# Clinical Cases: Psychiatric Evaluation and Mental Status Examination ## Case 1: Major Depressive Episode - Comprehensive MSE ### Patient Presentation **Demographics:** 45-year-old female **Chief Complaint:** "I can't get out of bed anymore and I don't care about anything." **History of Present Illness:** A 45-year-old married woman is brought to the outpatient psychiatry clinic by her husband who reports that she has been increasingly withdrawn over the past 6 weeks. She stopped going to work 2 weeks ago after being a reliable employee for 15 years. She has lost approximately 10 pounds due to poor appetite and wakes up at 4 AM daily unable to return to sleep. She admits to feeling "worthless" and having fleeting thoughts that "everyone would be better off without me," though she denies any specific plan or intent to harm herself. Her husband reports she barely speaks and shows little emotional response to anything, including visits from their grandchildren whom she previously adored. **Mental Status Examination:** - **Appearance:** Middle-aged woman appearing older than stated age, disheveled with unwashed hair, wearing wrinkled clothing, poor hygiene noted - **Behavior:** Psychomotor retardation with slowed movements, minimal spontaneous gestures, poor eye contact - **Cooperation:** Cooperative but minimally engaged - **Speech:** Soft volume, slow rate, monotonous tone, increased latency, poverty of content - **Mood:** "Empty... hopeless" (patient's words) - **Affect:** Blunted range, unreactive, congruent with depressed mood - **Thought Process:** Linear but impoverished, goal-directed with significant latency - **Thought Content:** Passive suicidal ideation without plan or intent; no homicidal ideation; no delusions; pervasive guilt and worthlessness - **Perceptions:** Denies hallucinations - **Cognition:** Alert and oriented x4; attention mildly impaired (difficulty with serial 7s); memory intact - **Insight:** Partial - acknowledges something is wrong but attributes it to personal failure - **Judgment:** Impaired - stopped taking blood pressure medication, not attending to hygiene **Workup:** - **PHQ-9:** Score 24 (severe depression) - **Columbia Suicide Severity Rating Scale:** Passive ideation without intent - **TSH:** 2.4 mIU/L (normal) - **CBC, CMP:** Within normal limits - **Urine drug screen:** Negative - **Vitamin B12, folate:** Normal **Diagnosis:** Major Depressive Disorder, single episode, severe, without psychotic features **Treatment:** - Started on sertraline 50 mg daily with plan to titrate to therapeutic dose - Safety plan developed collaboratively with patient and husband - Husband agreed to secure firearms and medications in the home - Referral for cognitive behavioral therapy - Weekly follow-up appointments initially to monitor suicidal ideation - Discussed sleep hygiene and structured daily activities **Clinical Pearl:** The mental status examination provides a cross-sectional snapshot of the patient's current mental state. The distinction between mood (subjective, patient-reported) and affect (objective, clinician-observed) is crucial. This patient demonstrates congruence between her depressed mood and blunted affect. The presence of passive suicidal ideation requires careful safety planning and close follow-up, even without active intent. --- ## Case 2: First-Episode Psychosis - MSE in Acute Psychosis ### Patient Presentation **Demographics:** 22-year-old male **Chief Complaint:** Brought by parents who state "He's been acting strange and says people are watching him." **History of Present Illness:** A 22-year-old college senior was brought to the emergency department by his parents after they received a call from campus security. The patient was found wandering in the library at 3 AM, talking to himself and attempting to disconnect security cameras because he believed "they" were using them to monitor his thoughts. His parents report a gradual change over the past 6 months: declining grades, social withdrawal, dropping out of his fraternity, and increasingly bizarre statements about being "chosen for a special mission." He has not slept more than 2-3 hours per night for the past week and has been eating poorly. He has no psychiatric history and no substance use other than occasional alcohol. Family history is significant for a maternal uncle with schizophrenia. **Mental Status Examination:** - **Appearance:** Young male appearing stated age, disheveled with unkempt hair and soiled clothes, malodorous, appears not to have bathed in days - **Behavior:** Psychomotor agitation with restless pacing, frequently looking toward the door and windows, guarded posture - **Cooperation:** Initially guarded and suspicious, became more cooperative with calm reassurance - **Speech:** Pressured rate, normal volume, somewhat disorganized with occasional tangential responses - **Mood:** "I'm fine, they're the ones with the problem" (patient's words) - **Affect:** Restricted range, inappropriate at times (laughed when discussing surveillance), anxious - **Thought Process:** Tangential with loose associations; circumstantial at times; some thought blocking observed - **Thought Content:** Paranoid delusions (believes government agents are monitoring him through cameras and his phone); grandiose delusions (believes he has been chosen for a special mission); ideas of reference (believes news anchors are sending him coded messages); denies suicidal or homicidal ideation - **Perceptions:** Endorses auditory hallucinations - two male voices commenting on his actions and occasionally commanding him to "stay alert"; denies visual hallucinations - **Cognition:** Alert and oriented to person and place, disoriented to date (off by one week); attention impaired; unable to complete serial 7s - **Insight:** Poor - does not believe he is ill, attributes symptoms to real external threats - **Judgment:** Poor - attempted to "escape" through window, has not been attending to self-care **Workup:** - **Urine drug screen:** Negative for all substances - **Blood alcohol level:** Undetectable - **TSH:** Normal - **CBC, CMP:** Normal - **RPR:** Non-reactive - **HIV:** Negative - **MRI brain:** No structural abnormalities - **EEG:** No epileptiform activity **Diagnosis:** Schizophrenia spectrum disorder, likely schizophrenia (first episode, acute) **Treatment:** - Admitted to inpatient psychiatric unit on voluntary status after much discussion - Started on risperidone 2 mg at bedtime - Sleep hygiene measures implemented - Daily supportive therapy - Family psychoeducation initiated - Duration of untreated psychosis estimated at 6 months - early intervention emphasized - Discharged after 10 days with significant improvement in positive symptoms - Enrolled in first-episode psychosis early intervention program **Clinical Pearl:** First-episode psychosis requires thorough medical workup to exclude organic causes. The MSE in psychosis typically reveals disorganized thought process, impaired insight and judgment, and often incongruent or inappropriate affect. Auditory hallucinations, particularly voices commenting or conversing, are characteristic of schizophrenia. Early intervention programs for first-episode psychosis improve long-term outcomes. --- ## Case 3: Manic Episode with Psychotic Features - Documenting the MSE ### Patient Presentation **Demographics:** 34-year-old female **Chief Complaint:** Brought by police after attempting to direct traffic in the middle of a highway, stating "I'm the only one who can prevent accidents." **History of Present Illness:** A 34-year-old woman with a known history of bipolar I disorder was brought to the emergency department by police. She was found standing in the middle of a busy highway, attempting to direct traffic. When approached, she became irritable and explained that she had developed the ability to see into the future and knew that a major accident would occur without her intervention. Her husband reports she has slept only 2-3 hours per night for the past week yet appears "full of energy." She maxed out three credit cards in the past 3 days buying "essential supplies" for her "mission." She has made numerous inappropriate sexual comments to neighbors. She stopped taking her lithium 3 weeks ago because she "felt so good I didn't need it anymore." Her last manic episode was 2 years ago. **Mental Status Examination:** - **Appearance:** Well-groomed female appearing younger than stated age, wearing bright, mismatched clothing with excessive jewelry, heavy makeup - **Behavior:** Psychomotor agitation, unable to remain seated, pacing around the room, animated gestures - **Cooperation:** Intermittently cooperative; becomes irritable when interrupted or redirected - **Speech:** Pressured, rapid, loud, difficult to interrupt, increased quantity - **Mood:** "Fantastic! I've never felt better in my life!" (patient's words) - **Affect:** Elevated, expansive, labile (rapidly shifts to irritability when thwarted), euphoric, incongruent at times - **Thought Process:** Flight of ideas with rapid topic shifts; some loose associations; clanging noted ("I'm here to save, to pave, the brave new way") - **Thought Content:** Grandiose delusions (believes she has supernatural powers to predict the future); denies suicidal or homicidal ideation; no paranoid content - **Perceptions:** Denies hallucinations - **Cognition:** Alert and oriented x3 (disoriented to date); attention severely impaired (unable to complete any testing due to distractibility) - **Insight:** Absent - believes she is "better than ever" and does not need treatment - **Judgment:** Severely impaired - engaged in dangerous behavior, excessive spending, social impropriety **Workup:** - **Lithium level:** <0.1 mEq/L (undetectable - confirms non-adherence) - **Urine drug screen:** Negative - **TSH:** 2.8 mIU/L (normal) - **CBC, CMP:** Mildly elevated WBC, otherwise normal - **Pregnancy test:** Negative - **ECG:** Normal sinus rhythm, QTc 410 ms **Diagnosis:** Bipolar I Disorder, current episode manic, severe, with mood-congruent psychotic features **Treatment:** - Involuntary admission due to danger to self (highway behavior) and inability to care for self - Lithium restarted at 600 mg twice daily with levels monitored - Olanzapine 10 mg added for acute mania with psychosis - Lorazepam 2 mg as needed for agitation - One-to-one observation initially due to poor judgment - Sleep hygiene and low-stimulation environment - Psychoeducation about importance of medication adherence once stable - Family meeting to discuss warning signs and relapse prevention - Gradual improvement over 2 weeks; transitioned to voluntary status **Clinical Pearl:** The manic MSE demonstrates elevated or irritable mood with increased energy, pressured speech, and flight of ideas. Mood-congruent psychotic features (grandiose delusions consistent with the elevated mood state) are common in severe mania. The documentation of absent insight and severely impaired judgment provides the clinical basis for involuntary treatment. Lithium non-adherence is a common precipitant of manic relapse, and levels should be checked to confirm suspected non-compliance. --- ## Clinical Image ![Mental Status Examination Components](case_01_image.jpg) **Image Description:** Diagram illustrating the components of the mental status examination, including appearance, behavior, speech, mood, affect, thought process, thought content, perceptions, cognition, and insight/judgment - the systematic approach to psychiatric assessment. **Attribution:** Educational diagram based on standard psychiatric assessment frameworks. For clinical educational use. **Image Source:** Suggested image - Search Wikipedia Commons for "mental status examination" or use Radiopaedia psychiatric imaging resources.