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    Mental Status Examination

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    Karl Angelo Montano
    This document provides a template for conducting a Mental Status Examination (MSE). The MSE is used to gather information about a client's mental functioning in various areas including: general appearance, motor activity, behavior during interaction, thought processes, mood/affect, cognitive functioning, insight and more. All areas are observed and described by the examiner to develop an appropriate treatment plan.

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    © All Rights Reserved
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    Mental Status Examination

    Uploaded by

    Karl Angelo Montano
    72 views6 pages
    This document provides a template for conducting a Mental Status Examination (MSE). The MSE is used to gather information about a client's mental functioning in various areas including: general appearance, motor activity, behavior during interaction, thought processes, mood/affect, cognitive functioning, insight and more. All areas are observed and described by the examiner to develop an appropriate treatment plan.

    Original Title

    MENTAL-STATUS-EXAMINATION

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    This document provides a template for conducting a Mental Status Examination (MSE). The MSE is used to gather information about a client's mental functioning in various areas including: general appearance, motor activity, behavior during interaction, thought processes, mood/affect, cognitive functioning, insight and more. All areas are observed and described by the examiner to develop an appropriate treatment plan.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    72 views6 pages

    Mental Status Examination

    Uploaded by

    Karl Angelo Montano
    This document provides a template for conducting a Mental Status Examination (MSE). The MSE is used to gather information about a client's mental functioning in various areas including: general appearance, motor activity, behavior during interaction, thought processes, mood/affect, cognitive functioning, insight and more. All areas are observed and described by the examiner to develop an appropriate treatment plan.

    Copyright:

    © All Rights Reserved
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    Download as docx, pdf, or txt
    of 6

    MENTAL STATUS EXAMINATION (MSE)

    Gathering the correct information about the client’s mental status is essential to the development of an
    appropriate plan of care. MSE is a description of all areas of the client’s mental functioning as observed
    by the examiner at the moment.
    Date:
    Name:
    Gender:
    Age: (How old are you? When were you born?)
    I. PREEXAMINATION Mark Description/Verbatim Quotes
    A. General Appearance
    1. Grooming and dress
    a. Note unusual modes of dress
    b. Evidence of soiled clothing
    c. Neat, unkempt?
    d. Use of make up?

    2. Hygiene
    a. Note evidence of body or breath odor
    b. Condition of skin, fingernails
    c. Disheveled
    d. untidy

    3. Height and weight


    a. Perform accurate measurements

    4. Level of Eye contact


    a. Intermittent
    b. Occasional and fleeting
    c. Sustained and intense
    d. No eye contact?

    5. hair and color texture


    a. Is hair clean and healthy looking
    b. Greasy, matted , tangled?

    6. Evidence of scars, tattoos or other


    distinguishing skin marks
    a. Note any evidence of swelling or bruises
    b. Birth marks
    c. Rashes
    7. Evaluation of client’s appearance
    compared with chronological age ,
    deterioration of appearance, client needs
    to be reminded
    B. General Mobility
    1. Posture
    a. Note if standing upright, rigid, slumped
    over
    b. Note for:
    Catatonia
    Catatonic Stupor
    Catatonic rigidity
    Catatonic posturing
    Waxy flexibility
    Catalepsy
    Cataplexy

    2. Gait patterns
    a. Any evidence of limping
    b. Limitation of range of motion
    C. Ataxia
    d. Shuffling

    C. Motor Activity
    Note for:
    Normoactivity
    Hyperactivity
    Psychomotor retardation
    Agitation
    Tremors (hands, legs, continuous, at
    specific time
    Tics
    Jerky or spastic movements
    Stereotypical Movements
    Mannerisms and Gestures
    Aggressiveness
    Echopraxia
    Bradykinesia
    Pacing and Rocking
    Somnambulism
    Anchoring
    Anergia
    Anhedonia
    Regression
    Compulsions
    D. Behavior/ Nurse patient Interaction
    Cooperative
    Cooperative (initially, all though out)
    Uninterested/Apathetic
    Friendly
    Embarrassed
    Seductive
    Impulsive
    Negativistic
    Indifferent
    Angry/hostile
    Evasive
    Withdrawn
    Warm
    Distant
    Guarded/Suspicious
    Dependent
    Distracted
    II. STREAM OF TALK
    A. Character
    Note for:
    Slowness or rapidity
    Intonation
    Volume
    Stuttering, hoarseness, slurring
    Spontaneous
    Blocking
    Deliberate
    Pressured
    Aphasia

