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Mental Status Examination Medical Transcription Examples

MENTAL STATUS EXAMINATION:  The patient is a well-nourished, well-developed female who looks her stated age.  Appearance, hygiene and grooming were adequate.  Her demeanor was uneasy.  Speech was rapid, pressured, repetitious.  She was impatient and impulsive in the interview, primarily during questions she had to answer and not because she was opposed to the examination.  Her responses were brief, rapid and tended to be somewhat wide of the point at times but were mostly relevant and goal directed.  No abnormalities to the content of her thought.  No perceptual disturbances.  Fund of general knowledge based on responses to questions estimated to be low average, possibly borderline normal.  Her mood was labile and elevated.  Affect likewise was labile, yet restricted.  Her judgment was impaired by history.  Insight was minimal at best.  No sign of any thoughts of wanting to harm herself or others.  She had difficulty with abstract reasoning.  Thinking was simplistic.  She could perform very simple arithmetical calculations.  Her sensorium was clear.  Cognition was impaired.  Memory was faulty, recent, remote and immediate.

MENTAL STATUS EXAMINATION:  Revealed a well-nourished, well-developed female who appears her stated age.  Satisfactory hygiene, grooming and personal appearance. The patient was accessible to examination.  She made good eye contact.  Her attitude was friendly and cooperative.  Speech was coherent, relevant and goal directed.  There were no abnormalities to the content of her thought.  There were no perceptual disturbances.  Fund of general knowledge was estimated to be in the low average range based on her use of vocabulary and syntax.  Her sensorium was clear.  Her cognition was impaired.  There were a number of inaccuracies in her memory, immediate, recent and remote, for the chronological account of events, both regarding her psych history and substance abuse history.  Her motor activity was within normal limits.  There were no abnormal involuntary movements.  Her affect was superficial and restricted.  Her mood was distant and somewhat detached.  There were no signs of any delusional ideation or thought blocking.  Insight was minimal.  The patient has failed to learn from the consequences of her prior illegal activities, failing to recognize the seriousness of her irresponsible behaviors.  Judgment was impaired.  She was able to abstract simple proverbs and do simple arithmetical calculations.  No signs of any thoughts of wanting to harm herself or others.

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

MENTAL STATUS EXAMINATION:  The patient was accessible to examination, although was guarded at first and somewhat evasive with her responses.  She became more open as the interview continued.  Her attitude was cooperative but very wary.  Her hygiene, grooming and personal appearance were satisfactory.  Speech was coherent, relevant and goal directed, although lacking some spontaneity.  Her responses were brief but logical.  No abnormalities to content of her thought.  No perceptual disturbances.  Her mood was detached initially, more accommodating and friendly as the interview continued.  Affect was blunted at first, more appropriate with better range later on.  Her fund of general knowledge was estimated to be low average based on the use of vocabulary, sentences and syntax.  Her memory was faulty in all three spheres.  There were numerous gaps in her accounts of her past history.  She denied any thoughts of self-harm or wanting to harm others.  Judgment was fair.  She recognized how impulsive her behavior has been.  Her insight was partial.  Attention and concentration were adequate.  There were no abnormal involuntary movements present.

MENTAL STATUS EXAMINATION:  The patient today presented alert, oriented to time, day of the week, date, month, year, person and place.  Motor activity was within normal limits.  She presented looking her stated age, fairly groomed and fairly clean.  There were no abnormal involuntary movements noted to any body parts.  Her mood was noted to be labile with some mild anxiety.  Her affect was consistent with her mood.  Thought content, she denies any delusions.  Denies any paranoia.  She denies any current audio or visual or any other type of hallucinations.  However, does admit having audio hallucinations on and off for the last, she estimates, 6 years.  The last time she reports that she heard voices was about 2 years ago.  Thought blocking was present in the interview on a minimal basis.  Ideas of reference were absent.  Memory when tested, immediate recall was 3/3.  Short-term recall was 2/3.  Her insight and judgment presented as being impaired to poor.  Attention and concentration were fair throughout the interview.  She admits to being easily distracted on a daily basis.  Interpretation of proverb was noted to be concrete.  Intelligence was noted to be average.  She denies any suicidal or homicidal ideation, plans or intention.  Her fund of knowledge was fair.

MENTAL STATUS EXAMINATION:  The patient looks her stated age.  She was clearly apprehensive during this evaluation; however, she became more relaxed as the interview progressed.  Her speech was slow in rate and low in volume.  There was evidence of increased latency in responding to questions by the examiner.  At times, she looked somewhat confused.  The patient verbalized no delusions; however, she repeatedly questioned the origin of her illness, drawing a connection to witchcraft practiced by her “enemies.”  She reported hearing voices calling her name but denies command hallucinations.  She also reports hearing conversations going on, but she is unable to make out the content.  She denies having visual hallucinations at the present time.  She describes her mood as depressed, anxious and scared.  Her affect was anxious and tearful off and on during the evaluation.  The patient denies having suicidal or homicidal thoughts, plans or intent.  She was alert and oriented to time, place and person.  She was able to repeat 3 objects immediately.  Short-term memory was 2/3 in 5 minutes.  Long-term memory was essentially intact.  She could not interpret proverbs.  She could not do serial 7's and made 2 errors in spelling "world" backwards.  Her fund of knowledge was low average.  Her insight into her mental illness was partial.  Hypothetical judgment was intact.