Post on 30-Nov-2015
description
MENTAL STATUS EXAMINATION
LEVEL OF CONSCIOUSNESS
Day1 Day2
Alert . .
Drowsy
Cooperative
Eye contact
AFFECT
Flat
Blunted
Inappropriate . .
MOODAppropriateAnxious . .AgitatedElatedDepressedDRESSAppropriateNeatHYGIENEGood Poor . .ORIENTATIONTimePlacePersonSituation
MEMORYRecent (Dinner/BreakfastRecent (Current Events)
Immediate (Short Term)Remote ( Long Term)DEFENSE MECHANISMDisplacementDenialIntellectualizationIntrojectionProjection .Rationalization .Reaction FormationRegressionRepressionSublimationSuppressionIdentificationIsolationOthers:
EXTRA PYRAMIDAL SYMPTOMSPSEUDOPARKINSONISMAkinesiaMask-like faceNo swinging of armsHesitancy of SpeechDecrease muscle strengths
Shuffling gaitDroolingFine intention tremorsACUTE DYSTONIC REACTIONMuscle spasm of the jaw, neck, tongue, eyes Laryngeal spasmAkathesiaRestlessness .TensenessInability to sit stillRocking back and forth of feetCrossing legs frequently . .Inability to relax . .
TARDIVE DYSKINESIA
Involuntary movement of mouth, tongue ,face, and may extend to finger arms and trunk
THINKING COMMUNICATIONS
Loose Association
Neologism . .
Word Salad
Echolalia
Echopraxia
Clang Association
Illogical thinking . .
Alogia
Concrete Thinking
Lack of Insight
PERCEIVING AND INTERPRETINGDelusions
Reference
Persecution . .
External influences
Somatic
Grandiose . .Hallucination
Cinesthetics
Visual
Olfactory
Gustatory
Auditory . .Tactile
SUMMARY OF MENTAL STATUS EXAMINATION:
During the two days of assessing the Mental State of the patient, He shows hostile, anxious, restless and uncooperative
behaviour and no eye contact. His mood is inappropriate and he is not oriented to time, place, person and situation. He was dressed with the hospital uniform and with poor hygiene as evidence by a foul smelling
odour.
While conducting the Nurse- Patient interaction, the patient shows defence mechanism characterized as rationalization and
projection. He showed rationalization, patient is assigning logical or socially acceptable motives to his belief to fool someone else and to
mislead himself as well like in his case he rationalizes why they kill people. Projection is seen when he attributed his own personal experiences to the
Student Nurse.
He doesn’t know that he is on a mental institution. He has a poor judgement on his condition. He always talks about being a former
member of NPA or New People’s Army. He’s always suspicious that they will get back on him because he knows a lot.