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VI. Mental Status

June 21, 2018

GENERAL APPEARANCE

The client appears well-groomed. She was able to take a bath and
combed her hair independently. She was wearing a clean uniform with no foul
odor and no cosmetics applied. Also, she maintains eye contact. She stands with
good posture without any awkward movement. There were no mannerisms
noted, however her movement and pacing is slow. He appeared worried and
fearful of her surroundings and sometimes smiles when she is happy with the
snack and when she sang a song.

GENERAL BEHAVIOR AND ACTIVITY

The client has no any unusual and abnormal movements. However, she walks in a
slow manner. During our conversation, I noticed that she makes irrelevant response or without
connection of what was asked like “ Pila edad sa imung anak?” and she answered “ Nasa
pampanga nga”.

ORIENTATION

The client is oriented to time, place, and person. When asked about the day, month
and year, she responded correctly.

AFFECT AND MOOD

The client shows little emotion during our conversation. Sometimes, her affect is
confusing, when ask if she is happy with the snack, she said yes but she has no facial
expression. Sometimes, she appears fearful and worried.

THOUGHT PROCESS AND CONTENT

The client doesn’t have any suicidal ideation. However, during our
interaction, she displays persecutory delusions and ideas of reference as she
verbalized that the songs of Willie Revillame are dedicated for her.
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MEMORY, PRESENT AND REMOTE

The client has good memory. She is able to recall her past memory, past recent
memory and recent memory. When asked about the therapy yesterday, she is able to give a
correct response. She is also able to give the exact date of her admission in SPMC which is
May 11, 2018. In addition, she is able to give the birthdates of her two children.

JUDGMENT

The client has good judgment. When asked what she will do if the doctor permitted
her to go home, she answered she would take care of her child because it is her obligation and
responsibility and not her sister. She also verbalized that she will make a piggery business to
make living.

INSIGHT

The client has still poor insight. She denies her mental illness and used projection by
stating “Yung ate ko talaga ang may sakit, hindi ako”

INTELLECT

The client has good intellect, she is able to solve simple problems like addition,
subtraction and multiplication

COPING MECHANISM

The client has good coping mechanism. By listening to the songs of Willie Revillame,
praying to God and exercising inside the female ward, she is able to reduce her anxiety and
fears.

DEFENSE MECHANISM

The client used defense mechanism of projection and denial. She denies her condition and
blames it to her sister.
105

June 22, 2018

GENERAL APPEARANCE

During our interaction, the client appeared well-groomed. Her uniform is neat and
clean with no foul odor noted. She holds herself erect and she walks properly in a slow manner.
She was smiling, her behavior was happy and calm. But sometimes she has suspicious stares
to the surroundings. In the depths of our conversation, she was friendly and cooperative.

GENERAL BEHAVIOR AND ACTIVITY

The client talks spontaneously in a calm manner. Her posture is relaxed. and her
movements are coordinated however in a slow manner. I didn’t observe any abnormal
movements during our conversation.

ORIENTATION

The client is oriented to time, place, and person. When asked about the day, month
and year, she response correctly.

AFFECT AND MOOD

The client’s mood and affect are appropriate to situation and congruent
to her feelings. However, she shows little emotion. During our interaction, she
is open, pleasant and friendly. Her mood changes when she remembered her son
and sister and appeared sad. She also displays moderate level of anxiety when
she was fearful and worried.

THOUGHT PROCESS AND CONTENT

The client is coherent, relevant and response to questions appropriately.


However, she displayed auditory hallucinations, persecutory delusions and
ideas of reference. She has no any suicidal ideations. In addition, she has a
phobia on knife and new people she meets.
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MEMORY, PRESENT AND REMOTE

The client has good memory. She is able to recall her past memory, past recent
memory and recent memory. When asked about the therapy yesterday, she is able to give a
correct response. She is also able to recall her viand during her breakfast and lunch. In addition,
she is able to recall her childhood favorite movies. However, the patient has poor
concentration, she was not able to spell the WORLD in a backward manner. She is able to
think abstractly, when asked what is the meaning of you are the apple of my eye she response
“ Ikaw ang paborito ko”.

JUDGMENT

The client has good judgment. When asked what she will do if she found a 1000
pesos in the street, she answered she will give it to the owner or offered it to the mass if she
won’t able to found the owner of the money.

INSIGHT

The client has still poor insight. She still denies her mental illness.

INTELLECT

The client has adequate intellect. She is able to response in an understandable and
correct answer. She is also able to solve simple problems yet in a sow manner.

COPING MECHANISM

The client has good coping mechanism. She always prays to God and walks around
the female ward when she is anxious and fearful. She also used deep breathing techniques.

DEFENSE MECHANISM

The client used defense mechanism of projection and denial. She denies her condition and
blames it to her sister.
107

June 27, 2018

GENERAL APPEARANCE

The client appears well-groomed. She was able to take a bath and
combed her hair independently. She still maintains eye contact. She stands with
good posture without any awkward movement. Her movements and pacing
were still slow. She appeared worried and fearful of her surroundings but well
responsive.

GENERAL BEHAVIOR AND ACTIVITY

The client has no any unusual and abnormal movements during ADLs. However,
she walks in a slow manner. I didn’t observe any abnormal movements during our
conversation or NPI.

ORIENTATION

The client is oriented to time, place, and person. When asked about the day, month
and year, she responded correctly.

AFFECT AND MOOD

The client shows little emotion during our conversation. Sometimes, her affect is
confusing, when ask if she is happy with the snack, she said yes but she has no facial
expression. Sometimes, she appears fearful and worried.

THOUGHT PROCESS AND CONTENT

The client doesn’t have any suicidal ideation. However, during our
interaction, she displays persecutory delusions as reported that there are still
people trying to kill her and ideas of reference as she verbalized that the songs
of Willie Revillame are dedicated for her.

MEMORY, PRESENT AND REMOTE

The client has good memory. She was still able to recall her past memory, past recent
memory and recent memory. When asked about the therapy yesterday, she is able to give a
correct response. She is also able to give the exact date of her admission in SPMC which is
May 11, 2018. In addition, she was still able to give the birthdates of her two children.
108

JUDGMENT

The client has good judgment. When asked what she will do if the doctor permitted
her to go home, she answered she would take care of her child because it is her obligation and
responsibility and not her sister. She also verbalized that she will make a piggery business to
make living.

INSIGHT

The client has still poor insight. She denies her mental illness and used projection by
stating “Yung ate ko talaga ang may sakit, hindi ako”

INTELLECT

The client has good intellect, she is able to solve simple problems like addition,
subtraction and multiplication

COPING MECHANISM

The client has good coping mechanism. By listening to the songs of Willie Revillame,
praying to God and exercising inside the female ward, she is able to reduce her anxiety and
fears.

DEFENSE MECHANISM

The client used defense mechanism of projection and denial. She denies her condition and
blames it to her sister.