Mental Status Examination – Training Record

Training-only MSE. For educational and supervision purposes.

Created: 01 May 2026, 19:14

Student & Batch

Student: Srishti Tyagi

Batch: April06

Case Header

Client / Case Name: Sarah

Date of assessment: 01/05/2026

1. General Appearance

Well-groomed, kempt, and appropriately dressed Appears stated age No signs of being overtly made up or unkempt Body build: Average (likely leptosome/normal) Facial expression appears sad and fatigued, with reduced expressiveness

2. Psychomotor Activity

Psychomotor retardation observed Slowed movements and reduced activity level

3. Attitude toward examiner

Cooperative and approachable Engaged during session No hostility or guardedness noted

4. Level of Consciousness

Alert and conscious Fully responsive to surroundings

5. Speech

Rate: Slightly reduced Volume: Low Tone: Monotonous Reaction time: Mild delay Coherent and relevant

6. Mood & Affect

Mood: Subjectively reports feeling “overwhelmed,” “drained,” and unable to feel happy Affect: Flat/restricted Congruent with stated mood Reduced reactivity

7. Thought

a. Thought Process:

Logical and goal-directed No formal thought disorder

b. Thought Content:

Excessive worry about work performance Fear of negative evaluation (“people will judge me”) Catastrophic thoughts about future No delusions or suicidal ideation reported

8. Perception

No hallucinations or illusions reported No depersonalization or derealization

9. Cognitive Functions

Orientation: Intact (time, place, person) Attention & concentration: Mildly impaired (due to anxiety and rumination) Memory: Intact (immediate, recent, remote) Intelligence: Average Abstract thinking: Intact Fund of knowledge: Adequate

10. Judgment

Personal judgment: Intact Social judgment: Intact Test judgment: Intact

11. Insight

Aware of illness and recognizes need for treatment

12. Additional parameters (when required)

No abnormal movements or catatonic features No language impairment

Summary & notes

Short title / summary: “MSE reveals an anxious and depressed mood with flat affect, psychomotor retardation, intact cognition, judgment, and good insight.”

Symptoms are consistent with anxiety and depressive features, particularly performance-related anxiety No risk indicators such as suicidality or psychosis noted