Mental State Examination Notes

Patient Information

• Marcus Vance
• 34 years old
• Male
• 14/05/2024

Appearance

• Appears stated age, dressed in rumpled trackpants and an oversized hoodie; grooming and hygiene are fair.
• Notable dark circles under eyes; mild signs of self-neglect with unshaven facial hair and unkempt hair.

Behaviour

• Mild psychomotor retardation noted; intermittent, downcast eye contact; cooperative with the assessment despite low energy.
• Occasional hand-wringing when discussing recent workplace stressors; no overt agitation or tics.

Speech

• Slow rate, low volume, monotonous tone, and fluent.
• Prolonged speech latency noted prior to answering open-ended questions; no slurring or pressured speech.

Mood

• Reports feeling "completely flat and exhausted."
• Persistently dysphoric and depressed.

Affect

• Restricted range, blunted intensity, and appropriate to the context of discussion.
• Congruent with self-reported dysphoric mood.

Thought

• Linear, logical, and goal-directed thought process; nil formal thought disorder, delusions, or obsessions.
• Preoccupied with themes of personal failure, financial ruin, and worthlessness; passive suicidal ideation ("sometimes I wish I just wouldn't wake up") with nil active intent or plan.

Perception

• Nil auditory, visual, or tactile hallucinations; nil illusions.
• Reports mild transient derealization during acute anxiety episodes, describing his surroundings as feeling "foggy and distant."

Cognition

• Oriented to time, place, and person; gross short-term and long-term memory intact.
• Mildly impaired sustained attention and concentration during serial sevens, likely secondary to depressive symptomatology and fatigue.

Insight

• Good insight; recognizes depressive relapse and acknowledges the need for psychological intervention and GP medication review (currently taking sertraline (Zoloft®) 50 mg PO OD).
• Tends to minimise the impact of social withdrawal on his current mood state.

Judgment

• Intact capacity to evaluate hypothetical safety scenarios and articulate appropriate courses of action (e.g., agreed to utilise crisis lines if suicidal ideation escalates).
• Recent history of maladaptive coping via skipping meals and isolating from social supports, though capacity for safe decision-making remains intact.

Counselor Information

• Dr. Elena Rostova
• MPsych (Clin), MAPS
• 14/05/2024