STUDENT/COURSE: _N_ U_ _R_ _2_ 5_ 3_ _- 1__2_D_0_1_________________________________________________________________________________________
3 3 M a le
DEMOGRAPHICS: Patient’s Age: _ _ _____________________ Patient’s Gender: _ __ _ ______________
Date of this Admission: _4_/_2_8_/_2_6____________________ HT: _1_._7_5_m_______ in. WT_3_0__6_lb_s_/_1_3_9_k__lb. / kg
Allergies: ✔ NKDA Other _______________________________________________________________________________________
Psychosocial and Environmental Problems:
✔ Primary support group: Strained relationships ✔ Social environment: Difficulty interacting with others
Educational: ✔ Occupational: Unable to maintain employment due
Housing: Economic:
✔ Access to health care services: History of non-compl Interaction with the legal system/crime
Mental Health Diagnosis:
PPhx SCAD, bipolar type and a PMHx of T2DM (poorly controlled), HTN, and OSA (CPAP non-compliant)
Brief Admission History (What led to your patient needing psychiatric hospitalization?):
Patient is a 33 year old with a history of schizoaffective disorder presenting to the ED for acute psychosis. Reports feeling stressed and
wanting a place to calm his mind. Patient states he stopped taking his meds four or five days ago and feeling better off medication.
Patient's mother contacted and reports patient has been acting not himself lately, has not been taking medications for schizoaffective
disorder, and has been threatening to break the window in her car.
Describe any Family History of Psychiatric Issues if available:
Denies
Describe any Substance History if available:
Denies
Describe any Trauma History if available: (Domestic Violence, sexual or physical abuse, etc.)
Denies
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, STUDENT/COURSE: _N_U
__R_-_2_5_3__-1_2__D_0_1______________________________________________________________________________________
MENTAL STATUS EXAMINATION (MSE)
ASSESSMENT OF CLIENT MENTAL STATUS: OBJECTIVE AND SUBJECTIVE DATA
YOUR ASSESSMENT AFTER INTERACTING WITH THE CLIENT
Describe General Appearance: (select all that apply)
Eye Contact: Dress: Build:
Absent Conservative Thin
Avoided Non-conservative Medium
Intermittent Appropriate Heavy
Direct Inappropriate Very Obese
Physical Handicaps Other: Other:
Posture: Gait: Hygiene: Facial Expression:
✔
Appropriate ✔ Steady ✔ Clean Calm ✔
Happy
Slumped Ataxic Unkempt Vacant Hostile
Rigid Slow Neat Mask-like Sad
Other: Rapid Unshaven Worried
Odorous Other:
Activity: Response to examiner:
Hyperactive Defensive
Hypoactive Trusting
Restless Cooperative
Normal Indifferent
Other: Other:
Notes Regarding General Appearance:
Patient appears appropriately dressed with clean hygiene. Posture is upright and gait is steady. Facial expression is pleasant with
appropriate affect. Patient maintained a cooperative attitude during the assessment and interacted with the nurse.
Describe Behavior, Mood and Affect:
BEHAVIOR: (select all that apply)
Cooperative Uncooperative Non-adherent Compulsions Posturing
Restless Agitated Relaxed Tearful Manipulative
Withdrawn Catatonic Seductive Lethargic
Other:
MOOD: (select all that apply)
Dysthymic Happy Elated Angry Calm Suspicious Anxious
Ashamed Frightened Consistent with thoughts Inconsistent with thoughts
Other:
AFFECT: (select all that apply)
Flat Blunted Labile Bright Fearful Euphoric Congruent Limited Range Full Range
Intense
Other:
Notes Regarding Behavior, Mood and Affect:
Patient cooperative during the assessment and engaged appropriately with the interviewed. Behavior notable for compulsive tendencies.
Patient appeared anxious and intermittently elated throughout the interaction. Mood was consistent with expressed thoughts. Affect
observed to be intense. Patient was observed responding to internal stimuli, evidenced by intermittently talking aloud and appearing to
engage in conversation without external prompts. Patient maintained perticipation in the assessment but demonstrated periods of distraction
consistent with internal preoccupation.
