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Mental Status Exam
From ANCC Review
| Question | Answer |
|---|---|
| Appearance includes | overall appearance related to age and culture, hygiene and grooming, style, appropriateness of clothing for age, weather and occasion, posture and mannerisms, psychomotor excitation and slowness |
| Behavior Includes | General behavior - impulsivity, passive, hostile, fearful. Motor behavior - pacing, lethargy, catatonic. Attitude toward clinician and willingness to cooperate. |
| Emotion includes | mood and affect |
| Mood is | internal feelings that influence behavior |
| Examples of mood provided | depressed, suspicious, elated, irritable, angry, euthymic |
| Affect is | the emotional expression variation - found in face, voice, use of body movements |
| Examples of affect provided | flat, guarded, inappropriate, blunted, restricted, labile |
| Thought Processes and Content include | ability to use words to communicate, stream of thought, continuity of logical progression of thought, content of thought. |
| Thought processes include | continuity/org. of ideas - problems w word finding, processing abstract ideas, blocking, unexpected thought stoppage. Consider flow & rhythm - slowed or racing thoughts. Logical coherency, amount - excessive/poverty of speech, language/meaning deficits |
| Evaluation of thought content includes | Suicide, Homocide, Delusions, Phobias, Obsessions, Insight, Judgement |
| Evaluation of thought content - suicide | plan, intent, opportunity means |
| Evaluation of thought content - Homicide | victim, realistic plan |
| Evaluation of thought content - delusions | fixed, false beliefs - control : can control others thoughts or someone has control over their thoughts |
| Evaluation of thought content - phobias | intense, unreasonable fear |
| Evaluation of thought content - obsessions | intrusive, repetitious |
| Evaluation of thought content - insight | realization of the problem. The extent of the individuals awareness, willingness to look at role in maintaining the symptoms, awareness of behavioral consequences - lifestyle changes needed for coping |
| Evaluation of thought content - judgement | decision making, realistic foresight. realistic decision making based on current level of knowledge and realistic understanding of options - resources, strengths and limitations. |
| Definition of delusion as provided by ANCC | False beliefs that cannot be dislodged by logic or contradictory evidence, not congruent with normative culture or religious beliefs. |
| Delusions - of reference | other people's thoughts words or actions refer to self |
| Delusions - of persecution | other people have malevolent intentions towards self or are conspiring against the person |
| Religious Delusions | unrealistic special relationship with God |
| Nihilistic Delusions | destruction of self, world, body part |
| Grandiose Delusions | special or gifted, powerful or important without factual support |
| Language & Thought Processing - Clanging* | choice of words based on similar sound, not associated ideas |
| Language & Thought Processing - Echolalia* | repetition of other peoples words or phrases |
| Language & Thought Processing - Neologisms* | creation of new words that don't make sense |
| Language & Thought Processing - Word Salad* | disorganized, senseless progression of words |
| Language & Thought Processing - Perseveration | tedious repetition of the same words or ideas regardless of stimuli |
| Language & Thought Processing - flight of ideas/loose association | ideas are not logically connected, abrupt changes in topic |
| Language & Thought Processing - thought blocking | interruption or delay in thought processing, not related to lack of concentration, distraction or anxiety |
| Language & Thought Processing - tangential | pt goes of on a tangent not related to subject |
| Language & Thought Processing - circumstantial | pt answers questions about everything related to question and finally gets to the point |
| Language & Thought Processing - confabulation | pt recalls false memories - could be part of disease processes - dementia |
| Disurbances of Perception - depersonalization | A sense of alienation from normal identity, as though one has become an outside observer with no control of one’s own mental or physical processes. |
| Disurbances of Perception - derealization | The false sensation that one’s surroundings have become unfamiliar or unreal. |
| Disurbances of Perception - illusions | A distorted perception of reality; unlike delusions, illusions are generally shared by most people, as in a 3D “hidden picture” puzzle. - breeze blows curtain - think someone is behind it |
| Disurbances of Perception - deja vu, jamais vu | A false sense of visual familiarity in a situation. The term means “already seen” in French. The strange feeling that one does not recognize a familiar situation. Literally means “never seen” in French. |
| Disurbances of Perception - flashbacks | involuntary recurrent memory |
| Disurbances of Perception - hallucinations | can be auditory/visual/olfactory/tactile command, pervasive, episodic with stress |
| Auditory hallucinations are found in | psychiatric disorders |
| visual hallucinations are more common in | cognitive and organic disorders |
| olfactory and tactile hallucinations are more common with | drug use, medical conditions |
| Mood congruent tends to occur in | depression* |
| Mood incongruent tends to occur in | schizophrenia* |
| Disturbances in sensorium and cognition are related to | organic dysfunction due to meds, substance abuse, cognitive disorder |
| Assess memory recall for | immediate, recent and remote |
| Assess orientation to | person, time and place |
| Assess concentration through | serial 7s - keep in mind educational level |
| Assess abstract thinking through | proverb interpretation |
| Two short tests to check cognitive impairment | MMSE (Folstein) and SLUMS (St. Louis University MSE) |
| Scoring on the MMSE is | 25-30 Normal 21-24 Mild cognitive d/o 16-20 Moderate cognitive d/o <15 severe cognitive disorder or mild and severe cut offs of 24 and 18 |
| Anything below __ on the MMSE is an indicator of dementia.* | 24 |
| This test has greater sensitivity than the MMSE | SLUMS |
| The Clock Drawing Task is incorporated into which test | SLUMS |
| Scoring on the SLUMS | w HS education 27-30 Normal 21-26 Mild Neurocog Impairment 1-20 Dementia <HS education 25 20 <20 |
| This can be used as a rapid screening for dementia | the clock drawing test (11:10 or 8:20) 4 points total |
Created by:
jonquil
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