Mental Status Exam Medical Transcription Samples for Medical Transcriptionists


MENTAL STATUS EXAMINATION:  The patient presents with generalized psychomotor slowing and somewhat blunted affect.  Cognition intact.  Speech is considered to be within normal limits, maybe slightly slowed.  No abnormal movements, tics or tremors are noted.  Not psychotic.  Denies any suicidal or homicidal ideation.  Insight is very good.  Intellect is considered to be average.  Has quite serious intent with her questions and with her planning for future treatment and help regarding her mental health as well as her substance use.
 

MENTAL STATUS EXAMINATION:  Showed a medium-built male with labile affect.  Oriented x3.  Insight was poor.  Judgment was very poor.  Behavior was hyperactive.  Denies any suicidal or homicidal ideations.  Denies hallucinations.  Memory appeared to be grossly intact.  Cognitive functioning appeared to be impaired.  Speech was pressured and rambling.  Trend of thought showed ideas of grandeur and omnipotence.  Mood was expansive but also was quick to change to anger.  Intelligence was average.  Reality testing appeared to be impaired.

 
MENTAL STATUS EXAMINATION:  The patient is alert and oriented.  Dress and hygiene are fair.  Looks his stated age.  Calm and cooperative.  Good eye contact.  No psychomotor agitation or retardation.  Speech is normal.  No pressure of speech.  No thought disorder.  Thoughts are goal directed.  Affect is euthymic and appropriate.  No emotional blunting.  The patient denied any audiovisual hallucinations.  No delusions noted.  Insight and judgment are fair.  Impulse control is fair.  The patient is cognitively intact.
 
MENTAL STATUS EXAMINATION:  This is a patient who appears to be of stated age.  She is neatly groomed.  She maintains good eye contact.  Mood is mildly depressed.  Speech is normal in rate, rhythm and volume.  Mood and affect are mildly dysthymic.  She denies any suicidal or homicidal ideation.  She denies any psychotic symptoms.  She denies any obsession, compulsion or phobia.  She is alert and oriented.  Insight and judgment are fair.         
 
MENTAL STATUS EXAMINATION:  This is a patient who appears to be of stated age, casually and neatly dressed and in no acute distress.  The patient engaged the examiner in a cooperative, friendly and polite manner.  The patient demonstrated good eye contact.  His speech was spontaneous with normal rate, rhythm and tone.  His reaction time to questions was normal.  While his affect was appropriate to the situation, his mood was euthymic with no evidence of depression, guilt feelings and suicidal or homicidal ideation at this time.  His stream of mental activity was logical, relevant, coherent and goal directed with no evidence of flight of ideas, looseness of associations, thought blocking, psychomotor retardation, pressured speech, racing thoughts, circumstantiality or tangentiality.  His thought content revealed no evidence of delusional ideation, interference or responses to internal stimuli, hallucinations, ideas of reference, mood swings, compulsions, obsessions, or any specific preoccupations.  The patient was alert and oriented in all three spheres.  His memory was intact including his immediate, recent past and remote memory.  His attention and concentration were intact.  His fund of general information was good.  The patient was able to perform simple arithmetic calculations and serial subtraction by 7s.  His comprehension and understanding were good.  Therefore, his intelligence was estimated to be above average; consistent with his level of formal education.  His abstraction of proverbs and symbolization were good.  His judgment, insight and reliability appeared to be good.

 
MENTAL STATUS EXAMINATION:  This is a patient who is well groomed and appeared his stated age.  There is no clinical evidence of psychomotor disturbance.  He was able to maintain adequate eye contact.  His speech was coherent, spontaneous, appropriate with normal rate, volume and rhythm.  He described his mood as normal.  Objectively, his mood was euthymic.  His affect is full range, appropriate, with spontaneous emotional reactivity.  There were no clinical features of affective or psychotic illness.  His behavior is appropriate.  His memory is intact for recent and remote events.  He is well oriented to place, time and person.  His concentration and attention were both adequate.  He was able to do serial 7s and was able to add and subtract figures without any difficulty.  His general level of intelligence and fund of general knowledge appears to be adequate.  His level of personal hygiene is 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 is 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 auditory or visual hallucinations.  He denied any preoccupations, illusions or phobias.  He has very poor insight into the nature of his substance abuse.

