PSYCHIATRIC ASSESSMENT TOOL/ PSYCHIATRIC REPORT

Part 1: PSYCHIATRIC HISTORY

I. Identifying Data
 Name: Satur, Ella May
 Age: 19 years old
 Sex: Female
 Address: Private Rd. New Lucban
 Marital Status: S
 Occupation: Student
 Religion: Free Believers in Christ Fellowship
II. History:
A.Chief Complaints/ Reasons for Admission
N/A
B. History of present illness
N/A
C. Changes in client’s life before the onset of illness
N/A

D. Family History
She describes family situation as more or less peaceful but feels pressure from the expectations placed upon her and the hierarchical system
employed in the family (as she feels she is the lowest due to her being the youngest or “bunso” in the family, she is always “wrong” when it comes to
arguments with her sibling and parents). There are no incidences or histories of mental illnesses in the family. Parents are alive and well. Home into
which client was born is in the middle class. Parents are happily married with no untoward feelings against children but were very strict. Client was an
unplanned but wanted birth. It made the family bigger however challenged the second child’s spot in being the youngest causes a sense of “dethroning”
on the part of the sibling.
E. Personal History
1. Prenatal history and mother’s pregnancy and delivery
Length of pregnancy was less than 12 hours; was delivered via LSCS due to occurrence of pre-eclampsia; no known birth trauma; pregnancy
was unplanned but wanted; attitude of parents during pregnancy was positive; no birth defects was with (+) with jaundice which was related to
the occurrence of pre-eclampsia and was suction due to aspiration of meconium.
2. Birth
July 2, 1998; positive parental reaction towards baby; 2nd sibling felt challenged by birth forth attention and felt “dethroned”;
Infancy
Breastfed fed for 2 years and was bottle fed complementarily around 6 months-1 yrs old; no feeding problem; no weaning problem; slept at day
and awakens at night (frequently cried); no physical or sexual abuse
3. Early childhood/ Pre-school
Was more attached to mother; above average language and motor development; toilet training was early as 1 year old (describes it as being
controlled and would only defecate and urinate in the toilet as she disliked the “smell” of the fecal matter); 1-2 playmates; Favorite play activities
were roleplaying in the classroom setting; techniques of getting attention from others; reacted passively to guidance and discipline;; Personality
and temperament as a child was described as shy and timid. Was disciplined harshly with spanks (especially from father, whenever she would
commit a mistake)
a. School
Age started and feelings and adjustments about it, went how far or age left for school – reasons for leaving; scholastic standing and
explanation for changes; special likes or dislikes in subjects; extracurricular activities (arts, organizations, sports); ambitions; attitudes and
relationships towards teacher and classmates
b. Further personality development
Had played outside with 1-2 friends while growing up, but was always put back by parents to study back home after around 1 hour. Such
comments were as such “no wonder your grades are getting lower; you keep on playing”
c. Health status
No illnesses, fell on chin accidentally but no traumatic affect was afflicted.
4. Adolescence
 Peer relationships
Around 6-8 close friends, was once intuned to being a leader but now in college, more of a follower role, social popularity, participates with in
groups and shares ideas though still with reservation, idealizes favorite singers; and has patterns of passivity, anxiety, antisocial behavior
 School history and Cognitive and motor development
Adjusted well initially to school but was slowly isolated due to perceived bossy behavior, relationships with teachers was teacher's pet, was
interested in leading during her highschool days in the student government
 Particular adolescent emotional or physical problems
Feeling of inferiority and isolation in class during highschool
Interests and hobbies
Sewing, singing and drawing
 Psychosexual history
Acquiring of sexual knowledge from books and peers. Attitude of parents toward sex for them is a closed subject; Onset of puberty was at 13
and felt reserved about it, feels menstruation is a natural part of being a girl, development of secondary sexual characteristics; Adolescent
sexual activity: Crushes, parties, dating, petting, masturbation, wet dreams and attitudes toward them; Attitudes toward same and opposite
sex: Timid, shy, aggressive, need to impress, seductive, sexual conquests, anxiety; Sexual practices: Sexual problems,
Religious background
Free Believers in Christ Fellowship
a. Occupational history
N/A
b. Social activity
Has a handful of close friends in college that she can open up to, recently left a relationship and is currently single.
c. Adult sexuality
N/A
d. Military history
N/A
e. Value systems
seen as a burden or a joy; work is seen as or an opportunity; current is devote and faithful to belief; believes in heaven and hell

