MENTAL STATUS EXAM

Appearance
Client is a medium built Filipino. He is single and 46 years of age. He was seen standing, slouching, shuffling from one foot to another. He was wearing the same setoff clothes yesterday: white old t-shirt and denim shorts. He was already dirty and malodourous. He has no missing limbs, wasn t jaundiced, coughing, or injured. Hearing s not impaired and he has missing, yellowing teeth.

Behaviour/Movements
Client was able to maintain eye contact. He was generally cooperative but needed coaching to get things done. He seemed indifferent, unconcerned, lethargic and slow in movement. Whenever he is standing, he seemed disinterested, bored and, slow to respond.

Communication
The way the client talked was slow and soft, and mumbling. He s also monotonous and doesn t seem to show emotion in his intonation. When being asked, his answers would always be short, minimal. He has not yet initiated conversation. He s able to follow simple commands like brushing teeth, sitting on the chair and eating on the table. He was able to name objects pointed like a pen and wrist watch, but was unable to name the second hand.

Affect/Mood
His affect was blunt. Mood appeared to shift to slightly irritable but mostly it was unreadable. He has very few facial expressions. He once had both corners of his mouth turned ever so slightly upwards. Client does not have any problems falling asleep, staying asleep, and waking up. He also appeared to be unaffected when he failed to identify the second hand.

Thought Content
The client said that he did not hear or see anything that is out of the ordinary. He also said that he did not think of harming anyone, or had suicidal ideation.

Thought Process
Client s thinking was slow and some of his replies were goal directed, some were not, like he refused to answer.

Perception
Client has not experienced hallucinations, illusions, derealisation, depersonalization.

Level of Consciousness
Client is drowsy most, if not all of the time. He responds when spoken to, may drift to sleep if not stimulated and wakes up when food and medication are being served.

Orientation
Client is able to state his name, know where he is, but is not oriented to date.

Cognitive Functioning
The client was able to remember student nurse s name after 30 minutes and he has able to remember any stimulating event that happened a day before like some of the content of the interview. He has a low attention span, refused or was able to gain insight, and refused to answer questions that needed logical thinking like counting backwards or subtracting.