I.

PHYSICAL AND MENTAL ASSESSMENT

A. GENERAL APPEARANCE The client appears stated condition with her age of 57 years old, well groomed and with good personal hygiene. Shes taking a bath everyday with a good daily routine. The client has a good posture, gait and coordination. During interaction, she has a good eye to eye contact and an appropriate affect or facial expression with regards to a certain situation. She was well nourished and has a fair skin as evidenced by her good body built and has no sleeping difficulties by the absence of dark circles under her eyes. She was well oriented with time, place, date and reality. The client considered the interview the interview as a normal thing and she was guided accordingly with no harsh or offending questions thrown to her during the interview. She was cooperative with consistency of speech and behavior.

B. GENERAL BEHAVIOR AND ACTIVITY The patient exhibited cooperation in the whole duration of duty and able to answers all questions asked to her and participates in all activities. But the client is sometimes lethargic during interaction.

C. ORIENTATION The client was well oriented on date, time, place and reality. She can relate to past experiences and able to organized ideas and thoughts related to her present condition. She know and aware that she was at the Mother Theresa.

D. AFFECT AND MOOD The client show appropriate affect with regards to a certain situation. But sometimes, she suddenly change in expression of mood and this makes hard to identify whether she was on stated condition and willing to cooperate and interested with the interaction. Sometimes, there was an alteration of the affective state of the client which was inappropriate and contrary to her feelings and emotions.

E. THOUGHT PROCESS AND CONTENT Even the client was at the center, she has a normal and logical thought process. What she uttered was meaningful and with sense. She can easily catch up what the interviewee mean and answer relevant to the questions but sometimes not. F. MEMORY, PRESENT AND REMOTE The client has good memory but sometimes she had lapses. She can recall and remember her past experiences and important events and people in her life. What were discussed in the previous days were recalled which were integrated on the present scenario on the interaction. G. JUDGMENT The condition of the client only started when she was on her adulthood. Therefore, it doesnt mean that she cannot make decisions on its own for she was at the center. She can formulate and think of other alternatives which later beneficial for solving her own problems. H. INSIGHT The client denies her condition but she knows she was at the Mother Theresa because of Hypertension. She knows the state of her illness being manageable and how was the progression with regards to it and in response to medication regimen and psychotherapies. She was able to respond of what was going on and can comprehend appropriately. I. INTELLECT She has a good sense of reasoning but it was limited. She was able to pinpoint and defend her answers but if asked for the main reason why she was at the center, she cant answer directly. J. COPING MECHANISMS The client has good pattern in handling stressors that arises in her life. Since she was able to formulate ideas and alternatives in order to divert her attention her problems, she just did her responsibilities at the center and just enjoyed the therapies especially during plays for her not to think or not be bothered by her problems even in a short period of time.

PERSONAL DATA Name: Age: Birth date: Birthplace: Address: M.L.T 57 y/o May 20, 1953 Quezon City Lot 1 Blk 3 Salazar Compound, Villa Matilde, Project 8, Quezon City Gender: Civil Status: Nationality: Religion: Educatonal Attaiment: Date of Admission: Time of Admission: Admitting Physician: Clinical Diagnosis: Agency: Female Single Filipino Roman Catholic College Graduate October 15, 2010 10:10 PM Dr. Dalisay Undifferentiated Schizophrenia, Chronic Mother Theresa Home that Care, Mandaluyong City

A. HISTORY OF PRESENT ILLNESS The present condition of the client started when she was 55 years old. Due to some circumstances, the client become hostile and showed untoward behaviors. She was admitted on October 15, 2010 with a diagnosis of Schizophrenia undifferentiated type, Chronic. She has a regular check up and taking the medications regularly. The clients condition now was already stable and manageable, but sometimes she still manifests some symptoms like delusion.