Mental Status Exam

what is mental status?

-total expression of a patient’s emotional responses, mood, cognitive functioning, & personality

what are the different types of mental status assessments?

-brief observations during general patient encounter

-brief screening tool < 5min

-comprehensive screening tool (10-20min)

-formal neuropsych eval

what are the general components of mental status?

-physical appearance

-behavior

-emotional status

-speech & language

-cognitive abilities

-thoughts & perception

-insight & judgement

what are the indications for a comprehensive mental status exam?

-patient seen in ED

-patient being referred for psych consult

-patient being admitted to psych unit

-age > 40 (55 clinically)

-Hx of psych d/o, substance abuse, organic brain d/o, or physical d/o that can affect brain function

-recent deterioration of patient’s personal habits, memory, concentration, or grasp

-clinical clues of current mood d/o, psychosis, or organic brain dysfunction

-PE indicates brain dysfunction

-forensic referrals (mental competence or legal insanity are being questioned)

how is physical appearance assessed?

-thru out pt interview & assessment

-take note of demographics, body habitus, clothing, hygiene, & odor

what data points should be included for physical appearance?

-demographics

-distinctive features

-clothing

-posture, gait, & body habitus

-grooming, self-care, & hygiene

-physical health

-odors

what are the 3 main components of the behavior assessment?

-motor activity

-eye contact

-interpersonal style/behavior

what data points should be included in the behavior assessment of motor activity?

-facial expressions

-posture

-body movements

when describing eye contact for the behavior assessment, what are the typical categories?

-good/appropriate

-sporadic

-fleeting

-poor

-none

what is akathisia?

-excessive motor activity

a patient’s posture can provide insight into what?

-mental health

what data points are included in the emotional status assessment?

-mood

-affect

what is mood?

-patient’s pervasive & sustained emotional state that usually shows underlying emotion of the patient

which is subjective: mood or affect?

-mood

how is mood assessed?

-direct questions = how is your mood? how have you been feeling lately?

what is affect?

-objective observation of a patient’s emotional state by noting posture, body movements, facial expressions, & tone of voice

when assessing a patient’s affect, what should you be noting?

-intensity

-quality

-fluctuation

-range

-is it situational

why should you assess mood & affect when determining a patient’s emotional status?

-b/c they should be congruent & appropriate

how is a patient’s speech & language assessed?

-thru out encounter

when assessing a patient’s speech & language, what data points should you note?

-rate of speech

-quantity of speech

-volume

-fluency of speech

-expressive language

-receptive language

what is expressive language?

-language being spoken by the patient

what is receptive language?

-language being interpreted by the patient (ability to understand)

does a patient’s ability to listen to you speak fall into expressive or receptive language?

-receptive

how can you quickly assess a patient’s speech & language?

-determine patient’s 1st language

-assess understanding

-test understanding

-assess spontaneous speech

-assess fluency & word choice

-assess word-finding ability & naming

-assess repetition

-assess severity of speech impairment

what is “blocking”?

-when you blank on a word & feel like its on the tip of your tongue

-normal in moderation

what is aphasia?

-language disorder characterized by impairments in expressive language, receptive language, or both

what are the 3 broad types of aphasia?

-fluid

-non-fluid

-global

what are the 2 most common types of aphasia?

-Wernicke’s aphasia

-Broca’s aphasia

if you suspect your patient might have speech dysfunction, what must you rule out?

-hearing issues

what is dysphonia?

-dysfunctional voice production

what is dysarthria?

-dysfunctional articulation of words

what is Broca’s aphasia?

-difficulty reading aloud w/o difficulty with comprehension due to a lesion that affects the frontal lobe

Broca’s aphasia is caused by a lesion where?

-frontal lobe

what is the hallmark feature of Broca’s aphasia?

-slow, effortful, MEANINGFUL speech with excessive repetition

what is Wernicke’s aphasia?

-difficulty reading aloud & comprehending speech due to posterior superior temporal lobe damage

Wernicke’s aphasia is caused by dysfunction of _____

-posterior superior temporal lobe

what are the 2 hallmark features of Wernicke’s aphasia?

-fluent, rapid, NONSENSE speech

-malformed & invented words

a patient with Wernicke’s aphasia would show impairment of what skills?

-word comprehension

-repetition

-naming of items

-writing

what is the most common cause of Wernicke’s aphasia?

-post-stroke

what is the most common cause of Broca’s aphasia?

-post-stroke

a patient with (Wernicke’s/Broca’s) aphasia is likely to have motor deficits

-Broca’s

a patient with (Wernicke’s/Broca’s) aphasia is likely to have visual deficits

-Wernicke’s

fatiguable dysphonia is associated with what condition?

-myasthenia gravis

gravelly dysphonia is associated with what conditions?

-vocal cord lesions

-inflammatory arthritis

soft dysphonia is associated with what condition?

-Parkinson’s dz

deep dysphonia is associated with what condition?

-hypothyroidism

raspy dysphonia is associated with what condition?

-laryngopharyngeal reflux

what are common causes of dysphonia?

-acute & chronic laryngitis

-functional/aging

-malignant lesions

-benign nodules/cysts of vocal cords

-neuro conditions

-systemic conditions

what neurological conditions are known for causing dysphonia?

-MS

-Parkinson’s dz

-myasthenia gravis

what systemic conditions are known for causing dysphonia?

-hypothyroidism

-RA

-SLE

how do you assess for dysphonia? what findings are indicative of the presence of dysphonia?

-have patient state name & address

• unable to produce normal volume OR speaks in a whisper

-have patient cough

• absence of typical explosive start

-have patient say “eeeeee”

• unable to sustain note

if a patient with dysphonia attempts to state their name & address, what would you expect to hear?

