Mental status examination

The MSE describes the present, not the history. It is observational: what you can see and hear in this meeting, recorded in terms specific enough that another clinician reading it can picture the person. "Patient appeared depressed" is not an MSE finding; "sat with shoulders forward, made brief eye contact, spoke in a low voice with long latencies, cried when describing her father" is.

Cultural caution

Almost every MSE domain is culturally patterned. Eye contact, emotional expressiveness, deference to authority, and beliefs held within a religious community are routinely misread as pathology when the clinician’s norms are treated as the baseline. Ask whether a behaviour is unusual within the patient’s own community before recording it as abnormal.