TABERNA, CATHERINE T.

BSN 4-2 (G4)

Mental Status Examination No. 1

Date: September 30, 2021 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    
✓
Clean / Hygienic    
✓
Good posture    
✓
Good gait    
While assessing the
patient she was
quiet, and she
Appropriate facial expression  ✓ looks irritated.
✓  With eye contact
but seem like angry
With eye contact   while talking
✓
With pupil dilatation    
✓
With pupil constriction    

Normal state of health & nutrition  ✓  

1.2. Speech

Descriptors Yes No Remarks

she has minimal
Rapid speech     speech when being
asked with some
Slow speech     questions also, her
speech is in normal
Loud volume     range and has a soft
volume, but became
Soft volume  ✓   anger because she
want to leave the
Minimal speech  ✓   mental hospital.
Pressured speech      
Stuttering    

Slurring of words    

Unusual accents  

1.3. Motor Activity

Descriptors Yes No Remarks

Lethargic  ✓
✓
Tensed  
✓
Restless  
 Patient seems tired
Agitated  ✓ and annoyed during
✓ the interview.
With observed tics    
✓  
Grimaces    
✓  
Tremors    
✓  
Compulsive    

1.4. Interaction During Interview

Descriptors Yes No Remarks

✓ The patient was
Hostile   cooperative during
✓ the assessment but
Uncooperative   shows irritability,
she was defensive in
Irritable  ✓ answering when being
asked about if she
✓
Guarded   was trying to kill
herself.
Apathetic ✓  
 (there’s some point
Defensive  ✓ in the movie that
she is seductive,
✓ she can easily fall
Suspicious  
in love with
someone, she doesn’t
have a stable
Seductive  ✓ relationship.

2. Emotional State
2.1. Mood

Descriptors Yes No Remarks

Patient cannot show
Sad ✓  her real emotion,
but her face looks
Fearful  ✓ gloomy, she’s also
hopeless to the
✓
Hopeless point that she’s
trying to kill
✓
Euphoric   herself by taking a
lot of aspirins.
Anxious    ✓  She also shows
inappropriate anger.
 
Happy    ✓  

2.2. Affect

Descriptors Yes No Remarks

✓  Patient does not
Congruent / Appropriate   express her thought
and feelings and is
Flat  ✓ having a neutral
expression
✓
throughout the
interview.
 
Labile    

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    
✓
Flight of ideas    
✓
Loose associations    
✓
Neologisms    
 ✓
Perseveration    
✓
Tangential    
✓
Thought blocking    
✓
Word salad    

5. Sensorium and Cognition

5.1. Level of consciousness

Descriptors Yes No Remarks

she is confused by
Confused  ✓   stating why does she
have to be in a
Sedated    ✓ psychiatric
facility, the
Stuporous    ✓ patient was aware
about the time,
✓
Oriented to: Time   place, and person,
 
✓  
Place  
 
✓  
Person    

5.2. Memory

Descriptors Yes No Remarks

✓
Intact remote memory    
✓
Intact recent memory    
✓
Intact immediate memory    

5.3. Level of concentration and calculation

Descriptors Yes No Remarks

 During the
Easily distracted  ✓ interview, it is
✓ shown that the
patient is easily
distracted she’s
also looking inside
and outside the room
and seems to be in
deep thought.
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

✓ Patient stated that
Appropriate judgment   being in the
facility and in her
home is both a
“problem”. She is
not sociable she is
a shy type person.
With good relationship to others ✓   

5.6. Insight

Descriptors Yes No Remarks

 During the
interview she does
not accept that she
must be in the
psychiatric facility
and stated “I guess
I’m puzzled as to
why it is I have to
be in a mental
Accepts presence of problem    ✓ institution.”

Blames the problem on others    ✓  

Descriptive Analysis:

The patient has a mental illness called Borderline

Personality Disorder, the sign and symptoms were present such as,
suicidal threats, inappropriate anger, risky behavior and also
she’s trying to seduce some staff in the mental institution, she
is cooperative during the interview even she does not fully
express what she feels, she’s a quiet person, she keeps a neutral
expression and has minimum answers when being asked. When the
interviewer ask why she tried to kill herself she became
irritable and annoyed, and she was is being defensive in
answering that she’s only having a headache. Patient also stated
that being in the facility and in her home is both a “problem”.
She still doesn't understand why she's in a mental institution
TABERNA, CATHERINE T.
BSN 4-2 (G4)

Process Recording No: 1

Borderline Personality Disorder

Date: September 30, 2021

Setting:
In a Mental Hospital, in the office of Dr. Melvin

Description of the Environment:

A closed, tidy, and quiet office space containing
bookshelves, a cabinet, a couch, and other office supplies and
stationery.
Objectives for the Day:
1. To build rapport
2. To know the patient
3. To observe client’s behavior, identify the problem, and
formulate plan of action. 

Description of Patient before the Interaction:

Before the interaction the patient was quiet and seems
irritable, annoyed, and shows minimum to no emotion, she is also
smoking before and during the mental status examination.
 Girl, Interrupted (1999)

SCENE 32:31 – 33:50

 Patient’s Response Rationale of
Analysis of Patient’s Nurse’s Statement
Nurse’s Statement (To include
Response (To include
Verbal Non-Verbal Defense Mech. Used)
Therapeutic
Communication
Technique used)
“You’ve been “I haven’t Patient looks She is responsive Open-ended
feeling bad in exactly been a little upset but she is question allows
general right? ball of joy” about the emotionless and to explore
You’ve been question, her speak in a sarcastic patient’s
feeling eyes looks way. feelings, idea,
depressed? angry while emotion, and
holding the thoughts.
cigarette.

By asking
questions, the
while she answers nurse was able to
“I had a the question, she is
seems to be learn more about
“I understand headache.” irritated and
lying the patient's
you tried to annoyed. feelings, ideas,
kill yourself
and thoughts, and
last week.
the nurse
Anything you
responded with an
want to tell me
attitude that
about that?”
shows to the
patient that she
is accepted and
that her feelings
are valid.
“I didn’t try
Presenting the
to kill seems to be She is annoyed and
“So, I assume reality to the
myself.” lying, looks irritable when
you took the patient on what
recommended irritable and answering the she did without
aspirin dosage defensive. question. judging her.
for headache”