MH Very Comprehensive MSE

MSE

Appearance -general: [select value="alert and oriented in all spheres|obtunded|disoriented|unknown"],[select value="appears to be of chronological age|appears younger than chronological age|appears older than chronological age|unknown"].
Appearance - accessibility:[select value="cooperative|friendly|uncooperative|irritated but not to the level of anger|angry|hostile|alert|confused|hostile|silent|inappropriate boundaries|seductive|playful|ingratiating|evasive|guarded|sullen|manipulative|contemptuous|demanding|withdrawn"].
Appearance - grooming: [select value="Average/WNL|well-groomed|poorly groomed|meticulously groomed|unknown"].
Appearance - clothing: [select value="clean|dirty|unkempt|neat|tidy|meticulous|worn out|skillfully applied|unconventional|fashionable|unknown|professional"],[select value="appropriate for season| inappropriate to season|unknown"],[select value="appropriate for setting| inappropriate for setting|unknown"].
Appearance - hygiene: [select value="clean|unbathed|dirty|body odor|smells of alcohol|unknown"].
Appearance - build: [select value="average height|tall|short|unknown"],[select value="average weight|thin|overweight|obese|underweight|unknown"].
Appearance - facial expression: [select value="casual(normal)|bland|flat|mobile(rapid changes)|angry|unknown"].

VOLUNTARY PURPOSEFUL MOVEMENT
[checkbox value="Nil observed|mannerism: a 'normal' movement done excessively often, like blinking or hair flicking|dyspraxia: difficulty in performing familiar tasks despite having the ability to do so|compulsive act: an act performed to relieve inner tension, such as checking locks repeatedly|pica: the eating of non-nutritive substances, which can be associated with certain deficiencies or disorders"]

VOLUNTARY NON-PURPOSEFUL MOVEMENT
[checkbox value="Nil observed|stereotypy: repetitive, non-purposeful movements like rocking or foot-tapping|simple tic: a sudden, brief, non-purposeful movement, like eye blinking|complex tic: a series of movements, like facial grimacing followed by a head twist|stress-induced exacerbation: increase in movement or tics due to stress"]

INVOLUNTARY PURPOSEFUL MOVEMENT
[checkbox value="Nil observed|hyperreflexia: overactive or overresponsive reflexes|hyporeflexia: below-normal or absent reflexes|exaggerated startle response: a heightened reaction to sudden stimuli, often seen in PTSD"]

INVOLUNTARY NON-PURPOSEFUL MOVEMENT
[checkbox value="Nil observed|abasia: difficulty walking, as seen in dissociative gait disorders|akathisia: irresistible compulsion to move, pseudoakathisia presents without restlessness|ambitendency: conflict between executing and resisting an action|asterixis: 'flapping' tremor of the outstretched hands, commonly seen in liver encephalopathy|ataxia: lack of voluntary coordination of muscle movements, typically gait|athetosis: slow, writhing movements, often affecting hands and feet|automatic obedience: executing another's orders without consideration of consequences|ballismus: violent flinging movements of the limbs, hemiballismus affects one side of the body|blepharospasm: strong, often intermittent contraction of the eyelid muscles|bruxism: grinding or clenching of teeth, especially during sleep|catalepsy: abnormal rigidity of muscles with a fixed posture for an extended period|cataplexy: sudden muscle weakness triggered by emotions, leading to collapses without loss of consciousness|catatonia: extremes of movement, from excessive motor activity to immobility|chorea: unpredictable, involuntary muscle movements, often resembling a dance|cog-wheeling: jerky resistance to passive movement as muscles tense and relax, seen in Parkinson's|copropraxia: involuntary obscene or inappropriate gestures|dyskinesia: involuntary muscle movements, can include a range of disorders such as tremors or tics|dystonia: sustained or repetitive muscle contractions resulting in twisting movements or abnormal postures|echopraxia: involuntary mimicry of another person's movements|essential tremor: a rhythmic shaking, often of the hands and arms|forced grasping: compulsive grasping or gripping, often involuntary|grimacing: involuntary, often spasmodic, movements of the facial muscles|intention tremor: a shaking that gets worse when the individual attempts a deliberate, purposeful movement|lead-pipe rigidity: uniform and constant resistance to movement, seen in conditions like Parkinson's disease"]

