock face has all numbers in proper position and hands pointing to the requested time; or the clock face is normal and one or two words are recalled.

UNEXPECTED:Clock face is not normal; words cannot be recalled. May indicate dementia.

imageMini-Mental State Examination (MMSE)*

Use this examination to quantify cognitive function or document changes.

EXPECTED:Score of 21 to 30.

UNEXPECTED:Score of 20 or less.

imageSet test

Use this test to evaluate mental status as a whole (motivation, alertness, concentration, short-term memory, problem solving). Ask patient to name 10 items in each of four groups: fruit, animals, colors, towns or cities. Give each item 1 point for a maximum of 40 points.

EXPECTED:Able to categorize, count, remember items listed. Score of 25 or more points.

UNEXPECTED:Score less than 15 points. Check for mental changes or cultural, educational, or social factors when score is 15 to 24.

imageAnalogies

Ask patient to describe analogies: first simple, then more complex.

• What is similar about peaches and lemons, oceans and lakes, trumpet and flute?

• An engine is to an airplane as an oar is to a _____?

• What is different about a magazine and a telephone book, or a bush and a tree?

EXPECTED:Correct responses when patient has average intelligence.

UNEXPECTED:Unable to describe similarities or differences.

imageAbstract reasoning

Ask patient to explain meaning of fable, proverb, or metaphor.

• A stitch in time saves nine.

• A bird in the hand is worth two in the bush.

• A rolling stone gathers no moss.

EXPECTED:Adequate interpretation when patient has average intelligence.

UNEXPECTED:Unable to give adequate explanation.

imageArithmetic calculations

Ask patient to perform simple calculations without paper and pencil.

• 50 − 7, − 7, − 7, etc., until answer is 8.

• 50 + 8, + 8, + 8, etc., until answer is 98.

EXPECTED:Able to complete with few errors within a minute.

UNEXPECTED:Unable to perform calculations.

imageWriting ability

Ask patient to write name and address or a phrase you dictate (or if unable to write—draw figures—triangle, circle, square, flower, house, clockface).

UNEXPECTED:Omission or addition of letters, syllables, or words; mirror writing; or uncoordinated writing (or figure drawings for patients unable to write).

imageExecution of motor skills

Ask patient to do a motor task such as combing hair or putting on lipstick.

UNEXPECTED:Inability to complete a task that is not related to paralysis.

imageMemory

Immediate recall or new learning: Ask patient to listen to, then repeat, a sentence or series of numbers.

Recent memory: Show patient four or five objects or give visually impaired patient four unrelated words with distinct sounds to remember (carpet, iris, bench, fortune). Say you will ask about them later. In 10 minutes, ask patient to list objects.

EXPECTED:Immediate recall: Able to repeat sentence or numbers (five to eight numbers forward, four to six numbers backward).

Recent memory: Able to remember test objects.

Remote memory: Able to recall verifiable past events.

UNEXPECTED:Impaired memory. Loss of immediate and recent memory with retention of remote memory.

Remote memory: Ask patient about verifiable past events (e.g., mother’s maiden name, name of high school, subject of common knowledge).

 

imageAttention span

Ask patient to follow a series of short commands (e.g., take off all clothes, put on patient gown, sit on examining table), or spell World forward and backward. Arithmetic calculation is another test of attention span.

EXPECTED:Responds to directions appropriately.

UNEXPECTED:Easy distraction or confusion, negativism.

imageJudgment

Explore:

• How patient meets social and family obligations, patient’s future plans.

• Patient’s solutions to hypothetical situations (e.g., found stamped envelope or was stopped for running red light).

EXPECTED:Able to evaluate situation and provide appropriate response; managing family and business affairs appropriately.

UNEXPECTED:Response indicating hazardous behavior or inappropriate action.

Observe speech and language

imageVoice quality

EXPECTED:Uses inflections, speaks clearly and strongly, is able to increase voice volume and pitch.

UNEXPECTED:Difficulty or discomfort making laryngeal speech sounds or varying volume, quality, or pitch of speech.

imageArticulation

EXPECTED:Proper pronunciation of consonants; fluent and rhythmic speech; easily expresses thoughts.

UNEXPECTED:Imperfect or slurring pronunciation, difficulty articulating single speech sound, or speech with hesitancy, stuttering, or repetitions.

imageComprehension

EXPECTED:Able to follow simple one- and two-step instructions.

imageCoherence

EXPECTED:Able to clearly convey intentions or perceptions.

UNEXPECTED:Circumlocutions, perseveration, flight of ideas or loosening of associations between thoughts, gibberish, neologisms, clang association, echolalia, or unusual sounds may be associated with a psychiatric disorder.

Hesitations, omissions, inappropriate word substitutions, circumlocutions, neologisms, disturbance of rhythm, or words in sequence may be signs of aphasia.

Evaluate emotional stability

imageMood and feelings

Ask patient how he or she feels, whether feelings are a problem in daily life, and whether he or she has particularly difficult times or experiences.

EXPECTED:Expresses appropriate feelings for the situation.

UNEXPECTED:Unresponsiveness, hopelessness, agitation, aggression, anger, euphoria, irritability, or wide mood swings.

imageDepression screening questions

• Over the past 2 weeks, have you felt down, depressed, or hopeless?

• Over the past 2 weeks, have you felt little interest or pleasure in doing things?

