MENTAL STATUS EXAMINATION

PERSONAL DATA:

Name: Date:
Address: Time:
Age: Sex: Civil Status: Occupation:
Nationality: Religion:
Date of Admission: Reason of Admission:
Medical Diagnosis:
Attending Physician:

I-GENERAL DESCRIPTION
General Appearance

Behavior & Psychomotor Activity

A. General Mobility
a. Posture & Gait

b. Actions & Gestures

( ) Normal ( ) Inappropriate
Justification:

Reaction:
( ) Normoactive ( ) Psychomotor Retardation
( ) Rigidity ( ) Agitated
Justification:

c.Facial Expression
( ) Smiling ( ) Worried ( ) Sad
( ) Ecstatic ( ) Tense ( ) Tearful
( ) Happy ( ) Frightened ( ) Distant
( ) Angry ( ) Suspicious

B. Behavior
( ) Depressed ( ) Impulsive ( ) Angry
( ) Embarrassed ( ) Negativistic ( ) Seductive
( ) Indifferent ( ) Withdrawn ( ) Manic
Justification:

C. NURSE-PATIENT INTERACTION
a. Attention
( ) Cooperative ( ) Uncooperative
( ) Initially ( ) Lately ( ) All through out
Justification:
b. Quality
( ) Warm ( ) Distant ( ) Dependent
( ) Hostile ( ) Suspicious ( ) Talkative
Justification:

II. EMOTIONAL STATE & REACTION MOOD

a. Mood
( ) Depressed ( ) Angry ( ) Frightened
( ) Anxious ( ) Suspicious ( ) Talkative
Justification:

b. Affect
( ) Appropriate ( ) Inappropriate
Justification:

c. Quality
( ) Flat ( ) Blunted
Justification:

III. NEUROVEGETATIVE FUNCTION

A. Sleep
( ) Normal ( ) Hypersomnia
( ) Early Insomnia ( ) Late Insomnia
( ) Mixed Insomnia
Justification:

B. Appetite
( ) Normal ( ) Increased ( ) Decreased
Justification:

C. Weight
( ) Increased ( ) Decreased ( ) No Changes
Justification:

D. Diurnal Variation
E. Libido

IV. Speech & Stream of Talk

A. Character
( ) Spontaneous ( ) Deliberate ( ) Loud ( ) Talkative
( ) Whispered ( ) Mumbled ( ) Hesitant ( ) Pressured
Justification:

B. Accessibility
( ) Good ( ) Defensive ( ) Fair ( ) Mute
Justification:

C. Organization of Thoughts
( ) Relevant ( ) Irrelevant ( ) Circumstantial
( ) Tangential
Justification:

V. Perception
( ) Present ( ) Absent
Justification:

VI. Thought
A. Delusions
( ) Present ( ) Absent
Justification:

B. Suicidal Potential
( ) Present ( ) Absent
Justification:

C. Homicidal Potential
( ) Present ( ) Absent
Justification:

VII. Sensorium & Cognition

A. Orientation
( ) Time
Justification: (Impaired/Unimpaired)
( ) Place
Justification: (Impaired/Unimpaired)

( ) Person
Justification: (Impaired/Unimpaired)

B. Memory
( ) Remote
Justification:(Impaired/Unimpaired)

( ) Recent
Justification: (Impaired/Unimpaired)

( ) Recent Past
Justification: (Impaired/Unimpaired)

( ) Immediate
Justification: (Impaired/Unimpaired)

C. Attention Span
( ) Good ( ) Fair ( ) Poor
Justification:

D. Calculation:

E. Spelling

F. Abstract Thinking Ability

J. JUDGEMENT and INSIGHTS

Judgement
( ) Impaired ( ) Unimpaired
Justification:

Insight
( ) Impaired ( ) Unimpaired
Justification:

H. Summary of Mental Status

A. Disturbances in:
( ) General Description
( ) Emotional State & Reaction Mood
( ) Neurovegetative Function
( ) Speech & Stream of Talk
( ) Perception
( ) Thought
( ) Sensorium & Cognition
( ) Judgement & Insights

Diagnostic Category
( ) Psychotic ( ) Non-Psychotic
Justification:

B. DSM IV Diagnosis
Axis I
Axis II
Axis III
Axis IV
Axis V
 MENTAL STATUS EXAMINATION

 MSE describes the sum total of the examiners observations

and impressions of the psychiatric patient at the time of
interview.
 The MSE is the description of the patient’s appearance,
speech, action, and thoughts during the interview.
 Patient’s MSE can change from day to day or hour to hour.

OUTLINE OF THE MSE AND ITS EXPLANATION

I. GENERAL DESCRIPTION

A. APPEARANCE- describes the patient’s appearance and

overall physical impression as reflected by posture, poise,
clothing and grooming.
Ex: Terms like healthy, sickly, ill, at ease, poised, old looking,
young looking, disheveled, childlike and bizarre.

B. OVERT BEHAVIOR AND PSYCHOMOTOR ACTIVITY

 refers to the quantitative and qualitative aspects of the
patient’s motor behavior.
 Ex: Mannerisms, gestures, twitches, hyperactivity, agitation,
combativeness, flexibility, rigidity, gait, restlessness, wringing
of the hands, pacing or generalized slowing down of the body
movements.
C. ATTITUDE TOWARD EXAMINER
 May be describe as cooperative, friendly, attentive,
interested, frank, seductive, defensive, hostile, playful,
guarded and the level of rapport should be recorded.

