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The Formal Mental Status Examination

Category

Sample Observations

Appearance
Behavior

Elderly, agitated, disheveled, muscular, well-dressed


Polite, cooperative, avoids direct eye contact, restless,
moves slowly and rigidly,
Alert, drowsy, unresponsive to loud noises or painful
stimuli
Readily distracted, neglects right side, concentrates
successfully on serial tasks
Rapid, hesitant, incoherent, garbled, uses nonsense words,
mute
Sad, anxious, agitated, euphoric
Demonstrates wide range or appropriate affect, including
anger, sadness, crying, laughter
Knows person, place, date
Recalls recent and remote events
Suicidal ideas, preoccupied with loss of job, says
commentator on TV is talking about him
Logical, loose associations, unclear reasoning, sluggish
Has little appreciation of whats wrong, saying he has a
liver condition that will improve soon without treatment
Says If I reject dialysis, Ill probably die in a few weeks.
Bright, dull
Knows last five presidents, describes recent events in
Nicaragua
Serial subtraction of 7s: 100, 93, 86, 79, 72
Overall impression is that his depression and suicidality
have resolved, and that he currently shows moderate
sadness but an otherwise normal range of affect and no
significant cognitive deficits or disorders of sleep, appetite,
or energy

Level of consciousness
Attention
Speech and language
Mood
Affect
Orientation
Memory
Thought content
Thought processes
Insight
Judgment
Higher cognitive functioning
Fund of knowledge
Calculation
Assessment

Appearance and Behavior


-How old does the patient appear to be? Does the patient appear much younger or older than his
or her actual age?
-General health
-Cleanliness and self-care (shaven, use of makeup, condition of hair and nails)
-Dress: Care in dressing (neatness, cleanliness vs. disheveled, dirty, stained, neglecting one side
of the body). Type of clothing (appropriateness to social setting and season; highly stylized,
eccentric, muted)
-Facial expression (tense vs. relaxed, blank, fixed, smiling, staring)
-Posture (erect, slumped, bizarre stance)
-Motor activity: Amount and character (overactive, restless, fidgety, frenzied; motionless,
underactive, slow). Abnormal movements (rigid, tremulous, repetitive movements mannerisms,
posturing)

-Attitude and cooperation (friendly, interested, flirtatious, belligerent,, combative, preoccupied,


restless, withdrawn, suspicious)
-Eye contact
-response to environment and appropriateness of behaviour (talking to self, becoming hostile
when certain subjects are broached, startles when phone rings)
Level of consciousness
Performance of the entire history and portions of the physical examination, including most of the
mental status examination, presupposes that the patient has a fair normal level of consciousness (
i.e. the patient is alert rather than lethargic, somnolent, stuporous, or comatose) and exhibits
normal arousability (responds to usual speech rather than requiring special maneuvers to gain
and maintain attention). The patients attention, concentration, and cooperation are also required.
Significant disturbances in these functions would normally be mentioned at the beginning of the
history under reliability.
-Level of consciousness (alert, drowsy, stuporous, hypervigilant). Rather than using vague labels
(e.g. semicomatose) for patients with depressed consciousness, describe the patients response
verbal and physical to verbal, visual, and tactile (including, at times, painful) stimuli (e.g., No
response to commands, calling his name, or being touched firmly, but moves all four extremities
when shaken or pinched)
-Attention is the ability to focus on specific stimuli and screen out irrelevant stimuli, rather than
being distracted or attending only to one portion of the body. Apprehensive patients will often
have trouble attending to complex tasks, although they have no cognitive deficit when more
relaxed
-Concentration (ability to persist with tasks vs. distractibility in many tests in the mental status
examination).
Speech and Language
Spontaneous speech and conversation during the history can be characterized as follows:
-Quality or quantity, including fluency, clarity, speed (e.g., slurred, garbled, stuttering, slowed,
rapid, pressured)
-Content and organization: coherence, logic, relevance, redundancy, precision, spontaneity,
disordered syntax, loose associations, circumstantial, evasive, perseverating, periods of
prolonged silence or seeming distraction
Mood and Affect (Emotional State)
The term mood is used to describe a prevailing emotional tine; the term affect refers to momentto-moment expression of emotion and the range of observable emotion. Mood and affect have
qualities such as range, intensity, changeability, and appropriateness.
Mood and affect have qualities such as range, intensity, changeability, and appropriateness. A
common and important clinical finding is discordance between patients stated feelings and their
nonverbal communication.
Both inquiry and observation are used to examine mood and affect. Pay attention to the four
basic affective states: sadness 9indlucing grief and depression), happiness (including elation and
mania), anxiety (including panic), and anger.
See the following questions about mood and affect:
-How is your spirits/mood? In general/this moment?