MENTAL STATUS EXAMINATION:  Reveals a well-nourished, well-developed, athletic built female who looks her stated age.  Hygiene and grooming are adequate.  Initially, she was quite secretive about divulging any information about her unusual experience, asked that the door be closed and it was.  The conversation from start to finish is effusive, voluminous, circumstantial, tangential and loosely organized but it is coherent.  There are no abnormalities to the content of her thought; however, an illusionary experience is suspect, of many years' duration and conversion symptoms.  The content of her thought reveals grandiosity and expansiveness with respect to her own capacity to assess her symptoms.  There are no abnormalities to the content of her thought and no perceptual disturbances.  Fund of general knowledge is probably low average.  Her mood is one of detachment and indifference; although, at the conclusion of the interview, she was tearful but more so because she seemed not to want to accept the psychiatric explanation for her possible symptomatology.  Her attitude is self-centered.  Her affect is labile, histrionic.  Her demeanor is quite self-absorbed.  Her memory is faulty due to her preoccupation with religious ideas and her own capacity for self-introspection and assessment.  Her judgment is impaired by her obsession and fixation with this probable illusionary experience and her conversion symptoms of long years' standing.  Her insight is lacking and judgment, as stated, is impaired.  No suicidal or homicidal ideation.  She was too fixated to do proverb interpretation or simple arithmetical calculations.  Her attention is limited due to the fact that she is so preoccupied.

MENTAL STATUS EXAMINATION:  This patient was appropriately dressed.  Her hygiene was adequate.  She was cooperative for the evaluation, and with prompting, she was able to remember some of the long-term information regarding her psychiatric treatments.  Her mood was anxious.  Her affect was mood congruent.  Thought processing was goal directed and coherent.  Thought content, she says she hears women mumbling but cannot make out what they are saying.  She also describes this as not interfering or being intrusive in her daily life.  She says she sees shadows only at night and not during the day, and those are not visual hallucinations.  It is questionable whether she is having a true auditory hallucination since she does not hear these women mumbling as she does hear this physician’s voice.  She describes it as “in my head.”  She has no thoughts to harm herself or others.  She does not self-mutilate.  Her sleep is chronically poor regardless of what her mood is.  She did not describe any symptom criteria for PTSD or OCD or panic episodes.

MENTAL STATUS EXAMINATION:  Today, the patient is moderately distracted and has thoughts that are slightly tangential.  He is in a normal mood range without signs of being either in depression or mania currently.  He does have a past history of frequent depressive episodes.  There is a moderate amount of discouragement about his current legal situation, which we told him, would be expected at this point, but otherwise, he does not feel overwhelmingly hopeless, and he does not have any suicidal thoughts currently.  There are no homicidal thoughts.  He tends to think concretely but does have some insight into his situation.  He realizes he needs more structure and needs to stay in treatment and have better compliance in the future so that he does not have difficulty with probation and treatment programs.  Currently, his thoughts are connected, although slightly tangential.  He is able to comprehend fairly well, and he has fairly good judgment at the current time.  He seems motivated for treatment.  He does not speak much about the physical abuse from early childhood and one has the impression that there may be more traumas.  He said he is committed to staying in recovery from the drug and alcohol problems, and he has maintained sobriety in the recent past.

MENTAL STATUS EXAMINATION:  He is awake and alert.  Thoughts are organized.  He is uncooperative with the interview.  He is not suicidal or homicidal.  The patient denies any auditory or visual hallucinations or any paranoia.  The patient's mood is angry.  Affect is irritable.  He makes sarcastic remarks, and he is disrespectful.  His speech is coherent and minimal.  His eye contact is sporadic.  No tremors.  No EPS.  His insight is limited, and he tends to blame others for all his problems.

 
MENTAL STATUS EXAMINATION:  Reveals a well-nourished, well-developed, attractive, small-statured female who looks her stated age.  Her appearance is neat, clean and well groomed.  She is accessible to examination and made an effort to be cooperative.  Her attitude is friendly.  Speech is coherent, relevant and goal directed.  Thinking is well organized, and she is able to elaborate on her responses and shows insight into her drug use and drinking.  There are no abnormalities to the content of her thought.  There are no perceptual disturbances.  Her mood, for the most part, is euthymic.  Her affect likewise shows a good range and is appropriate.  Her judgment is adequate on examination; however, impaired by history and failure to learn from the consequences of her illegal behavior.  Insight, as stated, is partial in intellectual level.  Fund of general knowledge is probably low average.  There is no sign of any thoughts of wanting to harm others or herself.  She is able to abstract proverbs.  Her memory is fair.  Sensorium is clear.  She is able to perform simple arithmetical calculations.  No abnormal involuntary movements are present


