Mental Status Examination Consciousness Level of consciousness Arousal (Eye opening closing) Attention Concentration Orientation Kinetic melody Affect Mood Behavior Cognition Language Memory Thinking: Content, Speed Reasoning Judgment Abstract thinking Insight Construction Praxis Gnosis
Consciousness Consciousness is Awareness of self and environment or knowledge of one's own mental process (subjective) Arousal and Level of consciousness Content of consciousness or Cognition Test for responsiveness (objective) Verbal, motor , and vegetative response to visual, verbal, tactile and noxious stimuli, one step or two step command Level of response: Meaningful -> not meaningful -> reflex -> none Verbal word, phrase or sentence
Level of Consciousness Alert: awake, aware, interesting, responsive to stimuli Lethargic (drowsy): Can be roused but cannot maintain arousal. Stuporous: Can be roused with intense stimulation Comatose: Cannot be roused with any stimuli Confusion: Unable to think in customary speed and clarity. Altered awareness and responsiveness with inattention and distractibility. Delirium: confused, agitated and hallucinating.
B. Attention and Concentration (RAS) Alertness is aroused and attend to all extraneous stimuli. Attention is the capacity to focus on single stimuli and screen out irrelevant stimuli. Clinical: noting the distractibility while history taking. Digit span: (forward and backward) Letter span Alphabet repetition read randon alphabets and asks to tap when particular alphabet repeated. Word repetition Sentence repetition
Concentration is the ability to focus attention over a more extended period of time. Seven subtraction Random letter repetition
C. Behavior (limbic system, prefrontal area, caudate area) Clinical assessment: Observation of a patient’s mood, facial expression, clothing, and ability to relate to the examiner. Appearance. Clothing and grooming. Bizarre, seductive, soiled, stained. Motor activity: Increased activity Decreased activity Tics Repetitive acts Facial expression: Normal, blunted, abnormal twitching Mood and affect: Affect is immediate overt expression of an emotional state. Mood is more sustained or underlying emotion. Behavior: Irritability, demanding, anger and euphoria, helplessness
D. Language Comprehension Expression Repetition Reading Writing Naming
Comprehension: Identification of color, object, action, letter, number and forms. Body part identification One, two and three step command Complex ideation material Two ideas (boat/stone sink in water) Story comprehension
Expression: Word output Fluency Prosody: loss of melodic aspect of speech (emotional speech – right hemisphere corresponding to Broca’s area) Grammar Paraphasias: Verbal - Green -> Red literal - Green -> Gret Neologism: Green -> Grump Word finding difficulty Automatic speech: number, alphabet, month, days, poem, song.
Reading: Oral reading, word phrase and sentence Reading comprehension Symbol Word Oral spelling, Word, picture matching, Reading sentence
Writing Mechanical: name, address Primer level dictation, letter, number, word, sentence, paragraph Written confrontation naming Narrative writing
Naming: Responsive naming (what do we tell time with) Visual confrontation naming: object, color, action, letter, number, form Body part naming Object naming: Animal, vegetable and fruit
Thought (Speed, content, coherence and logic) Form Reduced content: poverty of ideas, associated with vague repetition, overtly abstracts speech, which contains little information. Circustantiality: delay in reaching the point, because of unnecessary detail and parenthetical speech Derailment: shift in thinking from one topic to another. Loss of association. Tangentiality: Loosing of association or derailment in response to the examiners questions. Shift in topic at first may be related but progressively move further away from the starting topic. Blocking: sudden cessation of speech because of thought was lost or mind became blank Flights of idea: accelerated speech and rapid shift in topic. Speech may become disorganized and incoherent. Syntax and vocabulary are usually intact. Clang association: a form of derailment in which shift in topic are based on the sound of words rather than the meaning. Confabulation: apparent fabrication of facts or events to fill gaps in memory. Neologism: are new words or distortion of standard words. Echolalia: the echoing of words or phrases of others. Often associated with perseveration repetition of the same words Perseveration: persistent repetition of words and phrases. Word salad: syntax is lost, vocabulary is idiosyncratic.
Content of Thought An illusion:is a misperception of real external stimuli. A delusion: is a false personal belief based on an incorrect interpretation of reality Hallucination: i. Auditory: ii. Visual iii. Olfactory iv. Gustatory v. Tactile Assaultive thought: wishes or intensions to harm an individual or less commonly an institution or organization. Homicidal thoughts: wishes or intension to kill another person, these may be vague or poorly formulated or may be impulsive. Homicidal plans: the intensions or wishes to kill have been crystallized into a potentially real threat. Feeling of hopelessness: Feeling of guilt: i. Suicidal thoughts: j. Suicidal plans Obsessions: recurrent, persistent ideas, images, or impulses that are not experienced as being produced voluntarily but as being invaded thoughts.
Phobias: irrational, persistent, fear of an object, activity or situation that produces a wish to avoid the stimulus. Closeness to the stimulus causes increased feeling of anxiety and over activity of autonomic nervous system. Sexual concerns: Somatic preoccupation: Religiosity.
Memory Short term memory: testing require a patient to be attentive, cooperative and good comprehension Recall of recent event, confirm with relative Four semantically unrelated words, sentence, Objects, design, Short story Remote memory: Personal Historical events
Constructional ability (graphomotor) A complex task involving visual, perceptual and analytical function of the occipital and parietal lobes and the motor planning and action of the prefrontal and frontal lobes. Both hemisphere are involved but, right parietal lobe produces more severe impairment in performance. Copy two and three-dimensional objects and shapes.
Calculation Measure the ability of a person to perform mental arithmetic. Performance is highly correlated to intelligence and education. Normal attention concentration and language memory are prerequisite. Simple calculation Serial 7 subtraction
Abstract thinking Similarities: to abstract the essential relationship between word pairs consisting of objects and ideas. Ask the patient how word pairs are alike (e.g. turnip and cauliflower; chair and table, painting and symphony) Proverb interpretation: depends on the patient’s cultural, intellectual and educational background. Prefrontal and frontal cortex involved.e.g. Rome wasn’t built in a day.
Conceptual ability Prefrontal cortex. Ask to complete following sentence. A C E G --- 1 4 7 10 --- AZ BY CX D— Hydrangea 789876332 Jewel 46883 Hat ----- (any three letter number)
Judgment Refer to the patient’s understanding of what he has done or will do in various situations. To see the patient’s ability to cope with difficult situation. Insight Refers to the patient’s awareness of the significance of his symptoms and illness. Which may range from partial to full understanding of the origin, nature and prognosis.
Frontal Lobe Observe: Behaviour, Attention, Memory, Motor, Speech, Planning, Bladder MotorBilateral/ Left Kinetic melody Frontal release sign Gagenhaltan Gait apraxia Eye movement Akinetic, abulic, (mesial) Right Motor neglect Motor impersistence Dysprosody Euphoria Emotional liability, euphoria, dysphoria Jocularity (Orbital) Lack of social judgment (orbital) Behavioural Utilization and imitation behavior Intelligence, attention, concentration and learning
Parietal Lobe Any hemisphere Cortical sensation Optico kinetic nystagmus Quadrinopia Dominant Right left orientation Finger agnosia Acalculia Agraphia logicogramatical and syntactical language Optic alexia Non dominant Neglect (bisect line, dazy, clock drawing) Spatial disorientation (map drawing, object in a room) Constructional apraxia ( two and three dimentional) Dressing apraxia Bilateral Ideomotorapraxia
Callosal function Anterior Left hand praxis Left hand agraphia Middle Matching left finger, left hand Naming object in left hand Posterior Naming object left field Right hand constructional apraxia