Mental Status Exam Notes

Assess the patient's general knowledge with simple geographical or current events questions.
Determine how the patient identifies and learns best (visual, kinesthetic, etc.).
Assess the patient's awareness of current events and basic facts (e.g., knowing who the president is).

Evaluate concentration using tasks like serial sevens (counting backward by sevens from 100), which is considered difficult.
A more common method is asking the patient to spell "world" backwards to assess their thought process.

Abstract thought assessment is crucial, especially for psychotic disorders.
Administer a common proverb and ask the patient to explain its meaning.
Example: "Kill two birds with one stone."
- A normal response would be that you can get two things done at once.
- A patient with impaired abstract thought might take the proverb literally and not understand its figurative meaning.
If English is not the patient's first language, this assessment may not be valid.

Insight: Assess the patient's understanding of their illness.
- Can they acknowledge their diagnosis and its implications (e.g., bipolar disorder and medication adherence)?
- Or do they deny their illness, possibly attributing symptoms to external factors (e.g., conspiracy theories)?
To gauge insight, review the patient's chart and ask directly if they agree with their diagnosis.
- Example: "I saw in the chart that you've been diagnosed with schizophrenia. Do you agree with that diagnosis?"
- This approach gives the patient a voice and allows you to understand their perspective.
Judgment: Evaluate the patient's decision-making abilities and understanding of consequences.
- Assess recent choices and circumstances leading to their current situation (e.g., seeking help vs. being brought in by law enforcement).

Use a rating scale (poor, fair, good) to evaluate insight, judgment, and impulse control.

Anxiety: Inquire about anxiety levels, panic attacks, obsessions, and compulsions, as anxiety is prevalent across many disease states.
- Assess the severity of anxiety (mild, moderate, severe).
Sleep: Always ask about sleep patterns, including the amount and quality of sleep.
- Determine if they are having difficulty falling or staying asleep.
- Note if the patient is sleeping excessively (e.g., 17-18 hours a day), which can indicate severe depression.

Integrate all information gathered during the mental status exam to formulate a differential diagnosis.
Consider the patient's history, symptoms, and observations.
Differentiate between drug-induced psychosis and primary psychotic disorders like schizophrenia, which require symptoms to be present for several months outside of drug use or medical conditions.

Avoid a checklist approach; engage in a natural conversation.
Start with open-ended questions to build rapport.
- Examples: "How's it going?", "Tell me about what brought you here.", "What things have been going well for you since you got here?"
Address topics as they arise in conversation, even if they are out of order.
- If a patient mentions hearing voices, explore that topic even if it was not planned for that point in the interview.
Manage tangential responses by redirecting the patient back to the topic at hand.
- Acknowledge their comments, then refocus with a direct question.
When dealing with patients who are incoherent, rely on observations, history, and collateral information.
Prioritize what the patient is saying, but also pay close attention to nonverbal cues and behaviors.
- Example: If a patient denies hearing voices but is seen talking to their wrist, document the observation.

Engage in role-playing exercises to practice conducting mental status exams.
Simulate real-life scenarios with challenging patient behaviors.
Provide constructive feedback on interview techniques, focusing on creating a comfortable and non-judgmental environment.