Category Archive : Mental status exam example child

2 Oct, 2012 | Nizilkree | Comments

Mental status exam example child

Lucy is a 34 year-old Indian-Portuguese woman of average weight and height. At the time of examination, she was well groomed and dressed. She was not confined to bed.

FREE 7+ Sample Mental Status Exam Forms in PDF | MS Word

On appearance, were no signs of tremor or abnormal movements; however, Lucy showed signs of proptosis, consistent with Grave's disease. Then, she appeared depressed. Lucy articulated herself clearly. She answered questions spontaneously, although at slow rate and speed.

She spoke softly throughout the conversation, particularly when mentioning past unhappiness. Lucy's affect was depressed and her range of mood reduced.

She also appeared anxious and irritable. Lucy's thought stream was decreased.

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It was also disturbed and Lucy's speech slowed down and content reduced significantly when mentioning past unhappiness. Lucy did not exhibit any formal thought disorders. She was able to answer questions spontaneously and directly. She did not use any new or created words.

Lucy did experience thought block when exploring sensitivities in her past. No negative thought disorder was detected. Lucy was depressed and anxious about her health. She was obsessed with knowing her biopsy result and was constantly asking the doctors and nurses for her result. Thoughts that the tumour could be cancer were causing Lucy to lack motivation and feel restless. Other than feeling obsession and guilt, Lucy has no other positive symptoms, such as delusions, phobias or compulsions.

Suicidal ideation was not detected. Lucy exhibits normal perception. Symptoms, such as illusions, misinterpretations, depersonalisation, passivity phenomena, were not elicited. Lucy was alert and orientated to time and place.

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She was able to answer questions and recall her past without difficulties. When questioned about her condition, Lucy accepted the fact that she is ill and requires treatment. She has cooperated with doctors and nurses and is compliant with management. You may use the simple past tense to describe the patient's state at the time of the MMSE, as in Example This emphasises that the exam findings are specific to the time of conducting the MMSE, but suggests that they are probably subject to change if repeated.A few months ago I received a question about writing mental status exams MSE and realized I've never talked about this!

So, here is some direction regarding all things MSE A mental status exam is a brief snapshot of a client's presentation. The MSE is meant to assist with diagnosis, capturing and identifying symptoms, but also to create a succinct picture of the presentation at a specific moment in time.

This means that a person's MSE may appear very different at various stages in treatment, and that's perfectly fine. For example, a client experiencing a manic episode will present very differently at the height of the episode than they will during times of mood stability or during a depressive episode. I should note that an MSE is always meant to be completed by the clinician who saw the client, and should include a visual assessment meaning over the phone would not capture many of the applicable sections.

The MSE is generally more useful for clients with acute, chronic or more severe symptoms. While it can be useful in all circumstances, many sections may not apply to clients with general adjustment or change of life issues.

The most common use for the MSE is during a clinical assessment. The MSE can actually provide a great source of documentation to support diagnoses for clients.

If you have difficulty diagnosing or worry about substantiating diagnoses for insurance companies, try using a mental status exam and then make sure DSM diagnostic criteria match up with the identified presentation. An MSE is generally completed during the first sessions, and then any other time when re-assessing symptoms.

That might include regular intervals of time, in order to identify progress, or only as needed during the treatment process. It can be helpful to complete one at the end of treatment to highlight any differences in presentation and celebrate growth.

Some clinicians do complete a brief MSE as part of every progress note but I find this unnecessary in most cases. Of course, that is a preference and if using the MSE every time works for you, great!

Just remember to include some information about what transpired during the session, as well. Like it or not, mental status exams were created to capture dys function, not ordinary function. That's why you'll find most of the categories very "clinical" sounding.University Health clinical operations on the University of Nevada, Reno School of Medicine campus remain open and prepared to continue to serve their patients. Patients should call the office to receive appropriate guidance about seeking care, especially if they are acutely ill.

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The Mental Status Exam is analogous to the physical exam: it is a series of observations and examinations at one point in time. Focused questions and observations can reveal "normal" or pathological findings. Although our observations occur in the context of an interview and may therefore be ordered differently for each patient, the report of our findings is ordered and "paints a picture" of a patient's appearance, thinking, emotion and cognition.

The data from the Mental Status Exam, combined with personal and family histories and Psychiatric Review of Systems, forms the data base from which psychiatric diagnoses are formed.

A synopsis of the four MSE sections is presented below. In following pages, there are elaborations of each section, with sample descriptors. MSE Components in greater detail: these adjectives and descriptors may be helpful in describing your mental status exam findings. Usually some apply more than others and you may find your own descriptors that fit your patient best.

Signs and symptoms of psychiatric illness are often described in the history of present illness. The ROS in psychiatry "covers all the bases" and queries for important signs and symptoms that have not been discussed during the first part of the history.

Similar to the ROS in other fields of medicine, the ROS in psychiatry is a systematic inquiry, searching for pertinent positives and negatives over a period of time preceding the time of interviews. Suggested Texts and references for the Clerkship In Psychiatry: suitable for in-depth reading on a patient problem or formulation in a write-up. C73 vs. Stoudemire: Clinical Psychiatry - Dept. Manley Mosby Internet Searches on topics in Psychiatry for up-to-date information on medications as well as published research in psychiatry Advanced PubMed search : at University or with special access.This page focuses on high-yield clinical aspects of performing the MSE.

