LEVEL OF CONSCIOUSNESS Alert

Drowsy Cooperative Eye contact AFFECT Flat Blunted Inappropriate

Day1
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Day2
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MOOD Appropriate Anxious Agitated Elated Depressed DRESS Appropriate Neat HYGIENE Good Poor ORIENTATION Time Place Person Situation

MEMORY Recent (Dinner/Breakfast Recent (Current Events) Immediate (Short Term) Remote ( Long Term) DEFENSE MECHANISM Displacement Denial Intellectualization Introjection Projection Rationalization Reaction Formation Regression Repression Sublimation Suppression Identification Isolation Others:

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EXTRA PYRAMIDAL SYMPTOMS PSEUDOPARKINSONISM Akinesia Mask-like face No swinging of arms Hesitancy of Speech Decrease muscle strengths Shuffling gait Drooling Fine intention tremors ACUTE DYSTONIC REACTION Muscle spasm of the jaw, neck, tongue, eyes Laryngeal spasm Akathesia Restlessness Tenseness Inability to sit still Rocking back and forth of feet Crossing legs frequently
Inability to relax

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TARDIVE DYSKINESIA Involuntary movement of mouth, tongue ,face, and may extend to finger arms and trunk

THINKING COMMUNICATIONS
Loose Association Neologism Word Salad . .

Echolalia
Echopraxia Clang Association Illogical thinking . .

Alogia Concrete Thinking Lack of Insight PERCEIVING AND INTERPRETING Delusions Reference Persecution External influences Somatic Grandiose Hallucination Cinesthetics Visual Olfactory Gustatory . . . .

Auditory Tactile

SUMMARY OF MENTAL STATUS EXAMINATION: During the two days of assessing the Mental State of the patient, He shows hostile, anxious, restless and uncooperative behaviour and no eye contact. His mood is inappropriate and he is not oriented to time, place, person and situation. He was dressed with the hospital uniform and with poor hygiene as evidence by a foul smelling odour. While conducting the Nurse- Patient interaction, the patient shows defence mechanism characterized as rationalization and projection. He showed rationalization, patient is assigning logical or socially acceptable motives to his belief to fool someone else and to mislead himself as well like in his case he rationalizes why they kill people. Projection is seen when he attributed his own personal experiences to the Student Nurse. He doesnt know that he is on a mental institution. He has a poor judgement on his condition. He always talks about being a former member of NPA or New Peoples Army. Hes always suspicious that they will get back on him because he knows a lot.