Chapter 4: Mental Status Flashcards
Mental stats examination
Observe physical appearance and behavior.
Investigate cognitive abilities.
-State of consciousness, response to analogies, abstract reasoning, arithmetic calculation, memory, attention span
Evaluate emotional stability for signs of depression or anxiety, disturbance in thought content, hallucinations.
Observe speech and language for voice quality, articulation, coherence, comprehension.
Initial greeting
During the initial greeting, observe the patient for behavior, emotional status, grooming, and body language. Note the patient’s body posture and ability to make eye contact.
A&p
Cerebrum
-The cerebrum of the brain is primarily responsible for a person’s mental status.
-Lobes: frontal, parietal, temporal; each plays a role in mental status; any disruption in the lobes can lead to altered mental status.
Limbic system
-Mediates certain patterns of behavior that determine survival
Reticular activating system (RAS)
-In the brainstem; regulates the level of wakefulness or arousal
Infants, Children, and Adolescents
Infants and children
-All brain neurons are present at birth, but development continues for several years.
-Infection, trauma, or metabolic imbalance can damage brain cells, leading to potentially serious dysfunction in mental status.
Adolescents
-Brain maturation with greater capacity for information and vocabulary
-Abstract thinking
-judgement
Older adults
Cognitive functions are intact, but cognitive abilities in executive functioning decline.
Speed of information processing and psychomotor speed decline after age 30.
Verbal skills and general knowledge increase into 60s and remain stable into 80s.
History of Present Illness
Disorientation and confusion
-Onset, associated health problems, associated symptoms, medications
Depression
-Troubling thoughts or feelings, low energy level, recent changes in living situation, thoughts or plans to hurt self or others
Anxiety
-Sudden unexplained attacks of fear, anxiety, or panic; avoids or feels uncomfortable with people; prior experience with traumatic event; associated symptoms
Patient Histories
Family history
-Psychiatric disorders, mental illness, alcoholism, Alzheimer disease, learning disorders, autism, intellectual disability
Personal and social history
-Emotional status
-Life goals, attitudes, relationship with family
-Intellectual level, education
-Communication pattern
-Changes in sleeping patterns
-Use of alcohol or street drugs, especially mood-altering drugs
Test a child’s memory
Test a child’s memory recall by using familiar objects.
Infant alertness
Note this infant’s level of alertness and interest in various objects and people
Children hx
Impact on school or daycare
Family or social dysfunction (divorce, foster care; no friends)
Previous counseling or treatment
Hospitalizations/ surgeries/ trauma/ abuse
Recent or concurrent illness
Moderate to severe morning headache with morning vomiting (brain tumor)
Weight loss
Speech and language, behavior, performance of self-care activities, personality and behavior patterns, learning difficulties
Adolescent hx
Risk-taking behaviors
School performance and peer interactions
Family interactions; reluctance to communicate and to speak of attitudes and experience
Older adult hx
Changes in cognitive functioning, thought processes, and memory
Changes in activities of daily living
Depression, somatic complaints, hopelessness, helplessness, lack of interest in personal care
Behavior and Appearance
Mental status is assessed throughout the physical examination.
Evaluate:
Grooming: poor hygiene, lack of concern, inappropriate appearance
Emotional status: carelessness, apathy, insensitivity, docility, rage, irritability
Body language: slumped posture, lack of expression or eye contact, excessively energetic, constantly watchful
State of Consciousnes
Oriented to person, place, and time and makes appropriate responses to questions, as well as physical and environmental stimuli
-Person disorientation: cerebral trauma, seizures, or amnesia
-Place disorientation: psychiatric disorders, delirium, and cognitive impairment
-Time disorientation: anxiety, delirium, depression, and cognitive impairment
Goodenough-Harris Drawing Test.
Ask the child to draw a picture of a man or woman. The presence and form of body parts provide a clue about the child’s development when following the scoring criteria of the Goodenough-Harris Drawing Test.
Cognitive Abilities
Evaluate cognitive functions as the patient responds to questions during the history-taking process.
Signs of cognitive impairment: significant memory loss, confusion, impaired communication, inappropriate affect, personal care difficulties, hazardous behavior, agitation, suspiciousness
Several screening tests are available to assess cognition in adults:
Mini-Mental State Examination (MMSE)
-Most studied to date
Mini-Cog
-Three unrelated words
-Clock face
Analogies
Abstract reasoning
Arithmetic calculation
Writing ability
Execution of motor skills
Memory
Attention span
Judgment
Speech and Language Skills
A detailed evaluation of receptive and expressive communication skills should be performed if the patient has difficulty communicating during the history.
-Voice quality
-Articulation
-Comprehension
-Coherence
-Aphasia
Emotional Stability
Emotional stability is evaluated when the patient does not seem to be coping well or does not have resources to meet his or her needs.
