Name: Aya B.

Bolinas
Care Center

Area of Exposure: Bacolod City Mental Health

Level: BSN-4A

Date of Exposure: July 4-5, 2016

CI: Mr. Renato D. Lacanilao, RN, MAN

MENTAL STATUS EXAMINATION
I.

Baseline Data

Name: L.P.
Age: 31 years old
Sex: Male
Birthdate: January 7, 1985
Nationality: Filipinno
Civil Status: Single
Children: The client has no children.
Religion: Roman Catholic
Occupation: Client has no current occupation. However, he has tried working in Sagay Cable and Sugar
Milling Company as an electrician
Educational Attainment: The client finished his 3rd year in Bachelor of Science in Marine Transportation in
John B. Lacson Foundation. He didnt continue with his apprenticeship. He also studied in TESDA
wherein he specialized in technician/electrician.
Number of Siblings: 2
Name Next to Kin: Mother- E.P.
Father- P.P.
Relationship: Parents
Date of Admission: December 9, 2015
No. of days in the unit: 209 days
Attending Physician: Dr. S.
Chief Complaint/s: The patient is manifesting the symptoms of talking to himself, inability to sleep and
religiously pre-occupied.

Medical Diagnosis: Bipolar Mood Disorder

Nursing Diagnosis:
Actual: Disturbance in Sensory Perception related to imbalance in neurotransmitters secondary to
Bipolar Disorder
Potential: Risk for Self-Directed Violence related to impulsive behaviour secondary to Bipolar
Disorder
History of Present Illness:
On 2005, Client L.P. had a vacation in Capiz with his aunt where he was forced to work in the
rice fields and do heavy manual jobs. He returned to Sagay City 3 months after and upon his
return, he is manifesting the symptoms of talking to himself, inability to sleep and religiously
preoccupied. He was consulted by Dr. Gerona. The physician prescribed medications which
offered temporary relief of symptoms.
On 2006, the client studied in John B. Lacson but exacerbation of symptoms occurred. The
client was then admitted at the National Center for Mental Health in Mandaluyong City for 3
months where he received electroconvulsive therapy.
Last December 9, 2015, he was for readmission in BCMHCC. He threw bottles at his
neighbors house and this event made his parents decide to have him admitted again. He was
admitted having visual and auditory hallucinations. He mentioned that he has imaginary friends
and he saw an angel and Virgin Mary.
Appearance and Behavior
a.

Attitude
The client is friendly and is cooperative with the various therapies that we conducted. He
always smile and laughs. He is a jolly person and he is eager to answer most of the questions
that is being asked.

b.

General Appearance and Grooming

The client is relaxed and cooperative every time we have our NPI and therapies. He would
openly answer to the questions asked. The client listens to the questions however he doesnt maintain
eye contact during conversations. He seems to be excited with the questions and would answer without
finishing the question. He is jolly and would always laugh. During the culmination day he actively
participates in games and he even sang a song for the program.
The client appears to be thin and pale-looking. He is well- groomed and he dresses
casually. He has normal gait and has relaxed posture. He crosses his legs most of the time. He is neat
and clean. He appears to be thin and pale looking.

c.

Facial Expression
The client has labile mood. It changes rapidly from being euphoric to flat.

d.

Posture

The client has slouchy posture. He tends to slouch when walking and sitting.
e.

Gait and Carriage

The client has normal and steady gait. He walks in normal pace.

f.

Body Build
The client appears to be thin.

g.

Psychomotor Activity
The client appears to be hyperactive and impulsive. For instance, during our Culmination Day,
the client volunteered sing another song and he grabbed the microphone from the emcee. The
client also tends to cross his legs and he moves rapidly and fast.

h.

Voice and Speech

The client has modulated voice. The client was able to verbalized her thoughts and feelings
clearly. He was able to answer all questions appropriately. The was able to focus on topics discussed.
He was able to convey his message by using simple words. The client was able to understand and
speak Hiligaynon. There were no neologism, flight of ideas and other speech problems encountered
during the nurse-patient interaction.
Mood and Affect
The clients mood is incongruent. For instance, during the culmination day, while praying
client was seen laughing all by himself and during the nurse patient interaction he mentioned that he
is disappointed and sad because even though he engages in sexual interactions with his girlfriends
God didnt give him the opportunity to be a father and after sharing that he burst out laughing.
He has labile mood. His mood changes rapidly from being euphoric to flat affect.
Perception
The client has both visual and auditory hallucinations. According to the client, he has
imaginary friends. He also sees angels and Virgin Mary. The client mentioned that his imaginary
friends visits him whenever he hasnt drink his medications.
Aside from visual hallucinations, the client also experiences auditory hallucinations.
According to the client, the voice is telling him to get wild and to burn the church.

Thinking
The client was able to give relevant data about his experiences in life and he was able to
follow in the conversation. The client seems excited in answering the questions being asked and

would not wait for the person to finish the sentence or question. There were no flight of ideas, word
salad, looseness of association and neologism noted during the nurse-patient interaction.
The client seems to be persevered in going out of the institution. According to him, he wants to go to
America and meet his co-patients girl cousin. He also wants to own a hotel within 10 years.
Judgment
The client was able to answer the hypothetical question being asked to her appropriately.
For instance, when her student nurse asked her, Ano ang himuon mo kung makakita ka sang 50
pesos samang galagaw ka sa SM?. The client answered, Ihatag ko ang kwarta sa guard kay basi
pangitaon sang tag-iya. The clients answer is relevant to the question being asked.
Insight
The client is aware of his condition and he is also aware that his symptoms manifest whenever
he doesnt drink his medications. He mentioned that he is now being careful in controlling himself so
as not to commit any problems.
Sensorium and Cognition
10 KHANS QUESTIONS
1. What is the name of this institution?
2. Where is it located?
3. What day is today?
4. What is the month now?
5. What is the year now?
6. How old are you
7. When were you born?
8. Where were you born?
9. Who is the present president?
10. Who is the president before?
TOTAL:

CORRECT

WRONG

8 correct
information out of
10

2 mistakes out of 10