Challenging environment Essay

Mrs. Dae is a 28 year old Caucasian female. She presents clean and well dressed. She is approximately 5’ 6†, 145 lbs. She appears healthy and in shape. No visible physical deformities. She has normal gate. She is open and cooperative. She has a normal rate of speech and makes appropriate eye contact. Mrs. Dae expresses herself appropriately. In discussing family history, Mrs. Dae has little trouble recalling events. She is unaware of some family history on her father’s side. Mrs. Dae is orientated x 4. She has logical thought process. Mrs. Dae is alert, however, states she has been busy lately and is tired today. She reports getting approximately 6-8 hours of sleep nightly. Mrs. Dae is able to count backward from 100 by 7’s. She displays logical thought processes. No report of hallucinations or delusions. Mrs. Dae appears to have good judgment and insight. She is of high intelligence and is able to appropriately explain the meaning of a common proverb. (â€Å"A rolling stone gathers no moss†) (â€Å"How to†). Mrs. Dae appears happy and confident, with appropriate affect. During the interview Mrs. Dae was relaxed and participated in spontaneous conversation. She denies any suicidal or homicidal ideation. Strengths/ Weaknesses: Mrs. Dae is highly educated. She appears confidant with high self esteem. She reports she enjoys caring for others. She has good insight and appears to have good coping skills. Mrs. Dae has a supportive family. In terms of weaknesses, Mrs. Dae admits to taking on too many activities at once and at times she feels â€Å"burned out†. Family History: Mrs. Dae is the second of three children and grew up in a typical middle class American home. She has an older brother and a younger sister. Mrs. Dae’s parents were divorced when she was 7 years old. Ms. Dae and her siblings lived with their mother. Mrs. Dae reports her father was verbally and physically abusive toward her mother. This was the reason for the divorce. She does not recall being the victim of such abuse herself. However, she reports that her mother tells her that her father was â€Å"mean to all of us† (referring to Ms. Dae, her siblings and mother). Mrs. Dae denies any sexual abuse. Shortly after the divorce, Mrs. Dae reports all three children stopped seeing their father. She currently has no relationship with her father, however she reports speaking to him on the phone occasionally. Aside from these events, Mrs. Dae reports a normal childhood. She reports discipline as a child in the form of â€Å"grounding, which rarely occurred†. Mrs. Dae is currently married. She has been married for the past 8 years. She denies any previous marriages. Ms. Dae describes her marriage as â€Å"good†. She states she and her husband attended marriage counseling for approximately 3 months earlier in their marriage. Mrs. Dae reports that her husband has a well paying job. She denies any current financial hardship. The couple recently bought their first home. She reported some stress during the process. However, she did not think it was â€Å"more then would be expected when buying a home†. Mrs. Dae and her husband have one child, a 5 year old girl. Education and Work: Mrs. Dae graduated high school in the top 10% of her class and went on to college. She majored in psychology and graduated Cum Laude. She continued to earn her Master of Science degree. Mrs. Dae currently works with at risk youth in the prevention and advocacy department of a non-profit company. She has been with her current employer for one year. She reports being satisfied with her job. She states she makes â€Å"good† money and the work she does is rewarding. Mrs. Dae stated she plans on returning to school in the near future for her PhD in Psychology. Her long term goal is to go into private practice serving youth. Mental/ Physical Health: There is no known history of mental illness on her mother’s side of the family. Mrs. Dae reported there may be depression on her father’s side. Mrs. Dae denies any form of depression aside from â€Å"the blues† every now and then. Mrs. Dae reports history of cancer on both sides of her family. Mrs. Dae participates in annual physical examinations. According to her last physical she is in good health. Mrs. Dae denies substance use. She stated she will drink a glass of wine â€Å"once in a while†. Mrs. Dae denies tobacco use. Legal History: Mrs. Dae denies any significant legal history, aside from a few traffic tickets. Social: Mrs. Dae reports she has a group of friends, other married couples, that she and her husband spend time with. She is also a member of her church and participates in social events at the church. As her child recently started attending elementary school, Mrs. Dae stated she has joined the school’s Parent-Teacher Association. Spiritual: Mrs. Dae reports growing up Catholic but she did not go to church often as a child. She states that she no longer practices Catholicism, however, she does go to a non denominational Christian church. She goes to church on a regular basis. She feels strongly about her beliefs. Mrs. Dae reports that she prays on a daily basis and stated â€Å"this keeps me grounded†. Hobbies/Activities: Mrs. Day states she enjoys reading, yoga, and going to the spa with friends. She admits she has little time to spend on these activities. However, she reports that she and her husband give each other time with their friends, time together, and family time on a regular basis. References How to do a Mental Status Exam. Retrieved on November 9, 2007 from http://www.psychpage.com/learning/library/assess/mse.htm