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The mental status examination (MSE) is the quantitative and qualitative assessment of behavior, thought, emotion, and cognition at a specific point in time. It can be viewed as the psychological equivalent of the physical exam. According to the Association of Directors of Medical Student Education in Psychiatry, the MSE is categorized as a core competency for undergraduate medical education and a key component of coursework in clinical psychiatry. While neurologists and psychiatrists primarily conduct a formal MSE as part of their evaluations, statistics reveal that 1 in 5 adults in the United States experience mental illness each year. Moreover, 29% of adults with medical conditions have comorbid mental illness, and 68% of adults with mental illness have comorbid medical conditions. These staggering figures underscore the need for all physicians across specialties to possess the fundamental knowledge and skills to conduct an MSE because they are likely to encounter individuals requiring a nuanced understanding of their mental status. This chapter aims to empower the reader with critical tools for enhanced clinical reasoning and diagnosis by offering practical insights and tips for conducting an MSE.
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Key Considerations in the Approach to the Mental Status Exam
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Like physical exam findings, the results of a well-performed MSE (coupled with the medical and psychiatric history) guide clinical diagnosis and treatment planning for an array of mental and medical issues.
Several components of the MSE are based on observations that begin when the clinician first meets the patient and continues throughout the course of the interview.
The way in which the patient relates their history of present illness will reveal much about behavior, alertness, speech, thought process, affect, and attitude. The MSE provides a language and structure for describing and discussing these features.
To avoid misinterpretation, it can help to write down key patient responses (eg, mood, thought process) verbatim and the order in which they were expressed.
Informal observations made during the interview about the patient’s mental state are woven together with the results of specific testing. For example, the clinician will gain considerable information about memory, organization of thought, and attention span from the general interview, whereas the formal cognitive assessment measures the degree of attention or memory dysfunction.
The sensitivity of the entire medical history is dependent on the mental state of the patient.
Usually, the formal portion of the MSE is conducted toward the end of the evaluation, to compile specific data about the patient’s cognitive functioning. However, in patients with cognitive impairment (eg, dementia or delirium), it is beneficial to conduct a cognitive assessment early in the interview to identify and characterize the level of impairment.
In some instances, the patient’s condition (eg, markedly depressed level of consciousness, intoxication) will preclude a complete, ordered evaluation of mental status. As such, flexibility is important when gathering these data, which includes knowing when to “cut your losses” and abandon a more detailed examination. This will come ...