DAILY CLINICAL ACTIVITIES

You should complete all the required clinical activities according to each activity evaluation criteria.
MENTAL STATUS EXAMINATION (MSE)

Student Name: Wadha Alholibi,391230-555

Clinical Area: Acuet

Section: Section 2

Date: 10 Oct,2021

Mental Status Examination (MSE) Student Mark

Total Mark / 5

1. Client History (0.1 Mark)

Ms.F
Patient’s Name _______ 38
Age _______ Diagnosis_______ Bipolar ,F31
Date of Admission 20/9/2021
______________Type of Admission: Voluntary _______ Involuntary_______

Married
Marital status: _______ With husband
Living arrangement: _______

Occupation: House
_______ wife Education: Middle
_______ school

2. Complaint (patient’s statement put into quotes) (0.1 Mark)

Patient verbalized “I am having family problems especially with my husband ,I get nervous easily ,I have bipolar from 7 years “

3. History of Present Illness: (0.15 Mark)

From one month,20/9/2021
Onset of Present Problems ------------------------------------------------------------------------------------------------

4. Family History of mental health problems (0.05 Mark) Positive ( ) Negative ( )

5. Past Psychiatric Hospitalizations (0.05Mark) Yes ( ) No ( )

Number of previous psychiatric hospital admissions: (12 ) First date of admission 6/1/2015

Reasons for Previous Admissions:

She was agitated,uncontrollable behavior,try to harm her husband,asking for divorce

1. Psychotropic Medications: She consum only 2 medications for this mouth

Medication Name(0.1 Mark) Medication Group(0.05 Mark) Dose(0.05 Mark) Route(0.05 Mark)

Olanzapine Atypical antipsychotics 10mg P.O,orally

Depakene Anti epileptic 500mg P.O,orally
 2. Physical Complaints (0.05 Mark)
:………………………………………:…………………:…………………………………………………………………
Patient verbalized “she doesn’t complain from any medical
…………………..…………………………………………………………………………………………………………
problems,however,if had any episodes of stomachache,or heartburn she
…………………………………….…………………...................................................................................……………
……………………………………………………………………………………………………..……
will consume a tablet ,moreover,she said “I have bipolar “
……:…………………………………………………………………………………………………………………

MENTAL STATUS EXAMINATION (MSE)

Sign / Symptom Objective Evidence Subjective Evidence

Check (Observed by the student) (Reported by the patient)
General Appearance
Overall General Appearance (0.05 Mark) (0.05 Mark)
She doesn’t complain from any medical problems ,and she
Looks Healthy looks healthy

Looks Unhealthy
Old Looking
Young Looking
Looks Stated Age
Posture (0.05 Mark) (0.05 Mark)
Erect She can stand properly .
Slumped
Tense / anxious
Fetal Position
Gait (0.05 Mark) (0.05 Mark)
Coordinated Gait She can balance her self
Uncoordinated Gait
Shuffling Gait
Limping Gait
Assisted Gait
Others, Specify
Dressing (0.05 Mark) (0.05 Mark)
Appropriate to Situation She dresses a suitable dresses for
the hospital
Inappropriate
Flamboyant / colourful / showy
Other, Specify
Grooming /Hygiene (0.05 Mark) (0.05 Mark)
Clean
Unclean
Groomed
Dishevelled / messy/ Unkempt She just took a shower,but she is
wearing yesterday clothes
Other, Specify
Facial Expression (0.05 Mark) (0.05 Mark)
Reactive By answering the questions
She paying close attention to me when I am talked to her
Attentive
When she talked about her self in postive thing her
Smiling facial expression looks happy

Indifferent
Hostile
Angry
Sad
 Sign / Symptom Objective Evidence Subjective Evidence
Check (Observed by the student) (Reported by the patient)
Maintains Eye Contacts While she was speaking , she looks to my eyes

Does not Maintain Eye Contact

Starring
Other, Specify
Attitude towards Interviewer (0.05 Mark) (0.05 Mark)
Cooperative She was welcoming any questions
Defensive
Seductive
Hostile
Guarded / Secretive
Communicating Verbally She answered me by words
Communicating Non verbally She used her thumbs up to express that
Mute she is okay

Other, Specify
Psychomotor Activity / Behavior (0.05 Mark) (0.05 Mark)
Within average activity Normal activity walking and sitting.
Mannerism
Preservation
Tics
Compulsion / rituals
Tremors
Twitches
Stereotype
Echopraxia
Rigidity
Retarded /Hypoactive
Clumsy / Irresponsible
Restlessness
Agitation
Violence / aggression
Perspiration
Drooling of Saliva
Incontinence
Negativism
Automatic Obedience
Waxy Flexibility
Other, Specify
Speech
Speech Rate (0.05 Mark) (0.05 Mark)
Within average rate
Accelerated Fast speech
Retarded
Pressured Continuously talking about many topics at the Same time
Stuttering
Slurred
Other, Specify
Speech Tone (0.05 Mark) (0.05 Mark)
Moderate within average Her voice can be heard
Loud
Low
Monotonous
 Sign / Symptom Objective Evidence Subjective Evidence
Check (Observed by the student) (Reported by the patient)
Speech Association / Relevance (0.05 Mark) (0.05 Mark)
When i was asking the questions she answered
Logical / Relevant about the same subjective and related
Illogic /Irrelevant
Unfocused
Mood (0.05 Mark) (0.05 Mark)
Euthemic
Dysphoric
Worried / anxious She verbalized i am worried about my daughter

Depressed
Angry
Irritable
Guilty
Frightened
Apathy
Happy
Elated
Euphoric
Labile
Indifference
Others, Specify
Affect(0.05 Mark) (0.05 Mark) (0.05 Mark)
Her Facial expression is sad , and she
Congruent / Appropriate looks anxious. She verbalized I am worried about my daughter
Incongruent / Inappropriate
Intense
Constricted
Blunted
Flat
Ambivalence
Infantile
Thinking Process
Form of thinking (0.05 Mark) (0.05 Mark)
I asked her to talk about her mirage life ? She said
Coherent / relevant / intact / logic thinking the sequence of events logically.

Circumstantiality
Clang Association
Fight of ideas
Looseness of Association
Neologism
Perseveration
Tangentiality
I
Incoherence / Word salad
Echolalia
Palilalia
Ambivalence
Reasoning (0.05 Mark) (0.05 Mark)
None
I gave her a quote “people who live in glass houses shouldn't throw stones
Abstract Thinking on others.”,and asked her what do you understand for this quote?
She answered “treat your people like what you want to be treated”
Concrete Thinking
Stream of Thinking (0.05 Mark) (0.05 Mark)
None
Poverty of thought
I asked her about her feelings?
Pressure of Thoughts She answered “I am okay yesterday I didn’t feel well but
today I am fine,because yesterday I have a stomachache
Thought blocking and it was painful ,I had also a headache but I am fine ,but
The headache is in the right side of my head and yeah “
 Sign / Symptom Objective Evidence Subjective Evidence
Check (Observed by the student) (Reported by the patient)
Thought Content
Delusions (0.05 Mark) (0.05 Mark)
None
Bizarre delusion
Nihilistic delusion
Delusion of poverty
Somatic / Hypochondriacal Delusion
Persecutory
I asked her if she know how to cook?
Reference She answered I know how to do everything,everything
comes to your mind I can do it
Grandeur
Delusion of Infidelity / Jealousy
Erotomania
Litigious Delusion
Delusion of Control
Thought Withdrawal
Thought Insertion
Thought Broadcasting
Delusion of Sin/Guilt/Self Blame
Systematized Delusion
Non systematized Delusion
Mood Congruent Delusion
Mood Incongruent Delusion
Suspiciousness (Ideations) (0.05 Mark) (0.05 Mark) None
Ideas of Reference (0.05 Mark) (0.05 Mark) None
Preoccupation (0.05 Mark) (0.05 Mark) None
Obsessions (0.05 Mark) (0.05 Mark) None
Phobia (0.05 Mark) (0.05 Mark) None
Suicidal Ideations(0.05 Mark) (0.05 Mark) None
Homicidal Ideation /Antisocial Ideation (0.05 Mark) (0.05 Mark) None
Religiosity (0.05 Mark) (0.05 Mark) None
Magical Thinking(0.05 Mark) (0.05 Mark) None
Other, Specify
Perception
Hallucinations(0.1 Mark) (0.05 Mark) (0.05 Mark)
None
Non Commanding / Running Auditory Hallucination
Commanding Auditory Hallucination
Visual Hallucination
Tactile Hallucination
Olfactory Hallucination
Gustatory Hallucination
Illusion (0.05 Mark) None (0.05Mark)
Depersonalization (0.05 Mark) None (0.05 Mark)
Derealization (0.05 Mark) None (0.05 Mark)
Level of Consciousness(0.05 Mark) (0.05 Mark)
She looks alert, responds immediately and
Alert fully to commands . She was fully oriented.
Drowsy
Stuporous
Delirious
Orientation (0.05 Mark) (0.05 Mark)
Oriented to Person Do you know who am I?
She verbalized yes , you are wadha.
 Sign / Symptom Objective Evidence Subjective Evidence
Check (Observed by the student) (Reported by the patient)
Disoriented to Person
Oriented to Place Do you know were are you now ?
she verbalized that I am in a psychiatric hospital

