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General Appearance The patient appears to be of average height and weight. Patient was dressed appropriately for the weather and her clothes were clean and well-kept, suggesting good personal hygiene. The patient maintained eye contact during the conversation and facial expressions was lively and she often smiled. Behaviors/Attitude During Interview: The patient presented a positive and cooperative demeanor, which may suggest a stable emotional state at the time of the examination. No agitation was observed Psychomotor Activity : The patient was very calmly seated throughout the period of the interview Speech Patterns :The patient’s speech was very clear and coherent, and she expressed her thoughts logically and coherently. The patient was soft-spoken, and her speech was not too fast. Mood: The patient often smiled and responded promptly to questions. She also showed a willingness to participate in the examination, demonstrating a cooperative attitude. Patient stated that she is enjoying her treatment and taking it seriously. She also said she is excited to go back to school. Affect: The patient’s emotional expression aligns with her facial appearance Thought Process: The patient expressed her thoughts logically and coherently. Patient answered all questions and explained what led to her depressive situation. Thought Content : Suicidal ideation – Patient stated that she has attempted to take her life 3 times within the last 4 weeks. She took 70 tablets of 35mg Benadryl to kill herself in this last attempt. Orientation Patient was fully alert and oriented to time, place and time Memory (immediate recall, short-term, long-term): – Patent had good immediate memory. – Patient had a brief Impaired short-term memory shortly after taking 70 tablets because of the medication. As she stated she was not aware of what happened to her for 3 days after taking the medication. Other than this her memory was very good. – Good long-term memory- The patient recalled her childhood experience with her mother when she was 11 years old. Intellectual Functioning:Patient performed very well intellectually. She understood and explained her feelings clearly. Patient stated her short-term goal is to be done in School and graduate by mid-year. Judgment: The patient’s judgment is severely impaired. Despite her ability to understand and articulate the reasons for her depression, she has made multiple attempts to end her life in the past month, including a recent attempt involving a significant overdose of medication. This indicates a significant inability to make decisions that are in her best interest Sensorium/Cognition: Patient is oriented and alert. She has intact attention and memory t Insight: Patient displayed very good insight. She explained that her situation was due to the breakup with her boyfriend. She stated that herself and her boyfriend were moving at different pace in their relationship and decided to end the relationship in November 2023. Impulse Control: Patient exhibits severe impairment in impulse control. Although presenting as happy and cooperative, she has made multiple suicide attempts within the last month, including a recent attempt involving a significant overdose of medication. This suggests a significant inability to control harmful impulses, despite understanding the reasons for her depression. indicating a significant lack of impulse control. Motivation for Treatment : Patient stated that she is enjoying her treatment and taking it seriously. She said she appreciated the support given to her by her school professors and friends and she is excited to go back to school and looking forward to her graduation by May this year 1) List 2 items that are “abnormal” from the MSE above. Explain how the abnormal findings may impact the person’s relation to their environment (e.g. social, personal, educational, legal, occupational). *Provide references*
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