-abnormal low speech volume OR whisper speech

if a patient with dysphonia has a normal-sounding cough, what is the most likely cough?

-local laryngeal pathology

if a patient with dysphonia has a cough w/o the expected explosive start, what is the most likely cause?

-vocal cord palsy

if a patient with dystonia can’t hold prolonged notes, what is the most likely cause?

-myasthenia gravis

the speech of a patient with dysarthria typically sounds ______

-slurred or unintelligible

what are the 7 types of dysarthria?

-ataxic

-flaccid

-hyperkinetic

-hypokinetic

-mixed

-spastic

-unilateral UMN

how do you assess for dysarthria?

-have patient repeat difficult phrases (yellow lorry, baby hippopotamus) → note rhythm of words, slurring, & which sounds cause difficulty

what 2 phrases are used for assessing dysarthria?

-yellow lorry

-baby hippopotamus

what phrase should you have a patient with dysarthria repeat to test lingual sounds?

-yellow lorry

what phrase should you have a patient with dysarthria repeat to test labial sounds?

-baby hippopotamus

when documenting a patient’s dysarthria, how should you note the severity?

-as a percentage of how intelligible speech was

what are the components of the sensorium & cognition assessment?

-level of consciousness

-orientation

-memory

-concentration & attention

-reading & writing

-abstract thinking

what is the normal state of consciousness?

-state of wakefulness, awareness, & alertness that most patients function at while being awake

what are the 5 main levels of consciousness?

-alert

-lethargy

-obtundation

-stupor

-coma

how does an alert patient appear?

-responds appropriately to verbal & physical stimuli

how does a lethargic patient appear?

-severely drowsy

-aroused by moderate stimuli & then drifts back to sleep

-1 step below alert

how does an obtunded patient appear?

-lessened interest in environment

-slow responses to stimulation

-sleeps more than normal

-drowsy when not sleepy

-step below lethargic

how does a stuporous patient appear?

-only aroused by vigorous, repeated stimuli

-when left undisturbed, immediately lapses back to unresponsive state

-step below obtunded

how does a comatose patient appear?

-in a state of unarousable unresponsiveness

what are the 2 levels of consciousness between alert & lethargic?

-clouding of consciousness (1a)

-confusional state (1b)

how does a patient in a clouding of consciousness state appear?

-very mild altered mental status

-inattention

-reduced wakefulness

-closer to alert than lethargic

how does a patient in a confusional state appear?

-more profound deficit

-disorientation

-bewilderment

-difficulty following commands

-closer to lethargic than alert

what are the commonly used standard scales for documenting a patient’s level of consciousness?

-Grady Coma Scale

-Glasgow Coma Scale

what is a vegetative state?

-form of altered consciousness where the patient appears to be awake but doesn’t respond meaningfully to outside world

what is locked-in syndrome?

-rare catastrophic state of quadriplegia & anarthria with preserved consciousness

what is anarthria?

-speechlessness due to severe dysarthria

what are the 2 requirements of locked-in syndrome?

-retained alertness & cognitive abilities

-paralysis of limbs & oral structures

what is brain death?

-irreversible loss of all brain functions (including brainstem)

what are the 3 essential findings of brain death?

-coma

-absence of brainstem reflexes

-apnea

what are the 4 components of a patient’s orientation?

-person

-place

-time

-situation

what data points are used to determine if a patient is oriented to person?

-name

-address/phone number

-age

-occupation

-marital status

what data points are used to determine if a patient is oriented to place?

-building/room

-city

-county

-state

what data points are used to determine if a patient is oriented to time?

-day of week

-date

-month

-year

what does it mean if a patient is A&Ox1?

-oriented to person

what does it mean if a patient is A&Ox2?

-oriented to person & place

what does it mean if a patient is A&Ox3?

-oriented to person, place, & time

what does it mean if a patient is A&Ox4?

-oriented to person, place, time, & situation

what are the components of a higher cognitive functioning assessment? what does each entail?

-attention = ability to focus based on internal or external priorities

-executive functioning = ability to complete a task

-gnosia = ability to name objects & their function

-language = verbal & written

-memory = recent & past events

-orientation = ability of a patient to recognize their place in time & space

-praxis = ability to carry out intentional motor acts

-prosody = ability to recognize emotional aspects of language

-thought content & process

-visuospatial proficiency = ability to perceive & manipulate objects/shapes in space

what is concentration?

-capacity to maintain mental effort despite distraction

what are the clinical tests of attention & concentration?

-subtract 7s & 3s serially from 100

-reverse days of week or months of year

-spell simple words forwards & then backwards

-repeat digits forward & backward

-perform mental arithmetic

what are the 3 stages of memory?

-registration

-short-term memory

-long-term memory

what is amnesia? what is the difference between retrograde & anterograde amnesia?

-memory loss

-retrograde = loss of memory of past events

-anterograde = inability to form new memories

what is dysmnesia?

-distortion of memory

what is retrospective falsification?

-unconscious distortion of past memories to conform to a patient’s emotional/situational needs

what is confabulation?

-creating false memories to fill holes in a timeline, but wholeheartedly believing the false memory

what are clinical tests of immediate recall?

-repeat digits forward & backward

-repeat 3 unrelated words

-repeat 3 3-part words

what are clinical tests of recent memory?

-repeat 3 unrelated words after 1, 3, & 5min

-repeat 3 3-part words after 1, 3, & 5min

-recall events in recent past

-recount a short, simple story with as many details as possible

what is the clinical test of remote memory?

-recall parents’ names, date & place of birth, graduation dates, age & year of marriage, & occupational Hx

what components are included in the assessment of abstract thinking?

-similarities

-differences

-proverbs

-concrete vs abstract responses