Disoriented to Place
I asked her do you know what time is it ?
Oriented to Time She verbalized “ yes , i know the time is afternoon and I am going to
pray know “

Disoriented to Time

Attention (0.05 Mark) (0.05 Mark)

Attentive I gave her 3 words ( red , black , and green) , after a while iasked her to
repeat the 3 words ? She verbalized the 3 colors red ,black,and green

Distracted
Concentration (0.05 Mark) (0.05Mark)
Intact I asked her “ can you tell the days of the week in reverse? “
She answered correctly in order
Impaired
Memory (0.05 Mark) (0.05 Mark)
I told her my name is wadha. I asked her what is my name ?
Immediate: Intact She verbalized that your name is Wadha

Impaired
Recent: Intact I asked her what did you eat today in breakfast? She verbalized “ I ate toast with
cheese “ after 5min I asked her again and she answered the same

Impaired
Remote / long term : Intact I asked her how many times you have been admitted to hospital ?and
What is your birthday?

Impaired
Calculations (0.05 Mark) (0.05 Mark)
Accurate I asked her to calculate 5+3 ? She answered it’s 8

Inaccurate
Fund of knowledge (0.05 Mark) (0.05 Mark)
I asked her about Who is the king of Saudi Arabia ?
Fund She verbalized “ the king is Salman bin Abdulaziz “
Not fund
Insight (0.1 Mark) (0.1 Mark)
Complete Denial
Slight Awareness but Denies
Awareness but Blaming Others
Awareness that Illness is Due to Something Unknown
Intellectual Insight I asked her about if she knows her diagnosis . She verbalized
“ yes I know it’s bipolar “

True Emotional Insight

Judgment (0.05 Mark) (0.05 Mark)
Sound I asked the patient if you are going to a part ,what will you wear ?
She verbalized “ I will wear a beautiful dress “

Inappropriate / illogical
Poor / impaired

Summary of Psychopathology (0.1 Mark):


1-I noticed that the patient have pressure of thoughts,but was logic
 2-I noticed that the patient was having an episode of bipolar at the beginning of the visit

 3-I noticed that the patient thinks in coherent way ,and have an deep understanding for things which
indicates to me that she has an abstract thinking
 4-I noticed that the patient had a strong memory and she was able to memorize the long term event.