mental status exam pp

8/3/2019 Mental Status Exam Pp

1/11

MENTAL

STATUS EXAM


2/11

Appearance

Clientis a medium built Filipino. Heissingle

and 46 yearsofage. He wasseenstanding,

slouching,shufflingfrom onefootto another.

He was wearingthesamesetoffclothes

yesterday: whiteoldt-shirt anddenim shorts.

He was already dirty and malodourous. Hehas

no missinglimbs, wasnt jaundiced,coughing,or injured. Hearingsnotimpaired andhehas

missing, yellowingteeth.


3/11

Behaviour/Movements

Client was ableto maintaineyecontact. He

wasgenerally cooperative butneeded

coachingtogetthingsdone. Heseemed

indifferent,unconcerned,lethargic andslow in

movement. Whenever heisstanding,he

seemeddisinterested, bored and,slow to

respond.


4/11

Communication

The way theclienttalked wasslow andsoft, and

mumbling. Hes also monotonous anddoesnt

seem toshow emotioninhisintonation. When

being asked,his answers would always beshort,minimal. Hehasnot yetinitiatedconversation.

Hes abletofollow simplecommandslike

brushingteeth,sittingonthechair andeatingon

thetable. He was abletonameobjectspointedlike a pen and wrist watch, but wasunableto

namethesecondhand.


5/11

Affect/Mood

His affect was blunt. Mood appearedtoshift

toslightly irritable but mostly it was

unreadable. Hehasvery few facial

expressions. Heoncehad bothcornersofhis

mouthturnedever soslightly upwards.Client

doesnothave any problemsfalling asleep,

staying asleep, and wakingup. He alsoappearedto beunaffected whenhefailedto

identify thesecondhand.


6/11

Thought Content

Theclientsaidthathedidnothear or see

anythingthatisoutoftheordinary. He also

saidthathedidnotthinkofharming anyone,

or hadsuicidalideation.


7/11

Thought Process

Clientsthinking wasslow andsomeofhis

replies weregoaldirected,some werenot,like

he refusedto answer.


8/11

Perception

Clienthasnotexperiencedhallucinations,

illusions,derealisation,depersonalization.


9/11

Level ofConsciousness

Clientisdrowsy most,ifnot allofthetime. He

responds whenspokento, may drifttosleepif

notstimulated and wakesup whenfood and

medication are beingserved.


10/11

Orientation

Clientis abletostatehisname,know where

heis, butisnotorientedtodate.


11/11

Cognitive Functioning

Theclient was ableto remember student

nursesname after 30 minutes andhehas able

to remember any stimulatingeventthat

happened a day beforelikesomeofthe

contentoftheinterview. Hehas a low

attentionspan, refusedor was abletogain

insight, and refusedto answer questionsthatneededlogicalthinkinglikecounting

backwardsor subtracting.

mental status exam pp

Documents