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Mental Status Exam

Mental Status Exam

During mental status examination, Virgil is anxious and fidgety, often with pauses in his speech. He is coherent without looseness of associations, pressure of speech, flight of ideas, or evidence of hallucinations. He is pleasant and very cooperative. He is oriented to person, place, time, and situation.

He has excellent immediate recall as he immediately repeats 3 items and later numbers. He has some concentration difficulty as revealed by struggling and losing his place in subtracting serial 7s and serial 3s. He can reverse the spelling of a 5-letter word but has difficulty with reversing 4 and 5 digit numbers.

He has slight impairment of recent memory, having difficulty fully remembering 3 items at 5 minutes.

He demonstrates good past memory by recalling general information and describing major current events. He is able to make simple change.

He is capable of abstractly describing similarities of items. He is capable of giving abstract interpretations of general proverbs.

His affect appears concerned, worried, downcast, and at times appears flat and restricted. He describes his present mood as “heavy,” and his recent mood as “relaxed but heavy and trying to move forward.”

He demonstrates good judgment with his answers to formal judgment questions except the question about a gun, saying he would keep it because he likes guns. He demonstrates good insight about why he is being evaluated. When asked about 3 wishes, he replies that he would like to have a better house, a good car, and have the strength to “fix what ever I wanted, a super power.”

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