Mental Health Assessment and Intervention Report - Andy's Case Study

Running Head: ANDY’S CASE STUDY 1
Mental health assessment and intervention report
Student’s Name
Institutional Affiliation

ANDY’S CASE STUDY 2
Table of Contents
PART A: HISTORY......................................................................................................................4
PART B: MENTAL STATE EXAMINATION..........................................................................4
Appearance.................................................................................................................................4
Behavior......................................................................................................................................4
Affect...........................................................................................................................................5
Mood............................................................................................................................................5
Speech..........................................................................................................................................5
Thoughtform...............................................................................................................................5
Thought content.........................................................................................................................5
Perception...................................................................................................................................5
Cognition/intellectual functioning............................................................................................6
Insight and Judgment................................................................................................................6
Risk assessment..........................................................................................................................6
Formulation................................................................................................................................6
Provisional diagnosis..................................................................................................................6
Need for referral.........................................................................................................................7
PART C: CARE PLAN.................................................................................................................7
Medical intervention..................................................................................................................7
Psychosocial intervention..........................................................................................................8
Nursing intervention..................................................................................................................8

ANDY’S CASE STUDY 3
PART A: HISTORY
Andy was a 21-year-old gentleman who lived with his roommates in college at that time.
He had been referred to the psychiatrist by his doctor since he had shown signs of mental illness.
The patient claimed that a device had been implanted in his body by his roommates who
allegedly were working for M15. He further states that he realized this when he went home and
found out that they had moved the TV to the other side of the room. He asserted that a new
lecturer in the campus that worked for MI5 incited his housemates to turn up against him. He
had not experienced any mental condition before, and he claimed to be in good health. Andy was
not under any medication and had not experienced any scandals with the police before. His
family was not aware of what he was going through, however, he tried to explain to his mother
but she failed to believe him. The patient was under drug influence since he told the psychiatrist
that he took small amounts of alcohol, smoked cannabis and took a bit of speed. He also
disclosed that he felt safe at his parents’ house, and claimed that he was in the hospital to avoid
his mother from getting worried.
PART B: MENTAL STATE EXAMINATION
Appearance
Throughout the interview, Andy appeared to be distressed and frowned. He sat inclining
towards the front and was quite insecure since he kept turning his head. He was also very restless
and failed to maintain eye contact with the psychiatrist.
Behavior
He generally had a disorganized behavior and a very isolative behavior, since he stayed in
his room most of the time and only left when his housemates went to buy food. He was also very
insecure around his roommates.