Mental Status Assessment

Date: 11-26-2009

Time: 1:15-2:00 PM

A) General Appearance and Behaviour

The patient is appropriately dressed, clad in a red t-shirt, blue jogging

pants and light blue slippers. Personal hygiene is not so meticulously

done; her hair is unkempt and uncombed, and her face is oily and

unwashed. Patient was having hand tremors during the interview and

cannot sit still. She shifts her position constantly, and then stands up and

walks around the room during the course of the interview suddenly,

without explanation. She has an unsteady gait, and favors her right foot

when walking. Her body is of normal build and she slouches when sitting

down. Facial expression is noted to be sleepy, although she verbalized

that she is not sleepy at all. Eyebags are apparent. It was noted that her

affect was inappropriate—blunted. Overall, her appearance is haggard and

tired-looking.

She makes eye contact only when her attention is called and is spoken to

directly. But in most situations, she avoids eye contact and averts her gaze

elsewhere. Then she would look around her surroundings suspiciously

without the presence of any observable stimuli.

Speech is spontaneous and answers some questions with incoherent

mumbling. Thought blocking is apparent; she talks about unrelated topics

(e.g. the church) when asked about something else, and says, “Ay,

ambot,” or “Basta” or abruptly stops in the middle of her sentences and

 would no longer continue to answer the question provided. Other than that,

the quality of speech is spontaneous, deliberate and coherent except

when she mumbles to herself.

B) Intellectual Functioning (Cognition)

a. Orientation

i. Orientation to Time: Patient is oriented to the time of day, and the exact

date (November 26, 2009).

ii. Orientation to Person: She was able to verbalize her complete name.

iii. Orientation to Place: Patient is aware that she is in DMC-Psychiatry

section.

b. Attention and Concentration

i. Attention: Fair. During the interview, the patient was easily distracted

by non-observable stimuli. She was also quite restless and prefers to

walk around the room during the interview.

ii. Concentration

1. Serial 7’s or Serial 3’s: Client was able to perform the test within 5

seconds for solving. She was, however, not able to correctly answer

some items.

2. Digit Span: She was able to follow the digit span test by repeating

the given digits clearly and correctly.

3. Information and Current Events: She was able to determine the

name of the current president of the Philippines,, which being aware

that the elections are coming soon.

 4. Vocabulary: She described house as, “Balay nga kanang gi poy-an

bitaw. Simbahan… (incoherent mumbling)” while a home was

described as, “Dadto ga puyo ang pamily, mga ginikanan. Ah,

basta.”

5. Abstract Reasoning: The interviewers asked her to interpret,

“Habang may buhay, may pag-asa.” She replied by saying, “Kana

gud… kung may buhay ang tao, naa’y pag-asa lagi.”

6. Judgment: The question was, “Kung tagaan ka og kwarta, unsa

imong buhaton? Kanang daghan jud.” She replied, “Ihatag sa mga

nangangailangan.”

7. Sensory Perception and Coordination: The patient was distracted

several times by non-existent stimuli, as evidenced by rolling of

eyeballs in an effort to look around the room.

8. Affect and Mood:

a. Affect: Inappropriate—Blunted; the client does not reflect the

intensity of the material being discussed.

b. Mood: Patient reported that she is experiencing a mood that

pertains to euthynism, except for the occasional tiredness she

feels. “Ok ra man. Dili lang sakto akong tulog diri sa hospital.”

9. Ideational Content: There were several instances wherein the

patient seemed to be distracted by something at the corners of the

room, with her eyes looking around the surroundings in a cautious

manner. Sometimes, she would talk to herself in incoherent

mumblings.

C) Memory
 a. Memory of Remote Events: The client was able to recall the birthdays of

her mother (December 5, 1956), father (February 24, 1955) and herself

(April 2, 1988). She remembers where she went to grade school

(Langkila-an Grade School) and high school (Trento National High

School).

b. Memory for Recent Past Events: In the last three monthsm she

remembers spending her time in Bukidnon, verbalizing “Gap unit og

prutas sa bukid.” She said that her recreational activities are “Manilhig,

agto sa bukid para mag trabaho sa dapat trabahuon” and “Mag apil sa

simbahan, kay facilitator man ko didto.” She also remembers that her last

job was working in a bakery.

c. Memory for Recent Events: The patient can remember what she ate for

breakfast. “Pan at kanin,” as verbalized by the patient.

d. Immediate Memory and Recall: The patient was assessed using the digit

span test, and was able to memorize and dictate it properly.

D) Attitude

The patient’s overall attitude was manifested in her dislike for interacting

with others, and discomfort in making eye contact, and was very restless

during the interview. She refuses to be seated and prefers to walk around

the room. But despite her withdrawn demeanour, she was still cooperative

during the whole process.