Mental Status Interview Essay

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

Visual fields full to confrontation. Extraocular muscles intact. Pupils are slightly enlarged on the left compared to the right, which she states is old since her eye injury. They do respond directly and consensually. Normal facial symmetry, sensation, and movement. Tongue and uvula are midline. Normal shoulder shrug. Normal auditory acuity.

BEHAVIORAL OBSERVATIONS: Ms. Copeland was alert and co-operative during the interview. During testing she appeared to motivated to perform optimally on all tasks. Her frustration tolerance was moderate. She seemed somewhat sullen, incurred during the initial portions of the testing but became more relaxed with the examiner as testing proceeded.

not associated with the disorder. These characteristics were met by the client who is as follows: 1.

She has been making progress in integrating multiple thoughts, feelings, ideas, and experiences. Overall, her tolerance of holding ambiguity and ambivalence

Desires to be perfect and is quite self-critical Worries more; may have low self-confidence Tends to complain; has strong emotional reactions

| * Likes to be praised * Plays along with everyone of all ages * Very calm, not too demanding * Very chatty during meal times * Gets very upset and moody when very tired while being out of house * Can be very shy or embarrassed when asked to show and tell in front of group of family or friends/teachers * No more tantrums

Example: She says wap instead of lap. She likes to listen to stories and responds with “what’s that?” and “Why”. She uses syntax. She understands the meaning of most words. Example: Her mother said “do you love mommy” and Haper replied “yes” the mother asked “how much” and Harper replied “sixty dollars”.

She rarely or hardly starts disputes with other children, throws temper tantrums, or seeks revenge when feeling picked on. She also performed within the normal range in the Impulsive-Hyperactive subscale. She rarely or hardly calls out unexpectedly, interrupts, or finds it hard to play quietly. She scored within the normal to borderline range in the Antisocial Conduct subscale. She rarely or hardly ever steals, acts dangerously before considering consequences, or destroys the possessions of

stage where she is able to do logical thinking, recognise the conversation of mass, numbers

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

As can be seen from the account of the stages of cognitive and psychosexual development, the child observed the regular pattern of development in all areas. Her physical traits are completely normal so it seems that she is a well-developing, healthy child. From what she was saying and doing during the time I observed her, it might be concluded that she is even intellectually gifted. For instance, she was able to conduct a full conversation with her mother which is unusual for a child of that age.

Can understand the names of various parts of the body. Will pint or scream to get something. Understands many words and instructions. Points to named people or toys. Will chatter away to self when playing.

She can recognize and write all of her letters, knows how to spell her first and last name, can recognize and write simple words such as “mom” and “dad”, can recognize numbers up through ten and can count up to about thirty.

My client is a 25-year-old South Asian woman. She appears thin with long black hair and brown eyes. She is wearing dark pants, a long sleeved blue shirt with a multicoloured scarf. Her clothing is neat and appropriate to her environment. She is wearing makeup, appears clean and is well put together. The client answers direct questions but does not provide a lot of information. Patient is willing to provide more information when asked directly or prompted by the writer. The client’s rate of speech was slow at first but as the interview continued, became a normal rate. Her speech was clear; however spoke in a soft volume with a monotone voice. Her rhythm was smooth and her speech was not pressured. The client’s