Mental Status Observation Sample
He refers to his friends as the only means of support he receives. Mr. Kaiser will often cause problems during school hours by interrupting class and disobeying authority figures (teachers, principal, faculty). He expresses an interest in a future basketball career. Mr. Kaiser enjoys writing, he will often write poetry and journal entries for pleasure. The location of Mr. Kaiser’s home, as he described it, “a low-income area”. The Catholic high school he attended is a prestigious all boys school. Uniforms are required as the dress code. Mr. Kaiser indicated that Caucasians are the dominate race at the school. No other races were mentioned. Reggie, the other male friend mentioned earlier, is an ongoing figure that plays basketball with Mr. Kaiser and “talks real life” with him. Mr. Kaiser describes, Reggie as an African-American, middle-aged man that lives in the same community as him.
Medical History As for medical conditions, Mr. Kaiser has no known health conditions. However, he has been tested for human immunodeficiency virus or (HIV) since engaging in unsterile needle exchanges for injecting heroin. He reported that his recent blood test came back and there were no anti-bodies present in the panel. His status was reported, negative (HIV-).
Mental Status Observations
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Kaiser’s general appearance is worrisome. He is very emaciated, pale, and clammy. His clothing is unclean. He is wearing a jacket, shirt, and shoes. His shirt has holes and his shoes strings are missing. He mentioned that it’s been a week since he bathed himself. His hands have a dark residue covered on them and has dirt underneath his fingernails. He has a slight odor coming from his clothing. The smell is similar to a mildew scent. Mr. Kaiser’s current mood is irritable, aggressive, and emotionally unsettled. Mr. Kaiser stated before leaving Reggie’s home, “he wanted a taste (injecting heroin) to release the pain”. He also states, “getting high makes
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