The patient always take a bath every day, wears appropriate ward dress which is blue and sometimes

in color of red. The patient is in good posture and can able to sit, stand and ambulate without any support from staff nurses on the ward. She also has a good eye to eye contact. As observing the patient, her actions and thoughts are always in match. The patient also describes her problems that may be precipitates in any circumstances of her condition.

Presenting Appearance including sex, chronological and A. General Appearance Motor behavior and D I S T U R B A N C E Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), work speed, any noteworthy mannerisms or gestures. Basic Grooming and Hygiene, dress and whether it was appropriate attire for the weather, for a doctor's interview, accessories like glasses or a cane apparent age, ethnicity, apparent height and weight (average, stocky, healthy, petite), any physical deformities (hearing impaired, injured and bandaged right hand)

The patient talks in a proper way, but sometimes expresses an over joy feeling. She also manifest a repeatedly thoughts with matching insisted actions.

Blocking - There were times in our conversations that the D patient abruptly stop talking or sharing her thoughts,

I B. Communication S T U R B A N C E

especially when it comes to the topic of abuse and rape.

Euphoria - The patient experiences excessive happiness whenever there are topic about any jokes and happy thoughts. But there are times that the patient only adapts the laughing actions of people around her.

Latency of Response - The patient takes a few seconds before answering some questions for about 20-30 seconds and sometimes the question should be asked twice so that she can understand what we trying to say.

The patients way of thinking was appropriate for his age. She thinks precisely and concretely with inability to demonstrate abstract thinking and proper reasoning. She always avoids any sensitive topic about her past especially on what she is experiencing now.

Orientation (person, place, time, presidents, your name) Alertness (sleepy, alert, tired for working late, dull and uninterested, highly distractible)

Coherence

(responses

were

coherent

and

easy

to

understand, simplistic and concrete, lacking in necessary D I C. Perception, Thought process S and Content T U R B A N Concentration and Attention (based on Digit Span and attention to your questions, serial 7's or 3's in which they count backwards from 100 to 50 by 7s or 3s, naming the days of the week or months of the year in reverse order, spelling the word "world", their own last name, or the ABC's backwards) detail, overly detailed and difficult to follow)

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Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)

Mood and affect are unpredictable.

Restricted Affect - This means that a person displaying one type of expression. The patient always in serious mode, expressing her thoughts and emotions. Even though she was telling that she were sad, she remains on smiling and laughing. D I S D. Mood and Affect T U R B A N C E Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, Labile Mood - The patient rapidly changes in mood. She was unpredictable from being serious to funny and certainly to funny then serious again.

anxious, angry). Think of the climate in an area. Affect or how they felt a a given moment (comments can include range of emotions like broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation and facial expressions, pessimistic, optimistic) as well as inappropriate signs (began dancing in the office, verbally threatened examiner, cried while discussing recent happy event and unable to explain why). Think of the weather, which varies slightly from day to day.

The patient was oriented to time, place and person that shes having a

regular interaction. Some persons outside the institutions like her friends before are unrecognizable. Her short and long term memories are impaired, but her abstract thinking ability was good and always present. The patients concentration and focus can be easily distracted by nuisance and other stimuli.

Thought Processes (could/could not recall the plot of a D I S E. Sensorium and Intellectual process T U R B A N C E Intellectual Ability (roughly average, above average, or below average based on answers to questions like "name last four presidents," "who is the governor of the state," "what is the capitol of the state," "what direction does the sun set," etc) favorite movie or book logically, difficult to understand line of reasoning, showed loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization)

Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)

Rapport (easy to establish, initially difficult but easier over F. Judgment and Insight D I S T U R B A N Poor Insight - The patient was not able to identify strengths Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, daydreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such) time, difficult to establish, tenuous, easily upset)

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and weaknesses that may affect the response of treatment. She didnt have understanding of her disease and its management.

The patient sense herself as a bad and useless person.

G. Self-concept

The patient has weak ego and sometimes hopeless about achieving her dreams in life because for her, it will take more time before she finally go home.

The patient has difficulty in maintaining relationship because of lack in trust.

H. Roles and Relationships Cooperation - The patient are so cooperative in terms of different activities that we prepared for a day. But she only listens to girl student nurses because she have a traumatic experience with boys.