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The history should generally be supplemented by information obtained from a person other than the patient, because, through lack of insight, the patient will have no grasp of his illness or its gravity; indeed, he may be ignorant even of his chief complaint Special inquiry should be made about the patient s general behavior, capacity for work, personality changes, language, mood, special preoccupations and concerns, delusional ideas, hallucinatory experiences, personal habits and care in hygiene, and such faculties as memory and judgment The examination of the mental status should be systematic and include some of the following general categories with suggested examples for testing as modi ed for each patient s circumstances: 1 Insight (patient s replies to questions about the chief symptoms): What is your dif culty Are you ill When did your illness begin Orientation (knowledge of personal identity and present situation): What is your name, address, telephone number What is your occupation Are you married a Place: What is the name of the place where you are now (building, city, state) How did you get here What oor is it on Where is the bathroom b Time: What is the date today (day of week and of month, month, year) What time of the day is it What meals have you had When was the last holiday Memory a Remote: Tell me the names of your children (or grandchildren) and their birth dates When were you married What was your mother s maiden name What was the name of your rst schoolteacher What jobs have you held We also nd it useful to quiz the patient about cultural icons of the past that are appropriate to his age Most patients should be able to name the presidents in reverse order dating to their twenties b Recent past: Tell me about your recent illness (compare with previous statements) What is my name (or the nurse s name) When did you see me for the rst time What tests were done yesterday What were the headlines of the newspaper today c Immediate recall (attention and short-term memory ): Repeat these numbers after me (give series of 3, 4, 5, 6, 7, 8 digits at a speed of one per second) Now when I give a series of numbers, repeat them in reverse order d Memorization (learning): The patient is given three or four simple data (examiner s name, date, time of day, and a fruit, structure, or trait, such as honesty we use a red ball, Beacon Street, and an envelope ) and is asked to repeat them after a minute or a brief story containing several facts and is asked to recount the main.

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facts as soon as the story is over The capacity to reproduce them at intervals after committing them to memory is a test of retentive memory span e Another test of memory and verbal uency we have found useful is the generation of a list of objects in a category; ask the patient to give the names of animals, vegetables, or makes of cars, as many as come to mind in 30 s or so; most individuals can list at least 12 items in each category f Visual span: Show the patient a picture of several objects; then ask him to name the objects 4 Capacity for attention and working memory: Crossing out all the a s on a printed page; counting forward and backward; saying the months of the year forward and backward; spelling world forward and then backward Verbal trail making (reciting alternating letters of the alphabet and their ordinal place (ie, A-1, B-2, C-3, D- ) a Calculation: Test ability to add, subtract, multiply, and divide Subtraction of serial 3 s and 7 s from 100 is a good test of calculation as well as of concentration b Constructions: Ask the patient to draw a clock and place the hands at 7:45, a map of the United States, a oor plan of her house; ask the patient to copy a cube and other gures c Abstract thinking: See if the patient can describe the similarities and differences between classes of objects (orange and apple, horse and dog, desk and bookcase, newspaper and radio) or explain a proverb or fable ( People who live in glass houses shouldn t throw stones ; A stitch in time saves nine ; A rolling stone gathers no moss ; Idle hands are the devil s workshop ) 5 General behavior: Attitudes, general bearing, evidence of hallucinosis, stream of coherent thought and attentiveness (ability to maintain a sequence of mental operations), mood, manner of dress, etc 6 Special tests of localized cerebral functions: Grasping, sucking, aphasia battery, praxis with both hands, and corticosensory function In order to enlist the full cooperation of the patient, the physician must prepare him for questions of this type Otherwise, the patient s rst reaction will be one of embarrassment or anger because of the implication that his mind is unsound It should be pointed out to the patient that some individuals are rather forgetful or have dif culty in concentrating, or that it is necessary to ask speci c questions in order to form some impression about his degree of nervousness when being examined Reassurance that these are not tests of intelligence or of sanity is helpful If the patient is extremely agitated, suspicious, or belligerent, intellectual functions must be inferred from his remarks and from information supplied by the family This type of mental status survey can be accomplished in about 10 min In our experience, a high level of performance on all tests eliminates the possibility of dementia in 95 percent of cases It may fail to identify a dementing disease in an uncooperative patient and in a highly intelligent individual in the earliest stages of disease The question of whether to resort to formal psychologic tests is certain to arise Such tests yield quantitative data of comparative value but cannot of themselves be used for diagnostic purposes.

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