CHAPTER IV

COURSE OF HOSPITALIZATION

1. Vital Signs
DATE & SHIFT BP T PR RR

Out In Out In Out In Out In

June 14, 2022 120/80 120/80 36.4 36.4 75 70 20 20

June 15, 2022 120/90 110/90 36.9 36.6 75 70 18 20

June 16, 2022 120/90 120/90 36.8 36.8 72 71 20 20

June 17, 2022 120/80 120/80 36.3 36.3 78 74 20 20

June 20, 2022 120/80 120/80 36.5 36.5 76 73 21 20

June 22, 2022 120/80 110/70 36.1 36.8 76 80 20 20

June 23, 2022 120/80 110/80 36.7 37.4 75 81 20 20

June 24, 2022 120/80 100/70 36.5 36.8 74 76 19 20

June 27, 2022 120/80 110/70 36.4 36.7 79 75 18 20

2. Mental Status Examination

CRITERIA DAYS
1 2 3 4 5 6 7 8 9
I. GENERAL DESCRIPTION
A. Appearance / / / / / / / / /
B. Behavioral & Psychomotor Activity
Normal / / / / / / / / /
Inappropriate
Restlessness
Psychomotor Retardation
Agitation
Rigidity
Others

II. MOOD AND AFFECT

A. Mood
 Depressed
Anxious
Angry
Euphoric
Frightened
Labile
Others Narcissistic
B. Affect
Appropriate
Inappropriate
Flat
Blunted / / / / / / / / /
Constricted

III. NEURONEGATIVE FUNCTION

A. Sleep
Normal / / / / / / / / /
Hypersomnia
Early Insomnia
Late Insomnia
Mixed Insomnia
B. Appetite
Normal / / / / / / / / /
Increased
Decreased
C. Weight 55 kg
D. Diurnal variation
E. Libido
F. Attention
Good / / / / / / / / /
Fair
Poor

IV. SPEECH
Spontaneous / / / / / / / / /
Pressured
Whispered
Deliberated
Loud
Hesitant
Talkative
Mumbled
Slurred
Others
V. PERCEPTION
A. Type Visual &
auditory
hallucinatio
n
B. Description She said,
she would
see her
workmate at
the window
talking
random
things and
said her
coworkers
would talk
to her
outside the
room.
Her sister
also she
found
Boning
talking to
herself
“katingin
kamo,
katingin”.

VI. THOUGHT
A. Thought Process
Loose association
Tangentiality / / / / / / / / /
Neologism
Flight of Ideas
Circumstantiality
Thought blocking
Others
B. Thought Content
Type of delusion Grandiose
delusion
Preoccupation
Suicidal ideation
Homicidal ideation
Ideas of reference
Others
VII. SENSORIUM AND COGNITON
A. Orientation
Time / / / / / / / / /
Place / / / / / / / / /
Person / / / / / / / / /
B. Memory
Remote
Impaired / / / / / / / / /
Unimpaired
Recent past
Impaired
Unimpaired / / / / / / / / /
Recent
Impaired
Unimpaired / / / / / / / / /
Immediate
Impaired
Unimpaired / / / / / / / / /
C. Concentration & Attention
Serial subtraction
Spelling
Abstract thought
Information & Intelligence

VIII. JUDGMENT AND INSIGHT

A. Judgment
Impaired
Unimpaired /
B. Insight (Specify Level)

IX. SUMMARY OF M S E
A. Disturbances in:
General description /
Perception /
Thought /
Sensorium & Cognition /
Judgment and Insight /
B. Diagnostic Category
Psychotic /
Non-psychotic
Functional
Organic
Both functional and organic
 Within 9 days in contact with the patient, Higala Boning’s vital signs are all within

normal. Her general appearance is rated GOOD as what it is observed that the patient is well

groomed, well dressed, fixed hair, and no foul odor noted.

During the interaction, the patient does not maintain eye contact, does head twitching

when responding to the question. She has a narcissistic mood because she shows no emotion, flat

and numb. She has blunted affect because she shows a little facial expression, sometimes she

smiles or when she told to. She sleeps and eats normally with a weight of 55kg. Her attention

towards us was rated good.

She has visual and auditory hallucinations, as stated she would see her coworkers at the

window and someone was talking to her outside the room and her sister also found Boning

talking to herself “katingon kamo, katingon” (stop you guys, stop). She has grandiose delusion

and always says she is a “CPA” and wants the title after her name. Her thought process is

tangentiality because she’s wandering off the topic “comes from within, not from without”. She

has an impaired remote memory, where she can’t remember her past and made things up about

her past. She has unimpaired judgment and insight.