Medical Transcription

Mental Health Exam

APPEARANCE

PHYSICAL CHARACTERISTICS: GROOMING, DRESS, PERSPIRATION, USE OF MAKE-UP, TATTOOS, HEIGHT, WEIGHT, NUTRITIONAL STATUS... DILATED PUPILS (DRUG INTOXICATION) & PINPOINT PUPILS (DRUG WITHDRAWAL)

BEHAVIOR / PSYCHOMOTOR

GAIT, POSTURE, GESTURES, SCANNING, EYE CONTACT, STEREOTYPIES

SPEECH / LANGUAGE

RATE, VOLUME, TONE

EMOTION

AFFECT (OUTWARD EMOTIONAL EXPRESSION DURING INTERVIEW)
            DYSPHORIA
            CONSTRICTED (ONLY ONE SHOWN)
            INAPPROPRIATE (EUPHORIA DESCRIBING DEATH OF CHILD)

MOOD (LONG RANGE EMOTIONAL STATE -- REPORTED)
            DYSTHYMIA
            EUTHYMIA

COGNITIVE FUNCTIONS

ORIENTATION: PERSON (WHO ARE YOU), PLACE (WHERE ARE YOU), TIME (WHAT IS TODAY'S DATE), SITUATION (WHY ARE YOU HERE)

CONSCIOUSNESS: ALERT, CONFUSED, CLOUDED, STUPOROUS, UNCONSCIOUS, COMATOSE

ATTENTION/CONCENTRATION: SERIAL 7'S, HOUSE & WORLD, DIGIT SPAN

MEMORY:
   IMMEDIATE: 3 WORDS AT FIVE MINUTES (SHOULD GET 2+; APPLE, DESK, SHOE)
   RECENT: LAST WEEK OR SO
   REMOTE: DOB, HOW LONG MARRIED, PRESIDENTS

INTELLIGENCE: ACADEMIC PROBLEM SOLVING, PRACTICAL INTELLIGENCE, CREATIVE INTELLIGENCE (STERNBERG TRIARCHIC THEORY); OBSERVE LANGUAGE USE, DEFINITIONS, BASIC FUND QUESTIONS, INFER FROM EDUCATION AND OCCUPATIONAL STATUS, GENERAL INTERACTIONS...

ABSTRACT REASONING:
   SIMILARITIES (HOW ARE A DOG AND CAT ALIKE)
   PROVERBS (DON'T CRY OVER SPILLED MILK)

THOUGHT

PROCESS: LOGICAL, CIRCUMSTANTIAL, LOOSE, TANGENTIAL, WORD SALAD

CONTENT: THEMES, PREOCCUPATIONS, DELUSIONS
 

PERCEPTIONS

ILLUSIONS: MISPERCEPTIONS OF REAL SENSORY EXPERIENCE

HALLUCINATIONS: NO SENSORY STIM, BUT THEY BELIEVE THERE IS
 

JUDGEMENT/ INSIGHT
   WHAT IS THE THING TO DO IF YOU FIND SOMEONE'S KEYS ON CAMPUS? .....
   REAL LIFE JUDGEMENT INFERRED
   MED COMPLIANCE
   AWARENESS OF ILLNESS & NEED FOR HELP

 

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