MSE 3

Personal Information/Demographics

Patient Name:

L.B

Admission Date and Unit RM- 1614 Admitted to:03/7/23

Age and Gender: Male

22years

Marital Status: Single

Religious Preference: Christian

Race: African - American

Ethnic Background:

Employment: Unknown

Living Arrangements: Patient lives at 711 West Schiller #204 Chicago alone. Patient part of the Williams Quinn/Colbert program and receive intensive management care.

Patient’s Reason for Admission/ Chief Complaint: Patient is a 22year male who presents in ED with Psychiatric behavior and was brought CFD with the social worker. The patient is delusional and states he needs treatment for foreign radiation

Co-morbid Conditions: Acute Psychotic

Schizophrenia, Asthma

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

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

· Relationship between appearance and age

The patient is wearing a hospital gown and socks. The patient’s hair is uncombed, and the skin appeared disheveled.

Pupil dilated/constricting.

Patient facial expressions were relaxed and engaged with a morning greeting,

No evidence of scars or tattoos was seen on the patient’s skin.

The patient’s posture was erect in the chair and walked without additional support

The patient was a 22-year-old African American who is short with disheveled hair that was not combed. His hygiene appeared good except for his hair. The patient had no foul smell and his cloth appeared to be clean. He looks age appropriate and there is no evidence of scars, bruises, tattoos, or any other marks on his skin

Patient’s eye followed PEERLA.

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

Patient was cooperative during the initial interview but experienced thought blocking.

Patient displayed no evidence of tremors/abnormal movement. Patient was focused, not scanning the environment or repetitive gesture. Balance and gait are normal. Patient shows evidence of psychomotor retardation

The patient maintained good eye contact with me and the nurse.

Patient appeared to be hypoactive but was still able to participate in the group activities and communication

Patient could not answer a question without taking a break to put his thoughts together. No abnormal or peculiar body movement was observed.

Patient displays psychomotor retardation.

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.

Patient was able to follow simple commands.

Patient provide reliable information and it was precise.

Patient was cooperative and calm during the interview.

Throughout the interview, my patient was able to follow commands and answer questions in sequential order. Patient verbalized the reason for his admission stating hearing of voice as well as going to the sky for the invention of radiation.

The patient was cooperative during the interview.

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)

Patient speech is slow and latent.

Patient shows flatted and the tone is soft.

The patient was also willing to engage in conversation with the nurse and me. There was no evidence of slurred, stuttering speech.

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

Patient has flat affect which is inconsistent and incongruent with his mood. He was inactive in group therapy discussions.

Patient displays average intensity in his communication.

Patient displays a flat mood process.

Patient expresses the feeling of sadness and shows anxiety that someone wants to hurt him in the right arm.

Upon observation of the patient, he did not say a word and did actively engage in group activities. Patient was calm and hostile to the group.

The patient’s chart described his mood and affect as flat and also appeared to be depressed. Patient is not cooperative, intelligence is average as well as poor insight and judgment

According to the patient’s chart on 03/12/23, he always sits with his peer mate but engages solemnly. The patient was found to be sadder, with more depression and lower energy. He was seen in the dining room sitting calmly and quite with his peers.

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:

· 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

Patient thought process is circumstantial. Patient shows disorganized of thought process and is content with delusion, paranoid. The patient exhibited thought blocking and provided direct and appropriate answers to my questions and conversation.

Patient denies any thought disturbance, hallucination, and current idea of reference.

Patient denies no illusion or suicidal ideation.

Throughout my observation on this patient, his thought process was circumstantial and disorganized. He responded to some of the answers were a loose of association. Patient was in delusional stage throughout our conservation. Patient was presented to the ED according to his chart with paranoid delusion that people are trying to hurt him.

The patient displayed signs of disorganized, circumstantial, tangential, loose association, flight of ideas, coherent, incoherent, racing thought blocking, perseveration, and neologism.

Patient shows no signs of suicidal ideation despite the auditory hallucination during his admission.

7. Perceptual disturbances

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

· Illusions

Patient shows no signs of auditory hallucination or delusion.

Patient displays thought disturbance, hallucination, and ideas of reference

During the examination, the patient denies visual hallucinations and hearing voices.

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

Patient show impaired due to mood. This patient is X2 oriented place, and situation.

Patient displays confusion, clouded and stuporous.

Patient was able to recall partial events that lead to his admission based on the chart.

The patient directs poor insight and impaired judgment because he is not able to say any coping mechanism, he will use to experience a crisis.

No coping mechanisms were found in this patient

In my observation of this patient, he was not able to assess abstract and concrete cognition. His Alert and orientation was X2 to person, place, and situation

Throughout my observation of this patient, he displays poor insight and impaired judgment because he definitely knows what is wrong with him.

Patient displays no possible defense mechanism in solving problems of his mentally 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

Patient verbalized that he has no intention of hurting himself.

Patient shows no sign of aggressive and impulsive behavior.

Patient displays no self-harm to others in the facility

No suicidal ideation.

Patient denies harm to himself and to others.

No plans to harm- himself.

No indication of the risk of property destruction.

The patient chart on records shows that he was admitted due to Acute psychotic and Asthma but denies no sign of suicidal ideation.

Patient has not destroyed any property in the facility.

No report of the patient’s willingness to harm- himself and others as well as destroying in the hospital facility,