Mental Status Examination:
- Appearance: The patient appears well-groomed and is dressed in clean, casual clothing. Hygiene is appropriate for the setting.
- Behaviour: The patient is cooperative and maintains good eye contact throughout the interview. They are restless, fidgeting slightly in their chair.
- Speech: Speech is of normal rate and volume, clear and coherent. There is no evidence of pressured speech or other abnormalities.
- Mood: The patient reports feeling "a bit down" and "stressed" due to recent life events.
- Affect: Affect is congruent with reported mood, with some flattening noted. The patient's emotional responses appear appropriate to the context, but with a restricted range.
- Thoughts: The patient's thought process is linear and goal-directed. No evidence of delusions or hallucinations is present. The patient expresses some worry about their financial situation.
- Perceptions: No hallucinations or sensory misinterpretations reported.
- Cognition: The patient is alert and oriented to person, place, and time. Memory appears intact for recent and remote events. Concentration is good during the interview.
- Insight: The patient acknowledges that they are experiencing symptoms of anxiety and low mood and recognises that these are impacting their daily life.
- Judgment: The patient demonstrates good judgment and understanding of the consequences of their actions.
Risk Assessment:
- Suicidality: Patient denies any current suicidal ideation or plans. No history of suicide attempts.
- Homicidality: Patient denies any thoughts of harming others.
Mental Status Examination:
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Mood: [Record the patient's self-described emotional state, using their own words if possible] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Thoughts: [Assess the patient's thought process and content, noting any distortions, delusions, or preoccupations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
Risk Assessment:
- [Suicidality, homicidality, other risks] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely)
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
