Mental Status Examination Medical Transcription Examples

MENTAL STATUS EXAMINATION:  Reveals a Hispanic male, well groomed, lying in bed peacefully, greeted the examiner in a friendly polite way with good eye contact. Affect is sad and flat. Mood can be described as depressed. Thought process: He was coherent and logical. Speech: The patient spoke with normal tone, normal volume, normal prosody, and normal vocabulary. Language: Within normal limits. Thought content: He denies delusions or hallucinations. He denies, at the moment, suicidal or homicidal ideations. He denies obsessions or compulsions. Sensorium: The patient was oriented to time, person, and space. The patient’s attention, concentration, and recall were within normal limits. The patient’s present and past memories were intact. The patient seems to be of average intelligence with good fund of general information. The patient has insight and motivation for treatment. The patient shows good control of impulses.

MENTAL STATUS EXAMINATION:  The patient is appropriately dressed and groomed. He is cooperative and communicative. He maintains eye contact. His attention is sustained. Psychomotor activity is normal. No involuntary moments. Speech is spontaneous with normal volume and tone. He describes his mood as okay. His affect is full range. He denies any suicidal or homicidal ideation or abnormal perceptions or delusions. His judgment is intact. He has insight into his illness.

MENTAL STATUS EXAMINATION:  This is a (XX)-year-old male who is lying in bed. The patient is somewhat disheveled but pleasant and cooperative. No abnormal dyskinetic movement noted. The patient’s affect is slightly blunted but has no suicidal thought. No evidence of any impulsive or homicidal ideation. The patient was alert and oriented to year, season, month, day, city, county, state. Recalled 3/3 words after 5 minutes. Able to spell “world” backwards, able to identify 2 objects, and follow 3-step commands. The patient scored 27/30 on mini-mental state exam.

MENTAL STATUS EXAMINATION:  The patient is here for self-injury and depression. The patient reports that he self-injures and that he has become progressively more severe in that. The patient showed grossly normal development and physique. He showed attention to grooming and hygiene. The patient’s speech was mildly slowed, and there was some speech impairment. The patient showed normal associations. He denied any hallucinations and no delusions were evident. This patient showed very poor judgment and poor insight. The patient’s thought process was mildly disorganized. The patient showed poor recent and remote memory, and he did show poor attention and concentration. The patient showed normal orientation and knowledge. The patient’s affect was flat. The patient was alert. The patient’s attitude was pessimistic, and he was severely depressed. Regarding dangerousness, the patient reported suicidal ideation, and he has had self-harming behavior.

MSE Examples

MENTAL STATUS EXAMINATION:  The patient is cooperative and patient with the questions. Occasional smiles, does not seem angry or sad. Intelligence is average. There is no evidence of a thought disorder. He denies suicidal or homicidal ideation. There is no evidence of hallucination or psychosis. There is no abnormality of speech. No apparent insight. Judgment is poor. He does not appear to regret any of his actions.

MENTAL STATUS EXAMINATION:  The patient is appropriately dressed and groomed. She is cooperative and communicative. Rapport is rather limited. She maintains eye contact. Her attention is sustained. Psychomotor activity is normal. No involuntary movements. Speech is spontaneous with low volume and tone. The patient restricted most of her responses to monosyllables. She describes her mood as “okay.” Her affect is restricted. She denies any suicidal or homicidal ideations or abnormal perceptions or delusions. Her judgment is intact. She has insight into her problems.

MENTAL STATUS EXAMINATION:  The patient is alert and oriented x3. Speech had regular rate and rhythm and was of normal volume. Mood was “happy.” Affect was euthymic. The patient has a history of having stated that she wanted to hurt herself but did not act on those thoughts. The patient denied vegetative symptoms. He denied feelings of helplessness or hopelessness. Denied anhedonia. He denied homicidal or suicidal ideation or behavior. The patient denied auditory or visual hallucinations. The patient’s short-term memory was 3/3 objects at 5 minutes. The patient’s proverb interpretation was concrete. The patient was able to spell the word “world” both backwards and forwards. Serial 7s was not attempted.

MSE Samples

MENTAL STATUS EXAMINATION:  The patient appears to be his stated age. He makes eye contact. Attention is fair. No overt thought disorder. There are no hallucinations. The patient struggles with anger and irritability. There is no suicidal or homicidal ideation. Judgment is fair to poor. Impulse control is fair to poor. Insight is limited. No sleep problems or nightmares.

MENTAL STATUS EXAMINATION:  The patient arrived for the interview appropriately attired and demonstrated good hygiene and grooming. The patient was cooperative and compliant throughout the interview. Eye contact was good. Verbal responses were within normal limits. The patient was extroverted and was friendly. The patient’s speech was relevant and coherent. The patient was oriented to name and date, but was uncertain of time or place. Mood was initially tense. Broadly, the patient displayed a broad range of affect. The patient did not display signs or symptoms of psychosis. Insight was mildly below normal limits. Judgment was within normal limits. The patient did not display signs or symptoms of suicidal or homicidal ideation. Immediate recall was observed to be within normal limits. Recent recall was observed to be within normal limits. The patient’s remote recall was observed to be within normal limits. Concentration was observed to be within normal limits. The patient displayed some occasional fidgeting over the course of the interview. No constant moving or hyperactivity was noted.

MENTAL STATUS EXAMINATION:  The patient is cooperative. Eye contact is poor. He is not restless. The patient seems bored and disinterested. His answers to questions are brief with one or two word answers or nod or shake of his head. The patient is oriented to person, place, and time. His memory is difficult to evaluate due to his lack of involvement in this interview. His mood appears largely bored. He does not appear depressed. His affect is blunted. Thoughts are goal directed without loose associations. No evidence of psychotic symptoms such as hallucinations or delusions. There is no suicidal or homicidal thinking. Judgment cannot be assessed due to his lack of involvement in this interview. Insight seems limited. Intellect also cannot be adequately assessed due to his lack of involvement in this interview.

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