-How are you feeling about the way your life is going/will be going in your future/in the nearest
future?
-Have you had any change of feelings come over you?
-Are you nervours/anxious/irritable/frightenend?
-Are there specific situations that make you feel panicked?
-Are you afraid of crowded places/going alone?
-Have you been angry/ out of control?
-Have you been sad?
-Have you felt like crying?
-Have you cried a lot?
-Have you felt discouraged?
-Have you felt like you cannot go on?
-Have you ever thought that life is not worth living?
-What do you do for fun?
-Have you been able to enjoy yourself?
-How is your energy/ambition?
-Are you able to concentrate/to think clearly?
-Has your memory changed?
-How is your sleep/appetite/sexual drive?
-How do these feelings affect your?
Patients may describe themselves or appear in some of the following ways: sad, depressed,
lacking energy, apathetic, unable to enjoy life, energetic, happy, euphoric, irritable, angry,
furious, anxious, fearful, panicked, or feeling fine ( perhaps despite events that would lead one
to expect differently.
The observer may note the following: the affect and its quality and appropriateness, the ability of
the patient to describe this emotional life, such behaviors as retardation, agitation, lability,
irritability, suspiciousness, defensiveness, impulsiveness, the communication of quilt, shame,
worry, self-deprecation, or suspiciousness; and how the patient affects the examiner (e.g.,
producing fright, boredom, sadness, hopelessness, or anxiety).
Orientation and Memory
Now I would like to ask you some routine questions to test your memory. Some of these
questions may seem a little sill, but being sick can affect our ability to think clearly, and its
important that I check you.
-Let me first ask you some simple questions. Do you know todays date?
-What day did you get admitted?
-Can you give me your address and phone number?
The most frequently employed formal tests of the mental status involve examination for the
ability to identify person (patients name, age, and birth, date, or the name and occupation or
function of the examiner or another familiar person), place (the name of the institution or type of
building the patient is in and where it is located), and time (date, day of week, hour and season).
Person
-What is my name/occupation?
-You know who I am, dont you?
Place
-Where are we right now?
-What is the name of this place?

-What kind of place is this?


-What city are we in? What state?
-How long have you been here?
-Have you been here long?
Time
-What is todays date/year, month, date?
-What day of the week is it?
-About what time is it?
-What season of the year is it now?
-What year is it this year? Do you know that?
-Do you remember what day of the week it is?
Memory
-Long term, or remote, memory is tested by obtaining either verifiable personal information
or widely know historical facts.
Birth date, address, phone number, names and birthdays of children or relatives.
Name the last four Presidents of (country) or describe major historical events
-Recent memory is tested by inquiring about orientation or asking the patient to recall verifiable
events of the past few days
-How long have you been in hospital?
-Who is the doctor here?
-Did you get any test today? What tests were done yesterday?
-Can you recall any recent news?
-Do you remember when you were born?
-What month were you born in?
-Do you remember what time of the month? What was the date?
-Immediate recall (sometimes called registration, short-term memory, or immediate retention) is
tested by digit or phrase repletion, and overlaps with attention.
Thought Content and Process
The content of thought includes major concerns (worries, conflicts, interests, feelings of
inadequacy, longings, ambition, somatic preoccupations), obsessions, phobias, perseverations,
strange experiences, suicidal or homicidal ideation, and various distortions of perception such as
disturbances in the sense of self (depersonalization, derealization) or of the control of thinking.
Questions about thought content and process:
Delusions
Delusions are fixed, false beliefs that are not in keeping with the patients culture and that often
contain misinterpretations or a finding of special meaning in events (e.g., a sense of being
singled out or being paid special attention, or of being persecuted or influenced).
-Have you felt that people have been taking special notice of you?

