SOCIAL HISTORY:  The patient lives with a mother, who takes care of the patient's ADLs. The patient completed school, up to two years in college and worked as accounting tech for eight years. Denies use of alcohol, tobacco, or illicit drugs.


MENTAL STATUS EXAMINATION:  The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel. Decreased motor activity, but did blink her eyes often, but arrhythmically. Poor eye contact. Speech illogic. Concentration was not able to be assessed. Mood is unknown. Flat and constricted affect. Thought content, thought process and perception could not be assessed. Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.


MINI-MENTAL STATUS EXAM:  Unable to be performed.

AXIS I: Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.
AXIS II: Deferred.
AXIS III: Deferred.
AXIS IV: Deferred.
AXIS V: 1.

