Mental Status Examination and Care Plan for a Patient with Auditory Hallucinations

Activity 1 :Mental status examination: modelled from NSW HEALTH documents
APPEARANCE
Mr Tan, is 30 years old male Asian look with skinny
Casual bright clothes inappropriate with the weather, wearing two layers of cloths.
Unshaven and clothing appeared bright.
Appeared younger then the stated age
Long black hair and un groomed hair
Folding arms and scratching left side of chick repeatedly while having a conversation,
slightly anxious at the start of the interview.
Poor eye contact with the interviewer few times during the interview.
BEHAVIOUR
Co-operative with the nurse but partially engaged in conversation because Dimitrie asked the
assessor to repeat the question few times to repeat the question and which proven that he was
pre- occupied.
Slightly agitated and restless by demonstrating fidgety hands and scratching chicks
repeatedly at the beginning of the interview.
During his course of interaction with the nurse he looked pre-occupied and had his hands
folded close to his body.
Willing to shake hand but firmly
Psychomotor retardation, Reduced body language.
AFFECT
Dimitrieemotional state appeared euthymic during his conversation with the nurse.
There was a blunt look on his face and seemed indifferent of showing active participation in
the interview.
Restricted in speech as well as emotional expression because he didn’t show much interest
even while he was explaining about the things which interest him much.
Dimitrie showed Inner irritability because he has unable to finish his novel writing which he
had started while in high school. He was agitated with this topic and started mumbling.
Showed little bit flat, subdued affect however he provides appropriate responsiveness
throughout the interview.
MOOD

Dimitrie stated that he felt uncomfortable with the hearing voices and them seems scary for
him.
Dimitrie seems to apathetic because when the nurse asked him about his interest he had a
long pause and was not able give clear answer about his interest however he has only one
thing to do that is writing.
Dimitrie also claimed that the voices interfere him in his writing novel which makes him
frustrated.
SPEECH
Slow & ordinary speech; no obvious speech impediments; taciturn; repetitive.
Flow of speech: hesitant, long pauses mid-sentence, forgetful, emotional.
Soft volume, appropriately animated when in discussion of particular topics such as friends
and his mum.
Mumbled once when nurse asked if he is a writer.
Tone of speech: monotonous; scant.
Long intermittent breaks were applied by him during his speech (poverty of speech)
THOUGHT FORM
Evidence of thought blocking, taking a longer time to respond to questions, poverty of
thoughts.
Nil Thought delusions because Damitrie believes that no one can put voices in his head.
THOUGHT CONTENT
Denies thought of suicide but does not rule it out in the future
He denies thoughts of wanting to harm others but does not rule out in future because he stated
to nurse that if someone attack him or if he is in danger then he will defend himself.
He is experiencing auditory hallucinations, as he speaks of hearing voices criticizing him.
The evidence of Dimitriesaying “shut up“to the voices in the video also proven that the
voices was interrupting him.
Nil delusions:Damitrie stated to nurse that no one can put voices in his head.

PERCEPTION
Auditory hallucinations: Damitrie stating he hears voices and in particular that he can hear
voicescriticizing him and saying stupid things. Voice also interrupting him while having
conversation with the nurse. Voices was telling him that “his maths sucks” when he was
trying to count the numbers.
COGNITION & INTELLECTUAL FUNCTIONING
Alert and oriented.at time of interview. Dimitrie was able to recall the date and month and
year and the place. Generally, Dimitra was able to follow the interview process.
The evidence of unfinished writing creative novel also proven that Dimitrie is lacking
intelligence.
Lack of concentration as Damitrie was only able to count twice when the nurse asked him to
count downwards from 100 with subtracting 7. He was not able to tell any other friends name
when the nurse mentioned about his friends, Either he did not want to answer or cannot
recall. Further assessment required such as MMS / RUDAS.
INSIGHT & JUDGEMENT
However, Damitrie stated in the conversation that hebelieves that he has illness, but he was
brought in hospital by his friend Cheryl which proves that he has some absent degree of
awareness of his treatment. He also stated that he will continue writing his novel once he
stopped hearing voices. He knew that skipping medication can make him worst, so he agrees
to continue with medication.Later in the conversation, hedidn’t show interest in staying
hospital, he was not sure how bad is his condition is and agreeto stay in hospital if required.
Thus,Damitriehas some insight present of his illness.
(15 marks)
Risk factors Identify 4 ( 5 marks)
1.Risk of harm to others or
2.either self-harm or AuditoryCommand Hallucination
3.Social isolation/ lack of role – unemployment and financial difficulties
4.Current medication withdrawal