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Abnormal Findings in Mental Status Assessment

I. Levels of Consciousness
1. Alert (Normal) - Awake or readily aroused;
-oriented; -fully aware of external and internal stimuli and responds appropriately; -conducts meaningful interpersonal interactions.

2. Lethargic (or Somnolent) Not fully alert drifts off to sleep when not stimulated can be aroused to name when called in normal voice but looks drowsy responds appropriately to questions or commands but thinking seems slow and fuzzy Inattentive loses train of thought spontaneous movements.

3. Obtunded (Some sources omits this level) Transitional state between lethargy and stupor Sleeps most of the time difficulty to arouse needs loud shout or vigorous shake acts confused when is aroused converses in monosyllables speech may be mumbled and incoherent requires constant stimulation for even marginal cooperation.

4. Stupor or Semi Coma Spontaneously unconscious responds only to persistent and vigorous shake or pain has appropriate motor response (e.g., withdraws hand to avoid pain) otherwise, can only groan, mumble, or move restlessly reflex activity persists.

5. Coma Completely unconscious no response to pain or to any external or internal stimuli (e.g. When suctioned does not try to push the catheter away), light coma has some reflex activity but no purposeful movement deep coma has no motor response.

Acute Confusional State (ACS) Is also called delirium. Theres a clouding of consciousness (dulled cognition, impaired alertness) Inattentive incoherent conversation impaired recent memory and confabulatory for recent events often agitated and having visual hallucinations; Disoriented with confusion worse at night when environmental stimuli are decreased.

II. Speech Disorders

1. Dysphonia -Is difficulty in talking with abnormal pitch or volume due to laryngeal disease. -Voice sounds hoarse or whispered but articulation and language are intact.

2. Dysarthria. -Distorted speech sounds -speech may sound unintelligible; basic language (word choice, grammar, comprehension) intact.

3. Aphasia. Is true language disturbance. Defect in word choice and grammar or defect in comprehension defect in higher integrative language processing.

Examples of Aphasia
a. Expressive Aphasia. -The patient is unable to speak clearly. This is due to lesion in the motor speech center or Brocas area in the left frontal lobe of the brain. b. Receptive Aphasia. -The patient can hear sounds and words but cannot interpret or understand them. This is due to lesion in the auditory speech center or Wernickes area in the temporary lobe.

c. Global Aphasia. -Spontaneous speech and comprehension are absent. -This is due to lesions affecting both the Brocas area and Wernickes area.

III. Abnormalities of Mood and Affect 1. Flat affect (Blunted Affect) Lack of emotional response; no expression of feelings; voice monotonous and face immobile. Topic varies, expression does not.

2. Depression Sad, gloomy; symptoms may occur with rainy weather, after a holiday, or with an illness; if the situation is temporary, symptoms fade quickly. Patient states, Ive got the blues.

3. Depersonalization (lack of ego boundaries) Loss of identity, feels estranged, perplexed about own identity and meaning of existence. Patient states, I dont feel real. I feel like Im not really here.

4. Elation Joy and optimism, overconfidence, increased motor activity, not necessarily pathologic. Patient states, Im feeling very happy.

5. Euphoria Excessive well-being, unusually cheerful or elated, which is inappropriate considering physical and mental condition, implies a pathologic mood.
Patient states, Im high. I feel like Im flying. I feel on top of the world.

6. Anxiety Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown. Patient states, I feel nervous. I worry all the time. I cant seem to make up my mind.

7. Fear Worried, uneasy, apprehensive from the anticipation of a danger whose source is known. Fear of flying in airplanes.

8. Irritability Annoyed, easily provoked, impatient.

Person internalizes a feeling of tension, and a seemingly mild stimulus sets him (or her)off.

9. Rage Furious, loss of control.

Person has expressed violent behavior toward self or others.

10. Ambivalence The existence of opposing emotions toward an idea, object, person.
A person feels love and hate toward another at the same time.

11. Lability Rapid shift of emotions.

Person expresses euphoric, tearful, angry feelings in rapid succession.

12. Inappropriate Affect Affect clearly incongruent with the content of the persons speech. Laughs while being told of his/her diagnosis as cancer.

IV. Abnormalities of Thought Process

1. Blocking Sudden interruption in train of thought, unable to complete sentence, seems related to strong emotion. Patient states, Forgot what I was going to say. What was I talking about? What was my last word?

2. Confabulation Fabricates events to fill in memory gaps. Gives detailed description of his long walk in the hospital patio, although you know, the patient remained in his room all day.

3. Neologism Coining a new word; invented word has no real meaning except for the person. Patient states, I have to turn on my thinkilator. Or Are you a grittiz?

4. Circumlocution Round about expression, substituting a phrase when cannot think name of object. Patient says, the thing that you open the door with, instead of can opener.

5. Circumstantiality Talks with excessive and unnecessary details, delays reaching point. Sentences have a meaningful connection but are irrelevant. Patient says, When was my surgery? Well, I was 26, I was living with my cousin, shes the one with psoriasis, she had it bad that year because of the heat, the heat was worse then than it was summer92, the year when the Miss Universe beauty pageant was held in the Philippines...

6. Loosening Associations Shifting from one topic to an unrelated topic; person seems unaware that topics are unconnected. Patient says, My supervisor is angry with me and it wasnt even my fault. I saw the movie, For the first time of KC Concepcion and Richard Gutierrez. It was fun to go swimming that summer. I bought a new blouse from the mall.

7. Flight of Ideas Abrupt change, rapid shifting from topic to topic, practically continuous flow of accelerated speech; topics usually have unrecognizable associations or are plays on words. Take this pill? The pill is blue. I feel blue. Blue, blue my world is blue. She wore blue velvet.


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