INITIAL MENTAL STATUS EXAMINATION I. APPEARANCE The client appears to be at her age. She wears blouse with shorts, sometimes with short pajama. For me, she is neat. She has a long and shiny hair. She has clean fingernails and always combing her hair. She brings a comb with her every time we had an activity. II. MOOD AND AFFECT The client facial expression appears to be appropriate. She is energetic and you will observe that she is enjoying our activity because she was happy. III.
BEHAVIOR, ATTITUDE AND COPING PATTERNS The client is not violent. She talks whenever you ask her. You can observe her that she will pick up some garbage/trash during or after our activity. She loves arranging everything. IV. COMMUNICATION AND SOCIAL SKILLS The client has a soft speech. She’s talkative and responds whenever you ask her a question. She doesn’t used unknown words or any terms that we can’t understand. V. CONTENT OF THOUGHTS The client does not experience any hallucination and delusions.
Sometimes she may feel that she is unworthy because she was not able to take care of her child. She always tells me that she misses her child so much. VI. MEMORY The client has the ability to remember her past history. She may recall and answer what happened to her before she have been here in St. Peters. VII. INTELLECTUAL FUNCTIONING The client can answer some easy mathematical question such as, “5+5”, she answered “10”. VIII. NEUROVEGETATIVE CHANGES The client eats what is served to her.
She urinates only ones during our 4 hours of duty. She is comfortable to have her female nurse. IX. JUDGEMENT The client can answer some questions like, “What would you do after, when you will be out in this institution? ” she answered, “syempre, ako atimanon ako anak. dugay pud me nga walay bonding, gusto nako mailhan ko niya na ako ang iya mama. ” X. INSIGHT The client may answer question about her understanding on her present illness like, “Why are you here in this institution? ” she answered,