Assessment 2 – Case Formulation and Summary

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Assessment 2 – Case Formulation and Summary
Required Fields – the below are required but not included in the word count
Clinician Name and Classification (undertaking the interview – your name)
Date and Time of Assessment
Context of Assessment (actual location)
Obstetrician or midwife (Pseudonym)
Other clinicians involved in the case
Purpose for Assessment
The primary purpose of this assessment was to evaluate the heath condition of the patient and also monitor
her schizophrenia condition and how well it is managed by the patient as the patient was 4 weeks pregnant.

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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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Family and Social History (HEADSS + VIP)
HEADSS and 4P Framework for Case Formulation
Home
She belonged to the indigenous culture and stayed in out-of-home care
Education / School / Other
She was not much educated and had just completed her primary school
Activities
She was involved in vocational activities
Drugs and Drinking
Yes, she was involved in drugs and drinking but since she was pregnant
Sex and Sexuality
Female
Suicide Risk / Self Harming Behaviours / Risk Taking Behaviours (self / family / peers)
Suicide risk (self-risk) due to bad mental health condition
Vaccination Status
No
Vaccinations Missed (if applicable)
Injuries / Illnesses / Disabilities
She was suffering from Schizophrenia
Plans: hopes and dreams (individual or for unborn or child)
Her dream was to take fullest care of her unborn child who was just 4 weeks old and take care of the child
so that the child can lead a healthy life.