How to do MSE of unconcious, uncooperative and mute patients

[ELOVL4]

Good Morning everyone,

I was reading an old article about the terminology "MSE" and almost agreed with the writer that MSE is not and examination, it is "the hotch-potch of observations, interpretations, guesses and psychiatric folklore dignified by the term " examination". Anyway, I am a newbie and having difficulties to do the so called "MSE" on extremely uncooperative and mute patients. I would like to learn from the experts, please provide your references.🙂

Sincerely,

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[strangeglove]

Focus on behavior, eg uncooperative, mute, agitated, intubated, etc. Level of consciousness is also important. Hopefully, your MSE, along with your history, will provide an understanding of why you could not obtain verbal responses. You can defer the cognitive exam by stating that patient unable or unwilling to provide responses (don't just leave it blank).

 

[nitemagi]

I found this helpful during my training:
http://www.amazon.com/Psychiatric-Mental-Status-Examination/dp/0195062515

Start with observations at baseline. Then think about the level of responsiveness to basic interactions (a conversation). Then assess the responsiveness to more provocative interactions (challenging them, etc.). Such as in the neuro MSE, you don't just write "unconscious." You assess for what they respond to (voice, tactile, painful stimuli).

The MSE is most definitely an examination. What you do with it and your level of expertise at it is quite user dependent.

 

[splik]

Good Morning everyone,

I was reading an old article about the terminology "MSE" and almost agreed with the writer that MSE is not and examination, it is "the hotch-potch of observations, interpretations, guesses and psychiatric folklore dignified by the term " examination". Anyway, I am a newbie and having difficulties to do the so called "MSE" on extremely uncooperative and mute patients. I would like to learn from the experts, please provide your references.🙂

it most certainly is an examination. Observation, the key component of the mental state examination is also the most important part of the physical examination. The great thing about it, is it allows you to formulate a possible differential and initial management, even in patients who are too psychotic or disorganized to take a history from.

I use the European way of doing the MSE which is slightly different (thought form instead of thought process, and no documentation of affect, also more of a focus on first-rank symptoms and tendency to use Germanic jargon - e.g. gedankenlautwerden, vorbeireden, verstimmung) I will give you some examples.

 

[splik]

Appearance and Behavior: 23 year old caucasian female wearing jeans and a t-shirt, appears dishevelled with unwashed dark blonde hair, refuses to make eye contact, promiment psychomotor agitation, non-cooperative, and physically assaultive
Speech: booming voice, highly pressured speech, almost incomprehensible, with prominent circumstantiality
Mood: s: patient refuses to answer o: patient appears irritable
Thought form: flight of ideas
Thought content: patient expresses grandiose delusions and homicidal ideation: 'I'm gonna f*cking kill you, you c***s', unable to assess suicidal or paranoid ideation but appears to have persecutory ideas
Perception: patient appears to be responding to auditory and possibly visual hallucinations, but not hallucinations in any other modality; refuses to answer on direct questioning; no evidence of thought insertion, withdrawal, broadcast or passivity phenomena
Cognition: alert, unable to assess orientation to time, place, person or situation; MMSE: not done
Insight: patient does not appear to recognize anything is wrong, not willing to engage with us or receive treatment

 

[heyjack70]

Appearance and Behavior: 23 year old caucasian female wearing jeans and a t-shirt, appears dishevelled with unwashed dark blonde hair, refuses to make eye contact, promiment psychomotor agitation, non-cooperative, and physically assaultive
Speech: booming voice, highly pressured speech, almost incomprehensible, with prominent circumstantiality
Mood: s: patient refuses to answer o: patient appears irritable
Thought form: flight of ideas
Thought content: patient expresses grandiose delusions and homicidal ideation: 'I'm gonna f*cking kill you, you c***s', unable to assess suicidal or paranoid ideation but appears to have persecutory ideas
Perception: patient appears to be responding to auditory and possibly visual hallucinations, but not hallucinations in any other modality; refuses to answer on direct questioning; no evidence of thought insertion, withdrawal, broadcast or passivity phenomena
Cognition: alert, unable to assess orientation to time, place, person or situation; MMSE: not done
Insight: patient does not appear to recognize anything is wrong, not willing to engage with us or receive treatment

Exactly. This is a whole lot more informative than saying the patient is acting out of control and yelling at everyone. Unfortunately, there is not enough emphasis placed on MSE in my experience. It is often glossed over, or an afterthought to the hx of present illness. I think the money in psychiatry is the mental status examination. Anyone can check boxes for SIGECAPS, but if the patient doesn't appear depressed on MSE, should you really be starting meds? Our training seeing hundreds/thousands of patients, and getting good at communicating with these types of patients, I think really defines the field of psychiatry.

 

[ELOVL4]

Thank you all for your valuable inputs. I am trying to write up an article about it and hope to find more info.