mse revised

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MENTAL STATUS EXAMINATION Name: Jabol, Federico B. Age: 20 yrs. old Sex: Male Civil Status: Single Educational Attainment: Fourth Year – College Level Referred by: Prof. Serafina P. Maxino A. General Appearance, Attitude, and Behavior 1. Appearance of the Subject The subject was wearing a white school uniform with a checkered white rubber shoes. His hair was simple and arranged into one-sided style. His body, together with his fingernails was neat and tidy. The subject has no accessories and physical deformities in his body. The color of his skin is brown and his eyes are weary because of his eye bags. The subject has a proportionate height of 5’6” and a weight of 143 lbs. The scent of the subject was good, but his body is getting sweat in which it is seems to be nervous. 2. Attitude of the Subject The subject was silently entered the consultation room and become loquacious when relaxed after he came. The subject is friendly and courteous in making conversation to people. The subject understands the purpose of the examination but suddenly felt shocked because of his belief that his deepest secrets of his life may be revealed. The subject is also joyful and likes to make good social contact and confident to have a conversation to them. 3. Behavior of the Subject The subject is calm when entering the consultation room and quiet when the conversation begins. Before the interview, the subject likes to interact to other people and humorous. In this manner, the people around him easily get close to him. During the

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Page 1: Mse revised

MENTAL STATUS EXAMINATION

Name: Jabol, Federico B.Age: 20 yrs. oldSex: MaleCivil Status: SingleEducational Attainment: Fourth Year – College LevelReferred by: Prof. Serafina P. Maxino

A. General Appearance, Attitude, and Behavior

1. Appearance of the Subject

The subject was wearing a white school uniform with a checkered white rubber shoes. His hair was simple and arranged into one-sided style. His body, together with his fingernails was neat and tidy. The subject has no accessories and physical deformities in his body. The color of his skin is brown and his eyes are weary because of his eye bags. The subject has a proportionate height of 5’6” and a weight of 143 lbs. The scent of the subject was good, but his body is getting sweat in which it is seems to be nervous.

2. Attitude of the Subject

The subject was silently entered the consultation room and become loquacious when relaxed after he came. The subject is friendly and courteous in making conversation to people. The subject understands the purpose of the examination but suddenly felt shocked because of his belief that his deepest secrets of his life may be revealed. The subject is also joyful and likes to make good social contact and confident to have a conversation to them.

3. Behavior of the Subject

The subject is calm when entering the consultation room and quiet when the conversation begins. Before the interview, the subject likes to interact to other people and humorous. In this manner, the people around him easily get close to him. During the first interview, the subject is placid and answers the question and answers the question with no pressure. The subject is active, acquainted, and gracefully interacts to psychologist. The posture of the subject is relaxed, but suddenly changes for a short period of time. His mannerism is tapping his foot over the ground with his legs are slightly opened.

B. Stream of Talk (Speech) and Mental Activity

When the subject expresses himself, he talks freely and hesitant in giving information. His speech is pertinent, coherent, and relevant in which he delivers his responses in clear vocalization and thinks of responses easily with a little tendency of having vocal tics. The subject’s tone of voice is in low pitch with an average volume; has focus to the responses, and self-reliant. The subject shows no manifestation of flight of ideas, queer condensation of words, neologism, multitude thoughts, crowding,

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distractibility, verbigeration, perseveration, echolalia, stereotypy of words and circumstantiality. There is no problem in his speech in terms of labial, dental, lingual, and guttural test words and phrases and test stories.

C. Emotional Status

During the interview, the subject is tensed but tried to endure it by deliver his responses. His affect is appropriate in which is happy when talking pleasant but suddenly changes into staid reaction when talking unpleasant things. Because when the psychologist asked him if there’s a tendency to become irritated and angry, the subject responded as “Nagiging irritable at galit ako sa mga plastic na tao” and feels that he likes to gone on earth when his long-time girlfriend decided to end their relationship for almost two years. After suffering from excruciating break-up, he become anxious and feels like there was no one to give him care off. The psychologist asks him “Meron ka bang karanasan na nagbigay sa iyo ng matinding kalungkutan?” and the subject replied as “Oo, nung mag-break kami ng girlfriend ko, pakiramdam ko wala na akong pag-asa”. To alleviate his feeling of hopelessness, he seeks another relationship which would give him happiness and comfort. The subject is fine and optimistic but lacks initiative in concentrating to his studies.

