2. Mental state examination
Use the headings in Bloch and Singh (2001:94-105) to organise your notes:
- General appearance and behaviour
- Affect and mood
- Depersonalisation and derealization
- Thought (stream, form, content)
General appearance and behaviour
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. On appearance, were no signs of tremor or abnormal movements; however, Lucy showed signs of proptosis, consistent with Grave's disease. Lucy was cooperative throughout the interview. She maintained eye contact, except during the times when recounting the history of her father's death and her previous marriage. 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.
Affect and mood
Lucy's affect was depressed and her range of mood reduced. She also appeared anxious and irritable.
Lucy's thought stream was decreased. 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. Lucy was also feeling guilty for not being able to care for her son and fiance since having the headache. 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. She was able to answer questions and recall her past without difficulties.
Insight and judgement
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 11. 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.
Alternatively, you may use the simple present tense to report the findings of the MMSE. This would contribute toward a consistent reference point for the report by placing the activity of the MMSE at the same time as the interview, the findings of which are forming the basis of this report. It would also grant the MMSE findings more immediate perspective. Over multiple interviews it is important to state at which point the MSE and MMSE were done, especially if the patient's mental state changes or fluctuates.
Both approaches to reporting the findings of the MMSE are acceptable. It is important to be consistent, though, in the approach you adopt.