It also lists specific strategies for assessing children.

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One way to assess this is to ask: "How are you feeling now? Some commonly used terms to describe mood: depressed, despairing, angry, expansive, euphoric, empty, guilty, euthymic non-depressed, reasonably positive moodself-contemptuous, frightened, etc. Jamais vu describes any familiar situation which is not recognized by the patient.

A psychiatrist can ask the patient what mental diagnosis has been given to her in the past, and what that means. Piaget stages of cognitive development can be mentioned here: e. Views Page Discussion View source History. Jump to: navigationsearch. Introduction This page focuses on high-yield clinical aspects of performing the MSE. Child : comment on whether speech clarity, vocabulary, and grammar is age-appropriate: e.

Quality refers to depth, intensity or range of affect; another way to think about is is the amplitude of a feeling state, or the "y-axis" of affect graphical representation.

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Being "irritable" is a specific manifestation of affect lability. Is the affect appropriate to content. Is it congruent with mood, speech? Modulation is a term sometimes used to describe patient's apparent level of control over his affect. Isolation of affect is an extreme form of a over-controlled affect.

mental status exam example child

Concrete thought process refers to logical thought process that lacks some capacity for abstract thinking Child : Piaget stages of cognitive development can be mentioned here: e. A question of the type "What would you do with a stamped envelope you found on the street? In childrenreaction to a false statement, a joke may give an indication of judgement capacity: e. The idea is for the patient to complete the task without forgetting the initial instructions.These Tables are not comprehensive, but along with other resources provide relatively good coverage of how and when to administer an MSE and some useful vocabulary words.

In addition to the Tables below, Dr. Thom Field from City University of Seattle has a set of training videos. Also, there are several other resources posted on this blog. When and where do you usually see or hear these things checking for hypnogogic or hypnopompic experiences? Has anyone been trying to steal your thoughts or read your mind?

What was happening in your surroundings when you saw or experienced what you saw or experienced? Did the vision or image or sounds come out of nowhere, or was there something happening? Have you had any similar experiences before in your life?

Sometimes when people have had very hard or bad things happen to them, they keep having those memories come back to them. Does that happen to you? Was there anything happening that triggered this memory or flashback to the past? Table 8. You are commenting using your WordPress. You are commenting using your Google account. You are commenting using your Twitter account. You are commenting using your Facebook account.

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mental status exam example child

Name required. The place to click if you want to learn about psychotherapy, counseling, or whatever John SF is thinking about. Aggressive: The client attacks the examiner physically or verbally or through grimaces and gestures.

Cooperative: The client responds directly to interviewer comments or questions. There is a clear effort to work with the interviewer to gather data or solve problems. Frequent head nods and receptive body posture are common. Guarded: The client is reluctant to share information about himself. When clients are mildly suspicious they may appear guarded in terms of personal disclosure or affective expression.

Psychiatric Interviews for Teaching: Mania

Hostile: The client is indirectly nasty or biting. Sarcasm, rolling of the eyes in response to an interviewer comment or question, or staring off into space may represent subtle, or not so subtle, hostility.An MSE is the psychological equivalent of a physical exam and describes the mental state and behavior of an individual undergoing the exam.

A Mental Status Examination includes objective observations from the clinician and subjective descriptions coming from the patient. A Mental Status Examination can be conducted for a lot of reasons, but it is mainly done to provide information that is critical for the diagnosis, the assessment, and the treatment of a disorder. Does he make eye contact? Does he fidget or wring his hands? Do you notice any tremors or abnormal movements? In order to provide a structured assessment of speech, the clinician will ask patients to name objects or repeat short sentences.

mental status exam example child

Another aspect of a Mental Status Exam is to observe if the patient has the ability to process information correctly. How a patient perceives and responds to stimuli is important in a pychiatric assessment because the inability to do so may be a sign of psychosis. Does the patient have the ability to focus, sustain, and properly shift his mental attention?Generally, mental status examinations MSEs can have a more neurological focus or a more psychiatric focus.

mental status exam example child

The following two fictional reports are samples of psychiatric-oriented MSEs. Clinical Interviewing has a chapter devoted to the MSE, as well as chapters on suicide assessment interviewing and diagnostic interviewing and many others chapter on other important topics.

Gary Sparrow, a year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age.

During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech i.

His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life.

Sparrow described grandiose delusions regarding his sexual and athletic performance.

Mental state examination

He reported auditory hallucinations God had told him to quit his job and become a professional golfer and was preoccupied with his athletic and sexual accomplishments. He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation.

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He refused to participate in intellectual- or memory-related portions of the examination. Sparrow was unreliable and exhibited poor judgment. Insight was absent. Her grooming was adequate and she was cooperative with the examination. Her speech was slow, halting, and soft. You know, I have lots of visitors coming by later.

Jackson was oriented to person and place, but indicated the date as January 9, today is July 8,