-Mood and feelings
-Thought process and content
-Perceptual distortions and hallucinations
Glasgow Coma Scale
Used to quantify consciousness in person with head trauma or hypoxic event
Versions are available for adult, infant, and young child
Assesses the function of the cerebral cortex and brainstem through the patient’s verbal, motor, and eye opening responses to specific stimuli
Scores range from 3 to 15, with 15 being the optimal level of consciousness.
Pediatric Mental Health
Monitoring starts at birth.
Edinburg: assess for postpartum depression (0 to 2 months)
Developmental Surveillance with well-child care
-Ages and Stages Questionnaire (ASQ) (4 to 60 months)
-Ages and Stages Questionnaire Social/ Emotional Scales (ASQ-SE)
-Pediatric Evaluation of Developmental Status (PEDS) (0 to 8 years)
Pediatric Symptom Checklist (age 7 and up)
Patient Health Questionnaire-9 (PHQ-9)
-Adolescent depression
Infants, children, and adolescents mental health assessment
Infants
-Levels of activity: lethargic, drowsy, stuporous, alert, active, irritable
-Responsiveness to environmental stimuli (smile)
-Crying and other vocal sounds
Children
-Types of words and speech patterns, mood, activity level, preferences, responsiveness to parent and ability to separate
Adolescents
-Patient Health Questionnaire-9 (PHQ-9)
-School failure, risky behavior, substance abuse
Preg pt mental health assessment
Postpartum depression (“blues”)
-Risk factors for postpartum depression: History of depression, Prior postpartum depression, Poor social support
Screening: during pregnancy, postpartum period, routine well-child visits -Edinburgh Postnatal Depression Scale
Older adults mental health assessment
Assess for cognitive changes and dementia.
-Montreal Cognitive Assessment (MoCA)
-Mini-Mental State Examination (MMSE)
-Mini-Cog
Assess for depression.
-Geriatric Depression Scale
Assess other causes of cognitive dysfunction.
-Cardiovascular
-Hepatic
-Renal
-Metabolic
Assess reaction to medications.
-Slow reaction times
-Disorientation
-Confusion
-Loss of memory
-Tremors
-Anxiety
Assess for elder abuse.
-Facial expressions and stance: Mask-like or dramatic, Stooped and fearful
Disorders of Altered Mental Status
Traumatic brain injury: concussion
A direct blow to the head or face that bruises the brain as it moves against the skull and causes inflammation; often caused by a sports injury
Signs and symptoms
-Dazed expression
-Slurred speech
-Slow motor and verbal responses
-Emotional lability
-Nausea and vomiting
-Loss of consciousness may indicate severe injury.
-Deficits in coordination, cognition, memory, attention
Disorders of mood
Depression
-Feelings of sadness, loss, anger, or frustration that interfere with everyday life for an extended period
Mania
-Persistently elevated, expansive, euphoric, or irritable mood lasting longer than 1 week; one phase of the bipolar disorder
Anxiety disorder
-Group of disorders with such marked anxiety or fear that it causes significant interference with personal, social, and occupational functioning
Schizophrenia
-A severe, persistent, psychotic syndrome with relapses throughout life
Mental disorders effecting infants and children
Intellectual disability
-A developmental, cognitive, or intellectual deficit that begins before 18 years of age, with accompanying deficits in adaptive behavior, academic performance, and adaptive functioning; previously called mental retardation
Attention-deficit/hyperactivity disorder (ADHD)
-A neurobehavioral problem of impaired attention and hyperactive behavior affecting 5% to 10% of school-age children
Autism
-A pervasive neurodevelopmental disorder of unknown etiology; refers to a wide spectrum of disorders (including autistic disorder), Asperger syndrome, pervasive developmental disorder not otherwise specified (PDD-NOS), typically identified before 3 years of age and in more boys than girls
Mental disorders affecting older adults
Delirium
-Impaired cognition, arousal, consciousness, mood and behavioral dysfunction of acute onset
Dementia
-A chronic, slowly progressive disorder of failing memory, cognitive impairment, behavioral abnormalities, and personality changes that often begins after age 60 years
Assessing orientation to person, place, and time helps determine:
Ability to understand analogies
Abstract reasoning
Attention span
State of consciousness
ANS: D
Rationale: Orientation to person, place, and time are measures of states of consciousness and awareness, not degrees of attention span. Analogies and abstract reasoning are higher functions than orientation. Emotional status can be better evaluated by observing behaviors.
One method to evaluate mental status, cognitive function, and assess for dementia is:
Mini-Cog
Glasgow Coma Scale
Geriatric depression inventory
Coherence testing scale
ANS: A
Rationale: The Mini-Cog is a brief screening tool for measuring cognitive function; it takes 5 minutes to administer.
Testing the patient’s arithmetic calculation will assist in determining:
Dementia and Parkinson disease
Depression and diffuse brain disease
Schizophrenia and brain damage
Intellectual disability
ANS: B
Rationale: Arithmetic calculations should be completed with few errors and within 1 minute. When the patient has average intelligence, impairment of arithmetic skills may be associated with depression and diffuse brain disease.
