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Mental Exsamnation

By denalicious May 07, 2013 358 Words
General appearance and behaviour Lucy is a 34 year-old Indian-Portuguese woman of average weight and height. At the time of examination, she was well groomed and dressed. She was not confined to bed. On appearance, were no signs of tremor or abnormal movements; however, Lucy showed signs of proptosis, consistent with Grave's disease. Lucy was cooperative throughout the interview. She maintained eye contact, except during the times when recounting the history of her father's death and her previous marriage. Then, she appeared depressed. Speech Lucy articulated herself clearly. She answered questions spontaneously, although at slow rate and speed. She spoke softly throughout the conversation, particularly when mentioning past unhappiness. Affect and mood Lucy's affect was depressed and her range of mood reduced. She also appeared anxious and irritable. Thought a. Stream Lucy's thought stream was decreased. It was also disturbed and Lucy's speech slowed down and content reduced significantly when mentioning past unhappiness. b. Form Lucy did not exhibit any formal thought disorders. She was able to answer questions spontaneously and directly. She did not use any new or created words. Lucy did experience thought block when exploring sensitivities in her past. No negative thought disorder was detected. c. Content Lucy was depressed and anxious about her health. She was obsessed with knowing her biopsy result and was constantly asking the doctors and nurses for her result. Thoughts that the tumour could be cancer were causing Lucy to lack motivation and feel restless. Lucy was also feeling guilty for not being able to care for her son and fiance since having the headache. Other than feeling obsession and guilt, Lucy has no other positive symptoms, such as delusions, phobias or compulsions. Suicidal ideation was not detected. Perception Lucy exhibits normal perception. Symptoms, such as illusions, misinterpretations, depersonalisation, passivity phenomena, were not elicited. Cognition Lucy was alert and orientated to time and place. She was able to answer questions and recall her past without difficulties. Insight and judgement When questioned about her condition, Lucy accepted the fact that she is ill and requires treatment. She has cooperated with doctors and nurses and is compliant with management.

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