Metal Status Exam Medical Transcription Words and Phrases
MENTAL STATUS EXAMINATION: At the time of discharge, the patient was alert and oriented x3. The patient was fairly groomed and dressed. The patient was cooperative with the interview with normal speech pattern and psychomotor activity. The patient reported mood as better. Affect was appropriate. The patient was goal directed and did not voice any delusions, illusions or obsessions. The patient denied any auditory or visual hallucinations. The patient denied any suicidal ideation or homicidal ideation. Insight and judgment fair, and cognitive examination was unremarkable.
MENTAL STATUS EXAMINATION: Reveals a male looking older than his stated age, disheveled with poor dental health. The patient's affect was flat, but he was cooperative and showed some sad affect. Mood can be described as depressed. Speech: The patient spoke with some hoarseness, slow low tone with not too extensive vocabulary. The patient's main conversation was around his pain and the need of a medication that would take care of it. Thought content: The patient denies obsession or compulsions. The patient denies illusions or hallucinations. The patient admits having had some suicidal ideation with vague intention. Sensorium: The patient was oriented to time, person and space. The patient's attention, concentration and recall were poor. The patient seems to be of below average intelligence. The patient's fund of general information is poor. The patient's motivation for treatment is fair. The patient's insight is poor. The patient shows good control of impulses.
MENTAL STATUS EXAMINATION: During interview, the patient remained clingy, dependent and sought to prolong exchange through long tangential departures, parenthetical asides and over elaborate descriptions of events. Efforts to set limits found the patient unable to generalize the intent of these redirections and to honor the implicit need for concise focused exchange. Rather, the patient is clingy, juvenile, regressed and loquacious. This loquacity does not suggest bipolar disorder but rather Axis II features of intolerance for solitude, dread and dramatic expression of anxiety in the face of abandonment, loss of an objective sense of shared boundaries on terminology with the patient feeling abandoned even when abandonment in the medical/legal sense or even a general customary understanding of the term would not be an accurate description of the process. Mood is profoundly fragile and deeply overdramatized without apparent sensitivity on the patient's part to her loss of credibility and an apparent expectation derived from prior experience that her juvenile regression will be a successful gambit with adults. Clearly, there is anxiety but equally clearly there is a dramatic and disingenuous embellishment with sole goal being to manipulate decision making of others. That manipulation is clearly intended to postpone solitary functioning by this patient. She is depressed. She currently discounts suicidality but again her fragility is intense and I make no claim that she would not, within minutes, be willing to express the belief that she was suicidal for the goals outlined above. Lucid when engaged, but logical and able to demonstrate understanding in the process and medication tools. This woman is intact to any cursory testing and does not appear to be responding to internal stimuli. Spontaneous speech clearly takes liberty with words in order to, in an impressionistic way, cast herself as a victim and to underscore how distraught and overwhelmed she is. Nonetheless, she is able to display logic at other times. Folstein mini-mental state exam shows awake, alert, attentive and oriented in 3 spheres. She is able to spell backwards a 5-letter word. She is able to do serial 7s slowly and methodically, errors made with vague feedback noting error feedback. She was able to rethink and methodically write an accurate answer. Serial 3s similarly errors made. Digit span, 7 forward, 3 in reverse. General fund of information was good. Insight fair. Judgment poor. Similarities and differences: Abstract conventional. Proverbs: Abstract conventional.
MENTAL STATUS EXAMINATION: The patient presented as an adequately groomed and apparently overnourished female who appeared her stated age. There are no observed abnormalities in terms of posture, gait or motor movements. Eye contact was good. Rapport seemed adequate. She was alert and oriented x3. Responses were linear and goal directed and without circumstantiality, tangentiality or loose associations. Speech was normal rate, tone, volume and inflection. There was no evidence of word substitution or difficulty finding words. She denies current suicidal or homicidal ideation and auditory or visual hallucinations. There is no evidence for formal thought disorder. There was an absence of paranoia, grandiosity, flight of ideas, ideas of reference, delusions, episodes of thought control, obsession or withdrawal. Judgment and insight presently deemed to be adequate; although, when she drinks, the judgment and insight seem to drop off significantly. Short-term and long-term memory is thought to be adequate. Fund of knowledge was estimated to be average. Intelligence was estimated to be average given her clinical presentation. Overall mood was euthymic. Affect was full range and appropriate.
MENTAL STATUS EXAMINATION: This is a patient who is well groomed and appears his stated age. There was clinical evidence of psychomotor restlessness. However, 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, appropriate, with spontaneous emotional reactivity. We 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 within normal limits. He was able to do serial 7s and able to subtract and add figures without difficulty. His general level of intelligence and fund of general knowledge were both adequate. His level of personal hygiene was fairly good. He was able to communicate clearly, unable to achieve goal directed ideas. He denied any suicidal or homicidal ideation. His level of abstract reasoning was intact. He denied any ideation of worthlessness or hopelessness. There were no clinical features of auditory or visual hallucinations. He was preoccupied about his attention deficit difficulties.
MENTAL STATUS EXAMINATION: The patient is a (XX)-year-old male who was well groomed and appear his stated age. During the interview, there was no clinical evidence of psychomotor disturbance. He was very pleasant and cooperative and displayed positive attitude towards the psychiatric evaluation. 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. At the time of the psychiatric assessment, 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 add and subtract figures without any significant difficulty. His general level of intelligence and his fund of general knowledge were adequate and appropriate with his level of education. His level of personal hygiene was fairly 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 ideations. 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 auditory or visual hallucinations. He denied any preoccupation, illusions or phobias. He had very poor insight into the nature of his polysubstance dependence. His judgment appeared to be impaired.
MENTAL STATUS EXAMINATION: This is a (XX)-year-old male sitting on a chair appropriately dressed. He was alert. He was oriented to time, place, person and cooperative. Concentration was intact. Memory: Recent and remote memory grossly intact. Mood was euthymic. Affect was slightly restricted. No suicidal or homicidal ideation. No auditory or visual hallucinations evident on examination but he did complain of regular daily auditory and visual hallucinations. Apart from his delusional thinking or possible delusional thinking, there was no psychosis. He was able to have rational goal-directed conversation. He was able to discuss options. His proverb interpretation was intact. There was no flight of ideas. There was no loosening of association or tangential thinking. Apart from his claim of grandiosity and delusions of grandeur, there was no other abnormality noted on the mental status examination. There was no extrapyramidal side effects or tardive dyskinesia noted. He was able to have very coherent conversation. He seems to have poor insight into his psychiatric condition but his general judgment was intact.
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