MENTAL STATUS EXAMINATION:  The patient was alert.  She was able to state the day of the week, the date, the month, the year, and the place.  Motor activity:  She is able to move all extremities without any difficulties.  She does have a deficit to her right hand. General appearance:  She was fairly groomed and fairly clean.  She appears looking older than her stated age.  There were no signs and symptoms of abnormal involuntary movements to any body parts noticed.  Her affect was appropriate.  Her mood was normal.  Thought content was on topic and logical; however, she was noted to be very forgetful throughout the interview.  There were no ideas of reference noted.  The patient presents with a lot of thought blocking.  Reports that she has difficulty remembering things and finishing her thoughts since her brain aneurysm surgery a couple of years ago.  She denies any current or past signs and symptoms of audiovisual hallucinations or any other type of hallucinations when questioned.  Her memory when tested, immediate recall was 3/3; short-term recall when tested was only 1/3.  Her insight is impaired.  Her judgment is also impaired.  Attention and concentration are decreased as a result of a brain aneurysm surgery a couple of years prior.  Since the surgery, she has difficulty with focus and concentration and gets easily distracted at times.  Her interpretation of proverbs is concrete.  Her level of intelligence is noted to be borderline.  She denies having any difficulties with her growth and development.  Reports that her functioning was normal prior to the removal of the brain aneurysm and that when in school, she attended regular classes.  Denied attending special education classes.  Suicidal and homicidal ideations, plans and intentions were denied when questioned.  Her fund of knowledge was below adequate, again believed to be caused by removal of the brain aneurysm.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old Hispanic male.  He was alert, oriented, and fairly cooperative.  He was quite manipulative and demanding.  His concentration and memory were intact.  His speech was normal rate, flow and tone, goal directed.  Language was appropriate.  His mood was euthymic.  Affect was a little edgy.  No suicidal or homicidal ideation per se, but he did report that he may try to hurt himself if he does not get his way.  The examiner did not find any psychosis on evaluation or disorganization.  In thought process, he was quite goal directed, quite organized, and appeared to be working on a strategy.  He did complain of ongoing auditory and visual hallucinations, but there was no evidence of disorganization or any other psychotic features on examination.  There was no flight of ideas, loosening of association, tangentiality, or circumstantiality.  He seems to have reasonable insight into his situation.  His judgment though was somewhat impaired.

MENTAL STATUS EXAMINATION:  This female was appropriately dressed.  Her hygiene was adequate.  She appears her stated age.  She seemed cooperative and reliable for this evaluation.  Her mood was anxious.  Her affect was mood congruent.  Thought processing was goal directed and coherent.  Thought content, there is no auditory or visual hallucinations or delusions.  She does not have thoughts to harm herself or others and she does not self-mutilate.  She is anxious and complains of chronic poor sleep.  Cognition, she is alert and fully oriented.  Her gross memory functions are intact.  Her IQ appears to be borderline intellectual functioning, and her insights and judgments appear intact.

MENTAL STATUS EXAMINATION:  Reveals a tall, slender but athletic built woman who is alert, attentive, cooperative and accessible to examination. She appears older than her stated age. Hygiene and grooming are satisfactory. Her sensorium is clear. Motor activity is somewhat uneasy and restless. There are no abnormal involuntary movements present. Her affect is animated. Her mood is elated/elevated. No abnormalities to the content of her thought.  No perceptual disturbances. Fund of general knowledge is estimated to be low average based on her responses and use of vocabulary. Memory is faulty. There are inconsistencies and inaccuracies and gaps with respect to her mental health issues and treatment during the course of her growing up years and later on in adulthood. Insight is partial at best and intellectual. Judgment is impaired. Failed to learn over the years from the consequences of her illegal activities. Continued to use poor judgment, acting impulsively.  There is no evidence of any SI or HI. The AIMS test is negative.


MENTAL STATUS EXAMINATION:  General appearance was that of a (XX)-year-old female of average height and obese weight.  Hygiene was within normal limits.  General appearance was somewhat messy.  The patient was alert and oriented x4, cooperating fully with the exam.  Motor activity was within normal limits.  Gait was not assessed.  Speech was within normal limits for rate, articulation, verbosity, and coherence.  There were no signs of impairment in attention, concentration or memory.  Judgment and insight were poor or lacking.  Thought and perceptual acuity were within normal limits.  There were some signs during the exam of deficits in impulse control.  The patient acknowledged anhedonia.  Her affective range was skewed in the direction of dysphoria.  She ranked her recent mood as a 2 on a scale from 0-10.  She acknowledges suicidal ideation and admits to considering options, though she can articulate no specific plan at this time.  The patient denies any history of cutting.  Her responses to the Beck Hopelessness Scale produced a score of 8/20.  Such persons have reduced hope for the future.  Her responses to the Brief Reasons for Living Scale indicated that 6 of the 10 commonly given reasons for wanting to live are important to the patient to some degree.  Despite the absence of a prior suicide attempt, the patient's substance abuse combined with her current dysphoric mood and difficulties with impulse control make it difficult to rule out risk of harm to self.