    B. Organization of Talk/Form of Thought


    Relevant
    Irrelevant
    Incorrect
    Flight of Ideas
    Loose association
    Circumstantiality
    Tangentiality
    Neologism
    Concrete Thinking
    Clang Association
    Word Salad
    Perseveration
    Echolalia
    Mutism
    Bradylalia
    Poverty of Speech
    Glossolalia
    Coprolalia
    Verbigeration
    Condensation
    III. EMOTIONAL STATE AND
    REACTIONS
    A. Mood
    Euthymic
    Depression/despairing
    Euphoria
    Elation
    Fearful
    Irritable
    Anxious
    Guilty
    Labile

    B. Affect
    Congruence with mood
    Constricted/ Blunted
    Flat
    Appropriate
    Inappropriate

    IV. THOUGHT CONTROL/PROCESSES


    Content of Thought
    A. Delusions
    Persecutory
    Grandiose
    Reference/ideas of reference
    Control/Influence (Thought Broadcasting,
    Thought Withdrawal, Thought Insertion)
    Somatic
    Nihilistic
    Erotomanic
    Jealous
    Religious

    B. Suicidal Thought/ideation
    Attempt
    Threat
    Gestures

    C. Obsessions
    D. Magical Thinking
    E. Phobia
    F. Poverty of Content

    Perceptual Disturbances
    1. Hallucinations
    Hypnagogic
    Hypnopompic
    Visual
    Auditory
    Tactile
    Olfactory
    Gustatory
    Trailing Phenomenon
    Micropsia (lilliputian)
    Marcopsia

    2. Illusions
    Visual
    Auditory
    Tactile
    Olfactory
    Gustatory
    3. Depersonalization
    Derealization
    4. Preoccupation
    Ruminations
    5. Déjà vu
    Jamais vu

    Impulse Control
    Ability to control impulses
    a. Aggression
    b. Hostility
    c. Fear
    d. Guilt
    e. Affection
    f. Sexual feelings
    V. NEUROVEGETATIVE DYSFUNCTIONS
    A. Sleep
    Normal
    Hypersomnia
    MNA
    EMA
    DFA
    Interrupted

    B. Appetite
    Poor/fair/good
    Polyphagia
    Voracious
    Pica
    Binge eating
    Coprophagia
    C. Diurnal Variation
    D. Weight
    E. Libido
    VI. GENERAL SENSORIUM AND
    INTELLECTUAL STATUS
    Describe impaired or unimpaired
    A. Orientation(place, time , person,
    situation)
    B. Memory
    Recent
    Remote
    Immediate
    Confabulation
    Agnosia
    Apraxia
    Amnesia

    C. Attention Span
    D. General Information
    E. Abstract Thinking Ability
    F. Judgment /Reasoning
    1. Ability to solve problems and make
    decisions, make plans for the future

    VII. INSIGHT
    Describe impaired or unimpaired
    Knowledge about Self, limitations
    Awareness of illness
    Ask: Do you think you have a problem?
    Do you think you need treatment
    Adaptive/Maladaptive use of coping
    mechanism
    VIII. SUMMARY OF MSE
    A. Disturbances in:
    ( ) Presentation
    ( ) Stream of Talk
    ( )Emotional State and Reactions
    ( ) Thought Processes
    ( ) Neurovegetative Dysfunctions
    ( ) Sensorium and Intellectual Status
    ( ) Insight
    B. Diagnostic Category (DSM IV :
    Diagnostic and Statistical Manual of
    Mental Disorders

    Assessed by: __________________________

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