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    Mse - Depression

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    Kervin Jude D. Manahan
    KJM, a 21-year-old male college graduate, appeared worn out and sad with poor eye contact during his mental status examination. He reported depressed mood with suicidal thoughts of wanting to follow his grandfather but no plans or intent. His orientation, memory, concentration, vocabulary and ability to conceptualize were fair. He demonstrated fair insight into being depressed but good judgment in prioritizing important items if his house caught fire.

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    Mse - Depression

    Uploaded by

    Kervin Jude D. Manahan
    100 views6 pages
    KJM, a 21-year-old male college graduate, appeared worn out and sad with poor eye contact during his mental status examination. He reported depressed mood with suicidal thoughts of wanting to follow his grandfather but no plans or intent. His orientation, memory, concentration, vocabulary and ability to conceptualize were fair. He demonstrated fair insight into being depressed but good judgment in prioritizing important items if his house caught fire.

    Original Title

    MSE- DEPRESSION

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    KJM, a 21-year-old male college graduate, appeared worn out and sad with poor eye contact during his mental status examination. He reported depressed mood with suicidal thoughts of wanting to follow his grandfather but no plans or intent. His orientation, memory, concentration, vocabulary and ability to conceptualize were fair. He demonstrated fair insight into being depressed but good judgment in prioritizing important items if his house caught fire.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    100 views6 pages

    Mse - Depression

    Uploaded by

    Kervin Jude D. Manahan
    KJM, a 21-year-old male college graduate, appeared worn out and sad with poor eye contact during his mental status examination. He reported depressed mood with suicidal thoughts of wanting to follow his grandfather but no plans or intent. His orientation, memory, concentration, vocabulary and ability to conceptualize were fair. He demonstrated fair insight into being depressed but good judgment in prioritizing important items if his house caught fire.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 6

    MENTAL STATUS EXAMINATION:

    PERSONAL DATA:
    1. Name: KJM
    2. Age: 21
    3. Sex: MALE
    4. Educational Attainment: College Graduate

    General
    Description
    A. Appearance
    Grooming/dress- appropriateness, cleanliness(neglect personal hygiene) and color
    combination Client KJM appeared with appropriate clothes and cleanliness

    Hygiene: N/A
    Eye Contact(maintain, poor eye contact)Patient seems to
    be a little uncomfortable for eye contact during the
    meeting, pt appears to be averting his gaze
    Posture (slouch, erect,opisthotonus (severe arching of the back): Unable to identify
    Gait( unsteady, shuffling and robot gait: Unable to determine patient’s gait
    Identifying features (marks/scars/tattoos): Unable to identify patient’s features.
    Facial Expression (mask like,worn out, happy and sad): Client’s appearance is worn
    out and sad
    Appearance versus stated age The client appeared accordingly to her age
    Overall appearance :(summary in a narrative form) patient KJM appeared to be
    appropriate with grooming and has poor eye contact and sad facial expressions

    Motor Behavior/Activity (check if present and describe further)


    Hyperactive Agitated Psychomotor retardation Calm
    Tremors/Tics
    Unusual movements/gestures Catatonia
    Akathisia
    Rigidity Facial Movements (jaw/lip smacking)
    Others:
    Speech
    Rate: Slow/rapid
    Amount: Paucity/ Mute/ Pressured
    Volume: (loud/soft)
    Characteristics: Fluency (mute/hesitation/latency of response)

    Attitude during the Interview


    Is the client:
    Cooperative/ Uncooperative Cooperative
    Warm/friendly/Distant - Warm
    Suspicious/Combative Suspicious Guarded/ Aggressive Guarded
    Hostile/ Aloof Apathetic Others:

    B. Emotional
    State Mood
    and Affect
    Is the client:
    Elated (euphoric)/Sad/Depressed (dysphoria) Depressed Euthymic Irritable/Anxious
    Anxious
    Fearful/ Guilty: Guilty Worried/ Angry: Worried Hopeless/ Labile: Hopeless
    Mixed (anxious and depressed)
    Is the Client’s Affect:
    Flat Appropriate /Inappropriate/incongruent APPROPRIATE
    Labile affect Apathy Others:

    C. Thinking
    Thought Process (refers to “how” of the patient’s self expression)
    Concrete Thinking Circumstantiality Tangentiality Loose association
    Echolalia Flight of ideas Perseveration Clang associations
    Blocking Word salad Neologism Other:

    SN: Anong gagawin mo kung sakaling nasunog ang bahay ninyo?


