MENTAL STATUS EXAM

A. History
MR is fully immunized as a child and she experienced having measles when she was still a child.
They were taken care of by their parents. She was able to experience being breastfed by her
mother. According to her she is a very hardworking person and would always put her familys
need first. She was very close to her mother and has a good relationship with her siblings except
with her eldest sister. Her father died in the year 2005 due to hypertension.
MR has no known allergies and she has not undergone blood transfusion. According to MR, she
does not drink, or use illicit drugs but she does smoke cigarette four times a week and when she
is under stressed. She has not experienced being hospitalized due to other general medical
conditions.
According to her, MR was only able to finish elementary because of her lost of interest in
studying because of financial problems. She has manifested great interest on work related
activities. She described herself as a normal child and would love to play with girls of her age.
Gusto ko sanang mag-aral kaso wala kaming pera. Kaya sumasama nalang ako minsan sa mga
magulang ko sa bukid., as verbalized by MR.
When MR was 12 years old, she went to Manila to apply for a job as a housemaid. But a
traumatic experienced happened to her when her employer almost raped her. Fortunately, she
was able to defend herself and ran off. She just walked for two days without eating and drinking
until an old man found her lying on the side of the road unconscious. The oldman brought to
BANTAY BATA but they transferred her at the nearest DSWD. She stayed there for two years.
According to her, she studied vocational course like cooking and baking.
She went home at Gattaran when she was 14 years old, during her stay she accidentally saw a
man who was hit a truck and she saw the mans head cracked open with lots of blood flowing
from it. According to her, she just shouted and had a tantrum. From then on, she started to have
phobia with blood.
After few months, MR went back to Manila to apply for a job again as a housemaid and stayed
there for 11 years. Her first employer is abusing her, she slaps her and pulls her hair often. Due to
that incident, she decided to apply to another employer. She mentioned that she shifts employers
every two years.
She again went back to Gattaran when she was 26 years old and married when she was 27 years
old. There was once a time that she had a fight with her eldest sister because of envy in the
division of their house. Her eldest sister quarrel to her husband, she did not control herself and
she began to pull her sisters hair and punch her in the eye.

According to the patient there was a time when her neighbours were bickering and they taunt
each other with machetes, in that incidence she again shouted and had a tantrum.

Another incidence happens when her younger sister was died due to pre-eclampsia, in that
scenario she again shouted and runoff while having tantrum.

MR started to experience delusion and auditory hallucinations accompanied by sadness and

crying spells few months after her sisters death. According to the patient there were times when
she saw a talking frog and a talking leaf, she verbalized Meron yung time nun na nasa labas ako
tas nagulat nalang ako sa palaka na nagsasalita tapos kinakausap ako,nilagay ko pa nga sya sa
loob ng supot tapos nag uusap kami. Tapos yung sa dahon naman ng kappa kappa eh narinig ko
na sinasabi nyang sumakay daw ako sa kanya at dadalhin daw nya ako sa ilog tas kinuha ko at
kinausap ko sya sabi ko pano naman ako makakasakay sayo eh dahon kalang. According to her
there was also a time when she heard something whispering to her commanding her to hurt her
children but she didnt do it because she thought why would she hurt her children.
She also experienced being obsessive-compulsive, she verbalized pag nakikita kong nagugulo
yung mga tinupo ko eh binabalik balikan ko ng ilang beses kasi naiinis ako pag nakikita kong
magulo.
On April 16, 2016 when her husband died she again shouted and had a tantrum and according to
her she felt her whole body shaking due to shock. She also mentioned that she started undressing
herself and just cried.
On April 19, 2016 she was brought by her mother at Psychiatric Ward and was admitted there
until now. During her stay in psychiatric ward she again shouted and had a tantrum and started
running around at the oval when two of her companion there had a fight physically.
According to Dr. , THs family does not support her especially her brother. It was in her history
that her brother would not want TH to go home and stay with them. You know when TH feels
sad she usually goes here tapos she suddenly cries tapos sasabihin niya bakit di ako tanggap ng
kuya bakit niya ako pinabayaan then after few moments tatawa na naman yan., as verbalized by
Dr. Pagaddu.

B.

General Appearance and Motor Behavior

The client is a 37 year old woman that appears to be in her stated age. The client is properly
dressed and groomed upon inspecting her. She wears leggings and sleeveless with colourful
prints. According to her, she takes a bath every day after doing her chores in the ward. She is
well groomed and would carry with her a bag with comb and a powder. Upon observation, the
client has no automatisms, psychomotor retardation and waxy flexibility.
Her skin is smooth and moist. Her hair is shiny and fingernails are well trimmed and clean.
She actively responds during conversations and was cooperative throughout the interview. She
does not manifest unusual motor behavior. She participates during activities when encouraged by
her companions.

C.

Speech

The client is talkative and enjoys telling stories about her life that sometimes she gets out of the
topic and never comes back. She also seemed to be stuck in one topic specially when talking
about her husband and children. She always elaborates her answers very long when asked with
questions answerable by yes or no. She talks fast in a very loud tone. However, the client doesnt
use neologisms and any lisping or stuttering in her speech.