He believes that “Life has a purpose because God created us with purpose and follow his will para magkaroon ng direksyon ang mga ito”. His feeling for a day depends on what will happen and what the surrounding is going to give. The subject has a good feeling in the morning and become sober during nighttime. He responded as “Mas masaya ako sa umaga dahil kasama ko ang aking mga kaibigan ko at sa gabi naman iniisip ko ang mga ginawa ko ngayon. Dahil dun, nagkakaroon ako ng self-realization habang nanonood ng T.V.”. The subject also noted that “Having positive outlook can release distress of mind”. The subject complaints about muscle pain in his chest after having work-out on the gym but it does not alter his responses. He emphasizes intensified tension and vocal tics during reporting on the class by responding as “Kinakabahan ako kapag nag-rereport at may tendency rin na nauutal ako”. The subject fears of making mistakes that produces obnoxious result. The subject becomes euphoric when bought things that are not yet achieve. He is confident of what he have doing right now and when it comes of decision making, he makes sure that it is firm and his mind is settled.

The subject hopes to graduate on time by having good study habits. He is sociable except that he hates he person/s that is reticent by responding as “Sociable ako pero ayoko sa mga taong plastic.” During the conversation, the subject responds to the question with a normal interest and attention. He believe that he has strong responsive stimuli in which he can dodge unavoidable circumstances such as self-defense from a snatcher, catch a falling things, and capable of fast reflexes.

D. Content of Thought

1. Illusion

There was no manifestation of illusional delusion when the psychologist asked the subject as “Meron ka bang nararamdaman ngayon na siyang dahilan ng iyong

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pagkailang o hindi mapalagay sa kung saan?” and then he replied as “Wala naman, lahat ng nasa paligid ko ay walang pagbabago at kakaiba”.

2. Hallucination

The psychologist inquired the subject as “May naamoy, naririnig, o nalalasahan ka ba na sa tingin mo ay ikaw lang ang nakakadama?” and then he replied as “Minsan, sa pang-amoy lang. Kapag nag-iisa ako, may naamoy akong usok ng kandila”. The subject smells unusual scent of candle when he was alone.

3. Delusion

To clarify the subject if there’s a delusion of persecution, grandiosity, and self-depreciation, the following questions are formulated:

Q1: Mayroon ka bang kaaway na sa tingin mo ay may binabalak silang patayin ka at pagplanuhan ng masama?

A:

Q2: Sa tingin mo ba mayroon kang kapangyarihan at kaya mong gawin lahat gaya ng paglipad at biglang pagkawala?

A:

Q3: Isa ka ba sa naging dahilan ng kamalasan, kalupitan, o immoral na gawain at sinisisi mo ba ang iyong sarili sa lahat ng ito?

A:

4. Obsession and Compulsion

The following questions are initiated to elucidate if the subject possesses obsession and compulsion:

Q1: May mga naaalala ka ba na di maialis-alis sa iyong isipan at papaano mo ito napipigilan?

A:

Q2: May mga gawain ka ba na hindi mo mapigilan at meron ka bang hindi pangkaraniwang kakayahan upang isagawa ang mga ito?

A:

5. Phobias and Doubts

To investigate if the subject has any phobias and doubts in everyday life, the following questions are inititiated:

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Q1: Ikaw ba ay natatakot nang walang dahilan tulad ng takot sa malaking espasyo, maliit na espasyo, dumi, mikrobyo, lugar, at sa kung ano pa man?

A:

Q2: Ikaw ba ay nakakaranas ng kahirapan sa pagpapasiya at pagkalito?

A:

6. Hypochondria

These questions are initiated in order to investigate if there’s any psychosomatic illness to the subject. “May masakit bas a iyong katawan ngayon at sa palagay mo ay saan nagmumula ito?”

E. Sensorium and Intellectual Resources

1. Attention and Impression

The subject has a sharp attention which has not easily distracted from his surroundings. He has bountiful expression in delivering his responses.

2. Orientation

Anong oras na ngayon? Ito ba ay umaga, tanghali, o hatinggabi? Anong araw nagyon, buwan, at taon?

Anong lugar ito? Saan ka galling? At saan ka nakatira? At sino ang mga taong nasa paligid mo? Kilala mo ba kung sino ako?

Anong pangalan mo? Sino ang tatay mo? Ano ang pangalan ng mga kapatid mo? At sino ang mga pinsan at kaibigan mo?

3. Memory

a. Remote Recall – Saan at kailan ka ba pinanganak? Kailan ka nagsimulang mag-aral at natatandaan mo pa ba kung ano ang pangalan ng eskuwelahan na una kang pumasok?

b. Recent Memory – Ano ang mga bagay na ginawa mo kahapon? Sinu-sino ba ang mga nakita mo ngayong umaga at kilala mo ba sila?

c. Retention and Recall –

d. Recognition –

Fairview – ang lugar na kung saan ay ako ay pinanganak Basketball – ang aking paboritong sport Clinical Psychology – ang aking kurso ngayon Isabela – ang aming probinsya

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Red Horse – isang inuming alak Polytechnic University of the Philippines – ang eskuwelahan na aking

pinapasukan Padilla Bldg – ang pangalan ng apartment na inuuwian ko ngayon Sisig – karaniwan na ginagawang pulutan tuwing inuman Efren – ang pangalan ng aking ama

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