EXPECTED:Negative response to one or both questions.

UNEXPECTED:Positive response to both questions indicates a need to ask more questions about depression symptoms of fatigue, restlessness, and poor concentration.

image

Geriatric Depression Scale. From Sheikh and Yesavage, 1986.

TECHNIQUE

FINDINGS

imageThought process and content

• Ask patient about obsessive thoughts relating to making decisions, fears, or guilt.

EXPECTED:Patient’s thought processes can be followed, and expressed ideas are logical and goal directed.

• Ask patient about the need to compulsively repeat actions, check, and recheck (or observe the patient’s actions).

• Observe sequence, logic, coherence, and relevance of topics.

• Does patient have delusions (of grandeur, of being controlled by external force)? Does the patient feel watched, followed, persecuted, or paranoid?

UNEXPECTED:Illogical or unrealistic thought processes; blocking, or disturbance in stream of thinking. Obsessive thought content, compulsive behavior, phobias, anxieties that interfere with daily life or are disabling. Delusions.

imagePerceptual distortions and hallucinations

Ask patient about any sensations not believed to be caused by external stimuli.

Find out when these experiences occur.

UNEXPECTED:Sensory hallucinations—hears voices, sees vivid images or shadowy figures, smells offensive odors, feels worms crawling on skin.

* MMSE can be obtained from Psychological Assessment Resources, Inc., 16204 N. Florida Avenue, Lutz, FL 33549; 1-800-331-8378; 813-449-4066; www.minimental.com.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Dementia

Subjective Data:Forgets significant events; gets lost in familiar areas; unable to manage shopping, food preparation, medications; mood changes (depression, uncharacteristic anger, anxiety, or agitation); apathy.

Objective Data:Impaired memory, social and occupational functioning, and activities of daily living; impaired use of language; progressive deterioration in cognitive function.

Delirium

Subjective Data:Sudden impairment of memory and attentiveness, mood swings, increased or decreased activity.

Objective Data:Altered consciousness; fearful, suspicious; rambling and irrelevant conversation, illogical flow of ideas. Misperceptions, illusions, hallucinations, and delusions; symptoms increase and decrease during the day.

Depression

Subjective Data:Feels sad, hopeless, worthless; loss of pleasure or interest; insomnia or excessive sleeping; increased or decreased appetite. May have had a loss, change in health status, stressful life event.

Objective Data:Altered mood and affect with extreme sadness, anxiety, irritability; impaired concentration, reduced attention span, indecisiveness, slower thought processes.

Mania

Subjective Data:Persistently elevated and expansive mood, hyperactivity, overconfidence, exaggerated view of own abilities.

Objective Data:Impaired attention, judgment, social, occupational, and interpersonal functioning; grandiose or persecutory delusions; loud, rapid-fire speech, excessive rhyming or puns, flight of ideas.

Anxiety disorder

Subjective Data:Anxiety or fear that interferes with personal, social, occupational functioning. Panic attacks (palpitations, sweating, shaking, dizziness, nausea, chest pain, abdominal distress); nightmares; flashbacks; poor concentration; sleep poorly.

Objective Data:Tachycardia, diaphoresis, tremors, impaired attention, ritualized acts performed compulsively.

Concussion

Subjective Data:Recent blow to head; may have had loss of consciousness; headache, dazed or dizzy; nausea or vomiting, blurred vision, ringing in ears, restless or irritable; cannot remember what happened.

Objective Data:Dazed expression; slow motor and verbal responses; emotional lability; hypersensitive to stimuli; deficits in coordination, cognition, memory, or attention.

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

MENTAL STATUS

Use parent’s impression of infant’s responsiveness to guide your assessment. Questionnaires completed by parents (e.g., Ages and Stages or Parent’s Evaluation of Developmental Status) are effective screening tools.

EXPECTED:Infant responds appropriately to parent’s voice—is attentive, comforts easily.

Child follows simple directions, performs age-appropriate skills (see Chapter 17).

UNEXPECTED:Nonresponsive, inconsolable, combative, lethargic.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Mental retardation

Subjective Data:Delayed motor, speech, and language development.

Objective Data:Delayed developmental milestones, impaired cognitive functioning and short-term memory. Inability to discriminate among two or more stimuli, lack of motivation.

Autism

Subjective Data:Does not make eye contact or point to share experiences with others; resists being held or touched; odd and repetitive behaviors, ritualized play, preoccupation with objects; motor development appropriate for age.

Objective Data:Impaired social interactions and language, odd intonation to speech, pronoun reversal, nonsensical rhyming; lacks awareness of others.

Attention-deficit/hyperactivity

Subjective Data:Short attention span, easily distracted, fidgets and squirms, often moving, disruptive behavior, talks excessively, temper outbursts; has problems in more than one setting.

Objective Data:Increased motor activity, difficulty organizing tasks, poor school performance.

SAMPLE DOCUMENTATION

Subjective.A 16-year-old male fell playing basketball and struck the back of his head on a wooden floor. No loss of consciousness, got up and walked immediately, was dazed and confused for a few moments, has a headache.

Objective.Oriented to time, place, person. Reasoning and arithmetic calculation abilities intact. Immediate, recent, and remote memory intact. Appropriate mood and feeling expressed. Speech clearly and smoothly enunciated. Comprehends directions.