Psychiatric and Mental Status MT Words and Phrases For Medical Transcriptionists


Explanation of Axis I to V:
 
Axis I:     Clinical disorders, syndromes and/or other areas of concern
 
Axis II:   Personality disorders and mental retardation
 
Axis III: Medical conditions (which may impact emotions)
 
Axis IV:  Psychosocial stressors (death, divorce, loss of job, etc.)
 
Axis V:    Global assessment of functioning.

 
 
COMMON PHRASES AND WORDS:
 
 
3-step command
 
able to spell "world" backwards
 
able to provide a correct year, month, date, day of the week, correct state, city
 
able to recite alphabet correctly in a timely manner and count backwards
 
able to maintain attention on the task at hand

able to name 2 out of 2 common objects and 5 out of 5 body parts

able to comprehend presented questions and commands correctly
 
ankle jerks
 
able to name objects, repeat phrases
 
able to process information
 
able to recall 3 out of 3 words
 
able to spell the word "world" backwards
 
adjustment disorder with depressed mood
 
adjustment disorder with depressed mood, in full remission
 
adjustment disorder with diminished mood
 
adjustment disorder with mixed anxiety and depression
 
affect was appropriate to content and normal in range
 
affect was blunted / affect was full range
 
affect was tearful / affect was euthymic
 
alcohol-induced psychotic disorder with hallucinations
 
all three spheres / all 3 spheres
 
anhedonia
 
antisocial behavior
 
antisocial traits (personality disorder with antisocial traits)

apathy, indifference
 
aphasia
 
appears detached and aloof

ataxia
 
attention and concentration
 
attention deficit hyperactivity disorder, combined type
 
auditory or visual hallucinations
 
awareness of current events
 
bipolar affective disorder, type II
 
borderline personality disorder with obsessive-compulsive features
 
bradykinesia
 
bradyphrenia, bradykinesia, rigidity, psychomotor slowing
 
Broca's aphasia
 
buccofacial and ideomotor apraxia
 
capacity for self-introspection
 
chronic schizophrenia, paranoid type
 
chronological order
 
cluster B traits
 
cocaine-induced mood disorder
 
cogwheeling, rigidity, spasticity
 
command hallucinations
 
constricted affect
 
conversion disorder

coordination and gait are intact
 
deep tendon reflexes are brisk and equal
 
delayed grief
 
delusional
 
demonstrated good recall
 
depressive disorder, not otherwise specified (NOS = not otherwise specified)
 
despondent
 
difficulty establishing and switching cognitive sets
 
disheveled
 
dysarthria
 
dysgraphia
 
dyskinetic movement
 
dysnomia, jargon or paraphasic errors
 
dysphoric mood
 
dysthymic disorder

emotional dyscontrol, lability, over-excited behavior and irritability 
 
expressive and receptive language
 
expressive aphasia
 
flight of ideas
 
Folstein Mini Mental status Exam
 
formal thought disorder
 
frontal release signs such as sucking, snout reflex, grasp, palmomental reflex, nuchocephalic and self-grasping were not elicited on testing
 
fund of knowledge
 
fund of general knowledge
 
gait is narrow based or wide based
 
glabellar reflex
 
good vocabulary
 
grandiose and expansive
 
grandiose ideation
 
grandiosity
 
grip strength
 
groomed
 
hallucinatory disturbances
 
hygiene and grooming (are fair / good / poor, etc)
 
hypothetical judgment

ideas of reference
 
illusionary experience
 
immediate recall / short-term recall

impulse control
 
impulse control disorder, not otherwise specified
 
impulsive reasoning
 
impulsivity, disinhibition
 
incoherent
 
insight and judgment

intermittent explosive disorder
 
internally preoccupied
 
judgment and problem-solving abilities
 
knee jerks
 
knows the city and state
 
limited vocabulary
 
letter perception was intact
 
loosening of association or flight of ideas
 
maintains eye contact  / does not maintain eye contact
 
major depressive disorder
 
major depressive disorder, recurrent
 
memory abstractions
 
mental status is intact in all four spheres
 
mental status is intact in all four spheres
 
mood appears depressed
 
mood was labile
 
narcissistic and histrionic features
 
narcissistic personality disorder with antisocial traits
 
new learning and delayed recall
 
no field cut to gross confrontation
 
no field cut to gross confrontation
 
no strange or odd posturing or mannerism
 
noncommand hallucinations

nonpressured speech
 
normal tone, bulk and power in all extremities
 
Novel motor programming
 
object perception
 
opioid-induced anxiety disorder
 
oriented to time, place, and person
 
palate moves symmetrically
 
palate moves up in the midline
 
panic attack
 
panic disorder
 
panic disorder without agoraphobia
 
paranoid
 
paranoid ideations
 
paresthesias
 
passive death wishes
 
paucity of thought
 
perceptual abnormalities

persecutory delusions
 
persecutory ideas of reference
 
perseverations or stimulus bounded behavior
 
plantar reflexes are flexor bilaterally
 
plantar responses
 
poor historian
 
postictal confusion
 
posttraumatic stress disorder (PTSD)
 
postural tremor
 
poverty of content
 
poverty of speech
 
prodromal symptoms of schizophrenia
 
proverb interpretation is concrete
 
proverb interpretation is fair
 
psychomotor dysfunction
 
psychopathology
 
psychotic symptoms
 
psychotic disorder, not otherwise specified
 
pupils are _____ (2, 3, or 4) mm and reactive
 
rapport seemed adequate
 
rate, volume and prosody of speech
 
reaction time to questions
 
reality testing was intact
 
recent and remote memory

recognition of low-level words
 
redirectable
 
reduplicative paramnesia
 
remembered 0/3 objects after 5 minutes
 
remembered 1/3 objects after 5 minutes
 
remembered 2/3 objects after 5 minutes
 
remembered 3/3 objects after 5 minutes
 
response to internal stimuli
 
responses were linear
 
restraints
 
Romberg
 
schizoaffective disorder, bipolar type
 
schizophrenia, paranoid subtype
 
schizophreniform disorder
 
sense of hopelessness
 
sensorium
 
Sensory exam:  All modalities are intact
 
serial 3s
 
serial 7s
 
shoulder shrugs
 
social phobia
 
somatic conversion symptom
 
somatic delusions
 
speech was clear, coherent, and goal directed
 
speech was normal rate, tone, volume
 
speech was rambling

staring into space

stream of mental activity was logical, relevant, coherent
 
stressors
 
suicidal or homicidal ideation
 
suicidal or homicidal ideas

switching cognitive sets
 
tactile discrimination
 
tangential thoughts
 
thought process was goal directed
 
thought blocking
 
thoughts, plan or intent (eg - suicidal or homicidal thoughts, plan or intent)
 
tongue protrudes to the midline
 
trend of thought
 
trouble with word finding
 
unintelligible and illogical
 
unresolved grief
 
uses rationalization and denial to explain

verbally contract for safety
 
vision was notable for floaters
 
visual fields are full to threat
 
visual fields were full and tactile localization was intact
 
visual withdrawal
 
visuoconstruction and visuomotor integration
 
voluminous details
 
Wernicke's aphasia
 
word salad and loose associations
 
word substitution 







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