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Mental Status Examination Medical Transcription Examples

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male.  No particular mannerism noted.  He was cooperative.  His speech was relevant and coherent.  Affect was full and congruent to the content of thought.  Mood depressed on and off.  He denied suicidal and/or homicidal thoughts.  He denied paranoia.  No thought or perceptual disorder noted.  No obsessive-compulsive symptoms evidenced.  No panic disorder symptoms reported.  No period of mania or hypomania reported.  Alert and oriented.  Memory functioning is intact.  Judgment and insight seemed reasonable.

MENTAL STATUS EXAM:  The patient presents as a (XX)-year-old male who appears slightly older than his stated age.  He is of a slim build but adequately nourished body habitus.  He wears his clothes inappropriately.  He is polite, reserved and laughs politely and easily.  He is able to give answers to simple questions such as his date of birth, the home address, the street address of his home.  The patient presents as ingenious and child-like.  On answers to questions he is not able to give, he does not appear to embroider answers.  He will make repetitious attempts asking for validation of each of his guesses, and then before validation is given, stating “no, I know that’s not right.”  He does not appear to be particularly concerned when he is not able to give an appropriate answer to simple questions.  The patient does not present any overt delusions, paranoia or unreasonable fears.

MENTAL STATUS EXAMINATION:  The patient presents as an adult male who appears to be about his stated age.  He has excellent personal hygiene and grooming.  When I called his name in the waiting area, he came to the interview area with a smooth, fluid gait.  He was pleasant, cooperative throughout the interview.  His speech was of normal tone and volume and productivity.  He was serious but future oriented.  He presented no blocking of thoughts, circumstantiality, perseveration.  He presented with no flight of ideas, grandiosity or distractibility.  He showed a fair range of affect, generally appropriate to context.  He became more somber and serious when speaking of the impending birth of his child and his legal problems and was less somber when speaking of potential for early resolution of those legal problems.  He presented no apathy, extreme flattening of affect, disorganization, apparent response to internal stimuli, paranoia or delusion.  He did not present any obvious cognitive deficit.

MENTAL STATUS EXAMINATION:  The patient presents as a (XX)-year-old man who still appears slightly older than his stated age.  He is polite, calm, almost placid and unconcerned throughout the interview process.  He is able to give an organized, lucid, coherent and generally consistent history, which is consistent with the psychiatric history he has given.  He reports that in the past he used to worry that he did not have the memory he had before his accident.  After asking specific questions such as his social security number, events in the past, major events in his life, which he is able to identify readily, he laughed and said “may be I still remember things.”  The patient was able to readily answer historical questions for distant past events with relative consistency.  He was able to discuss intermediate and short-term events with equal ease and facility.  Based on his vocabulary, usage and fund of general information, I assess him to be of approximately average intelligence.  The patient presents no entitlement, irritability, pressured speech, flight of ideas or delusional grandiosity.  He presents no extreme disorganization, involution, flattening of affect or disorganization.  The patient denies any current suicidal ideation, presents himself as future oriented and optimistic in spite of his relatively unconcerned affect.

MENTAL STATUS EXAM:  The patient appears to be about his stated age.  He is adequately nourished, neatly dressed, has excellent hygiene and grooming.  He appears to be somewhat sleepy and sedate.  He freely acknowledges that since he has been taking the Thorazine, that he has been sleeping a lot and he is very lethargic during the daytime.  He reports that he is very appreciative of the sleep he gets from the medication at night but would like to be more alert during the day.  He is able to confirm and deny some historical details that I referred to on the chart.  He volunteers very little new information.  His speech, although somewhat sparse, is organized and coherent and internally consistent, is consistent with previous documentation.  His affect is bland and unconcerned.  He denies any suicidal or self-harmful ideation.  He presents no pressured speech, flight of ideas or delusional grandiosity.  He presents no disorganization, apparent response to internal stimuli, extreme withdrawal or extreme flattening of affect.  He presents no apparent response to internal stimuli or paranoid delusional system.  From his understanding of vocabulary and words, he has the potential for average IQ.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male.  His speech was noted to be logical and goal oriented.  Content was with past allegations of psychotic features; although, these sound more like voices that are “inside my head” and consistent with thoughts.  He denied thought broadcasting, thought insertion, paranoid ideation, bizarre delusions or other psychotic symptoms.  His mood was self-described as “normal.”  His affect was appropriate.  The patient was fully oriented.  His memory was 2/3 after 5 minutes.  He performed reasonably well with past presidents and serial 7s.  Test judgment was intact.  Insight was fair.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who is very difficult to interview.  He answers questions briefly.  He becomes argumentative.  He is paranoid.  His mood is of irritability with underlying anger and sarcasm.  He does not want to give information.  He states that he hears voices.  He at times laughs and talks to the interviewer, and when the interviewer asks questions, he states that he was not talking to the interviewer.  He specifically denies voices talking to him or commanding him.  They are just “screaming at me.”  He is alert and oriented.  He is not suicidal.  He is not homicidal at this time.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who looks his stated age.  No particular mannerism noted.  His speech was relevant and coherent.  Affect was congruent to the content of thought.  The patient denied being homicidal and suicidal.  No formal thought disorder noted.  No perceptual disorder noted.  The patient denied ideas of reference, thought broadcasting, thought insertion, experiences of influence.  No obsessive-compulsive symptoms evidenced.  The patient was alert and oriented.  Memory functioning intact.  Judgment good.  Insight was good.