Mental State Examination Report: Analysis of Mr. Jones' Mental State

This report presents a detailed Mental State Examination of a patient identified as Mr. Jones, who is experiencing symptoms of depression and anxiety following a separation from his wife. The examination covers various aspects of his mental state, including appearance, behavior, communication, affect, perceptions, cognition, insight, and judgment. The report details Mr. Jones's social withdrawal, lack of motivation, and increased alcohol consumption. It includes an ISBAR clinical handover, background information, a diagnosis of acute depression and anxiety, and recommendations for treatment, such as cognitive behavioral therapy (CBT) and antidepressant medications. The assessment highlights the patient's avoidance of eye contact, psychomotor retardation, blank facial expressions, and difficulties with memory recall. The report also addresses potential risk issues like lack of concentration, sleep problems, and possible liver issues related to alcohol consumption, providing a comprehensive overview of Mr. Jones's condition and suggesting appropriate interventions.

0Running head: MENTAL STATE EXAMINATION
Mental State Examination
Name of the student
Name of the University
Author note

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MENTAL STATE EXAMINATION
ISBAR Clinical Handover
Identify the client:
NAME: Mr. Jones
Age: Late 50’s
Gender: Male
D.O.B
Situation:
Mr. Jones had been abandoned by his wife 3 months ago, since then he is suffering from depressions and anxiety. He is showing social
widrawal. It has also affected his job. Most of the time he sits idle, lies around in bed and watches T.V. He had also increased his alcohol
consumption.
 He is close to his mother.
 He has 2 daughters who are married and does not have much contact with them.
 His energy levels are down and he doesn’t get motivation to do thing s or work.
 The patient is incessantly avoiding eye- contact and is found to rub his forehead, probably to avoid eye contact.
 He gets often irritated and agitated by people which have led to social withdrawal.
 No violence has been reported on his part.
 No visual changes or change in food test has been recorded.
 Has reported to feel negativity surrounding him all the time.
 He is not addicted to any sort of drugs.
 He reported that he lacks confidence and self motivation.
Background:
 Diagnosis: Mr. Jones is suffering from acute depression and anxiety.
 Reason of being presented in to the hospital: The patient is suffering from depression and has withdrawed himself from the society
and work. His alcohol consumption has decreased and he has been showing signs of some sorts of mental disorders. His mother on
being worried about his mental health has recommended him to visit the hospital.
 Medications: Takes medicines for high B.P.
 Allergies: no allergies have been reported.
 Primary carer: Mother
 Accommodation: Lives with his mom.
Assessment:
Summary of the patient’s current condition: Mr. Jones had been suffering from acute depression and anxiety, since he and his wife has
separated. Clinical signs: Avoids eye contact, does not want to work or talk much. Mr. Jones had discontinued from work as he lacks self
motivation and concentration.

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MENTAL STATE EXAMINATION
Carer engaged with treatment: Mr.Jones’ mother.
Risks to self and others: No risks to self and others have been recognised
Recommendations:
To treat Mr. Jones via vigorous counselling therapies like cognitive behavioural therapy (CBT), Interpersonal therapy. Several
psychotherapies are there that can reduce depression. Group therapies are recommended to bring him back to the social life antidepressant
medications like selective serotonin reuptake inhibitors (SSRI ) has to be given.

