PAJARILLAGA, PAULA BIANCA B.

BSN 4B/G1

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 ✓
Appropriate facial expression ✓
With eye contact ✓
With pupil dilatation  ✓
With pupil constriction ✓
Normal state of health & nutrition  ✓
1.2. Speech
Descriptors Yes No Remarks
Rapid speech ✓
Slow speech ✓
There are times
when he is loudly
Loud volume ✓ expressing himself
When he is talking
to Nurse Ratched,
he used his soft
Soft volume ✓ tone of voice
Minimal speech ✓
Pressured speech ✓
Stuttering ✓
Slurring of words ✓
Unusual accents ✓
1.3. Motor Activity
Descriptors Yes No Remarks
Lethargic ✓
Tensed ✓
Restless ✓
 He shows agitation
when the place and
his mates is too
Agitated ✓ loud
With observed tics ✓
Grimaces ✓
Tremors ✓
Compulsive ✓ When he wants to
do something, he
PAJARILLAGA, PAULA BIANCA B.
BSN 4B/G1

will do it
compulsively
without thinking the
consequences of
his actions

1.4. Interaction During Interview

Descriptors Yes No Remarks
 When it’s too loud
and chaotic he had
an outburst of
Hostile  ✓ emotion
Uncooperative ✓
He becomes
irritable when his
surroundings
Irritable  ✓ become chaotic
 When he asked to
drink his meds, he
verbalized that he
Guarded  ✓ doesn’t want it
Most of the time he
shows no interest
to people, but when
he will gain
something from
someone he will try
Apathetic  ✓ to manipulate them
Defensive ✓
When he is asked
to drink his meds,
he is suspicious
Suspicious ✓ that it’s pepper salt
 He tried to be
charming to nurse
Ratched when he
is asking to turn of
Seductive  ✓ the music

2. Emotional State
2.1. Mood
Descriptors Yes No Remarks
Sad ✓
Fearful ✓
Hopeless ✓
Euphoric ✓
Anxious ✓
PAJARILLAGA, PAULA BIANCA B.
BSN 4B/G1

Happy ✓
2.2. Affect
Descriptors Yes No Remarks
Congruent / Appropriate ✓
Flat ✓
Patient shows rapid
changes of his
Labile ✓ mood

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 ✓
 He always
presents himself
with confidence
and he always act
Grandiose ✓ highly
Paranoid ✓
Thought broadcasting ✓
Thought insertion ✓
Depersonalization ✓
Hypochondriasis ✓
Ideas of reference ✓
Magical thinking ✓
Nihilistic ideas ✓
Obsession ✓ He has obsession
with being right all
PAJARILLAGA, PAULA BIANCA B.
BSN 4B/G1

the time and being

the center of
attention
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
Confused ✓
Sedated ✓
Stuporous ✓
Oriented to: Time ✓
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
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
PAJARILLAGA, PAULA BIANCA B.
BSN 4B/G1

 He is very self-

centered and
compulsive in
making decisions
just to satisfy his
Appropriate judgment ✓ needs
 He has good
relationship with his
With good relationship to others ✓ mates
5.6. Insight
Descriptors Yes No Remarks
Accepts presence of problem ✓
Blames the problem on others ✓

Descriptive Analysis:

According to the assessment, the patient has antisocial personality disorder since as I
observed he manipulate others for his personal gain or pleasure, he always disregards the ward
rules and regulation, and feelings of other people. He lacks empathy to those people around
him and he became hostile when he does not get what he wants.