Mental Status Examination 1 (Orientation Phase

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A. General Appearance a. Appearance I. Facial expression: Serious, but smiles when greeted II. Grooming and dressing: Slightly clean clothes, no odor, slightly groomed,a little bit of white hair III. Body language 1. Posture: Straigtht 2. Movements: Swift Action b. Behavior: Cooperative c. Speech I. Quality: poverty II. Rate: starts from slow to fast III. Volume: Soft IV. Fluency and rhythm: Slurred B. Assessment of Mood and Affect

a. Mood? Quiet at first, but smiles in every conversation. Is it appropriate for their current situation? Yes, because this is the first time we meet he is just
being cautious.

b. Affective expression? Does not speak if not being called his attention.

Is it appropriate for their current situation? Nods and recognizes all the questioned asked.

Tangentiality V. Clang association VI. Perception and Thinking YES I. Perseveration IV. Flight of ideas VIII.C. Others NO x x x x x x x x x x x x C. Thought content disturbance YES Delusion of grandeur Ideas of reference Delusion of persecution Delusion of control Delusion of religiosity NO x x x x x III. Hallucination III. Phobia II. Word Salad III. Pre-occupation 1. Confabulation XI. Looseness of association II. Alexithymia XIII. Thought content I. Waxy Flexibility VII. Sexually preoccupied NO x x x x B. Blocking IX. Circumstantiality XII. Thought process YES I. Depersonization IV. Suicidal intentions rating scale (SIRS) 0 – No evidence . Obsession compulsion 2. Illusion II. Neoligism X.

Intellectual Functioning 1. Eye contact: Yes II. Reasoning: Good F. Insight: Good 4.He like socializing with his friends. Things he would like to change about himself – does not know b.Patient was well oriented. Sensorium . Current Medication: Chlorpromazine . Answers was kindly to the questions.D. Memory Recent: Intact Remote: Intact 2. Judgment: Good 3. Subject assessment I. Participation in group activities: Always participating H. Ego Defense Mechanism G. Level of Self-Esteem: High a. E. II. Objective assessment I. Things client like about himself . Personal Hygiene: Good III.

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