MENTAL STATUS ASSESSMENT

Student Patient
Name: Initials: SC
Jacqueline
smith

Diagnosis: Date: 06-25-

Bipolar 2020
Disorder
Complete all sections below based upon your assessment of your patient.
Iinclude all findings, as well as a brief description of observations.(Give specific
examples for each)
PHYSICAL APPEARANCE
Patient is in hospital grown and hair is uncombed and knotted.

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Patient has no make-up and is unbathed.
Her looks are appropriate to age, sex, and climate. She has a

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cast on the lower right leg due to a fall.
PSYCHOMOTOR BEHAVIOR

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Patient is tense and sitting uncomfortably in the hospital bed, so
Gait: rs e
I was not able to assess her gait. However, she keeps asking to
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get up and leave regardless of just having surgery.
Abnormal Her movement is hyperactive and agitated. She shuffles in the
Movements: bed trying to get in position.
o

Her energy is restless with excessive movements of her arms

aC s

Energy:
and hands. Frequently, she rubs the back of her neck.
vi y re

Posture is sometimes ridged, and other times slumped. She

Posture:
moves a lot and cannot maintain stillness for long.
THOUGHT PROCESSES
ed d

Patient is coherent but thought process is unclear and

Clarity: disorganized. Patient talks constantly and has impaired
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judgment. Speech is pressured.

Patient is experiencing grandiose thoughts and false beliefs
Patient states, ‘You are jealous that I work for the president,”
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Content: Patient denies suicidal ideations but confidently admits to

wanting to kill a “secret service guy” Patient is suffering from
Th

delusional thinking.
The flow is tangential. Patient expresses a flight of ideas and
Flow: loses track of the topic easily. Patient is ruminating on
sh

“Washington” and “working for the government.”

LEVEL OF CONSCIOUSNESS

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 Patient is alert but responds inappropriately to the environment
and questions. When asked “What do you enjoy doing?”
patient replies “The nursing assistance is cute.”
INTELLECTUAL PERFORMANCE
Knowledge is adequate. Patient has the intellectual ability to
Fund of Knowledge: state all the previous presidents starting with Obama.
Patient is college educated and works as a lawyer.
Attention and Patient can count from 100 subtracting 7 effectively. Patient can
Concentration: repeat a series of numbers forward and backward.
Patient cannot interpret a proverb but conceptualizes
differences in objects. When asked to explain “Don’t put all your
Capacity for eggs in one basket” patient states “The government controls all
abstraction: the eggs; they are poison.”
When asked to describe the difference between an orange and
an apple, patient states “Red, round, yellow, long.”
Patient is in denial and insight is absent. She states, “I feel

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Insight into illness: great” Patient does not see the negative effects mental illness is

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having in her life.

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Judgement is poor. Patient came to hospital involuntarily and
wants to leave the hospital against medical staff orders.

o.
Judgment: She is delusional and not focused on therapeutic measures for
rs e
healing. Patient had a fall that resulted from her poor
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judgement.
Patient is orientated to place and person. X2 Patient is
Orientation: disoriented to situation and time. Patient is unaware how she
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got to the hospital and cannot tell me the time or date.

aC s

SPEECH
vi y re

Pressured and loud. Patient is asked to lower her voice multiple

times.
MOOD & AFFECT
ed d

Lively, labile, defensive, suspicious of nurse, playful, irritable,

euphoria, and pride.
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Mood and affect are incongruent. Patient states, “I feel great,

you’re just jealous you don’t feel this way’ but facial expression
is agitated, and movements are restless.
is

ATTITUDE/FEELINGS
Th

Patient is suspicious of the nurse and frequently states sexually

inappropriate remarks towards hospital staff. Patient states “I
want to show him what real love is.” “You all are trying to kill
me.”
sh

Patient is in denial about her mental illness and is noncompliant

with the treatment regimen. Patient continually asks to take off
the PCA IV-line infusing on the left AC. Patient has no
willingness to change currently.
AXIS DIAGNOSIS
I Bipolar Disorder

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 II
III
IV
V* 40

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ed d
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