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    Mental Status Examination

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    judssalangsang
    The client had good general appearance and hygiene. He was slow moving due to arthritis and used a cane to walk. He was friendly and cooperative throughout the assessment. His speech was spontaneous and relevant. He had a euthymic mood and appropriate affect. He was oriented to place but not time or date. His immediate memory was intact but recent and remote memory were impaired.

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    Mental Status Examination

    Uploaded by

    judssalangsang
    583 views3 pages
    The client had good general appearance and hygiene. He was slow moving due to arthritis and used a cane to walk. He was friendly and cooperative throughout the assessment. His speech was spontaneous and relevant. He had a euthymic mood and appropriate affect. He was oriented to place but not time or date. His immediate memory was intact but recent and remote memory were impaired.

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    The client had good general appearance and hygiene. He was slow moving due to arthritis and used a cane to walk. He was friendly and cooperative throughout the assessment. His speech was spontaneous and relevant. He had a euthymic mood and appropriate affect. He was oriented to place but not time or date. His immediate memory was intact but recent and remote memory were impaired.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    583 views3 pages

    Mental Status Examination

    Uploaded by

    judssalangsang
    The client had good general appearance and hygiene. He was slow moving due to arthritis and used a cane to walk. He was friendly and cooperative throughout the assessment. His speech was spontaneous and relevant. He had a euthymic mood and appropriate affect. He was oriented to place but not time or date. His immediate memory was intact but recent and remote memory were impaired.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    The document describes a mental status examination of a client. It notes details about his appearance, mobility, interactions, thought processes, mood, memory, and intellectual abilities.

    The client has a generally good appearance but is noticeably slouched when sitting or standing. He walks slowly with a cane due to arthritis. He is cooperative and friendly throughout the assessment.

    The client is oriented to place but not time or date. His immediate memory is intact but his recent and remote memory are impaired - he cannot remember recent activities or significant past events.

    MENTAL STATUS EXAMINATION

    I. Preexamination A. General Appearance On the day of assessment, client was sitting at the dining area waiting for his meal. Client had good overall appearance. His hair was combed properly. On his head, he had his gray hat on. He was wearing his white and blue polo short together with shorts and slippers. Skin color was brow in color in areas exposed to the sun, while those that are not are fair in color. Also, senile lentigo was noted. Pallor was not noted nor was there any form of respiratory distress. Neither body odor nor halitosis was noted in the entirety of the assessment. Client had eye contact when in conversation. B. General Mobility 1. Posture and Gait: Whether he was sitting or standing, client was noticeably slouched. However, when ambulating and in performing activities of daily living, he needs little assistance from nurses and caregivers. He uses his cane as assistive device for walking and balancing his gait. When walking, client is slow-paced since he suffers from arthritis . 2. Activity: (/) normoactive ( ) hyperactive 3. Facial Expression: 4. Behavior (/ ) friendly ( ) impulsive ( ) angry ( ) embarrassed ( ) negativistic ( ) evasive (/ ) seductive ( ) indifferent ( ) withdrawn C. Nurse- Patient Interaction (/) cooperative ( ) uncooperative ( ) initially (/) all throughout Quality: (/ ) warm ( ) distant ( ) dependent ( ) hostile ( ) suspicious ( ) talkative II. Stream of talk A. Character (/ ) spontaneous ( ) Deliberate ( ) pressured ( ) blocking B. Organization of talk ( /) relevant ( ) loose association ( ) tangentiality ( ) irrelevant ( ) flight of ideas ( ) neologism ( ) psychomotor retardation ( ) agilated

    ( ) incorrect ( ) circumstantiality C. Accessibility (/ ) good ( ) self-absorbed ( ) fair ( ) mute III.

    ( ) others: incomprehensible ( ) defensive ( ) inaccessible

    Emotional State and Reactions: A. Mood (/) euthymic ( ) depression B. Affect (/ ) appropriate ( ) inappropriate Quality: ( ) flat ( ) elated () blunted ( ) labile ( ) hostile ( ) anxious C. Depersonalization & Derealization ( ) present ( /) absent D. Suicide Potential ( ) present (/ ) absent Thought Control A. Perception ( ) present B. Delusions ( ) present

    ( ) euphoria

    ( ) histrionic ( ) angry ( ) others

    IV.

    ( /) absent (/ ) absent.

    C. Ideas of references: NONE D. Preoccupations & Ruminations: NO RUMINATIONS; SPO E. Deja Vu & Jamais Vu NONE

    V.

    Neurovegetative Dysfunction:

    A. Sleep (/ ) normal ( ) hypersomnia ( )MNA ( ) EMA ( )DFA (/ ) uninterrupted sleep

    B. Appetite During meal time, client was observed to have good appetite. He was able to consume the entire meal served to him. In addition, during activities, when he is given his share of snacks, client was able to consume it.

    C. Diurnal Variation D. Libido VI. General Sensorium & Intellectual Status:

    A. Orientation The patient is oriented to place but he is not oriented to time and date. He was able to recognize the name of the institution where he resides and knows the purpose why he was there. B. Memory Immediate To test his immediate memory, we named certain objects such as ball, pencil and eraser and had him repeat them immediately. He was able to repeat them without fail. Recent To elicit recent memory, we asked our client what kind of activity that they had yesterday at the activity area. Unfortunately, he was not able to remember and verbalized, Unsa gani to atong gihimo?. Remote When we asked our client to recall significant events that occurred many years ago such as his wedding anniversary and what he did on his birthday last year, he cannot remember. A. Attention Span () good (/) fair ( ) poor

    B. General Information: Client was not able to name the current president of the Republic of the Philippines. C. Abstract thinking: At the end of the activities, when client is asked to evaluate what has transpired, client gives his opinion and own reflections about said activity D. Insight (/ ) unimpaired ( ) impaired ( ) intellectual ( ) true

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