Training-only MSE. For educational and supervision purposes.
Created: 29 Apr 2026, 13:35
Student: Kashish
Batch: april26
Client / Case Name: Megha, 27-year-old unmarried female school teacher
Date of assessment: 29-04-2026
Appears her stated age. Moderately built and appropriately dressed. Facial expression reflects anxiety and emotional distress. Well-groomed and kempt. Maintains personal hygiene. Average / Athletic body build.
Mild psychomotor agitation observed. Increased alertness and restlessness. Startles easily to sudden environmental sounds. No catatonic symptoms observed.
Cooperative and responsive. Mildly guarded while discussing trauma-related experiences. Maintains appropriate eye contact.
Conscious and alert. Fully responsive during interview. No fluctuation in awareness.
Speech rate: Normal to slightly slowed when discussing distress. Volume: Soft to moderate. Tone: Low and emotionally strained. Reaction time: Mild delay during trauma-related questions. Speech remains coherent and spontaneous.
Subjectively anxious, fearful, and emotionally distressed. Reports persistent guilt and emotional numbness. Reduced emotional range. Appropriate to content discussed.
a. Thought Process:
Logical and goal-directed. Coherent and relevant. No loosened associations or flight of ideas.
b. Thought Content:
Preoccupation with accident-related memories. Survivor guilt and self-blame. Trauma-related intrusive thoughts. Hypervigilant beliefs regarding safety.
Flashback-like experiences related to trauma triggers. Occasional dissociative-like moments when exposed to horns or sudden braking sounds. No persistent depersonalization or derealization reported.
Oriented to time, place, and person. Recent memory: Mild interference due to distress. Average intelligence based on educational and occupational functioning. Abstract thinking preserved. Basic calculations intact. No major cognitive deficits noted.
Personal judgment: Fair. Social judgment: Preserved. Test judgment: Adequate. Able to understand consequences of actions.
Insight Grade V. Acknowledges psychological distress and recognizes need for help. Understands symptoms are linked to trauma.
Right-handed. Language: Hindi, English.(assumed)
Short title / summary: Mental Status Examination – Post-Traumatic Stress Symptoms with Anxiety, Hypervigilance, and Intact Insight/Judgment.
Client appears emotionally distressed with trauma-related symptoms following a road traffic accident. Insight is preserved, cognition remains largely intact, and symptoms are significantly affecting sleep, social interaction, and work performance. Clinical features are consistent with trauma-related anxiety and stress responses.