MENTAL STATUS EXAMINATION:
APPEARANCE/BEHAVIOR: The patient is disheveled, noticeable bilateral tremor in both upper extremities. He was cooperative. Poor hygiene. Fair eye contact.
SPEECH/LANGUAGE: Irregular rate, rhythm and tone.
MOOD: Mood is elated, but mildly irritable. Affect is labile.
THOUGHT PROCESSES: Somewhat disorganized as loose associations, circumstantiality and tangentiality.
THOUGHT CONTENT: He has delusions of grandeur and is preoccupied with money, women and his career goals, which include becoming an actor, going to Stanford, becoming a police officer and running for president.
HI/SI: The patient denies any suicidal or homicidal thoughts.
PERCEPTUAL ABNORMALITY: He denies any hallucinations.
ORIENTATION: He is alert and oriented x3.
MEMORY/ABSTRACTIONS: He does have some concrete thinking, but otherwise grossly intact memory. IQ, fund of knowledge average.
INSIGHT AND JUDGMENT: Impaired.
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.
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.
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.
