PA Quiz 1 - Mental Status Exam

What are the four lobes of the higher brain? What are their functions?

1. frontal - behavior, emotion, perception
2. parietal - sensory processing
3. occipital - visual processing
4. temporal - sensory processing

Which lobe of the higher brain is heavily impacted by seizures?

temporal

What are the 7 components of the limbic system?

1. amygdala (fight/flight)
2. hippocampus (memory)
3. hypothalamus (homeostasis)
4. anterior thalamus
5. cingulate gyrus
6. basal ganglia
7. septal nuclei

What is the function of the limbic system?

emotional center

In infants and children, lower brain/spinal cord are fully functional _____ and higher brain function development continues through _____.

at birth
adolescence

In adolescents, _____ maturation occurs, _____ increases, _____ thinking and _____ reasoning develop, and brain development continues through _____.

intellectual
vocabulary
abstract
logical
mid 20s

In older adults, brain _____ in weight and volume, age related changes occur in _____ function, _____ skills decline, _____ memory declines, and _____ memory remains intact.

decreases
sensory
problem solving
recent
long term

What is a mental status evaluation?

the total expression of a person's responses, mood, cognitive functioning, and personality

When is the mental status evaluation performed?

throughout the entire interaction with the patient via behavioral observations and strategic questions

What are the factors that affect mental status?

-age
-physical health
-medication/drug use
-stress
-education
-mental illness

It is important to establish _____ with the patient when performing a mental status examination.

rapport

What should be observed during a mental status examination?

-behavior
-emotional status
-grooming
-body language

What are the four main areas of assessment during a mental status examination?

1. appearance/attitude
2. behavior
3. cognitive functioning
4. thought process/content/perceptions

What are the components of appearance?

-age
-race
-gender
-grooming
-dress
-hygiene
-dentition

What are the components of behavior?

-attitude
-psychomotor activity
-eye contact
-facial expressions and reactions
-gait
-posture
-impulse control
-abnormal movements
-consciousness

What are the components of speech?

-rhythm
-tone
-rate

What are the components of language?

-voice quality
-articulation
-comprehension
-coherence
-aphasia

What is mood in terms of emotional state?

how the patient feels
**needs to come from PATIENT

What are the five moods in order from lowest to highest?

depressed, dysphoric, euthymic, elevated, euphoric

What is affect in terms of emotional state?

how the patient displays their proposed mood
**what you OBSERVE

What are the possible ranges of emotional state?

-full
-restricted
-blunted
-labile
-flat

If a patient's proposed mood does not match your observation, this is known as what?

incongruent

If a patient's proposed mood does match your observation, this is known as what?

congruent

If a patient says they are "good", but they are displaying outlandish behaviors, this is a sign of what?

euphoric feeling

When determining a patient's cognitive functioning, what are we assessing?

orientation (time, place, person)

what is your full name?
what day is it? what year?
what building are you in?

Orientation to _____ is typically lost first followed by _____. Orientation to _____ is rarely lost.

time
place
person

In what four ways can you assess a patient's concentration and attention?

1. analogies (what is similar about these objects or a ____ is to a ____ as a _____ is to a _____)
2. abstract reasoning/proverbs (a rolling stone gathers no moss)
3. calculations (serial 7 subtractions or spell a five letter word forward and backward)
4. writing ability (write your name and address or a simple sentence)

How would you assess a patient's attention span?

ask them to follow a series of short commands or repeat a short story

How would you assess a patient's execution of motor skills?

-ask them to complete a task like combing hair or putting on lipstick
-ask them to take a piece of paper, fold it in half, and put it on the floor

What are the three types of recall? How would you assess each?

1. immediate recall (3 words)
2. recent recall (events in the news)
3. long term recall (birthdays or presidents)

What is the patient's insight?

perception of current self and situation

How do you assess a patient's insight?

ask "what brought you to the hospital", "do you consider yourself in need of help", "what does this med do for you", etc.

How do you assess a patient's judgement?

given them a scenario and see how they respond

ex: "what would you do if you smelled smoke in a crowded theater?" good response=call 911 bad response=do nothing

What are goal orientated/linear thoughts?

thoughts that are connected and presented in a logical manner

What are the 11 thought process abnormalities?

1. circumstantial
2. world salad
3. tangential
4. perseveration
5. flight of ideas
6. echolalia
7. loose associations
8. neologism
9. concrete thinking
10. through blocking
11. confabulation

What is a circumstantial thought process abnormality?

gives all details related to a direct question

What is a tangential thought process abmormality?

goes off on a tangent about one piece of a larger question

What is a confabulation thought process abnormality?

unaware/forgetful of what happed but is able to put pieces together to make up a logical story

What are the 8 abnormalities to thought content?

