The Mental Status Examination: Fill & Download for Free

While I have adhered strictly to the Goldwater Rule until now, I no longer think it should apply to the current political climate. One tenet of the Goldwater Rule is that it is unreasonable for psychiatrists to make long distance diagnoses of public figures because a structured diagnostic interview is required for an accurate evaluation. Some would go further to suggest that psychiatrists have no business offering professional opinions about people who are not their patients.The current climate is unique in several ways. First, the sheer volume of information publicly available about the behavior and mental processes of the President is greater than might be gleaned from many hours of formal psychotherapy. Most of the elements of a comprehensive mental status examination are available for all to see between public appearances and tweets. The one area that might fall short is the depth of neuropsychiatric data that would be needed to determine with confidence whether or not he suffers from dementia and, if so, to what degree.A second crucial factor is the stakes involved in overlooking mental impairment. As we continue to careen toward the possibility of nuclear disaster, it would be irresponsible to ignore evidence that such a disaster may be not only possible, but imminent. When psychiatrists deal with patients, they have a “Duty to Warn” potential victims if the doctor perceives an imminent threat of harm. This responsibility supersedes even confidentiality. While there is no statutory Duty to Warn outside of the doctor patient context, one could reasonably argue that there is a corresponding responsibility to warn if a psychiatrist perceives an imminent physical threat to others by a person in a position of great power, particularly if the potential victims might number in the millions.Another issue is the difference between formal psychiatric diagnosis and the identification of traits or behaviors that indicate risk. In the case of the President, we are seeing example after example of his inability to empathize with others or to value the welfare of others above his personal welfare and reputation. Even more critical, there has been example after example of this failure of empathy being even more stark in the case of brown people. Since the most immediate consequence of nuclear conflict with North Korea would be the deaths of millions of Asians, this lack of empathy might seriously lower the threshold for initiating a first strike, particularly if there is a limited understanding of the worldwide environmental consequences of a war even if the US mainland is spared from a direct strike. And the possibility of waging war on impulse as a distraction from growing legal and political jeopardy is horrifying.So as professionals with expertise in understanding human behavior, I believe that psychiatrists and other experts in human behavior have a responsibility to speak out in the face of imminent danger. And the moral responsibility is even greater if we are not among the most likely victims.

I was working as a radiologist at Marin General Hospital in the Bay Area of California. We took care of some of the wealthiest people in the country as well as inmates from San Quentin. Everyone got the same treatment.One night I was on call and came in to take care of a female inmate with pelvic pain. The technologist performed a standard ultrasound which was unrevealing so performed a transvaginal ultrasound (in which a transducer that looks like a giant dildo is inserted into the patient's vagina. It's more sensitive for picking up certain pathology that may be obscured by fat or bowel gas.As I examined the adnexa (the sides of the pelvis that contains the ovaries and fallopian tubes) I asked the patient if she was having any pain (a possible sign of pathology such as infection)."Honey, hurts so bad I don't want you to ever stop!" came the reply. The female guard bit her lip and my technologist (also female) had to leave the room.This is republished from my answer to "What are some unbelievable ER stories:I was a med student in the Hopkins ER on "check day." This referred to the day when public assistance checks were received in the mail. Inevitably this would lead to an escalation of partying and mayhem in East Baltimore. Everyone knew when "check day" was; the patients, physicians and nurses all referred to it that way.The ER got particularly busy on hot humid summer nights when folks would congregate on the stoops of row houses, bottles of forty ounce Colt 45 (and similar fortified beverages) in brown paper bags..A call came from the paramedics that they were bringing in a man "with a bicycle in his nose."In an ER that had seen just about every permutation of bizarre "knife and gun club" incidents, this had everyone stumped.Sure enough, the patient was brought in in a wheelchair, with the front forks of a bicycle (no wheels) embedded deep in the bridge of his nose. He had been in a fight and his assailant weaponized the nearest object which was now buried deep in his victim's ethmoid sinus region.We took an x-ray; the ENT resident and his crew came down and they just stared at it for about ten minutes. No one knew what to do.After conferring with multiple colleagues he came to a decision."Let's pull it out" he announcedWith several sets of hands, that's exactly what they did.Afterwards, a Baltimore police officer asked the intoxicated patient if he knew the name of the perpetrator."His name is 'dead man'" came the response.And the cop wrote it down, word for word.This brings to mind a different story.I was on the medical service and we admitted a comatose man from the ER to the neurological service.Each day on rounds, our chief resident would ask the patient a series of "mini-mental status questions (http://en.wikipedia.org/wiki/Min...), typically limited to orientation to name, location, date. For several days there was no response. The patient remained somnolent.Then, on the sixth or seventh day we stopped by the gentleman's room and the resident asked the same questions."Do you know your name?" No answer."Do you know where you are? No answer."Do you know what today is?"Not a moment passed. "Check day" came the patient's response.And he was right.

