COUC 521 BENCHMARK INTAKE PART TWO: MENTAL STATUS EXAM (MSE) ASSIGNMENT INSTRUCTIONS
Important
Simply add this part of the assignment (Intake Part Two: Mental Status Exam (MSE) Assignment) to the first part (Intake Part One: Initial Interview Assignment) and submit them as one Microsoft word document. Your assignment will not be considered complete until you upload both parts together.
Overview
One task in the initial interview is a gathering of information about the client’s mental status. You already have gathered background information in the Intake Part One: Initial Interview Assignment. In this Intake Part Two: Mental Status Exam (MSE) Assignment, you will write up the Mental Status Exam (MSE) portion of that Benchmark Initial Interview Assignment. In the Initial Interview Assignment report, you primarily focused on what the client revealed to you.
For the Mental Status Exam (MSE) Assignment, most of what you report on will be based on your observations from that initial interview (appearance, behaviors, mood, affect, thought processes, etc.), from specific questions you would ask in the initial interview. These observations provide information about the client that is not readily discernable from the initial interview data.
Instructions
- Length of Mental Status Exam (MSE) Assignment: 600-900 words (not including the title page)
- Format of Mental Status Exam (MSE) Assignment: APA for font (Times New Roman, 12 pt.), title page, margins, and section headings
- Number of citations: none
- Acceptable sources: none
For this Mental Status Exam (MSE) Assignment, you will continue to the fictional character that you interviewed for the initial interview. Remember, the client that you selected is a relatively well-adjusted individual who has already passed the initial interview process with the referring agency. Therefore, your Mental Status Exam (MSE) Assignment will mainly indicate functioning that is considered within the normal limits (WNL) of adaptive functioning.
Important points regarding the Initial Interview:
- Because the psychological evaluation was not performed for clinical, forensic, or legal reasons, your character did not have a life-threatening medical condition, a chronic or debilitating psychological disorder, or an extensive criminal history.
- Report all applicable MSE information.
Format of the Mental Status Exam:
- Gather the MSE information using the categories from pages 345-346 of the Sheperis et al. (2020) text and the “How to Conduct a Mental Status Exam” handout. Report the information using the Mental Status Exam Rubric as a guideline. Remember, you will use this information for another project. As you can see, there are various ways to organize and present MSE information (e.g., the text, the handout, and the sample is up to you). However, for the purposes of this Benchmark Mental Status Exam (MSE) Assignment, make sure that you have all of the information required on the grading rubric.
- Please make sure to note if the functioning is adaptive. For example, if no delusional thoughts are present, state it. If you do not specifically note this, the reader does not know if the client did not have delusions or if the counselor simply forgot to ask.
- Written in the third person (e.g., “Mr. Jones is a 42 years old…,” or “His greatest strengths are…”).
- Be sure that the information is consistent with the Initial Interview. Remember that your client is a well-adjusted individual that does not present with severe pathology.
Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.
Be sure to review the Benchmark Mental Status Exam (MSE) Grading Rubric before beginning the Benchmark Mental Status Exam (MSE) Assignment.
Categories of Mental Status Exam from the Handout
(see MSE Part 2 Template for how to organize information below)
Appearance: Presenting Appearance (including sex, chronological and apparent age, ethnicity, build, and physical deformities; Basic Grooming and Hygiene (plus appropriateness of attire, accessories like glasses or a cane); Gait and Motor Coordination (plus posture, work speed, any noteworthy mannerisms or gestures).
Manner and Approach: Interpersonal Characteristics and Approach to Evaluation (resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness); Behavioral Approach (distant, indifferent, anxious, alert, etc.) Speech (normal rate and volume, pressured, slow, etc.); Eye Contact (makes, avoids, etc.); Expressive Language (circumstantial and tangential responses, mumbling, vocabulary usage) Receptive Language (normal, difficulty understanding questions); Recall and Memory (can explain recent and past events in their personal history, recalls three words, etc.).
