Mental state examination

Introduction

• Wash hands; Introduce self; ask Patient’s name, DOB and what they like to be called; Explain examination and obtain consent

Appearance and behaviour

You don’t need to ask this!

• Appearance: dress, physical appearance, neglect
• Behaviour: suspicious, paranoid, irritable, aggressive, eye contact
• Distractions: preoccupied, distractible, withdrawn, quiet

Speech

You don’t need to ask this!

• Rate: pressure of speech, slow
• Volume/tone: monotonous
• Fluency and rhythm

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Mood and affect

Ask about their mood (e.g. ‘How are you feeling?’, ‘What is your mood like?’, ‘Have you felt low/anxious recently?’)

• Mood (sustained emotion over prolonged period of time)
  • Subjective: low, high, anxious
  • Objective: depressed, elated, euthymic, labile
• Affect (immediately expressed emotion): facial expressions, overall demeanour 

Thoughts

Ask about delusions (e.g. ‘Have you noticed any strange thoughts, or thoughts that others find strange?’, ‘Can anyone interfere with or hear your thoughts?’, ‘Do you feel you are in control of your actions?’, ‘Do you ever get thoughts which keep going round and round in your head?’, ‘Are there any actions you feel you need to do repeatedly?’)

Ask about risk to self and others (e.g. ‘Some people in your situation feel like harming themselves or taking their own life, have you had such thoughts?’)

• Form: coherence, muddled, flight of ideas, knight’s move thinking, preoccupations
• Content: harm to self/others, suicidal ideas, delusions, over-valued ideas, thought insertion/withdrawal/broadcasting, control of thoughts

Perceptions

Ask about hallucinations (e.g. ‘Have you ever heard or seen anything you can’t explain?’, ‘Have you ever heard people commenting on what you do?’, ‘Do you ever feel events have a special meaning for you?’, ‘Have the voices ever told you to harm yourself or anyone else?’)

• Hallucination (sensory perceptions without stimulus)
• Illusion (misinterpreted stimulus)
• Pseudohallucination (a hallucination that the patient is aware is not real)

Cognition

Assess cognition

• Concentration and attention
• Short-term memory
• Orientation to time/person/place and cognition test, e.g. mini mental state examination

Insight

Assess insight

• Awareness of illness
• Understanding of the need for medications and willingness to take them

To complete

• Other parts of psychiatric history; summarise