Mental Status Assessment Bessie Bohnke Cedar Hills Langley Student Name Dermot Connolly Stenberg College

Client has being a resident of Cedar Hills since December 2011. She is a 93 year old Caucasian female with green eyes and average height and weight. Client arrived at interview with the aid of a walker. Client is able to ambulate herself with no assistance, posture was slouched with slow relaxed pace during ambulation. At the time of the interview, client was well dressed and groomed. Client was very cooperative throughout the interview. She made periodic eye contact but tended to stare at the floor or into space when recalling events from her past. Clients speech was auditable with no unusual changes in pitch and tone recorded. Client is taking Exelon 4.5 mg po / day to treat confusion and hallucinations. During interview, client often appeared confused which is consistent with cognitive impairment. Clients affect was depressed when she recalled the events surrounding her fathers death and the implications it had on her family dynamics. She cried often and appeared embarrassed by this cathartic response. Clients affect changed to happiness when discussion topics relating to grandchildren and great grandchildren. Clients thought process was fragmented with frequent gaps in her responses. Client exhibited signs of confusion consistent with a thought disorder and negative thoughts were expressed during interview. Client has colorful blankets on her bed for identification purposes as she is often disorientated and wanders into other clients rooms. Client complied when asked to participate in a mini mental status exam. Results showed client has impaired attention span along with poor short/ medium and long term memory. Client appeared agitated and embarrassed while taking exam and frequently expressed her guilt for not being able to recall events from memory. Client did not exhibit any signs of impaired insight or judgment but visual perception was diminished when asked to write a sentence, consistent with client macular degeneration in right eye. Client frequently experiences perceptual disturbances which take the form of hallucinations

where she has reported seeing children and guns in her room. When asked about Cedar Hills, client accepted that her cognitive deterioration meant it was in her own best interest to live in assisted living.