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Module 5 Mse

Ms. P is a 21-year-old single woman who is adequately dressed and groomed but reports feeling sleepy, fatigued, and experiencing body pain due to examination stress. She maintains eye contact, denies suicidal ideation, and demonstrates fair insight and intact judgment, although her attention span is low, possibly related to stress. Overall, she shows signs of anxiety and difficulty in memorization but has average intelligence and coherent thought processes.

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3 views3 pages

Module 5 Mse

Ms. P is a 21-year-old single woman who is adequately dressed and groomed but reports feeling sleepy, fatigued, and experiencing body pain due to examination stress. She maintains eye contact, denies suicidal ideation, and demonstrates fair insight and intact judgment, although her attention span is low, possibly related to stress. Overall, she shows signs of anxiety and difficulty in memorization but has average intelligence and coherent thought processes.

Uploaded by

bhavaniraj2003
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

MODULE 5

MENTAL STATUS EXAMINATION

I. Appearance :
The client was adequately dressed and groomed, ambulant, maintained a relaxed
posture, on par with the environment.
II. Behaviour :
The client was initially tense and soon became relaxed, eye contact was
maintained, psychomotor activity was normal.
III. Attitude :
She was cooperative towards the counsellor.
IV. Level of consciousness :
Normal.
V. Orientation :
Oriented to time, place and person.
VI. Speech and Language :
The client responded to the questions. Her reaction time was normal. Her tone of
voice was soft with normal rate. Her speech was relevant and coherent.
VII. Mood :
Subjectively, the client reported that she was anxious lately. Objectively, she
seemed anxious.
VIII. Affect :
Consistent with the mood, with normal intensity.
IX. Thought Process / Form :
There was no flight of ideas and thought blocking. No formal thought disorder
was noticed.
X. Thought Content :
There was no presence of hallucinations and delusions. No presence of
obsessions and compulsions.
XI. Suicidality and Homicidality :
No suicidal and homicidal ideas was noticed.
XII. Insight and Judgement :
The client knows that she has problem and needs guidance. Her personal,
social and test judgement was found to be adequate.
Personal Judgement: She wants to complete her master’s successfully.
Social Judgement : She is friendly with everyone and doesn’t have any problem in
socializing.
Test Judgement: When the client was asked the question of what would she do when
if the place in which she was catches fires, what is the first thing she would do ? she
said that she will try to put it off with water.
XIII. Attention Span :
Serial subtraction : Her level of attention was low. She had difficulty in
subtracting 100 by 7s.
XIV. Memory :
Immediate memory : she could recall the digits forward and backward
Recent memory : she could remember what she had for breakfast and dinner
previous night
Remote memory : she could recall when she went to vacation with her
family
XV. Intellectual Functioning :
Based on her education, she is found to have an average intelligence. In abstract
thinking, she could tell the difference between strawberries and onions. She was able
to tell the meaning of the proverb “Health is Wealth ”. She could tell the name of the
Prime minister of India and name of any five countries.

SUMMARY :

Ms. P is a 21 year old single woman. She dressed and groomed adequately She reported
of feeling sleepy, fatigue and experiencing body pain lately due to examination stress.
Recently, the client experienced difficulty in memorizing. She was on par with environment
and eye contact was maintained. She denies any suicidal ideation and demonstrates fair
insight and intact judgement. Her level of attention was low, it might be stress related.

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