MSE Assingment

CATHOLIC UNIVERSITY OF HEALTH AND ALLIED SCIENCES
(CUHAS)
ARCHBISHOP ANTONY MAYALA SCHOOL OF NURSING

(AAMSON)
DEPARTMENT OF MENTAL HEALTH AND PSYCHIATRIC

NURSING
YEAR OF STUDY; 3 2022/2023 SEMESTER 6
NAME : TUMAINI J LIFA -CUHAS/BSN/5000963/T/20
SUPERVISOR’S NAME; NANKONDO MTAITA
DATE OF SUBMISSION: 19TH JUNE 2023.

MENTAL STATE EVALUATION
DEMOGRAPHIC DATA
Name: Andy
Age: 21 years
Sex: male
BRIEF HISTORY
Andy is a 21 year old university student who is seeing a psychiatrist due to
concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends. He
believes his house mates are doing stuffs to his brain who are working for MI5
conspiracy for about 2 months this has been going on.
APPEARANCE
Andy is a 21 year old African male, who appeared healthy, well dressed
his hair is well groomed, He looked anxious as per facial expression and didn’t
maintain eye contact.
PSYCHOMOTOR BEHAVIOR
Andy kept on turning on his left side several times as he said he could hear
his house mates talking about him , raising his right arm low hitting his
right thigh, raising hands, touching his hands almost through out the
interview.
ATTITUDE
The client's attitude toward the examiner was cooperative through out the
interview as evidenced by his cooperation in giving responses and fully alert
during the interview.
SPEECH PATTERN
He had normal rate, volume and tone of speech.
MOOD AND AFFECT
His mood was euthymic and varied to dysphoric as he felt unpleasant to what is
happening to him, His affect was appropriate to his dysphoric mood as he looked
sad and kind of worried, due to the MI5 conspiracy and the chip in his head.
PERCEPTION
The client experiences auditory hallucinations as evidenced during the interview
where he says he can hear 3 of his housemates talking about him, and even when
he is in his room he can hear them talking about him. Andy is also experiencing
tactile hallucinations as he can feel there is a chip in his head giving him ideas
which aren’t his, he claims the MI5 conspiracy did that. He has no illusions, he
doesn’t experience depersonalization or de realization.
THOUGHT
Andy’s thought form and stream were coherent, logical and well directed; In
thought content he shows delusions of persecution where he believes that his
housemates are after him and the MI5 conspiracy, as well as his housemates want
to poison him. He also has delusion of reference as he believes whenever his
roommates are together they are talking about him “always talking about him “. He
also has delusion of thought insertion as he believes the chip kept in his head is
making him think of things that aren’t his interest at all. He also has suicidal
thoughts and thoughts of harming his housemates because of the knife and baseball
bat he keeps for self defense.
COGNITION
Andy seemed to have no disturbance in orientation , he was fully alert and aware ,
his attention was drawn away in some moments where he experienced auditory
hallucinations , his memory seemed to be intact as he was able to recall the duration
he took in using the illicit drugs and he he was aware and understood the effects of
the drugs when he claimed it’s not the drugs that make him feel that way.
JUDGMENT
Andy had impaired judgment as evidenced in his self harm thoughts due to what is
happening to him, as well as the thought of harming his housemates because they
are talking about him, he keeps a knife and baseball bat for defense.
He also has some sort of critical judgment because he doesn’t want to hit his room
mates fearing to go to the police so he is trying to control himself.
His responses to social judgment questions were positive; he described social
relationship with his parents, it’s the place he felt safe but didn’t want harm them
due to his condition.
INSIGHT
Andy has a loss of insight because he denies having a mental illness and says he is
not ill but only the chip in his head they kept where he doesn’t know why they have
kept it.
RELIABILITY
Overall, this client appeared forthright and reliable. He was open about his drug
abuse history.
FINAL CONCLUSION
Therefore from the above mental status examination the patient is suffering from a
psychotic disorder and the most likely diagnosis according to DSM V is
schizophrenia. Differential diagnosis would include a drug-induced psychosis.

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CATHOLIC UNIVERSITY OF HEALTH AND ALLIED SCIENCES

ARCHBISHOP ANTONY MAYALA SCHOOL OF NURSING

DEPARTMENT OF MENTAL HEALTH AND PSYCHIATRIC

YEAR OF STUDY; 3 2022/2023 SEMESTER 6

NAME : TUMAINI J LIFA -CUHAS/BSN/5000963/T/20

SUPERVISOR’S NAME; NANKONDO MTAITA

DATE OF SUBMISSION: 19TH JUNE 2023.

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