Monash University PSY3032: Clinical Report on Jim's Mental Status

This clinical report presents a Mental Status Examination (MSE) of a young male client named Jim, who was brought to the pediatric ward by his parents due to mood swings, irritability, and repetitive behaviors. The report details Jim's appearance and behavior, including clothing, grooming, posture, communication style, and psychomotor activity. It also assesses his speech, mood, affect, perceptions, cognitions, and intellectual functioning. The MSE reveals specific observations, such as monosyllabic communication, tangential thought content, and restricted affect. Jim's memory and intellectual capabilities appear strong, but his insight and judgment are assessed as limited due to his age. The report concludes with relevant observations, including prior diagnosis and current medication, and suggests the potential benefits of psychotherapy for Jim. The report follows the structure of a clinical research report and includes a completed MSE record form and provides a comprehensive overview of the client's mental state.

Mental Status Examination Record Form Date: 14.09. 2019
Client Name: Jim Circumstance of presentation: Presented in the paediatric ward by
his parents in order to understand the reasons behind this mood
swings, irritability and repetitive behaviour. He is presented with
other children between the age group of three to 7 years who have
various other mental health complication
Date of Birth: 26th Jan 2014
Gender: Male
Appearance and Behaviour
General
Appearance
Clothing:
Normal and
clean
Grooming: Normal Other Features: Unable to adjust the
clothes while out of washroom unlike
children of same age group
Attention and
Attitude
Posture:
Walking
slowing with
head held low
and staring at
the fllow
Communication style:
Mono syllable
communication with
repetitive words
Other Features: Refusing to
communicate with elder however,
communicating with the children of
same age group but communication
in limited
Behaviour Rapport:
Having limited
rapport with
the children of
same age
groups
Eye contact: Refusal
to maintain eye
contact
Psychomotor activity: Frequent
nodding to head and blinking of eyes
when asked to answer any question
along with Hand wringing
Other Features:
Speech
Rate: Pressured Rhythm: monotone Volume: loud
Content: The child repeats the same words three to four times in order to answer any particular
question but speaks in monosyllables. When asked to reply do you love to eat food:, Jim said,
Chicken..... Chicken.., chicken.... with nodding to head and eyes staring at floor. Response came
after 2 mins with limited facial expression. Moreover, when asked to speak in sentence his content
is tangential that is never returning back to the original topic
Mood: Irritable
1 2 3 4 5 6 7 8 9 10
Affect: anxious

Range:
Restricted to flat
Congruence:
Mood and affect are not
congruence
Stability: Facial expression and
body movement is linked with
mood
Perceptions and Cognitions
Memory: Immediate memory is
strong
Long-term memory is
poor
Short-term memory is
also strong
Intellectual
functioning:
Moderate
Orientation: Person: Normal Place: Normal Time: Normal
Thought processes:
Thought process is not uniform, shifts from one
through to another (tangential or flight of
ideas)
Thought content: The thought content is relevant
with so significant indication for hallucination but
at times shows signs of dissociation
Insight and Judgement: Jim’s memory is strong he as he can remember the name of 10 states at a
stretch when asked to play memory game with his peers. His intellectual capability is also strong as
he sum addition, multiplication, division and subtraction verbally without any pen or paper or use of
calculator (with more than two digit number)
Jim is too young to state that whether he is ill or not. However, it seems that he will agree to take
part in the therapy as he is obedient. The application of the psychotherapy will help to bring
promising outcome for Jim.
Other relevant observations
Prior diagnosis
Current psychotherapy Nil
Current psychoactive medication Nil
Current illicit drug use Nil
Other