Mental State Examination and Nursing Report for a Patient with Substance Abuse and Sleep Disorder

Student Name: Student Number:
Adult Mental Health Services
CONSUMER ASSESSMENT
Date: 14/09/2018 Time: 1400hrs
URN:
Family name:
Given names: Harry
Date of birth: 01/01/1990
Sex: Male
MENTAL STATE EXAMINATION
General
appearance
- The patient looks little calm and nervous when
asked questions. He is sober and often avoids eye
contact with the doctor
Behavior
- The patient appears shy and afraid of speaking what
is on his mind.
- He exhibits aggressive behavior and detached from
the surrounding environment he is in.
Speech - The speech of the patient is low and requires a lot of
probing for more talking and opening to take place.
Mood and
Affect
- The mood of the patient is quite low and looks bored
and not satisfied with the idea of being brought to
the health facility. He is not willing to talk a lot
despite the doctor probing for much information and
elaboration.
Thought
process
- The patient has negative thoughts of doing harm to
his brother due to what he calls disturbing him.
Thought
content
- The patient has negative thoughts on all his thinking
and sees those disturbing his way of habit as
distracters.
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Student Name: Student Number:
Perception - The patient perceives that he needs to be left alone
and continue being invisible and doing his own
things.
- The hallucination for the patient is real and hampers
how he is doing things and sees that he has a future
with the hallucination.
Cognition
- The patient has an issue in his judgment of issues.
His thinking, remembrance, and problem solving are
quite irrational and lead to harm infliction on others.
He perceives himself as right and talking to
supernatural forces which make him invisible.
Judgment
- The patient is judging events and his actions
wrongly. He sees himself as the one who knows
everything, especially he considers himself as
having reached where he is going and this is
portraying by his decision not to focus in his studies
because he has already secured a future already.
Insight
- The patient has no insight into any issues which he
is facing. He is blackmailed by delusions and
controlled by his thoughts which he claims gives him
powers to do the things he is engaging
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