II. MOOD AND AFFECT

A. MOOD
 mood is defined as a pervasive and sustained emotin that
colors the perception of the world.
 Terms used to describe mood: depressed, despairing,
irritable, anxious, angry, euphoric, empty, guilty, and
frightened.
B. AFFECT
 Defined as the patient’s present emotion responsiveness,
inferred from the patient’s facial expression, including the
amount and the range of expressive behavior.
 Affect may be described as within normal range, blunted or
flat, there is variation in the facial expression, tone of voice,
use of hands and body movements.
C. APPROPRIATENESS OF AFFECT
 appropriateness on the patient’s emotional response in the
context of the subject the patient is discussing.
  Ex: Flattened affect when speaking about murderous
impulses.

III. SPEECH CHARACTERISTICS

 describe the physical characteristics of speech.
 Described in terms of its quantity, rate of production and
quality.
 Terms used: talkative, unspontaneous, or normally
responsive to cues from the interviewer.
 Speech may be rapid, slow, hesitant, emotional, dramatic,
monotonous, loud, whispered, slurred, staccato, stuttering, or
mumbled.

IV. PERCEPTION
 perceptual disturbances like hallucinations and illusions may
be experienced in reference to the self or environment.
 Ex: feelings of depersonalization- the feeling of detachment
form self or the environment, formicating- the feeling of bugs
crawling on or under the skin.

V. Thought content and mental trends

A. THOUGHT PROCESS
 refers to the way in which the person put together ideas and
association, the forms in which the person thinks.
 Process or forms may be logical and coherent or completely
illogical or incomprehensible.
 Ex: Flight of Ideas- rapid thinking, loose association- ideas
expressed appear to be unrelated, blocking- is an
interruption of the train of thought before an idea has
completed, circumstantiality- indicates the loss of capacity for
goal-directed thinking.
B. THOUGHT CONTENT
 Refers to what a person is actually thinking about: ideas,
beliefs, preoccupations, and obsessions.
 Ex: delusions, obsession, compulsions, phobias, recurrent
ideas about suicide/homicide, and specific antisocial behavior.

VI. SENSORIUM AND COGNITION

 seeks to assess organic brain function and the patient’s
intelligence, capacity for abstract thought, and level of insight
and judgment.
 Perfect score is 30

A. CONSCIOUSNESS
 Disturbances in the consciousness usually indicate organic
brain impairment
 Some terms used to described the LOC are clouding-overall
reduced awareness of the environment, stupor, coma,
lethargy, and alertness.

B. ORIENTATION AND MEMORY

 Ask patient that would assess if he is oriented to time, place
and person.
 Ask questions that would assess remote memory, recent past
memory, recent memory, and immediate retention and recall.
  Recent memory- ask what he ate in the breakfast?
 Immediate retention- repeat six digits forward and the
backward
 Remote- ask his childhood days.
 Recent past memory- recall important events from the past
few months
 Used to cover up memory loss is confabulation- making up
false answers unconsciously.

C. CONCENTRATION AND ATTENTION

 Patient’s concentration may be disturbed due to anxiety,
depression, internal stimuli such a auditory hallucinations.
 Attention is assessed by calculations or by asking the patient
to spell the word backward. The patient can also name five
things that start with particular letter.
D. READING AND WRITING
 The patient should be asked to read a sentence like “close
your eyes and then do what the sentence says”
 The patient should be asked to write a simple but complete
sentence

E. VISUOSPATIAL ABILITY
 The patient should be asked to copy a figure such a s clock
face or interlocking pentagons.
F. ABSTRACT THOUGHT
 abstract thinking is the ability to deal with concepts.
 Can patients explain the similarities such as those between an
apple and a pear or those between truth and beauty?
 Answers may be concrete- give specific examples to illustrate
the meaning, the answers should be noted because in
catastrophic reaction brain damaged person become
extremely emotional and cannot think abstractly.
G. INFORMATION AND INTELLIGENCE
 the patient’s intelligence is related to the vocabulary and
general fund of knowledge.
 The education level and socioeconomic status should be taken
into account.
 Mental task may be assessed such as counting the change
from P10 after a purchase of P6.37? or how many 25
centavos in three pesos?

VII. IMPULSIVITY
 an assessment of impulse control is critical in ascertaining the
patient’s awareness of socially appropriate behavior and is a
measure of the patient’s potential danger to self and others.
 Patients may unable to control impulses secondary to
cognitive and psychotic disorders or personality disorders.
 Assessment like the patient is capable of controlling sexual,
aggressive, and other impulses?

VIII. JUDGEMENT AND INSIGHTS

A. JUDGEMENT
 during the course of history taking the examiner should
assess the aspects of the patients capability of social
judgment.
  Assessment like does the patient understand the likely
outcome of his or her behavior? Does his understanding
influence him? Can the patient predict what he or she would
do in imaginary situation?
B. INSIGHT
 insight is a patient’s degree of awareness and understanding
about being ill.
 A summary of levels of insights as follows:
a. complete denial of illness
b. slight awareness of being sick and
needing help but denying it at the same
time
c. awareness of being sick but blaming it
on others, on external factors or on
organic factors.
d. Awareness of illness is due to something
unknown in the patient.
e. Intellectual insight- admission that the
patient is ill and the symptoms of
failures in social adjustments are due to
patient’s own particular irrational
feelings or disturbances without
applying this knowledge to future
experiences.
f. True emotional insight- emotional
awareness of the motives and feelings
within the patient and the important
people in his or her life which can lead
to basic changes in behavior.

IX. RELIABILITY
 the MSE concludes with the psychiatrist impression of the
patient. Reliability and capacity to report his or her situation
accurately.
 Ex: If the patient admits about use of active substances and
knows may reflect badly then patient’s reliability is good.