PSYCHOPATHOLOGY - NAMED SYNDROMES
[checkbox value="Nil observed|mitmachen: compliance in allowing body to be positioned with a return to resting position upon release|mitgehen: extreme form of mitmachen, with movement initiated by the slightest pressure|myoclonus: sudden muscle contraction, may be part of seizure activity|negativism: motiveless resistance to any attempt to be moved|nystagmus: involuntary eye movement around a particular axis|obstruction: irregular hindrance of motor activity with often late reaction|oculo-gyric crisis: prolonged dystonic positioning of the eyes upwards or laterally|omega sign: furrowing of the brow commonly seen in depression|opposition: resistance to movement resulting in equal and opposite pressure, no net movement|parkinsonism: a syndrome characterized by bradykinesia, tremor, and rigidity|perseveration: continuous repetition of a particular response beyond its relevance|physiological tremor: normal tremor, can be exaggerated by various factors|posturing: maintaining bizarre or inappropriate positions for prolonged periods|psychological pillow: holding the head above the floor while lying on the back|resting tremor: tremor present in a limb that is relaxed and supported|schnauzkrampf: puckering of the lips forward, seen in some neurological disorders|tardive dyskinesias: late-onset movement disorders often related to neuroleptic medication|titubation: tremor of the head, involving the neck muscles|torticollis: neck twisting due to sternocleidomastoid muscle spasm|trismus: lock-jaw due to masticatory muscle spasm|waxy flexibility: extreme pliability of limbs and body, maintaining positions for long periods"]

PSYCHO-MOTOR ACTIVITY
[select value="no change|hyperactivity: increased movement and physical activity|akinesia: absence or impairment of voluntary movement|psychomotor retardation: slowed physical activity and thought processes|psychomotor agitation: excessive and purposeless motor activity|catatonia: abnormality of movement and behavior arising from a disturbed mental state|echopraxia: mimicking another's movements|stupor: lack of critical cognitive function and a level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain"]

SPEECH
[select value="normal rate and rhythm|pressured speech: rapid and incessant speech|poverty of speech: limited amount of speech often seen in schizophrenia|alogia: lack of speech, associated with severe depression or schizophrenia|mute: no speech in a person who is typically capable of speech|tangentiality: going off on a tangent and not reaching the desired point or goal|circumstantiality: speech that is indirect and delayed in reaching its goal due to unnecessary detail|flight of ideas: rapidly changing or disjointed thoughts"]

MOOD OBSERVED
[select value="euthymic: normal, non-depressed, reasonably positive mood|dysphoric: generalized dissatisfaction with life|euphoric: an exaggerated state of happiness and well-being|anxious: experiencing worry, unease, or nervousness|irritable: easily exasperated or angered|labile: showing rapid shifts or fluctuations in mood|depressed: showing symptoms of sadness, hopelessness, and a loss of interest|elated: high spirits, cheerfulness, and increased energy"]

AFFECT
[select value="appropriate to context and congruent with mood|blunted: showing significantly reduced intensity in emotional expression|flat: absence or near absence of any signs of affective expression|incongruent: not corresponding with the individual’s actual emotional state or situation|labile: abnormal variability in affect with repeated, rapid, and abrupt shifts|restricted or constricted: reduced in range or intensity|elevated: higher than typical level of affective expression"]

NEUROTIC CONCERNS
[checkbox value="NAD|compulsion: distressing obsessional impulses not typically acted upon, such as harming one's child|conversion: psychological distress manifesting as physical symptoms, also known as dissociation or hysteria|dissociation: a separation of normal subjective experiences from conscious awareness due to psychological distress, can range from partial to complete|hypochondriasis: an unfounded belief of having a specific physical illness, may be delusional|obsession: recurrent, intrusive, and unwanted thoughts or impulses that cause distress and are recognized as irrational by the individual|phobia: an extreme and uncontrollable fear of a specific object or situation, often with insight into its irrational nature|ruminations: persistent and intrusive obsessional thinking|somatization: presentation of physical symptoms without a physical cause, often as an expression of psychological distress"]

MOOD / AFFECT CONGRUENCE
[checkbox value="congruent: mood is appropriate to the context and situation|abulia: loss of willpower or decisiveness|alexithymia: difficulty in identifying and describing one's emotions|anhedonia: inability to feel pleasure in normally pleasurable activities|anosodiaphoria: indifference to illness or disability|anxiety: state of apprehension, unease, or nervousness|apathy: lack of interest, enthusiasm, or concern|asthenic: perceived inadequacy or weakness, prone to complaints|belle indifference: apparent indifference to one's medical condition|blunting/flattening of affect: reduced intensity in emotional expression|cyclothymia: mood swings from mild depression to emotional highs|delusional mood/atmosphere/intuition: feeling on the verge of important, often sinister, revelation|dysphoria: general dissatisfaction or restlessness|elation/euphoria: heightened state of happiness or well-being|euthymia: stable and 'normal' mood state|guarded: cautious and reserved, especially in giving information due to perceived threat|incongruity of affect/mood: mood is inappropriate for the circumstances or discussion|lability of mood: rapid and unpredictable changes in mood|emotional incontinence: extreme lability of mood with loss of emotional control|moria/witzelsucht: frivolous demeanor and a tendency towards inappropriate joking, often due to neurological issues|perplexity: sense of confusion or uncertainty about one's state|restricted affect: limited range of emotional expression|verstimmung: irritable or morose mood that may affect those around them"]

