Mental Status Case Study

The mental status exam was completed using an abbreviated version of the Mental Status Exam for adults (MSE). As well, the client was screened with the CAGE assessment tool and the Patient Health Questionnaire (PHQ-9). Ann arrived on time for her counselling session. She was a bit nervous about her first counselling session. The session took place in a counselling office on the third floor. The room was well lit and had no distracting elements. Ann appeared casually dressed, groomed, and had good hygiene. Her grooming and dress were appropriate to the situation. She did not wear glasses, hearing aid, or any prosthetic devices. She had adequate eye contact. Her face showed sadness, anger, and fatigue for most of the session. She was fidgety with her hands at times. Her posture changed from sluggish to sometimes erect. She was attentive and cooperative throughout the session. …show more content…
She elaborated and said her husband would find her crying, teary, and exhausted at odd times, which she could not explain. She claimed being sad for the past six months because of the deaths of her two coworkers and two friends who died by suicide. These deaths occurred within a five-year span. She discovered her coworkers’ deaths in the obituaries section of the newspaper. The deaths of both of her coworkers happened within a one-year span. It caught her by surprise. Her friends also died through completed acts of suicide which were also unexpected to her. She reported, “I am confused as to why my husband and friends are saying that I am