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Mental Status Examination Samples / Examples Part 2

MENTAL STATUS EXAMINATION:  Upon admission showed a medium-built male with good eye contact.  Affect was flat.  Oriented x2.  There was some partial insight into his condition.  Judgment appeared to be poor.  Behavior was passively cooperative during examination.  Denied any current suicidal or homicidal ideation.  Claims to have auditory and visual hallucinations, which on retrospect seems somewhat suspect.  Memory appeared to be intact.  Cognitive functioning was judged to be impaired.  Speech was unremarkable.  Trend of thoughts, the patient claims visual hallucinations at bedtime only.  Mood appeared to be depressed.  Intelligence was average or lower.  Reality testing was grossly intact.

MENTAL STATUS EXAMINATION:  He is a (XX)-year-old male who is fairly well groomed.  He appeared his stated age.  There was clinical evidence of psychomotor agitation.  He has difficulty maintaining eye contact.  His speech is somewhat coherent, spontaneous, appropriate with normal rate, volume and rhythm.  He described his mood as depressed.  Objectively, his mood was dysphoric.  His affect was restricted, sad, despondent and he was unable to display spontaneous emotional reactivity.  There were clinical features suggestive of severe depression.  His behavior, however, is appropriate.  His memory is intact for recent and remote events.  He is well oriented to place, time and person.  His concentration and attention appeared to be impaired.  His general level of intelligence and fund of knowledge appeared to be within normal limits.  His level of personal hygiene was fairly good.  He was able to communicate clearly and he was able to achieve goal directed ideas.  At the time of the evaluation, he denied any suicidal or homicidal ideation.  His level of abstract reasoning is within normal limits.  He was able to maintain adequate rapport with me throughout the interview, and he was able to follow directions.  He denied any ideation of worthlessness or hopelessness.  He denied any auditory or visual hallucinations.  He has good insight into the nature of his mental illness.

MENTAL STATUS EXAMINATION:  He is a (XX)-year-old male who is well groomed and appeared his stated age.  During the interview, he was pleasant and cooperative and displayed a positive attitude.  He went into details, the circumstances surrounding his admission.  He was able to maintain adequate eye contact.  His speech was coherent, spontaneous and appropriate with normal rate, volume and rhythm.  He described his mood as depressed.  Objectively, his mood was euthymic.  His affect is somewhat restricted but he was able to display spontaneous emotional reactivity.  At the time of the clinical evaluation, I could not elicit any clinical features of affective or psychotic illness.  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 both adequate.  He was able to do serial 7s.  His general level of intelligence and fund of general knowledge are adequate and appropriate for his age.  His level of personal hygiene was fairly good.  He was able to communicate clearly and 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 denied any auditory or visual hallucinations.  He denied any preoccupation, illusions or phobia.  He has a fair amount of insight into the nature of his depression.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old male who is fairly well groomed and appeared his stated age.  During the interview, there was no clinical evidence of psychomotor disturbance.  He was able to maintain adequate eye contact.  His speech was coherent, spontaneous and appropriate with normal rate, volume and rhythm.  He described his mood as normal.  Objectively, his mood was euthymic.  His affect was full range and appropriate with spontaneous emotional reactivity.  There were no clinical features of affective or psychotic illness. 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 both adequate.  He was able to do serial 7s and able to subtract and add without difficulty.  His general level of intelligence is average.  His fund of general knowledge is adequate.  His level of personal hygiene is 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 significant difficulty.  He denied any suicidal or homicidal ideation.  His level of abstract reasoning was intact.  I was able to maintain adequate rapport with him throughout the interview and he was able to follow directions.  He denied any ideation of worthlessness or hopelessness.  He denied any hallucinatory experiences.  He denied any preoccupation, illusions or phobia.  He has very poor insight into the nature of his dysfunctional behavior.  His judgment is impaired.

MENTAL STATUS EXAMINATION:  The patient presents as a (XX)-year-old male who 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 the effects of drugs on his life.  The patient currently denies lowered 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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