BEHAVIOUR - GENERAL
[select value="cooperative: willing to engage with others|withdrawn: avoiding social interaction|aggressive: prone to hostility or violence|passive: accepting or allowing what happens without active response or resistance|disinhibited: showing a lack of restraint or social appropriateness|compulsive: engaging in behavior driven by the need for perfection or control|obsessive: dominated by a persistent, troubling preoccupation"]

BEHAVIOUR EYE-CONTACT
[select value="appropriate: maintains eye contact that is socially acceptable|avoidant: consistently avoids eye contact|intense: excessively strong or piercing eye contact|fleeting: brief and infrequent eye contact|fixed: prolonged and unchanging eye contact|absent: no eye contact whatsoever"]

ORIENTATION
[select value="oriented x3: aware of person, place, and time|disoriented: not aware of person, place, and/or time|confused: unable to think with clarity or act with understanding|time/place/person confused: specific confusion about the time, place, or personal identity"]

ATTENTION
[select value="focused: able to concentrate on a task or speaker without difficulty|distractible: easily drawn away from the task or topic at hand|hyperalert: unusually or excessively alert|inattentive: lacking focus or attention to the ongoing activity or conversation"]

COGNITION / MEMORY - OVERALL
[select value="intact: functioning within normal limits|impaired: noticeable difficulty in cognitive or memory performance|enhanced: performing above expected cognitive or memory ability|variable: inconsistent cognitive or memory performance"]

COGNITION / MEMORY - ABSTRATION
[select value="intact: capable of understanding abstract concepts and ideas|concrete: difficulty with abstract thinking, tends to think literally|impaired: noticeable difficulty in understanding or using abstract concepts|variable: inconsistent ability to understand or apply abstract thinking"]

AWARENESS
[checkbox value="NAD|automatism: actions performed without conscious intent or recollection|clouding of consciousness: reduced ability to focus attention and interact appropriately, less severe than delirium|coma: state of unconsciousness from an organic cause, typically with low Glasgow Coma Scale score|delirium: fluctuating consciousness with disorientation, often with restlessness and bizarre manner|depersonalization: feeling detached from oneself with retained awareness of associated low mood or anxiety|derealization: feeling detached from reality, perceiving the environment as unreal|insight: objective understanding of one's mental state, often regarding agreement between patient and professional|oneiroid state: dream-like experience with some awareness of surroundings, shifts in perception, affect, and behavior|stupor: reduced reactivity to surroundings, may appear alert or have reduced consciousness|torpor: drowsiness with reduced awareness, tendency to fall asleep easily|twilight state: oneiroid-like state with organic causation, defined onset and end, and potential for unpredictable behavior"]

THOUGHT - FORM AND FLOW
[select value="coherent: thoughts are logically connected and goal-directed|circumstantial: excessive detail that is eventually relevant to the question|tangential: straying from the topic without ever answering the initial question|loose associations: ideas shift from one subject to another in a loosely connected way|flight of ideas: rapid movement between topics with a perceptible association|word salad: incoherent mix of words and phrases|neologism: invention of new words or phrases|thought blocking: abrupt interruption in the train of thought|perseveration: persistent repetition of words or ideas|echolalia: repetition of another's words|poverty of thought: limited quantity of thought|pressured speech: rapid and insistent speech often associated with manic symptoms|thought withdrawal: belief that thoughts are being removed from one's mind|thought insertion: belief that thoughts are being placed into one's mind"]

THOUGHT - PERCEPTION 
[checkbox value="Unremarkable|ideas of reference: belief that events or media are specifically referring to oneself, may indicate delusions of reference|overvalued idea: a preoccupation that is strongly held despite being open to counterargument, not as fixed as a delusion|delusion: a firm belief that is resistant to reason or confrontation with actual fact, often bizarre and obviously untrue given the subject's background|primary delusion: a delusion that arises spontaneously without apparent cause, often following a delusional mood|secondary delusion: a delusion that is understandable given the subject's previous mental state or circumstances|delusional perception: a correct perception that is given a bizarre delusional meaning, a type of primary delusion|delusions of control: belief that one's thoughts or actions are being controlled by an external force|delusional misinterpretation: misinterpretation of a real percept due to a pre-existing delusion|delusional memory: a false memory that is believed to be true, despite being implausible or bizarre|partial delusion: a diminishing delusion that is in the process of resolving|paranoia: belief that others' actions or conversations are directed at oneself, may be persecutory or grandiose in nature"]

