Escolar Documentos
Profissional Documentos
Cultura Documentos
Category
Sample Observations
Appearance
Behavior
Level of consciousness
Attention
Speech and language
Mood
Affect
Orientation
Memory
Thought content
Thought processes
Insight
Judgment
Higher cognitive functioning
Fund of knowledge
Calculation
Assessment
-How are you feeling about the way your life is going/will be going in your future/in the nearest
future?
-Have you had any change of feelings come over you?
-Are you nervours/anxious/irritable/frightenend?
-Are there specific situations that make you feel panicked?
-Are you afraid of crowded places/going alone?
-Have you been angry/ out of control?
-Have you been sad?
-Have you felt like crying?
-Have you cried a lot?
-Have you felt discouraged?
-Have you felt like you cannot go on?
-Have you ever thought that life is not worth living?
-What do you do for fun?
-Have you been able to enjoy yourself?
-How is your energy/ambition?
-Are you able to concentrate/to think clearly?
-Has your memory changed?
-How is your sleep/appetite/sexual drive?
-How do these feelings affect your?
Patients may describe themselves or appear in some of the following ways: sad, depressed,
lacking energy, apathetic, unable to enjoy life, energetic, happy, euphoric, irritable, angry,
furious, anxious, fearful, panicked, or feeling fine ( perhaps despite events that would lead one
to expect differently.
The observer may note the following: the affect and its quality and appropriateness, the ability of
the patient to describe this emotional life, such behaviors as retardation, agitation, lability,
irritability, suspiciousness, defensiveness, impulsiveness, the communication of quilt, shame,
worry, self-deprecation, or suspiciousness; and how the patient affects the examiner (e.g.,
producing fright, boredom, sadness, hopelessness, or anxiety).
Orientation and Memory
Now I would like to ask you some routine questions to test your memory. Some of these
questions may seem a little sill, but being sick can affect our ability to think clearly, and its
important that I check you.
-Let me first ask you some simple questions. Do you know todays date?
-What day did you get admitted?
-Can you give me your address and phone number?
The most frequently employed formal tests of the mental status involve examination for the
ability to identify person (patients name, age, and birth, date, or the name and occupation or
function of the examiner or another familiar person), place (the name of the institution or type of
building the patient is in and where it is located), and time (date, day of week, hour and season).
Person
-What is my name/occupation?
-You know who I am, dont you?
Place
-Where are we right now?
-What is the name of this place?
-have you noticed that the television or newspapers have had messages especially for you?
-Have other people been able to control your thoughts or read your mind?
Hallucinations
Hallucinations are false sensory impressions, either auditory, gustatory, olfactory, or tactile.
-Have you heard voices?
-Have you heard your thoughts out loud, as if they were spoken?
-Have you seen anything unusual, perhaps things that do not really exist?
Illusions
Illusions are misinterpretations of real experiences (e.g., a delirious patient thinks the doctor in
the white coat is an ice cream vendor).
Bizarre, paranoid, or grandiose thinking
-Are there thoughts that continually run through your mind/frighten you?
-Do you ever have a feeling that people are talking about your or watching you?
Homicidality and suicidality
-Have you had thoughts about harming others/yourself/about taking life?
-Have you ever considered suicide in the past?
-Have you attempted suicide? If yes, tell me more.
-How serious are you?
-How would you do it?
-Do you have any plans for doing it?
-Do you have the means (pills, gun other) to hurt yourself?
-Could you stop yourself?
-What keeps you from doing it?
-Would you be able to call for help before you did anything serious?
-Sometimes people who are upset (or very ill) have unusual (or frightening) thoughts. Has this
happened to you?
-have you heard or seen things that turned out not to really be there or that others could not hear
or see?
Insight and Judgment
The term insight refers to the patients ability to understand that he or she is suffering from an
illness.
-Why are you here today? Did you want to come?
-Do you think anything is wrong with your? Why?
-Do you have a physical illness?
-Do you have trouble with your thinking/emotions?
-Have you changed?
-What do the doctors (or family, or others) make of it?
-What do the tests show?
-Do you believe you are thinking clearly?