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:
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 firstname.lastname@example.org.