NUR2200 - Mental State Examination: Leroy's Case Report

This report presents a Mental State Examination (MSE) of a 35-year-old Caucasian male named Leroy, conducted in the context of adult mental health services. The MSE evaluates various aspects of Leroy's mental state, including his general appearance, behavior, speech, mood, affect, thought processes, thought content, perception, cognition, and judgment & insight. Leroy's appearance was noted as not matching his chronological age, with manic indicators in his dress. His behavior included a slumped posture, lack of eye contact, and hand tremors. His speech was rapid and disorganized, with signs of palilalia. His mood was euphoric, and his thought process was characterized by racing thoughts and incoherence. Despite no reported hallucinations or delusions, he displayed overconfidence. The report also lists interventions for symptoms like tremor, insomnia, and racing thoughts, including medications and therapies. The report is based on the assignment brief which requires observation of client behavior and accurate documentation of observations as findings on the Mental Status Examination (MSE) and risk screening tool in the correct assessment categories using the correct terminology.

Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN:
Family Name:
Given Name(s):
Address:
Date of Birth:
MENTAL STATE EXAMINATION
General
appearance
Leroy was aged 35 years and was a Caucasian male.
However, his chronological age was not in accordance to his
appearance and he appeared more than 50 years. his dress
was colourful and consisted of green trousers, orange cap
and blue shirt, indicating mania. He was tidy and not
unkempt. There were no signs of any harm caused due to
alcohol or drug abuse. However, on comparing his
appearance to his last visit, it appeared that he had lost
considerable body weigyht due to lack of adequate nutrition
and eating problems.
Behaviour
He did not sit straight all throughout the interview and
maintained a dropping posture. He remained slouched on the
chair and his posture was kyphotic. This suggests that he
might be suffering from spine curvature. He failed to maintain
direct eye contact during the interview and looked at the floor
all throughout, while exchanging short glances with the
interviewer. Tremor of hands was a common sign. In
addition, he also continuously put his hands on his head on
being inquired about his health. Psychomotor agitation was
also noticed.
Speech
Cluterring of speech was quite evident from his responses.
He spoke rapid sentences and words and could not maintain
a syntax or rthythm in his speech. His thoughts were
disorganised during the initial stages and gradually helped
him gain confidence, while answering the questions during
the later stages. Palilalia was a prominent sign, manifested
by repetition of phrases and statements.
Mood and
Affect
His mood was euphoric and he remained excited all during
the course of the interview. He laughed on being inquired
about use of drugs, adherence to medications, and
experience of hallucinations or delusions.

Thought
process
His speech was characterised by inappropriate content and
repeatedly diverged from one topic, thereby demonstrating
racing thoughts. Incoherent speech was also observed and
there was a lack of connection between his ideas and the
words used to express them.
Thought
content
His resposnes suggested that he did not ever experience any
kind of hallucination of delusion and stated that harming
himself or any other person was the last thing that he could
ever think about. Thus, there was no suicidal ideation.
However, he considered himself superior in the field of
business, thereby demonstrating empowerment and
overconfidence about self.
Perception
No symptoms of delusion or hallucination were observed.
Cognition
No cognitive assessments were performed. He reported that
the medications had been consumed two weeks ago.
Judgment &
Insight
He considered himself as an extremely busy person, despite
the fact that he was suffering from unemployment. He also
though that since his symptoms had improved, there was no
need of consuming the prescribed medications.

SYMPTOM INTERVENTIONS
Tremor
 40 mg twice daily of Inderal, a β-adrenergic receptor
antagonist (Van Gerpen & Ross, 2015)
 150 mg of Primidone daily, a phenobarbital structural
analogue (Rindone & Mellen, 2018)
Insomnia
 Cognitive behavioural therapy for insomnia (Ballesio et
al., 2018)
 1 mg daily of LUNESTA® (eszopiclone), a sedative
hypnotic (Spierings, McAllister & Bilchik, 2015)
Racing
thoughts
 Mindfulness based meditation (Van Dam et al., 2018)
 Deep breathing exercises (Jerath et al., 2015)
References
Ballesio, A., Aquino, M. R. J. V., Feige, B., Johann, A. F., Kyle, S. D.,
Spiegelhalder, K., ... & Baglioni, C. (2018). The effectiveness of
behavioural and cognitive behavioural therapies for insomnia on
depressive and fatigue symptoms: a systematic review and
network meta-analysis. Sleep Medicine Reviews, 37, 114-129.

Jerath, R., Crawford, M. W., Barnes, V. A., & Harden, K. (2015). Self-
regulation of breathing as a primary treatment for anxiety. Applied
psychophysiology and biofeedback, 40(2), 107-115.
Rindone, J. P., & Mellen, C. K. (2018). Warfarin resistance from
primidone in patient with essential tremor. European journal of
clinical pharmacology, 74(3), 377-378.
Spierings, E. L., McAllister, P. J., & Bilchik, T. R. (2015). Efficacy of
treatment of insomnia in migraineurs with eszopiclone (Lunesta®)
and its effect on total sleep time, headache frequency, and
daytime functioning: A randomized, double-blind, placebo-
controlled, parallel-group, pilot study. CRANIO®, 33(2), 115-121.
Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C.
D., Olendzki, A., ... & Fox, K. C. (2018). Mind the hype: A critical
evaluation and prescriptive agenda for research on mindfulness
and meditation. Perspectives on Psychological Science, 13(1), 36-
61.
Van Gerpen, J. A., & Ross, O. A. (2015). Essential Tremor. In Movement
Disorders (pp. 605-614). Academic Press.