Info
🌱 來自: Huppert’s Notes
Mental Status Exam🚧 施工中
Mental Status Exam
• Appearance: Apparent age, weight, clothing, personal hygiene, odor, skin markings, etc. (Goal: Document a description with enough salient details that another provider could identify the patient on sight.)
• Behavior: Movements (i.e., resting comfortably vs. fidgeting, tics, stereotyped movements), facial expression, eye contact, attitude (i.e., cooperative vs. hostile)
• Speech: Rate, rhythm, volume, tone, articulation, quantity (i.e., hyper-verbal or pressured vs. paucity of speech/content)
• Mood: “How would you describe your mood right now?” Document the patient’s own words. (Goal: Capture the subjective state of the patient at the time of the interview.)
• Affect: Assessment of how the patient’s mood appears to the examiner – quality (flat, blunted, constricted, full, intense), motility (sluggish, supple, labile), appropriate/not appropriate
• Thought process: Progression and form of thought. Normal thought process is linear and goal-oriented. Abnormal thought processes include disorganized, tangential, circumstantial, loosened associations, flight of ideas, neologisms (i.e., made up words), word salad, clanging (e.g., “bed, red, fed, led”)
• Thought content: Suicidal ideation (SI), homicidal ideation (HI), paranoia, poverty of thought (the absence of content (such as a one-word response to a complex question, reduced spontaneity of speech/thought, or the use of vague/stereotyped phrases), delusions, phobias, obsessions, compulsions
• Perception: Hallucination (i.e., sensory experience not based in reality; can be auditory, visual, or tactile), illusions (i.e., inaccurate perception of real sensory stimuli, such as a shadow misperceived as a cat)
• Sensorium: Alertness, orientation, memory (3 words), calculations, fund of knowledge (e.g., presidents), attention (e.g., spelling “WORLD” backward), abstract thinking (e.g., what does it mean to say, “The grass is always greener?”)
• Insight: Intact, fair, or impaired. The patient’s understanding of their illness and or current mental state, as well as the impact on their well-being.
• Judgment: Intact, fair, or impaired. The patient’s ability to make rational decisions (i.e., weigh evidence, assess pros and cons, anticipate consequences, etc.).