MSE

By : Karl Angelo Montano

Edan Louie Viola
Patient’s Data

Date: N/A
Name: N/A
Sex: Female
Age: N/A
PRESENTATION
 General appearance

The resident was wearing a neat, unbuttoned red

coat with a maroon shirt inside. She was also
wearing eyeglasses and 2 bracelets, one each arm,
and 2 rings, one on the index finger and the other
on the ring finger. The lady did not wear make-up
or any cosmetics.

Level of eye contact of the resident during the

entire duration of the interview was
intermittent.
• The resident has a healthy-looking blonde hair
and it was slightly disheveled. Further assessment
of the hair was not carried out.

• Skin assessment based on appearance in the

video was difficult to carryout. This is due to the
resident’s clothes which have concealed the body
mostly except for the hands and the head.

• The resident seems to be a Senior Citizen.

Comparison to her appearance with her
chronological age was not carried out due to the
 General Mobility

The patient was able to swing his arms freely

while doing hand gestures. She has no
difficulty in sitting. He has no signs of waxy
flexibility. Overall, the resident’s body posture
was good.
 Motor Activity

• No signs of hypoactivity, hyperactivity, nor

psychomotor retardation

•The resident tends to use an open-hand

gesture when explaining or elaborating stories.
In other occasions, she would interlace her
fingers and placed it on her lap when asked
with questions related to her alcohol abuse.
STREAM OF TALK
 Character

The patient has been observed to have stuttered

words during the interview.
 Organization of Talk/Form of
Thought

•Per organization of talk/form of thought, some

of her statements were relevant but incorrect

•Generally, the patient answered the questions

with relevance and correctness, all of her
sentences/responses were mostly short but
appropriate to the subject matter.
EMOTIONAL STATE AND
REACTIONS
 Mood

•The mood of the client was depressive

•Her facial expression was just suitable to what

she feels and to what she says.
 Affect

• Our client manifests an appropriate affect in

which it was definitely fitting to her mood.

• At the start of the assessment,

depersonalization and derealizations were
absent
 THOUGHT
CONTROL/PROCESSES
 Content of Thought
•The resident may have a somatic delusion

•As observed in the video the client has no signs of suicidal

intention and didn’t mention any suicidal attempts nor
ideation.

•No hallucinations noted/reported.

•Upon interaction with the client, preoccupation and

ruminants were not noted. There were no repeated
thoughts that hinder or agitate the thinking process of the
client.
 Content of Thought
•The resident may have a somatic delusion

•As observed in the video the client has no signs of suicidal

intention and didn’t mention any suicidal attempts nor
ideation.

•No hallucinations noted/reported.

•Upon interaction with the client, preoccupation and

ruminants were not noted. There were no repeated
thoughts that hinder or agitate the thinking process of the
client.
 NEUROVEGETATIVE
DYSFUNCTIONS
•Sleep was not discussed in the interview (N/A)

•Appetite was not discussed in the interview (N/A)

•Diurnal Variation was not assessed

•Weight was not assessed

•Libido was not assessed.

GENERAL SENSORIUM AND
INTELLECTUAL STATUS
Describe impaired or unimpaired

•No questions that would extract the answers to

assess the resident’s orientation to time, person,
situation was given.

•Although her memory was not thoroughly assessed,

the resident was able to recall her recent and could
possibly remote experiences
INSIGHT
Describe impaired or unimpaired

Client still has poor insight regarding on how

alcohol is affecting her life. Before the interviewer
explained that her alcoholism might be the root
cause of her broken personal relationship and her
throwing up of blood, she had rationalized that
she drinks alcoho to help her alleviate the
feelings/stressors that she encounters in her life
Describe impaired or unimpaired

Client still has poor insight regarding on how

alcohol is affecting her life. Before the interviewer
explained that her alcoholism might be the root
cause of her broken personal relationship and her
throwing up of blood, she had rationalized that
she drinks alcohol to help her alleviate the
feelings/stressors that she encounters in her life
Describe impaired or unimpaired

Client still has poor insight regarding on how

alcohol is affecting her life. Before the interviewer
explained that her alcoholism might be the root
cause of her broken personal relationship and her
throwing up of blood, she had rationalized that
she drinks alcohol to help her alleviate the
feelings/stressors that she encounters in her life
 Nursing Diagnosis

•Deficient knowledge related to insufficient

information on the effects of drinking too
much alcohol as evidenced by of poor insight
of the current health condition.

•Risk for injury related to excessive alcohol

consumption.