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Patient Details
Patient’s Name (pseudonym)
Agatha
Date of Birth (years & months or mother’s DOB or Estimated)
1996 April
Gender
Female
Developmental Level (age and development – consider any implications for the interview engagement)
22 and pregnant
Known or suspected risks (implications for interview)
Known risk
Capacity to consent (please explain)
The patient was not in her complete sense to sign the consent before conducting the interview. Hence, it
was required by the healthcare provider to include her family member and consider them to sign the
consent on behalf of the patient as she was suffering from schizophrenia and was mentally unfit.
Name of parent, carer or other present (pseudonym)
Rose was the mother of Agatha
Reason and time for the interview explained
No, the reason and time of the interview was not explained
Sources of stated information
Community members were the source of the information
Allergies
No such allergies were noted
Alerts (risks)
The patient had a delusion that Antipsychotics affected her baby development and growth.
Diagnosis (if known)
The patient was managed well using Aripiprazole
Presenting problem/s
The primary concern of the patient was her schizophrenia condition ad bad mental health condition.
Cultural sensitivity considerations (see module)
The identity of the patient’s cultural background was highlighted that would help the healthcare provider to
understand the prospective of the patient and what knowledge the patient has regarding their cultural
explanation of mental illness.

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Assessment 2 – Case Formulation and Summary

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