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3 3 M a le
DEMOGRAPHICS: Patient’s Age: _ _ _____________________ Patient’s Gender: _ __ _ ______________
Date of this Admission: _4_/_2_8_/_2_6____________________ HT: _1_._7_5_m_______ in. WT_3_0__6_lb_s_/_1_3_9_k__lb. / kg
Allergies: ✔ NKDA Other _______________________________________________________________________________________
Psychosocial and Environmental Problems:
✔ Primary support group: Strained relationships ✔ Social environment: Difficulty interacting with others
Educational: ✔ Occupational: Unable to maintain employment due
Housing: Economic:
✔ Access to health care services: History of non-compl Interaction with the legal system/crime
Mental Health Diagnosis:
PPhx SCAD, bipolar type and a PMHx of T2DM (poorly controlled), HTN, and OSA (CPAP non-compliant)
Brief Admission History (What led to your patient needing psychiatric hospitalization?):
Patient is a 33 year old with a history of schizoaffective disorder presenting to the ED for acute psychosis. Reports feeling stressed and
wanting a place to calm his mind. Patient states he stopped taking his meds four or five days ago and feeling better off medication.
Patient's mother contacted and reports patient has been acting not himself lately, has not been taking medications for schizoaffective
disorder, and has been threatening to break the window in her car.
Describe any Family History of Psychiatric Issues if available:
Denies
Describe any Substance History if available:
Denies
Describe any Trauma History if available: (Domestic Violence, sexual or physical abuse, etc.)
Denies
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, STUDENT/COURSE: _N_U
__R_-_2_5_3__-1_2__D_0_1______________________________________________________________________________________
MENTAL STATUS EXAMINATION (MSE)
ASSESSMENT OF CLIENT MENTAL STATUS: OBJECTIVE AND SUBJECTIVE DATA
YOUR ASSESSMENT AFTER INTERACTING WITH THE CLIENT
Describe General Appearance: (select all that apply)
Eye Contact: Dress: Build:
Absent Conservative Thin
Avoided Non-conservative Medium
Intermittent Appropriate Heavy
Direct Inappropriate Very Obese
Physical Handicaps Other: Other:
Posture: Gait: Hygiene: Facial Expression:
✔
Appropriate ✔ Steady ✔ Clean Calm ✔
Happy
Slumped Ataxic Unkempt Vacant Hostile
Rigid Slow Neat Mask-like Sad
Other: Rapid Unshaven Worried
Odorous Other:
Activity: Response to examiner:
Hyperactive Defensive
Hypoactive Trusting
Restless Cooperative
Normal Indifferent
Other: Other:
Notes Regarding General Appearance:
Patient appears appropriately dressed with clean hygiene. Posture is upright and gait is steady. Facial expression is pleasant with
appropriate affect. Patient maintained a cooperative attitude during the assessment and interacted with the nurse.
Describe Behavior, Mood and Affect:
BEHAVIOR: (select all that apply)
Cooperative Uncooperative Non-adherent Compulsions Posturing
Restless Agitated Relaxed Tearful Manipulative
Withdrawn Catatonic Seductive Lethargic
Other:
MOOD: (select all that apply)
Dysthymic Happy Elated Angry Calm Suspicious Anxious
Ashamed Frightened Consistent with thoughts Inconsistent with thoughts
Other:
AFFECT: (select all that apply)
Flat Blunted Labile Bright Fearful Euphoric Congruent Limited Range Full Range
Intense
Other:
Notes Regarding Behavior, Mood and Affect:
Patient cooperative during the assessment and engaged appropriately with the interviewed. Behavior notable for compulsive tendencies.
Patient appeared anxious and intermittently elated throughout the interaction. Mood was consistent with expressed thoughts. Affect
observed to be intense. Patient was observed responding to internal stimuli, evidenced by intermittently talking aloud and appearing to
engage in conversation without external prompts. Patient maintained perticipation in the assessment but demonstrated periods of distraction
consistent with internal preoccupation.
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