MENTAL STATUS EXAMINATION

A. Baseline Data
Name: Sex: Religion: Occupation:
A.M M Baptist Former Security
Guard
Address:
Brgy. Sum-ag, Bacolod City
Educational Status: Chief Complaint: Contact
Attainment: Single Depression, Paranoid Thoughts, Ritualistic Behavior Number:
College Level,BS 444-4515
Criminology
Medical Diagnosis:
Schizoaffective Disorder – Depression
Nursing Diagnosis:
Disturbed thought process r/t chemical alterations as evidenced by delusions, paranoid thoughts, ritualistic
behavior, and depression
B. Brief History of Present Illness:
Patient was intellectually normal before the age of 27, without any medical problem and have worked
as a security guard. He has no children, never married, and lived with his older sister. He had been smoking for
approximately 10 or more years, denied alcohol and other psychoactive substance abuse. His father was a
drunkard and violent, often goes out for without reason and committed suicide several years ago. In 2009, the
patient gradually became depressive; showed diminished pleasure, insomnia, fatigue, and was unwilling to talk to
others. He developed delusions of persecution and reference, which made him believe that someone had insulted
him and planned to kill him without evidence. He was then brought to the clinic of Pototan and was prescribed
paroxetine 20mg tab once a day and sulpiride 0.2g/day. He took these irregularly, with minimal improvement in
depressive symptoms and delusions. In August 2013, he was sent to the hospital for schizoaffective disorder-
depression. The following month, he was given quetiapine 600mg/day and lithium carbonate sustained-release
tablet 0.6g/day which made his depressive and positive symptoms improve. Unfortunately, he discontinued these
medications in May 2017. He again gradually developed fear of the sound of water, lack of pleasure and negative
ideas, and claimed that he could not trust anyone. Furthermore, the patient performed ritualistic behaviors, such as
walking with a specific order. He was once again sent to the hospital by his older sister. He presented depressive
symptoms, ritualistic behaviors, and distrust. Upon admission, tests were done and were all normal. During his
interview, he displayed depressive symptoms, delusions, and ritualistic behaviors. He was given medications
(quetiapine and lithium carbonate) which moderately improved his symptoms. However, the ritualistic behaviors
gradually worsened. These disturbed behaviors made him anxious. The medical team wanted to reduce these
behaviors by adding sertraline at a dose of 50mg/day and titrating it to 100mg/day. The symptoms further
worsened and he developed agitation, pressure of thoughts, and delusion of control. He felt that his ritualistic
behaviors gradually became out of control, realizing that “unknown thoughts” and “a black shadow” affected his
mind. He also felt sad and there was nothing that brought him pleasure. He was then diagnosed with
schizoaffective disorder-depression. During his 23rd day in the hospital, the patient gradually began to talk with
the doctors and other patients, also joining some activities in the ward. The pressure of thoughts and delusions of
control almost disappeared. It also took him less time to perform ritualistic behaviors. On his 31st day, he was
given lithium carbonate sustained-release tablets 0.6g/day and oral risperidone 4mg/day. These medications made
his psychotic and depressive symptoms stable.
C. General Appearance and Behavior: (Observe the following: Physical stature, facial expression, motor
mannerisms or gestures, scars or marks, grooming, gait.)
 Patient appears to be tall and slender in figure. Patient has dark circle around his eyes which could
indicate that the patient has trouble in sleeping pattern. He was wearing an un-ironed yet clean white shirt
and knee length shorts yet shows lack of interest in personal grooming (patient appears to have just woken
up). Patient walks straight and sits erectly on chair while talking to the student nurse, facial expression
looks tensed and worried. Patient always looks on both sides.
D. Behavior (Presence of unusual movement and psychomotor changes (Check the types of responses:
coherent, easy to understand, simple, lacking or overly in detail, difficult to follow)
Take note of: Rate (rapid, slow)
Volume (loud, soft)
Amount (route, pressured, paucity)
Character (Stuttering, slurring, unusual accents, mumbling, echolalia)

The patient presents an open and friendly behavior upon interaction. The patient was able to talk
and respond in a clear and normal tone. Eventually, he becomes anxious of his surroundings and talks in a low
and rapid manner. Patient takes a long time to answer then responds with unrelated words.
E. Mood and Affect
Mood – feeling inside; (happy, sad, elated, angry, anxious, euphoric, melancholic)
Affect – can be seen outside: (flat, dull, appropriate, inappropriate, labile, restrained, constrained,
blunt – flat)

Patient verbalized that he experiences varying moods from being sad, irritable, and anxious.
Patient states that he rarely feels happy or pleasurable. The patient has labile affect wherein his mood
changes rapidly from being sad and quiet to being overly irritable and anxious, patient states he is anxious
for he thinks that someone plans to persecute him.
F. Form of Thought
Thought content – what the patient is thinking: delusions, depersonalization, magical thinking,
obsessions, phobias
a. Concrete (Literal Meaning)
b. Abstract (Proverb Interpretation, Comparison/ Differences)
Thought process – form in which the client thinks or how the client thinks (Flight of Ideas,
Phobias,Tangibility)

The patient is able to give information about his experiences in life although there are a few
instances that the client uses unrelated words in response to the student nurse during nurse-patient
interaction. The client also has difficulty with abstract thinking demonstrated by an inability to
understand common proverbs. Patient often reports that he is seeing dark shadows and would
sometimes hear different voices that would talk to him. He also reports seeing deceased father.
The voices and shadows would mostly happen at night causing him anxiety and trouble sleeping.
It would also happen when he does not take his medications.
 G. Sensorium Function
Level of Consciousness (LOC)/Orientation
Time
Place
Person
Situation
The patient is aware of the time when asked yet needs further assistance in orientation of place
or location. The patient does not have trouble recognizing people whom interact with him and the
activities that were conducted for treatment although he only has little insight of his situation or condition.

