SCRIPT (MENTAL STATUS EXAMINATION)

Nurse: Hello Sir, I am Mia Grace Garcia your nurse for today. May I know your name and
birthdate, sir?

Patient: Hi. I am Prince Madduma. I was born on December 1, 2000

Nurse: I’m really glad that you came in today and it takes a lot to really come to the first
appointment.

Patient: Yes po

Nurse: So sir, what we’re gonna do today is to get to know you the best we can. I just want to get
a glimpse of what it’s like to be in your shoes, alright sir

Patient: Okay po ma’am

Nurse: So sir what we’re gonna do is work on your assessment together because I want to know
about your story. Do you have any question or queries sir before we proceed?

Patient: None po

Nurse: Okay sir so let’s proceed.

So may I know ur:

Name: P Madduma

Age: 21

Sex: Male

Marital Status: Single

Religion: R. Catholic

Educational level: Undergraduate

Address: Naguilian Ilagan, Isabela

Nurse: So sir, can you tell me what brought you today?

Patient: Im just having a lot of stress and I just don’t know how to handle these.

Nurse: When did this start

Patient: Like 6 days ago. Im not sure

Nurse: Have you ever had a time like this before

Patient: Maybe a year ago that’s like finishing up school semester

Nurse: What really helped you a year ago. Do you remember

Patient: I don’t. I just talk to my friends and that’s all I remember

Nurse: Talking to ur friends seems like it might have been helpful then

Patient: Yes

Nurse: So about three weeks ago. What do you know that you were starting to have that stress

Patient: I think like in interactions with my family and other people. I got overly like stress and
maybe lashed out a little bit or and I realize that wasn’t like me and I think that’s just stressed out
overreacting to situation this time

Nurse: So you really haven’t kind of a short fuse. Were they surprised

Patient: I Think they know what I get like I’m stressed but also I wasn’t really okay.

Nurse: What are your activities lately?

Patient: I can do my typical activities as usual like washing my clothes and cleaning my room

Nurse: Good knowing sir! Thank you for sharing

Nurse: Do you have any vices?

Patient: None

Mia: Do you take any medications? or any allergies

Prince: None. I only take medications if my physician said so and I don’t have any allergies on
drugs.
Nurse Okay, thankyou for sharing me that sir.

Nurse: Can you tell me how your sleep and food intake is?

Patient: I really eat a lot but sometimes when I have a hard time I feel like I lost my appetite and
I sleep late at night and wake up early around 8 am

Nurse: Is there a change what you typically get

Patient: A lot typically I get 7 hours but for now I get 5-6 hours of sleep

Nurse: Are you feeling tired?

Patient: Yes I took a nap in the afternoon and then feel energized again

Nurse: Does your family have any illness?

Patient: None.

Nurse: Okay sir, thankyou lets proceed to next assessment

Nurse Mia POV *After that ill be conducting a head to body checks for any abnormalities,
bruises and wounds especially any side effects of medication*

(Assuming that I conducted physical examination)

**So as I observe and conduct an examination on my pt. I don’t see anything abnormalities in his
body

Appearance

Mr. Madduma is 21 yrs old Filipino average of weight and height. At the time of examination he
is well groomed and dressed. He was not confined to bed.

Behavior

On behavior there were no signs of tremor or abnormal movements.

Cooperation:

He maintained eye contact and cooperative throughout the interview.

Speech:

Mr. Madduma articulated herself clearly. She answered questions spontaneously. He spoke softly
throughtout the conversation

Thinking

He was able to give relevant data abt his life and was able to follow in the conversation. There
were no flight of ideas during the nurse-patient interaction

Affect and Mood:

Client Madduma affects and range of mood was not reduced. He appeared relaxed.

Perception:

He exhibits normal perception. There were no signs of illusions, misinterpretations,

depersonalization, passivity phenomena, were not solicited

Cognitive:

Pt. is alert and oriented to time and place. He was able to answer question and recall her past
without difficulties

Judgement Insight:
Client was able to answer hypothetical question being asked to him appropriately. And The
client’s answer is relevant to the question being asked. He is cooperated with doctors and nurses
and is compliant with management