MANILA TYTANA COLLEGES

Manila Doctors College of Nursing

Pres. Diosdado Blvd., Metropolitan Park, Pasay City
Mental Status Examination

Name of Patient (Initials only) M.S.A.S.A. Date: 3/13/2022

General Description

Appearance
Grooming/ Manner of dress The client is well-groomed. She is wearing a plain t-shirt and maong pants paired with flat
sandals. She also has ponytail on her hair.
Hygiene/ Cleanliness The client exhibits good personal hygiene and smells good with her perfume.
Eye contact The client doesn’t maintain eye contact as it is intermittent. She keeps on looking at the things around her.
Pupil dilatation or constriction The client’s pupils are dilated.
Posture Couldn’t sit properly/upright and has her hands roaming around as well as it’s moist.
Gait Has good balance and is able to walk straight.
Facial Expressions Has anxious facial expressions.
Identifying features (marks/scars/tattoos) None
Appearance versus stated age Appearance is appropriate for her stated age.
General state of health and nutrition Have normal body shape and weight.
Overall appearance Client M.S.A.S.A. is neatly dressed appropriate for her age and the place. She has a good hygiene and
looks overall pleasant. The eye contact of the client is intermittent and looks at other things/objects as her pupils are
dilated. She has a tense posture and has her hands moving around as well as moisten. She has anxious facial expressions.
No marks or tattoos present. Appearance is appropriate for her age and have normal body proportions.

Motor Behavior/Activity (check if present)

Hyperactive ✓
Agitated ________________________________________________________________________________________
Psychomotor retardation ___________________________________________________________________________
Calm ___________________________________________________________________________________________
Tremors ✓
Tics ____________________________________________________________________________________________
Grimaces________________________________________________________________________________________
Unusual movements/gestures or mannerisms ✓
Catatonia ________________________________________________________________________________________
Akathisia ________________________________________________________________________________________
Rigidity _________________________________________________________________________________________
Facial movements (jaw/lip smacking) _________________________________________________________________
Other: Nail biting and stealing

Speech
Rate: Slow/rapid Rapid
Amount: Paucity/ Mute/Pressured Speech Pressured speech
Volume (loud/soft) Mumbled
Characteristics: (Stuttering, slurring of words or unusual accents) The client is stuttering and hesitant with what she is
saying.

Attitude during the Interview

Is the client:
Cooperative/ Uncooperative Uncooperative
Warm/friendly /Distant Distant
Suspicious /Combative Looks suspicious and hiding something.
Guarded /Aggressive None
Hostile/ Aloof Aloof
Irritable________________________________________________________________________________________
Apathetic ______________________________________________________________________________________
Defensive Yes
Seductive______________________________________________________________________________________
Other _________________________________________________________________________________________

1
Mood and Affect
Is the client:
Elated (euphoric) /Sad /Depressed (dysphoric) Sad
Irritable/Anxious Anxious
Feeling sad Uncomfortable
Fearful/Guilty Guilty
Worried/Angry Worried
Hopeless/ Labile Labile
Mixed (anxious and depressed) Yes
Euthymic _______________________________________________________________________________________
Is the Client’s Affect:
Flat ____________________________________________________________________________________________
Blunted or diminished _____________________________________________________________________________
Appropriate _____________________________________________________________________________________
Inappropriate/incongruent (sad and smiling/laughing) Yes. Has disharmony between the emotional tone and the actions.
Other __________________________________________________________________________________________

Thought Process
Concrete thinking ________________________________________________________________________________
Circumstantiality _________________________________________________________________________________
Tangentiality ____________________________________________________________________________________
Loose association Yes. The client’s ideas shift from one subject to another.
Echolalia _______________________________________________________________________________________
Flight of ideas ___________________________________________________________________________________
Perseveration Yes. She has repetition of the same phrases or ideas in response to different questions.
Clang associations ________________________________________________________________________________
Blocking ________________________________________________________________________________________
Word salad Yes. The client has incoherent mixture with use of words.
Derailment ______________________________________________________________________________________
Other: __________________________________________________________________________________________

