Clinical Assessment
Content
CLINICAL ASSESSMENT
Lady Ann Marfil (Patient- Airra Blente) I. IDENTIFYING DATA
BSIOP 3-3S
Airra Blente is 18 year old, Filipino, single who was given an assignment by their professor to go under a clinical assessment-group activity. She lives at 529 A-H. Ventura St. Sampaloc, Manila. II. CHIEF COMPLAINT/ HISTORY
A. Chief Complaint Ms. Blente’s temper get to burst easily every time her mother nags her. She can’t help herself from answering her mother back. Especially when she thinks she’s the one who is right. B. Problem History There was a time when her mother nag her and they end up throwing hurtful words towards each other. Ms. Blente understands that her mother has a diabetes and being angry often times is just one of the symptoms of this disease. C. Family History Ms. Blente is an adopted child. Her biological father entrusted her to Ms. Blente’s aunt who happens to be the sister of her father. She has a sister who was also adopted by her aunt and a brother-the real child of her foster parent. D. Personal/Social History
Ms. Blente know that she was adopted because her foster explained it to her in a way that she will clearly understand it. She grew up as a normal child, like children with biological parents. Never lacking of any emotional needs (love, care, etc.). She was never teased by her classmate about her identity.
III.
BEHAVIORAL OBSERVATION
A. Respect If I am to rate Ms. Blente from 1-5, I want to give her a rate of 5 for she is a very respectful person, she answered me in a pleasing way.
B. Interaction Posture Ms. Blente responds to me in a manner that draws out information, thoughts, and feelings. Ms. Blente deserves a rate of 5.
C. Orientation to knowledge Ms. Blente treats perceptions, knowledge, feelings and insights as inherent in the people and objects being perceived and assumes other people will always share the individual’s perception, attitudes and feelings if they are mature, knowledgeable or insightful.
D. Empathy Ms. Blente appears to respond with great accuracy to apparent and less apparent expressions of feeling and thought by others. She projects interest and provides verbal and nonverbal cues that he or she understands the state of affairs of others.
E. Role Behavior Ms. Blente is into relational role, she is more focus on building or maintaining relationships within the group she is in-circle of friends.
F. Interaction Management Ms. Blente has a great managing skill. She is active and really takes part on every group discussion. But there are also times that she fails on letting the people around her to take their turns on expressing what they want to say or share.
G. Ambiguity Tolerance Because Ms. Blente is a very friendly person, seldom she has problems when it comes to coping with a new environment. She is able to make friends easily and feel comfortable at once to them and vice versa.
IV.
MENTAL STATUS EXAMINATION
A. Intellect Ms. Blente is average in intelligence based on her interview presentation, we haven’t done any cognitive assessment at this time. Insight regarding the degree of her problems is adequate and she appears motivated to seek treatment. B. Affect Ms. Blente appears to be emotional during the interview. I’d felt that she is quite uncomfortable to share her story. But then she trusted me later on. She seems to be happy
and proud because she knows her biological parents and foster parents loves her so much even there are misunderstandings. C. Thoughts Ms. Blente keeps on saying that she is happy and her actions never fails to compliment with what she says. She is thankful because she is with her foster parents and her biological parents still loves her. She did not focus on the part where she and her foster parents always fight. D. Sensorium She is oriented as to time, place and person. Memory appears sound. E. Judgment The way Ms. Blente decide in things is average. She knows what to do at times but there are times when she is over ruled by her emotions. F. Insights Her insights are great. At a young age she understands why she was adopted by her aunt and even think that she is really fortunate because she has two sets of parents that will take care of her and will love her as she grows. G. General Appearance and Behavior Ms. Blente is chubby, medium in height. She is dressed correctly. Her speech is soft. Inreview behavior is cooperative. The way she answers is excellent.
V.
SUMMARY OF CONCLUSION Ms. Blente is really a fortunate child, it happens that she can’t take when he hears her mother shouting at her or nagging her. Because her mother has diabetes, the situation
is now different. Every small mistake will be notice by her mother and will nag her at once. VI. RECOMMENDATION Ms. Blente must deeply understand the situation of her mother. As her daughter she may just try to stay calm whenever that nagging happens. It is also a sign of respect for a parent that even they are the one who is wrong, we still take time to just listen to them and not compete with their airing voices. Her mother just need to feel cared and loved even she has that present condition.
