Mental Status Examination No.

Date: September 17, 2021 Day: 1

Note: Put a check mark in the appropriate box of significant observed descriptor/s.

1. General Description
1.1. Appearance
Descriptors Yes No Remarks
Congruent apparent age      
 dressed in three
hospital gowns and
a robe, which she
is wearing
Appropriate dressing    / backward.
Clean / Hygienic      
Good posture    
Good gait      
Appropriate facial expression      
With eye contact      
With pupil dilatation    
With pupil constriction      
Normal state of health & nutrition    
1.2. Speech
Descriptors Yes No Remarks
Rapid speech      
Slow speech    
Loud volume      
Soft volume      
Minimal speech      
Pressured speech      
Stuttering      
Slurring of words      
Unusual accents      
1.3. Motor Activity
Descriptors Yes No Remarks
Lethargic      
Tensed      
Restless      
Agitated      
With observed tics      
Grimaces    
Tremors      
Compulsive      
 1.4. Interaction During Interview
Descriptors Yes No Remarks
Hostile      
 She is cooperative
Uncooperative    / with the interviewer
Irritable      
Guarded      
Apathetic      
 there is a gross
impairment in
Defensive  /   reality testing
Suspicious      
Seductive      

2. Emotional State
2.1. Mood
Descriptors Yes No Remarks
Sad      
Fearful      
Hopeless      
Euphoric  /    
Anxious      
 She states that
Happy  /   her mood is good

2.2. Affect
Descriptors Yes No Remarks
Congruent / Appropriate      
Flat      
Labile      

3. Experiences
3.1. Perceptions
Descriptors Yes No Remarks
 no suicidal or
homicidal ideation,
hallucinations, or
Hallucinations: Auditory    / delusions
Visual      
Tactile    
Gustatory      
Olfactory      
 Illusions      

4. Thinking
4.1. Thought content
Descriptors Yes No Remarks
Delusion: Religious      
Somatic      
Grandiose      
Paranoid      
Thought broadcasting      
Thought insertion      
Depersonalization    
Hypochondriasis    
false belief about
her thoughts she
said that she is an
Ideas of reference  /   avid astrologer
 She speaks at
length about how
the rape was
“written in the
stars” for all to see;
she is an avid
astrologer.

She admits that

she has worked
intermittently as a
Magical thinking  /   “crystal ball gazer”
Nihilistic ideas      
Obsession    /  
Phobia    /  
4.2. Thought process
Descriptors Yes No Remarks
Circumstantial      
Flight of ideas      
Loose associations      
Neologisms      
Perseveration      
Tangential      
Thought blocking      
Word salad      

5. Sensorium and Cognition

 5.1. Level of consciousness
Descriptors Yes No Remarks
Confused      
Sedated      
Stuporous      
Oriented to: Time      
Place      
Person      
5.2. Memory
Descriptors Yes No Remarks
Intact remote memory      
Intact recent memory      
Intact immediate memory      

5.3. Level of concentration and calculation

Descriptors Yes No Remarks
Easily distracted      
With difficulty in simple math      
5.4. Information and Intelligence
Descriptors Yes No Remarks
With learning disability      
With learning difficulty      
Able to interpret simple proverb      
5.5. Judgment
Descriptors Yes No Remarks
Appropriate judgment      
With good relationship to others      
5.6. Insight
Descriptors Yes No Remarks
Accepts presence of problem      
Blames the problem on others      

Descriptive Analysis:
The patient was recognized having a schizotypal personality
disorder, this patient is viewed by members of the obstetrics
team as odd, but she does not see herself in this manner.
Although several abnormalities are observed during her
mental status examination, including ideas of reference (not
delusions of reference), unusual beliefs, unconventional
thinking, a constricted affect, and an odd appearance, she
does not exhibit any signs of a true psychosis. She does not
have hallucinations or fixed delusions, and therefore her
symptoms do not meet the diagnostic criteria for
schizophrenia. She does not appear to have any
psychological sequelae resulting from the rape (no
symptoms of posttraumatic stress disorder), although she
does seem to have incorporated its meaning into her
unusual beliefs about the world.