Professional Documents
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Psych MSE
Psych MSE
as I received him. He dressed appropriately for his age and appears to be in his stated age. He is 41 yrs. old, male, single and a Filipino citizen. His hair was well groomed. He appears happy and smiles when talking. He looks clean and well groomed. Movement and Behavior: The client has erect posture when he stands and sits. He has coordinated body movements. He was able to sit, walk and move freely without any assistance. During the nurse patient interaction the client was swaying his legs. There was no involuntary muscle movement observed. He was cooperative during our conversations. He listens to me when I ask questions and answers all questions being asked in distant manner. He has concentration during the interaction and makes good eye contact when talking. He was not distracted easily during the conversations even though there were many people talking that might catch his attention. But he was bothered because of his colds. Our conversation was interrupted for a while when he go back inside because of his colds. He was expressive of himself. He was not hesitant to talk about himself and his past experiences. The clients facial expression was appropriate for the situation. Affect: The client has appropriate affect. He seems happy but there were times that he looks sad when he talks about sad memories. He has appropriate expressions or emotions congruent with the context of the situation. Mood: The clients mood was happy. There were no signs of depression but he told me that sometimes he become bored because of similar activities that happen every day. Speech: The content of clients speech was relevant to the question being asked. He has quite fast rate of speech. He has normal pitch. The tone was audible and the voice was clear. No speech difficulties noted. He doesnt use neologisms. Thought content and process: The client thinks about why he is still there because he knows that he is okay and there is no problem in him. The client had delusions before that he was Jesus Christ. His verbalizations make sense and ideas were related to each other. He doesnt use neologisms. He never thought of committing suicide.
Cognition: The client has normal cognition. He is oriented to person, place and time. He knows where he is and the correct day, date and year. He has the ability to concentrate. He was able to spell the word blue in normal way and in backward manner correctly. With regards to his memory, he was able to recall events during the day and he knows the name of the current president. Judgment: The client makes decision by thinking about it many times and he also makes strategies. He has poor judgment because when ask about how was his childhood he said that it was okay. When how can it be okay if he said earlier in our conversation that he was always punished and bullied by his brother when he was a child. Insight: The client has poor insight. He lacks insight into the fact that he is mentally ill and denies the fact that there is anything wrong. He believes that he is fine and has no problem.