e-Module Mental Status Exam Patient Encounter 1 GABA: Abby is a young adult Caucasian female with normal body habitus. She is casually dressed in a black hoodie and well-groomed with lightly applied makeup. Regarding mannerism, she is well composed and actively engages with the psychiatrist. She maintains good eye contact and responds appropriately to the therapistâ€™s inquiries. Mood: Forrest and Shortridge (2020) characterize mood as sustained emotion that the patient is experiencing as expressed in their own words. Therefore, it is reported in an emotional tone in quotations (â€œMental Status Exam,â€ n.d.). Abbyâ€™s mood is thus better expressed in her own words: â€œI am okay; I am doing Good.â€ Affect: Full and appears congruent and appropriate to stated mood. Her emotional state is relatively neutral based on her normal emotional outpour throughout the interview. Speech: Speech normal regarding production, rate, rhythm, and volume. Thought Process: Logical, linear, and goal directed. No made-up of new words and meaningless repetition of another personâ€™s spoken words were noted. Thought Content: She is reflective and reminisces about her familyâ€™s future encompassing her husband and daughter. She has a positive outlook. She also denies suicidal ideation. Insight: Abby has a good understanding of her treatment, including potential side effects. For example, she notes that her current medication has not adversely affected her sexual life as initially projected. 3 Judgment: There are no concerns regarding her decision-making capacity regarding adherence to the treatment plan and other issues regarding her health. Generally, she exhibits sound judgment. Cognition: Alert with intact memory as she effortlessly recalls past events. She seems well-oriented in terms of person, time, place, and situation. Patient Encounter 2 GABA: Mercedes is a middle-aged Caucasian woman, probably in her early 50s, wearing a white top, Chiefâ€™s hat, and has her glasses on. She also has multiple rings on her fingers, which may seem inappropriate for her age. She seems to be too familiar with the examiner and is overly expressive. However, she maintains good eye contact. Mood: â€œI am great, great, great, great.â€ Affect: She exhibits a full range of feelings, a euphoric sense of freedom (elated), and high vitality (energy). Speech: Her speech seems mildly pressured but redirectable. However, she expresses herself enthusiastically and tends to talk spontaneously. Thought Process: Circumstantial, rapid with a flight of ideas. She tends to answer questions with excessive, unnecessary details and quickly shifts from the point of focus. Thought Content: Cannot be inferred because the examination did not focus on matters related to suicidal ideation, delusions, obsessions, and hallucinations. Insight: Limited. While she is aware of the medicationâ€™s side effects, she ignores the potential risks of discontinuing medicines without the approval of her physician. Judgment: Poor judgment. For example, she is spindrift and discontinues medications without the doctorâ€™s approval. 4 Cognition: Alert and well-oriented to person, place, and situation.