As not only the disease interested the physician, but he was strongly moved to look into the character and qualities of the patient. … He deemed it essential, it would seem, to know the man, before attempting to do him good. —Nathaniel Hawthorne (1804–1864)
I. THE MENTAL STATUS EXAMINATION: A NONPROGRAMMED INTERLUDE
A. How to derive the mental status information
Most of the data for judging the patient’s (Pt’s) mental status emerge as a natural consequence of the questions posed during the standard medical history, which this text does not cover. Although you do the basic Neurologic Examination (NE) by a set routine, you should probe the Pt’s mental status unobtrusively and flexibly. If you blurt out questions obviously designed to test the mental status, such as, “Do you hear voices?” the Pt may respond with annoyance, sullen silence, or outright anger. Nevertheless, just such a question, introduced at the proper time, encourages the disclosure of distressing thoughts. The Pt then may describe the voice that repeats, “You have a duty to kill your family.” Because your personal characteristics and interview techniques condition what the Pt can and will disclose, you must remain flexible, empathetic, and nonjudgmental. This is the first point: the interview technique is everything.
By monitoring the Pt’s responses, you determine which questions to use and how far to pursue any particular line of inquiry. As long as the Pt talks productively, continue the line of inquiry. If the Pt changes the subject or becomes evasive, flustered, or silent, you have pressed too hard. The Pt is not ready to talk about that. Try another tack. A mentally ill Pt may permit a full NE but completely resist inquiries obviously designed to disclose thoughts. Patients will talk about whatever problems and anxieties occupy their thoughts, if they can tolerate the thought and its communication. This is the second point: Pts will disclose their mental state, particularly their worries and concerns, if you provide a free opportunity.
We have highlighted the two most important statements. With these in mind, you may find it useful to re-read Chapter 1, Section I E.
B. Categories of the mental status examination
The examiner (Ex) must know and explore each category of the mental status examination (Arciniegas and Beresford, 2001; Strub and Black, 2000). Learn Table 11-1.
Because much of the mental status examination belongs to the psychiatric history, this text focuses on the sensorium because:
Sensorial testing uses questions that require more or less objective answers for passing or failing, for example, either you know what day it is, or you do not know what day it is.
Sensorial deficits are sensitive to organic impairment of the brain.
TABLE 11-1Outline of Mental Status Examination
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