Chapter 4: Mental Status

Question 1

Mental stats examination

Answer 1

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.

Question 2

Initial greeting

Answer 2

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.

Question 3

A&p

Answer 3

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

Question 4

Infants, Children, and Adolescents

Answer 4

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

Question 5

Older adults

Answer 5

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.

Question 6

History of Present Illness

Answer 6

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

Question 7

Patient Histories

Answer 7

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

Question 8

Test a child’s memory

Answer 8

Test a child’s memory recall by using familiar objects.

Question 9

Infant alertness

Answer 9

Note this infant’s level of alertness and interest in various objects and people

Question 10

Children hx

Answer 10

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

Question 11

Adolescent hx

Answer 11

Risk-taking behaviors

School performance and peer interactions

Family interactions; reluctance to communicate and to speak of attitudes and experience

Question 12

Older adult hx

Answer 12

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

Question 13

Behavior and Appearance

Answer 13

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

Question 14

State of Consciousnes

Answer 14

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

Question 15

Goodenough-Harris Drawing Test.

Answer 15

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.

Question 16

Cognitive Abilities

Answer 16

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

Question 17

Speech and Language Skills

Answer 17

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

Question 18

Emotional Stability

Answer 18

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

Question 19

Glasgow Coma Scale

Answer 19

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.

Question 20

Pediatric Mental Health

Answer 20

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

Question 21

Infants, children, and adolescents mental health assessment

Answer 21

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

Question 22

Preg pt mental health assessment

Answer 22

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

Question 23

Older adults mental health assessment

Answer 23

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

Question 24

Disorders of Altered Mental Status

Answer 24

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

Question 25

Disorders of mood

Answer 25

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

Question 26

Mental disorders effecting infants and children

Answer 26

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

Question 27

Mental disorders affecting older adults

Answer 27

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

Question 28

Assessing orientation to person, place, and time helps determine:

Ability to understand analogies
Abstract reasoning
Attention span
State of consciousness

Answer 28

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.

Question 29

One method to evaluate mental status, cognitive function, and assess for dementia is:

Mini-Cog
Glasgow Coma Scale
Geriatric depression inventory
Coherence testing scale

Answer 29

ANS: A

Rationale: The Mini-Cog is a brief screening tool for measuring cognitive function; it takes 5 minutes to administer.

Question 30

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

Answer 30

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.