,Mental Status Examination No.

Date: 11-19-21 Day: 1

Note: Put a check mark in the appropriate box of significant observed descriptor/s.

1. General Description
1.1. Appearance
Descriptors Yes No Remarks
Congruent apparent age  /    
Appropriate dressing  /    
 She admits
shamefacedly that
there are days
when she does not
wash or even brush
Clean / Hygienic    / her teeth.
Good posture  /    
Good gait  /    
Appropriate facial expression  /    
With eye contact  /    
With pupil dilatation  /  
With pupil constriction    /  
 
She is healthy and
has no medical
Normal state of health & nutrition  /   problems
1.2. Speech
Descriptors Yes No Remarks
Rapid speech    /  
Slow speech   /   
 she was constantly
arguing with the
senior manager
and found it
difficult to remain
calm and
Loud volume  / composed at work
Soft volume  /    
Minimal speech  /    
Pressured speech    /  
Stuttering    /  
Slurring of words    /  
Unusual accents    /  
1.3. Motor Activity
 Descriptors Yes No Remarks
She complains of
tiredness 
She feels ‘empty’
Lethargic  /   most of the time
Tensed    /  
 She watches TV
until late finding it
Restless  /   difficult to sleep
Agitated   /   
With observed tics    /  
Grimaces    /  
Tremors    /  
Compulsive    /  

1.4. Interaction During Interview

Descriptors Yes No Remarks
 lack of enthusiasm
on her life and she
avoids socializing
Hostile  /   with other people
Uncooperative   /   
 She’s irritable
with her boyfriend,
and gets upset
easily if he tries to
Irritable  /   ‘motivate’ her
Guarded   /   
 Not showing
Apathetic  /   enthusiasm
Defensive   /   
Suspicious    /  
Seductive    /  

2. Emotional State
2.1. Mood
Descriptors Yes No Remarks
Sad /     
Fearful   /   
Hopeless  /    
Euphoric   /   
 She complains of
tiredness and a
lack of enthusiasm
Anxious  /   for life.
  She admitted that
she was on the
psychiatric
hospital at the age
of 19, she become
very high, then she
became quite
elated and was
convinced that she
was Venus, the
Happy /  goddess of love.

2.2. Affect
Descriptors Yes No Remarks
Congruent / Appropriate  /    
Lack of emotional
responses she feels
empty most of the
time, cannot react
with her
Flat  /   boyfriends effort.
she can change her
mood in a short
Labile  / period of time.

3. Experiences
3.1. Perceptions
Descriptors Yes No Remarks
Hallucinations: Auditory    /  
Visual    /  
Tactile    /  
Gustatory    /  
Olfactory    /  
Illusions      

4. Thinking
4.1. Thought content
Descriptors Yes No Remarks
Delusion: Religious   /   
Somatic    /  
Grandiose  /   ------ 
 Paranoid    /  
Thought broadcasting    /  
Thought insertion    /  
Depersonalization    /  
Hypochondriasis   / 
Ideas of reference   /   
Magical thinking  /  
Nihilistic ideas    /  
Obsession    /  
Phobia    /  
4.2. Thought process
Descriptors Yes No Remarks
Circumstantial    /  
 Jump from talking
about her holiday
to Coron, Palawan
when she became
quite elated and
was convinced that
Flight of ideas  /   she was Venus
Loose associations   /   
Neologisms    /  
Perseveration   / 
 She’s currently
experiencing high
Tangential  /   level of anxiety.
Thought blocking    /  
Word salad  /    

5. Sensorium and Cognition

5.1. Level of consciousness
Descriptors Yes No Remarks
Confused    /  
Sedated    /  
Stuporous    /  
Oriented to: Time  /    
Place  /    
Person  /    
5.2. Memory
Descriptors Yes No Remarks
Intact remote memory  /    Can recall events
 from the past
Intact recent memory  /    
Intact immediate memory  /    

5.3. Level of concentration and calculation

Descriptors Yes No Remarks
Easily distracted    /  
With difficulty in simple math    /  
5.4. Information and Intelligence
Descriptors Yes No Remarks
With learning disability    /  
With learning difficulty    /  
Able to interpret simple proverb    /  
5.5. Judgment
Descriptors Yes No Remarks
Appropriate judgment    /  
With good relationship to others   /   Avoid socializing
5.6. Insight
Descriptors Yes No Remarks
Accepts presence of problem  /    
Blames the problem on others   /   

Descriptive Analysis:

Bipolar (1) disorder with a present depressive episode is the most

likely diagnosis. Bipolar 1 is characterized by severe mood shifts
or a mix of depression and high-energy phases which are present
to our patient, she was experiencing lack of enthusiasm on her
life, and she avoids socializing with other people, she complains
of tiredness, and she feels ‘empty’ most of the time which causes
her to become lethargic. This patient was having a moderate to
severe depressive episode with a past history or two episodes of
mood disorder which appeared to be manic, and she was having
delusions of grandeur and elated mood.