Mental Status Examination

A. GENERAL DESCRIPTION
Instruction: Describe following actual patient physical characteristic.
1. Appearance
Manner of dressing: Patient enters the clinic wearing a dark purple blouse topped with a dark grey cardigan
and light grey sweat pants.
Posture: Patient was staying still while being carried out by her father upon arriving in the clinic.
When lying down, patient has a normal posture but slightly slouches when
standing walking, and sitting.
Cleanliness: Patient is generally clean except for the blood because of a cut in her arm.
Facial expressions: Patient appears to be distressed. Patient is seen crying that caused for the corners of her
lips to droop. At the same time, patient is frowning which causes wrinkles to
appear in her forehead and furrowing of her eyebrows.
General state of health: Patient appears to be generally in good condition and as stated by family members,
except for the cut she sustained in her arms. However, patient seems to be
mentally distressed as evidenced by her crying upon arrival in the clinic.
Grooming: Patient is well-groomed and hair was kept in a bun but was messy.
Gait: Patient has a normal gait.
Eye contact: Patient maintains eye-contact with the nurse except when she uses her arms to cover her
eyes when crying,

Instruction: Put a check mark if present and x if absent and for additional information write it on the space provided.
2. Speech
Rate: _____rapid
ᵡ 
_____slow

Volume: ᵡ
_____loud 
_____soft

Amount: 
_____paucity ᵡ
_____muteness

Characteristics: ᵡ
_____stuttering ᵡ
_____slurred

Quantity: ᵡ
_____poverty of speech (few words)
_____poverty
ᵡ of contents (lack of content)
_____voluminous
ᵡ (too many words)

Quality
_____articulate
 (well-spoken) ᵡ
_____disorganized (unstructured)
_____congruent
 (makes sense) ᵡ
_____incongruent (does not make sense)
ᵡ
_____confabulation (fabrication ) ᵡ
_____pressured (rapid, urgent)
ᵡ
_____tangential (superficial) ᵡ
_____stereotyping (repetitive)
_____aphasia
ᵡ (loss ability to express self)
_____echolalia
ᵡ (repeat speech of others)
_____neologism
ᵡ (words made up by client)
ᵡ clanging (speech pattern characterized by rhyming)
_____
 _____mutism
ᵡ (lack of communication over a period)
ᵡ
_____perseveration (repeating single words, phrases over and over again)

Additional information:
At times, the patient’s speech volume and rate increase when talking with the nurse but not significantly abnormal.

3. Motor Activity
Level of activity:
_____Lethargic
 ᵡ
_____Tense ᵡ
_____Restless ᵡ
_____Agitated

Type of activity:
ᵡ
_____Tics _____Grimace
 ᵡ
_____Tremors

Unusual motor behavior:

ᵡ Akathisia –extreme restlessness, client can’t remain still
ᵡ Compulsive behavior – repetition of specific action
ᵡ Catatonic behavior – extreme hypoactivity
ᵡ Echophraxia – repetitive impersonalization of others’ movement
ᵡ Hyperkinesias – excessive movements
ᵡ Choroeiform movements – irregular involuntary movements of the face and extremities
ᵡ Catalepsy – a trance-like state with a lack of voluntary movements
ᵡ Waxy flexibility – maintaining the extremities in certain positions for longer period of time
ᵡ Impulsiveness – sudden unpredictable outburst of activity
ᵡ Dyskinesia – involuntary motor activity, tics/spasms
ᵡ Psychomotor retardation – a major decrease of overall activity
ᵡ Parkinson like movements – shuffling [drag] gait, tremors, rigidity, mask like facial appearance and drooling
of saliva
Additional information:
Patient appears to have normal motor activity.

B. EMOTIONAL STATE
1. Mood
Can be evaluated by asking non-leading question “How are you feeling?”
Does the patient report feelings of:
Scale of 0 to 10

 Fearful _9/10 _______

 Sad _10/10 ______

 Hopeless _7/10 _______

 Anxious _10/10 ______

 Depressed _8/10 ______
ᵡ Angry __0_________
ᵡ Happy __0_________
ᵡ Grandiose __0_________
ᵡ Ambivalent (opposing feelings) __0 ________
ᵡ Ecstatic (overjoyed) __0_________
ᵡ Elated (a powerful sense of self confidence/optimism) _ 0_________
Additional information:
Patient expressed feelings of sadness, hopelessness, fear, and anxiety. Patient continued to express her fear of
losing her fiancé for good which caused her to be depressed. She also verbalized that she everything was fine before the
recent fight she had with her fiancé.
2. Affect
ᵡ Apathetic (indifferent)
ᵡ Constricted (narrowed)
ᵡ Blunted (little expression)
ᵡ Flat (no expression)
ᵡ Labile (changing expression)
ᵡ Euphoric (exaggerated happiness)
ᵡ Bizarre (odd, abnormal)
Additional information:
Patient’s facial expression is parallel to her statements.
C. EXPERIENCES
Perceptions

