Patient Name: Lovings Asheley Ann

Admission Date: 3/04/21

Patient Age and Unit Admitted to: 32 year old

Patient’s Reason for Admission/ Chief Complaint: A patient who has a depressive disorder. The patient describes symptoms including low mood, tearfulness, reduced energy, reduced motivation, early morning wakening, loss of appetite, poor concentration, reduced enjoyment and reduced interest in selfcare.

Co-morbid Conditions: Obsessive compulsive disorder

Mental Status Examination

What You See (list)

Descriptive example (narrative)

1. Appearance (observed)

· Grooming/Clothing

· Hygiene

· Posture

· Gait

· Obese/average or normal/ underweight

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

-Patient appeared clean

-Patient wearing a black pants and a yellow top.

-Steady and smooth gait, patient posture was erect in the chair

-Normal weight

– Patient skin looks clean and calm, no scars/ abrasion or bruises, no tattoos and her was uncombed

The patient was a 32-year-old Africa American, with thick hair that looks a bit uncombed. She was wearing a black pants and yellow top. There was no evidence of scars, bruises, tattoos or any other marks on the skin that was visible.

-Patient was sitting in a chair without any assistance. She appeared to be a little bit relaxed, not too calm and she participated in the conversation.

2. Behavior (observed)

· Mannerisms

· Gestures

· Eye contact

· Psychomotor activity (ex. retardation or agitation)

· Movements: tremor/ tics/ abnormal movements

· Possible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia

-Patient was cooperative when interviewed.

-No evidence of tremors,

-Patient maintained good eye contact with everyone, but sometime bow her head.

There was no psychomotor retardation observed.

Patient answer all questions clearly.

Patient have a good memory, she was able to remember some certain things in her past, for example her coping skills. Information provided during her admission. She also talked about where she use to work.

She’s able to verbalize needs.

Patient was goal direct directed in her communication. This is because even though I did not her come up with any specific coping skills, patient stated that the coping mechanism she uses to calm down is reading a book which eventually puts her to sleep.

– Patient maintained eye contact.

– At this stage patient talking was not much appropriate, she was talking too much.

– Patient was hyperactive.

up3. 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

-She was able to follow commands.

-Reliable reporter, patient came to the hospital alone.

-Able to verbalize needs

-She is co-operative and willing to accept treatment.

She was able to verbalize how she copes with stressors.

which was reading a book which made her fall asleep. She

stated how her sisters have helped by being self-sufficient.

which has helped reduce the burden. She feels she is a useless sister that can’t be there for her sisters.

4. Cognition (observed/inquired)

· Level of Consciousness

· Orientation

· Attention

· Concentration

· Memory (immediate, recent, remote)

· Abstract vs. concrete cognition

-Patient was alert and oriented x 4.

-Patient attention was focused during the interview.

-she was able to assess memory and abstract vs concrete cognition.

-She was aware of her surroundings and participated in the interview.

-She was attentive as she was able to answer every question being asked.

-She had a good memory as she was able to remember things that happened years ago. Example she talked about her former place of work

-She was complaint with participation within the group and provided goal- oriented communication. Patient chart supports the A/Ox4, specifically when assessment was noted upon admission.

5. Speech and Language (observed)

· Content of speech

· Rate

· Volume

· Tone and Rhythm

-Clear and soft speech.

-Patient content of speech was free from hallucinations, suicidal ideations, and delusions.

-Patient spoke with even tone and rhythm.

-Patient was interactive as she answered and participated in the interview at an even rate.

-Patient was audible.

-During our conversation, I did not observe any content of hallucinations, suicidal or homicidal ideations and delusions.

-The patient was on task and on subject with what we were asking.

-The patient was cooperative in the interview as she stated that she copes with the situation by reading a book.

-She spoke evenly in tone and rhythm.

6. Mood and Affect (inquired/observed)

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

· 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:

-Observed patient in a depressive mood, she was compliant in participation and since she was in a depressive mood her demeanor tallied her mood

AFFECT:

-Patient affect was appropriate to the situation and her thoughts and affect was consistent and congruent with her mood and affect.

-She displayed a normal intensity within his communication and had appropriate affect.

-The patient’s demeanor was just appropriate for the situation she is.

-Patient was able to verbalize feelings and needs.

-I observe during the interview the patient stated she was in a depressed mood, even though she was polite as much as she could but she was sad and had to wipe some tears.

7. Thought Disturbance (inquired/observed)

Process

· Describes the rate of thoughts, how they flow and are connected

· Possible descriptors: Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing, blocking, perseveration, neologisms.

Content and/or perceptual disturbances:

· Refers to the themes that occupy the patient’s thoughts and perceptual disturbances

· Possible descriptors: preoccupations, illusions, ideas of reference, hallucinations, derealization, depersonalization, delusions, obsessions, suicidal/homicidal ideation, rumination

-Patient did not voice suicidal ideations and thought disturbances. She also did not present any form of delusions and command auditory hallucinations.

-Patient did not exhibit thought blocking and provided direct and appropriate answers to questions and conversation.

-Patient thought were goal oriented and linear and there was no presence of neologisms or loose associations.

-No suicide attempt.

While watching the patient, I realized the conversations were

goal directed. She directly answered questions that were

asked such as “What do you do to cope with

your inability to go to bed” and the patient answered that he

“I read a book and i fall asleep in the process”. I did not

observe the patient use any neologisms or loose associations.

The patient was free of delusion and preoccupations. Throughout her conversations.

8. Judgment and Insight (Inquired/Observed):

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 made use of reading a book to overcome her inability to sleep.

-•The patients’ insights were clear and fair. Every statement she made was understandable and corresponded to her situation.

In the interview she made mention of how if she was going through any depressive moment in her life she would come see the general practitioner which displays the insight to her situation.

9. 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

•From the interview the patient did not make mention of any suicidal ideations and the patient was calm but sad.

No suicidal plan

-No suicide attempt.

-No violence risks

-No history of violence towards others.