MENTAL STATUS EXAMINATION

Patient has been diagnosed case of Major Depression Disorder since she was 18 years old (11yrs.PTA),when she was first noted to have episodes of depressed mood with crying bouts particularly around her high school graduation associated with regrets of poor grades and altercations with teachers. One week PTA, patient had to go back to Philippines due to expired visa.Patient noted to be withdrawn always keeping herself in her room with incessant text messages to the mother,who lives in the same house.Noted to be paranoid ,accusing household members of talking about her,irritable and impatient with interrupted sleep 4-5hrs,restless with increase goaldirected activity,always verbalizing she has plenty to attend to when in fact,she did not have a job and only stays at home,hypertalkative with flight of ideas.Patient feels that nobody attends to her needs ,for which she reports feeling pushed to the edge. April 9,2012,few hours PTA patient was very agitated with shouting bouts,particularly very angry towards her mother which prompted consultation and subsequent admission.

General Data:
Adult female of small built and stature petite,looking appropriate for chronological age,well-kempt,wearing t-shir,pants and slippers. Mood was labile,mostly depressed and anxious.Restless,angry,tearful. With appropriate affect,mostly goal-directed responses with some tangentiality and perseveration. Polite conversant with good eye-contact,speech was spontaneous,with clang association,hyperproductive. No hallucination,no paranoid delusions.No suicidal ideation. Alert,oriented to 3 spheres. Preoccupied with relationship with mother and husband with negative views with feelings of hopelessness and being alone and uncared for. Intact memory,good concentration,abstract thinking. Judgement and fund of knowledge,fair impulse control. Poor insight.

NURSE PATIENT INTERACTION

DAY 1

Patient Name: Maria Carmela N. Alcantara Age : 29yrs.old Time: 9:00am-10:00am

Diagnosis : Major Depressive Disorder Date of Interaction : May 23,2012 Venue: Hallway,Female ward

NURSE
Goodmorning maam,Im Dianne and this is my partner Robel.Were from Iloilo.We will be your student nurses from 8am2pm and we will be staying until May 3.

PATIENT RESPONSE
(nodding & smiling) Okay,so youre going to help me with my needs.Youre my angels now.(patient proceeded to the hallway) Follow me angels.

ANALYSIS
Giving Information Client responds to the Student Nurses greetings and recognizes them.Giving information builds trust with the client.

Kamusta po yung pakiramdam nyo maam?

I feel better now that youre here,my angels.(smiling at us) So you guys will help me wash my hair and with my shaving. Not yet.Do you guys want some pizza?Maybe I should order chao fan w/ siomai and this (pointing at the menu list) with sprite and kangkong w/ bagoong and rootbeer.

Seeking information Client understands the question and responds to it and the shows approachability.

What have you eaten in your breakfast maam?

Seeking information Client understands the question and responds to it and the shows approachability.It helps the client to articulate thoughts,feelings and ideas more clearly.

 Yes,maam.Ill just refer to the staff nurse.

Did you get my order?

Accepting Information It indicates that the student nurse has heard and followed the train of thoughts.

Maam Ill just clarify that your order ischao fan w/ siomai and kangkong w/ bagoong and rootbeer. Maam,Is there something you want to talk about?

Nodding (smiling)

Restating Client responds to the question.This restatement lets the client know that she communicated the idea affectively.

(patient is crying and agitated) I just want to go home,I want to see my Dad for the last time.I want to see my family right now.Someone died in my family.I just want someone to tell me the truth.You call Dr. Cordero,I want him to let me out of here. Patient cries silently and uttering words like not telling her the truth,that she has no one to trust

Broad Opening Clients states that she wants to go home and having delusions that someone died in her family.And keep on asking to let her see her family.Makes explicit that the client has the lead in the interaction.

Student Nurses keep silence.

Silence Encourages the client to verbalize,provided that it is interested and expectant.

NURSE PATIENT INTERACTION

DAY 2

Patient Name: Maria Carmela N. Alcantara Age : 29yrs.old Time: 8:30-9:30am

Diagnosis : Major Depressive Disorder Date of Interaction : May 24,2012 Venue: Hallway,Female ward

NURSE Good morning Maam Carmela,can we get your vital signs?

