Mental Status Examination Interview

General Appearance

My client is a 25-year-old South Asian woman. She appears thin with long black hair and brown eyes. She is wearing dark pants, a long sleeved blue shirt with a multicoloured scarf. Her clothing is neat and appropriate to her environment. She is wearing makeup, appears clean and is well put together. The client answers direct questions but does not provide a lot of information. Patient is willing to provide more information when asked directly or prompted by the writer. The client’s rate of speech was slow at first but as the interview continued, became a normal rate. Her speech was clear; however spoke in a soft volume with a monotone voice. Her rhythm was smooth and her speech was not pressured. The client’s energy level appeared low, and sat with rigid posture and was very still during the interview. The client maintained focused eye contact with the writer throughout the interview. Her body language showed no sign of emotion and her facial expression appeared sorrowful and times and bored at others.

Emotional State

The client described her mood as “very sad and unhappy.” She rated her mood on a scale of one to ten, one as being described as the worst you have ever felt and 10 being the best, as a three. When asked to rate her was mood when she entered the hospital on the same scale she rated her previous mood to be a one to a two. She acknowledged she has started to feel a little bit better but her mood was still low. She felt that her mood has improved due to the medication she has been on as well as being around more people. The client also had a flat affect. When the client told the writer about her break up with her ex-boyfriend, there was very little indication of feelings or emoti...

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...the interview until then end, I could have clarified and reflected on more of her answers more but I did clarify how often she was hearing auditory hallucinations at 4:58 of the video.

I prepared for this assignment and believe that through my inquiry skills and active listening, I effectively assessed my patient. One aspect that I plan to focus on in the future and improve upon is my anxiety when interviewing my patients. If I were less anxious, I would not fidget as much as well as eliminate some awkward phrases to make my speech more fluent. Although I omitted asking about illusions, I believe I collected relevant and important information. The information I collected would be helpful to the health care team because they could then tailor interventions and treatments that would best fit my patient and improve the overall care in which she would receive.