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Mental Status Exam Example Transcription Format

MENTAL STATUS EXAMINATION:  The patient's general appearance was fairly neat and clean.  She was a hesitantly willing participant in the interview.  Her behavior was indifferent, attentive, and cooperative with giving information.  Her eye contact was poor.  Her affect was flat, depressed, tearful at times.  Her speech was soft spoken at a normal rate and clearly articulated.  The patient exhibited no psychomotor restlessness nor retardation.  The patient ambulates with a steady gait and a stooped posture.  Her hygiene is within normal limits.  Her thoughts were nonspontaneous, negativistic, hopeless, and helpless.  There were no gross or overt signs of psychosis.  She was alert and oriented to person, place, time, and situation.  Her short-term, long-term, and immediate recall memory were completely intact.  Her intellectual functioning was within normal limits and average.  Her insight is grossly impaired and her judgment has been fair.

MENTAL STATUS EXAMINATION:  The patient's general appearance was neat and clean.  She was a willing participant in the interview.  Her behavior was cooperative and free with information giving.  Her eye contact was virtually constant.  Her affect was depressed.  Her mood is depressed and irritable.  Her speech is of normal rate and tone and clearly articulated.  There was no psychomotor restlessness nor retardation.  She ambulates with a steady gait and a relaxed posture.  Her hygiene is within normal limits.  Her thoughts were spontaneous, organized, linear, and logical with no current evidence of a formal thought disorder.  There were no gross or overt objective signs of psychosis.  She is alert and oriented to person, place, time, and situation.  Her memory is intact.  Her intellectual functioning is at baseline and is average.  Her insight and judgment are fair.

MENTAL STATUS EXAMINATION:  The patient's general appearance is neat and clean.  He was a willing participant in the interview.  His behavior was overly cooperative, charming, information giving, and extremely attentive.  His eye contact was intermittent and appropriate.  His affect was mood congruent and inappropriately bright at times.  His mood appeared to be somewhat hypomanic.  His speech was loud and in normal rate and clearly articulated.  There was some psychomotor tics noted secondary to his Tourette.  He ambulated with a steady gait and a relaxed posture.  His hygiene was within normal limits.  His thoughts were spontaneous, organized, logical, and linear.  There is no current evidence of a formal thought disorder of any kind.  The patient was able to stay on topic and was able to stay attentive.  His thought process never became circumstantial nor tangential.  There was no evidence of delusional thought process or ideas of reference.  There were absolutely no gross or overt objective signs of psychosis.  He is alert and oriented to person, place, time, and situation.  His memory is completely intact.  His intellectual functioning is at baseline and is probably above average.  His insight is lacking.  His judgment is questionable.

MENTAL STATUS EXAMINATION:  General appearance:  Acceptable motor activity, cooperative, maintained good eye contact.  Fair grooming and hygiene, casually dressed.  The patient had short dark hair and dark eyes.  Speech and Thought Pattern:  Verbal, and coherent, relevant, and spontaneous.  Mood:  Described as anxious.  Affect:  Full range.  Thought Content:  The patient denies hallucinations and/or delusions.  Denies current suicidal, homicidal ideations.  Orientation:  Oriented x3.  Average intellectual functioning.  Fair judgment and insight.

MENTAL STATUS EXAMINATION:  On examination, the patient refused to come to the interview room.  He was seen in his classroom.  At that time, he was being placed in a passive restraint after pushing the staff.  He was crying and was quite dysphoric, and he was actually verbally threatening the staff during the interview.  He refused to address the interviewer and refused to answer any direct questions.  He was unable to engage in any play or joking comments, he was verbal.  He was articulate particularly in talking with his staff worker.  There were no extrapyramidal symptoms apparent.  He did not evidence any bradykinesia or abnormal involuntary movements.  He did not manifest any flight of ideas or pressured speech.  He did not appear to be responding to any psychotic stimuli.

