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 therapist’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 (“Mental Status Exam,” n.d.). Abby’s mood is thus better expressed in her  own words: “I am okay; I am doing Good.”  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 person’s spoken words were noted.  Thought Content: She is reflective and reminisces about her family’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, Chief’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: “I am great, great, great, great.”  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 medication’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 doctor’s approval.    4    Cognition: Alert and well-oriented to person, place, and situation.

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