Mental Status Evaluation

I. HISTORY
a. Family History
- The patient was born on October 12, 2000 in Solana, Cagayan. She is single. Their
family consists of six people: her parents, the patient, and her two sisters and one
brother. She is the youngest of the four children; her parents are both still alive.
However, her mother has a gastric ulcer while her father has no known disease.

b. Health History
- According to the patient father, patient C.V is a certified honor student from
elementary up to high school, but when she lost her top at school, her behavior was
started to become different. She is no longer socializes with others and prefer to be
alone in her room. One morning (August 22, 2019), she was seen lying on the floor
with cuts on her hands. They immediately brought her in to the hospital and suddenly
referred her to the psychiatric department at Cagayan Valley Medical Center
(CVMC). Upon interview, the patient stated that she was hopeless "wala nang silbi
ang buhay ko, kaya gusto ko nalang mawala at para hindi na ako maging pabigat sa
mga magulang ko".  Her chief complaint was, sleep disturbances, irritability, thought
of suicide and dead. She was admitted at the same date and with a nursing diagnosis
of risk for self-harm related to feeling of hopeless and loneliness

c. Growth and Development

- According to Erik Erikson’s Psychosocial Theory, the patient belongs to the sixth
stage, which is intimacy vs. Isolation (18-40 years old). The patient is on the isolation
stage, because of her disorder, she distance herself with his peers and family and he
also distance herself from the other patient.
According to Sullivan’s life stages theory, the patient belongs to the adolescence
stage (puberty to adulthood). This stage promotes the needs for expanding values,
career, decisions and social concerns which the patient failed to achieve.
 d. Beliefs: cultural, spiritual, health and illness belief
- According to the patient's father, the patient is a Roman Catholic and she has a fear of
God and considered herself someone who is religious since she religiously followed
the teachings of her church. She also mentioned that she always attends mass virtually
or on site. That’s why her religion is very important to her. However, when she
experiences all the hurtful situations in life, it seems like she doesn’t go to church
anymore and sometimes they hear her blaming God for what is happening to her right
now. She also believes that nothing is wrong with her.

II. ACTIVITIES OF DAILY LIVING (During Hospitalization)

a. Diet and Elimination
- The patient father stated that she usually ate three times a day and also ate snacks in
between meals and claimed to have a good appetite. She usually drinks 6–8 glasses
per day. She ate more vegetables, fish, and sometimes meat. Moreover, she
mentioned that she did not have any allergies to food. She did not feel any difficulty
in swallowing. Prior to the hospitalization, her weight was 57 kg and her height was
5’4 with a total BMI of 21.5 kg/m2. In relation to her nutrition, the appearance of her
skin is normal. The patient verbalized that she usually urinated 4 times a day with a
measurement of at least 960 ml, which is considered normal since she drinks 6–8
cups a day with a measurement of 1500 ml. She mentioned that she defecated on a
regular basis and sometimes defecated twice a day depending on the foods she ate.
She did not have difficulty urinating and defecating, so she did not use any laxatives
or other medications to help her with her elimination.

b. Exercise and Activity

- After 3 days of admission, the patient mentioned that walking was the only exercise
she did in the hospital, since there is only a limited space. She often rests and does not
do difficult tasks. She loved watching TV, playing music and reading books.
III. GENERAL APPEARANCE
a. Appearance/Speech/Motor activity
- Upon admission, the patient’s appearance is well kept. However, she always wears
dark colored clothes that are not appropriate for her age. Moreover, she had good
hygiene. She can walk, but she cannot look straight.

IV. BEHAVIOR
- The patient is able to follow commands but cannot maintain eye contact. She had a
mannerism like hair tossing. During the interview, she remained in a sitting position
and her posture was bowed. However, she knew how to respect others and health
professionals. In other words, she knew about her limitations.

V. ATTITUDE
- During the first interview, the patient is not able to cooperate and is easily distracted
by her environment. While asking her a question, she refuses to answer it. Instead,
she remains silent and show flat affect.

VI. LEVEL OF CONSCIOUSNESS

- Upon receiving the patient, she is alert consciousness but not active especially during
the interview.

