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MENTAL STATUS EXAMINATION FORM

NAME: Pungay, Greggy “Gerald” E. DATE: February 24, 2015

I- GENERAL DESCRIPTION

A. Appearance:

He was fairly groomed and fairly clean.  There were no signs and symptoms of abnormal involuntary movements to any body parts noticed.  His affect was appropriate, and his mood was normal.  However, thought content was impaired; ideas of reference were noted, and patient claimed to have hallucinations and delusions.

B. Behavior and Psychomotor Activity

The patient was cooperative and maintained eye contact throughout the interview. He did not show any signs of psychomotor retardation.

II- MOOD AND AFFECT

The patient’s mood and affect was appropriate. He did not show any signs of depression, anxiety nor anger.

III- NEUROVEGATATIVE FUNCTION

The patient has no problems regarding his sleep. He sleeps at around 6 – 7pm and wakes up at 3 -4 am. He has good appetite, and currently weighs 76 kg. He claims to masturbate as a way to vent out his stress. He was attentive throughout the interview and was able to respond accordingly.

IV- SPEECH

The patient’s speech was audible. He was talkative throughout the interview.

V- PERCEPTION

The patient experiences auditory and visual hallucinations and were characterized as ideas of reference.

VI- THOUGHT

A. Thought Process

( x ) Looseness of Association ( x ) Flight of Ideas

( x )Tangentiality ( x ) Circumstantiality

( ) Neologism ( ) Thought Blocking

( ) Others

B. Thought Content

( x ) Delusions

( ) Preoccupations

( ) Suicidal Ideation

( ) Homicidal Ideation

( x) Ideas of Reference

( ) Others

VII- SENSORIUM AND COGNITION

The patient was oriented to self, time and place.

A. Memory

Remote ( x ) Unimpaired ( ) Impaired

Recent Past ( x ) Unimpaired ( ) Impaired

Recent ( x ) Unimpaired ( ) Impaired

Immediate ( x ) Unimpaired ( ) Impaired

B. Concentration and Attention

1. Serial Subtraction –...