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Domingo, Jerick G.

N3A A1

MENTAL STATUS EXAM A. Appearance and motor behavior Appearance is appropriate to age: hair is properly cut and colored, in casual attire with clean or unstained shirt and shorts that are conservative; there are no cosmetics except with light powder. In proper hygiene and grooming but is slightly slouched. Cannot spontaneously establish eye contact. There is slight unusual odor and no physical handicaps or skin marks or injuries. Noted tattoo in right deltoid, left forearm, right and left thigh, right leg mid upper back

B. Communication There is clear, spontaneous speech with medium speed, intensity and volume. Client offers well-spoken but limited information. C. Thought process and content Client thinks practical and slight logical with thoughts of wanting what is best for his family. There is a relevant, organized, coherent use of words and is able to answer questions correctly. There are no unusual thoughts like delusions or feelings of unreality except with obsession in drinking alcohol. D. Mood and affect There is slight anxiousness observed from the client especially with personal questions asked from him. Shifts to a happy mood when there is light conversation. Affect is appropriate and congruent with mood. E. Sensorium and cognitive ability Client is alert and conscious, oriented to place, time and situation but cannot recall some of the person in his past. Able to recall recent and remote memory but attention span and ability to concentrate sometimes shift. Client is not able to use abstract thinking and intellectual ability is not appropriate. There are no hallucinations, illusions or depersonalizations observed from him. F. Judgment and insight There is an ability to assess and evaluate situations but client fails to make rational decisions. Though he has insights about the cause of his behavior, he has maladaptive coping mechanism and poor self-concept. G. Impulse control Client is able to control impulses related to hostility, fear, guilt and sexual feelings but affection and aggression is altered when faced to problems that are out of control.

Domingo, Jerick G. N3A A1

COMMENTS: Client seemed sad and quiet towards the nurse on initial interview but eventually relaxed after proper introduction. When answering questions, he stares at me with flat affect first before speaking but eventually smiles. Client responded only to questions. I noticed that client is comfortable with his current environment. Client maintained the eye to eye contact with me throughout the Nursing-Patient Interaction.

STN: Domingo Jerick G. N3A A1