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MSE - Mental Status Examination Examples / Words and Phrases

MENTAL STATUS EXAM: The patient appears stated age, a bit drowsy, closing eyes at times, otherwise with fair eye contact. No psychomotor agitation or retardation noted. Speech had normal volume, rate, tone, prosody, and quantity. Mood was described as "okay." Affect was appropriate, a bit sedated. As regards thought content, denies any suicidal or homicidal ideations as well as any auditory or visual hallucinations. No evidence of ideas of reference or delusions. The patient is future oriented, stating she wants to read a book and listen to music at home. Stated that earlier her spirit was not right prior to taking the medications. Thought process, tangential with non sequiturs at times. Insight and judgment limited. Cognition limited. The patient was only oriented to name and place.

MENTAL STATUS EXAMINATION: The patient appears disheveled, older than stated age, malnourished and emaciated. The patient has a psychomotor retardation. Intermittent poor to fair eye contact. Speech is soft and slow with latency in response. Appears to have dysphoric mood. Depressed affect. Thought process was linear but with thought blocking. Thought content without suicidal ideation, homicidal ideation, audio/visual hallucination. No expression of delusional ideation. The patient is awake but appeared confused at times. The patient is oriented to person but not to place and time. Attention and concentration poor. With respect to memory, the patient registered only 1 object out of 3. The patient had poor insight and judgment.

MENTAL STATUS EXAMINATION: This is a patient who appears slightly older than her stated age. She is of a petite build. She exhibits good grooming and hygiene. She is well developed and well nourished and is not in any acute distress. The patient is cooperative with the exam. The patient maintained intermittent eye contact throughout the exam. The patient was pacing continuously throughout the exam making it difficult for her to maintain eye contact. She was unable to sit down. She did seem to have a slight bit of cogwheel rigidity, more so in the left arm. No tics or tremor noted. The patient spoke in somewhat soft tone of voice with normal rate and prosody. Mood was described as "worried," however, the patient denied feeling anxious. The patient is somewhat irritable and her affect does appear anxious, although she denies it. Her affect is somewhat constricted. Thought process is linear. Regarding thought content, the patient states she has worries that she might harm her family. No paranoia or delusions. No current suicidal ideations; although, the patient has expressed worries that she would harm herself in the past. The patient denies having any auditory or visual hallucinations. The patient is alert. The patient has limited insight into her current condition. The patient is expressing poor judgment at this time.

MENTAL STATUS EXAMINATION: The patient is a well-nourished, well-developed female who looks somewhat older than her stated age. She is oriented to time, date, month, year and person. Her responses are brief, sometimes wide of the point. Attention and concentration are brief. She is primarily preoccupied with "getting back on my meds." She is not an accurate historian and is given to a number of inconsistencies. Motor activity is slightly restless. Her hygiene and grooming are fair. There are no noted abnormal involuntary movements. Her affect is inappropriate, constricted and superficial. Mood is somewhat labile, irritable and impatient. No abnormalities in content of her thought. Speech is rambling, tangential and circumstantial, not very well organized. She is illogical at times and persecutory ideas of reference were present. Hallucinatory disturbances are denied. No history of hallucinations. Memory is impaired, immediate, past and remote. Insight is minimal. Judgment is impaired. She is preoccupied with minute irrelevant details of "a conspiracy." Judgment is impaired. Her thinking is impulsive with frequent distortions and fabrications. Her attention and concentration are brief. Proverb interpretation is concrete. Intelligence is probably below average. She denies suicidal or homicidal ideations. Fund of general knowledge is fair.

MENTAL STATUS EXAMINATION: The patient appears older than her stated age, missing the majority of her teeth, is disheveled, agitated and combative. The patient makes eye contact but in a menacing fashion, is screaming and overall uncooperative with the interviewer. The patient's speech is fluent, although rate and volume are elevated and pressured. The patient did not respond to questions about mood. Her affect is agitated and combative. The patient's thought process is loose, disorganized and tangential. The patient is not willing to respond to questions concerning the presence of any auditory or visual hallucinations; although, she does appear to be responding to internal stimuli. The patient does appear to be endorsing paranoid delusions in some of her statements, particularly towards nursing staff. The patient's cognition is poor. Insight and judgment are poor.

