How do you know if your patient has an injury to their brain? How can you tell if they’re suffering from a traumatic brain injury or stroke, or if they just fainted due to something else? One of the best ways to help ensure that your patient’s injuries were not caused by head trauma, as well as to provide them with the best care possible, is through the mental status examination. This guide will teach you everything you need to know about performing a mental status examination, including how to identify abnormalities and the best way to approach them, as well as the most effective treatments and approaches to prevention.

The Three Components of the MSE:

The first component of the mental status examination is to assess the person's level of consciousness. Consciousness is the awareness that one has of his or her self and the environment, and it can be measured by asking simple questions such as what time it is, who you are, and where you are located. The second component is an evaluation of orientation. Orientation refers to the person's knowledge about what has happened in their life (past), who they are with at this moment (present), and where they currently are in relation to other places that they know about (future). The third component is an assessment of mood and affect. Mood describes how a person feels emotionally, while affect describes how a person looks emotionally on the outside.

The General Appearance:

The person's general appearance can be indicative of his or her mental status. For example, if the person is unkempt and disheveled, he or she may not care about personal hygiene or appearance, which may be indicative of depression. Similarly, if the individual's hygiene is poor and their clothing dirty and stained, it might indicate neglect. Another sign of poor mental health is poor grooming habits. If the individual has neglected his or her hair for a period of time, this could signify decreased self-esteem or self-confidence. Neglecting one's clothes often indicates they have lost interest in what they wear. There are many more signs to look out for during an exam, but these are some basics you should always examine when assessing an individual's general appearance.

The Behavior:

A mental status examination is a way of assessing the level of cognitive function and physical health of an individual. The exam includes observation and questioning, but can also include other tests like intelligence tests or memory tests. Here are some tips on how to perform a mental status examination:

-Ask questions that are appropriate for the person's age range and ability level, such as What year is it? or What day is it?

-Be aware that if you ask difficult questions and the person cannot answer them, it may be because they do not know the answer. If this happens, try asking easier questions, such as What month is it?

The Mood and Affect:

It is important to assess the mood and affect of the person. Mood includes whether the person is sad, irritable, elated, or anxious. Affect includes whether the person appears inattentive or distracted and if any agitation or lethargy is present. The best way to examine mood is by asking open-ended questions such as How has your mood been lately? The best way to examine affect is by watching for facial expressions and body language. For example, patients who are inattentive may have a blank expression on their face while patients who are agitated may be fidgeting with their hands or looking around erratically. It's also important to take into account how long these symptoms have been present because they can help you make an accurate diagnosis.

The Speech:

A mental status examination is an assessment of the mental function of an individual. It typically consists of interviews with the patient and observation in person or via video conferencing. The assessment may also include formalized testing, such as paper-and-pencil testing or electroencephalography (EEG). Psychometric tests are often used for cognitive assessments. Paper-and-pencil tests can be administered by a clinician in person or remotely through videoconferencing. They provide objective data about memory, attention span, sequencing abilities, vocabulary usage, and other cognitive skills. Cognitive Functioning Evaluation System - Alternative Test; Rey Complex Figure Test; Trail Making Test Part B; Weschler Memory Scale - Revised; Bender Visual Motor Gestalt Test.

The Thought Process:

To perform an examination, you must first have background knowledge of the person’s mental health history. If you do not have this information, it is best to ask questions such as What are some symptoms you have been experiencing? or Can you tell me about your past psychiatric history? Next, document your findings. Start by asking the person if they feel suicidal. If they answer yes, go through the suicide risk assessment process with them. The SARA includes: 1) Have you thought about killing yourself? 2) Do you want to kill yourself? 3) Do you have a plan for how to kill yourself? 4) When did these thoughts start? 5) What makes them better or worse?

The Perception:

Perform the following steps in order to perform an examination of the mental status of someone:

1. Observe the person's behavior and mannerisms 

2. Ask them questions relevant to their surroundings, such as what they do for a living or what they are currently doing 

3. Ask them where they live and if they have any close family members that live close by

 4. Ask them what day it is 

5. Ask them what year it is 

6. Find out if they know who the president of the United States is

 7. Find out if they know how old they are 

8. Check their comprehension by asking questions like What does one plus one equal? or What color is this house? 

9. Determine whether the person is oriented to time, place, and person

 10. Determine whether the person remembers recent events

 11. Determine whether the individual has hallucinations

 12. If you suspect dementia ask them to draw a clock with numbers around it

 13. Perceive whether they are oriented to objects 

14. Re orientate back to time-place-person

 15. Re orientate back to objects

 16. Ask another set of orientation questions

 17. See if there are other signs of mental health issues 

The Cognition:

The following questions are used to assess cognition. The examiner should ask all of these questions, as well as others that may be more relevant for the patient's situation.

1. What is your age?

2. What is the date today?

3. Who is the current president of the United States?

4. Can you tell me what time it is now?

5. How many fingers am I holding up right now?

6. What season is it right now outside?

7. Do you know where you are right now and why we're here today?