MENTAL STATUS EXAMINATION

Note: (*) Indicates the patient's verbalization of his alleged profile.

HISTORY:
Name: *Machete* Gender: Male Status: *Single* Age: *28*
Developmental History:
He said he only finished 6th grade/ elementary but upon interviewing he does not
sound elementary at all, on the second day, he remembered that he studied 3rd
year of highschool.
Cultural Considerations: Allegedly claims to be from Sierra Madre
Spiritual Beliefs: N/A

Previous History: Pt. Machete was admitted 8 months ago and he was said to be
repeating the words, "Machete, or Syete" over and over until that became his
name. He says he cannot remember his past or wants to forget his past but he
says prior to his condition he was once hearing auditory hallucinations/ voices
making him go to other directions, but also he claimed that his mother went on to
various hospitals because of his mood changes and only until now that he
recognized that he had this hallucinations. He was found by the ambulance in
Bacoor in the streets, with feces smears on his clothes and the area where he
stays, as a 'taong grasa'.

GENERAL APPEARANCE:
Patient is dressed up appropriately, with the hospital policy dress code, wearing a
green tank top or "sando" and green shorts that goes over his knees having clean
clothes, hair is washed, with a wary and tense expression. His overall appearance
looks about to be 30s to 40s with a body build of an average male, having an
approximate weight of 60 - 70 kilos with facial and arm scars and hair cut very
short unto his scalp.
MOVEMENTS and MOTOR BEHAVIOR/ACTIVITY DURING INTERVIEW:
Behavioral Characteristics/Manner:
Patient is observed to be cooperative, answers every question except when
pressed hard questions, polite (use of po), slightly agitated, on some occasions
patient has slow response, smiles when praised or motivated in an optimistic
group, seeks approval/ acceptance. He is defensive, "Di ko alam… etc." and says,
"Pagod na ako" when asked during interview.
Eye Contact:
He avoids eye contact at the start of orientation phase, looks eye to eye during
therapies (art, dance, recreational…etc.) especially when he is praised or during
accomplishment. He is able to maintain eye contact but he seemed to be hesitant
when asked about his past history.
Patterns of Movement:
He exhibited slight waxy flexibility when asked to show his painting and he did
this by holding the painting for a long time, he remained in that position unless he
was commanded to relax.
Speed of Movements:
Patient is observed to have a slow careful movement, like he does not want to
make any noise or that his movements are caused by shyness.
COMMUNICATION: SPEECH AND LANGUAGE
Volume Patient whispers in answering questions, answers softly.
Rate Some moments, Pt. Machete has a slowed long pause before
answering a question, slightly hesitant, may be pressured, but most of the time he
has a normal rate of speech.
Amount Patient ashes straight to the point, usually with a minimum of one-
two words and a maximum of five to ten words.
MOOD and AFFECT:
Stability: Pt. M is consistent with the affect & mood in the duration of the activity.
Range: Pt.'s affect is expansive to the point that he smiles and laughs on jokes and
perceived funny logic.
Intensity: Pt. has mild to moderate anxiousness during the interviewing phase but
is able to lose it during therapies.
Appropriateness: Pt.'s mood and affect are appropriate in his environment and
reactions to activity.
Emotional Facial Expression: He is worried, anxious, nervous at the start of each
of the activities but after it he is getting used to the people except the presence of
the CI which he knows is a figure of authority, and when the CI pressed him
continuously with demanding tone, his facial expressions went on defensive. The
questions that ticks him off are about his family. He got sad when he retold the
story of going away from home. He is friendly & polite. He smiles, claps, laughs,
and does two high-fives with both of his hands when he wins in basketball.

THOUGHT CONTENT and THOUGHT PROCESS

THOUGHT CONTENT: Currently, during the first day, the client answers very
directly to the point, with short answers, he uses "po" and he understands the
questions and responds to it carefully. He used the words, "Dinosaur, root crops,
weather disturbance, Malagkit 160, bus, highschool, elections, MAPEH
abbreviations and its meaning, G-Clef, tune (do-re-mi-fa-so-la-ti-do)", but he
doesn't know the proper position in the music lines, he also know how to plant
"palay", he remembers his friend, "Domingo" and the game "thumb war". He also
referred to 'Odie' as his friend, he also knows where he is, and is oriented. He also
knew Imelda Marcos, but he said Imelda became the president in 2008."
THOUGHT PROCESS: His answers are connected to the questions, he stops a
few seconds to rethink his response. He is goal directed, focused, excellent in
judgment in logical situations and questions, he is coherent, although he had
thought blocking due to his condition, being a taong grasa, probably for a year or
more.
ORIENTATION:
Name: Only remembers *Machete* Address: *Sa taas ng Sierra Madre Mt*
Place where he is: *CCMH* Day: *Friday, Biyernes* Date and Month: May 4
Season: --- Year: 2023 (He knew Bongbong Marcos as the current President
*He also said that he has been in CCMH for 2 months, this information is what he
heard*
SENSORIUM and INTELLECUAL PROCESSES:
COGNITIVE FUNCTIONING:
He has excellent judgment in logical questions, good insight, steady focus in
coloring, painting, or art activities, attentive and cooperative. His capacity of focus
is long, he concentrates hard, when tested for the short term memory in
remembering the student nurses names, he got it right 3 times it was repeated
during the course of 2 days. Recent Memory is tested by asking on what he ate,
he responded, "Embutido", as for the remote memory, he did not remember
when he was admitted. He is satisfactory at abstract ability, havibg a hard time
understanding the proverbs.

MOTIVATION for TREATMENT:

Patient Machete is very cooperative when the nursing students would always
treat the patient with positive regard, acceptance, easy demeanor, smiles and has
an open and positive reinforcement. He likes to be praised, rewarded, respected,
and it is observed that he likes to have a sense of purpose, and accomplished
something.