MENTAL STATUS EXAMINATION: The patient appears her stated age. She appears somewhat unkempt and has a 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 friendly. She is alert and oriented to person, time and place. Speech was of normal volume, rate was pressured, but articulation was clear. Affect seems somewhat constricted but stable and appropriate to content. She did exhibit some flight of ideas. Content was negative for suicidality or homicidality and she did seem to have some odd beliefs of religious nature, however, it is unclear whether these are delusional. She denies experiencing any perceptual disturbances. Her judgment and insight are thought to be poor at this time.

MENTAL STATUS EXAMINATION:  The patient was casually dressed and groomed, appearing her stated age. She approached the session in a calm and cooperative fashion.  No unusual mannerisms or gestures were noted. Eye contact was good and speech was of normal tone, volume, rate and clarity. Mood appeared euthymic and was described in a similar sense by herself. Affect was appropriate. She denied any thought planning or intent towards harming herself or others in any way. Conversation was optimistic and future oriented. Stream of thought was without disorganization. Thoughts or experiences consistent with hallucinations, illusions, delusions, obsessions, compulsions or mania were denied. At no time during the session did she appear to be under the influence of any type of abnormal internal stimuli. Sensorium was alert. Cognitive functioning was intact. Thought style was inclusive of abstract ability. Intelligence as assessed by syntax, vocabulary and general interaction appeared to be in the average range. Insight appeared fair and judgment good.

MENTAL STATUS EXAMINATION: The patient presented as a casually dressed and groomed woman. She approached the session in a somewhat tense fashion, feeling irritable and ill at ease. Eye contact was good while speech was of an elevated tone and volume. No unusual mannerisms or gestures were noted. She did not have any appreciable tremor and no cogwheeling was present on exam. Mood appeared irritable. She described herself in a similar sense. Affect was restricted. She denied thought planning or intent towards harming herself or others. Stream of thought was relevant and coherent, without any type of disorganization. Thoughts or experiences consistent with obsessive-compulsive disorder were denied. However, she did describe a cyclic pattern of mood disturbance, the key features being insomnia, elevated energy, restlessness, inability to concentrate and anger. These go together and last for a week or two, then tends to resolve for several months. She indicated that Tegretol helped. Also, the patient described a history of hallucinations, beginning around age (XX), consisting of a female voice that frequently speaks to her in a degrading manner or tells her to harm people. She indicated that talking to herself sometimes works but Risperdal has helped her out the most. At no time during the session did she appear to be under the influence of mania or psychosis. Sensorium was alert and cognitive functioning was intact. Thought style was inclusive of abstract abilities. Intelligence as assessed by syntax, vocabulary and general interaction appeared to be in the average range. Insight appeared to be fair and judgment adequate.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who is well groomed and appears his stated age. There was clinical evidence of psychomotor agitation. He has difficulty maintaining eye contact and he was easily distractible. However, his speech was coherent and spontaneous with increased rate and volume. He described his mood as anxious. Objectively, his mood was anxious. His affect was sad and restricted and unable to achieve spontaneous emotional reactivity. His behavior was appropriate. His memory was intact for recent and remote events. He was well oriented to place, time and person. His concentration and attention were grossly impaired. He had difficulty doing serial 7s. His general level of intelligence and fund of general knowledge appear to be in the average side. His level of personal hygiene was good. He was able to communicate clearly and his use of language was quite sophisticated. He was able to achieve goal directed ideas without any difficulty. He denied any suicidal or homicidal ideation. His level of abstract reasoning was intact. I was able to establish adequate rapport with him throughout the interview and he was able to follow directions. He denied any ideation of worthlessness or hopelessness. He was very much preoccupied with his current symptoms and stated that if he does not get adequate help, he will snap. He has poor insight into the nature of his prior drug use and mental illness.

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