VII. ORIENTATION
- During the interview, the client cannot state her full name; she remains silent in her
chair. However, she is oriented to the time, date, and place. He is also aware of the
people around her. She knows her conditions, but she always tells us that she is in a
good state.
VIII. MEMORY
- From the beginning of the interview, I introduce my name to the patient, and when I
assess her memory, she can state my name. Therefore, her recent memory is good.
However, her remote memory is partially bad since she cannot remember her
birthplace but she can remember her birthday. Moreover, her immediate memory is
good since she can remember the three things that she was told to memorize in a few
minutes.

IX. SPEECH AND LANGUAGE

- The patient spoke in Ilocano. That’s why during the interview I used her native
language so that she could understand what I was asking. However, the patient did
not speak too much, and sometimes she could not answer my questions and remained
silent. And when she answered, she spoke with pressured, weak, slurred speech.

X. EMOTIONAL STATE
- When the patient is asked how is she feeling she remain silent and show flat affect.

XI. THOUGHT PROCESS

- The patient's thought process is unclear, but she can answer basic questions like
personal beliefs, but sometimes she is reluctant to give an answer regarding her
personal feelings.

XII. THOUGHT CONTENT

- The patient always uses denial as a defense mechanism. She always says, "okay lang
ako, ito nga, or masaya ako ngayon," but in contrast to its actions, the emotions show
flat affect.

XIII. SUICIDALITY AND HOMICIDALITY

- This was the second attempt of the patient in harming herself. She stated that “wala
ng rason para mabuhay pa ako, sobra yung pressured saakin tapos natanggal pako sa
rank, paano ako makakakuha ng scholarship, wala ng silbi ang buhay ko magiging
 pabigat lang ako sa mga magulang ko”. However, she never had the idea of killing
someone and there are no voices telling him to do so.

XIV. JUDGMENT AND INSIGHT

a. Judgement
- The patient’s judgment is quite not good. When asked “Ano gagawin mo kapag may
nakita kang kutsilyo o sharp object sa daan?” she answered “parang na tetempt akong
gamitin ito para saktan ang aking sarili”
b. Insight
- Patient C.V. verbalized that when she is alone she regrets the past decisions he made,
and when asked what are those she stated “Hindi ko na alam” but when asked if she
were to be given another chance, she replied “Pagbubutihin ko pa hanggang sa
makamit ko ang aking pinapangarap na buhay sa aking pamilya”.

XV. Level of Concentration and Calculation

a. Digital Span
- Since the patient is difficult to talk to, For example, I, the nurse, decided to command
her to follow me after I was done stating the words or numbers. Like for example,
numbers are recited by the nurse as follows (4-6-2) and asked the patient to repeat it,
first forward then backward. The patient didn’t do it well.
b. Spelling Backward
- She was asked to spell "happy," then spell it backward. She is not able to do it since
she is still silent and not able to talk in a manner.

Calculations

- The patient can’t answer mathematical questions.

XVI. SELF CONCEPT

- Patient C.V. described herself as a smart, kind, and helpful person. Not until she
experienced anxiety, wherein she did not like to socialize anymore because she
thought that she was a loser.
XVII. EXPERIENCES AND COPING STRATEGIES
- When asked about his childhood experiences he said “Masaya ma’am” and when
asked what She does when he has problems he stated “ iniisip ko lagi, hanggang sa
mawalan nako ng gana at panghinaan ng loob”.

XVIII. ROLE RELATIONSHIP

- According to the patient father, the patient is a caring and loving daughter. She has a
good relationship with his parents, also with his siblings, neighbors and friends.

XIX. INTELLECTUAL
a. Information and Vocabulary
- The patient knows the name of her teacher, she stated “Kelly Belen Camero”.
b. Vocabulary
- The patient stated that from elementary and high school, she graduated as a
valedictorian.
c. Abstraction
- When the patient asked about the the similarity of banana and orange she replied they
are both fruits and when asked what is the difference between the two he said “Ikaw
nalang sir”. When asked about his insight regarding the saying “aanhin pa ang damo
kung wala ng kabayo” she stated “Di ko alam sir, ikaw nalang.”