MSE 2

Personal Information/Demographics

Patient Name:

T. R

Admission Date and Unit Admitted to 10/30/22 15 Floor

Age and Gender:

53years and Male

Marital Status:

Single

Religious Preference:

Atheist

Race:

Caucasian

Ethnic Background:

Hispanic

Employment:

N/A

Living Arrangements:

At home with my parents and brother

Patient’s Reason for Admission/ Chief Complaint:

Suicidal ideation with plan to cut, psychiatric evaluation

Co-morbid Conditions:

N/A

Mental Status Examination

What You See (list)

Descriptive example (narrative)

1. Appearance (observed)

· Grooming/Clothing

· Level of hygiene

· Pupil dilation or constriction

· Facial expression

· Height, weight, nutritional status

· Posture

· Gait

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

· Relationship between appearance and age

Well groomed Good hygiene No pupil dilation or constriction No facial expression Well-nourished for height Straight posture Evidence of scratches and cuts

Presenting presents with well-groomed hair, no body odor, and clean, well-fitting clothes. Patient is wearing a flannel shirt with jeans. Patient has good posture. Looks appropriate for state age. Uninterested facial expression. Scratches visible on face and hands and superficial cuts noted on left arm

2. Behavior (observed)

· Excessive or reduced body movements

· Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance and gait)

· Abnormal movements: (e.g., tardive dyskinesia, tremor/ tics/ abnormal movements)

· Level of eye contact (keep cultural differences in mind)

· Possible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia

Normal body movements

Maintains eye contact

Hypoactive

No abnormal or peculiar body movements observed. Maintains eye contact during conversation. Appears hypoactive.

3. Attitude (observed)

· Ability to follow commands

· Ability to provide reliable information.

Possible descriptors: cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter/good historian.

Follows commands Provides reliable information Trustworthy reporter/good historian

Open to the conversation, answers all questions, cooperative but not interested in talking unless being asked a question

4. Speech

· Rate: slow, rapid, normal

· Volume: loud, soft, normal

· Disturbances (e.g., articulation problems, slurring, stuttering, mumbling)

· Cluttering (e.g., rapid, disorganized, tongue-tied speech)

Rate: rapid Volume: normal No disturbances No cluttering

Responsive to cues and provides appropriate responses. Monotonous tone. No speech impairments noted.

5. Mood and Affect (inquired/observed)

Affect

· How the client outwardly is expressing emotion

· Appropriateness to situation

· Congruency with mood

· Congruency with thought

· Other descriptors include: broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate

Mood

· How the patient describes what they are feeling

· Possible descriptors include: labile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable

Outward: sad Congruent with mood and thought Blunted affect

“sad, down, anxious”

Openly expresses emotions and is appropriate to situation. Blunted Affect.

Client reports to be “a little sad, down, and anxious.” Mood remains constant. States this has been going on for a year.

6. Thought (inquired/observed)

Process

· Describes the rate of thoughts, how they flow and are connected

· Possible descriptors: Linear, goal-directed, disorganized, circumstantial, tangential, loose associations, flight of ideas, coherent, incoherent, evasive, racing, thought blocking, perseveration, neologisms.

Content and/or perceptual disturbances:

· Refers to the themes that occupy the patient’s thoughts and perceptual disturbances

· Possible descriptors: preoccupations, ideas of reference, delusions, obsessions, suicidal/homicidal ideation, rumination

Linear thoughts

Suicidal ideation Homicidal ideation

Thoughts appear linear, coherent, and logical. Responses are relevant.

Reports suicidal and homicidal thoughts with no intent or plan.

7. Perceptual disturbances

· Hallucinations (e.g., auditory, visual)

· Illusions

Auditory hallucinations

No illusions

Reports auditory hallucinations without commands

8. Cognition

· Orientation: time, place, person

· Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose)

· Memory: remote, recent, immediate

· Attention/concentration: performance on serial sevens, spelling a word backwards

· Abstract vs concrete thinking: proverbs, involving similarities

Judgment

· Good, fair, or poor

· Impulse control

Insight

· Good, fair, partial, poor

Adaptive Coping Strategies vs Defense Mechanisms

Possible defense mechanisms:

Denial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression

A&O x 3

Alert

Intact memory

Maintains attention

Fair Judgement

Good insight

Avoidance

Oriented to time, place, and person, and is alert. Intact remote and immediate memory. Maintains attention and concentration as evidence by spelling “world” backwards.

Has fair judgment and good insight. Is aware of sickness, and how medications affect self and does express wanted to improve mental health by treating internal factors. Does avoid extensive conversation about illness.

8. Safety of Self/ Others

Risk of Self/Suicidal/Self-Injury

· Fully assessed-no indicators of risk

· If yes then

· Suicidal ideation (current, past)

· Suicide attempts (hx of)

· Plans to attempt (current, past)

· Access to means

· Family history

· Non-suicidal self-injury (cutting, scratching, or other self-mutilation) present?

· Unintentional (when delusions, demented, intoxicated, in manic stages) present?

Harm to Others/Aggression

· Fully assessed- no indication of risk identified

· If yes then

· Plan (current, past) to assault

Property Destruction

· Fully assessed- no indication of risk identified

· If yes then

· Current admission

· Hx of

Current suicidal ideation

No hx of attempts

No plans

Non-suicidal self-injury present

No unintentional self-injury present

Yes, no plan

No indication of risk of property destruction identified

Current suicidal risk present. No history or plans to attempt suicide, but does state having access at home. No family history of mental illness. Presence of non-suicidal self injury to arms and face of scratches and cuts. No unintentional injuries present.

Reports willingness to harm mom and brother when triggered, but no plan to assault. No indication of risk for property destruction.