ᵡ Hallucinations (perceptual distortions arising from any of the five senses)
ᵡ
_____Auditory _____Visual
ᵡ _____Tactile
ᵡ
_____Gustatory
ᵡ ᵡ
_____Olfactory


ᵡ Illusions (false perceptions or false response to a sensory stimuli)
Additional information:
Patient showed no signs of abnormalities regarding perceptions.
D. THOUGHT PROCESS
1. Thought Content: refers to “what” the patient is thinking
ᵡ Delusions: false belief not shared by others and is contradicted by social reality

ᵡ Religious delusions- belief one is favored by higher being or instrument of that being

ᵡ Somatic delusions- belief that one’s body are disease/distorted
ᵡ Grandiose delusions- belief that one possesses greatness or special power


ᵡ Paranoid delusions- excessive irrational suspicious/distrustfulness to others
ᵡ Though insertion- delusions that thoughts are place into the mind by outside people or influences


ᵡ Thought broadcasting- delusions that thoughts being aired to the outside world


ᵡ Depersonalization – feelings of having self-identity and things around to the persons are different
Additional information:
Patient verbalized, “I felt like the world was ending”, - referring to the thought of her fiancé leaving her for good.
She also continued to say, “I just wanted to die”, because of what she is feeling.
2. Thought Process – refers to “how” of the patient self-expression

 Circumstantial – thought/speech associated with excessive and unnecessary details that is usually relevant
to a question and answer is ultimately given
ᵡ Flight of ideas – over productive speech characterized by rapid shifting from one topic to another
fragmented ideas
ᵡ Loose associations – lack of logical relationships between thoughts and ideas making thought process
vague/unfocused
 ᵡ Perseveration – involuntary, excessive repetition of a single response or ideas
ᵡ Tangential – similar to circumstantial but patient never answers original questions
ᵡ Thought blocking – sudden stopping in the train of thoughts or in the midst of sentences
ᵡ Word salad – series of words that seems completely unrelated
Additional information:
When asked, “Do you feel like you want to repeat what you did?” the patient answered, “I just want him to be
back”, which doesn’t really answer the question asked.

E. SENSORIUM and COGNITION

1. Level of Consciousness
ᵡ Confused (state of mind in which one is unsure of place, time and identity)


ᵡ Sedated (induced state of reduced activity and excitability)
ᵡ Stuporous (state of unresponsiveness)

Orientation

_______aware of person 
_______aware to place _______aware
 to time

_______aware to situations

2. Memory
 Remote memory – recall events, information, events from distant past: place of birth, name of schools

attended
 Recent memory – recall of events, information, people of the past 24 hours or from past weeks

 Immediate memory – recall of information/data to which a person was just exposed

Additional information:
Upon arrival in the clinic, patient was slightly unconscious and crying. However, during the treatment of her
wound, she regained full consciousness and was responsive. Patient is fully oriented and can recall memory but provides
irrelevant answers to some questions.
3. Level of Concentration – ability to pay attention during the course of interview
 Good attention span


ᵡ Poor attention span
Additional information:
Patient maintained good attention span during the interview that occurred between her and the nurse. Patient
answers questions appropriately though her answers to some questions are slightly irrelevant.
Level of calculation – ability to do simple math; assess level of cognitive
ᵡ Count from 1 to 20
ᵡ Do simple calculations such as 2 x 3 or 21 + 8
ᵡ How many 25 centavos are there in one peso
Additional information:
Level of calculation was not assessed, thus inapplicable.
 4. Intelligence – has sufficient knowledge

ᵡ Ability to name the name of Philippine President
ᵡ City Mayor of Zamboanga

ᵡ NOD and supervisor of ward 9


ᵡ Test ability to explain some proverbs such as “Don’t cry over spilled milk”
Additional information:
Intelligence was not assessed, thus inapplicable.
5. Judgement – ability to understand facts and draw conclusions from relationships
ᵡ What would you do if you found a stamped, addressed envelope lying on the ground?
ᵡ What would you do if you entered and smelled gas?
ᵡ If you won’t 100 thousand pesos, what would you do with it?
Additional information:
Judgment was not assessed, thus inapplicable.
6. Insight – patient’s understanding of the nature of the problem/illness

 Sees the need for treatment, therapy and follow up check up

 Adheres to the health teaching and instructions given by NOD

 Understand the importance of stress management and ability to utilize effective coping abilities
Additional information:
Patient gave full cooperation during the interview and expressed willingness for treatment plan.

Process Recording
Date and Time of Interaction: March 14, 2022 at 3:00pm
Appearance of the Patient: Patient is well-clothed and –groomed but with a slightly messy hair. Patient is seen
crying, frowning, and weak which may indicate distress.
Length of Interaction: 5 minutes
Feelings prior to interaction: The nurse prepared herself by appearing calm and composed prior to interviewing the
patient. The nurse showed willingness to help the patient, and the family by
providing information that can be of help to the patient.
Sources of Data: Patient (Primary Data), Patient’s Parents (Secondary Data), and Nurse’s Observations
(PrimaryData)
Setting (Drawing or Photos):