Case History and MSE

A. HISTORY OF THE CLIENT

Name: Mr.S
Age: 62 years
Sex: Female
Occupation: Unemployed (previously an administrator at a real-estate office)
Education: -NA-
Socio-economic status: -NA-

A.1 Complaints and their Duration

Progressive deterioration of memory, confusion, mild difficulties with gait, and balance,
fatigued easily, problems with fine motor skills. Present complaints have caused her
problems with daily life, affecting sleep quality and quantity, and social communication.

A.2 History of present illness

Symptoms worsened in the past 3 months, causing her recent unemployment. The client
reports progressive worsening of memory, and confusion, rendering her unfit for work.
Attempts have been made to retard the conditions’ physical progression, through
physiotherapy; there are problems with gait, balance, and becoming fatigued easily. The
client has stumbled and tripped multiple times during the last three months, but was unhurt.
Increasing difficulty with fine motor skills such as writing and doing up buttons while
dressing.

A.3 Associated disturbances

The client reports problems with ADLS, sleep quality and quantity, and social
communication, due to her symptoms. Because of these disturbances along with her
cognitive and psychomotor symptoms, she is no longer able to work.

B. MENTAL STATUS EXAMINATION

B.1 General Description

The client appears attentive, conscious and alert, looking around keenly when they first
entered the therapy room. The patient was initially tense, but was eventually relaxed, as the
conversation progressed. The patient appears to be in a low mood and fatigued, but is able
to establish a rapport with the therapist. The eye contact is optimal, the posture is normal,
and the patient is cooperative, and able to more or less express their concerns clearly;
however, they occasionally lost track of what they mentioned a few minutes back. The
patient was dressed well, but there were some signs of struggle with combing her hair and
buttoning of her sweater.

B.2 Psychomotor activity

The psychomotor functioning appears normal, but there are difficulties in fine motor skills,
such as being unable to grasp and manipulate the pen instantly when the client was asked
to sign their name. When the patient first entered the room, they found it difficult to walk
around the furniture and were about to lose their balance as they navigated their way around
the table placed in the centre of the sitting area.

B.3 Talk

The client initially spoke only spoken to, but was able to eventually carry on a conversation
normally. They initially spoke quickly, but eventually began pacing themselves, as they
revealed more details about their condition; the speech was clear, and their reaction time to
verbal prompts was normal. They were coherent, but sometimes experienced lapses in
recalling, making it occasionally difficult to follow.

B.4 thought