Mental Status Exam Report Outline

Rahman Akinlusi Behavioral Science

Patient Medical Record Number Date of Record: October 10, 2018

Identifying Information: Dottie Wright

Source and Reliability/Cooperation/Attitude: Patient was cooperative

Source of Referral: None

Chief Complaint: Patient came in for concerns about her diabetes

Mental Status Exam Appearance and Behavior Level of Consciousness:

Patient is very conscious in terms of responding to questions asked, but it’s doubtful that she’s fully aware or conscious of the full breath of the questions asked

Orientation:

Patient seems slightly disoriented as she can’t remember the day, but has to reference the date of her granddaughter’s birth to orient herself around what day it is. She’s also somewhat unaware of her location as she gives answers that shows she’s not exactly sure where she is.

Motor Behavior:

Her motor skills might be partially impaired as she’s unable to properly replicate the double pentagon design. We don’t get to see her walking in the video, but from her hand gestures, or lack thereof (because she always kept her arms folded) she could be trying to hide tremors.

Speech Characteristics

Her speech seems unaffected as she doesn’t seem to slur her words nor does she have any problems phonetically or vocally expressing herself. She is able to list why is here, and is able to respond to the

Rahman Akinlusi Behavioral Science

questions being asked of her properly. The question is whether she fully comprehends what’s being asked.

Mood and Affect Mood:

She seemed to have a somewhat depressed mood, as her tone of voice was somewhat somber, and she rarely raised her tone. She sounded somewhat monotone as well. She rarely elevated nor depressed her voice

Affect:

She had a somewhat constricted affect, as there was some but not a lot of emotional undertones to her speech.

Thought Content and Mental Process Disorders in Form of Thought: She does not seem to show any disorders in form of thought

Thought Content:

She shows normal thought content, but used her granddaughter’s birthdate to orient herself around what the date was

Perception

Her perception of date and location is a little off. The double design drawing test also shows that she may have some problems in perceiving what’s being asked of her. She also failed to fold the paper when she was asked to, so there might be some gaps in her perception of what’s going on

Judgment and Insight Judgment:

Her judgement is a little off as she had trouble recognizing and drawing the two pentagons in the challenge

Levels of Insight:

Insight was absent

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Attention

She seemed attentive, but the extent to which was unclear as she could not remember the sequence of “Apple, Table, Penny” no matter how many times the examiner reiterated herself

Memory

The patient has very apparent memory deficits as she’s unable to recall the sequence of words or each of the words in “Apple Table Penny.”

Intellectual Functioning

There’s also a slight impairment when she’s asked to spell WORLD. She spells it correctly the first time, but does so incorrectly when she’s asked to spell it backwards. She is able, however to recognize common items like the pen. However, she’s still has very apparent memory deficits even though she’s able to read somewhat well. She’s able to read and write

End Statement of Impression Ms. Wright has very apparent memory deficits and she may also have some issues with spatial memory or cognition. Her language facilities seem normal as it is not difficult to understand the things that she says. However, the problem arises when it becomes apparent that she’s only able to answer fragments of questions being asked of her or follow instructions halfway through. She may be showing signs of Alzheimer’s or some other form of dementia, as she has severe short-term memory impairments