Simon admits to using speed IV a few times a week in the past three weeks before
his presentation to ED, and smoking cannabis but can’t remember the last time he used it.
Simon states he has been experiencing suicidal thoughts for past of two weeks and he uses
cannabis get rid of the thoughts. His brother suicided eight years ago but no other family
history of suicide. Simon also admitted to not taking his medications for the past two
months and he did not attend his follow-up appointment with his GP two days ago.
His most recent hospitalisation was 6 months ago, and lasted for 6 weeks. During
this admission, Simon was on Form 6A when the consultant psychiatrist granted him
unescorted ground access (UGA) and he absconded from the hospital (AWOL – absent
without leave). He was later brought back to the ward by the police. You note in his file
Simon has one previous charge of assault in 2014, for physically assaulting his neighbours
while unwell. Simon doesn’t work but he is on Disability Pension. He also has a supportive
partner, but they don’t live together.
Questions:
Identify and describe Simon’s mental health symptoms that would be detected through the
Mental State Examination (MSE) presented in the case scenario. You can use the MSE
template to complete the mental state examination (Mental status examination – 500
words).
Select the two most significant presenting risks and describe how you would manage such
risks within the next 24 hours. Your answer needs to be supported with evidence. That is,
your interventions and rationale should be supported by references (Risk identification,
prioritisation and intervention – 600 words).
Case Study on Mental Status Examination
Assessing the behavior and appearance of the patient: he is unkempt, dirty clothing,
he also has many scars on his arms associated with the recent scratching of the arms. His
behavior is a major concern; though he is alert, he shows unusual mannerism, tics and
inattentiveness during history taking which are consistent with abnormal mental function (Mittal
and Walker, 2011). During the assessment he is cooperative, but he is afraid of maintaining eye-
contact.
Orientation to place, time and person of the patient: He is oriented to both location
and person but not oriented to time and situation
MENTAL STATUS EXAMINATION 3
Thought process of the patient: He has no thought block in giving his ideas. He is not
circumstantially when answering, perseveration of words or ideas nor neologisms. He has a
flight of ideas since some stimuli make him tearful during the assessment.
Assessing the thought content of the patient: The patient also has delusions of
persecution since he believes his troubles are caused by neighbors. He has also had suicidal
ideation and pre-occupied with thoughts of neighbors causing harm to him (Lehmann, Pascual-
Marqui, Strik & Koenig, 2010).
Assessing appetite, sleep, and sex: He has a partner who is supportive but they don’t
leave together hence his sexual life may be a concern. No report about her food appetite but he
complains of difficulty in having enough sleep since he claims that neighbor will attack him or
they have associated the itching he experiences while in bed (El-Bilsha, 2010).
Memory assessment of the patient: recent memory is intact since he can remember
using speed IV but a remote memory in questions since he does not remember when last he
smoked cannabis(Krueger and Kramer, 2011).
Assessing the speech of the patient: He is coherent with no incidence of poverty of
expression in his words, retardation, palilalia, echolalia or word salad of some of the term used
while talking (Simons et al., 2010)
Assessing judgment and insight of the patient: He has partial view since he attacked
his neighbors while unwell claiming they wanted to cause harm to him. He does not know why
he is in the hospital or why police brought him to the hospital, he has not been taking
medications by two as reported and attending follow-up clinics hence his insight is not intact
(Schennach et al., 2010).
Question 2
MENTAL STATUS EXAMINATION 4
Risk Factors, Interventions, and Rationale
Risk for self-harm
This is related to his delusional thinking that his neighbors intend to harm him. He also
has a history of violence toward self-attributed through his scratching of arms and violence to
others because he does trust them. He also has recurrent suicidal ideations which is a common
feature in patients with mental disorders (Andover and Gibb, 2010).
Expected outcomes in caring the patient
Within the 24 hours of care, the client will not harm self or others
Interventions and Rationale for self-directed violence
a) All objects that are dangerous should be removed from environment
Rationale: this is to ensure that the patient does not use the objects when he is in
an agitated or confused state.
b) Administering tranquilizing medications that are prescribed by the
physician. The effectiveness and side effects should be monitored
Rationale: this helps in determining the alternative medication that is least
restrictive while laying out interventions in caring for the patient.
c) Observation of the client behavior should be done at least after fifteen
minutes while at the same time maintaining the routine activities in caring for the patient.
