Carpo, Daryl R.

BSN104; G16
2007732181

History

The name of the patient is Dan Jay Sisayan; 19 years old; Adolescent (13-19 y/o). The patient
verbalizes that he has no cultural considerations and spiritual belief. He also stated that he is a roman
catholic. The patient has no previous history of hospitalizations and traumatic experiences in the past.

General Assessment of Motor Behaviour

The patient is relaxed, well groomed, no body and breath odour, wears and appropriate dress
and has no signs of distress. The patient maintains eye contact all throughout the interview. No unusual
movements and mannerisms are noted. The patient has a happy facial expression. The patient’s speech
is understandable, at moderate pace, clear tone and exhibits thought association.

Mood and Affect

The patient stated that he is happy and ranged it 7 out of 10 as the highest. The patient shows a
blunted affect

Thought Process and Content

The patient’s verbalizations make sense; the ideas are related and flow logically from one to the
next. The patient shows no signs of depression or hopelessness. No verbalizations about threatening
other people are noted.

Sensorium and Intellectual Process

The patient recognizes that when and where he was during the interview. The patient does not
loses track of time, place and the person whom his talking to and can make sense of his surroundings.
(Oriented X 3)
After asking series of question that tests his memory, the patient shows no signs of problem.

Abnormal Sensory Experiences or Misconception

After series of questions, the patient shows no signs of problems related to his ability to
concentrate. The patient also shows that he can conceptualize, generalize and understand that each
concept has multiple meanings. The patient can see patterns beyond the obvious.

Judgement and Insight

After series of questions, the patient shows that he can correctly interpret his environment as
well as his situation. He also shows that he has the ability to adapt to one’s behaviour and decisions
accordingly.

Self concept
 The patient sees himself as a nursing student in a particular university and full of responsibilities.
He describes himself as slim and cute. The patient verbalizes that he is good in dancing and computer
gaming.
Roles and relationship

The patient verbalizes that his roles are a student, a son to a 3-member family, a boyfriend, a
friend and a leader. The patient stated that was partly successful and satisfied with his roles. The patient
has his parents that financially support his studies; he also added that he has a girlfriend. The patient
also added that when he encounters a difficult problem, he always seek out his parents and his friends.

Physiologic and Self-care Considerations

The patient has no allergies to a certain food, eats three times a day and maintains balance diet.
The patient sleeps for at least 6 hours a day. No serious health problems are stated.