MSE

Personal Information/Demographics

Patient Name : M.L

Admission Date 10/29/2022 and Unit Admitted to 2nd Floor

Room 224 Bed - 1

Age 67 and Gender: Female

Marital Status: Divorced

Religious Preference: Catholic

Race: White

Ethnic Background:

Employment: Retired

Living Arrangements: Lives at home

Patient’s Reason for Admission/ Chief Complaint: Depression, Alcohol withdrawal and suicide Ideation

Co-morbid Conditions: Asthma and Hypertension

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 was dressed in her own clothes and wearing the hospital soaks. Patients skin appeared cleaned, but hair was not well combed.

Patient had no foul odor on her body.

Patient posture looked erect in her chair but walks with a walker for additional support. Her gait unsteady, walks slowly and smooth.

Patient appeared underweight.

No scars/abrasions/bruises/tattoos or physical markings were present.

The patient was a 67-year-old American female who was short , blonde hair that was not well combed. Her hygiene appeared good except her hair. She had no foul odor or smell and her clothes appeared to be clean. She was wearing her own clothes and the hospital soaks. She looked age appropriate. There was no evidence of scars ,bruises, tattoos, or any other marks on her skin. Patient appeared attentive during group meeting therapy. She was actively watching sports with the other patients. She later played cards with me. Patient appeared underweight with unsteady slow gait.

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

Reduced body movement due to history of falls. Patient was cooperative during the interview. She appeared calm, interactive, and very alert. There was no evidence of tremors, ticks, or abnormal movements. Patient maintained eye contact throughout the interview. The patient followed commands.

The patient states that she fell and broke her leg and had since not been able to walk as supposed. Therefore, the patient uses a walker to walk and has walk slowly. The patient does not have any peculiar body movements aside her walking slowly. The patient talks very clearly and answered every question I asked. The patient’s gait was not smooth. Patient was calmed and did not speak the much but when I asked her questions, she thoroughly explained it. Patient did not show any 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.

The patient was able to follow command and provide adequate information. She was able to answer every question she was asked. Patient was sorry for attempting to commit suicide. Patient opened about many drugs and drinks she took to attempt the suicide. Patient was focused and not defensive. Patient wasn’t aggressive. She was a reliable reporter and good historian.

Patient can follow command and provide sufficient information. She was answered all question that were asked without falter. Patient felt sorry for trying to commit suicide. Patient talked about her drug use and alcohol consumption. Patient didn’t respond defensively but was instead focused. Patient was calm and not aggressive during the interview. Patient gave good and reliable information and was able to recall important information.

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 content was free from hallucination, delusions, or suicidal ideation. Patient was calm and interactive but does not speak much unless you ask her questions. She spoke at a low volume with even tone of rhythm. Patient had no problem articulating her sentences. There was no evidence of rapid, organized, or tongue-tied speech.

The interview I had with the patient was free from hallucination, delusion, or suicide ideation. Patient was interactive the whole-time during group therapy. She said she watches television or read as her coping mechanism. She was speaking at a low volume with even tone or rhythm.

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 colabile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable

The patient was without a flat affect. She was congruent with her mood. She was interactive with me during group therapy. We played uno card although I did not know how to play. She took the time to explain the rules to me. Patient displayed an average intensity within her communication and had no flat affect and was appropriate.

During group therapy, the patient was very interactive and participated actively. Patient did not display any anger, hostility, or anxious affects. Patient appeared to be in a good mood without any suicide ideation thought, hallucination, paranoyance or delusion. Her intelligence was average. Her instinct was good, and judgement was good.

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 thoughts were goal oriented throughout our interview. Questions were answered properly by the patient. Her utterances were well organized. There was not any tangential, loose association or flight of ideas. She was coherent in her conversation. She did not exhibit any sign of responding to internal stimuli.

From my observation, her conversation with me was goal oriented. She answered all the questions I asked her to the best of her knowledge without any loose association. The patient was free of delusion, hallucination throughout our interview. According to the patient, she was intoxicated when she arrived at the Emergency Department. Nevertheless she was able to give the nurses a little bit of information.

7. Perceptual disturbances

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

· Illusions

Patient did not show any signs of hallucinations, auditory or visual disturbances. She was alert and oriented to our conversation.

Although our interview, patient did not exhibit any hallucination, delusions, auditory or visual disturbances. She was very alert.

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 was alert oriented x4. Patient was oriented to person, place, and time. She was very attentive and maintained adequate eye contact. Patient had a good memory. Her thought process was good. Her immediate memory was present because she was able to repeat some words, I pronounced back to me. She also remembered having a sister called Lilian. She also remembered that she was divorced four years after her marriage without children. The patients abstract thinking was present.

Patient has a good judgement because she was able to say sorry for drinking that much and taking overdose of her medication. Patient wish such error may not repeat itself. Patient continue to say she watches television and read books for her coping mechanics.

Patient was aware of her surroundings. She was actively listening and concentrating on the questions I was asking her without any interruptions. She was able to absorb information from her sense and make connection to a wider world. She also remembered something she did in high school. According to her, she was a candy stripper.

I observed that the patient had a good judgement and insight. She realized how inappropriate it was to overdose herself with such amount of alcohol to end her life.

The patient had a good insight because she knew it was inappropriate to attempt to take her own life.

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 was on suicide precaution, but she never tempted to harm herself or anyone since her admission. She has a family history of suicide. Patient was calm and verbalized that she will not attempt to kill or harm herself or anyone. Patient had no evidence of self harm. The patient was calm and had no intention to harm herself or anyone. Patient had no intention of destroying any property and has not done that in the past.

According to the patient’s chart, she was admitted for suicide ideation using alcohol and overdose of her drugs but she has regretted doing that and said she will not try to harm herself or anyone again. There was no evidence of cutting scratching or other self-mutilation present.