MENTAL STATUS EXAMINATION:

PERSONAL DATA:
1. Name: KJM
2. Age: 21
3. Sex: MALE
4. Educational Attainment: College Graduate

General
Description
A. Appearance
Grooming/dress- appropriateness, cleanliness(neglect personal hygiene) and color
combination Client KJM appeared with appropriate clothes and cleanliness

Hygiene: N/A
Eye Contact(maintain, poor eye contact)Patient seems to
be a little uncomfortable for eye contact during the
meeting, pt appears to be averting his gaze
Posture (slouch, erect,opisthotonus (severe arching of the back): Unable to identify
Gait( unsteady, shuffling and robot gait: Unable to determine patient’s gait
Identifying features (marks/scars/tattoos): Unable to identify patient’s features.
Facial Expression (mask like,worn out, happy and sad): Client’s appearance is worn
out and sad
Appearance versus stated age The client appeared accordingly to her age
Overall appearance :(summary in a narrative form) patient KJM appeared to be
appropriate with grooming and has poor eye contact and sad facial expressions

Motor Behavior/Activity (check if present and describe further)

Hyperactive Agitated Psychomotor retardation Calm
Tremors/Tics
Unusual movements/gestures Catatonia
Akathisia
Rigidity Facial Movements (jaw/lip smacking)
Others:
 Speech
Rate: Slow/rapid
Amount: Paucity/ Mute/ Pressured
Volume: (loud/soft)
Characteristics: Fluency (mute/hesitation/latency of response)

Attitude during the Interview

Is the client:
Cooperative/ Uncooperative Cooperative
Warm/friendly/Distant - Warm
Suspicious/Combative Suspicious Guarded/ Aggressive Guarded
Hostile/ Aloof Apathetic Others:

B. Emotional
State Mood
and Affect
Is the client:
 Elated (euphoric)/Sad/Depressed (dysphoria) Depressed Euthymic Irritable/Anxious
Anxious
Fearful/ Guilty: Guilty Worried/ Angry: Worried Hopeless/ Labile: Hopeless
Mixed (anxious and depressed)
Is the Client’s Affect:
Flat Appropriate /Inappropriate/incongruent APPROPRIATE
Labile affect Apathy Others:

C. Thinking
Thought Process (refers to “how” of the patient’s self expression)
Concrete Thinking Circumstantiality Tangentiality Loose association
Echolalia Flight of ideas Perseveration Clang associations
Blocking Word salad Neologism Other:

SN: Anong gagawin mo kung sakaling nasunog ang bahay ninyo?

Pt: kukunin ko yung mga mahahalagang gamit naming ni lolo

Thought Content (refers to “what” the patient

actually thinks) Does client have:
Delusions (grandiose/persecutory/paranoid/somatic/religious) NONE
Suicidal/homicidal thoughts SUICIDAL THOUGHTS, If homicidal, towards whom?
● What thoughts have you had about hurting (person’s name)?
● What is your plan?
● What do you want to do (person’s name)?

If suicidal, ask the following Suicide Assessment Questions:

Ideations Plan Method Access Where When Timing
Does the client have?
Obsessions ParanoiaPhobias Magical Thinking
Depersonalization Hypochondriac Echolalia Others:

SN: ano ang pakiramdam na naidudulot nito sa iyo sa hinaharap?

Pt: Pakiramdam ko wala akong pag-asa , oo at feeling ko guilty ako sa nangyari kasi mag
isa narin ako. Parang wala nang silbi yung buhay ko, wala na kong inaalagaan at wala
na rin nag aalaga sakin.
SN: Okay, minsan naisip mo ba na saktan ang ibang tao?
Pt: hindi, pero yung sarili ko oo, minsan ayuss pa sakin na nagkakasakit ako.
SN: Maaari mo bang sabihin sakin ang dahilan at naisip mo yan?
Pt: Para makalimutan ko na lahat, gusto ko nalang sumunod kay lolo.
D. Experiences
Perceptual Disturbances
Is the client experiencing:
Visual Hallucinations: NONE
Auditory Hallucination, specifically, Commenting, Discussing, or Commanding: NONE
Other Hallucination (olfactory/tactile/gustatory): NONE
Illusions: NONE
SN: Nakaririnig ka ba ng mga boses na hindi naririnig ng ibang tao?
Pt: Hindi
SN: o may nakikita ka ba na hindi nakikita ng pang karaniwan?
Pt: Wala
SN: Minsan pakiramdam mo ba na may sumusunod sa iyo o may gustong manakit sa
iyo?
Pt: Wala naman

E. Sensorium and Intellectual Process:

Level of consciousness- confused/ sedated/ stuporous confused
Orientation: Person Place Time
 Memory (recent/remote/immediate) Recent
SN: Naaalala mo pa ba kung ano ang kinain mo kaninang umaga?
Pt: Uhmmm, nag kape lang ako. Wala din kasii akong gana kumain eh.,
SN: Ano ang naidudulot ng pakiramdam na ito sa iyo?
Pt: Hindi ko alam, hindi ko talaga ito iniisip
SN: Okay ano ang pakiramdam na naidudulot nito sa iyo sa hinaharap?
Pt: Pakiramdam ko wala akong pag-asa , oo at feeling ko guilty ako sa nangyari kasi mag
isa narin ako. Parang wala nang silbi yung buhay ko, wala na kong inaalagaan at wala
na rin nag aalaga sakin.
SN: Okay, minsan naisip mo ba na saktan ang ibang tao?
Pt: hindi, pero yung sarili ko oo, minsan ayuss pa sakin na nagkakasakit ako.
SN: Maaari mo bang sabihin sakin ang dahilan at naisip mo yan? Pt: Para makalimutan ko
na lahat, gusto ko nalang sumunod kay lolo.

Level of Concentration is weak

Can you perform certain tasks, like?
Level of Calculation GOOD
Can do simple math, like?
General fund of knowledge is
(ask about current events)
Use of vocabulary is GOOD Can define meaning of the word.

SN: Maaari mo bang sabihin sakin ang pangalan ng mga buwan ng pabaliktad?
PT: uhmm, December, … November…. October….*nakatulala….. uhmmm

Ability to conceptualize abstract is Fair

SN: Maaari mo bang sabihin saken ang pinagkaiba ng Lamesa at Upuan
Pt: uhhmmm ang lamesa ay kinakainan habang ang upuan ay inuupuan
SN: Ano naman ang pagkaka pareho ng lamesa at upuan
Pt: Parehas itong gawa sa kahoy
Knows how to interpret proverbs or
identify similarity or difference between
objects:

SN: Ano ang ibigsabihin para sa iyo ng salawikaing “Nasa Diyos ang awa nasa tao ang
gawa?
Pt: Uhmm, kailangan nating gumawa at magsumikap?

Insight and Judgement

Insight is (good, fair or poor) Fair
SN: Anong gagawin mo kung sakaling nasunog ang bahay ninyo?
Pt: kukunin ko yung mga mahahalagang gamit naming ni lolo

Judgement is (good, fair or poor) good

SN: Bilang panghuli, mayroon ka na bang ideya sa iyong sarili sa kung ano ang iyong
nararanasan?
Pt: Feeling ko depressed ako