NRNP 6634 Week 3 Mental Status Exam Example

Mental Status Examination: A 72-Year-Old Woman, Domain by Domain, With Mood Quoted, Affect Observed, and a MoCA of 23 Read Item by Item

Student Name

College of Nursing, Walden University

NRNP 6634: Psychiatric Mental Health Advanced Practice Nursing Care of Adults and Older Adults

Instructor Name

Month Day, Year

Mental Status Examination: A 72-Year-Old Woman, Domain by Domain, With Mood Quoted, Affect Observed, and a MoCA of 23 Read Item by Item

Appearance

Composite patient, the woman whose interview was written up in week 2. Appears her stated age. Dressed in a cardigan buttoned one button off, clean slacks, and house slippers; hair combed; no makeup, which her daughter later said she wore daily until spring. A wedding ring worn on a chain around her neck. Visible weight loss suggested by a loose waistband held with a safety pin.

Behavior and Psychomotor Activity

Sat still with hands folded for most of the interview; few spontaneous gestures. Eye contact directed at the floor or her hands for most of the interview, meeting the examiner's eyes when asked a direct question and then looking down. Latency of 3 to 5 seconds before many answers. No tremor, no tics, no abnormal movements. Rose from the chair slowly, using the armrests.

Speech

Rate slow; volume soft, requiring her to repeat two answers; quantity reduced, with answers of a few words unless prompted; prosody flat, with little variation in pitch. Articulation clear; no word-finding pauses beyond the latency above.

Mood and Affect

Mood, in her words: "Empty. Like I'm waiting for something and I don't know what."

Affect, as observed: restricted in range; tearful twice, both times when her sister was mentioned; one brief smile when describing her granddaughter's recital. Congruent with the stated mood: the observed affect matches the emptiness she describes, with reactivity preserved for grief and for her granddaughter.

Her Geriatric Depression Scale score of 11 of 15 from the waiting room (Yesavage et al., 1982) is consistent with the observed affect and is recorded here beside it.

Thought Process and Content

Process: linear and goal-directed; slowed; no tangentiality, circumstantiality, or loosening of associations; she lost her train of thought once and recovered it when given the last few words she had said.

Content: preoccupied with her memory and with the loss of her sister; expressed guilt that she "should have made Ruth see a doctor about the chest pain." Passive death wish as recorded in the interview, without active suicidal thoughts, plan, or intent at the time of examination. No homicidal thoughts. No delusions elicited; asked whether she feels she deserves punishment or that others are against her, she said no.

Perception

Denies auditory or visual hallucinations; did not appear to respond to internal stimuli during the interview.

Asked specifically about seeing people or animals in the house at night, a question worth asking in an older adult with memory complaints and new sleep medication use, she said no.

Cognition, With a Screen and Its Numbers

Alert throughout. She gave her name, the clinic's name and city, the full date, and why she was here without error. Montreal Cognitive Assessment (MoCA), version 8.1, administered in a quiet room: total 23 of 30, with 1 point added for 12 or fewer years of education not applicable (she completed 2 years of college). The MoCA was designed to detect mild cognitive impairment in people who score in the normal range on the Mini-Mental State Examination, using a cutoff of 26 (Nasreddine et al., 2005). By item: visuospatial and executive, 4 of 5 (clock hands placed correctly, numbers crowded); naming, 3 of 3; attention, 4 of 6 (digit span correct forward and backward, lost 2 points on serial sevens, with slow responses); language, 2 of 3 (fluency 9 words in 1 minute, short of the 11 needed for the point); abstraction, both pairs correct, 2 of 2; delayed recall, 2 of 5 free recall, rising to 5 of 5 with category and multiple-choice cues; orientation, 6 of 6.

Observation on the pattern: the lost points cluster in attention, fluency, and free recall, with recall improving to full marks when cued. A retrieval pattern of this kind is often seen with depression and differs from the storage deficit typical of Alzheimer disease, but a screen cannot settle that; the pattern is recorded here for the differential, not interpreted as a diagnosis.

Insight and Judgment

Insight: partial. She recognizes that her mood has changed and that her memory complaints followed her sister's death, and she said, "Maybe some of this is the sadness." She also attributes all of it to "the start of what my mother had." Judgment: intact for the decisions observed; she stopped highway driving on her own when her concentration worsened, and she agreed to her daughter taking over the bills. The APA practice guideline recommends that the evaluation include a mental status examination with cognitive assessment (American Psychiatric Association, 2015); the findings above are the basis for the differential that follows.

References

American Psychiatric Association. (2015). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults (3rd ed.). https://doi.org/10.1176/appi.books.9780890426760

Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695-699. https://doi.org/10.1111/j.1532-5415.2005.53221.x

Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. https://doi.org/10.1016/0022-3956(82)90033-4