Comprehensive Assessment of an Adult/Older Adult

Basic Patient Information

Patient Demographics:

Initials Age: 64           Sex: Female    Marital Status: Married

Language:                 English            Race: Caucasian White

Sexual Orientation:   Bisexual          Education: University          

Occupation:   High School Teacher (Retired)

Allergies: No notable allergy  

Pertinent Data about the Case

Chief Complaint: I am feeling depressed and weak.

History of Presenting Illness

Rosaline Smith is a 64-year-old Caucasian White family friend diagnosed with depression. Rosaline presented herself to a GP for depression treatment. The patient presents a medium-sized body older woman but still strong to walk without being assisted. Rosaline says that the onset of her depression was triggered by the death of her beloved husband two years ago and even worsen following the death of his son less than a year ago. Rosaline enjoys socializing and taking part in several church activities. The GP settled that the patient’s case needed special attention and referred her to Community Mental Health Team.

Past Psychiatric History: No history of psychiatric problem

Medications (current medical & mental health)

Rosaline’s referral notes indicate that the depression should be examined further because of the patient’s mental health deterioration. The examination underscored significant depression symptoms, including fatigue, decreased appetite, reduced concentration and memory, and anhedonia. The symptoms of depression vary in intensity, and she primarily uses SSRI medication to control the symptoms. Rosaline also experiences occasional panic attack attacks where she complains of her fear of death and extreme anxiety (Wilkinson, Ruane, & Tempest, 2018). The symptoms are highly likely to affect the patient’s coping ability, personal life, and overall quality of life.

Assessment of Appearance and Behavior

The mental health examination starts when the physician first encounters and observes the patient. The patient’s interaction with the physician in the first encounter and setting may signify the patient’s mental or emotional state or reveal underlying psychiatric disturbances (Norris, Clark, & Shipley, 2016). The following section describes Rosaline’s appearance and behavior.

Patients dress: disheveled, clothes and hair not well kept.

Striking characteristics: the patient looks sad and dull.

Motor behavior: observations of motor behavior including general body movement, body posture, facial expression, level of psychomotor activities, and gesture, among other features (Kennedy-Malone, 2018). Rosaline exhibited psychomotor retardation characterized by general slow emotional and physical reactions.

Presence/absence of displacement activities: often talk alone to ease her anger.

Attitude toward examiner: positive. The patient even visited the GP herself for treatment.

Assessment of Speech Characteristics and Thought Processes

Observing speech during mental examination assesses spontaneity, volume, rate, and coherence. The form of speech is more critical during the examination than the content and may link the associated mental disorder. Slow speech may signal depression, while faster speech can be due to mania (Norris, Clark, & Shipley, 2016).

Rate of speech: Slowly

Pressured speech: No

Tangential thought: Yes, the patient moves from thought to thought but never seems to connect the ideas to make sense out of them.

Derailment/loosening of associations: Yes, the patient keeps jumping from one idea to another during the speech unconsciously.

Flight of ideas: Not observed 

Thought blocking: Yes, the patient sometimes goes silent without uttering even a single word for ten minutes.

Illogical thoughts: Yes, the patient sometimes thinks of and communicates things that do not make sense.

Assessment of Thought Content

Ruminations: Yes, the patient dwells on little negative emotion and may not talk to immediate family members for hours following a disagreement. Kaiser et al. (2018) argue that rumination is an adverse reaction when a person feels pain, and they tend to dwell much on emotions, causes, and other outcomes instead of addressing the problem actively. The person may be immersed in overthinking and other circumstances limiting their motivation and inhibiting their active behavior.

Obsessions: Yes, but minimal

Compulsions: Yes, but minimal

Delusions: Yes

Thoughts concerning dangerousness to self/others: Yes,attempted suicide once.

Assessment of Perception

Hallucinations (visual/auditory/tactile): The patient is experiencing hallucinations, including thinking and fear of death and illness alongside worthlessness and personal inadequacy. Study shows that patients with clinical depression are also prone to suffering hallucinations and delusional thinking. The symptoms are linked to psychosis or psychotic depression (Dubovsky et al., 2021).

Illusions: Recent research have concluded that individuals with depression are more prospective to perceive visual illusion considerably weaker than people with no depression episodes (Matute et al., 2015). The fast-paced and life pressures take a toll on people’s mental health.

Assessment of Mood and Affect

Mood: Mood refers to the patient’s internal subjective emotional state. It relies on the patient’s self-report alongside physician observation. The physician may ask the patient their moods for the past few weeks or a month instead of merely asking about the present moment. The physician can also make the assessment more objective by requesting the patient to rate their mood on a scale of 1 to 10 in each visit, with one being sad and ten happy (Norris, Clark, & Shipley, 2016). The patient mood is was observed at 3, which is slightly sad.

Affect: Affect refers to the physician’s objective observation and recording of the patient’s expressed emotional status based on interaction or facial expression (Norris, Clark, & Shipley, 2016). The patient’s affect was described as flat, less intense, or dull emotion.

Assessment of Sensorium, Cognitive Functioning, and Insight

Level of consciousness: the patient is awake and understands what is happening in her surroundings.

Intellectual functioning: the patient is mentally sound and can learn, reason, and plan hospital visits and other activities of daily living.   

Memory: the patient is alert and speaks fluently.

Insight: The patient is aware of her health condition and the need for treatment.

Judgment: The patient is aware and makes decisions that do put her into harm

Motivation: Less motivated.