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MENTAL STATE EXAMINATION
Mental State Examination
Appearance:
The general appearance of Mr.Jone seems normal. He might be in his late 50s. He has no distinguishing marks or tattoos in any of
his exposed areas of the skin. He was dressed in a casual attire with a round neck graphic T-shirt and a pair of track pants. Overall
his physical appearance and dressing scene seems normal. He wore a normal analogue watch in his left hand and has a big golden
ring in his ring figure (might be his engagement ring). During the conversation he did not have any firm vocation indicators. He
normally spent his days via watching TV in most of the time. However, he state that after coming from work, he watch “tele” but
exact vocation is not mentioned. However, I feel that he is now jobless and does nothing apart from watching television.
Behaviour:
His sitting posture seems fine. He did not showcase any grimace or tremors mannerisms during the entire conversation and
was polite.
His he was not at all overactive but on contrary it can be said that he is underactive and was taking a whole lot of time to
answer some basic question like “Do you have any children”. In response to this particular question took more than usual time, he
put pressure in his brain to think and recollect and then answered. However, there was no Disorganised Stereotypical Graceful
Echopraxia Apraxia. The patient didnot repeat involuntary repeat or imitate the interviewer mannerisms.
He showed visible indication for psychomotor retardation. He showed slowing down of thought, took more than extra time in
answering simple yet basic answers and refused to make eye contact. Whenever he tired to show eye contact he brushed his hands
over his forehead thus preventing direct contact of eyes.
He showed blank facial expression. He most showed a dreamy depression. After watching he interview, I feel that he was
extremely sleepy and his facial expression was completely blank or rather say he was expression less. He was neither tensed nor
worried and there are no indications from his side to project himself have happy, frightened or angry. However when asked about his
wife and his divorce, he looked at bit sad.
He was not ecstatic laughing smiling or suspicious
He was a bit indifferent when asked about her children. He told that he was two daughters and both of them are married and
he has limited contact with them. He was not at all frank however, he tried to answer the entire question that he was being asked and
there was no spontaneous reply, he only answered what he was asked and nothing more than that. He was a bit dramatic as he
repeated few words and fumbled over few sentences especially when asked about his drinking habits. He was not irritable or afraid.
He was not seductive exhibitionistic, impulsive. He was rather embarrassed about his separation with his wife.
Conversation/Communication/Speech:
The client was soft and there was not echolalia or meaningless repetition of another person’s spoken words.
His communication flow was even, however, he took time to recollect his thought, sometimes his voice became inaudible and
dissolved few words while making a statement.
The client conversation contains no references to disordered thoughts or ideas of reference but he supported the interviewer
statement when he told him (Mr.Jone) that he might be suffering from depression. There are certain thought blocking too, especially
when asked about his drinking habits.
Affect/Mood:

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MENTAL STATE EXAMINATION
The feeling of state of Mr, Jones as inferred by me on the basis of the patients statements appearance and behaviour is, he is
suffering from depression after his separation from his wife. There is an indication of shallowness in his thought process but there
was no signs of flattering. There are indications of inappropriate affect between in the thought content. During the conversation he is
getting lost in thoughts. Taking extra time than normal to think and reply. He rate of word delivery was also slow and his voice was
extremely soft. There are significant indications of fluctuating affect. He was aloof with his daughters and he showed no concern for
them. He was apathetic too and was composed within his thoughts.
The patient’s subjective statement showed he is in depression and he feeling sad most of the time.
Perceptions:
He has no misperceptions of external stimuli and shows no sign of hallucinations or flase sensory impression without any external
basis.
Cognition (Including thoughts, memory and orientation):
There were no significant signs of delusions. But he nurture a mixed false believe that his wife might come ack to him (which
might not be the scenario in reality).He also provided unnecessary detail when asked about his drinking habits.
He has a poor memory recall as he took time in answering the question, “Do you have any children?”. He however has recent
past recall as he told that he was under medication for hypertension. The interviewer however did not conducted any test for recent
past recall.
There was orientation in his thoughts but not that pronounced. When asked about the current address of his daughters he
mentioned that one lived overseas but failed to mention the exact name of the place.
Insight & Judgement:
Insight: The patient did not recognise the significance of his symptoms but he is aware that he is depressed. His appreciation
is his illness is affecting his sleep at night and in order to kill time he watch television and refuse to set outside the house. He was
able he explain his reason to visit in the hospital He told that he was not having a proper sleep for the past few days (Friday,
Saturday, Sunday) and was mostly watching television and so his mother brought him to the hospital.
Judgement: He is able to manage his own finance.
Rapport:
The therapeutic relationship has been established considerably. Mr.Jone is showing co-oprationg during his interaction with the male
therapist.
Risk Issues (if identified):
 Lack of concentration
 Lack of sleep
 Weight loss (as he needs to cook his own food)
 Helplessness (as he has no one to look after, only his mother visit his once/twice a week)
 Liver problems (due to extra intake of alcohol)

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MENTAL STATE EXAMINATION