Patient Name:

B.K

Admission Date:

02/26/2021

Patient Age and Unit Admitted to:

21 years old / 15th Floor

Patient’s Reason for Admission/ Chief Complaint:

Patient was brought to the emergency department via EMS for paranoid behavior. Patient was at hotel yelling racial slurs at other people. Upon police arrival, patient seemed very paranoid was complaining that people were following her because she is “Facebook Famous”.

Co-morbid Conditions:

Bipolar disorder, Psychosis

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 wearing jeans, black shirt.

Patient’s skin appeared clean, and hair was combed.

Patient had no foul odor present.

Patient’s posture was erect in the chair.

Patient appeared to have a normal gait and does not look overweight for his age

No Scars/abrasions /bruises/tattoos

The patient was a 21-year-old female that was wearing a blue jeans and black shirt. Her hygiene appeared good, and her hair was well combed. She was A/O x 4 with normal strength and tone. She appeared not to be in distress, and she had no foul odors and her skin appeared to be clean with no rashes or lesions. Patient looked her age and there was no evidence of tattoos, scars, bruises, or any other marks on the skin that was visible.

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 while talking to the writer.

There was no evidence of tremors/tics/abnormal movements.

Patient demonstrates good eye contact with everyone.

There was no psychomotor retardation observed.

Patient responded to question adequately.

Patient smile, tone and steady eye contact shows flexibility and approachability

The writer had a good interaction with the patient while in the day room for some minutes before the patient went back to her room. Patient talked about her present situation and future goals after discharged. Patient demonstrates good eye contact with everyone while talking. Patient was cooperative and answered question appropriately. Patient appeared happy and well behaved without any visual sign of agitation throughout the meeting.

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

Patient was cooperative.

Patient was willing to talk with no sign of hostile behavior.

Patient sat quietly in the day room while waiting for others for the group meeting. She was able to obey all commands of therapist when she asked to pick her favorite song. Patient danced to the song and was very happy. She also verbalizes how she likes warm weather rather than cold weather.

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 listened good in break room and during the group meeting.

Patient stated the name of the president, where he came from, and the day he was admitted.

Able to access memory and abstract vs concrete cognition.

Patient was alert and oriented x4. Patient was aware of surroundings, she remembers the date that she was admitted, where she came from and very cooperative with the group meeting activities.

5. Speech and Language (observed)

· Content of speech

· Rate

· Volume

· Tone and Rhythm

Patient’s content of speech was positive regarding his future and free from suicidal ideations, homicidal ideations, hallucinations, and delusions.

Patient had normal rate of speech, rhythm, volume, and tone.

The writer observed that patient was free from hallucinations, suicidal or homicidal ideation, and delusions based on our conversation. The patient was very patience with the writer during interaction, patient did not interrupt question at any time before answering. Patient was concise and cooperative as evidence by answering question appropriately. She was speaking at the medium tone, and not yelling on the writer and at the group meeting.

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

Patient mood was appropriate and related.

Patient stated, “I am happy because the therapist played my favorite song”. The writer observed she was not in distress, and she was friendly at the time of interactions.

Patient affect was normal intensity, stable, and congruent with his mood.

Patient thought was organized at the time of interaction.

Patient looks peaceful with herself and others, she patiently waits for others to come in at the music therapy meeting, and she performed actively when the activities started. Patient smiles while interacting and she did not present any angry, hostile behavior with anyone.

Patient records at the time of admission, described patient’s mood and effect as irritable at times, decreased range in effect, but my observation during my interaction at the day room and watching her at the group meeting was that she has a pleasant mood and effect. Patient stated, “I am happy because the music therapy played my favorite song”. I observed patient to be calm and happy.

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 thought process was positive and goal oriented.

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

Patient thought content upon admission was that she denied SI/HI or ARH. Patient also denies any thought of SI/HI for now.

Patient focused more on her future ambition of becoming a better person. When asked if she has a boyfriend she replied maybe in future with a smile. she was goal focused with her communication. The writer observed patient is free of delusion, hallucination, or any suicidal ideation at the time of group meeting.

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 judgement and insight at the time of admission recorded capable of reality-based thinking but the writer observed good insight from patient based on our conversation.

Patient likes listening to music, reading, dancing, and talking as coping strategies.

Based on the interaction with patient, the writer observed she has a good insight of where she came from, her environment, and her future. She likes to share ideas with anyone that is willing to talk to her, very open and welcoming. The writer did not observe any defense mechanisms from the patient.

Patient judgement and insight at the time of admission recorded capable of reality-based thinking but the writer observed good insight from patient based on our conversation and she wished to see her family soon.

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

Patient was not on a risk precaution for now.

Patient was calm and did not displayed any aggressive behavior towards staff or peers for now.

Patient was not involved in harming others or herself for now.

According to patient’s chart, patient has a past medical history of bipolar disorder, present to the emergency department via EMS for paranoid behavior. Patient was at hotel yelling racial slurs at the other people. Upon police arrival, patient seemed very paranoid was complaining that people were following her because she is “Facebook famous”. Patient denies drug use. Patient was calm did not displayed any aggressive behavior towards the writer or staff for now.