MSE1

Personal Information/Demographics

Patient Name:

P. R

Admission Date and Unit Admitted to: Client was admitted to St Joseph hospital behavioral unit on the 2nd floor 1/20/23.

Age and Gender: 23 years old male

Marital Status: Single

Religious Preference:

Client believes in God use to go to church but has stopped

Race: white

Ethnic Background: American

Employment: Unemployed

Living Arrangements: Client said he lives with his mother.

Client’s Reason for Admission/ Chief Complaint:

Client was admitted to the hospital through emergency with the complaints of depression, suicidal ideation to hang or stub himself.

Co-morbid Condition:

Lymphoma

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 client was clean and well-dressed, but his hair was not well combed.

· The client wore sweatpants, sweaters and hospital socks.

· The client’s eye was normal it dilates about 2 to 4 mm and they are equal.

· The client’s skin color was pink and usual for ethnicity.

· The client ambulates independently with a steady gait.

· The client has no abrasions, bruises, tattoos or any other physical markings on his skin.

· The client weighs 174 lb., and his height was 5.2inches, which looks appropriate for his age.

The client is a 23-year-old American male who looks clean, well-groomed and had no body odor, but his hair was not well combed. The client is average in height and weighs 174 lb. and was 5.2 inches tall. The client was wearing sweatpants, a sweater and a pair of hospital socks. The clients eye was normal, it dilates about 2 to 4 mm and they are equal. The clients ambulate independently by himself with a steady gait. client has pink skin which is usual for ethnicity but has no tattoos, abrasions, bruises or physical markings on his skin . During a group therapy, he actively participated.

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 listening attentively during group therapy on stress management.

-No evidence of tremors/tics/abnormal movements.

-There was no psychomotor retardation observed.

– He was able to follow instructions

The client-maintained eye contact throughout the interview stated that: “I feel happy talking to you” but I normally don’t talk to people I do not know.

Prior to interviewing the patient, I found him sitting quietly in a chair watching TV with others before the group therapy. Upon questioning, client was happy and answered all my questions. During the interview, the client-maintained eye contact, followed instructions appropriately displayed no abnormal movements nor 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.

-The client was cooperative and followed commands correctly.

-Reliably reported information and remembered clearly the events preceding his admission to the hospital.

The client cooperated and followed commands given correctly. client communicated openly about his life and shared how he has been depressed of late and felt nothing was working in his favor. He felt anxious about his future which according to him felt more dim. He felt happy that the hospital was a safe and secure place for him.

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 had no auditory or hallucinations.

-The client spoke clearly and with a medium volume.

– client spoke with an even tone and rhythm and communicated information coherently

During my conversation with the client, the client informed me he previously had intentions of hurting himself but at the time he was feeling happy and had no such thoughts. He reported that the hospital was a good place for him, and he felt comfortable. His speech content had no evidence of auditory hallucinations. He spoke with a medium voice.

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

AFFECT:

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

MOOD:

-I observed the patient was in positive mood as evidenced by patient displaying willingness to talk.

-During conversation, he was accommodative and actively participated.

He had a pleasant mood but became anxious when he discussed the future and fears associated with the unknown.

During my interaction with the client, I observed that he was in a positive mood and was pleasant during the entire period. He only appeared sad when he made mention of not working due to his health condition.

Also, I noted that his mood and affect had changed as compared to that on admission which on his chart had been indicated to be irritable.

He was a bit anxious and clearly expressed his fears about the future. His affect was congruent with mood. The client stated that he feels sad about not working due to his health condition.

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 linear thoughts which were purposeful

The client provided direct and appropriate answers to questions and conversation.

-Patient experiences were realistic –patient had some small memory lapses especially on things that happened 2 to 3 years ago.

Chart stated patient has difficultly concentration due to flight of ideas.

-The client’s conversation was goal directed. He provided clear answers to questions asked. The patient had no delusion or auditory hallucinations.

7. Perceptual disturbances

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

· Illusions

The client denied experiencing auditory hallucination during the interview.

Patient stated, he sometimes hears voices telling him to harm himself.

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 was alert and oriented x 4

-The client looked relaxed during first contact

-The client had no trouble remembering things that happened several years ago

-The clients have good judgement fair insight throughout the interview, e.g. I asked him if it was fair for the doctor to admit him in the hospital and he said yes he caused it if he had taken his medication he would not be depressed ,therefore he caused it,

-The client coping mechanism is suppression because he feels depressed for not being able to work due to his medical condition.

The client also said he sometimes talk to friends and family to relieve him of his depression.

The patient was able to state why he was at the hospital, what led him to come there and how he felt at this time. His chart supported that he has A/OX4.

I was able to assess his short- and long-term memory based the answers he gave me during questioning. He also appears to have good judgement and has fair insight. He reports that he avoids thinking about bad things as his life is full of those. However, this time things got really had that why he was contemplating to commit suicide prior to admission.

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 patient has not displayed any self-harm behaviors or threats to any other person

The client stated that he occasionally has thought of harming himself whenever he gets depressed.

The client said he had a history of property destruction when he was a toddler, he uses to throw their TV remote away and break it.

The client admitted having suicide by trying to harm himself with any sharp he get hold of.

The client currently has no thought of harming himself or anyone.

The client use to throw way their TV remotes and destroy them

.

According to his chart, he was admitted with complaints of depression with suicidal ideations to hang himself.

The client denial thought of harming himself and others at the hospital.

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. 

Section has no more than one error in any of the following areas:  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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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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