M2-Worksheet -MSE-FRED

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Indiana University, Purdue University, Indianapolis *

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517

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Health Science

Date

Apr 3, 2024

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docx

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2

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Page 1 of 2 INTRODUCTION (1/2 page maximum) Fred is a single 37-year-old male completing an intake today at the request of his sister. Fred is disabled due to a work injury and currently resides in his sister’s home with her and his mother. Fred’s sister is reportedly concerned that Fred spends too much time online, does not leave the home, and his personality/behavior has changed. Fred does not work and relies on SSDI for income. His reported changed in behavior has interfered with interpersonal relationships as his long-term girlfriend broke up with in the last year and he does not see his friends. MENTAL STATUS EXAMINATION (¾ page maximum) Domains Type here Appearance and Behavior: Fred arrived on time, he appeared disheveled and unkempt, but hygiene is good. He moves with an unsteady gait and appears frail/thin and tired. Speech: His speech is normal, articulate, expansive with some latency with responses. Can be difficult to follow at times. Mood Subjective: Fred reports being “fine” and there is nothing wrong with him. Objective: Fred’s mood is incongruent with affect; he reports no issues but is tense and distracted. He seems detached and anxious at times throughout the intake. Risk: There is no identified risk as Fred denied thoughts of harming himself or others. Thoughts Form: He is overall coherent, but his thoughts can be tangential and flighty at times. Content: Fred is paranoid to leave the house as he believes it is unsafe. He attributes symptoms of anxiety to being around people and avoids crowds. Beliefs-Overvalued or Delusional: No reported delusions. Perceptions: No abnormal perceptions reported. Cognition: No abnormality on formal testing was detected.
Page 2 of 2 Insight: Fred has poor insight; he believes his sister is being hard on him and he does not have issues. He is here today to appease his sister and asked this writer to tell his sister to “cut him a break”.  Diagnostic Impressions: Post-traumatic stress disorder (PTSD) DSM-5 CROSS-CUTTING MEASURES include a summary with data – no more than ½ page TREATMENT PLAN ( no more than ½ page) Include summary of MSE, SAFE-T risk level and rationale, DSM-5 cross-cutting measures and treatment plan to address/reduce current risk and increase protection. An ecological focus should be present. Caregivers must be included in a role in treatment. APPENDIX 1. Using the Snipping Tool in Microsoft Office or another similar tool, make a picture of your scored Level I assessment 2. Complete the table below to record both Level 1 and Level 2 outcomes Level I Domains Threshold Record Level Level 2 Cross-Cutting Symptom Measure Record Measure and Result Somatic Symptoms Sleep Problems Inattention Depression Anger Irritability Mania Anxiety Psychosis Repetitive Thoughts/Behavior s Substance Use
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