-have you noticed that the television or newspapers have had messages especially for you?
-Have other people been able to control your thoughts or read your mind?
Hallucinations
Hallucinations are false sensory impressions, either auditory, gustatory, olfactory, or tactile.
-Have you heard voices?
-Have you heard your thoughts out loud, as if they were spoken?
-Have you seen anything unusual, perhaps things that do not really exist?
Illusions
Illusions are misinterpretations of real experiences (e.g., a delirious patient thinks the doctor in
the white coat is an ice cream vendor).
Bizarre, paranoid, or grandiose thinking
-Are there thoughts that continually run through your mind/frighten you?
-Do you ever have a feeling that people are talking about your or watching you?
Homicidality and suicidality
-Have you had thoughts about harming others/yourself/about taking life?
-Have you ever considered suicide in the past?
-Have you attempted suicide? If yes, tell me more.
-How serious are you?
-How would you do it?
-Do you have any plans for doing it?
-Do you have the means (pills, gun other) to hurt yourself?
-Could you stop yourself?
-What keeps you from doing it?
-Would you be able to call for help before you did anything serious?
-Sometimes people who are upset (or very ill) have unusual (or frightening) thoughts. Has this
happened to you?
-have you heard or seen things that turned out not to really be there or that others could not hear
or see?
Insight and Judgment
The term insight refers to the patients ability to understand that he or she is suffering from an
illness.
-Why are you here today? Did you want to come?
-Do you think anything is wrong with your? Why?
-Do you have a physical illness?
-Do you have trouble with your thinking/emotions?
-Have you changed?
-What do the doctors (or family, or others) make of it?
-What do the tests show?
-Do you believe you are thinking clearly?

-Do you think you need any help? What kind?


-Do you think you will get better?
-What are your plans for the future?
Judgment is best described in medicolegal terms: Does the patient appreciate the consequences
of various actions? For example, what if treatment were foregone?
-Is the patient able to reason about actions and their consequences?
-Does the patient act impulsively?
-Would the patient act on the basis of delusional beliefs or hallucinatory perceptions/ on wishful
thinking?
-What is his or her capacity for homicidal or suicidal behavior?
-What is the basis for the patients reasoning? Is such judgment appropriate to the patients age
and cultural background?
Higher Cognitive Function
Fund of Knowledge
Calculation
Cognitive or intellectual function may be conceptualized as involving either basic levels, such as
consciousness, attention, concentration, orientation, and memory (and, in some schemes,
language and thought) or higher functions, such as fund of information, calculations, and
abstraction 9 and, in some schemes, insight and judgment). Tests of visual perception and
constructional ability may also be included under higher cognitive function or higher intellectual
function.
For patients with intact basic cognitive abilities, you should learn to characterize the higherlevel functions, especially fund of information and calculation. Tests of such higher intellectual
functions can also be used to screen for defects of basic cognitive function, since, for instance,
calculations are dependent of attention as well as arithmetic ability.
You need to inquire about the patients level of education, type of employment, and cultural
background in order to estimate his or her optimal level of cognitive functioning.
-How are you at figures?
-How would you do in subtracting 7 from 100? Try it?
-Simple addition, subtraction, multiplication: What would you get in change if you bought a 15ruble juice with a fifty ruble bill?
-In order to test your concentration, I would like to ask you to try the following: Repeat this
number, 1 6 7 4 3 Thats fine. Now lets try a longer number.
-You moved to (the domicile) in 1986. So about how many years have you been living there?
-Who is the President? Who was President before him?
-Do you recall any recent important news?
-What have you read in the paper or heard on the news?
-Do you know anything about what is going on in the United States, for example?
-Name four large cities in Russia.
-Why are these people famous? (name some famous people)
-What is the similarity between a plum and a peach/a plane and a boat?
-Red and blue are colors. A chair and a table are both what?
Proverb interpretation:

-Tell me what people mean when they say:


-People in glass houses should not throw stones.
-Dont cry over spilled milk.
-A rolling stone gathers no moss.
-Write your name/draw a clock with the correct time/ copy this figure (give a person a picture
with a figure)