This report presents a comprehensive Mental Status Exam (MSE) of Jamilla, a 32-year-old woman with a history of trauma stemming from her upbringing in rural Afghanistan and subsequent refugee experiences. The MSE evaluates Jamilla's appearance, behavior, speech, mood, affect, thought processes, perception, sensorium, cognition, insight, and judgment. The report details presenting factors, including current mental health challenges triggered by financial instability and past trauma, and predisposing, precipitating, and perpetuating factors. A clinical formulation is provided, followed by a nursing care plan that prioritizes professional guidance and addresses the need for therapeutic relationships and job opportunities for her husband. The report concludes with a clinical handover summary, including recommendations for continued counseling and therapeutic interventions to address Jamilla's depression and improve her overall well-being. The importance of establishing a therapeutic relationship is emphasized throughout the report, with a discussion of key strategies such as empathy, trust, and active listening.
![[object Object]](/_next/static/media/star-bottom.7253800d.svg)