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Part 2: MENTAL STATUS EXAMINATION
I. Appearance  Perseveration ______
A. Dress 7. Vocabulary, diction
 Appropriate dressed appropriate to situation; is  Appropriate to socioeducational background
wearing type B uniform for Peer counseling utilizing right ___✓_
color of shirt specified for day  Not appropriate socioeducational background
 Inappropriate ______ ______
B. Grooming and Hygiene  Remarks: (Brief nontechnical description)
 Appropriate Appropriate; had taken a bath prior to Speaks at the level expected of a university student,
coming to P.C with well kempt hair making remarks related to course
 Inappropriate ______
C. Age appearance: III. Affect
 Appropriate Appears appropriate to age; not  Appropriate
looking older or younger than current age to content ___✓_
 Inappropriate ______  Apathetic ______
 Remarks:(Brief nontechnical description )  Inappropriate ______
_____________________________________________  Shallow ______
_____________________________________________  Blunted ______
___________________________________________  Flattened ______
 Remarks: (Brief nontechnical description)
II. Behavior Changes affect from nature of topics discussed
A. Manner of Relating (becoming more cautious hesitant when talking about
 Cooperative __✓__ family issues etc.)
 Indifferent ______
 Withdrawn ______ IV. Mood
 Defensive ______  Normal ___✓_
 Remarks: ( Brief nontechnical description)  Anxious ______
Cooperates well with student nurse and answers  Depressed ______
appropriately well with questions  Happy, elated ______
B. Psychomotor  Worried ______
1. Activity  Labile ______
 Appropriate  Remarks: (Brief nontechnical description)
to situation ___✓_ Is relaxed and at peace when asked
 Hyperactivity ______
 Retardation ______ V. Thinking
 Tremor ______ A. Thought
 Purposeless 1. Form
Activity ___✓_  Normal ___✓_
 Repetitive  Concrete ______
Behaviors ______  Referential ______
2. Posture  Illogical ______
 Normal __✓__  Scattered ______
 Abnormal ______ 2. Progression
3. Gait and station  Normal ___✓_
 Normal ___✓__  Circumstantial ______
 Abnormal ______  Tangential ______
 Remarks: (Brief nontechnical description)  Loose
_Moves and acts appropriately in terms of interview Associations ______
(gestures congruent with what she is saying)  Flight of ideas ______
C. Speech and language  Blocking ______
1. Intensity 3. Content
 Normal ______  Normal ___✓_
 Loud ______  Persecutory ______
 Soft ___✓_  Paranoia ______
2. Pitch
 Hypochondrial ______
 Normal ___✓_
 Grandiosity ______
 Monotone ______
 Obsessions ______
 Wide swings ______
 Phobias ______
3. Rate
 Depressive ______
 Normal ___✓_
 Poverty
 Pressured ______
of thought ______
 Slow ______  Remarks: (Brief nontechnical description)
4. Spontaneity Speaks and answers appropriate to question
 Normal ___✓_ B. Perception
 Intrusive ______  Normal ___✓_
 Decreased ______  Hallucinations
5. Relevance  Olfactory ______
 Normal ___✓_  Visual ______
 Incoherent ______  Auditory ______
 Irrelevant ______  Tactile ______
6. Deviations  Visceral ______
 None ___✓_  Remarks: (Brief nontechnical description)
 Aphasia ______ Does not perceive any extraordinary delusions or
 Neologisms ______ illusions during course of interview
 Echolalia ______ C. General knowledge
 Stammering ______ 1. Tests:
 Clanging ______ a. Last Five Philippine Presidents
 Verbigeration ______  Benigno Aquino III
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  Gloria Macapagal-Arroyo 82574 82574
 Estrada 396157 396157
 Fidel Ramos  Reversed Response
 Cory Aquino 419 914
b. Capitals 5372 2735
 Philippines Manila 19386 68391
 Ilocos Norte Laoag 103958 859301
 USA Washington c. Visual Immediate 5 mins
 China Beijing  Pencil __✓__ __✓__
c. Three Main Islands of the Philippines  Chair __✓__ __✓__
 Luzon  paper __✓__ __✓__
 Visayas 4. Abstraction
a. Sayings
 Mindanao
i. Two heads are better than one. Collaborations
d. Date of the Philippine Independence Day
ii. Pagbinato ka ng bato, batuhin mo ng tinapay. You
 June 12
must be kind.
e. Title of the Philippine National Anthem
b. Similarities
 Lupang Hinirang i. Axe – Saw both cut
f. Name of the Holiday celebrated every November 2 ii. Car – Bicycle both roll
 All Souls Day 5. Calculation and concentration
g. Date of Labor Day in the Philippines a. 100 – 7 (serially) 93
 May 1 b. Multiplication
2. Conclusion  2x3 = 6
 Normal for socioeducational background  4 x 12 = 48
__✓__  8 x 11 = 88
 Not normal for socioeducational background  12 x 5 = 60
______
 4x3 = 12
 Remarks: (Brief nontechnical description)
 24 x 3 = 82
 Answers all items correctly
D. Sensorium and Intellectual Function  80 x 4 = 160
1. Orientation c. If bananas cost P20 per dozen, how much do 18
Time __✓__ bananas cost? P18
a. Place __✓__ d. Reverse days of the week: Saturday, Friday, Thursday,
b. Person __✓__ Wednesday, Tuesday, Monday, Friday
c. Situation __✓__ e. Reverse months of the year: December, November,
2. Memory October, September, August, July, June, May, April,
a. Remote March, February, January
 Remarks: (Brief nontechnical description)
 Normal __✓__
Finishes all items correctly
 Impaired ______
E. Insight
b. Recent
1. Normal __✓__
 Normal __✓__ 2. Impaired ______
 Impaired ______  Remarks: (Brief nontechnical description) No signs of
c. Specific abnormalities disorted insights, insights are congruent with what is
 Amnesia ______ presented
 Hyperamnesia ______ F. Judgment
 Paramnesia ______ 1. Normal __✓__
 Confabulation 2. Impaired ______
3. Retention and Recall  Remarks: (Brief nontechnical description)
a. Auditory Immediate 5 mins  No signs of disorted judgments, judgments are
 Purple __✓__ __✓__ congruent with what is presented
 Steamship __✓__ __✓__
 Baguio __✓__ __✓__
b. Digit span
 Forward Span Response
372 372
4916 4916