MENTAL STATUS EXAMINATION

I. Preexamination A. General Appearance On the day of assessment, client was sitting at the dining area waiting for his meal. Client had good overall appearance. His hair was combed properly. On his head, he had his gray hat on. He was wearing his white and blue polo short together with shorts and slippers. Skin color was brow in color in areas exposed to the sun, while those that are not are fair in color. Also, senile lentigo was noted. Pallor was not noted nor was there any form of respiratory distress. Neither body odor nor halitosis was noted in the entirety of the assessment. Client had eye contact when in conversation. B. General Mobility 1. Posture and Gait: Whether he was sitting or standing, client was noticeably slouched. However, when ambulating and in performing activities of daily living, he needs little assistance from nurses and caregivers. He uses his cane as assistive device for walking and balancing his gait. When walking, client is slow-paced since he suffers from arthritis . 2. Activity: (/) normoactive ( ) hyperactive 3. Facial Expression: 4. Behavior (/ ) friendly ( ) impulsive ( ) angry ( ) embarrassed ( ) negativistic ( ) evasive (/ ) seductive ( ) indifferent ( ) withdrawn C. Nurse- Patient Interaction (/) cooperative ( ) uncooperative ( ) initially (/) all throughout Quality: (/ ) warm ( ) distant ( ) dependent ( ) hostile ( ) suspicious ( ) talkative II. Stream of talk A. Character (/ ) spontaneous ( ) Deliberate ( ) pressured ( ) blocking B. Organization of talk ( /) relevant ( ) loose association ( ) tangentiality ( ) irrelevant ( ) flight of ideas ( ) neologism ( ) psychomotor retardation ( ) agilated

( ) incorrect ( ) circumstantiality C. Accessibility (/ ) good ( ) self-absorbed ( ) fair ( ) mute III.

( ) others: incomprehensible ( ) defensive ( ) inaccessible

Emotional State and Reactions: A. Mood (/) euthymic ( ) depression B. Affect (/ ) appropriate ( ) inappropriate Quality: ( ) flat ( ) elated () blunted ( ) labile ( ) hostile ( ) anxious C. Depersonalization & Derealization ( ) present ( /) absent D. Suicide Potential ( ) present (/ ) absent Thought Control A. Perception ( ) present B. Delusions ( ) present

( ) euphoria

( ) histrionic ( ) angry ( ) others

IV.

( /) absent (/ ) absent.

C. Ideas of references: NONE D. Preoccupations & Ruminations: NO RUMINATIONS; SPO E. Deja Vu & Jamais Vu NONE

V.

Neurovegetative Dysfunction:

A. Sleep (/ ) normal ( ) hypersomnia ( )MNA ( ) EMA ( )DFA (/ ) uninterrupted sleep

B. Appetite During meal time, client was observed to have good appetite. He was able to consume the entire meal served to him. In addition, during activities, when he is given his share of snacks, client was able to consume it.

C. Diurnal Variation D. Libido VI. General Sensorium & Intellectual Status:

A. Orientation The patient is oriented to place but he is not oriented to time and date. He was able to recognize the name of the institution where he resides and knows the purpose why he was there. B. Memory Immediate To test his immediate memory, we named certain objects such as ball, pencil and eraser and had him repeat them immediately. He was able to repeat them without fail. Recent To elicit recent memory, we asked our client what kind of activity that they had yesterday at the activity area. Unfortunately, he was not able to remember and verbalized, Unsa gani to atong gihimo?. Remote When we asked our client to recall significant events that occurred many years ago such as his wedding anniversary and what he did on his birthday last year, he cannot remember. A. Attention Span () good (/) fair ( ) poor

B. General Information: Client was not able to name the current president of the Republic of the Philippines. C. Abstract thinking: At the end of the activities, when client is asked to evaluate what has transpired, client gives his opinion and own reflections about said activity D. Insight (/ ) unimpaired ( ) impaired ( ) intellectual ( ) true