Two Sample Mental Status Examination Reports


The following two fictional reports are samples for those individuals learning to conduct Mental Status Examinations and write MSE reports. They’re from the forthcoming 5th edition of Clinical Interviewing.

If you’d like to see a short video-clip MSE example, you can go to: http://www.youtube.com/watch?v=1lu50uciF5Y

Mental Status Examination Reports

A good report is brief, clear, concise, and addresses the areas below:

1.  Appearance

2.  Behavior/psychomotor activity

3.  Attitude toward examiner (interviewer)

4.  Affect and mood

5.  Speech and thought

6.  Perceptual disturbances

7.  Orientation and consciousness

8.  Memory and intelligence

9.  Reliability, judgment, and insight

The following reports are provided as samples.

Mental Status Report 1

Gary Sparrow, a 48-year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner. Mr. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15”). His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Sparrow described grandiose delusions regarding his sexual and athletic performance. He reported auditory hallucinations (God had told him to quit his job and become a professional golfer) and was preoccupied with his athletic and sexual accomplishments. He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Mr. Sparrow was unreliable and exhibited poor judgment. Insight was absent.

Mental Status Report 2

Ms. Rosa Jackson, a 67-year-old African American female, was evaluated during routine rounds at the Cedar Springs Nursing Home. She was about 5’ tall, wore a floral print summer dress, held tight to a matching purse, and appeared approximately her stated age. Her grooming was adequate and she was cooperative with the examination. She reported her mood as “desperate” because she had recently misplaced her glasses. Her affect was characterized by intermittent anxiety, generally associated with having misplaced items or with difficulty answering the examiner’s questions. Her speech was slow, halting, and soft. She repeatedly became concerned with her personal items, clothing, and general appearance, wondering where her scarf “ran off to” and occasionally inquiring as to whether her appearance was acceptable (e.g., “Do I look okay? You know, I have lots of visitors coming by later.”). Ms. Jackson was oriented to person and place, but indicated the date as January 9, 1981 (today is July 8, 2009). She was unable to calculate serial sevens and after recalling zero of three items, became briefly anxious and concerned, stating “Oh my, I guess you pulled another one over me, didn’t you, sonny?” She quickly recovered her pleasant style, stating “And you’re such a gem for coming to visit me again.” Her proverb interpretations were concrete. Judgment, reliability, and insight were significantly impaired.

The latest edition (4th edition, updated) of Clinical Interviewing also includes a DVD with me (John) demonstrating a mental status examination. You can check our and/or purchase the whole DVD at: http://www.wiley.com/WileyCDA/Section/id-302475.html?query=John+Sommers-Flanagan

If you’re interested in having me come to your organization to provide a workshop or keynote on this or on a related topic, please email me at johnsf44@gmail.com.

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5 thoughts on “Two Sample Mental Status Examination Reports”

    1. Thanks Rachel. I hope it’s okay with you and Wiley that I post these intermittent materials from our various Wiley books. I figure it’s all under the umbrella of marketing and helpful to blog readers.

  1. This is an example of how the ridiculous Fiat mental illness is diagnosed. It is so true that people are disturbing rather than disturbed. The first example is a man exhibiting unusual behaviors, not illness. “He reported auditory hallucinations (God had told him to quit his job and become a professional golfer)” , how is this any different than sermon on Sunday, where the preacher says that Jesus lives in his heart? Was Jesus sick when his father in heaven spoke to him? No, he was a god obsessed Jew. These are not illness, these are behaviors and conversations outside of normal conventions, psychiatry is a means to control unusual behaviors and speech, not diagnosis.

    1. Hello Free Thoughts.

      Thanks for your comment. You make several excellent points. Also, believe it or not, I agree with most of them, but I also think some clarification is needed.

      First, I don’t believe in using the term “mental illness” unless I’m using it to describe why I don’t use the term “mental illness.” I believe the term is mostly misunderstood, and used for stigmatizing or political purposes.

      Second, mental status is different than mental illness. My belief is that understanding an individual’s mental status can be a useful process. It’s especially useful when MSEs are conducted collaboratively. . . which is what I recommend.

      Third, you’re correct in that it’s often difficult to discern the difference between auditory hallucinations and other experiences, particularly religious ones. Really, one of the only ways to do this effectively is to engage clients or patients in a cooperative, collaborative conversation. In fact, many people (but not all) are tormented or in great distress and consequently want support for improving their mental and emotional health.

      Finally, I’m not a psychiatrist. I’m not interested in behavioral coercion. That’s not to say that my viewpoint is perfect, but I do think that respecting clients and wanting to engage with them in a collaborative manner and recognizing that sometimes that means helping them understand their mental status . . . I think that’s a reasonable way for mental health professionals to work.

      Thanks again for your comments, the opportunity to learn from them, and the chance to clarify my perspective on these important issues.

      Have a great weekend.

      John SF

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