Example 11:

Student's report

General appearance and behaviour

Lucy is a 34 year-old Indian-Portuguese woman of average weight and height. At the
time of examination, she was well groomed and dressed. She was not confined to bed.
On appearance, were no signs of tremor or abnormal movements; however, Lucy
showed signs of proptosis, consistent with Grave's disease. Lucy was cooperative
throughout the interview. She maintained eye contact, except during the times when
recounting the history of her father's death and her previous marriage. Then, she
appeared depressed.

Speech
Lucy articulated herself clearly. She answered questions spontaneously, although at
slow rate and speed. She spoke softly throughout the conversation, particularly when
mentioning past unhappiness.

Affect and mood

Lucy's affect was depressed and her range of mood reduced. She also appeared
anxious and irritable.

Thought
a. Stream
Lucy's thought stream was decreased. It was also disturbed and Lucy's speech slowed
down and content reduced significantly when mentioning past unhappiness. b. Form
Lucy did not exhibit any formal thought disorders. She was able to answer questions
spontaneously and directly. She did not use any new or created words. Lucy did
experience thought block when exploring sensitivities in her past. No negative thought
disorder was detected. c. Content
Lucy was depressed and anxious about her health. She was obsessed with knowing her
biopsy result and was constantly asking the doctors and nurses for her result. Thoughts
that the tumour could be cancer were causing Lucy to lack motivation and feel restless.
Lucy was also feeling guilty for not being able to care for her son and fiance since
having the headache. Other than feeling obsession and guilt, Lucy has no other positive
symptoms, such as delusions, phobias or compulsions. Suicidal ideation was not
detected.

Perception
Lucy exhibits normal perception. Symptoms, such as illusions, misinterpretations,
depersonalisation, passivity phenomena, were not elicited.

Cognition
Lucy was alert and orientated to time and place. She was able to answer questions and
recall her past without difficulties.
Insight and judgement
When questioned about her condition, Lucy accepted the fact that she is ill and requires
treatment. She has cooperated with doctors and nurses and is compliant with
management.