Mental State Examination Assessment Report, September 2019

This report presents a mental state examination of a 35-year-old Caucasian male named Leroy, who was referred to a psychologist due to recent behavioral changes. The report details Leroy's situation, including separation from his partner, job loss, and conflicts with his parents. It highlights his history of a manic episode, refusal of follow-up services, and current symptoms such as mood swings, agitation, sleep problems, and racing thoughts. The assessment reveals signs of a manic disorder, including disorganized thought, psychomotor agitation, and incoherent speech. The report recommends specific treatments for tremor, insomnia, and racing thoughts, including medication and cognitive behavioral therapy. The report also includes the background information, assessment findings, and recommendations for the patient's care.

Running head: REPORT
Documenting patient information
Name of the Student
Name of the University
Author Note

1REPORT
PATIENT DOCUMENTATION
Identification- Leroy, aged 35 years, Caucasian male, referred to psychologist at the
request of his parents.
Situation- He has been separated from his partner since six months, lost his job and is
currently unemployed and lives with parents. He has arguments with father, and also reports
sudden mood swings from happy and excited state to threatening and abusive state. He has
stopped taking medications, frequently becomes agitated. He suffers from sleeping problems
and has not slept for more than four hours recently. In addition, he also appears busy with
business ideas, has poor eating pattern, and does not eat with family.
Background- Previously treated six months ago at the local mental health service for
manic episode, refused follow-up service.
Assessment- Suffers from manic disorder. Appears more than his chronological age
and demonstrates a euphoric mood. Has racing thoughts and flight of ideas. Speech is
incoherent, repetitive, diverges from one topic to another, and lacks rhythm. Thought is
disorganised. Continuously reports wringing of hands, psychomotor agitation, resting tremor,
repetitive movements, and places hands on head. Fails to maintain direct eye contact and does
not report signs of any hallucination or delusion. Does not have suicidal thoughts, however,
suffers from insomnia. Considers himself to be in possession of extraordinary business talent.
Medications had been last consumed two weeks earlier and he states that since he has
improved, there is no need to continue the medications any more.
Recommendations- Three issues that need immediate treatment are tremor, insomnia
and racing thoughts. For resting tremor, administer 40 mg Inderal, the β-adrenergic receptor
antagonist (twice daily) and 150 mg Primidone, the phenobarbital structural analogue (daily).
For insomnia, administer 1 mg Lunesta daily that will act in the form of a sedative hypnotic,
and subject him to cognitive behavioural therapy. For racing thoughts, help him perform
mindfulness based meditation. Also provide assistance to perform deep breathing exercises.