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Mental Status Examination (MSE)
 
Appearance:
The patient is a -year-old female appearing as stated age, dressed appropriately but somewhat disheveled. Hair is unkempt, and grooming is suboptimal, consistent with depressive symptoms.
 
Behavior:
The patient is cooperative, no psychomotor retardation observed. She maintains minimal eye contact and has a slumped posture. There is no agitation or fidgeting.
 
Speech:
Speech is soft, monotone, and slow, with a decreased rate and volume. Responses to questions are brief, with long pauses before responding, consistent with depressive symptoms.
 
Mood:
The patient reports feeling “extremely sad and hopeless”, with a dysphoric mood. She describes feelings of worthlessness and guilt, commonly seen in depressive episodes of bipolar II disorder.
 
Affect:
Affect is restricted and congruent with the stated mood. The patient’s emotional expression is blunted, and there is a noticeable lack of variability in her emotional tone.
 
Thought Process:
Thought processes are linear but slow. The patient exhibits poverty of thought, with a noticeable decrease in the flow and content of ideas. There is no evidence of flight of ideas or racing thoughts, indicating the absence of hypomanic symptoms.
 
Thought Content:
The patient denies suicidal ideation but reports feeling that “life is pointless.” There is no evidence of delusions, hallucinations, or other psychotic features. The content is centered around hopelessness and self-deprecation.
 
Perception:
The patient denies auditory or visual hallucinations. Perception is within normal limits.
 
Cognition:
The patient is alert and oriented to person, place, and time. However, there is no difficulty concentrating or maintaining focus during the interview.
 
Insight:
The patient demonstrates fair insight into her illness, acknowledging her diagnosis of bipolar II disorder and understanding that she is currently experiencing a depressive episode.
 
Judgment:
Judgment is intact, though the patient reports having difficulty making decisions related to everyday matters.
 
Activities of Daily Living (ADLs):
Self-Care: The patient reports a significant decrease in personal hygiene, stating, “I don’t have the energy to shower most days.” She also reports neglecting other self-care tasks like grooming and dressing appropriately.
  
Nutrition: The patient mentions irregular eating habits, sometimes skipping meals or overeating, which she attributes to a lack of appetite and comfort eating during depression.
 
Sleep: The patient describes hypersomnia, reporting that she sleeps for more than 10 hours per day but still feels tired, consistent with depressive episodes in bipolar II disorder.
  
Mobility: The patient is physically able to move and engage in daily activities.
  
Work/Family Roles: The patient reports having difficulty maintaining responsibilities at work and home, stating, “I just don’t have the energy or motivation to do anything.” She has taken several days off from work due to depression.
 
Social Interactions: The patient reports social withdrawal, stating, “I haven’t seen or talked to any friends in weeks.” She avoids social activities and interactions due to feelings of sadness and hopelessness.
 
Assets:
Good Insight: The patient has a clear understanding of her bipolar II diagnosis and can recognize that her current symptoms are part of a depressive episode.
Willingness to Engage: The patient is cooperative during the interview and expresses a desire to receive help for her symptoms, indicating openness to treatment.
Compliance with Past Treatment: The patient has a history of compliance with medication and therapy in previous episodes, indicating the potential for adherence to treatment plans.
Strong Family Support: The patient mentions having family support, although she has been socially withdrawn recently. This may be an asset in recovery once she re-engages with them.
 
Liabilities:
Social Withdrawal: The patient’s tendency to isolate herself during depressive episodes can limit support from friends and family, hindering recovery.
Anhedonia and Lack of Motivation: The patient reports an inability to experience pleasure and a lack of motivation, which may impact her adherence to daily routines and activities, including follow-up on therapeutic recommendations.
Difficulty with Decision-Making: Her difficulty in making decisions, as a result of her depression, may impair her ability to engage in treatment decisions or carry out recommended strategies.
Possible Treatment Resistance: Given the severity and persistence of her depressive symptoms, she may require adjustments in her medication or more intensive therapy, and there is a potential for treatment resistance to traditional antidepressants in bipolar II depression.