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Mental Status Examination Samples / Examples

MENTAL STATUS EXAMINATION:  The patient is an obese but adequately groomed female who appears stated age.  No observed abnormalities in terms of posture, gait or motor movement.  Eye contact was good.  Rapport seemed adequate.  She was alert and oriented x3.  Responses were linear and goal directed.  No other circumstantiality, tangentiality or looseness of association.  Speech was normal in tone, volume, inflection.  She denies current suicidal or homicidal ideations, auditory or visual hallucinations.  There is no current evidence for formal thought disorder.  There was absence of paranoia, grandiosity, flight of ideas, ideas of reference, delusions, episodes of thought control, social withdrawal.  Judgment and insight were deemed to be adequate at present.  Short-term memory and long-term memory were felt to be adequate.  Fund of knowledge was estimated to be average.  Overall mood is mildly depressed.  Affect is full range and appropriate.  She denies alcohol problems but does report cocaine use and also states that she used ecstasy the day before yesterday.

MENTAL STATUS EXAMINATION:  The patient is a white male who is calm and cooperative.  Poor eye contact.  His mood is sad and irritable with appropriate affect.  His speech is spontaneous and goal directed.  No evidence of any delusions.  Denies any auditory or visual hallucinations or suicidal or homicidal ideations at this time.  Some anhedonia noted.  He is alert and oriented in all three spheres.  His cognitive function is grossly intact.  His insight and judgments are fair.  His impulse control is adequate.

MENTAL STATUS EXAMINATION:  This is a patient who appears stated age, is lying in bed.  Mood is depressed.  Affect was sad.  Thought process was goal directed.  No auditory or visual hallucination.  No delusional thought noted.  Denies suicidal or homicidal thought.  No indication of this behavior.  The patient is alert and oriented x3.  Recalled 0 out of 3 words after 5 minutes.  Able to spell "world" backwards.  Able to identify 2 objects and follows 3-step commands, scored 24.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old female who appears her stated age. She appears somewhat unkempt and has very poor body odor. She does not display any psychomotor agitation or abnormal movements. She makes good eye contact. She is not considered a reliable historian, but was cooperative and indeed friendly. She is alert and oriented to person, time, and place. Speech was of normal volume, however, rate was pressured, but articulation was clear.  Affect seems somewhat constricted, but stable and appropriate to content. Speech, thought process was very circumstantial. She did exhibit some flight of ideas, content was negative for suicidality or homicidality. She denies experiencing any perceptual disturbances. Her judgment and insight are thought to be poor at this time.

MENTAL STATUS EXAM:  General appearance:  The patient is appropriately dressed in hospital clothes. He is lying on a hospital gurney. He appears to be slightly disheveled. There is good eye contact. He is calm and cooperative with exam. There is no psychomotor agitation or retardation. Speech is normal volume and normal prosody. Mood is depressed. Affect is mood congruent and constricted. Thought process is linear. Thought content is positive for suicidal ideation with plan to overdose, also positive for vague homicidal ideation without a plan and against no one in particular. Orientation:  The patient is oriented to time, person, place, date, and situation. Concentration is good. Knowledge is good. Insight is fair. Judgment is fair.

MENTAL STATUS EXAMINATION:  The patient is a thin, less than average height female who appears younger than stated age with fair-to-good grooming. Hygiene is fair with decreased care for dentition. The patient has no unusual movements or posturing. She is lying supine. The patient was awake, alert, oriented to person, place and date. She had fair-to-good eye contact and was cooperative with interviewer. Her mood was okay. She denies depression, endorses anxiety. Affect full, however inappropriate. She has over-exaggerated smile and laughter at unusual times. Speech was clear, normal rate, rhythm, and volume with accent. Thought process, disorganized, tangential, perseverating on the fact that her parents were not truly her parents as well as the need to leave their home. Likewise, described delusions about being choked by hands outside of herself. Thought content, continues to have delusions about parents stating that they are not her biological parents, but rather her adoptive parents and that she is searching for her real parents. She feels that if she did live with her real parents they would not be "as abusive and animal-like" as the people she lives with.  Denies suicidal ideation, homicidal ideation. Endorses anxiety, some suspiciousness. No evidence of grandiose perception. Endorses auditory hallucinations ranging from one voice to multiple voices. Denies command hallucinations. Insight, fair to poor. Knowledge is fair. Judgment is fair to poor. Abstraction is fair. Oriented to person, place, and time. Memory was difficult to evaluate.

MENTAL STATUS EXAMINATION:  The patient is an average-built male who is dressed in a hospital gown, sitting in bed, in no acute physical distress.  No involuntary movements noted though at times fine tremors of the hand were noticed.  No agitation is noticed.  Psychomotor activity within normal limits.  Speech and language functions are intact and adequate.  State of mood, he feels depressed.  Affect is appropriate.  Good range of emotions noted, depressed.  Thought process is linear and coherent.  Thought content shows recurrent psychotic symptoms, no suicidal ideation or plans, no homicidal ideation or plans.  The patient denies of hallucinations and does not appear to be reacting to internal stimuli.  Cognitive functions are intact for orientation to place, person, day.  Memory is intact to remote, recent, and immediate recall.  General fund of information is average.  Intellectually appeared average.  Insight and judgment are good.

MENTAL STATUS EXAMINATION: This is a female who is appropriately dressed.  Her hygiene was adequate.  Her demeanor and attitude was cooperative, and I felt that she was a reliable historian.  Her mood was quite anxious.  There were times that she became irritable but she was trying to manage her reactions.  Affect was mood congruent.  Thought processing was goal directed and coherent.  Thought content, there were no auditory or visual hallucinations or delusions.  She has no thoughts to kill herself or others.  She does not self-mutilate.  She absolutely denies any suicidal intent or thoughts at this time.  She has two children and she hopes to return to them.  She makes future plans.  She does have symptoms that indicate generalized anxiety.  She has no symptoms to indicate PTSD or OCD or panic disorder.  Cognitively, she is alert and fully oriented.  Gross memory functions are intact.  IQ appears to be low average.  Insight and judgment are intact.

MENTAL STATUS EXAMINATION: The patient appears to be about his stated age.  He is neatly and appropriately dressed.  He is a pleasant but somewhat subdued conversationalist.  He does show appropriate affective response throughout the interview.  He is able to give a lucid, coherent and generally consistent history.  He presents considerable insight into his life.  The patient currently denies low mood or anhedonia and presents no suicidal ideation and is in fact very much hopeful and future oriented.  He presents no pressured speech, flight of ideas or delusional grandiosity.  He presents no irritability or pugnaciousness.  He does not appear to be particularly distressed or anxious.  I assessed him to be of approximately average intelligence by his vocabulary, usage, and fund of general information.  He presents no delusional system, disorganization, paranoia, extreme affect flattening or withdrawal consistent with formal thought disorder.

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