Mental Status Examination

I would like to share a mental status examination checklist and reminders to all psychology students out there and to all those who are interested in psychology and mental health. This examination is vital to psychologists and other mental health professionals as it provides them with details about the patients problems which facilitiates sufficient and right intervention for the sucess of the therapy. anyways i just want to post this because classes have started and i would like to review the things we took up last semester and at the same time share with you the information i have gathered whilst i was studying my abnormal psychology subject.

This is the mental status examination i made which is an integrated checklist from other sources.

i got me a 97 grade for this.

Discussion of Form:

Client description: Ask patients their name or what name they prefer to be called. If the patient is a child or adolescent, asking what grade the patient is in also may be appropriate. Also, ask patients their marital status, occupation, religious belief, and living circumstance. Also document their sex and race in this section.

 

Problem Description: This is the patient’s problem or reason for the visit. Most often, this is recorded as the patient’s own words, in quotation marks. This statement allows identification of the problem by identifying symptoms that lead to a diagnosis and, eventually, a specific treatment plan. To elicit this response, the interviewer should ask leading questions such as “What brings you here today?”

 

Relevant History:

1)       Past psychiatric History: List all of the patient’s treatment, including outpatient, inpatient, and therapy-based (ie, individual, couples, family, group), including dates. Inquire about past psychotropic medications and response, compliance, and dosages. Ask patients if they feel that they received any benefits from the treatments. If so, inquire about the specific type of benefit. Additionally, ask patients which medications they feel helped them most in the past and ask which ones helped them least. From an insightful patient, this information may offer clues as to which class of medication the patient responds to best. If possible, try to obtain old psychiatric records.

 

2)       Family History: List any psychiatric or medical illnesses, including method of treatment such as hospitalization (medical and psychiatric) of family members and response. Once again, the emphasis here is strong. Record any information obtained because it may help in treatment planning. If a patient’s family member has been diagnosed with the same psychiatric illness and has been treated successfully, treating the current patient with that same medication may be appropriate

 

3)       Social History: 

Ÿ          Ask patients their marital status. Also, inquire about employment status. If the patient is employed, inquire about the frequency of absences from work. If the patient is not employed, inquire about whether the patient currently is looking for work. Also inquire if a previously held job was lost as a result of the illness. Obtain as much detailed information as possible.

Ÿ          Recording an accurate educational history is imperative. Inquire how far the patient went in school. Ask if he or she was in special education classes. Ask if the patient has a learning disability and if the patient has any other problem such as a hearing impairment or speech problem. These issues are very important in the evaluation of patients undergoing psychiatric assessment, and patient care could be jeopardized if they are not addressed. A patient’s communication problems, for example, could be due to a language disorder rather than a thought disorder, and the initiation of psychiatric medications could further affect communication, not to mention cause legal concerns for the prescribing physician. All of these things must be kept in mind at all times when completing the social history.

Ÿ          Record the number, sex, and age of the patient’s children. Ask if any of the children have any medical or psychiatric problems. List the patient’s toxic habits, including past and current use of tobacco, alcohol, and street drugs. This is important because many patients can become dependent on prescribed medications. Try to determine whether the patient has a history of drug abuse.

Ÿ          Include any military history, including length of service and rank. This could help determine if a patient is eligible for US Veterans Administration benefits or other assistance.

Ÿ          Another important issue in obtaining a very thorough patient history is the patient’s housing status. This becomes a vital part of the discharge plans. Ask if the patient has a home. Inquire if they have a family and if they have contact with that family. Ask where the patient will go at the completion of his or her hospital stay. Also ask who will ensure that the patient remains compliant with medication therapy. These become crucial points when finding placement for patients at discharge and planning long-term follow-up care. Therefore, careful recording of housing and support is very important.

Ÿ          Inquire about the existence (and number) of siblings, their names and phone numbers, and any church affiliations, just in case the information is needed later.

Ÿ          Also in the history section, record any legal problems the patient may have had in the past. This should include jail time, probation, arrests (eg, for driving while intoxicated or driving under the influence of drugs), and any other relevant information that can provide insight into the patient’s problems with the law.

Ÿ          Patient history also should include hobbies, social activities, and friends. If the patient has any history of abuse, mental or physical, it should be recorded here. Any other relevant information that may be useful in treating the patient or helpful in aiding in aftercare should be recorded in the patient history.

Ÿ          Inquire about the patient’s and the patient’s parents’ religious beliefs. Did the patient grow up in a strict religious environment? Does the patient have a particular religious belief and has that changed since childhood, adolescence, or adulthood? Investigate what effect the patient’s beliefs have on treatment of psychiatric illnesses or suicide.