PERCEPTION
[checkbox value="NAD|perceptual distortion: altered threshold or experience of a percept due to sensory abnormalities|hyperacusis: increased sensitivity to sound|hypoacusis: decreased sensitivity to sound|macropsia: objects appear larger than they are|micropsia: objects appear smaller than they are|dyschromatopsia: color perception is distorted, colors may seem unusually vivid or desaturated|completion illusion: ambiguous percepts are completed by the mind and misinterpreted|affect illusion: emotional state influences the interpretation of perceptions|pareidolia: seeing distinct images within random patterns, like faces in clouds|false perception: experiencing a perception without an actual stimulus, regarded as real|extracampine hallucination: perception of stimuli outside the normal sensory field|functional hallucination: a real percept triggers a hallucination in the same modality|hypnagogic hallucination: occurring while falling asleep, often pseudohallucinations|hypnopompic hallucination: occurring while waking from sleep|reflex hallucination: a percept in one modality triggers a hallucination in another|elementary auditory hallucination: basic sounds or noises|complex auditory hallucination: voices or music|voices - thought echo: own thoughts heard as spoken aloud|running commentary: voice comments on the person’s actions|auditory hallucinations in various persons: first, second, or third person voices|palinacousis: auditory perseveration, sounds or voices echo after the stimulus ends|proprioceptive hallucination: false perception of body or limb movement or position|phantom limb: sensation that an amputated or missing limb is still attached"]

HALLUCINATIONS
[checkbox value="NAD|perceptual distortion: altered threshold or experience of a percept due to sensory abnormalities|hyperacusis: increased sensitivity to sound|hypoacusis: decreased sensitivity to sound|macropsia: objects appear larger than they are|micropsia: objects appear smaller than they are|dyschromatopsia: color perception is distorted, colors may seem unusually vivid or desaturated|completion illusion: ambiguous percepts are completed by the mind and misinterpreted|affect illusion: emotional state influences the interpretation of perceptions|pareidolia: seeing distinct images within random patterns, like faces in clouds"]

HALLUCINATIONS - AUDITORY
[checkbox value="NAD|elementary auditory hallucination: basic sounds or noises|complex auditory hallucination: voices or music|voices - thought echo: own thoughts heard as spoken aloud|running commentary: voice comments on the person’s actions|auditory hallucinations in various persons: first, second, or third person voices|palinacousis: auditory perseveration, sounds or voices echo after the stimulus ends"]

HALLUCINATIONS - PROPRIOCEPTIVE 
[checkbox value="NAD|proprioceptive hallucination: false perception of body or limb movement or position|phantom limb: sensation that an amputated or missing limb is still attached|vertigo: sensation of spinning or moving, considered a vestibular hallucination|kinaesthetic hallucination: hallucination of movement or position of parts of the body"]

HALLUCINATIONS - SOMATIC
[checkbox value="NAD|superficial hallucination: sensations of skin such as touch, temperature, or feeling of liquid, including formication and Lhermitte’s sign|deep hallucination: visceral sensations like pushing, pulling, or twisting, which may be painful|coenestopathic hallucination: a qualitative change in the perception of the material characteristics of a body part, leading to localized distortion"]

HALLUCINATIONS - OLFACTORY AND GUSTATORY
[checkbox value="NAD|olfactory hallucination: a false perception of smell, often mood-congruent and indicative of temporal lobe epilepsy|gustatory hallucination: a false perception of taste, can be prolonged and mood-congruent, suggestive of temporal lobe epilepsy or functional psychoses|dysgeusia: an impaired or distorted sense of taste"]

HALLUCINATIONS - VISUAL
[checkbox value="NAD|Lilliputian hallucination: visions of miniature people or objects, linked to alcohol withdrawal and possibly pleasurable|autoscopic hallucination: visual hallucination of oneself, may lead to belief in a Doppelganger|negative autoscopy: inability to see one's reflection in a mirror|experiential hallucination: vivid, memory-like visual hallucinations, often associated with temporal lobe epilepsy|phosphenes: brief flashes of light, indicative of optic pathway issues|palinopsia: visual perseveration due to an organic cause|teichopsia: zigzag lines seen in the peripheral vision preceding a migraine"]