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Mental Status Exam
Heidi Combs, MD
What it is it?
• The Mental Status Exam (MSE)
is the psychological equivalent
of a physical exam that
describes the mental state and
behaviors of the person being
seen. It includes both objective
observations of the clinician
and subjective descriptions
given by the patient.
Why do we do them?
• The MSE provides information for
diagnosis and assessment of
disorder and response to treatment.
• A Mental Status Exam provides a
snap shot at a point in time
• If another provider sees your patient
it allows them to determine if the
patients status has changed without
previously seeing the patient
• To properly assess the MSE
information about the patients
history is needed including
education, cultural and social
factors
• It is important to ascertain what
is normal for the patient. For
example some people always
speak fast!
Components of the
Mental Status Exam
• Appearance
• Behavior
• Speech
• Mood
• Affect
• Thought process
• Thought content
• Cognition
• Insight/Judgment
Appearance: What do
you see?
• Build, posture, dress, grooming,
prominent physical
abnormalities
• Level of alertness: Somnolent,
alert
• Emotional facial expression
• Attitude toward the examiner:
Cooperative, uncooperative
2
Behavior
• Eye contact: ex. poor, good,
piercing
• Psychomotor activity: ex.
retardation or agitation i.e..
hand wringing
• Movements: tremor, abnormal
movements i.e.. sterotypies,
gait
Speech
• Rate: increased/pressured,
decreased/monosyllabic, latency
• Rhythm: articulation, prosody,
dysarthria, monotone, slurred
• Volume: loud, soft, mute
• Content: fluent, loquacious, paucity,
impoverished
Mood
• The prevalent emotional state
the patient tells you they feel
• Often placed in quotes since it
is what the patient tells you
• Examples “Fantastic, elated,
depressed, anxious, sad, angry,
irritable, good”
Affect
• The emotional state we observe
• Type: euthymic (normal mood),
dysphoric (depressed, irritable, angry),
euphoric (elevated, elated) anxious
• Range: full (normal) vs. restricted,
blunted or flat, labile
• Congruency: does it match the mood-
(mood congruent vs. mood incongruent)
• Stability: stable vs. labile
Thought Process
• Describes the rate of thoughts, how
they flow and are connected.
• Normal: tight, logical and linear,
coherent and goal directed
• Abnormal: associations are not
clear, organized, coherent. Examples
include circumstantial, tangential,
loose, flight of ideas, word salad,
clanging, thought blocking.
Thought Process:
examples
• Circumstantial: provide
unnecessary detail but
eventually get to the point
• Tangential: Move from thought
to thought that relate in some
way but never get to the point
• Loose: Illogical shifting
between unrelated topics
3
• Flight of ideas: Quickly moving
from one idea to another- see
with mania
• Thought blocking: thoughts are
interrupted
• Perseveration: R
Give a brief summary of the components of the mental status exam. Why is this critical to the care of the mental health patient?
Rubric
NU671 Unit 3 Assignment – Clinical Preparation Journal Rubric
NU671 Unit 3 Assignment – Clinical Preparation Journal Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeThe psychiatric/mental health area investigated is identifiable in the submission.
5 pts
Proficient
The submission is clear on the psychiatric/mental health area investigated.
3 pts
Approaching Proficiency
The submission is unclear on the psychiatric/mental health area investigated.
0 pts
Not Proficient
The submission does not contain an identified psychiatric/mental health area investigated.
5 pts
This criterion is linked to a Learning OutcomeThe reflection submitted is focused on the identified psychiatric/mental health area investigated.
10 pts
Proficient
An exemplary discussion of the identified psychiatric/mental health area is noted in the submission.
7 pts
Approaching Proficiency
A satisfactory discussion of the identified psychiatric/mental health area is noted in the submission.
3 pts
Not Proficient
The discussion of the identified psychiatric/mental health area is limited in detail.
10 pts
This criterion is linked to a Learning OutcomeThe reflective discussion is supported by scholarly resources.
10 pts
Proficient
The reflective discussion is supported well by scholarly psychiatric/mental health literature.
5 pts
Approaching Proficiency
The reflective discussion is supported by basic resources in the psychiatric/mental health literature.
2 pts
Not Proficient
The reflective discussion is not supported by psychiatric/mental health resources.
10 pts
This criterion is linked to a Learning OutcomeThe submission demonstrates the appropriate application of APA 7th edition guidelines for the construction of in-text and reference citations.
5 pts
Proficient
The submission is free from citation construction errors.
3 pts
Approaching Proficiency
The submission contains 1-3 citation construction errors.
1 pts
Not Proficient
The submission contains greater than 3 citation construction errors.
5 pts
Total Points: 30
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