DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

COLLEGE OF NURSING
2nd Semester, S.Y. 2020-2021
NCM 117

NAME : ENDRIANO, WYETH EARL P.

COURSE, YEAR, & SECTION : BSN III B
DATE : April 5, 2021

Mental Status Examination

I. APPEARANCE

Female patient is seen to have a good appearance and seemed hygienic. She wore a
clean peach dress with tidy combed hair, and fair skin with no lesions or apparent trauma,
looking appropriate for the meeting. The patient has a good posture and is apparently full of
energy while talking, manifesting over activity of gestures.

II. BEHAVIOR

The female patient is observed to have a restricted to elated affect. She seemed to have
a full energy when talking and is able to maintain eye contact with the interviewer. She
responds to all the questions but in a broad and indirect manner, sometimes expounding that
leads in the conversation derailing from the topic.

III. ATTITUDE

Patient is observed to have an open attitude while being interviewed and is very
cooperative towards the interviewer. She answers all the questions but sometimes she talks
about unnecessary things that leads to the answer eventually.

IV. LEVEL OF CONSCIOUSNESS

Interviewee has shown an alert level of consciousness evidenced by her answering all
the questions asked by the interviewer but sometimes in an indirect manner.

V. ORIENTATION

Patient seems to know where she since she had been able to answer the question “why
are you here?”. She was brought to the facility by her friend and is observed to be compliant.
She is aware of what is happening and is cooperating effectively. She also know that she has a
problem since she had stated that she does not know what is wrong with her.

VI. SPEECH AND LANGUAGE

 When the patient was being interviewed, she responds coherently and speaks intently
with the interviewer. Her tone was congruent with the emotions and context of the topic being
discussed but the patient was observed to over expound before arriving to the answer and
sometimes the questions was not answered.

VII. MOOD

The patient seems energized and even elated in how she speak and discuss her
experiences. She is observed to be having a manic episode.

VIII. AFFECT

The patient’s gestures are in congruent with her thought process and context of the
conversation. She seems to possess a labile to elated affect evidenced by her energetic
movements and speech.

IX. THOUGHT PROCESS/FORM

The patient’s thought process can be described as tangential as she does not answer the
questions directly. She first talks about other topics and eventually leads to the answer. She
appeared to be goal directed as the questions are answered.

X. THOUGHT CONTENT

The thought content of the patient comprises of the things that happened earlier of the
day prior to their arrival at the facility. She mostly talks about what she have done on the day
and how other people react to her, particularly an observant individual.

XI. SUICIDALITY AND HOMICIDALITY

Not observed on the patient.

XII. INSIGHT AND JUDGEMENT

Patient knew that she had a problem with her mental state since other people are
confronting her with it and was compliant in coming to the facility to be treated.

XIII. ATTENTION SPAN

It was observed that the patient has a good attention span and possibly matching to the
normal individual since her thinking was described as tangential. She brings up other topics but
definitely arrives to the answer. No specific inquiry was done.

XIV. MEMORY
 Patient was observed to have a good recent memory with incredible detail based on the
questions answered. No specific inquiry was done.

XV. INTELLECTUAL FUNCTIONING

The patient was able to recall the events with details such as who, where, and why. She
was able to rationalize the events. Particularly, when she stated that she was called a manic
and was able to recognize that something is wrong with her, confirming that she is able to
intellectually function. No specific inquiry and additional assessment was done.