BACKGROUND INFORMATION: Ms. Hester is a 78-year-old, African American, divorced, female receiving treatment at Paradise Valley Hospital Inpatient Psychiatric Services Program on the Closed Unit. Ms. Hester was referred for psychological testing to assess her current neurobehavioral baseline to understand level of cognitive functioning. Ms. Hester was admitted to the hospital on a 5150 grave disability and danger to self and was unable to verbalize a plan for self care. Ms. Hester is currently diagnosed with Paranoid Schizophrenia, Chronic and her current medication includes Seroquel 100mg at bedtime. According to her chart records and collateral from her ex-husband’s reports Ms. Hester’s onset of psychotic symptoms began three to five months …show more content…
Hester was administered the Mini mental status exam. This task provides a brief overview of her general neurocognitive status. Her total score was 26/30. Ms. Hester was oriented to the year, season, day, month, country, state, county and clinic. She was able to register objects, however when asked to recall the three objects, could only name one (she knew that one of the words was incorrect but could not recall the correct word). Ms. Hester was capable of following commands and written directions as well, but when Ms. Hester was asked to count backwards from 100 by seven she followed a sequence of subtracting one instead; she was able to spell the world the word WORLD backwards without difficulty as the alternative.
IMPRESSIONS/RECOMMENDATIONS: Despite some of Ms. Hester’s noted difficulties with delayed recall and attention on the Mini Mental Status Exam, her results suggest that her score of 26/30 is within normal limits. Due to Ms. Hester’s most recent presenting problem upon admission, she would likely benefit from more supervised care through an in home health service or senior care facility. Supervised care will work to ensure continued medication compliance and a connection with a senior services program will afford her the opportunity to gain support and stay active. Consider a more detailed neurological battery to assess further for possible neurological deficits or