1. delusions
2. suicidality
3. thought insertion/broadcasting
4. ideas of reference
5. hypersexuality
6. false perceptions
7. obsessions
8. compulsions

What are delusions?

fixed false beliefs

What is a thought insertion/broadcasting content abnormality?

patient thinks provider can put thoughts in their head or everyone can hear their thoughts

What is an ideas of reference content abnormality?

patient believes things are happening in relation to them or something they did when it is impossible that is the case

ex: I didn't do my chores yesterday and this thunderstorm is the consequence

What are obsessions and compulsions?

thoughts a patient has repeatedly and the actions they must do in response

What information about past medical history and family history would be helpful when conducting a mental health exam?

-neurological disorders
-brain injuries/seizures
-psychiatric hospitalizations
-developmental disabilities
-learning disorders
-schizophrenia
-bipolar disorder
-depression

What information about personal and social history would be helpful when conducting a mental health exam?

-emotional (current stressors, finances, marital status/problems, children)
-relationships with friends and family
-intellectual level (education, learning difficulty, job/career)
-sleeping
-eating patterns/weight loss or gain
-recreational drug use
-alcohol use

True or False:
All patients with changes in mental status should receive a complete medical evaluation.

true

What should be included in a complete medical evaluation of a patient who has changes in mental status? Why?

-urinalysis
-electrolytes
-glucose
-CBC
-renal, hepatic, thyroid function
-vitamin B12, folate and vitamin D3 levels
-toxicology screen

can help determine if there is a reversible condition that may be causing the problem

True or False
Mental state and mental status can be used interchangeably.

false

What is the Mini Mental State Exam (MMSE)?

patented (must pay to use) screening tool for cognitive impairment that takes 5-10 minutes and consists of 11 questions

What do the 11 questions of the Mini Mental State Exam (MMSE) assess?

-orientation
-registration
-attention and calculation
-recall
-language

What is the max score and normal average score for the Mini Mental Status Exam (MMSE)?

max 30
avg 27

What is the Montreal Cognitive Assessment (MoCA)?

free screening tool for cognitive impairment that sums all scores and adds one point if <12 years of formal educations

What is the max score and normal score for the Montreal Cognitive Assessment (MoCA)?

max 30
normal 26+

What domains does the Montreal Cognitive Assessment (MoCA) assess?

-attention and concentration
-executive functions
-memory
-language
-visuoconstructional skills
-conceptual thinking
-calculations
-orientation

What is the clock face drawing and what are the expectations to pass this test?

draw a large circle for the patient and have them add the numbers then ask them to draw in a specific time

patient should have numbers correctly spaced and about evenly spaced; there should be a distinction between length of hour and minute hand

What is a mental disorder?

clinically significant behavioral or psychological syndrome/pattern causing distress or impairment in function

Where can the current formulation for psychiatric diagnosis be found?

DSM-5

What are the 5 main types of mental disorders?

1. anxiety disorders
2. mood disorders
3. psychotic disorders
4. cognitive disorders
5. substance use disorders

What percentage of the population will experience an anxiety disorder?

25%

What are some of the subtypes of anxiety disorder?

-adjustment disorder
-GAD
-OCD
-panic attacks
-phobias
-PTSD
-social anxiety

The use of what medications can cause anxiety?

-antiasthma
-anticholinergics
-digoxin
-stimulants

The withdrawal of what medications can cause anxiety?

-alcohol
-antianxiety
-opioids
-sedative-hypnotics

What are common symptoms of a panic attack? What does this mimic?

-palpitations/pounding heart/accelerated heart rate/chest pain
-sweating
-trembling/shaking/paresthesias
-shortness of breath/sensation of smothering/feeling of choking
-nausea
-dizzy/unsteady/light headed/faint
-derealization/depersonalization
- fear of losing control/going crazy
-fear of dying
-chills/hot flashes

mirrors heart attack symptoms

In order to be diagnosed with depression, a patient must have how many of the symptoms for how long?

at least 5 symptoms during a 2 week period

What are the symptoms of depression?

-depressed mood for most of the day
-markedly diminished interest or pleasure in all or almost all activities
-appetite disturbances with 5% increase or decrease in weight within 1 month
-sleep disturbance
-psychomotor agitation or retardation that is observable by others
-fatigue or loss of energy
-feelings of worthlessness or excessive or inappropriate guilt
-diminished ability to concentrate or indecisiveness
-recurrent thoughts of death or suicidal thoughts, suicide attempt, or plan

The use of what medications can cause depression?

-corticosteroids

-antihypertensives

-antiparkinsonian agents

-antipsychotics

-neoplastic agents

-nonsteroidal anti inflammatory agents

-opioids

-sedative-hypnotic agents

The withdrawal of what medications can cause depression?

