Question

I am working in a homework for my nursing class

Topic: Mental Health

history:

physical Assessment:

normal finding:

abnormal finding:

related laboratory finding:

Answer 1

Ans) The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes the mental state and behaviors of the person being seen. It includes both objective observations of the clinician and subjective descriptions given by the patient.

- The Mental Status Examination
• Level of Consciousness
• Appearance and General Behavior
• Speech and Motor Activity
• Affect and Mood
• Thought and Perception
• Attitude and Insight
• Examiner's Reaction to the Patient
• Structured Examination of Cognitive Abilities.

General Observations

- Appearance
• Hygiene: clean, body odor, shaven, grooming
• Dress: clean, dirty, neat, ragged, climate appropriate — anything unusual?
• Jewelry: rings, earrings — anything unusual?
• Makeup: lipstick, nail polish, eye makeup — anything unusual?
• Other: prominent scars, tattoos
- Speech
• General: accent, clarity, stuttering, lisp
• Rate: fast (push of speech) or slow
• Latency (pauses between questions and answers): increased or decreased
• Volume: whispered, soft, normal, loud
Intonations: decreased (monotone), normal
- Behavior
General: increased activity (restlessness, agitation), decreased activity
Eye Contact: decreased, normal, excessive, intrusive

Mannerisms, stereotypies, posturing

- Cooperativeness
Cooperative, friendly, reluctant, hostile
- Thinking
• Thought Processes
Tight, logical, goal directed, loosened, circumstantial, tangential, flight of ideas, word salad
• Thought Content
Future oriented, suicidal ideation, homicidal ideation, fears, ruminative ideas

- Perceptions
• Hallucinations (auditory, visual, olfactory)
• Delusions (paranoid, grandiose, bizarre)
• Emotion
• Mood
(Patient describes in own words and rates on a scale 1-10)
- Affect
(You describe)
• Type: depressed/sad, anxious, euphoric, angry
• Range: full range, labile, restricted, blunted/flattened
• Appropriateness to content and congruence with stated mood
- Cognition
• Memory
Immediate recall, three and five minute delayed recall of three unrelated words
• Orientation/Attention
Day, date, month, year, place, president; Serial 7's (or 3's), WORLD — DLROW, digit span
• Insight/Judgment
Good, limited or poor (based on actions, awareness of illness, plans for the future)

Lab finding : major health concerns that may be contributing to symptoms of clinical depression. For example, hypothyroidism -- caused by an underactive thyroid gland -- is the most common medical condition associated with depressive symptoms. Other endocrine disorders associated with depression include hyperthyroidism -- caused by an overactive thyroid -- and Cushing's disease -- a disorder of the adrenal gland.

Related test: CT scan, MRI, EEG, ECG.