    Pt: kukunin ko yung mga mahahalagang gamit naming ni lolo

    Thought Content (refers to “what” the patient


    actually thinks) Does client have:
    Delusions (grandiose/persecutory/paranoid/somatic/religious) NONE
    Suicidal/homicidal thoughts SUICIDAL THOUGHTS, If homicidal, towards whom?
    ● What thoughts have you had about hurting (person’s name)?
    ● What is your plan?
    ● What do you want to do (person’s name)?

    If suicidal, ask the following Suicide Assessment Questions:


    Ideations Plan Method Access Where When Timing
    Does the client have?
    Obsessions ParanoiaPhobias Magical Thinking
    Depersonalization Hypochondriac Echolalia Others:

    SN: ano ang pakiramdam na naidudulot nito sa iyo sa hinaharap?


    Pt: Pakiramdam ko wala akong pag-asa , oo at feeling ko guilty ako sa nangyari kasi mag
    isa narin ako. Parang wala nang silbi yung buhay ko, wala na kong inaalagaan at wala
    na rin nag aalaga sakin.
    SN: Okay, minsan naisip mo ba na saktan ang ibang tao?
    Pt: hindi, pero yung sarili ko oo, minsan ayuss pa sakin na nagkakasakit ako.
    SN: Maaari mo bang sabihin sakin ang dahilan at naisip mo yan?
    Pt: Para makalimutan ko na lahat, gusto ko nalang sumunod kay lolo.
    D. Experiences
    Perceptual Disturbances
    Is the client experiencing:
    Visual Hallucinations: NONE
    Auditory Hallucination, specifically, Commenting, Discussing, or Commanding: NONE
    Other Hallucination (olfactory/tactile/gustatory): NONE
    Illusions: NONE
    SN: Nakaririnig ka ba ng mga boses na hindi naririnig ng ibang tao?
    Pt: Hindi
    SN: o may nakikita ka ba na hindi nakikita ng pang karaniwan?
    Pt: Wala
    SN: Minsan pakiramdam mo ba na may sumusunod sa iyo o may gustong manakit sa
    iyo?
    Pt: Wala naman

    E. Sensorium and Intellectual Process:


    Level of consciousness- confused/ sedated/ stuporous confused
    Orientation: Person Place Time
    Memory (recent/remote/immediate) Recent
    SN: Naaalala mo pa ba kung ano ang kinain mo kaninang umaga?
    Pt: Uhmmm, nag kape lang ako. Wala din kasii akong gana kumain eh.,
    SN: Ano ang naidudulot ng pakiramdam na ito sa iyo?
    Pt: Hindi ko alam, hindi ko talaga ito iniisip
    SN: Okay ano ang pakiramdam na naidudulot nito sa iyo sa hinaharap?
    Pt: Pakiramdam ko wala akong pag-asa , oo at feeling ko guilty ako sa nangyari kasi mag
    isa narin ako. Parang wala nang silbi yung buhay ko, wala na kong inaalagaan at wala
    na rin nag aalaga sakin.
    SN: Okay, minsan naisip mo ba na saktan ang ibang tao?
    Pt: hindi, pero yung sarili ko oo, minsan ayuss pa sakin na nagkakasakit ako.
    SN: Maaari mo bang sabihin sakin ang dahilan at naisip mo yan? Pt: Para makalimutan ko
    na lahat, gusto ko nalang sumunod kay lolo.

    Level of Concentration is weak


    Can you perform certain tasks, like?
    Level of Calculation GOOD
    Can do simple math, like?
    General fund of knowledge is
    (ask about current events)
    Use of vocabulary is GOOD Can define meaning of the word.

    SN: Maaari mo bang sabihin sakin ang pangalan ng mga buwan ng pabaliktad?
    PT: uhmm, December, … November…. October….*nakatulala….. uhmmm

    Ability to conceptualize abstract is Fair


    SN: Maaari mo bang sabihin saken ang pinagkaiba ng Lamesa at Upuan
    Pt: uhhmmm ang lamesa ay kinakainan habang ang upuan ay inuupuan
    SN: Ano naman ang pagkaka pareho ng lamesa at upuan
    Pt: Parehas itong gawa sa kahoy
    Knows how to interpret proverbs or
    identify similarity or difference between
    objects:

    SN: Ano ang ibigsabihin para sa iyo ng salawikaing “Nasa Diyos ang awa nasa tao ang
    gawa?
    Pt: Uhmm, kailangan nating gumawa at magsumikap?

    Insight and Judgement


    Insight is (good, fair or poor) Fair
    SN: Anong gagawin mo kung sakaling nasunog ang bahay ninyo?
    Pt: kukunin ko yung mga mahahalagang gamit naming ni lolo

    Judgement is (good, fair or poor) good


    SN: Bilang panghuli, mayroon ka na bang ideya sa iyong sarili sa kung ano ang iyong
    nararanasan?
    Pt: Feeling ko depressed ako

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