The parts of the mental status examination are listed in Table 2–1; the order in which they are most appropriately performed varies from patient to patient. Language function cannot be properly assessed in someone who is stuporous, and memory cannot be assessed in someone who is severely aphasic. How a mental status examination is conducted thus depends on what is abnormal.
Table 2–1.The mental status examination. ||Download (.pdf) Table 2–1. The mental status examination.
|Alertness and attentiveness |
|Behavior, mood, and thought content |
|Orientation and memory |
|Cognitive abilities |
|Gnosia and spatial manipulation |
ALERTNESS AND ATTENTIVENESS
The mental status examination usually begins with an assessment of alertness and attentiveness, for if either of these faculties is more than mildly compromised, a complete neurological examination becomes impossible (see Chapter 7). A number of terms describe degrees of nonalertness, for example, lethargy (the patient responds to verbal stimuli but tends to nod off when the stimulus is removed), obtundation (at least shouting or shaking is required to produce a response, which is then incomplete), stupor (the patient responds only to pain), and coma (there is no response, even to pain). Because these terms are not used identically by all clinicians, the examiner should note both the minimal stimulus required to elicit a response and the response elicited.
An impaired attention span is usually apparent during history-taking. It may emerge or worsen as the examination proceeds. Attention span can be more formally tested by having the patient repeat a series of numbers. Most normal adults can repeat seven digits forward and five backward after a single hearing. Sequential digit testing is sensitive but not specific; difficulty may connote impairment of immediate (“working”) memory rather than inattentiveness per se. Certain parts of the neurological examination, for example, visual field and proprioceptive testing, are more likely to be compromised by inattentiveness than by impaired working memory.
The term delirium denotes inattentiveness sometimes so severe that meaningful interaction with the environment is impossible. Mental content, if assessable, is usually abnormal. Such patients are often agitated or less than alert (sometimes rapidly alternating between agitation and obtundation), and in some delirious states, such as delirium tremens of alcohol withdrawal, tremor and hallucinations are prominent.
“Hospitalized for bronchopneumonia, a 55-year-old unemployed accountant becomes anxious and tremulous.”
BEHAVIOR, MOOD, AND THOUGHT CONTENT
Neuropsychiatric abnormalities can be identified in this part of the mental status examination. Affect, the outward expression of mood, may be manifested in clothing, facial expression, amount and type of activity, and stream of conversation.
Mood may be more disturbed than affect suggests, however; patients should be specifically questioned about depression and, if appropriate, suicidal ideation. Patients ...