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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MENTAL STATUS EXAMINATION:  The patient is disheveled with poor hygiene, psychomotor agitation and uncooperative with the interview and unpleasant. Speech and language are extremely pressured, elevated volume at times, irritable tone. Mood and affect are extremely irritable and labile. She is agitated, upset, tearful and using multiple obscenities throughout the interview. The patient displays flight of ideas at times but is redirectable. She is also circumstantial and tangential at times throughout the interview. The patient endorses delusions. She endorses feelings of wanting to hurt her mother, but no plan. She denies suicidality. Denies hallucinations, however, states that she has had visual hallucinations in the past, seeing aliens as well as seeing demons around her; however, they do not bother her. She is alert and oriented x 3. IQ and fund of knowledge are average. Insight and judgment are poor, stating that she does not need to be in the hospital and does not know why she was admitted.

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old female who is comfortably seated in the chair. She is calm and cooperative with the interview. Good eye contact. The patient’s mood is euthymic with appropriate affect. Her speech is nonspontaneous, monosyllabic, although goal directed. Dysarthria noted. Denies any auditory or visual hallucinations, suicidal or homicidal ideations at this time. She is alert, although disoriented to time and place. She does realize that this is a hospital. She has poor fund of knowledge, cognitively consistent with mild mental retardation. The patient, however, understands the nature of her illness. Her impulse control is adequate.

MSE Examples

MENTAL STATUS EXAMINATION:
APPEARANCE AND BEHAVIOR: Had good eye contact, well groomed, fair hygiene.
SPEECH AND LANGUAGE: Normal volume, tone and rate, nonpressured.
MOOD AND AFFECT: Mood was depressed and affect was congruent and restricted.
THOUGHT PROCESSES: Linear and goal directed.
THOUGH CONTENT: He does have some paranoia, believing that he is being experimented on by aliens.
HI/SI: He denies currently having suicidal ideations.
PERCEPTUAL ABNORMALITIES: He reports visual, auditory, gustatory and tactile hallucinations.
ORIENTATION: He is alert and oriented x 4.
MEMORY AND ABSTRACTIONS: Fair. Fund of knowledge and IQ average.
INSIGHT AND JUDGMENT: Limited and poor.

MENTAL STATUS EXAMINATION:  The patient is dressed in a hospital gown and lying in bed, somewhat restless with goal directed fidgety movements while talking. She does not maintain good eye contact. She is crying and tearful during the interview. She is histrionic in describing her problems, shaking and making too many hand gestures. Speech and language functions are intact and adequate. Her mood is still depressed. Her affect is appropriate, depressed, crying. Thought process is linear and coherent. Thought content shows no current homicidal ideation or plans. The patient denies hallucinations but admits to suicidal ideas, but no current plans to harm herself. No paranoia or grandiose ideation. Cognitive functions are intact for orientation to place, person, and day. Memory is intact to remote, recent, and immediate recall. General fund of information is average. Intellectuality appears average. Insight and judgment are fair.

MSE Samples

MENTAL STATUS EXAMINATION:  Did not reveal any significant cognitive difficulties. On evaluation of emotional status, the patient reported emotional distress with depression and anxiety symptoms in relation to her medical situation, ongoing pain problems, and hospitalization. She reported reduced sleep in relation to her pain. She reported lessened appetite but noted some improvement. She reported low energy with significant fatigue. She reported crying and was crying during the evaluation process. She reported thoughts of death, but no death wishes or suicidal thoughts. She reported significant concerns about her recovery. She also reported fears of closed places and high places. She did not report any symptoms suggestive of a formal thought disorder. She reported having a supportive family that has been involved in her care and recovery. She reported feeling hopeful in improving her functional status and return to her prior lifestyle.

MENTAL STATUS EXAMINATION:  The patient appeared disheveled and unkempt. He was child-like in his behavior and was very disorganized. He was talking about himself at times and refused to answer questions. He had an abnormal gait. His speech was monotone. His affect was reactive but inappropriate to content. He was laughing and giggling in an anxious fashion. His mood was guarded. His thought processes were tangential and concrete. His thought content was focused on abuse, allegedly by his father, years ago about which he was having nightmares and flashbacks. He denied any auditory hallucinations as well as any visual hallucinations. He denied any suicidal ideation; however, he had been suicidal and depressed prior to admission. He denied any homicidal ideation. His insight and judgment were poor. He was alert and oriented to person but not to place nor year. He was unable to state the name of the President of the United States and was unable to state anything in the news. His attention and concentration were fair. His memory for immediate, recent, and remote events was poor. His use of the language was limited. His fund of knowledge was considered to be below average.

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