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.