Mental Status Exam
Thuy Huynh
November 16, 2012
Mental Status Exam
1) Appearance (unkempt, unclean, clothing disheveled, atypical clothing, well-groomed, drab, meticulous, obese, underweight, etc.)
-clothing were disheveled, unshaven-ed beard, unclean, unkempt attire
2) Attitude (resistive, cooperative, complacent, detached, resentful, suspicious, uncooperative, overly compliant, provocative, other symptom)
-detached from surrounding environment, seemed to be on guard at all times
3) Mood (sad, melancholy, euphoric, labile, irritable, hostile, apathetic, anxious, other symptom)
-anxious
4) Affect (flat, blunted, appropriate to mood, inappropriate to mood, euphoric, other symptom)
-animated and/or inappropriate affect
5) Behavior (repetitive movements, posturing, waxy flexibility, agitated, impulsive, seductive, anxious, avoids eye contact, psychomotor retardation, hyperactive, violent, restless, other symptom)
-anxious, restlessness, pacing back and forth, talking to self, performing defensive moves in hallway, paranoid
6) Speech Content (grandiose, self-depreciative, flight of ideas, loose associations, ideas of reference, hallucinations, delusions, phobias, other symptom)
- loose associations
7) Speech Quality and Quantity (overly talkative, slowed, pressured, mute, stutter, dysarthria, guarded, calm, monotone, soft, loud, relevant, coherent, other)
- monotone at times, when speaking to self speech was soft, incoherent on occasion
8) Sensorium and Intellectual Functioning
A) Orientation- did not seem oriented to place or time
B) Memory (remote, retention, confabulation)- not able to track
C) Patient’s store of general information- knew basic information
D) Ability to Abstract-not able to assess
9) Insight (patient’s reaction to problem and assessment of causes)
-was not quite able to get an accurate assessment on whether or not he had insight to his disease
10) Judgement
November 16, 2012
Mental Status Exam
1) Appearance (unkempt, unclean, clothing disheveled, atypical clothing, well-groomed, drab, meticulous, obese, underweight, etc.)
-clothing were disheveled, unshaven-ed beard, unclean, unkempt attire
2) Attitude (resistive, cooperative, complacent, detached, resentful, suspicious, uncooperative, overly compliant, provocative, other symptom)
-detached from surrounding environment, seemed to be on guard at all times
3) Mood (sad, melancholy, euphoric, labile, irritable, hostile, apathetic, anxious, other symptom)
-anxious
4) Affect (flat, blunted, appropriate to mood, inappropriate to mood, euphoric, other symptom)
-animated and/or inappropriate affect
5) Behavior (repetitive movements, posturing, waxy flexibility, agitated, impulsive, seductive, anxious, avoids eye contact, psychomotor retardation, hyperactive, violent, restless, other symptom)
-anxious, restlessness, pacing back and forth, talking to self, performing defensive moves in hallway, paranoid
6) Speech Content (grandiose, self-depreciative, flight of ideas, loose associations, ideas of reference, hallucinations, delusions, phobias, other symptom)
- loose associations
7) Speech Quality and Quantity (overly talkative, slowed, pressured, mute, stutter, dysarthria, guarded, calm, monotone, soft, loud, relevant, coherent, other)
- monotone at times, when speaking to self speech was soft, incoherent on occasion
8) Sensorium and Intellectual Functioning
A) Orientation- did not seem oriented to place or time
B) Memory (remote, retention, confabulation)- not able to track
C) Patient’s store of general information- knew basic information
D) Ability to Abstract-not able to assess
9) Insight (patient’s reaction to problem and assessment of causes)
-was not quite able to get an accurate assessment on whether or not he had insight to his disease
10) Judgement