Standard
The CAGE-AID screening tool was used to determine substance abuse for Rick. Rick’s CAGE-AID indicates he needs further CD assessment.
We have looked Rick’s current life situation and reasons for the assessment. The next component is the mental status exam. We know the following about Rick.
Mental Status Exam
Rick maintained low level of eye contact and spent most of the time looking at the floor and mumbling. He appeared nervous and scared of engaging with the interviewer. He demonstrated no issues with thought content or process; he voiced no issues of harm to self or others. He was oriented to person, place, and time. He indicated no memory issues. He voiced concerns about being able to sustain attention and concentration but managed appropriately during the interview. He seemed to have insight into his knowing that his fears of failure and public humiliation were unrealistic but could not stop the worry anyway. His affect was flat, his mood was anxious, and he seems to be well within the average range of intelligence