ADMSEP Mental Status Examination Practice Module

ADMSEP Mental Status Examination Practice Module

Mental Status Examination Writing Exercise 1- Patient 1

GABA:  The patient is a young adult white female named Abigael. She is a 28-year-old long-term patient who is back at the clinic for a check-up following a medication dose modification. The patient appears well-groomed and is appropriately dressed for the occasion/ weather. She has long blonde hair and was attired in a dark hoodie with pink lipstick. She was well-composed during the interview without interruption of eye contact. No tics, tremors, or involuntary movements were noted, and facial expressions were appropriate to the conversation. The gait could not be assessed during this examination.

Mood: Patient reports that she is “okay, doing well” and “things are really going a lot better.” She also describes feeling “better

Affect: The effect is even and friendly. The patient exhibits normal intensity during the interview. The full range of affect is appropriate to the situation. Labile is absent, and she is euthymic. Mood swings and emotional instability are not noted.

Speech: The patient speaks clearly and articulates well. Her speech is of a normal rate, volume, and rhythm. Abnormalities are not noted in tone or fluency. Overall, her speech is coherent and easily understood.

Thought Process: A logical and organized thought process is present. Responses were appropriately focused, with a clear and goal-directed flow. She showed no evidence of disorganization or confusion.

Thought Content: The patient denies any SI or HI. Hallucinations and delusions were not tested for, and none were appreciated. The patient is optimistic regarding the future and shows no evidence of a disordered thought form.

Insight: The patient has full insight into her illness and the possibility of side effects from medications. She demonstrates a mature level of understanding of her condition and looks toward the future in an optimistic light.

Judgment: The patient demonstrates excellent judgment in that her decisions thus far seem appropriate and well-considered. There is no reason to question her judgment when making good decisions.

Cognition: Memory intact, oriented to person, place, time, and situation. She seemed alert with no evident difficulty concentrating. No formal assessment of cognitive function was performed; however, her recall of former thoughts and beliefs is appropriate and consistent.

Mental Status Examination Writing Exercise 2- Patient 2

GABA: The patient is a 56-year-old white female, Mercedes Manisch. She dresses rather unconventionally for the weather, sporting a red cap, bright red lips, a white crop top, gold rings, and a gold watch. She looks pleasant, appears to have a lot of energy, and is also very polite. She responds to questions appropriately, and her eye contact is perfect. The common signs that would include tics and tremors are not evident, nor does her gait become apparent as she is recorded in the video.

Mood: Patient reports feeling “great, great, and great, great.” This suggests a very elevated emotional state in a much-alive-and-energetic sense.

Affect: Full, non-labile affect- the patient is described as energetic, highly active, and euphoric. Her emotional state is overtly elevated and exuberant.

Speech: Pressured and spontaneous; the rate and rhythm are increased. The tone is excitable, with speech that is mildly pressured but fluid and rapid in volume and rhythm.

Thought Process: The patient has a detailed thought process, and her responses reveal rapid, sometimes flighty ideas. However, she is redirectable to the topic at hand.

Thought Content: SI, HI, hallucinations, and delusions were not discussed during the interview. These were not specifically reviewed.

Insight: The patient showed limited insight; she is somewhat aware of the side effects of medication but has low levels of understanding in general about her condition

Judgment: The patient has poor judgment, as evidenced by excessive spending on numerous rings, cessation of her medication without physician involvement, and unwisely selecting inappropriate clothes for winter weather conditions. Additionally, she also showed poor sleeping habits induced by online shopping as a sign of not making good decisions.

Cognition: The patient is alert and oriented to person, place, time, and situation. She has a history of previous thoughts and beliefs without apparent difficulty with concentration. A formal cognitive examination was not performed, and she otherwise appears generally cognitively intact.

Reference

ADMSEP – e-Resources Repository. (n.d.). https://www.admsep.org/eresourcesrepository.php?c=mse&&v=y 

ADMSEP Mental Status Examination Practice Module

CLICK HERE TO ORDER A PLAGIARISM-FREE PAPER