Mental status examination is a structured evaluation of the patient’s behavioral and cognitive functioning. It describes the appearance and the overall behavior of the patient, level of awareness and attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight, the reaction evoked in the examiner, and finally, higher cognitive abilities.
Mental Status Examination Report
Sharon, a twenties Asian Girl who stands around 6’ tall, weight fairly average based on her appearance. Regarding the dress, she is well-groomed who wore casual clothing of black T-shirt and black running shorts, has an earring on her right side and with straight dark brown waist-length hair. From her physical perspective, she did not show any self-harm on the body and self-neglect to her hygiene.
During the interview session, she shows normal posture and mannerisms who sitting on knees in front of the examiner. The way she behaviors is always mannerisms, such as interlocked her fingers, looked on the right-hand side, less eye contact with examiner and sometimes wry smile throughout the interview sessions.
She is forthright, cooperative, and friendly to tell her family background. However, from her gesture, it shows insecurity when she told her stories of past events, especially when she starts told about her elder brother, she shows finger interlock. The interlaced fingers are a sign of frustration, self-restrained, and other negative thought, while it offers security and comfort by locking the finger together (Chris, 2014). Regardless her elder brother, Sharon said she did not contact with her elder brother since he brother get marries with the a girl who has 2 children from different father, in addition, Sharon’s mother also did not like that girl and break the mother-and-son relationship.
Sharon explains that her emotion change when her parents are arguing wants to divorce during her primary six. During that time period, she still hopes her parents can going back together, but they were divorced when she was form 6. After she grew up, she stated that “if things are may to be, there will to be that, like someone are may to be together, then they will be together, forcing does give happiness.” It is good for her parents to divorce because they can find their own happiness. She stays with her mother, but the relationship with father is still in contact (close).
On the other hand, she reported that the feelings in past few days and last week as “annoyed”, “frustrated”, and “sad.” When she answers, she showed hesitant, bend over, frown, and a wry smile, then she started explaining her assignment stuff and blaming her group members. Sharon mentioned that her group members always spamming some source but did not do any things, while she tries to act her group members’ behavior to the examiner “Have you guys see the things that I send in group?” For her, that kind of behaviors are annoying. From the observation, she constricted to express her emotion, while using a smile to withdrawal her emotion. She also reported the way she relieved stress is normally sleeping, have some dessert, and go shopping.
Sharon has acknowledged her suicidal ideations in the past, when she broke the relationship with her boyfriend, it was three years ago. She declared that she had thought about cutting her hand by using the knife, but she did not do that because she not dare to do that. She felt frustrated at that time. She admitted that she is lack of love since she came from a broken family. From that situation, she actually conscious and understand her own behavior and the consequence if she decides to do that. Therefore, she did not take those actions in the end. In sum, she acknowledge the suicidal ideation and insight was present.
Memory comprises the ability to learn new materials, retain, and store the information. Sharon agreed to participate in memory-related portions of the examination. During the interview, there some questions were asked to test whether there have problems occur on Sharon’ s memory. Firstly, a series of numbers has given as verbally (such as 7, 9, 1, 6, 8, 3) to Sharon, then ask her to repeat them. The aims is to test immediate recall, while she did not show any problem in immediate recall. She repeated it 3 times correctly.
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