NURS686

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INITIAL EVALUATION NOTE PART 2: MENTAL STATUS EXAM (MSE)

Initial Evaluation Note Part 2: Mental Status Exam (MSE)

Heidy Canavaciolo

West Coast University

NURS 686

Dr. Vardah Seraphin

May 29, 2022

Initial Evaluation Note Part 2: Mental Status Exam (MSE)

Appearance:

Gender: Female

Marital status: Married

Occupation: Bachelor’s in art history and worked at the museum

Language: English

Birth place: United States

Race / ethnicity: American

Religion: None

Source: Patient

Well dressed and good hygiene noticed

Cooperative, attentive, engaged, frank and appropriate eye contact

Normal motor with no psychomotor retardation/agitation noted

Speech:

Fluent, coherent, normal tone, rate and volume.

Patient noticed to become emotional at times during interview

Mood and affect:

Lack of motivation

Emotional

Feelings of overwhelmed and guilt noticed

Thinking and perception:

Patient answers spontaneously when questions asked.

Answers are relevant and logical

Patient speech is clear and coherent

Cognition is intact

Thought of suicidal attempt with son last hospitalization because feeling of guilt “I thought about taking pills. I was in a really bad place that day”

Impulse Control: Low

No hallucinations or illusions expressed.

Patient denies hearing voices or having visions

Sensorium:

Patient is awake, alert and oriented to time, place and person.

Some level of fatigue noticed in the patient

Current and remote memories are intact

Level of education: Bachelor’s in art history. Patient is currently unemployed.

Abstract thinking: Intact

Insight:

Patient recognized the need for professional help due to worsening of symptoms. Patient express concern about the way she is feeling currently.

Judgment:

This patient noticed to start feeling depressed four months ago claiming that this years has been really stressful since her mother passed aways, she lost her job and her son, that is a special needs one, has been sick. Furthermore, patient had thoughts of suicidal attempt when her son was last hospitalized due to feelings of guilt “I thought about taking pills. I was in a really bad place that day” . After this episode, the patient realized that she needed to get professional help realizing that her depression was getting worse. Judgment refers to the ability to interpret one's environment and situation correctly and to make appropriate decisions and appropriately act on them in social situations. With that said, we can reach to the conclusion that patient’s judgment is a clear one at this moment since she knew it was time for her to get help.