MENTAL STATUS EXAMINATION:  Showed a (XX)-year-old Hispanic male who looked his stated age.  He was cooperative.  His speech was relevant and coherent.  His affect was congruent to the content of thought, mildly blunted.  Mood was okay.  No thoughts of perceptual disorder noted at this time.  The patient denied being homicidal and suicidal.  He denied any panic attacks; however, the patient reports he had some panic attacks earlier, but it was situation based and is no longer suffering from it and has not experienced it for a while.  He was alert and oriented.  Insight was reasonable.  Memory functioning was intact.


MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old man who looked his stated age.  He was of an average height and build.  He was calm and cooperative during the interview.  The patient made good eye contact and there was no psychomotor agitation or retardation observed.  His speech was fluent, normal in rate and volume, and there was no formal thought disorder.  His mood was euthymic, and his affect was within normal limits.  He denied both suicidal and homicidal ideation, intent, and plan.  He also denied auditory and visual hallucinations.  The patient states that he has not experienced auditory hallucinations in about six months.  There were no delusions elicited.  The patient was able to contract for safety.  His cognitive function was grossly intact.  Insight, judgment, and impulse control were within normal limits at the time of the interview.

MENTAL STATUS EXAMINATION:  The patient appears clean and neat, appropriate.  Appears his stated age.  Appears to give the impression that he is confused, but he is not.  He appears to present himself that he has limited intellectual functioning, but he is not.  When questions are asked, he would be able to answer most of the questions to prove that his intellectual capacity is normal average.  There is no evidence of any thought disorder.  Fixated with auditory hallucinations, but now he recently continued to say he is okay with the medication.  He says on medication he is okay, but at the same time, he was looking for Klonopin.  Definitely, when he gets out, he will get his Klonopin he wants from the community psychiatrist.  The patient has no insight, and judgment is impaired.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old female who appears to be of stated age.  She was cooperative during the interview.  She maintains good eye contact.  Speech is normal in rate, rhythm, and volume.  Mood is mildly depressed.  Affect is appropriate to her mood.  Thought processes are organized and goal directed.  She denies any delusions, hallucinations, suicidal or homicidal thoughts.  She denies any obsession, compulsion, or phobias.  She is alert and oriented.  Insight and judgment are fair.


MENTAL STATUS EXAMINATION:  Mental status shows a thin male with an angry look, constricted affect, and oriented x2.  Insight is zero.  Judgment poor.  Denied any suicidal or homicidal ideation.  Hallucinations denied.  Memory appeared to be grossly intact.  Cognitive functioning was very impaired.  Speech was sparse but within normal limits.  Thought contained paranoid delusions.  Mood was agitated and angry.  Intelligence appeared to be average.  Gross reality testing was impaired.

MENTAL STATUS EXAMINATION:  The patient is appropriately dressed but disheveled.  He is cooperative and communicative.  He maintains eye contact.  His attention is sustained.  Psychomotor activity is normal.  No involuntary movements.  Speech lacks spontaneity, but it is of normal volume and tone.  He describes his mood as "good."  His affect is restricted.  His thought process lacks flow.  He denies any suicidal or homicidal ideations.  The patient admits to hearing and seeing things.  His judgment is appropriate.  He has limited insight into his illness.
 
MENTAL STATUS EXAMINATION:  Reveals a small but well-nourished, well-developed female who looks slightly younger than her stated age.  Hygiene and grooming are satisfactory.  She is alert, attentive, accessible to examination.  Her speech is rapid, garbled and difficult to understand.  At times, she tends to speak tangentially. However, thinking is organized and goal directed.  No abnormalities to the content of her thought. No perceptual disturbances and no thought blocking or ideas of reference.  Her mood is sad and dysphoric.  Affect is restricted.  Fund of general knowledge is estimated to be low average based on her use of vocabulary and syntax.  Her sensorium is clear.  Memory is faulty in all three spheres.  There are no signs of wanting to harm herself or others.  Judgment is fair.  Insight is partial and intellectual at best. Her ability to abstract is fair.  She is able to do simple arithmetical calculations.

MENTAL STATUS EXAMINATION:  This is a patient who looks his stated age.  He is of a large build.  He was well groomed, calm and subdued during the interview.  He maintained good eye contact.  There was no psychomotor agitation or retardation observed.  His speech was normal in rate and volume, and there was no formal thought disorder.  His mood was euthymic and his affect was blunted.  He reports occasional passive suicidal ideation, however, denies any active suicidal ideation, intent or plan.  He also denied any homicidal ideation.  The patient denies auditory hallucinations; however, he reports visual hallucinations, which are perceptual disturbances, which are similar to his LSD flashbacks.  The patient reports feeling paranoid, feeling that people are talking about him.  He was able to contract for his own safety.  Insight, judgment and impulse control were within normal limits.  His cognitive functioning was grossly intact.



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