MENTAL STATUS EXAMINATION (MSE)

Date: March 18, 2013 (Monday)

Time: 8:30am

(Orientation Phase)

General Appearance
Mrs. Bride is an old woman, with a height of 49, she is pale but she has a good skin
turgor. She is wearing a Yellow dress and a pair of red slippers. She looks drowsy, and she has a
poor eye contact.she has a normal posture. Her hair is black, her nails are well trimmed and she
no foul body odor. Mrs. Bride is a well groomed woman.
General Mobility
Mrs. Brides posture and gait is normal and has a normoactive activity.
Behaviour
Ms. Nat has a poor eye contact and she looks suspicious. She doesnt also want that
anybody will touch her. She said that Kaya ko man na ako lang. Di nyo ako kaylangang
hawakan. She is a silent type person that she will not talk unless you ask her to.
Stream of talk

Mrs. Bride has relevant organization of talk. She has no flight of ideas and ideas of
reference. She answers the questions being ask to her and she confessed if she told a false
statement. She also talks slowly as if she is remembering something.
Emotional State and Reaction
Mrs. Bride has a flat affect so we cant identify her true emotions. But during our second
week of therapy, she already smiles to us.
Thought Content
Delusion:
Patients verbalized, Daghan ko kwarta sa Bancnet. Bigyan kita ng 50,000.
Ikakasal ako mamayang alas 11:00 ng tanghali, kaylangan ko nang mag prepare. Punta ka sa
reception naming, doon sa Dimsum Diner sa SM.
Neurovegetative Dysfunction
Mrs. Bride has a fair attention span. She spends the day by talking to her roommates and
sometimes, she is sitting near the entrance of the hospital.
General Sensorium and Intellectual Status
Mrs. Bride is oriented to time, place, situation, and person around her.

VIII. Summary of Mental Status Examination

With our assessment of Mrs. Bride, she has a problem of thought content
especially on delusion. Her actions is manipulated by her delusions.

DSM IV TR Diagnosis
Axis I Paranoid Schizophrenia
Axis II No personality disorder and mental retardation
Axis III No current medical condition
Axis IV Psychosocial problem
Axis V - 32 (GAF)