a. General Appearance:
The patient wears clothing that is conducive to the weather. No body odor or breath odors noted. The patient appears to be clean. He is wearing slippers when he is inside the cell. He has trimmed nails both in hands and feet. No discharges from the ears and nose noted. Minimal hair noted on the chin. His skin is smooth and warm to touch with no bleeding, lesions, ecchymosis noted. Hair is present on his axillae. The client’s stated chronological age is congruent with his apparent age. Client is able to walk independently without any assistance. He has an appropriate gait. He appears to have a slouching posture while standing, walking, and sitting. He has slow but purposeful movements. He has difficulty picking up things from the ground while standing. He is having tremors specifically in his both hands and right feet. He always moves his feet in a walking manner whenever he is only standing. A. Mood, Feelings and Affect
The client was in a euthymic mood. All of his mood and facial expressions are appropriate to what he feels. He appears agitated whenever we talk to him but it disappears later when there is consistent interaction.
B. Perceptual Disturbances
The client cannot see or hear anything that is not real as what he verbalized.
C. Thought Process
Client can answer the questions asked but it still takes time for him to process what we ask. He answers comprehensively with relevance to the questions asked. Client is aware of his mental disorder and still believes that he is in the mental hospital due to talking to himself. D. Sensorium and Cognition
The client is oriented to time, place and person. Client was able to identify the day correctly and was able to approximate the time. Client is aware that he is in the Mental Hospital. Client knows what are the names of his morning and afternoon student nurses. He is able to recall his younger years through...