PATIENT RESPONSE
Okay,sure.

EVALUATION
Asking an open-ended question Client answers the question politely.

Maam Carmela,kami po yung mga student nurses kahapon na taga Iloilo (while taking her BP)

(Nodding & smiling) I feel so tired guys, Im just so tired to talk with you so you guys just sit here and talk to each other. I just have a sandwich and fruits.(smiling)

Giving information
Client acknowledges the presence of the Student Nurses.

What did you eat for breakfast maam?

Seeking information Client understands the question and responds to it and the shows approachability.

What time nga po pala yung OT nyo mamaya?

I dont know,but theres a schedule over there.(pointing the activity schedule) No,sometimes,depe nde sa makakasama ko.

Seeking information Client understands the question and doesnt know the answer.

Sumasali po ba kayo sa OT maam?

Asking an open-ended
questions

Client response to the question hesitantly.

 Do you want to take a shower now maam?

Yes,I want to have a shower,but not here I want to do it at home.They put camera at the CR.I want to go home with my family. I want to but I dont have a towel.They just give me a toothbrush and a bottle last night.Kuya Paul gave it to me.(patient paused for a while looked bothered).I dont have to choose from them I dont want to wait for them.My husband filed an annulment.He doesnt want to be fired from his job.He doesnt want to be bothered by me.Im just so tired I dont have energy to talk with guys so just sit here and talk to each other. Patient keeps talking
about someone who put her in that state and sometimes manifest clang association.

Asking an open-ended question Client answers the question politely though shows agitated about the cameras in the CR and inside the female ward and keep on complaining that she wants her privacy.

Maam gusto nyo na bang maligo?Tutulungan po namin kayo kung gusto nyo po.

Offering-Self Client recognizes the Student Nurses

presence and slightly open herself by expressing her thoughts and feelings.

Student Nurses keep silence.

Silence Encourages the client to verbalize,provided that it is interested and expectant.

INTERACTION
During the interview, patient was cooperative, shows willingness to answer the questions. She was oriented to place and person but not to time and date. During the first interview, patient is approachable and shows willingness to obtain intervention though it wasnt verbally uttered. She shows cooperation to interact by trying to respond to the Student Nurses and demonstrates a sense of trust to us.Though around mid-day she got irritated and agitated that according to her nobody attends to her needs such us her toiletries and also due to her delayed order for lunch.Then have delusions that she predict or feels that someone died in her family,specifically her Dad.Saying that he might committed suicide and she wants to see him for the last time and she burst on silent tears. We tried to comfort her and she briefly opened up on us.We listened until she politely leave us. On the second day, patient was cooperative as depicted by answering the questions of the Student nurses with no sense of irritability. But complains being so tired and no energy to talk and deal with the Student Nurses.And began on complaining about cameras all over the female ward and the comfort rooms.Complains about invading her privacy.And politely refuse our offer to help her take the shower and politely dismiss us,saying shes so tired to deal with us.At some time patient slightly opens herself to us about her husband filing an annulment and blaming her mother for putting her in that place because they doesnt want to be bothered with her.And shes been advising us stuffs like to chose the right friends that can give us good influence.

MENTAL

STATUS

EXAMINATION

PREPARED BY: DIANNE LETICIA LAMBITO

ROBEL MAE L. MONTANO PREPARED FOR: MR. ROBERT SUMAGUINGSING,RN

MAJOR DEPRESSIVE DISORDER

A person who suffers from a major depressive disorder (sometimes also referred to as clinical depression or major depression) must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2 week period. This mood must represent a change from the person's normal mood. Social, occupational, educational or other important functioning must also be negatively impaired by the change in mood. Major depressive disorder is also known as major depression, clinical depression, or unipolar depression. The term unipolar refers to the presence of one pole, or one extreme of mood- depressed mood. This may be compared with bipolar depression which has the two poles of depressed mood and mania (i.e., euphoria, heightened emotion and activity). Different people are affected in different ways by major depression. Some people have trouble sleeping, they lose weight, and they generally feel agitated and irritable. Others may sleep and eat too much and continuously feel worthless and guilty. Still others can function reasonably well at work and put on a "happy face" in front of others, while deep down they feel quite depressed and disinterested in life. There is no one way that people look and behave when they have major depression. However, most people will either have depressed mood or a general loss of interest in activities they once enjoyed, or a combination of both. In addition they will have other physical and mental symptoms that may include fatigue, difficulty with concentration and memory, feelings of hopelessness and helplessness, headaches, body aches, and thoughts of suicide.