-stimulants

What is the pneumonic for depression symptoms? What does it stand for?

S: suicidal

I: decreased interest

G: guilty feelings or worthlessness

E: decreased energy

C: decreased concentration

A: decreased/increased appetite

P: psychomotor agitation/retardation

S: decreased/increased sleep

What is the pneumonic for suicide risk? What does it stand for?

S: male sex

A: older age/access to means

D: depression

P: previous attempt

E: ethanol abuse

R: rational thinking loss

S: social support lacking

O: organized plan

N: no spouse

S: sickness

Every _____ minutes, 1 person dies by suicide.

11

Suicide is the _____ leading cause of death for people 10-64, and the _____ leading cause of death for people ages 10-14 and 20-34.

9th
2nd

What are the mania symptoms of bipolar disorder?

D: distractibility
I: insomnia
G: grandiosity
F: flight of ideas
A: activity increase
S: speech
T: thoughtlessness/indiscretions

True or False
Someone with bipolar disorder will experience both manic and depressive episodes within the same day.

false
episodes occur throughout the year

When is the symptom onset for schizophrenia?

late teens - mid 30s

What are the positive symptoms (additions to exam) of schizophrenia?

-abnormal additions to mental status
-hallucinations
-delusions
-disorganized speech
-disorganized behavior

What are the negative symptoms (missing from exam) of schizophrenia?

-lack of function
-blunted affect
-alogia
-avolition
-anhedonia
-amotivation
-poor self care
-social isolation

What are the signs of alcohol intoxication?

-slurred speech
-incoordination
-unsteady gait
-nystagmus
-flushed face
-disinhibition of sexual or aggressive impulses
-mood liability
-impaired social or occupational function
-impaired attention
-sedation
-pinpoint pupils

What are the withdrawal symptoms of alcohol intoxication?

-nausea/vomiting
-malaise or weakness
-tremor
-anxiety
-depressed mood/irritability
-autonomic hyperactivity (tachycardia, sweating, increased BP)
-headache
-insomnia
-hyperthermia
-transient hallucinations or illusions
-delirium
-seizures

What are the signs of opioid intoxication?

-fluctuating mood
-psychomotor retardation
-impaired judgement
-impaired attention and memory
-pupillary constriction
-drowsiness
-slurred speech
-impaired social and occupational functioning

What are the withdrawal symptoms of opioid intoxication?

-lacrimation
-rhinorrhea
-mydriasis (pupillary dilation)
-piloerection
-sweating
-fever
-nausea/vomiting
-hypertension/tachycardia
-abdominal cramping
-anxiety
-craving for opioids
-insomnia
-anorexia
-agitation

What are the signs of stimulant intoxication?

-tachycardia
-pupillary dilation
-hypertension
-sweating/chills
-nausea/vomiting
-motor agitation
-euphoria
-grandiosity
-increased talking
-impaired in social and occupational function

What are the withdrawal symptoms of stimulant intoxication?

-fatigue
-insomnia/hypersomnia
-depression
-irritability
-anxiety

What are the four questions used in the CAGE substance use disorder screening?

1. have you ever felt you should cut down on your drinking

2. have people annoyed you by criticizing your drinking

3. have you ever felt guilty about your drinking

4. have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)

Delirium is most often associated with what?

medications or severe medical problems

What screening should be used to diagnose delirium?

MMSE or MoCA

What are the symptoms of delirium?

-disorientation
-confusion
-reduced attention/concentration/memory
-rambling speech
-hallucinations
-delusions
-behavioral disinhibition
-emotional lability
-irritability
-fragmented sleep/wake cycle
-tremors and abnormal reflexes

The use of what mediations can cause dementia?

-anticholinergics

-antiarrhythmics

-antibiotics

-antidepressants

-anticonvulsants

-antiemetics

-antihypertensives

-antineoplastics

-antiparkinsonians

-antihistamine/decongestant

-cardiac agents (digoxin)

-corticosteroids

-histamine receptor antagonists

-immunosuppressive agents

-narcotic analgesics

-muscle relaxants

-nonsteroidal anti inflammatory agents

-sedative-hypnotic agents

What are the common irreversible symptoms of dementia?

-primary degenerative dementia of the alzheimer type
-creutzfeldt jakob syndrome
-multi infarct dementia
-head trauma

What are the common reversible symptoms of dementia?

-intracranial tumors or trauma
-organ failure or insufficiency
-metabolic/endocrine (anemia, electrolyte abnormalities, thyroid problems, etc.)
-heavy metal poisoning
-infections
-arteriosclerotic disease
-vitamin deficiency states
-psychiatric disorders
-visual and hearing disorders