D.

Mood and Affect

The patient displays congruent facial expression throughout the interview. According to the
client she feels happy because she had the chance to go outside and meet the student nurses. She
uses hand gestures often while talking. She shows facial expressions in accordance to her feeling.
She has a normal and good posture. During the nurse patient interaction, TH does not manifest
labile mood (rapidly changing emotions). She also presented a normal affect. The patient is
expressive and used to laugh and smile a lot.
E.

Thought Process and Content

The clients thought process and content upon interview is circumstantial, she usually gets away
and stuck with one topic and only comes back at the question after finishing her whole story. She
is also experiences delusions such as a frog talking to her and sometimes a leaf falling from a
tree. She also mentioned that she also heard something whispering in her ears that say, Satan is
coming.

F.

Assessment of Suicide or Harm towards Others

According to the patient, she only once thought of committing suicide after her husband died.
She thought of joining him because of her extreme sadness but she said that her thought was
gone when she remembered her children who will suffer in case she will do it. She also
mentioned that she does not inflict harm towards others because she hates quarrelling and seems
to have trauma when she see someone fighting.
G.

Sensorium and Intellectual Processes

i. Memory
The clients memory is intact. She is able to recall recent and remote events. She was able to
recall what she did yesterday, naglaba po ako ma tsaka naglinis po., as verbalized by the client.
She correctly remembers her birthday which is January 13. She also stated the directions going to
their house.

ii. Ability to Concentrate

The client was able spell her name backwards. She has no difficulty counting backward from 10
1. The client stated, 10,9,8,7,6,5,4,3,2,1. She was also able to state the days of the week,
Lunes, martes, miyerkules, huwebes, biyernes, sabado, linggo., as verbalized by the patient.
She is oriented to place, person date and time.

iii. Abstract and Intellectual Abilities

The client is manifesting concrete thinking. The client provides literal responses to the proverb
Aanhin mo pa ang damo kung patay na ang kabayo? She verbalized: Eh di maghanap ulit ng
ibang kabayo.

iv.

Sensory and Perceptual Alterations

TH doesnt experience any hallucinations at the moment. TH experienced having auditory and
olfactory hallucinations in the past. According to TH, her auditory hallucinations where about
god talking to her. She also heard voices telling that they will kill her. TH also verbalized,
Meron ako naaamoy na kandila na parang may kaluluwa., which indicates that she experienced
olfactory hallucination. She doesnt have gustatory, tactile, and visual hallucinations.

v.

Judgment and Insight

What do you think about your medications? The client answered Eh wala parang pampatulog
lang naman yun kasi pag umiinom ako ng gamot eh inaantok na ako tas isa lang naman yung
gamot ko

When asked: Ate paano kapag nakakita ka ng wallet sa daanan, ano ang gagawin mo?
She stated: Ibabalik ko maam ah, kasi di naman sa akin yun. At may pera naman ako bakit ko
kukunin. The client answered the question without hesitations. She manifests intact judgement
and insight.
When asked about what she thinks about her illness, she verbalized, Parang ang dali nga po ng
recovery ko eh hindi parang yung iba dyan na umaabot ng ilang taon.
When asked about her medications, the client answered Eh wala parang pampatulog lang
naman yun kasi pag umiinom ako ng gamot eh inaantok na ako tas isa lang naman yung gamot
ko she verbalized that she complies with the medications they are giving her. TH also
verbalized that she needs the medications to prevent the relapse of her condition.
TH is compliant of her medications during admission and as well as when she is home.
vi.

Self concept

According to TH, she perceives herself as gumagawa ng mabuti at mapagbigay at matulungin

sa ibang tao. The client also stated okay naman wala naman akong kinaiingitan sa iba.She
also describes herself as a good friend.

vii.

Roles and Relationships

The client stated Maganda naman yung pakikitungo ko sa nanay ko at mga kapatid ko maliban
lang talaga sa panganay kong kapatid,pag may problema sila lagi akong andun para sa kanila tas
nung namatay yung asawa ko ni isa sa kanila parang walang gustong tumulong sakin.

When asked: Do you have relationship or want to be with someone else? The client answered
Ahy wala kamamatay lang ng asawa ko. The client stated that she is not engaged in a sexual
relationship at the moment. She has never been involved in abusive relationships in the past.
When asked about her previous relationship with her husband, the client verbalized, Masaya
kami sobrang niya akong inaalagaan. Ayaw pa niya ako pinagtatrabaho kasi gusto niya siya,
masipag siya.
She considers her roles at home as a provider because she was the one who helps her parents
when he was still alive.

viii.

Physiologic and Health Care

The client stated that she eats well; she eats three meals a day with snacks in between. She also
stated that she sleeps well except when she stays in the medical to accompany a patient. She is
fond of eating chicken and fruits. She is well groomed and properly dressed. She is also
compliant to her medications.