MENTAL STATUS EXAMINATION

I. General Overall Appearance

Patient is a 41 years old female, Filipino of average weight and height.

At the time of examination, she was well groomed and appropriately dressed
according to age. She preferred to wear jacket, T-shirt, jogging pants and
slippers. Her level of personal hygiene was fairly good. No foul odor from her
mouth upon examination. Patient’s skin integrity was intact, no lesions,
rashes or lumps noted during examination. Patient was also ambulatory
with normal anatomical posture and gait, no muscle weakness, injuries and
with active range of motion. There were no signs of tremor or abnormal
movements.
Patient appeared calm and relax. Client is healthy in appearance.
Generally, she is rarely conversant with difficulty maintaining eye contact
and minimal facial expression during interview. Prefers to lay down on her
bed most of the time. Her memory is intact for recent and remote events.
She is well oriented to time, place and person. She can do ADL
independently without being reminded.

II. Speech

Patient was able to communicate clearly and was able to achieve goal
directed ideas without any difficulty. Her speech is somewhat coherent,
spontaneously although at slow rate and speed. Tone and pitch are clear
and understandable. Frequent pauses noted before answering questions.
She spoke softly throughout the conversation. Shows non-verbal
communication like nodding, crossing of arms, walk away in the middle of
conversation.

III. Socialization and Interpersonal Relationship

Patient is often visited by her nephew. She rarely talks to other patient.
She doesn’t respond to questions when not insisted. More often she always
lying on her bed. She always partakes in OT with blank expression, no
emotions.
Social Isolation is prevalent to patients with bipolar disorder. Many bipolar
people tend to unconsciously isolate themselves from time to time. This
isolation fuels feelings of sadness and reduces feelings of optimism. The patient
lacks confidence as observed with having communication with her. As a result
she avoids communication to people.
 No intention of committing suicide or homicide. The following questions
were asked A. Suicidality: 1. “Ate minsan po ba naramdaman niyo na hindi
mahalaga ang mabuhay answered, “ Wala naman, alam ko marami pa rin
nagmamahal sa akin kahit ganito ang kondisyon ko”.
2. “ May araw po ba na sinaktan niyo ang inyong sarili?” answered, “Wala,
Hindi pa naman”
B. Homicidality: 1. “Nanakit na po ba kayo ng ibang tao?” answered, “ Oo
(pause) (thinks) kinuha ako ng pulis, Hindi ko alam kung bakit ayun sinisipa
at dinuduraan ko sila”

IV. Pathological Content of Thought

Patient did not exhibit any formal thought disorders. Auditory

hallucinations were noted. Patient claimed that prior to hospitalization she
hears voices but cannot be understood and describe either. No obsessions,
compulsions and illusions observed. Her delusions portrayed that another
person is in love with her despite no clear evidence against it (delusion of
erotomania) “ Uuwi ngayong week na to yung boyfriend ko galing Malaysia” (
patient’s nephew claimed that she did not have any boyfriend and has not
met one contrary to what the patient said on the NPI.) Patient also manifest
grandiosity by claiming that she is superior than men. Flight of ideas noted
during interview, shifting from one idea to another. No other manifestation
of abruptive behavior.

V. Intellectual Areas

Patient is oriented to time, place and person. She was able to answer
questions and recall her past without difficulties. Her General level of
intelligence and fund of general knowledge are adequate and appropriate for
her age. The patient didn’t have difficulty in giving consistent information
because she could give the names of her siblings and the place where she
stays, but most of her stated answers are not factual such as her
educational attainment , vices ( smoking and alcohol drinking).
 VI. Mood Affect

Patient rarely communicates to anyone. She is often seen lying and

sitting on her bed. Objectively, her mood was euthymic. Her affect is
somewhat restricted but she was able to display spontaneous emotional
reactivity. When called her attention looks at you with no facial
expressions, keeps quiet. To assess the inner feelings of the patient the ff
questions were asked, a. “Ano pong nararamdaman niyo ngayon? “
answered, “ Ok lang naman, malungkot dahil tahimik dito”
b. “Bakit po kayo malungkot? “ answered “ Ano eh, (pause) syempre
pamangkin ko lang bumibisita sa akin , yung mga kapatid ko hindi sila
pumupunta dito” Gustong gusto ko na ring gumaling at para makauwi na
ako

VII. Body Image

She denied any ideation of worthlessness or hopelessness. Social

Isolation from the environment was observed which makes her avoid any
interpersonal and social relationships.. She was able to identify the reason
of her admission in the ward, “ nandito ako para gumaling”, but has a fair
amount of insight into the nature of her mental illness.

VIII. Ability to Stress Captivity

During the NPI, The patient verbalized that when she feels bored she
diverts her attention on watching television, listen to radio, this are coping
mechanisms that are utilize by the client before confinement but during
hospitalization, she just sleeps whenever she feels bored.
During the OT , her actions were restricted, doesn’t show any expansive
mood during exercises but cooperates in every activities.
She also used defense mechanism of such as denial, sublimation,
intellectualization and showed limited affect.
 IX. Evaluation of how the client reacted to the interview

During the initial interaction with the patient, she was very hesitant to
converse freely. When rapport and trust was established she was able to
answer question with very limited response. Through consistent good
communication she became more conversant. Frequent pauses and brief
answers to questions was observed during interaction.
She did not exhibit any hostile or aggressive reaction during interviews.
But sometimes displays a blank expression.