MENTAL STATUS EXAMINATION:  The patient was alert.  She was fluent.  She was well modulated today.  She reports she continues to struggle with depression, but her main complaint is anxiety.  She reports significant features of social anxiety.  She feels awkward and anxious in new social situations, particularly if there are a number of people present.  She reports periods of time where she is intensely anxious even without a social cue.  She reports problems at times with difficulty falling asleep and sleep continuity problems, but less so on her current regimen.  She reports of all the medicines that she has been on, Klonopin has been the most effective for the anxiety.  She reports that in the past she has had the experience of auditory hallucinations that have a commenting or command quality to them.  She denies having any psychotic symptoms now.  She reports in the past, she has had extensive self-mutilation.  Indeed on exam today, she has healing multiple lacerations over the left forearm in a complex spider web pattern.  The patient denies any suicidal ideation or intent now.  She did not have evidence of any flight of ideas or pressured of speech.  She did not have evidence of any formal or informal thought disorder.  She reports that she does have perimenstrual worsening of her mood.  She reports marked irritability.

MENTAL STATUS EXAMINATION:  On examination, the patient was alert.  She was fluent.  She was actually, initially, shy during the interview but actually opened up quite a bit and was quite forthcoming during the interview.  She reports that she feels very sedated on the Depakote the way it is currently prescribed.  She reports that the Lexapro has been helpful.  She reports that she does have significant problems with her concentration and she is distractable.  She can, however, enjoy reading.  She reports that she is impulsive, sometimes saying or doing things on the spur of the moment that she later regrets.  She reports that she has ups and downs in her mood.  The patient did not have any flight of ideas or pressured speech during the interview.  She denied any psychotic symptoms.  There was no evidence of formal or informal thought disorder.  She was not suicidal or homicidal.

MENTAL STATUS EXAMINATION:  The patient was cooperative, pleasant, and maintained good eye contact.  Speech was normal in rate and pattern.  She was slightly hard of hearing.  She reports her mood is a bit down, worried.  Affect was sad.  She denies current visual hallucinations but has had some in the last year.  Denies other hallucinations and delusions, has a passive death wish, but not any active suicidal ideation.  Scored 23/27, unable to see well to do the reading or the drawing.

MENTAL STATUS EXAMINATION:  The patient was lying in bed, sleeping, but easily awakened, maintained fair eye contact.  Speech was slow with brief responses, but for the most part appropriate.  She described her mood as okay.  Affect was pleasant.  She was able to brighten when talking about her work in the past.  She denies hallucinations, suicidal ideation, death wishes, anger, or paranoia.  She scored 15/30 on her Folstein, could only remember one of three items and do one part of the three-step command, could not copy or write a sentence, and could not subtract, and only got one letter right in spelling "world" backwards.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old Hispanic female who presents alone for psychiatric evaluation.  She is appropriately dressed for the season and well groomed.  She is pleasant, cooperative, and relevant throughout the interview process.  She establishes rapport easily and is alert and able to discuss past and recent events appropriately.  She maintains normal eye contact and has normal motor controls.  She describes her mood as quite irritable.  Her affect is congruent.  Her speech is mildly pressured and quite rapid.  Her thoughts are well developed, well organized, goal directed, and appropriate.  She denies sensory hallucination, illusion, or delusion.  She denies suicidality, homicidality, self-injurious behaviors and contracts for safety.  Her insight, memory and judgment are fair.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old Hispanic female who appears slightly older than her stated age.  She is appropriately dressed for the season and well groomed.  She does not have any involuntary motor movements nor does she appear to be responding to internal stimuli.  She is alert and able to discuss past and recent events appropriately.  She was pleasant, cooperative, and relevant throughout the interview.  She makes normal eye contact and has normal motor controls.  She describes her mood as upset and anxious.  Affect is mildly blunted.  Speech is mildly slowed but of normal rhythm, volume, and tone.  She has no defects of articulation.  Thoughts are well organized, well developed, appropriate, and goal directed.  She denies suicidal or homicidal ideation or intent, and contracts for safety.  She denies sensory hallucination, illusion, or delusion.  Her memory is intact.  Her insight and judgment are limited.

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