Memory – Test the area of

Rote (nursery rhymes, alphabet, numbers)
Remote (Childhood experiences)
Recent (situation that happened 24 hrs. & above)
Immediate (just exposed to, below 24 hrs.)
Patient AM could count numbers and recite the alphabet. He also recall the moments
during his childhood when he was told by his mother to sing the alphabet and the multiplication table.
He stated that if he could memorize everything, he will get a reward from his parents and that is the
reason why he always wants to sing and recite the alphabet. But he gets emotional whenever he speaks
about the alphabet because according to him, it reminds him of the “chikiding” song that his mother
taught him.

Level of Concentration – count and reverse, arithmetic

Upon assessment patient AM was asked to count from 1 to 10 but when he reached the
number 6 he would pause and states that he forgot and starts again from 1. His eyes roams around the
room as if he is looking for something or as if he had seen something. He would always said “lakat
kamo to” in a whispering manner.

Information and Intelligence Test

- Use the Kahn’s 10 questions to assess if there is Organic Brain Syndrome
The patient obtained a score of 8 out of the 10 questions which indicates mild organic brain
syndrome.
10 Kahn’s Questions X /

1. What is the name of this place? /

2. Where is it located? /

3. What day of the week is it? /

4. What is the month now? /

5. What is the year now? /

6. How old are you now? /

7. When were you born? (month) /

8. When were you born? (year) /

9. Who is the president now? /

10. Who was the president before /

him?
Total Score from the 10 questions will determine if patient is suffering from Organic Brain Syndrome (OBS).

H. Insight and Judgment

Insight – perception of illness or awareness of situation
Judgment – decision-making of the patient; achieved through asking hypothetical questions
(excellent, good, impaired, poor, nil)

The patient has little insight of his condition and symptoms that he manifests. He only
knows that he is ill and requires treatment. Patient is also aware that he experiences symptoms of
depression and anxious behavior whenever he does not take his medications. The patient is capable of
basic judgment when asked which food is edible or rotten. The patient was also able to give a relevant
answer the question being asked. For instance, when the student nurse asks him "Ano himuon mo kung
makakita ka 50 pesos samtang galagaw ka?" the client answers, "Indi ko pag kwaon kay basi may gulpi
ma dakop sakon kag patyon ko nila."
I. Reliability – nurse’s perception on how reliable the patient is

Upon assessment and interaction, there would be a chance that the patient is reliable in based
on his judgments. He answered questions relevantly although his anxiety and paranoia can lead him to
negative thoughts and behavior.

J. Prognosis – It is the prediction of the course and end of a disease, and the estimate chance for
recovery.

Upon the nurse and patient interaction, there is a greater chance for the patient to be fully
recovered. He just need people who could understand and be with his side. Although, there might be
some circumstances that the recovery of patient AM might not be as effective as it is expected because
of smoking cessation. But with proper care and concern towards patient AM, everything will be in place
and be smoother.

Criteria Poor Good

1. Onset of Illness
· Below 20 and Over 40 years old
· Between 20 – 40 years old /

2. Educational Attainment
· High school level
· College level at least finished 1 /
year in College

3. Sex
· Male /
· Female

4. Family History
· Familial
· None /

5. History of Admission
· Chronic /
· Acute

6. Socioeconomic Status
· Unstable
 · Stable
/

7. Family Support
· Without
· With /

8. Behavior in the Ward

· Non-participative
· Participate /

9. Pre-Morbid Personality
· Introvert /
· Extrovert

10. Compliance to Medications

· Without compliance
· With compliance /

K. Evaluation
The patient, AM, a 35-year-old male, is admitted at Western Visayas Medical Center-Pototan Mental Health Unit
(WVMC- PMHU). Apparently, the patient was intellectually normal before the age of 27 years old without any
medical problem and have worked as a security guard. He had been smoking for approximately 10 or more years,
denied alcohol and other psychoactive substance abuse. In 2009, the patient gradually became depressive; showed
diminished pleasure, insomnia, fatigue, and was unwilling to talk to others. He developed delusions of persecution and
reference, which made him believe that someone had insulted him and planned to kill him without evidence. Patient
AM is not married and has no children. He lives together with his older sister. Patient AM is non participative in any
of the activities conducted by the student nurses and staff and reports that he sees dark shadows and sometimes sees
his deceased father. He also reports that he hears voices especially during the night talking to him and telling what to
do. These episodes would frequently happen during the night or when he does not take his medications. Upon
assessment, patient is well oriented of the time and date but requires further orientation of places. He has difficulty in
concentration for he cannot finish counting from 1 to 10 without forgetting a number. On the assessment for Organic
Brain Syndrome, using Kahn’s 10 questions, patient obtained a score of 8 which indicates that he has mild organic
brain syndrome.

A. References (CI, Patient’s chart, etc.)

• Patient's Chart and Medical History
• Clinical Instructors and Facilitating staff