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MENTAL STATUS EXAM
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GEN APPEARANCE (age,man,attire wnl)
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PSYCHOMOTOR (gait,activity wnl)
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SPEECH (rate,tone,vol,pros wnl)
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LANGUAGE (avg and intact)
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MOOD "patient's reported mood" (okay)
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AFFECT (full, semi-eu, congruent)
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THOUGHT PROCESS (gd,rat,relev)
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ASSOCIATIONS (intact)
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THOUGHT CONTENT (-SI/HI/AVH/rIS/del, wnl)
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ATTENTION/CONCENTRATION (avg, intact)
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ORIENTATION (person,place,time,situation)
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MEMORY (intact)
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FUND OF KNOWLEDGE (avg, intact)
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INSIGHT/JUDGMENT (adequate)
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PHYSICAL EXAMINATION (GENERAL)
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General WNL
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General Abnormal
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General Comments
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HEENT WNL
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HEENT Abnormal
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Neck WNL
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Neck Abnormal
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Neck Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
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Abdomen Comments
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MSK WNL
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MSK Abnormal
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MSK Comments
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Breasts WNL
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Breasts Abnormal
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Breasts Comments
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Neuro WNL
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Neuro Abnormal
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
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Extrem Comments
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