Consumer Assessment: Mental State Examination of Leroy James Smith

This report presents a detailed Mental State Examination (MSE) of Leroy James Smith, a 36-year-old male exhibiting symptoms consistent with bipolar I disorder. The assessment covers his general appearance, behavior, speech, mood and affect, thought process, thought content, perception, cognition, and judgment and insight. The report highlights specific symptoms such as mood swings, poor appetite, and insomnia, and provides recommended interventions including Cognitive Behavioral Therapy (CBT), nutritional strategies, and interpersonal and social rhythm therapy. The patient's history includes a previous manic episode, non-adherence to medication, and various psychosocial stressors, including unemployment and relationship issues. The report also includes references to support the interventions and assessment findings, providing a comprehensive overview of the patient's mental state and recommended treatment approaches.

Adult Mental Health Services
Consumer Assessment
Date: Time:
URN:8675309
Family Name: Smith
Given Name(s): Leroy James
Address: 11 Salisbury Lane,
Ipswich, QLD, 4306
Date of Birth: 25th December 1983
MENTAL STATE EXAMINATION
General
appearance
Leroy is 36 years old but he looks like more than 45 years old,
however, he managed to look good but his posture in not confident one,
as he was not making eye contact with the psychiatrist.
Behaviour
His facial expression told that he was lying about his state. His
psychomotor activity increased as he was talking fast. His body
language was not confident enough when he was telling about his
business ideas.
Speech
He was talking repeatedly about his business ideas. His tone was
tremulous. Volume of speech is also little loud when psychiatrist asked
about sleep, diet and medication. He is also having bizarre fluency and
racing thoughts. He also has pressured sppech.
Mood and
Affect
His facial expression changes whenever he asked about diet, sleep, and
medication. He seemed little agitated. But whenever he asked about his
business ideas he seemed interested. But throughout the session he
looked in some hurry.

Thought
process
His thoughts makes no logical sense as he was constantly taking about
strange business ideas. He was repetitively taking about them without
any stimulus.
Thought
content
He was obsessive about his business ideas. Also he felt that people who
watch TV or listening to music are useless. He thought that people who
have nothing to do, watch TV or listen to music. He has very inflated
self image of himself.
Perception
He lives in hallucinations. He had believed that his business ideas are
great and everybody should understand this. He also believed that he is
a very busy person.
Cognition
His orientation is poor as he was not talking on point. His attention and
concentration is not very good too.
Judgment &
Insight
Leroy was not ready to accept that he has problem. He thinks he is fine
and healthy. His problem sloving abilty is very poor. He has distorted
sentiment of thriving and confidence.

Symptom Interventions
Mood swings  Coginive behaviroul theraphy (CBT) for the mood swings and
bipolar issue is customarily used as a subordinate to
pharmacotherapy and incorporates recognizing maladaptive bits
of knowledge and practices that may be checked to calm
recovery and consistent perspective reliability. This kind of
strategy incorporates making sense of how to perceive and
change the instances of thinking that go with the perspective
developments and besides bases on practices that diminish
pressure (Freeman et al., 2015 and Scott).
 Counselling is connected with inside and out increasingly
noticeable clinical ampleness in short‐term passionate
wellbeing results diverged from typical thought, and moreover
gives some extra central focuses in the long‐term. with the help
of educating a couple of sorts regarding human administrations
utilization may be diminished (Webb & Rowse, 2017).
Poor appetite  Nutrition and mental illness or depression are complicatedly
and surely associated, as proposed by the mounting verification
by researchers in neuropsychiatry. A diet rich in carbohydrate
(boost production of serotonin). Eating a gala which is affluent
in sugars triggers the landing of insulin in the body. Insulin
empowers let to glucose into cells where it might be used for
essentialness and simultaneously it triggers the area of
tryptophan to cerebrum. Tryptophan in the mind impacts the
neural connections levels. Use of eating regimens low in sugar
will when all is said in done rush gloom, since the age of
cerebrum synthetics serotonin and tryptophan that advance the
assessment of thriving, is initiated through starch rich

