MENTAL STATUS EXAMINATION

I.

PRESENTATION A. General Appearance The Client is awake, conscious, afebrile and not in respiratory distress. Client is well groomed. His nails are well trimmed and clean. He has a fair complexion

B. General Mobility 1. Posture & Gait: ( ) Normal ( / ) Appropriate ( ) Inappropriate He is kyphotic appropriate for a 88 years old patient whom always sitting on the chair.

2. Activity:

( / ) Normoactive ( ) Agitated

( ) Hyperactive, Restlessness ( ) Psychomotor retardation

The Client has normoactive activity.

3. Facial Expression: Quantity: ( / ) Smiling ( ) Happy Ecstatic ( ) Fearful

( / ) Appropriate

( ) Inappropriate

( ) Worried ( ) Tensed ( ) Frightened ( ) Sad

( ) Angry ( ) Suspicious ( ) Tearful ( ) Distant ( )

The Client has an appropriate facial expression according to what he felt. He is also smiling when someone gives him food to eat.

C. Behavior ( / ) Friendly ( ) Embarrassed ( ) Seductive ( ) Impulsive ( ) Dramatic ( ) Indifferent ( ) Sullen ( ) Negativistic ( ) Withdrawn

The Client is friendly but sometimes causes trouble to other client. D. Nurse Patient Interaction ( / ) Cooperative ( ) Initially only ( ) Uncooperative ( / ) Throughout Interview ( ) Later only Quality: ( ) Warm Hostile The Client is cooperative ( ) Distant ( ) Suspicious ( / ) Talkative ( )

throughout the interview and very

talkative to the people around him.

II.

STREAM OF TALK A. Character of Talk ( / ) Spontaneous ( ) Blocking ( ) Deliberate ( ) Pressured

The client is always talking, always asking everyone who pass him.

B. Organization of Talk ( / ) Relevant ( ) Perseveration ( ) Tangential ( ) Loose of Association ( ) Circumstantial ( ) Clang Assoc ( ) Neologism

( ) Echopraxia

( ) Echolalia

( ) Flight of Ideas

The answer of the client are relevant and good enough to understand the given information.

C. Accessibility ( ) Good ( ) Inaccessible ( ) Fair ( ) Defensive ( / ) Self-Absorbed ( ) Mute

The Clients accessibility is self-absorbed, he only talks about food.

III.

EMOTIONAL STATE AND REACTION

A. Mood ( / ) Euthymic ( ) Depression ( ) Euphoric

The client has a normal mood and not depressed and reasonably positive mood.

B. Affect ( / ) Appropriate ( ) Inappropriate

Quality: ( ) Flat ( ) Blunted ( ) Elated ( ) Labile ( ) Histrionic ( ) Anxious ( ) Angry

C. Depersonalization and Derealization ( ) Present ( / ) Absent

He is oriented with what he had done.

D. Suicidal Potential ( ) Present ( / ) Absent

The Client has no Suicidal intentions.

E. Homicidal Potential ( / ) Present ( ) Absent

He has moderate potential for homicidal, the client sometimes hurt other clients.

IV.

THOUGHT CONTENTS A. Delusions ( ) Present ( / ) Absent

Type: ( ) Thought Control, Broadcasting, Insertion ( ) Influence ( ) Paranoia persecutory, grandiose ( ) Somatic The Client has a good mind set when being assessed.

B. Ideas of Reference No ideas of reference noted.

C. Preoccupation, Rumination ( ) Preoccupied ( ) Intrusive thoughts ( ) Dejavu & Jamais Vu N/A none of the above are noted to the client. ( ) Rumination ( ) Phobias ( ) Rituals

V.

PERCEPTION

A. Illusions

( ) Present

( / ) Absent

The Client has no any illusions when asked with his current situation. B. Hallucinations Type: ( ) Auditory ( ) Gustatory ( ) Olfactory No perceptual hallucinations noted. ( ) Visual ( ) Kinesthetic/Tactile

VI.

NEUROVEGETATIVE DYSFUNCTION A. Sleep ( / ) Normal ( ) Hypersomnia ( ) Early ( ) Late ( ) Insomnia ( ) Mixed

The client sleeps well, sometimes felt sleepy when ate a lot.

C. Appetite He can consume all food being served.

D. Weight Not assessed

E. Diurnal Variation The Client changes its mood when felt hungry.

F. Attention Span ( ) Good ( ) Fair (/) poor The Client has a short attention span. He always forgot what has been said just a while ago.

G. Libido Not noted.

VII.

GENERAL SENSORIUM & INTELLECTUAL STATUS

A. Orientation ( / ) Time ( / ) Person ( / ) Place ( / ) Situation

The Client is oriented to time, place, persons, and his situations.

B. Memory

Remote: ( ) Unimpaired ( / ) Impaired

The client does not know a name of a family member.

Recent: ( ) Unimpaired (/ ) Impaired

The client does not know what he did yesterday.

Immediate: ( / ) Unimpaired ( ) Impaired

The client knows the name of his student nurse after doing the activities. C. Calculations (Progressive Subtraction of 7s from 100) ( / ) Good ( ) Fair ( ) Poor The Client was able to count all the crayons and buttons given.

D. General Information The Client was unable to provide information relevant to his

condition and his family.

E. Abstract Thinking Ability The Client can able to understand simple short instructions.

F. Judgement and Reasoning ( / ) Unimpaired ( ) Impaired

The Client was able to compare trash from food and reasons out the need for more food.

VIII.

INSIGHT The client is always showing increase of appetite, does he always ask about food to eat.

IX.

SUMMARY OF MENTAL STATUS EXAMINATION

A. Disturbance in: ( ) Presentation ( ) Stream of Talk ( ) Emotional state and reaction ( ) Thought ( ) Perception ( ) Neurovegetative dysfunction ( / ) General Sensorium and intellectual state ( ) Insight ( ) Positive Signs of Organicity

B. Diagnostic Category ( ) Functional ( ) Organic ( ) Psychotic ( ) Non Psychotic ( / ) Both Functional and organic