CLINICAL ASSESSMENT
Submitted by:
Lady Ann G. Marfil Airra Blente (BSIOP 3-3S)
Submitted to:
Professor Lopiga
Lady Ann Marfil (Patient- Airra Blente) I. IDENTIFYING DATA
BSIOP 3-3S
Airra Blente is 18 year old, Filipino, single who was given an assignment by their professor to go under a clinical assessment-group activity. She lives at 529 A-H. Ventura St. Sampaloc, Manila. II. CHIEF COMPLAINT/ HISTORY
A. Chief Complaint Ms. Blente’s temper get to burst easily every time her mother nags her. She can’t help herself from answering her mother back. Especially when she thinks she’s the one who is right. B. Problem History There was a time when her mother nag her and they end up throwing hurtful words towards each other. Ms. Blente understands that her mother has a diabetes and being angry often times is just one of the symptoms of this disease. C. Family History Ms. Blente is an adopted child. Her biological father entrusted her to Ms. Blente’s aunt who happens to be the sister of her father. She has a sister who was also adopted by her aunt and a brother-the real child of her foster parent. D. Personal/Social History
Ms. Blente know that she was adopted because her foster explained it to her in a way that she will clearly understand it. She grew up as a normal child, like children with biological parents. Never lacking of any emotional needs (love, care, etc.). She was never teased by her classmate about her identity.
III.
BEHAVIORAL OBSERVATION
A. Respect If I am to rate Ms. Blente from 1-5, I want to give her a rate of 5 for she is a very respectful person, she answered me in a pleasing way.
B. Interaction Posture Ms. Blente responds to me in a manner that draws out information, thoughts, and feelings. Ms. Blente deserves a rate of 5.
C. Orientation to knowledge Ms. Blente treats perceptions, knowledge, feelings and insights as inherent in the people and objects being perceived and assumes other people will always share the individual’s perception, attitudes and feelings if they are mature, knowledgeable or insightful.
D. Empathy Ms. Blente appears to respond with great accuracy to apparent and less apparent expressions of feeling and thought by others. She projects interest and provides verbal and nonverbal cues that he or she understands the state of affairs of others.
E. Role Behavior Ms. Blente is into relational role, she is more focus on building or maintaining relationships within the group she is in-circle of friends.
F. Interaction Management Ms. Blente has a great managing skill. She is active and really takes part on every group discussion. But there are also times that she fails on letting the people around her to take their turns on expressing what they want to say or share.
G. Ambiguity Tolerance Because Ms. Blente is a very friendly person, seldom she has problems when it comes to coping with a new environment. She is able to make friends easily and feel comfortable at once to them and vice versa.
IV.
MENTAL STATUS EXAMINATION
A. Intellect Ms. Blente is average in intelligence based on her interview presentation, we haven’t done any cognitive assessment at this time. Insight regarding the degree of her problems is adequate and she appears motivated to seek treatment. B. Affect Ms. Blente appears to be emotional during the interview. I’d felt that she is quite uncomfortable to share her story. But then she trusted me later on. She seems to be happy
and proud because she knows her biological parents and foster parents loves her so much even there are misunderstandings. C. Thoughts Ms. Blente keeps on saying that she is happy and her actions never fails to compliment with what she says. She is thankful because she is with her foster parents and her biological parents still loves her. She did not focus on the part where she and her foster parents always fight. D. Sensorium She is oriented as to time, place and person. Memory appears sound. E. Judgment The way Ms. Blente decide in things is average. She knows what to do at times but there are times when she is over ruled by her emotions. F. Insights Her insights are great. At a young age she understands why she was adopted by her aunt and even think that she is really fortunate because she has two sets of parents that will take care of her and will love her as she grows. G. General Appearance and Behavior Ms. Blente is chubby, medium in height. She is dressed correctly. Her speech is soft. Inreview behavior is cooperative. The way she answers is excellent.
V.
SUMMARY OF CONCLUSION Ms. Blente is really a fortunate child, it happens that she can’t take when he hears her mother shouting at her or nagging her. Because her mother has diabetes, the situation
is now different. Every small mistake will be notice by her mother and will nag her at once. VI. RECOMMENDATION Ms. Blente must deeply understand the situation of her mother. As her daughter she may just try to stay calm whenever that nagging happens. It is also a sign of respect for a parent that even they are the one who is wrong, we still take time to just listen to them and not compete with their airing voices. Her mother just need to feel cared and loved even she has that present condition.
CLINICAL ASSESSMENT
Submitted by:
Lady Ann G. Marfil Airra Blente (BSIOP 3-3S)
Submitted to:
Professor Lopiga
