Mental State Exam (MSE) - Australia

APPEARANCE: - Gender and sex: Male - Age: 35 - Ethnicity: Caucasian - Complexion: Fair - Height and Build: 180 cm, athletic - Hair: Short brown hair, clean-shaven - Grooming: Well-groomed - Unique physical attributes: Tattoo on left forearm - Facial features: No notable features - Body fetor: None BEHAVIOUR: - Eye contact: Consistent - Relevant facial expressions: Neutral - Attitude towards interviewer: Cooperative - Repetitive movements: None observed - Gait: Normal - Psychomotor behaviour: Calm - Style of gesturing: Minimal SPEECH: - Rate: Normal - Volume: Moderate - Tone: Even - Other unique qualities: None - Stutter: None - Accent and dialect: Australian - Amount of speech: Appropriate - Speech impediments: None - Use of vocabulary: Appropriate - Is the person difficult to understand?: No - Presence of frequent, noticeable pauses: None MOOD: - How the person is feeling?: Anxious - Reported emotion: Anxiety - Reported depth: Moderate - Reported duration: Persistent over the past month - Reported degree of fluctuation: Occasional AFFECT: - How the person appears to be feeling, based on their non-verbals: Anxious - Range: Full - Emotions the person expressed: Anxiety - Are they appropriate to the topic?: Yes - Intensity: Normal - Reactivity: Reactive - Congruence: Congruent - Person’s affect is consistent with their reported mood: Yes Neurovegetative symptoms - Sleep: Disturbed - Appetite: Normal - Weight gain/loss: None - Motivation: Decreased - Interest in activities: Decreased - Energy levels: Low - Libido: Normal PERCEPTION: - Presence of Hallucinations: None - Presence of Illusions: None - Auditory: None - Visual: None - Tactile: None - Olfactory: None - Gustatory: None THOUGHT FORM AND FLOW: - Amount and rate of thoughts: Normal - How connected thoughts are to one another: Logical - Thoughts relate to a central idea: Yes THOUGHT CONTENT: - Main topics discussed in the session: Work stress, family issues - Presence of delusions (paranoid, grandiose, persecutory, nihilistic, passivity phenomena, including thought insertion, thought removal, thought broadcasting): None - Preoccupations/obsessions: None - Safety risks (Suicide, Self-harm, Violence/aggression, Vulnerability, Absence without approval, Child safety): None JUDGEMENT: - Person’s choices are adaptive or promote positive health outcomes: Yes - Person utilises a logical, reality-based decision-making process: Yes INSIGHT: - Aware of their symptoms: Yes - Understand how the symptoms are impacting their functioning: Yes - Note how the person explains their experience of symptoms: Good/intact COGNITION: - Alertness: Alert - Orientation: Oriented to time, place, person - Memory: Intact - Concentration: Good