MSE in Psychiatry

MSE in Psychiatry
Mental Status Exam

From Univ. Illinois Chicago Dept of Psychiatry
http://www.psych.uic.edu/psyclerk/psychiatric.htm
Within context of diagnostic interview write up.

Section IX. Mental Status Exam

The mental status exam is extremely important. The best mental status exams allow the person listening to the presentation to develop a snapshot of the patient being presented.

Appearance: Start out the mental status exam by giving a verbal picture of the patient, what the patient is doing, wearing, and how the patient looks. For example: 16 yo BM wearing age appropriate dress of clean jeans, a t-shirt, and sneakers with the laces undone. He was sitting on the floor playing with a train set. He looked up and smiled when the interviewer approached. "16 yo BM O X 3" is a lot less descriptive!

After the initial description you have probably already taken care of the general appearance, alertness, hygiene and grooming part of the general description, but if not, include some information here. Look for use of grooming that might be suggestive of a mood state or disorganization. Don't use diagnostic labels, just describe what you see.

Speech: volume, rate, idiosyncratic symbols or other odd speech, tone (include any accent or stuttering).

Motor activity: rate (agitated, retarded), purposefulness, adventitious (non-voluntary).

Mood: ask how they are feeling, usually put in quotes: "depressed," "sad," "great," etc...

Affect: observable emotion (euthymic, neutral, euphoric, dysphoric, flat), the range (full, constricted, blunted), whether it fits appropriate to stated mood or content, lability.

Thought process: organization of a person's thoughts (logical/linear, circumstantial, tangential, flight of ideas, loose associations or thought blocking).

Thought content: basic themes preoccupying the patient, sucidality, homicidality, paranoia, delusions, ideas of reference, obsessions, compulsions. If there is suicidal or homicidal ideation, is there a plan, intent?

Perceptual disturbances: hallucinations (auditory, visual, olfactory, tactile), illusions,
de-realization/depersonalization.

Cognitive: level of alertness and orientation. May want to perform full Folstein MMSE if concerned about dementia or delirium.

Insight: into level of illness and/or need for treatment/hospitalization.

Judgment/Impulse control: best determined by history of patterns of behavior and current attitude.

For more context and understanding, please see original article at
http://www.psych.uic.edu/psyclerk/psychiatric.htm