Rationale: Appropriate intervention is facilitated by having close observation of
the behaviour of the patient while maintenance of regular activities in caring the patient
reduces any suspicions by the client.
Risk to others
MENTAL STATUS EXAMINATION 5
While caring for the patient, the environment should have maintained a low level of
stimuli. The stimuli may involve people. In this case, few people are encouraged while attending
the client.
Rationale: A stimulating environment tends to increase the anxiety levels. When the
customer is suspicious and agitated, he usually perceives any individual as threatening hence he
can harm them.
All objects that are dangerous should be removed from environment
Rationale: this is to ensure that the patient does not use the objects when he is in agitated
or confused state to harm others.
Help the patient in redirecting violent behavior with physical outlets like punching bag
and jogging when anxiety of patient tends to rise.
Rationale: this helps to relieve anxiety and tension safely thereby reducing chance of
harming others.
Risk of absconding hospital
Using mechanical restraints or isolating the patient in a room. Ensuring there are
sufficient staff members and security officers to handle the patient when he wants to escape.
Rationale: This is to prevent the patient from absconding from the hospital. It also
portrays sense of control over any situation that may arise and provision of physical security to
both client and staff.
Risk of disturbed thought processes
This is related to delusional thinking or inattentiveness, inability of the patient to
trust others, being hypervigilance (Voss et al., 2010).
Expected outcomes
MENTAL STATUS EXAMINATION 6
By the end 24 hours the client should be able to verbalize reflective
thinking processes that are oriented to reality
By the end of twenty hours the client should be to refrain from response to
delusional thoughts in case they occur
By the end of twenty-four hours, the client should be able to distinguish
reality and delusional thinking.
Interventions and Rationale
- Avoiding arguing or denying the belief of the patient
Rationale: This is to prevent occurrence of delusional ideas since opposing or denying
what the client belief is not helpful in building a trusting relationship. - Being supportive in helping the client in attempting to verbalize his
feelings of fear.
Rationale: when the client can verbalize the feelings, he can solve the long-term
issues in an environment that is non-threatening that is created by the caregiver. - Help the patient to focus on reality and try its reinforcement. Moreover,
always assists the patient in talking about real events and people.
Rationale: focusing on real events and people helps the patient to avoid stimulating
occurrence of psychosis. - Assist the patient in connecting the false beliefs such cannabis in
regulating the suicidal thoughts and increased anxiety.
Rationale: prevention of delusional thinking occurs when escalation of anxiety is
interrupted.
MENTAL STATUS EXAMINATION 7
References
Andover, M. S., & Gibb, B. E. (2010).Non-suicidal self-injury attempted suicide and
suicidal intent among psychiatric inpatients. Psychiatry Research, 178(1), 101-105.
El-Bilsha, M. A. (2013).Effect of activity therapy on the Activity of daily living among
schizophrenic patients.MIDDLE EAST JOURNAL OF FAMILY MEDICINE, 7(10).
Krueger, C. E., & Kramer, J. H. (2011).Mental status examination. The Behavioral
Neurology of Dementia
Lehmann, D., Pascual-Marqui, R. D., Strik, W. K., & Koenig, T. (2010). Core networks for
visual-concrete and abstract thought content: a brain electric microstate analysis.
Neuroimage, 49(1), 1073-1079.
Mittal, V. A., &Walker, E. F. (2011). Dyskinesias, tics, and psychosis: Issues for the next
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158.
Schennach, R., Meyer, S., Seemüller, F., Jäger, M., Schmauss, M., Laux, G., … &
Klosterkötter, J. (2012). Insight in schizophrenia–course, and predictors during the
acute treatment phase of patients suffering from a schizophrenia spectrum disorder.
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Simons, C. J., Tracy, D. K., Sanghera, K. K., O’Daly, O., Gilleen, J., Krabbendam, L., &
Shergill, S. S. (2010). Functional magnetic resonance imaging of inner speech in
schizophrenia. Biological Psychiatry, 67(3), 232-237.
Voss, M., Moore, J., Hauser, M., Gallinat, J., Heinz, A., & Haggard, P. (2010).Altered
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consequences. Brain, 133(10), 3104-3112.