ASSESSMENT

A. Appearance

The patient is fairly groomed, wears a green polo shirt and black
jogging pants. Has neatly combed hair, wears slippers and untrimmed nails
both in the feet and hands, no bad odor. Patient appears happy and is
friendly, smiles to everyone who greets him.

B. Behavior, Attitude and Normal Coping Patterns

The patient is observed to be restless, moving in and out of the male

psych ward, sitting then after a while stands again. While talking to him, he
moves his hands in up and down position with a moderate pacing. The
patient however appears to be friendly and cooperative. He is willing to talk
for a long period of time without being agitated and violent. The patient is
just walking and sitting all throughout the shift.

C. Personality Style and Communication Ability

The patient speaks coherently, has natural flow of speech and logical.
The rate of speech is slow and speaks softly and sometimes stutter. The
patient is not socially isolated, he is initiating conversations with the other
patients, nurses and watchers. He spent his time with doing christmas
decorations for their ward. The patient was observed to be telling stories to
the other patients such as getting discharge the next day even without the
doctor telling him. No noted other behavioural symptoms.

D. Content of thought

All throughout the shift the patient did not experience any delusions,
hallucinations, compulsions and any abnormal thought content.

E. Orientation

The patient is oriented to person, place and time. He knows what time
is it when asked, he knows that he is in the hospital and in psychiatry ward.
He knows the names of the other patients and the nurses that are on duty.
F. Memory

Able to recall both recent and long-term memory.

• Recent memory: he knows that he was admiited 1 week ago, had a
conflict with his sister and father 2 weeks ago.
• Long-term memory: He said that he was diagnosed to have a
schizophrenia in 2004 and that he is a real estate broker.

G. Intellectual ability

Patient was able to name the last two presidents of the Philippines,
was able to answer correctly when asked to add 7 plus 10, he answered 17.
When asked what would he do if a person in front of him suddenly fainted he
answered “bubuhatin ko at dadalin sa ospital”.

H. Insight regarding Illness or Condition

The patient considers himself ill, he knows that he has schizophrenia

and knows that it is a mental illness. The patient has fair to good insight.

I. Neurovegetative Changes

No noted neurovegetative changes. The patient sleeps well and has

good eating patterns. Does not ignore elimination habits and nutritional
intake and has good appetite.