Mental Status Examination (MSE)
Patient 1: Mr. R
Appearance: Mr. R is a 42-year-old male, appropriately dressed for the weather. He appears his
stated age, with a clean and groomed appearance. There are no signs of physical distress.
Behavior: The patient is cooperative during the interview, but his movements appear slightly
agitated. He frequently taps his feet and fidgets with his hands. His eye contact is intermittent.
Speech: Mr. R speaks at a normal rate and volume. His speech is coherent, and his responses
are relevant. However, at times, he pauses briefly as though searching for words.
Mood and Affect: The patient reports feeling "anxious and overwhelmed." His affect is congruent
with the mood, appearing slightly tense and worried.
Thought Process: His thought process is logical, but there are moments when he appears
distracted. There is no evidence of flight of ideas or disorganized thinking.
Thought Content: Mr. R denies any suicidal or homicidal ideation. He expresses concerns about
work-related stress and personal relationships, which appear to be contributing to his anxiety.
He does not exhibit delusional thinking.
Perceptions: No hallucinations are reported, and he denies any perceptual disturbances.
Cognition: The patient is oriented to time, place, and person. His memory is intact for both
recent and remote events. His attention and concentration appear intact as he can follow and
respond to questions appropriately.
Insight and Judgment: Mr. R demonstrates fair insight into his condition, recognizing that stress
is affecting his well-being. His judgment appears intact, as he is seeking help to manage his
anxiety.
Risk Assessment: No current suicidal or homicidal ideation. No history of violence.
Patient 2: Mrs. S
Appearance: Mrs. S is a 58-year-old female who appears older than her stated age. She Is
dressed in a loose-fitting, faded dress, and her hair is unkempt. She appears to be fatigued.
Behavior: Mrs. S appears withdrawn and avoids eye contact. She speaks softly and reluctantly.
She remains seated with her arms crossed and seems to struggle with engaging in the
conversation.
Speech: Speech is slow and soft. Mrs. S frequently hesitates and appears to be searching for
words. There is no pressure of speech or poverty of speech.
Mood and Affect: Mrs. S reports feeling 'sad and tired all the time. Her affect is flat and
restricted, with little emotional expression.
Thought Process: Her thought process is coherent but slowed. She occasionally takes long
pauses before answering questions, which might reflect her emotional state.
Thought Content: Mrs. S denies any hallucinations or delusions. She reports feeling "worthless"
and has been thinking about her lack of social connections. She denies any current suicidal
Ideation but admits having passive thoughts of death at times.
Perceptions: No signs of perceptual disturbances.
Cognition: Mrs. S is oriented to time, place, and person. Her immediate memory appears slightly
impaired as she has difficulty recalling recent events. She is able to recall some remote
memories, but there are clear gaps in her memory.
• Insight and Judgment: Mrs. S shows limited insight into her condition, expressing a sense of
helplessness. Her judgment appears Impaired as she has withdrawn from activities and
relationships that might help improve her mood.
Risk Assessment: No immediate risk of harm to self or others, but passive suicidal thoughts are
present. Ongoing monitoring recommended.