 

4)       Past surgical history: List all surgical procedures the patient has undergone, including dates. Be as specific as possible when recording dates, and obtain medical records for review when possible. Patients may not volunteer this information unless asked specifically about operations.

5)       Perinatal and developmental History: Record any relevant perinatal and developmental history. Ask if the patient was born prematurely. Ask about any complications associated with their birth. Ask if they were told how old they were when they spoke their first word or took their first step..

  

6)       Assets: List attributes of the patient. Examples may include that the patient agreed to voluntary acceptance of treatment, has strong verbal skills, or exhibits above average intelligence, just to name a few.

 

Diagnostic impressions:

 

Mental Status : List all relevant impairment or problems in cognition, appearance, hygiene, mood, affect, orientation, manner and approach, thought processes and thought content.

 

Mood: Ask questions such as “How do you feel most days?” to trigger a response. Helpful answers include those that specifically describe the patient’s mood, such as “depressed,” “anxious,” “good,” and “tired.” Elicited responses that are less helpful in determining a patient’s mood adequately include “OK,” “rough,” and “don’t know.” These responses require further questioning for clarification.

 

Affect:  A patient’s affect is defined in the following terms: expansive (contagious), euthymic (normal), constricted (limited variation), blunted (minimal variation), and flat (no variation). A patient whose mood could be defined as expansive may be so cheerful and full of laughter that it is difficult to refrain from smiling while conducting the interview. A patient’s affect is determined by the observations made by the interviewer during the course of the interview.

 

Speech: Document information on all aspects of the patient’s speech, including quality, quantity, rate, and volume of speech during the interview. Paying attention to patients’ responses to determine how to rate their speech is important. Some things to keep in mind during the interview are whether patients raise their voice when responding, whether the replies to questions are one-word answers or elaborative, and how fast or slow they are speaking.

 

Thought process: Record the patient’s thought process information. The process of thoughts can be described with the following terms: Throughout the interview, very specific questions will be asked regarding the patient’s history. Note whether the patient responds directly to the questions. For example, when asking for a date, note whether the response given is about the patient’s favorite color. Document whether the patient deviates from the subject at hand and has to be guided back to the topic more than once. Take all of these things in to account when documenting the patient’s thought process.

 

Thought content

1. To determine whether or not a patient is experiencing hallucinations, ask some of the following questions. “Do you hear voices when no one else is around?” “Can you see things that no one else can see?” “Do you have other unexplained sensations such as smells, sounds, or feelings?”
2. Importantly, always ask about command-type hallucinations and inquire what the patient will do in response to these commanding hallucinations. For example, ask “When the voices tell you do something, do you obey their instructions or ignore them?” Types of hallucinations include auditory (hearing things), visual (seeing things), gustatory (tasting things), tactile (feeling sensations), and olfactory (smelling things).
3. To determine if a patient is having delusions, ask some of the following questions. “Do you have any thoughts that other people think are strange?” “Do you have any special powers or abilities?” “Does the television or radio give you special messages?” Types of delusions include grandiose (delusions of grandeur), religious (delusions of special status with God), persecution (belief that someone wants to cause them harm), erotomanic (belief that someone famous is in love with them), jealousy (belief that everyone wants what they have), thought insertion (belief that someone is putting ideas or thoughts into their mind), and ideas of reference (belief that everything refers to them).

Aspects of thought content are as follows:

• Obsession and compulsions: Ask the following questions to determine if a patient has any obsessions or compulsions. “Are you afraid of dirt?” “Do you wash your hands often or count things over and over?” “Do you perform specific acts to reduce certain thoughts?” Signs of ritualistic type behaviors should be explored further to determine the severity of the obsession or compulsion.
• Phobias: Determine if patients have any fears that cause them to avoid certain situations. The following are some possible questions to ask. “Do you have any fears, including fear of animals, needles, heights, snakes, public speaking, or crowds?”
• Suicidal ideation or intent: Inquiring about suicidal ideation at each visit is always important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent. “Do you have any thoughts of wanting to harm or kill yourself?” “Do you have any thoughts that you would be better off dead?” If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views suicide to determine if a suicidal gesture or act is ego-syntonic or ego-dystonic. Next, determine if the patient will contract for safety. For homicidal ideation, make similar inquiries.
• Homicidal ideation or intent: Inquiring about homicidal ideation or intent during each patient interview also is important. Ask the following types of questions to help determine homicidal ideation or intent. “Do you have any thoughts of wanting to hurt anyone?” “Do you have any feelings or thoughts that you wish someone were dead?” If the reply to one of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how he or she plans to control these feelings if they occur again.
• Cognition: Perform the Folstein Mini-Mental State Examination; Cognition refers to the act or condition of knowing. The evaluation assesses the person’s orientation (ability to locate himself or herself) with regard to time, place, and personal identity; long- and short-term memory; ability to perform simple arithmetic (counting backward by threes or sevens); general intellectual level or fund of knowledge (identifying the last five Presidents, or similar questions); ability to think abstractly (explaining a proverb); ability to name specified objects and read or write complete sentences; ability to understand and perform a task (showing the examiner how to comb one’s hair or throw a ball); ability to draw a simple map or copy a design or geometrical figure; ability to distinguish between right and left.
• Consciousness: Levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness.
• Orientation: To elicit responses concerning orientation, ask the patient questions, as follows. “What is your full name?” (ie, person). “Do you know where you are?” (ie, place). “What is the month, date, year, day of the week, and time?” (ie, time). “Do you know why you are here?” (ie, situation).
• Concentration and attention: Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as “serial 7s.” Next, ask the patient to spell the word “world” forward and backward.
• Reading and writing: Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, “Close your eyes.”). This part of the MSE evaluates the patient’s ability to sequence.
• Visuospatial ability: Have the patient draw interlocking pentagons in order to determine constructional apraxia.
• Memory: To evaluate a patient’s memory, have them respond to the following prompts. “What was the name of your first grade teacher?” (ie, for remote memory). “What did you eat for dinner last night?” (ie, for recent memory). “Repeat these 3 words: ‘pen,’ ‘chair,’ ‘flag.’ ” (ie, for immediate memory). Tell the patient to remember these words. Then, after 5 minutes, have the patient repeat the words.
• Abstract thought: Assess the patient’s ability to determine similarities. Ask the patient how 2 items are alike. For example, an apple and an orange (good response is “fruit”; poor response is “round”), a fly and a tree (good response is “alive”; poor response is “nothing”), or a train and a car (good response is “modes of transportation”). Assess the patient’s ability to understand proverbs. Ask the patient the meaning of certain proverbial phrases. Examples include the following. “A bird in the hand is worth 2 in the bush” (good response is “be grateful for what you already have”; poor response is “one bird in the hand”). “Don’t cry over spilled milk” (good response is “don’t get upset over the little things”; poor response is “spilling milk is bad”).
• General fund of knowledge: Test the patient’s knowledge by asking a question such as, “How many nickels are in $1.15?” or asking the patient to list the last 5 presidents of the United States or to list 5 major US cities. Obviously, a higher number of correct answers is better; however, the interviewer always should take into consideration the patient’s educational background and other training in evaluating answers and assigning scores.
• Intelligence: Based on the information provided by the patient throughout the interview, estimate the patient’s intelligence quotient (ie, below average, average, above average).

Insight

Assess the patients’ understanding of the illness. To assess patients’ insight to their illness, the interviewer may ask patients if they need help or if they believe their feelings or conditions are normal.

Judgment

Estimate the patient’s judgment based on the history or on an imaginary scenario. To elicit responses that evaluate a patient’s judgment adequately, ask the following question. “What would you do if you smelled smoke in a crowded theater?” (good response is “call 911″ or “get help”; poor response is “do nothing” or “light a cigarette”).

Impulsivity

Estimate the degree of the patient’s impulse control. Ask the patient about doing things without thinking or planning. Ask about hobbies such as coin collecting, golf, skydiving, or rock climbing.

Reliability

Estimate the patient’s reliability. Determine if the patient seems reliable, unreliable, or if it is difficult to determine. This determination requires collateral information of an accurate assessment, diagnosis, and treatment.

  

Medical History; List medical problems, both past and present, and all medical illnesses. At least ask a few screening questions regarding medical illnesses such as do you see a doctor regularly. If possible, try to obtain the patient’s entire medical records rather than depending solely on the patient’s self-report. Even the most minute detail of a patient’s medical history, from as far back as childhood, could play a significant role in the presenting problem. Be certain to inquire about specific events that may have occurred in childhood, such as falls, head trauma, seizures, and injuries with loss of consciousness. All of these could be relevant to their current problems.

 

Current Medication: List the patient’s current medications, including dosages, route, regimen, and whether or not the patient has been compliant. If possible, have the patient bring his or her medications to the visit. Also, inquire about past medications. Additionally, with all past medications, look for signs or patterns of noncompliance. If noncompliance issues or even drug-seeking behaviors appear evident, ask the patient who prescribed the medications and when or why the patient discontinued taking them

 

Allergies: List all drug and food allergies the patient currently has or has had in the past, and list what type of reactions the patient had to the medications

The data herein provides psychologists and other mental health professionals with guidelines in assessing and gathering data regarding the patient’s complete history. You could also use this to assess yourself and reflect upon the answers to understand more about yourself and your current woes and worries!.

so bye for now!. i will share with you new research materials i will be gathering as part of my student duties this school year, which is my last school year!… good for me!.