memory refers to intervals of years.

Orientation Perceptions

Thought processes

Thought content Insight


Affect Mood Language

Higher cognitive functions

Awareness of personal identity, place, and time;

requires both memory and attention Sensory awareness of objects in the environment and their interrelationships (external stimuli); also refers to internal stimuli such as dreams or hallucinations The logic, coherence, and relevance of the patient's thought as it leads to selected goals, or how people think What the patient thinks about, including level of insight and judgment Awareness that symptoms or disturbed behaviors are normal or abnormal; for example, distinguishing between daydreams and hallucinations that seem real

Process of comparing and evaluating alternatives when deciding on a course of action; reflects values that may or may not be based on reality and social conventions or norms An observable, usually episodic, feeling tone expressed through voice, facial expression, and demeanor

A more sustained emotion that may color a person's view of the world (mood is to affect as climate is to weather)

A complex symbolic system for expressing, receiving, and comprehending words; as with consciousness, attention, and memory, language is essential for assessing other mental functions Assessed by vocabulary, fund of information, abstract thinking, calculations, construction of objects that have two or three dimensions

Distinguishing the interplay of body and mind in relation to these attributes is very important but not always easy. Mental disorders such as anxiety or depression may take the form of somatic complaints. Likewise, physical illness can cause mental and emotional responses and in older patients, can impair mental function without causing typical symptoms or signs such as fever or pain. Always look carefully for physical or pharmacologic causes as you try to understand the context and emotional meaning of changes in mental status. Some mental status evaluations are complicated by personality factors, psychodynamics, or the patient's personal experiences, areas that can be explored during the interview (but not covered in this chapter). By integrating and correlating all the relevant data, the clinician tries to understand the person as a whole.

As a student, you may feel reluctant to perform mental status examinations, wondering if they will upset patients, invade their privacy, or result in labeling their thoughts or behavior as pathologic. Such concerns are understandable and appropriate. An insensitive examination of mental status may alarm a patient, and even a skillful examination may bring to conscious awareness an embarrassing or upsetting deficit that the patient was trying to ignore. You may wish to discuss some of these concerns with your instructor or other experienced clinicians. As with other realms of interviewing and assessment, your skills and confidence will improve with practice and rewards will follow. Remember that many patients will appreciate an understanding listener, and some will owe their health, their safety, or even their lives to your attention.

The format that follows should help to organize your observations, but it is not intended as a step-by-step guide. When a full examination is indicated, you should be flexible in your approach but thorough in what you cover. In some situations, however, sequence is important. If during your initial interview the patient's consciousness, attention, comprehension of words, or ability to speak seems impaired, assess this attribute promptly. Such a patient cannot give a reliable history and you will not be able to test most of the other mental functions.

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