Mental Status Examination in the ED

see also complete dictionary of terms used in the MSE

Introduction

There is much confusion and complex jargon about the mental state examination in the ED
The MSE only describes a person's mental condition at one point in time
The MSE may vary within the course of a few hours
Often it is difficult to make firm conclusions about diagnosis and management with one MSE
However, a comparison of MSEs over a period of time provides much more information
Despite the great number of terms used, there are some key observations that can be made

THE MENTAL STATE EXAM

Appearance

Drowsiness (suggests an organic condition)
Lack of personal hygeine/grooming (indicative of poor functioning/self care)

Behaviour

Agitated behaviour - pacing, fidgeting, hypervigilance, shouting (predictive of violent behaviour)
Severe withdrawal - psychomotor retardation, mutism (indicative of poor functioning)
Aggression - threatening gestures, combativeness

Conversation

Dysarthria/Dysphasia (suggests an organic condition)
Pressure of speech - difficulty in interrupting the patient (suggestive of mania)
Rapid speech
Mutism

Thought (can be elucidated by conversation or from direct questioning)

Form (Process)
Patients should be able to give history in logical, chronological order and pick up their train of thought if interrupted (ask the patient if they feel their thoughts are muddled)

There are many terms to describe abnormalities in form - if a patient's conversation appears odd, hard to follow, frequently interrupted or repetitive then further psychiatric evaluation is advisable

Content

If a patient's thoughts focus excessively on a limited set of concerns or have no clear basis for them then further psychiatric evaluation is advisable.

The most important features to observe are

Persecutory/Paranoid delusions (which may lead to retaliatory behaviour)

Homicidal/Suicidal ideas

Mood/Affect

Affect best describes the current MSE
Mood relates more to the pervasive feeling over a period over time

Important features to note:

Profound feelings of sadness or hopeless
Mood/Affect which does not seem to correlate with the patient's conversation/circumstances (incongruence)
Inability to express a range of emotions

Perception

Remember that a patient may indirectly indicate they are experiencing abnormal perceptions from their behaviour - speaking to non-existent people, looking at or manipulating non-existent objects.

Hallucinations - perceptions that do not correlate with any external stimuli
Illusion - Misinterpretation of external stimuli (common in organic brain syndromes)

Be alert to and specifically inquire about:

Command delusions - belief that someone is directing their behaviour (particularly if they are violent/criminal)

Cognition

[ see Mini Mental State Assessment Form]

Abnormalities in the mini-mental state usually are a manifestation of organic disease

Insight & Judgement

Inquire specifically about:

The patient's understanding of their illness and the source of their psychiatric symptoms
The ramifications of any concerning behaviour that has been observed
Their ongoing plans about how they will manage their condition and subsequent behaviour
Their compliance to medication and followup