Orientation, Alertness, and Thought Processes: Orientation (person, place, time, and situation); Alertness (sleepy, alert); Coherence (coherent and easy to understand, overly detailed and difficult to follow); Concentration and Attention (naming the days of the week in reverse order, ABC’s backward); Thought Processes (loose associations, flight of ideas, delusions); Hallucinations and Delusions; Judgment and Insight; Intellectual Ability; Abstraction Skills (able to explain a parable or saying).
Mood and Affect: Mood (feels most days: euthymic, sad, anxious, angry); Affect (felt at any given moment); Rapport (easy to establish, easily upset); Facial and Emotional Expressions (relaxed, tense, smiled, laughed); Suicidal and Homicidal Ideation (past and recent in both areas); Risk for Violence (previous criminal history, dislike for a specific demographic); Impulsivity.
Categories of Mental Status Exam from the Textbook (extra information)
Appearance: How was the client dressed and groomed (e.g., neat, disheveled, unkempt)?
Behavior/Psychomotor Activity: Did the client exhibit slow movement, restlessness, or agitation? Did the client have any unusual behaviors such as tics, mannerisms, gestures?
Attitude toward Examiner: Was the client’s attitude toward the examiner cooperative, friendly, attentive, defensive, hostile, evasive, guarded, and so forth?
Affect and Mood: Did the client have sad, angry, depressed, or anxious mood? Was the client emotionally responsive (affect)? Was affect congruent with mood?
Speech: How was the quantity, rate of production, and quality of the client’s speech (e.g., minimal – mostly yes and no answers; talkative; rapid/pressured speech)?
Perceptual Disturbances: Did the client experience hallucinations or illusions? If so, what sensory system did they involve (e.g., auditory, visual, olfactory, tactile)?
Thought: Did the client have any disturbances in thought process, which involves the rate of thoughts and how they flow and are connected (e.g., racing thoughts, flight of ideas, tangential). Were there any disturbances in thought content, such as delusions, obsessions, preoccupations, or suicidal or homicidal thoughts?
Orientation (Ox4): Was the client able to state (a) their name and recognize people around him or her, (b) the current location/place, (c) the date and time, and (d) the situation (can describe the purpose of the meeting).
Memory: How was the client’s recent memory (e.g., what did he or she have for breakfast?) and remote memory (e.g., memories from childhood)?
Concentration and Attention: Was
Note: Full answer to this question is available after purchase.
the client’s concentration or attention impaired? Was the client distractible?
Information and Intelligence: Can the client accomplish mental tasks that would be expected of a person of his or her educational level and background?
Judgment and Insight: Does the client have the capacity for social judgment? Does the client have insight into the nature of his or her illness?
Reliability: How accurately was the client able to report his or her situation?
Intake Report Part Two: Mental Status Exam (MSE) Assignment Template
Note: This template includes Part One of the assignment because it should be included in Part Two
Identifying Information
Client name, address, phone number, DOB, gender, marital status, occupation, work/school, work phone, emergency contact, date of interview
Reason for Referral
Referral source, reason for referral (why has the client been sent to you [e.g., consultation, clinical intake, counseling]); presenting complaint (hint: they are coming in for an evaluation)
Current Situation and Functioning
A description of typical daily activities, ability to complete normal activities of daily living (ADLs); general assessment of coping/character skills (e.g., stress management skills, emotional regulation ability; problem-solving, conflict resolution, empathy, cooperation, etc.); self-perceived strengths and weaknesses.
Relevant Medical History
Previous and current medical problems (major illnesses and injuries), medications, hospitalizations, and disabilities; any significant major medical disorders in blood relatives (e.g., cancer, diabetes, seizure disorders, thyroid disease, etc.)
Psychiatric Treatment History
Description of previous treatment received, including hospitalization, medications, psychotherapy or counseling, case management, etc. Include a description of all psychiatric and substance abuse disorders found in all blood relatives (i.e., at least parents, siblings, grandparents, and children, but also possibly aunts, uncles, and cousins).
Family History
Information about the client’s family background, including information about first-degree relatives (parents, siblings), the composition of the family during the client’s childhood and adolescence, and the quality of relationships with family members both past and present.
