SOLVED35

General Appearance The patient showed good personal hygiene by dressing appropriately for the weather and maintaining a clean and well-kept appearance. Throughout the interview, the patient kept eye contact, active facial expressions, smiled frequently, and engaged the topic. Behaviors/Attitude During Interview The patient displayed a stable emotional state during the examination. This was indicated by the patient’s cooperative and pleasant manner. There was not any indication of agitation. Psychomotor Activity The patient was very calmly seated throughout the period of the interview. No agitation observed during the interview Speech Patterns Patient speech was clear, soft spoken and responded appropriately to questions. The patient was able to follow the conversation and she was very engaging throughout the interview. Mood The patient was elated, questions with promptness and was highly engaging. She additionally demonstrated a cooperative attitude by accepting to take part in the exam. Affect Patient facial expression matched stated emotions Thought Process The patient’s thought process was logical, coherent, and sequential. Thought Content The patient thought was career and religiously occupied. She stated that she wants to be more spiritual and be closer to God while she pursues her marine program career Orientation The patient was fully alert and oriented to time, place and person Memory (immediate recall, short-term, long-term) Immediate recall, short-term and long-term memories were all intact. Intellectual Functioning The patient performed very well intellectually. She understood and explained her feelings clearly. Judgment Despite that the patient did not take her medication for two weeks which led to her mental breakdown, her Judgement at the time of the interview was sound. The patient stated that she loves traveling, and her short-term goal is to go for a marine school program, which she applied for on the morning of the interview. Sensorium/Cognition Patient is oriented and alert. She has intact attention and memory. Insight Patient displayed very good insight. She stated that her situation was due to her inability to sleep and non-adherence to her medication as prescribed for the past two weeks because the medication made her feel funny, which led to her mental breakdown. Impulse Control Patient appears to have “intact” impulse control. She does not appear to be impulsive or a danger to herself or others. Patient called 911 by herself when she felt she was breaking down mentally. Motivation for Treatment The patient is happy with the replacement of her medication with a new one, which she committed to adhering to. She is looking forward to going back home. Two abnormal findings in the MSE : 1) Non-adherence to Medication: The patient admitted to not taking her prescribed medication for two weeks because it made her feel “funny”. This led to a mental breakdown, exhibited through her display of uncontrollable aggression and anger, which is a significant concern. Non-adherence to medication can lead to a relapse or worsening of symptoms, which can impact the person’s ability to function in their environment. For example, it could affect her ability to concentrate or perform well in her marine program, potentially leading to academic difficulties. It could also strain personal relationships if her mood or behavior becomes unstable. 2) Sleep Disturbance: The patient mentioned an inability to sleep. Sleep disturbances can have a significant impact on a person’s mental and physical health. Lack of sleep can lead to mood swings, irritability, and difficulty concentrating, which can affect personal relationships, academic performance, and overall quality of life. 2) For each of the abnormal findings listed above, list one nursing intervention that could be used to support the patient and/or treat the problem.
SCIENCE
HEALTH SCIENCE
NURSING

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