Thought Content
Does client have: (None)
Delusions (grandiose/persecution/paranoid/somatic/ religious): _____________________________________________
Suicidal/homicidal thoughts: ________________________________________________________________________
If homicidal, toward whom? ________________________________________________________________________
Student Nurse: What thoughts have you had about hurting (person’s name)?
Patient: _________________________________________________________________________________________
Student Nurse: What is your plan?
Patient: _________________________________________________________________________________________
Student Nurse: What do you want to do to (person’s name)?
Patient: _________________________________________________________________________________________
If suicidal, ask the following Suicide Assessment Questions:
1. Ideations ______________________________________________________________________________________
2. Plan __________________________________________________________________________________________
3. Method ________________________________________________________________________________________
4. Access _________________________________________________________________________________________
5. Where _________________________________________________________________________________________
6. When __________________________________________________________________________________________
7. Timing _________________________________________________________________________________________

Obsessions She has obsessions with glancing at different objects around her.
Paranoia _________________________________________________________________________________________
Phobias __________________________________________________________________________________________
Magical thinking ___________________________________________________________________________________
Poverty of speech The client has minimal responses.
Other ____________________________________________________________________________________________

2
Perceptual Disturbances
Is client experiencing: (None)
Visual Hallucinations (Sight) __________________________________________________________________________
Auditory Hallucination (Sound)________________________________________________________________________
Tactile (Touch)_____________________________________________________________________________________
Gustatory (Taste)____________________________________________________________________________________
Olfactory (Smell)____________________________________________________________________________________
Commenting _______________________________________________________________________________________
Discussing ________________________________________________________________________________________
Commanding ______________________________________________________________________________________
Illusions __________________________________________________________________________________________
Depersonalization __________________________________________________________________________________
Other ____________________________________________________________________________________________

Sensorium and Intellectual Process:

Level of consciousness- confused/sedated/stuporous The client is confused.
Orientation:
Student Nurse: (Person) What is your name? Do you know me?
Patient: I’m patient M.S.A.S.A. I don’t know.
Student Nurse: (Place) Do you know where are you now?
Patient: Hospital room.
Student Nurse: (Time) What time is it?
Patient: I don’t know.
Memory (recent/remote/ immediate) ____________________________________________________________________
Student Nurse: (Recent) May I ask what have you eaten earlier? Where have you been yesterday?
Patient: Don’t ask me. They gave me chicken. I’m just around.
Student Nurse: (Remote) How did you celebrate the new year? Are you with your parents?
Patient: Yes. But my grandparents were away, I don’t know where.
Student Nurse: (Immediate) Can you tell me when was the last time you went in the bathroom?
Patient: I didn’t go to the bathroom. I’m alone.
Level of Concentration
Can perform certain task No. The client’s concentration is not well-organized and gets easily distracted.
Level of Concentration and Calculation
Can do simple math: Student Nurse: Can you countdown down from 100 by 7s?
Patient: No, I can’t. 100, 93? I don’t know. Stop asking me.
General fund of knowledge Student Nurse: How long have you been here? Do you know you are sick?
Patient: No, I am not sick. Stop telling me that, you’re lying.
Use of vocabulary: Student Nurse: Define the word lies.
Patient: That’s basic. You know it already.
Ability to conceptualize abstract: Student Nurse: Can you use your imagination to think you are in the future? What can
you visualize?
Patient: Nothing. I don’t want to think more.
Knows how to interpret proverbs or identify similarity or difference between object: Student Nurse: Can you differentiate
apple from orange?
Patient: They are both fruits. I’m not a kid.

Insight and Judgment

Student Nurse: Insight (awareness of the nature of the illness) Are you aware that you are sick? What do you know about
your illness?
Patient: No! I’m not sick, you just tell me I’m sick then blame me.
Student Nurse: (Judgment) If you have found money on the floor, what would you do?
Patient: I don’t know. Keep it, give to others.
Student Nurse: (Impulse control) The client is not capable to control the urges of stealing.

________________________ ________________________
Student Nurse Clinical Instructor