BIPOLAR I MOOD DISORDER MRE-MANIC

PREPARED BY: NORMAN GABUTIN LAHAR GENESILA PREPARED FOR: MR. ROBERT SUMAGUINGSING,RN

SCHIZOPHRENIAUNDIFFERENTIATED

TYPE
PREPARED BY:

SHIELA MARIE BOGLOSA ALAINE MHARIE SELAUSO

PREPARED FOR:

MR. ROBERT SUMAGUINGSING,RN

NURSE PATIENT INTERACTION

DAY 3

Patient Name: Maria Carmela N. Alcantara Age : 29yrs.old Time: 8:30-9:30am

Diagnosis : Major Depressive Disorder Date of Interaction : May 25,2012 Venue: Hallway,Female ward

NURSE
Good Morning, Maam Carmela..(in the hallway)

PATIENT RESPONSE
Good morning,excuse me..makulit talaga ako (as she passed through us.)

ANALYSIS
Giving Recognition Client recognizes the presence of the Student Nurse.Recognition to acknowledge clients presence.

Maam, can we get your Blood Pressure?

Can I use the restroom first? (patient looks irritated)

Seeking information Client shows irritation towards the student nurses.It helps the client to articulate thoughts feelings and ideas more clearly.Helps the nurse to avoid making assumption that has occurred when it has not.

Maam ok na po bang kunan kayo?(while taking her vital signs)

I only want one person to take care of me.At ayoko nang masyadong nakikialam at sipsip (patient looked irritated)

Seeking information Client shows irritation towards the student nurses while taking her VS.Seeking information helps client to express her thoughts and feelings.

Okay po maam,nakaligo na po kayo maam?

Not yet,I want to take shower at home.I want to go home.Tell that to the staff.(Patient looked irritated)

Asking open-ended question. Client answers the question politely though shows agitated about the cameras in the CR and inside the female ward and keep on complaining that she wants her privacy.

 Can I sit beside you maam?

Sure.. (as we sit,patient suddenly got up and leave)

Offering-Self Client recognizes the Student Nurses presence but client show aloofness and irritation) Seeking information Client understands and response to the question.Client shows obviously that she doesnt want to mingle with others.

Maam marunong din po ba kayong sumayaw? (In the hallway,when patient Cuervo is taking all the student nurses attention,as she dance and sing) Gusto nyo din po bang sumali maam?

No,I just want to be separated from them(Patient grimaced)

Patient shakes her head indicating no as an answer. (patient smiled shyly)

Seeking information Client understands and response to the question shyly.She shows that she doesnt want to engage herself with others. Offering-Self Client recognizes the Student Nurses presence but client show aloofness and agitation towards student nurses.Patient slightly raised her voiced as evidenced.

(Inside female ward after 10mins..) Maam,gusto nyo po bang maligo na?Tutulungan po naming kayo kung gusto nyo po.

(Patient is irritable,and slightly raised her voiced) No,I just want to go home and take shower there.Tell that to the staff.At pwedi ba?iwan nyo muna ako kasi hindi kayo nakakatulong! Yes,I want to be alone for a while,magulo ang utak ko,iwan nyo muna ako..

Are you sure you want to be alone maam?Cause were here to help you or if theres something you want to talk with us.

Restating Client responds to the question.This restatement lets the client know that she communicated the idea affectively.And she clearly clarify that she wants to be alone. Offering-Self Client recognizes presence of the Student Nurses but client show agitation and wanting to be alone for a while.

Okay maam,if thats what you want.But just in case you need anything or you need help on something were just in the hallway maam

Patient nod.