Detailed Case Study: Mental Health Assessment Form for Mr. Riley

This case study presents a comprehensive mental health assessment of Mr. Riley, conducted by Dr. Beddi, highlighting Mr. Riley's presenting problem of psychosis, where he confuses virtual reality, experiencing abnormal ideation related to cancer cures and anxiety stemming from his work as a mechanic. The assessment reveals symptoms such as hallucinations, delusions, and preoccupation, indicating a detachment from reality. There's no clear evidence of substance abuse or external influences, but contacting Mr. Riley's GP is recommended for additional context. The case study also covers medical and psychiatric history, personal history showing poor social development, and a mental state assessment noting suspicious behavior, psychomotor retardation, and impaired cognition. The risk screen identifies vulnerabilities related to suicide and aggression, emphasizing the need for cognitive behavioral therapy and antipsychotic medication as part of the management plan. Desklib provides access to similar solved assignments and study resources for students.

Comprehensive Mental Health Assessment Form
Clinician: Dr. Beddi Place: Program:
Date: Time:
Precipitants Presenting Problem (client’s perception of issues)
History of current episode &
treatment
Change in behaviour
Signs and symptoms:
•Hallucinations
•Abnormal Ideation
•Preoccupations
•Suicidal Ideation
•Aggressive
•Homicidal thoughts
•Anxiety states
•Mood disturbance
•Sleep
•Appetite
•Substance abuse
Other disability
IDS/Physical
Demographics
In this, Mr. Riley face the issue which is related with the psychosis
where he used to think that God is talking to him. It is clear that he
is facing the issue of psychosis. Additionally, it is also analysed that
he completely confuses within the virtual and reality. Therefore,
the major symptom which is analysed within the Mr. Riley is
abnormal ideation which is well related with the issue of cancer
where he used to write about the cure of cancer which is
completely and abnormal ideation which may show the major
symptoms which is well related with the issue of mental disease.
Mr. Riley also show the symptoms which is well related with the
anxiety due to their work experience where he just a mechanic and
at the initial he is used to demand for the food which is clear
indication of appetite. There is any accurate sign and symptom of
substance use and any more. The stress which is well related with
the Mr. Riley is preoccupation aspect which may show the
hindrance in the condition of mental illness which is determined as
psychosis.
Collateral History
History from sources external to
the person
There is no any history which is well related with the external to
the person. But as per the analysis of the case study, it is well
analysed that the issue is usually well related with the elongation
of the virtual aspect that is show by Mr. Riley who told Dr. Beddi to
call him John. Therefore, Mr. Riley living in such situation which
may render the condition of the mental health. In such situation,
the context which is helpful to provide the external information
regarding the patient is important but as per the reference from
his GP. Once contacted to the GP in order to analyse the what
circumstance that he shares with the GP and what situation that
he come to take the medication or management which may
support the psychiatrist to understand the issue of Mr. Riley.
1
Name: Signature: Designation: Date:

Medical History and Current Medications
Major Illnesses
Surgical Interventions
Current medical health
the major illness which is analysed as per the case study that the
Mr. Riley completely confuse between the virtual and reality.
Therefore, he called themselves John in the front of Mr. Beddi
and talking about some of the paper which is associated with the
cure of cancer. The major illness which is well analyse within the
case study of Mr. Riley is that he is facing the issue of psychosis.
There is any surgical intervention is analysed or evaluated as per
the case study. In addition, Mr. Riley was a car mechanic and due
to the longer period of stress and anxiety and show the aspect
which may cause the complication with the mental health and
currently he is advance psychosis where is completely forget the
reality and living on their own world which require strictly
intervention that may support the patient to overcome from such
issue.
Psychiatric History / MHA Status
History of psychiatric disorders
History of compulsory or voluntary
admission to services
There is no psychiatric history which is well presented in the case
of Mr. Riley.
Family History
Includes family history of mental
illness, quality of relationships,
current family issues)
As per the analysis of the case study, there is no any clue which is
analyse which indicate that Mr. Riley face the issue of family
history of psychosis or any kind of mental illness.
2
Name: Signature: Designation: Date:

Genogram
Genogram Key
Male
Female
Unknown
Married
Defacto
Separated
Divorce
Adoption
Death
the link which is not prominent within the case of Mr. Riley. In
addition, he only ssfaces the issue of psychosis. ss
Personal History
Milestones
School
Academic performance
Social development
Friends at school
Childhood interests
Hobbies
Current support network
Psychosexual development
Significant intimate relationships
Cultural Issues
Reason for migration
Connection with community
Recreational interests
Capacity for independent living
The personal history of the Mr. Riley is usually associated with the
poor social development which is analyse when the
communication is being held between Dr. Beddi and Riley where
Riley shows some kind of fun behaviour which show the proper
poor aspect of social develop or the issue of contrast that show the
psychosis. In addition, the Mr. Riley does not have the proper
capacity whichss is well related with the independent living.
3
Name: Signature: Designation: Date:

Mental State Assessment
Appearance
•Physical
•Dress
•Grooming
•Personal hygiene
Behaviour
•Guarded
•Suspicious
•Distracted
•Psychomotor retardation
•Compulsions
•Panic attacks
•Catatonic behavior
•Eye contact
•Mannerisms
•Degree cooperation
•Rapport
•Gait
Appearance and behaviour:
Physically fit, dressed, less groomed and poor personal hygiene.
The behaviour is suspicious, distracted, less eyes contact, less
mannerism and psychomotor retardation is also analysed.
Mood
•Sustained emotional state
•What client describes
Affect
•Expressed emotion
•Congruence with stated mood
Affect and mood
Mr. Riley have simple mood where he laugh and show their
emotion in term of empathy.
Speech
•Rate, volume, tone
•Coherence
•Spontaneity
•Repetition
Speech:
Repetition
Rate volume and tone.
4
Name: Signature: Designation: Date:

Thought form
•Flight of ideas
•Loosening of association
•Circumstantiality
•Confabulation
•Incoherence
•Poverty of thought
•Neologisms
•Perserverations
•Echolalia
•Clanging
• Logical, flowing, linear
Thought form:
Fight of ideas, confabulation.
Neologism.
Poverty of thought.
Clanging.
Thought content
•Overvalued ideas
•Illogical thinking
•Ideas of reference
•Paranoid ideation
•Thought withdrawal
•Thought insertion
•Delusions
•Anhedonia
•Homicidal/suicidal
•Hopes, dreams, strengths, skills
Thought content:
Overvalues ideas.
Ideas of reference.
Delusion.
Though and social withdrawal.
Disorders of perception
•Illusions
•Hallucinations
•Derealisation, depersonalisation
Perceptions:
Illusion.
Hallucination.
Orientation, Cognition &
Sensorium
•Orientation to time, place and
person
•Cognition refers to ability to
recognise and manipulate
information
•Sensorium refers to ability to pay
attention and focus
Orientation:
Poor
Cognition:
Poor
Sensorium: lack of focus and ability to concentration on things.
Memory Long term: poor
5
Name: Signature: Designation: Date:

•Capacity to recall information
Short term: for the sometime.
Judgment
•Ability to act safely & understand
consequences of actions
Level of insight
•Perception of current situation
Judgement: not justified with the conversation of Mr. Riley
Insight:
Doesn’t matter for Mr. Riley.
Drug and Alcohol Screen
Substance Past use Current
use
Quantity Frequency Route Age
first
use
Last
used
Depressants
Benzos
Codeine
Morphine
Cannabis
Methadone
Heroin
Unknow
n
Stimulants Meth (ICE)
Cocaine
Ecstasy
Unknow
n
Hallucinogens LSD
Mushrooms
Inhalants
GHB
Unknow
n
Alcohol Beer
Spirits
Wine
Unknow
n
Previous withdrawal attempts
Not recognised
Interaction between substances and symptoms
Not recognised
Function of use
6
Name: Signature: Designation: Date:

What the client thinks is good about use Unknown
Level of concern over use Unknown
Client’s perception of effects of use Hallucination and no clue regarding the effect of psychosis.
What would client like to do about use Unknown
Management plan
 Provide proper medication which is related with the psychosis such as antipsychotic drug.
 Use cognitive behavioural therapy as the treatment for the psychosis.
RISK SCREEN
STATIC BACKGROUND CURRENT (DYNAMIC)
Suicide Y N U Suicide Y N U Comments
Previous Attempts ✔ Expressing ideation ✔
Family history ✔ Plan/intent ✔
Major psych. Diagnosis ✔ Highly distressed ✔
Serious medical condition ✔ Hopeless ✔
Separated/divorced ✔ Substance abuse ✔
Loss of job/retired/role
loss
✔ Recent life event ✔
Lack of resources
Self-harm Y N U Self-harm Y N U
History of self-harm ✔ Actual or thoughts ✔
Y N U Y N U
Aggression Aggression
Previous violence ✔ Expressing intent ✔
Previous use of weapons ✔ Access to means ✔
Male ✔ Paranoid ✔
Criminal history ✔ Command hall. ✔
Previous ideation ✔ Anger, agitation ✔
Childhood
maladjustment
✔ Recent violence ✔
Role instability ✔ Substance use ✔
History of drugs/alcohol ✔ Reduced control ✔
Vulnerability Y N U Vulnerability Y N U
Intellectual disability ✔ Cognitive deficit ✔
Previous mental
illness
✔ Self-neglect ✔
Absconding ✔ Non-compliant ✔
Sexual vulnerability ✔ Delusional ✔
Predatory behaviours ✔ Intrusive ✔
Serious medical condition ✔ Physical illness
Poor memory &/
orientation
✔
Level of Risk L M H Disinhibition ✔
7
Name: Signature: Designation: Date:

Suicide ✔ Disorganization ✔
Self-harm ✔ Preoccupation with
hospital
✔
Aggression ✔ Intent on leaving ✔
Vulnerability ✔ Absconding risk ✔
Key: Y = Yes; N = No; U = Unknown
PROTECTIVE FACTORS (factors that reduce the likelihood of negative outcome, e.g. supports)
In addition, Mr. Riley require proper support and care for their medical condition. Therefore, the
medication is used to show the aspect which is well related with the drug.
MANAGEMENT PLAN
 Use cognitive behavioural therapy.
 Use antipsychotic drug and medication.
8
Name: Signature: Designation: Date: