MENTAL STATUS EXAMINATION

Date: December 2, 2023

I. BASIC INFORMATION

Name: George (The last name will be identified after the follow-up) Contact No.: Will be identified after the follow-
up
Age: The age was not stated and will Sex: Male Birthday: February 22, 1957
be for follow-up

Address: Los Angeles, California

Civil Status: Not Specified and for Race: Not Specified and for further Religion: Not Specified and for further
further evaluation evaluation evaluation
Client’s Occupation: Not Specified and for further evaluation

Father’s Name: Not Specified and for further evaluation Mother’s Name: Not Specified and for further evaluation

Occupation: Not Specified and for further evaluation Occupation: Not Specified and for further evaluation

II. OVERVIEW
Reason for referral:

The client has a history of suicide. He had hallucinations seeing visions of the horse shit the other one, girls Jumping
all over his ass, and boys too chewing the men, and that’s why he needed a bodyguard. He had symptoms of
delusions believing they were out of space way back 20 many light years and he needed to keep his feet on the
ground, the sickness could be cured by the melarril flatten them up with meat, the muscle plenty of meat and liver
mostly liver, meat, fish, egg, on the dairy products but don't mix the milk with meat go back to the Jewish dietary
laws got each day. Hence the longevity of the symptoms was not yet identified. The client's traumatic experience
when he was treated with an electric shock has impacted his mental state today and this could be for referral for
thorough assessment and evaluation for the right treatment to be needed.

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Presenting Issues (History of presenting problem, predisposing, precipitating, and perpetuating factors):

Presenting the 4P’s

The predisposing factors that lead to George's condition can be genetic, social, psychological and
sociocultural factors hence these factors need a thorough validation on the history of the client’s family
background and for further evaluation.

Precipitating factors could be his genetic vulnerability and his family support because George's
relatives were unaware of his condition, lack of emotional support from his family, and his traumatic
experience at the hospital.

Perpetuating factors are that they don’t know what treatment and who the right people to seek
because it was stated that they asked for help from the priest, doctors, and other people. Hence the
management of his disease still have some adverse effect from the treatment.

The protective factors that are needed from the client are total abstinence from his use of cigarettes
as well as seek consultation with the right professional who could manage him properly. Seek Medical
doctors, Psychiatry, and psychologists that could thoroughly assessed the client for correct
management.

Current Functioning/Behavior Changes related to presenting problem:

(Note/describe any changes and/or difficulties present in the following areas)
Not Specified and for further evaluation
Sleeping Same ___ Changed

The client was well groomed, hence classifying the personal care
Personal Care ____ Same Changed of the client when he was once before still needs further
evaluation because one observation in small period is not reliable
The client's statements shows that his self-esteem was low when
Self-esteem __Same √Changed his sister stated that he was hopeless and they had tried
everything to help him. Hence in the interview he is confident.

The client was full of energy, he was full of expressions and hand
Energy ____ Same Changed
gestures as well and he couldn’t stay composure, hence the
changes in behavior will be further evaluated because one
observation in small period is not reliable.
Based on the interview, some of the client responses were
Concentration Same ___ Changed irrelevant to the interview, and his concentration doesn’t seem to
focus on one single agenda. He can be easily distracted.
This aspect was not mentioned and needed to be specified for
Work/School Same ___Changed further interview.

The client mentioned his family hence, the relatedness to one another,
Relationship as well as who his friends are still needs further evaluation.
Same ___ Changed
(Family, Social)

Problems associated with manic, hypomanic, and depressive behavior (hospitalization/suicidal ideations/mood
disturbances/unrestrained or foolish decision-making):

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√ Yes, specify:
The client mentioned that he was hospitalized at the Brooklyn State Hospital, but it was not mentioned if his
hospitalization was associated with manic, hypomanic, or depressive behavior. He only stated that he was put on
three treatments which is he was put in electric shock, Mellaril medications, and Amobarbital (Amytal Sodium). In
addition the client was involved with suicidal Ideation and suicide attempts.
_ No __Unknown

III. PSYCHIATRIC HISTORY (Note/describe any difficulties present):

Is there a history of √Yes ___ No ___Needs further investigation

psychiatric hospitalization?
Is the person currently using √ Yes ___ No ___ Needs further investigation
psychotropic medications?
Stimulants: __ Caffeine __ Methamphetamine __ Marijuana _____ others (please specify)
If yes, what medications? Antidepressants: __ SSRIs __ Serotonin Stimulators __ MAOIs _____ others (please specify)
Antipsychotics: √ Phenothiazine __ Thioxanthenes __ Atypical _____others (please specify)
Anti-anxiety Drugs: ___Benzodiazepine_____SNRIs______SSRI’s_____ others (please specify)
Mood Stabilizers: ____Lithium ____Valproate____Lamotgrine_____ others (please specify)
√ Amobarbital (Amytal Sodium)
When last used: Not Specified and for further evaluation
PSYCHIATRIC TREATMENTS (Note/describe any difficulties present):
I IIs there a family history of ___ Yes ___ No √ Needs further investigation
mental health issues?
Describe:
Is there a personal history ___ Yes ___ No √ Needs further investigation
of mental health issues?
Describe: As stated in the interview, he had a medicine called Mellaril used to treat
Schizophrenia, he stated that he also tried to commit suicide. Therefore this
aspect need further evaluation.

