MSE 2

Personal Information/Demographics

Patient Name:

M H

Admission Date and Unit Admitted to: The client was admitted to the St. Joseph hospital behavioral unit 2nd floor on 1/18/2023.

Age and Gender: 29 years old male

Marital Status:

Single

Religious Preference:

The client stated, he has never attended church and does not belief in God.

Race: white

Ethnic Background:

Hispanic

Employment:

The client works at trans -Chicago truck group

Living Arrangements: The client said, he lives in his own apartment at Chicago western avenue.

Patient’s Reason for Admission/ Chief Complaint:

The client was admitted to the hospital during an emergency via wheelchair with the complaints of trying to kill himself by overdosing with alcohol, cocaine, attempted to hang himself and fighting with mother at home. Charts states patient is alert oriented * 3 and has history of depression, insomnia, lack of energy, poor appetite, hypertension, and paranoid.

Co-morbid Conditions:

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

· The client was clean, well dressed and had a nice haircut.

· The client wore a short black pant, a long black sleeve sweater and a hospital socks.

· The client has a normal pupil dilation which varies from 2- 4 mm in diameter in bright light and 4-8 mm in the dark.

· The client looks happy during the group and has a lot of facial hair which was nicely shaved. The client skin color was pink and usual for ethnicity.

· Height – 5.4 inches, weight- 220 Ib and has a BMI of 32.1. The client has good appetite during hospitalization and is on a regular diet.

· The client has no scars but tattoos on his fingers.

· . The client looks appropriate for his age and walks ambulates independently with a steady 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

· The client sat quietly in a chair during the group and participated during answering of questions.

· There was no psychomotor retardation observed. The client was conscious, walks independently without any assistance.

· No evidence of tremors/tics/abnormal movements.

· The client was able to follow instructions and maintained eye contact throughout the interview.

· The client stated, he easily gets agitated because he is no longer working due to hospitalization.

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 client was cooperative and followed commands correctly.

· Reliably reported information and remember the event preceding his admission to the hospital.

· No evidence of aggressive behavior and suspicious of hurting himself or others.

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)

· The client spoke clearly with a medium voice

· The client spoke with an even tone and rhythm and communicated information coherently.

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

· The client affect was appropriate to the situation. He was clear and consistent with his thoughts.

Upon observation, the client has a good mood as evidenced by client displaying willingness to talk.

· During the conversation, he was accommodative and actively participated.

· The client has a pleasant mood but became anxious when he mentioned his mother’s name.

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

· The client had a purposeful, linear thought

· The client provided direct and appropriate answers to questions and conversations.

· The client has no evidence of thought blocking or flight of ideas.

· The client has a history of suicide ideation and tried multiple times to hang himself at home.

7. Perceptual disturbances

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

· Illusions

The client has no signs of visual illusions or hallucination throughout the interview.

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

· The client is alert, oriented * 3

· The client was awake during the group and stated he is tired and needs to lay down a little bit in his room.

· The client was able to recall all his past events and stated he was part of a military but ended his contract 5 years ago.

· The client concentrated throughout the interview and was able to spell (Good) and spell it backwards.

· The client has a good judgement base on his current evaluation and cooperation.

· The client has a good insight base on his current medication compliance.

·

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

· The client has not displayed any self-harm behaviors or threats to any other person but has previous history of suicide attempt.

· The client stated that he occasionally has thought of harming his mother and siblings whenever he overdoses himself with alcohol or cocaine.

· No evidence of suicide injury such as scratching or cutting self.

· The client currently has no thought of harming himself or others.

· The client has no history of property destruction .

Criteria

Level 5

5 points

Level 4

4 points

Level 3

3 points

Level 2

2 points

Level 1

1 point

Level 0

0 points

Criterion Score

Personal Information/ Demographics Section Requirements

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Section is complete and contains all of the accurate information needed. There are no spelling errors & the section is typed. 

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Section has no more than four errors in any combination of the following:  missing an area, a piece of information that does not belong in that section, a misspelled word, or is not typed. 

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Appearance Section Requirements

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Behavior Section Requirements

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Attitude Section Requirements

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Speech Section Requirements

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Mood & Affect Section Requirements

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Thought Section Requirements

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Perceptual Disturbances Section Requirements

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Cognition Section Requirements

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Safety of Self/Others Section Requirements

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