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Saint Louis University

School of Nursing

PSYCHIATRIC ASSESSMENT TOOL/ PSYCHIATRIC REPORT


Part 1: PSYCHIATRIC HISTORY

I. Identifying Data
 Name: Satur, Ella May
 Age: 19 years old
 Sex: Female
 Address: Private Rd. New Lucban
 Marital Status: S
 Occupation: Student
 Religion: Free Believers in Christ Fellowship
II. History:
A. Chief Complaints/ Reasons for Admission
N/A
B. History of present illness
N/A
C. Changes in client’s life before the onset of illness
N/A

D.Family History
She describes family situation as more or less peaceful but feels pressure from the expectations placed upon her and the hierarchical system
employed in the family (as she feels she is the lowest due to her being the youngest or “bunso” in the family, she is always “wrong” when it comes to
arguments with her sibling and parents). There are no incidences or histories of mental illnesses in the family. Parents are alive and well. Home into
which client was born is in the middle class. Parents are happily married with no untoward feelings against children but were very strict. Client was an
unplanned but wanted birth. It made the family bigger however challenged the second child’s spot in being the youngest causes a sense of “dethroning”
on the part of the sibling.
E. Personal History
1. Prenatal history and mother’s pregnancy and delivery
Length of pregnancy was less than 12 hours; was delivered via LSCS due to occurrence of pre-eclampsia; no known birth trauma; pregnancy
was unplanned but wanted; attitude of parents during pregnancy was positive; no birth defects was with (+) with jaundice which was related to
the occurrence of pre-eclampsia and was suction due to aspiration of meconium.
2. Birth
July 2, 1998; positive parental reaction towards baby; 2nd sibling felt challenged by birth forth attention and felt “dethroned”;
Infancy
Breastfed fed for 2 years and was bottle fed complementarily around 6 months-1 yrs old; no feeding problem; no weaning problem; slept at day
and awakens at night (frequently cried); no physical or sexual abuse
3. Early childhood/ Pre-school
Was more attached to mother; above average language and motor development; toilet training was early as 1 year old (describes it as being
controlled and would only defecate and urinate in the toilet as she disliked the “smell” of the fecal matter); 1-2 playmates; Favorite play activities
were roleplaying in the classroom setting; techniques of getting attention from others; reacted passively to guidance and discipline;; Personality
and temperament as a child was described as shy and timid. Was disciplined harshly with spanks (especially from father, whenever she would
commit a mistake)
a. School
Age started and feelings and adjustments about it, went how far or age left for school – reasons for leaving; scholastic standing and
explanation for changes; special likes or dislikes in subjects; extracurricular activities (arts, organizations, sports); ambitions; attitudes and
relationships towards teacher and classmates
b. Further personality development
Had played outside with 1-2 friends while growing up, but was always put back by parents to study back home after around 1 hour. Such
comments were as such “no wonder your grades are getting lower; you keep on playing”
c. Health status
No illnesses, fell on chin accidentally but no traumatic affect was afflicted.
4. Adolescence
 Peer relationships
Around 6-8 close friends, was once intuned to being a leader but now in college, more of a follower role, social popularity, participates with in
groups and shares ideas though still with reservation, idealizes favorite singers; and has patterns of passivity, anxiety, antisocial behavior
 School history and Cognitive and motor development
Adjusted well initially to school but was slowly isolated due to perceived bossy behavior, relationships with teachers was teacher's pet, was
interested in leading during her highschool days in the student government
 Particular adolescent emotional or physical problems
Feeling of inferiority and isolation in class during highschool
Interests and hobbies
Sewing, singing and drawing
 Psychosexual history
Acquiring of sexual knowledge from books and peers. Attitude of parents toward sex for them is a closed subject; Onset of puberty was at 13
and felt reserved about it, feels menstruation is a natural part of being a girl, development of secondary sexual characteristics; Adolescent
sexual activity: Crushes, parties, dating, petting, masturbation, wet dreams and attitudes toward them; Attitudes toward same and opposite
sex: Timid, shy, aggressive, need to impress, seductive, sexual conquests, anxiety; Sexual practices: Sexual problems,
Religious background
Free Believers in Christ Fellowship
a. Occupational history
N/A
b. Social activity
Has a handful of close friends in college that she can open up to, recently left a relationship and is currently single.
c. Adult sexuality
N/A
d. Military history
N/A

1
e. Value systems
seen as a burden or a joy; work is seen as or an opportunity; current is devote and faithful to belief; believes in heaven and hell

