Mental Status Bench: Build the Note, Screen the Risk

Ask it this way

Domain	Ask it this way	Then follow with
Auditory hallucinations	“Do you ever hear voices or sounds when no one else is around?”	“What do they say? Do they ever tell you to do something?”
Command hallucinations	“Are the voices telling you to hurt yourself or anyone else?”	“Have you ever done what they said? What stopped you last time?”
Delusional content	“Has anything been happening lately that feels strange or hard to explain?”	“How much of the time do you think about it? What do you feel you need to do about it?”
Suicide risk	“Have you had thoughts of killing yourself?”	Plan, means, access, timing, intent, prior attempts, protective factors
Risk to others	“Have you had thoughts of hurting someone? Is there a specific person?”	A named target changes the observation level and goes to the provider now
Substances	“What are you using right now, and how much?”	Last use, route, quantity — ask without flinching
Adherence	“A lot of people stop these medicines. What has that been like for you?”	Side effects, cost, access, beliefs, forgetting — each has a different fix

You will not plant an idea by asking. You will miss it by waiting to be told. And in schizophrenia, suicide risk is highest early in the illness and in people whose insight is preserved — so the person who is just beginning to understand what has happened to them is the one to watch most closely.

The note you are building

Command hallucination risk screen

A person tells you a voice is instructing him to hit another patient. This is a formal risk assessment, not a checkbox. Tick what is true and watch what moves.

Lower risk of actingHigher risk of acting

Before anyone writes “first-episode psychosis”

	Delirium	Psychosis in schizophrenia
Onset	Acute, over hours to days	Prodrome over months
Course	Fluctuates across the day, worse at night	Relatively stable through the day
Attention	Impaired — cannot hold a thread	Usually intact between episodes
Orientation	Impaired	Usually oriented
Hallucinations	Often visual	Usually auditory

Much of the rule-out is nursing work: vital signs including temperature, a fingerstick glucose, a neurological check, a review of every prescribed and non-prescribed substance, and an accurate collateral history. Other mimics: stimulant, cannabis or hallucinogen intoxication; alcohol or sedative withdrawal; steroid or anticholinergic effect; thyroid disease; B12 deficiency; neurosyphilis and HIV; temporal lobe epilepsy; autoimmune encephalitis; lupus; Wilson’s and Huntington’s disease; space-occupying lesions.

Water intoxication. Primary polydipsia is common in chronic psychotic illness and can produce dilutional hyponatremia, confusion, seizures and death. Daily weights are the cheapest detection tool you have — a rise of more than three to four percent of body weight across a day, with new confusion, incontinence or vomiting, is a sodium check now, not at the next scheduled draw.