Social and Developmental History
Significant developmental events that may influence current problems or circumstances. This should include, as aplplicable, issues surrounding pregnancy or birth; social, behavioral, and cognitive milestones; and relational history (include interaction with peers, people in authority, academic performance, and extra-curricular activities – e.g., sports, clubs, etc.); current and previous marital/non-marital relationships, children, and social supports.
Educational and Occupational History
Schools attended, educational level attained, and any professional, technical, and/or vocational training; current employment status, length of tenure on past jobs, military service (rank and duties), job performance, job losses, leaves of absence, and occupational injuries.
Cultural Influences
Potential assessment issues (see chapter 3) when working with a diverse populations.
Note: The template and examples are provided as a guide for writing your reports. To avoid plagiarism, DO NOT submit report assignments with minimal changes to the templates/examples (i.e., only altering a few items).
Mental Status Exam
Appearance and Psychomotor
Susan is a 5’4” single White female of average weight. At the time of the interview, she had a pasty white complexion and several scars from adolescent acne. No atypical physical characteristics were observed. Basic grooming and hygiene were exercised except it was noticed that her fingernails appeared dirty. When asked about them, she stated that she enjoys gardening but that some of the products dye her fingernails. She was appropriately dressed for the season. Her gait was unremarkable as she was able to walk from the waiting room to the examiner’s office without any unusual movements or behaviors.
Fine motor and perceptual processes appeared to be within normal limits as she was able to adequately duplicate the drawing of a clock. Psychomotor activity was within normal limits as she moved comfortably during the interview. No psychomotor agitation was observed. No evidence of current drug or alcohol intoxication was observed.
Manner and Approach
Susan presented herself in a cooperative, friendly manner during the interview, and answered questions in a direct fashion. Her eye contact was appropriate as she did not stare at the examiner nor avoid eye contact. Her speech pattern did not reflect any unusual behaviors such as stuttering. Her expressive language skills were within normal limits as she was able to choose words (semantics) and create sentences (syntax) that were coherent and easily understood. She was able to understand the questions posed by the examiner suggesting that she had adequate receptive language skills. Susan was able to recall several events with details from childhood as well as three unrelated objects that she was asked to remember after 15 minutes.
Orientation, Alertness, and Thought Processes
During the interview, Susan was alert and oriented X 4 (person, place, time, and situation). She was coherent as she displayed a logical, sequential, coherent flow of thought. No tangential thinking, flight of ideas, or looseness of associations were noted. No evidence of hallucinations, delusions, paranoid ideation, or ruminations was apparent. She denied ever having any hallucinations, compulsions, and obsessions.
Her concentration was adequate as she was able to count backward from 100 to 51 by 7’s and was able to perform two-digit mathematical calculations (addition, subtraction) without paper. While not formally assessed, she appeared to have average to above-average intelligence as evidenced by her vocabulary and reported GPA in college. As it relates to judgment and insight, Susan was able to adequately explain her reasons for her choices in a dilemma posed by the interviewer (e.g., “Would they tell the truth leading to harm of a friend, or be loyal to the friend and withhold the truth?” “What would she do if a co-worker was stealing from the petty cash in the breakroom?”). Some abstract thinking difficulty was observed in her difficulty describing the meaning of the saying, “Strike while the iron is hot.”
Mood and Affect
During the interview, Susan generally displayed a euthymic mood. Her facial reactions were congruent with her mood. However, at one point she evidenced a labile affect as she cried and laughed while recalling a story from her childhood. She denied any history of manic-like symptoms. She denied any past or recent attempts at self-harm but acknowledged that she had suicidal thoughts for a period of three months while in high school after she broke up with her boyfriend. She denied ever having any homicidal thoughts. As it related to risk for violence and impulsivity, she denied any criminal history, assaultive behavior, and any instances in which she made impulsive decisions that had significant negative consequences.
RELATED: A SURVEY OF THE BASIC TENETS OF SOCIOLOGY INCLUDING RESEARCH, THEORIES, CULTURE DEVIANCE, GROUPS & ORGANIZATIONS, AND STRATIFICATION.
Order This Paper
Reviews
There are no reviews yet.