Part 2: MENTAL STATUS EXAMINATION


I. Appearance  Neologisms ______
A. Dress  Echolalia ______
 Appropriate dressed appropriate to situation; is  Stammering ______
wearing type B uniform for Peer counseling utilizing right  Clanging ______
color of shirt specified for day  Verbigeration ______
 Inappropriate ______  Perseveration ______
B. Grooming and Hygiene 7. Vocabulary, diction
 Appropriate Appropriate; had taken a bath prior to  Appropriate to socioeducational background
coming to P.C with well kempt hair ___✓_
 Inappropriate ______
C. Age appearance:  Not appropriate socioeducational background
______
 Appropriate Appears appropriate to age; not
 Remarks: (Brief nontechnical description)
looking older or younger than current age
Speaks at the level expected of a university student,
 Inappropriate ______
making remarks related to course
 Remarks:(Brief nontechnical description )
_____________________________________________
III. Affect
_____________________________________________
 Appropriate
___________________________________________
to content ___✓_
II. Behavior  Apathetic ______
A. Manner of Relating  Inappropriate ______
 Cooperative __✓__  Shallow ______
 Indifferent ______  Blunted ______
 Withdrawn ______  Flattened ______
 Defensive ______  Remarks: (Brief nontechnical description)
 Remarks: ( Brief nontechnical description) Changes affect from nature of topics discussed
Cooperates well with student nurse and answers (becoming more cautious hesitant when talking about
appropriately well with questions family issues etc.)
B. Psychomotor
1. Activity IV. Mood
 Appropriate  Normal ___✓_
to situation ___✓_  Anxious ______
 Hyperactivity ______  Depressed ______
 Retardation ______  Happy, elated ______
 Tremor ______  Worried ______
 Purposeless  Labile ______
 Remarks: (Brief nontechnical description)
Activity ___✓_
Is relaxed and at peace when asked
 Repetitive
Behaviors ______ V. Thinking
2. Posture A. Thought
 Normal __✓__ 1. Form
 Abnormal ______  Normal ___✓_
3. Gait and station  Concrete ______
 Normal ___✓__  Referential ______
 Abnormal ______  Illogical ______
 Remarks: (Brief nontechnical description)  Scattered ______
_Moves and acts appropriately in terms of interview 2. Progression
(gestures congruent with what she is saying)  Normal ___✓_
C. Speech and language  Circumstantial ______
1. Intensity
 Tangential ______
 Normal ______
 Loose
 Loud ______ Associations ______
 Soft ___✓_  Flight of ideas ______
2. Pitch  Blocking ______
 Normal ___✓_ 3. Content
 Monotone ______  Normal ___✓_
 Wide swings ______  Persecutory ______
3. Rate  Paranoia ______
 Normal ___✓_  Hypochondrial ______
 Pressured ______  Grandiosity ______
 Slow ______  Obsessions ______
4. Spontaneity  Phobias ______
 Normal ___✓_  Depressive ______
 Intrusive ______  Poverty
 Decreased ______ of thought ______
5. Relevance  Remarks: (Brief nontechnical description)
Speaks and answers appropriate to question
 Normal ___✓_
B. Perception
 Incoherent ______  Normal ___✓_
 Irrelevant ______
6. Deviations  Hallucinations
 Olfactory ______
 None ___✓_  Visual ______
 Aphasia ______
2
 Auditory ______  Baguio __✓__ __✓__
 Tactile ______ b. Digit span
 Visceral ______  Forward Span Response
 Remarks: (Brief nontechnical description) 372 372
Does not perceive any extraordinary delusions or 4916 4916
illusions during course of interview 82574 82574
C. General knowledge 396157 396157
1. Tests:
 Reversed Response
a. Last Five Philippine Presidents
419 914
 Benigno Aquino III 5372 2735
 Gloria Macapagal-Arroyo 19386 68391
 Estrada 103958 859301
 Fidel Ramos c. Visual Immediate 5 mins
 Cory Aquino  Pencil __✓__ __✓__
b. Capitals
 Philippines Manila  Chair __✓__ __✓__
 Ilocos Norte Laoag  paper __✓__ __✓__
 USA Washington 4. Abstraction
 China Beijing a. Sayings
c. Three Main Islands of the Philippines i. Two heads are better than one. Collaborations
 Luzon ii. Pagbinato ka ng bato, batuhin mo ng tinapay. You
 Visayas must be kind.
 Mindanao b. Similarities
d. Date of the Philippine Independence Day i. Axe – Saw both cut
 June 12 ii. Car – Bicycle both roll
e. Title of the Philippine National Anthem 5. Calculation and concentration
 Lupang Hinirang a. 100 – 7 (serially) 93
f. Name of the Holiday celebrated every November 2 b. Multiplication
 All Souls Day  2x3 = 6
g. Date of Labor Day in the Philippines  4 x 12 = 48
 May 1  8 x 11 = 88
2. Conclusion  12 x 5 = 60
 Normal for socioeducational background  4x3 = 12
__✓__  24 x 3 = 82
 80 x 4 = 160
 Not normal for socioeducational background
c. If bananas cost P20 per dozen, how much do 18
______
bananas cost? P18
 Remarks: (Brief nontechnical description)
d. Reverse days of the week: Saturday, Friday, Thursday,
 Answers all items correctly
Wednesday, Tuesday, Monday, Friday
D. Sensorium and Intellectual Function
e. Reverse months of the year: December, November,
1. Orientation
October, September, August, July, June, May, April,
Time __✓__ March, February, January
a. Place __✓__  Remarks: (Brief nontechnical description)
b. Person __✓__ Finishes all items correctly
E. Insight
c. Situation __✓__
1. Normal __✓__
2. Memory
2. Impaired ______
a. Remote
 Remarks: (Brief nontechnical description) No signs of
 Normal __✓__ disorted insights, insights are congruent with what is
 Impaired ______ presented
b. Recent F. Judgment
 Normal __✓__ 1. Normal __✓__
 Impaired ______ 2. Impaired ______
c. Specific abnormalities  Remarks: (Brief nontechnical description)
 Amnesia ______  No signs of disorted judgments, judgments are
 Hyperamnesia ______ congruent with what is presented
 Paramnesia ______
 Confabulation
3. Retention and Recall
a. Auditory Immediate 5 mins
 Purple __✓__ __✓__
 Steamship __✓__ __✓__