MSA #2-BIPOLAR

Mental Status Exam Adrianna Gherna Hernandez Client Name John Riley Date 06/11/2022 OBSERVAT I ONS Appearance x Neat x Disheveled □ Inappropriate □ Bizarre □ Other Speech □ Normal □ Tangential x Pressured □ Impoverished □ Other Eye Contact □ Normal □ Intense x Avoidant x Other Motor Activity □ Normal x Restless □ Tics □ Slowed x Other Affect □ Full □ Constricted □ Flat x Labile □ Other Comments: Client’s appearance is neat, proper clothing with overall good hygiene, but his hair was not groomed. The client seems a little disheveled due to the amount of movement and speed causing his hair and body posture to be all over the place. The client’s speech is pressured, hyperactive, and he is eager to have speech heard so the rate of the speech is too fast. The latency is short and fast, and volume of speech is loud and clear. The client spoke so fast the doctor had no chance to respond or ask questions as they had planned to during exam. The client’s eye contact is avoidant, and he focuses his attention on the newspaper and journal in his hands. The client’s motor activity is restless, and he explains that he has no need to sleep or rest because he has so much more to do for his cancer research. The client’s affect is labile due to the client’s change from hyperactive to agitated w/withdrawal from conversation with the doctor. The client was agitated because the doctor would not focus on his cancer study. This seems consistent with mania. MOOD □ Euthymic □ Anxious □ Angry □ Depressed x Euphoric x Irritable x Other Comments: The client’s mood is euphoric while expressing the work he has been doing with God and the Pope furthering his research in cancer and finding the cure. The client’s mood switched in seconds when the doctor would not pay attention to him and his studies of cancer. He stated, “Well you’re a shit boss and I want to talk to somebody else, there must be somebody else I can talk to”. COGN I T I ON Orientation Impairment □ None x Place □ Object x Person □ Time Memory Impairment □ None x Short-Term □ Long-Term □ Other Attention □ Normal x Distracted □ Other Comments: The client is oriented to place by knowing he was sent to see a psychiatrist. The client is oriented to person by knowing who he is and what his name is. The time and object are not identified throughout the exam. The client’s memory impairment is short-term and sporadic. The client’s attention and concentration are hyperactive and constantly fixated on his cancer research. PERCEPT I ON Hallucinations □ None x Auditory □ Visual □ Other Other x None □ Derealization □ Depersonalization Comments: The client’s hallucinations are described as second person auditory. The client states, “Well, how it works is God tells me you know, that I am doing a really good job and so I do not stop, I do not stop”. The client also states, “He talks to me, and he tells me I am doing a really good job and that I am fantastic”. The voice is said to have come through God’s mouth and into John’s ears. THOUGHTS Suicidality x None □ Ideation □ Plan □ Intent □ Self-Harm