MENTAL STATUS EXAMINATION:

PERSONAL DATA:
1. Name: N.T
2. Age: 75 years old
3. Sex: Female
4. Educational Attainment: HIGHSCHOOL UNDERGRADUATE

General Description
A. Appearance
Grooming/dress- Appropriate dressing for age and gender, wears sleeping pants, a simple shirt, the hair is
well-combed, and the tone\ color of the skin resembles a standard Filipina.
Hygiene – Showering is maintained and observed every day, usually at morning.
Eye Contact-Shows consistent and maintained eye-contact throughout the conversation.
Posture – Slouching happens momentarily after being upright for a while.
Gait- Partial robotic gait
Identifying features – Some moles in the face and flaked skin.
Facial Expression – Shows fine and joyful facial reaction and expressions.
Appearance versus stated age- Appearance seems appropriate to the stated age.
Overall appearance : The client has a well-maintained grooming and hygiene , an everyday-morning
showering was stated by the client. Upon interviewing, the client tends to look directly at the eye of the
one whom talking with her. Postural stiffening was observe whenever the client is walking and is holding
onto bars or objects that can support her while walking. 2 facial moles was seen and a greyish to white
fading of hair color. Lastly, the client showed joyful and smiling affect while talking to us.

Motor Behavior/Activity (check if present and describe further)

_Hyperactive_____
_Agitated____
_ Psychomotor retardation_______
/Calm- Client can withhold being in the same position even for a lengthy time.
/ Tremors/Tics – Pseudoparkinsonism was observed that is due to medications.
_Unusual movements/gestures ______________________________
_Catatonia_______________
_Akathisia_________________________
_Rigidity______________________
_Facial Movements (jaw/lip smacking)___________________
Others: __________

Speech
Rate: Rapid- The client speaks rapidly mostly for answers that is short in words. (oo, tama,and then
followed by the answer)
Amount: Ranging from 3-5 words per sentences.
Volume: Speaks at neutral volume.
Characteristics: The client answers immediately if she happens to remember the asked question then, a
partial hesitation and blunt answer when it is vague for her.
Attitude during the
Interview Is the client:
Cooperative/ Uncooperative- The client is cooperative.
Warm/friendly/Distant- Friendly, shows calm mood the entire interview.
Suspicious/Combative- No relative actions from the client.
Guarded/ Aggressive- No relative actions from the client.
Hostile/ Aloof- No signs of being unfriendly.
Apathetic- No signs of interest-neglect.
Others:___________________

B. Emotional State
Mood and Affect
Is the client
 Elated (euphoric)/Sad/Depressed (dysphoria) __ Euthymic / Irritable/Anxious__ Fearful/
Guilty__ Worried/ Angry __ Hopeless/ Labile__ Mixed (anxious and depressed)__ Is the
Client’s Affect:
Flat___________________________ Appropriate /Inappropriate/incongruent- Appropriateness of the
mood and affect to the answers were observed (even for non-realistic answers).
Labile affect__________________________ Apathy__________ Others:_________________________

C. Thinking
Thought Process (refers to “how” of the patient’s self expression)
Concrete Thinking __
Circumstantiality /
Tangentiality __
Loose association /
Echolalia__
Flight of ideas /
Perseveration__
Clang associations __
Blocking__
Word salad__
Neologism__
Other: _
SN: Kumusta naman po ba kayo ngayon nanay?
PT: “Ayos naman, patay na ako e, nabuhay lang ako, napakulong naming sa hearing ung sumaksak
sakin dati, dun kami sa munisipyo nanalo kami, tapos kami ay isa sa pinaka mayaman sa pilipinas,
nagulat lang sila bakit daw mainit ang patay, duon nalaman nung nagpaalbularyo ako, na kinukulam
pala ako”

Thought Content (refers to “what” the patient actually thinks)

Does client have:
Delusions (grandiose) – “Isa kami sa pinaka mayaman ditto sa Pilipinas”
Suicidal/homicidal thoughts- No verbalized thoughts
If homicidal, towards whom? No verbalized thoughts
● What thoughts have you had about hurting (person’s name)? No verbalized thoughts
● What is your plan? No verbalized thoughts
● What do you want to do (person’s name)? No verbalized thoughts

If suicidal, ask the following Suicide Assessment Questions:

Ideations _____ Plan_____ Method_____ Access_____ Where_____ When_______Timing_________
Does the client have?
Obsessions __ Paranoia __ Phobias__ Magical Thinking__ Depersonalization__
Hypochondriac__ Echolalia __ Others:__________

D. Experiences
Perceptual Disturbances
Is the client experiencing:
Visual Hallucinations – The client stated that someone have visited her at 12 midnight.
Other Hallucination - No verbalized thoughts
SN: “ Ano oras po ba kayo naligo kanina at paano po ninyo nalaman ang oras ?”
PT: “ Nung may bumisita sa akin ng alas dose, tinanong ko sa kaniya ang oras at naligo na ako”

E. Sensorium and Intellectual Process:

Level of consciousness- Confused (Delusional thinking was observed)
Orientation:Person / Place / Time
SN: “Nanay kilala moba sino president natin ngayon?”
PT: “Oo. Si bongbong, Bumoto nga ako”
SN: “ Kanina nabanggit mo nay, naligo ka ng madaling araw, paano mo nalaman yung oras?”
PT: “Yung bumisita sa akin ng alas dose , sakanya ako nangtanong”
SN: “Sino yung bumisita sa iyo?”
PT: “yung isang nakaduty”

Memory: remote/Immidiate
SN: “nanay ano sa tingin mo kung anong oras na ngayon?”
PT: “alam ko tanghalian na, kasi kanina nagalmusal na”
SN: “okay nay, teka tanong ko lang, naalala mopaba pangalan namin, sinabi ko kanina”
PT: “Alex at Joecell”
SN: “eh nay alam moba kung nasan tayo ngayon?”
PT: “nasa kwarto”

Level of Concentration is Light concentration

Can you perform certain tasks, like? ADL is done independently
Level of Calculation Light/ simple calculation
Can do simple math, like? Addition and subtraction of small numbers
General fund of knowledge is Knowledgeable about simple events
(ask about current events) Knows that February 14 is valentine’s day, December 25 as Christmas
Use of vocabulary is Appropriate
Can define meaning of the word.
SN: “Nay anong ibig sabihin natin sa salitang panananampalataya?”
PT: “Huwag makakalimot sa Panginoong Hesus”

Ability to conceptualize abstract is Capable but is delusional

SN: “Nay ano ang nakikita mo dito?”
PT: “May mangkukulam, na galit na galit”

Knows how to interpret proverbs or identify similarity or difference between

objects SN: “Nay, yung kumot san mo ginagamit? At yung unan?”
PT: “Panapal ko pag malamig, panlagay sa ulo”

Insight and Judgement

Insight is (good)
SN: “Ano sa tingin mo nay, kakayanin ba natin to?” PT:”Oo, wag lang makakalimot sa Hesus”
Judgement is (good) SN: ‘Tama ban a angdadasal tayo?” PT: “oo naman”
Impulse control is (fair) SN:”Naiirita kaba nay?” PT: “hindi nangangawit lang ako”