Mental Status Exam

A. General appearance and Overt behavior

The client, Mr.____ had been living in this world for 33 years and been in such psychological condition
for about a decade already. He was well-nourished and wearing the appropriate clothes for his age. He
wore t-shirt and short pants and looks tidy. There were no unnecessary things worn and found in his
body. There were no jewelry, earing, bracelets or necklaces worn. The clients skin was cool and moist
but the group was able to notice some skin problems such as scars and lesions. He has incomplete set of
teeth and obviously absent central incisors. His sclera was white in colour. He had no difficulties in
hearing. The patient looked appropriate with his age. He has short hair properly cut and black in color.
He can establish eye contact with the interviewers. He was observant and seemed to listen to our
questions. The patient behaved well.
B. Attitude
The client is cooperative and attentive throughout the whole psychiatric interview. He was interested
with all the questions of the group and could accommodate all our questions without hesitations.
C. Speech
There is clear, spontaneous speech with medium speed, intensity and volume. There is no speech
impairments. The quantity is appropriate, without excessive details and with good accent.
D. Mood and Affect
There is slight anxiousness observed from the client especially with personal questions asked from him.
But, during light conversations, he shifts to a happy mood. His affect is appropriate and congruent with
mood. He had a good tone of voice with appropriate body movements.
E. Thought Process and Content
The client thinks practical and slight logical with thoughts of wanting best for his family. There is a
relevant, organized, and coherent use of words and is able to answer questions correctly. There are no
unusual thoughts like delusions or feelings of unreality.
F. Sensorium and Cognitive Ability
The client is alert and conscious, oriented to place, time and situation. He is able to recall his past history
accurately. Able to recall recent and remote memory. He focusses and attends to questions asked to
him. The client was able to use abstract thinking and intellectual abilities like simple calculations. There
were no hallucinations, illusions, or depersonalizations observed from him.
G. Judgment and Insight
He had the ability to assess and evaluate situations but client sometimes fail to make rational decisions.
Though he has insights about the cause of his behaviour, he has maladaptive coping mechanism and
poor self-concept. The client is able to control impulses related to hostility, fear, guilt, and sexual
feelings but the feeling of aggression is altered when faced to problems that are out of control or like if
provoked by some external stimuli. As what the client imparted, he gets angry to those who calls him
lurong-lurong, and he respond by threatening those accused without any intention to harm.