Psych Anamnesis Sample
Psych Anamnesis Sample
I: not assessed
II: 2-3 mm pupils equally reactive to light
III, IV, VI: intact extraocular muscles
V: able to clench teeth
VII: no facial asymmetry
VIII: intact gross hearing
IX, X: able to swallow
XI: able to turn head side to side
XII: not assessed
MENTAL STATUS EXAMINATION
GENERAL APPEARANCE: Patient has large body frame, appears healthy,
appropriately dressed in gray shirt and black shorts with clean short hair.
BEHAVIOUR: He is seated on bed, with 4-point restraints, noted to be disinterested
throughout the interview.
ATTITUDE: He is uncooperative and would not answer any of the questions. Patient
does not maintain eye contact with interviewer.
SPEECH: not assessed
MOOD AND AFFECT: Patient appears to be detached
THINKING: not assessed
PERCEPTION: not assessed
SENSORIUM: He is awake but would direct his attention away from interviewer when
asked a question.
INSIGHT: not assessed
JUDGMENT: not assessed
IMPULSE: he would look away when asked a question.