sustenances (Kouidrat, Amad, Lalau & Loas, 2014).
 Intervention with micronutrient like omega-3-fatty acids,
selenium, vitamin. B12 and folate can boost the mood and fight
depression. Studies proved that thiamine can amend coginitive
routine. Meganisium also known to fight depression. Prebiotics
and probiotics can be incorporated to the diet. They both
increased the number of good bacteria in the gut and
significantly reduced the number of bad bacteria, thus improve
the immunity and overall health of an individual. It helps in
keep cortisol levels in check. Nuts, turkey, beans and yogout
can be added to the diet. (Pilgrim, Robinson, Sayer & Roberts,
2015).
Insomnia  Interpersonal and social rhythm treatment makes you make and
keep up a standard rest timetable and logically obvious step by
step plans. It regulates the daily routine and sleep and wake
cycle. It stabalizes biological and social rhythm. This theraphy
can make and bolster solid consistently timetables and
rest/wake cycles. it will Increase aptitudes to reduce the number
and reality of socially based stressors. it will help in learn
capacities affinities and timetables to foresee future loaded with
inclination scenes in this therapy (Castillo et al., 2019).
 Early mediation to fight misery is always valuable. Thought
hint a class of mind-body systems most everything considered
including the orchestrated motivation behind association of
thought. Consideration reduces cortisol age, a weight
influenced hormone that covers the protected structure and can
make you feel enthusiastic uneasy and maddens for no veritable
reason. Thought reduces weight-related conditions, for instance,
uneasiness and bitterness. In thought, the cerebrum and obvious
structure experience radical changes that reason the decrease
and altering development of these conditions (Gangadhar et al.,

2011).

Nursing Report
URN: 8675309
Patient Name: Leroy James Smith
Address: 11 Salisbury Lane, Ipswich, QLD, 4306
DOB: 25th December 1983
Caucasian male, 36 years of Age, living with parents and also unemployed since past 6
month, had break-up, history confirms that he has been suffering from bipolar I disorder or
manic depression (Mania and Depression). 6 months ago treated for manic episode at local
mental health service, refused to follow up further, Not taking medication. He is having
insomnia from past one month (maximum 4 hrs. of sleeping), poor appetite, mood swings,
heightened sense of self importance, racing views and euphoria. Often talking on phone with
strange people about his business ideas. Become loud, abusive and threatened when
questioned about his business ideas.

References
Castillo, E. G., Ijadi-Maghsoodi, R., Shadravan, S., Moore, E., Mensah, M. O., 3rd,
Docherty, M., … Wells, K. B. (2019). Community Interventions to Promote Mental
Health and Social Equity. Current psychiatry reports, 21(5), 35. doi:10.1007/s11920
019-1017-0
Freeman, D., Sheaves, B., Goodwin, G., Yu, L., Harrison, P., & Emsley, R. et al. (2015).
Effects of cognitive behavioural therapy for insomnia on the mental health of
university students: study protocol for a randomized controlled trial. Trials, 16(1).
doi: 10.1186/s13063-015-0756-4
Gangadhar, B., Kalyani, B., Venkatasubramanian, G., Arasappa, R., Rao, N., & Kalmady, S.
et al. (2011). Neurohemodynamic correlates of ′OM′ chanting: A pilot functional
magnetic resonance imaging study. International Journal Of Yoga, 4(1), 3. doi:
10.4103/0973-6131.78171
Kouidrat, Y., Amad, A., Lalau, J., & Loas, G. (2014). Eating Disorders in Schizophrenia:
Implications for Research and Management. Schizophrenia Research And
Treatment, 2014, 1-7. doi: 10.1155/2014/791573
Pilgrim, A. L., Robinson, S. M., Sayer, A. A., & Roberts, H. C. (2015). An overview of
appetite decline in older people. Nursing older people, 27(5), 29–35.
doi:10.7748/nop.27.5.29.e697
Scott, A. J., Webb, T. L., & Rowse, G. (2017). Does improving sleep lead to better mental
health? A protocol for a meta-analytic review of randomised controlled trials. BMJ
open, 7(9), e016873. doi:10.1136/bmjopen-2017-016873