W#5 Peer Replies
ASSIGNMENT:
The purpose of this assignment is to evaluate the patient and write up a mental status exam on what you observe in the video that you.
Your initial post should include a detailed mental status exam write-up of that patient. The intent of this exercise is to help you to develop your skills in the assessment of a patient’s mental status and documentation of the mental status exam.
Please watch the following video clips and write up a mental status of the patients:
POST # 2 NGOZI
The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood, and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning (Norris et al., 2017). For the purpose of this week’s discussion on mental status examination, I chose C-Mary Manic Episode Video.
Mental Status Examination: C-Mary Manic Episode
The domains that will be used for this mental status examination are appearance, attitude, behavior, mood, and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. A good report is brief, clear, and concise.
Appearance
Mary, a middle-aged white female, flamboyantly dressed in purple tights and unbuttoned shirt, presented to the clinic, and appears presumed age.
Behavior, Mood and Affect
During the interview, she was smacking and blowing bubbles with her gum; appears to have a lot of energy as she remained slouched in her chair. She was distant and appeared to be losing focus in her interactions with the examiner. She was cooperative and makes good eye contact. Not in acute distress, difficult to redirect for interviewing, inappropriately laughing and smiling. Mood was elated, elevated and euphoric, which she described as “on top of the world.” Affect was labile, but consistent with the content of the conversation and facial expression.
Speech
Speech rate was rapid, rambling, loud, and overelaborate. Latency of response was abnormal as patient jumps unto the last few words of the examiner’s questions.
Thought Content/Thought Process
Thought content was coherent, thought process circumstantial. Mary digresses to unnecessary details in thought and speech before communicating the central idea. She exhibited loosening of associations and flight of ideas, as she intermittently and unpredictably shifts the topic of the conversation from “working for God, incognito to describing her grandiose delusions and magical thinking regarding her ability to bring the wind, rain, and sunshine”. Endorses auditory hallucinations of people talking “at the front desk, people outside my window.”
Cognitive Examination
The patient was hyperalert, but unable to maintain a train of thought as she answers the examiner’s questions. Mary exhibited poor judgement and has poor insight to her problem, without realistic conception of its causes and possible treatments.
In summary, clear communication and regular meetings of the entire interprofessional healthcare team to discuss their observations on how the patient has been doing from each member’s perspective can point the team in the right direction for the patient’s care and improve patient outcomes. In an outpatient setting, there still needs to be open lines of communication, and each member of the interprofessional team should have some ability to perform mental status assessments, so patients can get the help they need promptly, leading to better outcomes (Neto et al., 2019).
References
Neto, H. G., Estellita-Lins, C. E., Martins, J. M., & Cavalcanti, M. T. (2019). Mental State Examination and Its Procedures—Narrative Review of Brazilian Descriptive Psychopathology. Frontiers in Psychiatry, 10(77), 1–10.
Norris, D. R., Clark, M. S., & Shipley, S. (2017). American Family Physician, 94(8), 635–641.