Adult Mental Health Services Consumer Assessment Report

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Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN: 8675309
Family Name: Leroy James Smith
Given Name(s): Leroy
Address: 11 Salisbury Lane, Ipswich,
QLD, 4306
Date of Birth: 25th December 1983
MENTAL STATE EXAMINATION
General
appearance
 The posture is erect and well seated in chair.
 The patient has good well-maintained hygiene and clothes
 He shows cooperation while assessment
 He avoids any sort of eye contact with the therapist
 No signs of self-harm or suicide is identified
 Patient has normal built and body type
Behaviour
 He shows cooperative and appropriate behaviour
 No signs of violent behaviour identified
 Shows certain level of agitation and restlessness
 Aggressive behaviour is not identified
 Answers the questions appropriately and well
 Follows respectful behaviour towards the therapist
Speech
 Speech is fluent and rapid
 Continuous and spontaneous speech is identified
 Speech is repetitive and use of disyllables is identified
 Tone and volume is normal
 Confusion during selection of words is seen
Mood and
Affect
 On assessment his mood is reported to be energetic, happy
and elated
 He shows agitation, irritability and some levels of
anxiousness
 Affect is restricted and intensity of affect is blunt
Thought
process
 He shows continuous and linear fashion of thinking
 The process of thinking includes relevant answers for the
questions
 The thought process is somewhat vague and has some
amount of confusion
 Delusional thinking is identified
Thought
 Content includes relevant information for the questions
asked with lot of irrelevant and repetitive information
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content associated
 The content is also including some delusional ideas
 No signs of abnormal sensations or idealization present
Perception
 No perception of abnormal sensations in surrounding
 No hallucination present
 No sense of derealisation seen
 No depersonalization identified
Cognition
 Well oriented to time, place and person
 Good levels of consciousness and attentiveness
 Moderate intelligence and memory present
Judgment &
Insight
 Moderate judgment present
 Poor in-sight with low awareness of own mental health
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SYMPTOM INTERVENTIONS
Irritation
Intervention 1
Use of antianxiety drugs- antianxiety drugs are highly beneficial in
reducing the effects of irritation and anxiety caused by different triggers
in individual’s life (Balasubramaniam et al., 2019).
Intervention 2
Behaviour management therapy- Use of ICP or CBT in behaviour
management of the individual helps reducing the irritability and low
tolerance of the individual (Sukhodolsky et al., 2016).
Aggression
Intervention 1
Use of mood-stabilizers- these drugs are helpful in stabilizing the mood
by acting on the neurotransmitters in brain and reducing anger
(Newman., 2018).
Intervention 2
Anger management through relaxation exercises- exercises and
meditation helps in reducing anger and is widely used for anger
management (Meichenbaum., 2017).
Delusion
Intervention 1
Use of antidepressants- pharmacological intervention cause changes in
brain neurotransmission that causes reduced delusional thoughts and
provides a linear thought process (Murri et al., 2017).
Intervention 2
Cognitive behaviour therapy- use of psychotherapy and behaviour
modification through CBT enables the individual to have better in-sight
towards change (Garland et al., 2016).
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Nursing Report
Mental State Examination is the tool that helps in assessment of the individual’s
mental state and wellbeing. The current case is of a 30 years old male patient Leroy,
who is presented with the history of delusional thoughts and mood swings. He was
found eligible for mental state examination and assessment for associated risks and
this report is the summarization of the findings of the assessment results. Leroy lost
his job six months back and is being suffering from depressed mood and problematic
drug abuse since then. His parents reported his violent and aggressive behaviour at
home and also reported that he has issues with sleep and does not take his meals
properly.
The MSE was done for Leroy and the therapist found that-
He has normal appearance with normal built but was wearing loose clothes that
indicated recent weight loss.
He shows cooperative behaviour with limited expressions and also indicated no
signs of aggression or violence
He was seen to have anxious, agitated and restless behaviour during the session
His mood was seen to be energetic yet restless and elated and the range of affect
was restricted with blunt intensity
The perceptions shows no abnormality with no signs of hallucination or derealisation
Thought process is linear and continuous but content includes delusional thinking
He shows well orientation with surrounding and cognition
The risks for suicide and self-harm are not high but the risk associated with violence
and aggressive behaviour were perceived to be high
He shows no risks towards vulnerability of harm but he can be discriminated or
abused
He was also identified to have associated risk of poor health due to enhanced drug
abuse and issues with treatment adherence
The overall evaluation suggested risks and symptoms that could further deteriorate
his health and wellbeing and should be addressed using appropriate nursing
interventions.
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REFERENCES
Balasubramaniam, M., Joshi, P., Alag, P., Gupta, S., Maher, S., Tampi, D., ... &
Tampi, R. (2019). ANTIDEPRESSANTS FOR ANXIETY DISORDERS IN LATE-
LIFE: A SYSTEMATIC REVIEW. The American Journal of Geriatric Psychiatry,
27(3), S125.
Garland, E. L., Roberts-Lewis, A., Tronnier, C. D., Graves, R., & Kelley, K. (2016).
Mindfulness-oriented recovery enhancement versus CBT for co-occurring substance
dependence, traumatic stress, and psychiatric disorders: proximal outcomes from a
pragmatic randomized trial. Behaviour Research and Therapy, 77, 7-16.
Meichenbaum, D. (2017). Anger management. The Evolution of Cognitive Behavior
Therapy: A Personal and Professional Journey with Don Meichenbaum, 125.
Murri, M. B., Nerozzi, E., Padula, N., Tacconi, C., Coni, A., Chiari, L., ... & Neviani, F.
(2017). Late life depression, postural instability and dyspnea: The He. siod study
(Hexameter study in older depressed). European Psychiatry, 41, S646.
Newman, W. J. (2018). Mood Stabilizers, Anticonvulsants, and Anti-agitants.
In Clinical Psychopharmacology for Neurologists (pp. 201-211). Springer, Cham.
Sukhodolsky, D. G., Smith, S. D., McCauley, S. A., Ibrahim, K., & Piasecka, J. B.
(2016). Behavioral interventions for anger, irritability, and aggression in children and
adolescents. Journal of child and adolescent psychopharmacology, 26(1), 58-64.
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