Mental Status (Highlight all that apply):

Appearance Neat √ Well Groomed Disheveled Dirty Drowsy Intoxicated Casual Other:
Inappropriate use cigarretes during the interview

Eye Contact: √Adequate √ Intense Staring Avoidant Guarded Poor Other

Speech: Normal Soft √ Loud Slowed Slurred Pressured Repetitive Stuttering Other:Fast

Interaction: Pleasant √ Cooperative Angry Guarded √ Suspicious Apathetic Aloof Passive √ Others: He was
cooperative interview but he is suspicious to the interview that he challenge to be silent for a while
Motor Activity: Appropriate √ Restless √Hyperactive Repetitive Agitated Ohers: His Hands is restless that keep
on having hand gestures as well as can stay still, He seem to be hyperactive during the interview because of
his energy.

Affect: √ Full Range Flat Blunted Labile Constricted Tearful Inappropriate Other

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Mood: Calm Anxious Depressed √ Manic Hostile Sad Euphoric Other

Thought Process: Coherent Goal Directed Blocking √ Loose Associations √ Tangential Word Salad Other

Coherent Suicidal Homicidal Grandiose √ Delusional √ Persecutory Somatic Jealousy

Thought Content:
Religious Broadcasting Other:
Orientation
Oriented Person Time √Place Disoriented

Risk Assessment (Note/describe any difficulties present):

Suicidal Ideation/
√ Yes _____No He wanted to cut his throat, upon trying all the means to treat his disease
Activity
hence he heard his sister said he was hopeless
Homicidal
Yes ____No Not Specified and for further evaluation
Thoughts/Violence:
Current/History of Violent Behavior (Include details/thoughts/plans if applicable):

Not Specified and for further evaluation, but he stated in the interview that the person who gave him the electrical
shock would pay with crushed hands an eye for an eye and a tooth for a tooth.

IV. MEDICAL INFORMATION

Medical History/Treatment (diagnosis/describe):

The client mentioned that he was hospitalized at the Brooklyn State Hospital, but it was not mentioned if his
hospitalization was associated with manic, hypomanic, or depressive behavior. He only stated that he was put on
three treatments which is are electric shock, Mellaril medications, and Amobarbital (Amytal Sodium). In addition,
the client was involved with suicidal Ideation and suicide attempts.
The patient stated that he was treated with 60 treatment of insulin.

Other Medical Conditions (descriptions):

Not Specified and for further evaluation

V. BIPOLAR DISORDER SYMPTOMS CHECKLIST

Direction: Under the observation column, put a ✓ when a symptom in each line is observed, and ⨉ if not. Supply
remarks if needed.
Manic or Hypomanic Observation Remarks
Symptoms
Not Specified and for further evaluation
1. Inflated self-esteem and grandiosity

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 Not Specified and for further evaluation
2. Decreased need for sleep

3. More talkative than usual

The client was very talkative during the interview
✓
The client has many thoughts and ideas that causes
4. Flight of ideas or racing thoughts ✓ loose associations of the topic being talked about.

5. Distractibility Not Specified and for further evaluation

6. Increase in goal-directed activity Not Specified and for further evaluation

Wanted to commit suicide

7. Excessive involvement in risky activities
✓
(e.g. overspending, sexual indiscretions,
foolish investments)

Note:
If a client has experienced 3 or more of these symptoms most of the day, nearly every day, over at least a 1 week
period (and the behavior and level of functioning is uncharacteristic of the person’s normal state), they may be
experiencing a Manic Episode.

If the episode lasts less than 1 week but at least 4 consecutive days, they may be experiencing a Hypomanic
Episode.

If a client has experienced at least 1 Manic Episode, they may meet criteria for a diagnosis of Bipolar I Disorder. If
a person has experienced at least 1 Hypomanic Episode followed by a Major Depressive Episode, they may meet
criteria for a diagnosis of Bipolar II Disorder.

Depressive Observation Remarks

Symptoms

1. Feeling low, irritable or appearing tearful Not Specified and for further evaluation

2. Reduced interest or pleasure in most Not Specified and for further evaluation
activities

3. Marked increase or decrease in appetite, or Not Specified and for further evaluation
significant weight loss
Not Specified and for further evaluation
4. Difficulties sleeping and waking

5. Increased agitation or lethargy Not Specified and for further evaluation

6. Fatigue Not Specified and for further evaluation

7. Feeling worthless or guilty Not Specified and for further evaluation

8. Less able to make decisions or concentrate Not specified and for further evaluation

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 9. Recurrent thoughts of death or suicide ✓ This portion still needs to be specified and for
further evaluation
Note:
If a client has experienced 5 or more of these symptoms most of the day, nearly every day,
over at least 2 weeks, they may be experiencing a Major Depressive Episode.

VI. DIFFERENTIAL DIAGNOSIS

The Differential Diagnosis can’t be made because the information given is not enough to support that the client has
a disorder and further evaluation and assessment as soon as possible is needed to have a clear basis on the client's
distress and circumstances.

Posttraumatic Stress Disorder in individual other than 6 years was considered where the client was exposed to
actual traumatic experience as basis on F43.10 on Criteria A.1 witnessing directly traumatic experience and A4
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (when he undergone
electric shock as his treatment.) Criterion B- Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event, on the Criteria B1-( Recurrent, involuntary, and intrusive distressing memories
of the traumatic event) B3-( Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring.), B4-( Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic event(s). This Diagnosis still needed a follow-
up assessment to support the criteria that needed to be validated.

Initial Recommendation:

There should be another intake interview will be conducted, that will cover the history of the life of the client as
well as the basic information that is needed to fill in the necessities of the client before diagnosis. Identification of
the 4D’s must be considered.

LYNNETTE D. TURIJA DECEMBER 2, 2023

Psychologist-in-Training Date Signed

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