Mental Status Examination
Mental Status Examination
Mental Status Examination
I. PSYCHIATRY HISTORY
A. IDENTIFICATION
Name : Mr Z
Age : 46 years old
Sex : Male
Marital Status : Married with 3 children
Religion : Islam
Education level : Master Degree in Mechanical Engineering
Address : Kangar, Perlis
Occupation : Lecturer in local universities
Source of referral : Patient
B. CHIEF COMPLAINT
E. FAMILY HISTORY
Grandmother had psychotic symptom after giving birth but never seek
medication
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F.PERSONAL HISTORY
CHILDHOOD HISTORY
Patient had normal development during childhood and teenage years.
He continued doing master and allegedly dropped out due to mental
illness
SCHOOL HISTORY
He identify himself as an active student where he always involved in
lots of school activities.
RELIGIOUS BACKGROUND
He came from a religious family background.
MARITAL HISTORY
Married with 3 children :
i)13 years old daughter,
ii)11 years old son
iii)6 years old daughter
Patient claimed his wife and children understands his problem and
there is no other significant problems in his marriage.
OCCUPATIONAL HISTORY
Claimed not having problem with his occupation, he feels comfortable
at his working place as all his colleges understands him.
MENTAL STATUS
B. GENERAL DESCRIPTION
He is well dressed with casual clothing
C. SPEECH
He speaks Malay rapidly, jumping from one idea to another
( flight of ideas), spontaneously answering
E. THOUGHT
Logical and goal oriented
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F. THOUGHT CONTENT
Patient has grandiosity delusion.He wants to be the richest man
and produce a helicopter.He claims to have a good handwriting
that he was awarded the best handwriting.Patient also wants to
propose singer/actress, Erra Fazira for marriage. Patient claimed
his uncle had a bad intention towards him and being told that he
was crazy.
Patient does not have any phobia.
G. PERCEPTION
No hallucination or illusion
H. ALERTNESS
Alert
I. ORIENTATION
Oriented to time,place and person
J. CONCENTRATION
Good. Able to count backwards by 7 starting from 100
K. MEMORY
No impairment in immediate, recent and remote memory.
L. FUND OF KNOWLEDGE
Very Good
M. ABSTRACT REASONING
Understand Malay Proverbs
N. INSIGHT
True Emotional Insight.Patient knows of his disease and it’s
significant.Heis willing to be treated.
O. JUDGEMENT
Good Social & Personal Judgement
IV.PROVISIONAL DIAGNOSIS
V. DIFFERENTIAL DIAGNOSIS
Bipolar type 2 Disorder
Schizoaffective Disorder
VII. PROGNOSIS
Good Poor
Family history Grandmother having
psychotic symptom
but never seek
medication.
Compliance Comply
Onset Early adulthood
Support Family supportive
Educational level High
Economic status Good
Marital status Good
Symptom Manic & depressive
Gender Male
Function Mildly altered
Duration 22years
Non pharmacological :
i) basic counseling
ii) psyco-education
• Pharmacological :
i) Valproate 200mg/day
ii) Lithium 300mg/day