Here’s my perspective as a highly trained doctor in a different field… Who had the misfortune of getting mixed up with some “psychiatrists” for “treatment”.I did not meet a psychiatrist or trainee psychiatrist who cleared the first, most basic “ARE YOU A COMPETENT DOCTOR?” hurdle… Examine the f—king patient. A suitable physical examination is of paramount importance for all doctors, ever. In many instances it need not be protracted; observe their body (skin, eyes, mucous membranes, and in my case probably take a moment to fawn over my taught muscular buttocks), listen to their chest, check/take a peripheral pulse, and take their blood pressure. Note the findings down. If there are any abnormalities, check up on that.I had been referred to psychiatrists, sure. But… My GP hadn’t examined me in depth in some time either. For him, he was my GP, I see him every month or so, and I’m fairly young and healthy - so taking my BP every time is likely over the top.For ALL psychiatrists and trainee psychiatrists……. None performed ANY physical examination EVER. Not on the first instances they saw me as a new patient. Heck, not even when I tried to induce an examination by stating a peripheral neurological abnormality.Not only that… In none of their offices did I see any equipment suggestive of them being prepared to conduct basic physical examinations of patients.As such, the first thing I note in psychiatrist notes is that psychiatrists are incompetent and/or negligent to the extent that they aren’t actually doctors.For the record, I went to one private psychiatrist as a patient, two other private ones to check if they were full of as much shit as the first (yes), then public psychiatrists… Of whom I saw one psychiatric resident, one junior doctor, and four psychiatric nurses - all for first-time-seeing appointments. None conducted ANY physical examination at all. As such, all of their notes lacked an appropriate physical examination record.C.f. other Specialists/consultants - when seeing a new patient, they ALL do this, or at very least ensure that it has been done that day/extremely recently by a professional known to them (e.g. nurse at their practice). It only takes like a minute to listen to a chest, take a B.P. and check a pulse AND write that shit down.By doing so, these other doctors do three things - 1) prove that they’re actually competent doctors 2) protect themselves from liability 3) rule out some other possible causes of any symptoms, or even diagnose important disease states and save patient’s lives.So… Psychiatrists… Perform clinical examinations you fucking morons. Write the damn results down, idiots. There are no excuses for failure to do so. You stupid bollocks.OK one excuse - for the genuinely unexaminable patients who won’t allow one or on whom performing one would be unsafe for you/them, then sure… Don’t do it then. Instead, write down “could not do one because [reason]” in your fucking notes.Instead of being competent, their notes start with an extraordinarily bizarre and offensive “mental status examination”.This commences with a detailed from-a-distance physical description which to me is a dumb was to start an “examination” of mental status.The two of mine that I’ve seen went “white male, X age, looks to be X age, short brown hair, wearing dark trousers and a jacket, and boots. Walks normally. Talks normally” - except it was extended out across about ten paragraphs, they were a description that would have been appropriate for them to have provided to Police if I had mugged them……. In medical notes, it was messed up. If there were anything notably abnormal in my appearance, yeah OK write that shit down… But… These were descriptions of a normal looking person, dressed normally, acting normally, and talking normally…….. So it was fucked up…….Then, just BS. For one of mine, they suggested things like “he might have brucellosis!” - well guess what shithead. No I don’t. If you thought I did, you should have asked about - or God forbid, even examined my -testicles and lymph nodes… And maybe I would have had any of the symptoms of brucellosis?! I hadn’t been to any nation or area where Brucella species infecting humans were present. And oh yeah… I’m an expert on zoonotic disease. So, you know, don’t just write shit down ‘cos you know the word. Makes you look fucking incompetent. I genuinely would have been more likely to have been rabid……… As I pointed out while insulting him for being a fucking moron…