Thursday, April 14, 2016

Step 2 CS: Writing a psychiatry note and mini mental status

Mnemonic: ABC MATTS

Appearance - Well groomed / Dishevealed
Behaviour - Appropritate / Inappropriate
Co-operation - Cooperative / Non-cooperative

Mood - Euphoric / Depressed
Affect - Normal / Blunt affect with poor eye contact
Thought Process- Direct / Disorganized
Thought Content - Normal / Delusional
Speech - Fluent speech / Slow speech

"Now I am going to ask you a few questions that may seem odd, but these are just to assess your mental status."

"What is your name?"
"Do you know where we are?"
"Do you know what time is it?"
AAOx 3

"I will name three objects for you, can you repeat them after me? I will ask you to repeat the same objects after a while."
3/3 registration, 3/3 recall at 3 minutes

"Can you spell the word 'world' backwards for me?"
Can / can't spell backwards

"Do you remember your graduation / first job?"
Distant memories intact / impaired

"What will you do when you see fire coming out of the paper basket?"
Judgement intact / poor

"Can you take this paper, fold it into half and give it back to me?"
Completed 3 step command (You can also document right handed here)

"What is 7 minus 5?"
Calculation intact

Some more notes I took while working on my psychiatry note:

You can also make statements like - patient is inattentive to the interviewer / patient is hostile towards the interviewer.

The normal expression of affect involves variability in facial expression, pitch of voice, and the use of hand and body movements.
Blunted affect is market by a severe reduction in the intensity of affective expression.

Physicians may note the rate of thought (extremely rapid thinking is called flight of ideas) and flow of thought (whether thought is goal-directed or disorganized).
Additional descriptors include whether thoughts are logical, tangential, circumstantial, and closely or loosely associated.

Thought content describes what the patient is thinking and includes the presence or absence of delusional or obsessional thinking and suicidal or homicidal ideas. 

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