Analysis of Mental State Examination in Consumer Assessment Case Study

This case study presents a mental state examination of a 35-year-old client, detailing observations on the client's appearance, behavior, speech, mood, thought process, and content. The analysis reveals disorganized speech, a euphoric mood, and poor insight and judgment. The report identifies symptoms such as disorganized thoughts, lack of sleep, and tremors. The document then proposes interventions, including writing exercises and mindfulness-based therapy for disorganized thoughts, health literacy and medication for sleep issues, and medication for tremors. References to supporting research studies are also included. This case study provides a comprehensive overview of the client's mental state and offers evidence-based interventions to address identified issues.

Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN:
Family Name:
Given Name(s):
Address:
Date of Birth:
MENTAL STATE EXAMINATION
General
appearance
The case study deals with the 35 year old, client who is
Caucasian in ethnic origin. During the mental state evaluation
interview, the client appeared to be dressed in bright and
vibrant attire that comprised of an orange cap, blue coloured
shirt and green trousers. The appearance of the client could
be mentioned as neat and tidy. However, a few factors that
were unusual included his significant weight loss in
comparison to his last clinical visit. Also, although the client’s
age is mentioned to be equivalent to 35 years, in the video,
the patient appeared to be over 50 years of age. Also, the
client’s excessive weight loss could be attributed to the lack
of proper nutrition.
Behaviour
The client maintained a drooping posture and was not seen
to maintain an erect posture throughout the interview
process. The client’s posture can be defined as kyphotic and
he was seen to be sloughing in his chair. On the basis of the
analysis of the quality of posture, it can be anticipated that
the patient might be suffering from spinal/posture problems.
Further, the client avoided direct eye contact throughout the
interview process and was seen to stare blankly at the floor.
However, on few occasions the client was seen to exchange
a few rapid glances at the interviewer. A few instances of
psychomotor irritation was observed, which included, tremor
movement in his hands and the client placing his hands over
the head on being asked about the quality of his physical
health.
Speech
The quality of speech of the client can be described as
cluttered. The client spoke words and sentences at a fast
pace and no appropriate was evident in the quality of speech.
It appeared that the thoughts of the client were disoriented
and disorganized at the initial stage but somewhat organised
during the final stage of the interview process. In addition to
this, it should also be noted that the quality of speech
included frequent repetition of phrases and sentences.

Mood and
Affect
The mood of the client can be described as ‘euphoric’ during
the entire interview process. The client exhibited unusual and
uncontrolled emotional surge. This can be explained in
reference to the instance where the client was asked
questions about his medication management and experience
of delusions and he laughed in response. This suggests that
the client experienced a euphoric mood throughout.
Thought
process
Upon analysing the quality of the speech it can be mentioned
that the client’s speech was disorganized and incoherent.
The client kept shifting from one topic to another and the
quality of speech was incoherent which was characterised by
racing speech. It can be mentioned that on account of racing
and disorganized thoughts, the client found it difficult to
express his thoughts in a coherent manner.
Thought
content
Upon critically analysing the responses of the patient, it can
be stated that there was no instance of experiencing a
delusion or a hallucination throughout the interview process
as revealed by the client. Also, the client did not mention
about any experience or feeling to cause harm to any person
or cause self-harm which reflects that the client did not
experience any traits of suicidal ideation. However, the
responses of the client suggested that he considered himself
superior to others in terms of business aptitude and business
ideas which appeared to make the client sound
overconfident.
Perception
The analysis of the interview response of the patient did not
reveal any incidence of delusion or hallucinations that was
experienced by the client.
Cognition
The case study did not furnish any evidence in relation to
performing cognitive assessment. Further, the client revealed
that the prescribed medication had been taken prior to 2
weeks.
Judgment &
Insight
Upon analysis of the case scenario, it can be stated that the
client had poor insight and judgement ability. The client was
unemployed but despite the same, he considered himself to
be extremely occupied and believed that his symptoms had
improved and on account of the same, he felt he did not need
to consume his medications.

SYMPTOM INTERVENTIONS
Disorganized
or Racing
Thoughts
Research studies mention that disorganized or racing
thoughts can be appropriately treated with the help of writing
exercises, where in the client is encouraged to note down his
appropriate thoughts before expressing so as to ensure
coherence of speech (Jensen & Clough, 2016). Noting down
the patient’s thoughts can help the patient to maintain
consistency over his thought and expression and exhibit the
same in person. This would prevent irrelevant expression and
jumping from one topic to another and hence would help the
patient align his thoughts in a coherent manner.
In addition to this, as per Gong et al. (2016), administration of
mindfulness based therapeutic intervention such as
meditation has been studied to facilitate positive recovery.
The evidence base suggests that meditation facilitates
improved concentration which helps to promote composure
and as a result the client can experience improved
organization of thoughts and communicate in an effective
manner (Martires & Zeidler, 2015).

Lack of sleep Impart health literacy to patient in relation to adequate food
intake and avoiding the intake of caffeinated beverages,
alcohol, smoking or consumption of heavy meal before bed
time so as to ensure that the patient gets optimal amount of
sleep. Research studies mention that consumption of the
listed food and beverage items often disrupt the normal sleep
pattern (Chaudhary et al., 2016).
Medication administration of prescription sedative hypnotics
or anti-anxiety drugs can help to ensure that the client
achieves optimal amount of sleep. Administration of
Diphenhydramine such as Benadryl are over the counter
available hypnotics which can be prescribed to treat lack of
sleep or insomnia (Sake et al., 2019).
Tremor or
disturbed
neurological
sensation
Administration of anti-Parkinson’s medication on order to
elevate the level of Dopamine within the CNS ( Elble, 2017)
Research studies further mention that the tremors are
generally characterised on account of the mechanism of
action of acetylcholine (Townsend & Morgan, 2017). In order
to prevent the same, administration of anticholinergic
medications can help to appropriately treat tremors as they
help to counter the action of acetylcholine (Townsend &
Morgan, 2017).
References:
Chaudhary, N. S., Grandner, M. A., Jackson, N. J., & Chakravorty, S.
(2016). Caffeine consumption, insomnia, and sleep duration:
Results from a nationally representative sample. Nutrition, 32(11-
12), 1193-1199.
Elble, R. J. (2017). Tremor. In Neuro-geriatrics (pp. 311-326). Springer,
Cham.

Gong, H., Ni, C. X., Liu, Y. Z., Zhang, Y., Su, W. J., Lian, Y. J., ... &
Jiang, C. L. (2016). Mindfulness meditation for insomnia: A meta-
analysis of randomized controlled trials. Journal of Psychosomatic
Research, 89, 1-6.
Jensen, L., & Clough, R. (2016). Assessing and treating the patient with
acute psychotic disorders. Nursing Clinics, 51(2), 185-197.
Martires, J., & Zeidler, M. (2015). The value of mindfulness meditation in
the treatment of insomnia. Current opinion in pulmonary
medicine, 21(6), 547-552.
Sake, F. T. N., Wong, K., Bartlett, D. J., & Saini, B. (2019). Insomnia
management in the Australian primary care setting. Behavioral
sleep medicine, 17(1), 19-30.
Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health
nursing: Concepts of care in evidence-based practice. FA Davis.