Mental Status Exam
Mental Status Examination: Brainteaser for Primary Care
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Why perform a mental status exam?
I suspect the answer to this question lies not in recalling the number of lives we may have saved, but those we have lost instead.
In my first year in practice, a man in his 30’s consulted me for treatment of hypertension. Married, a non-smoker and employed, he seemed not unlike other patients I had known in my young career. I examined him, ordered some blood tests and prescribed medication – all routine. Two weeks later, he shot himself.
Could I have uncovered his emotional strife? Would 10 seconds inquiring about his moods have made a difference? Although I will never know the answer, I understand now the importance of stepping back from the routine of the history and physical to read some non-verbal cues, note gaps in fluent speech and pick up on my emotional reaction to the patient. I can only hope that I will hear an unspoken warning.
My patient anticipates the opening of the exam room door, I look for clues in the chart before I enter, then our eyes meet and we instinctively form impressions of each other. We find ourselves observing posture, dress, movement, eye contact, apparent age. We introduce ourselves and observe still more: speech pattern, thought process, level of consciousness, and the disarmament of a smile.
We have performed a healthy chunk of a mental status exam on each other within the first 30 seconds of our encounter – not too much different than what we might do on a blind date.
If you are like me, trying to remember all the components of the mental status exam is daunting, and seems to test our own cognitive abilities. And there you have it: the mnemonic to help us incorporate this assessment into our daily interactions with our patients.
After reviewing much literature on how to perform a mental status exam, I created a mnemonic to help my brain get though it without any notes or checklists (can be done on a desert island without an EMR template). Try this mnemonic:
Alas, Someone Must Always Think About The Examiner’s Cognitive Abilities.
Translation (use first letter of each word in the above sentence):
Appearance and alertness
Affect and mood
Thought and perception
Attitude and insight
Threat of harm to self or others
Examiner reaction to patient
Remember that others assess us as we do them. That’s it.
Now that you have an outline, here are some details to record during the mental status exam:
Note grooming, dress, posture, eye contact
Note if speech is fluent, pressured, halting.
3. Motor activity
Note presence of tics, slowness, akathesia (can’t sit still?)
4. Affect and Mood
Mood is a patient’s sense of emotional state. Normal? Happy? Sad? Angry? (euthymic, euphoric, dysphoric?)
Affect is the observable expression of a patient’s subjective feelings. Appropriate? Flat? Blunted?
5.Thought and perception
Is thought process logical? (ideas flow in sequence)
Is there flight of ideas? (topics change abruptly without direction)
Does patient answer questions directly, or are answers vague (circumstantial), irrelevant (tangential) or drift away from the subject (derailed)?
Poverty? (limited information, vague answers, repeated phrases)
Delusions? (fixed beliefs)
Obsession? (recurrent thought)
Compulsion? (repetitive, ritualistic behavior)
6. Attitude and Insight
Note if the patient is cooperative, hostile, seductive, indifferent, or evasive
Does the patient seem to understand the problem or illness or deny it?
Assess judgement and impulse control (“what would you do if…”)
7. Threat of Harm to Self or Others
Suicidal, homicidal, or violent fantasies
Access to weapons
History of violence or attempted harm
Poor impulse control
8. Examiner’s Reaction to Patient
Note your own feelings toward the patient. These may offer clues to the underlying diagnosis – for example, do you feel dysphoric (depressed patient), off balance and unable to follow the conversation (schizophrenia), or frustrated (personality disorder)?
9. Cognitive Abilities
Attention during the interview: focused or easily distracted?
Language: Note fluency, word selection, ability to express ideas clearly
Memory: Assess recent and remote memory; general or selective amnesia
Reasoning: can the patient formulate a plan to solve a problem?
If you can remember the mnemonic, you are on your way to a succinct yet thorough mental status exam.
Need a checklist style mental status exam to incorporate into your EMR? One created by Jeff Patrick, the Mental Status Examination Rapid Record Form, (see Chart 1) is available at www.nevdgp.org.au
Andrea L. Brand, MD
Published on March 26, 2013
Andrea Brand has produced numerous articles, has presented, and has written a personal memoir. Since 2008, she has been a clinical assistant professor of Family Medicine at the Florida State University School of Medicine.
- Dennis Jerry L, MD; Medical Director, Arizona Department of Health, www.azdhs.gov
- Snyderman D, Rovner B. Mental status exam in primary care: a review. Am Fam Physician. 2009 Oct 15;80(8):809-814.
- Patrick, Jeff, Mental Status Rapid Record Form, www.nevdgp.org.au
- Martin, DC. The Mental Status Examination. In: Walker HK, Hall WD, Hurst JW. Clinical Methods:The History, Physical, and Laboratory Examinations, 3rd ed Boston, MA: Butterworth Publishers; 1990.