Scenario:
You are working on an inpatient psychiatric unit and need to do an initial assessment of R.B, who has just been admitted. He is 22 years old and has been attending the local university and living at home with his parents. R.B. has always been a good student and has been socially active. Last semester his grades began declining. He became very withdrawn and spent most of his time alone in his room. His personal self-care has deteriorated as he can go days without bathing. Before admission, R.B. spent several weeks in seclusion. He refused to join family gatherings, isolated himself, and closed the blinds. Within the past 2 days, he refused to eat, stating, "They have contaminated the food." As you approach R. B., you note that he appears to be talking to himself. When you talk to him, he looks around and answers in a whisper but gives you little information. He states, "They are watching me and told me not to cooperate."
Full Answer Section
. Medical History and Substance Use:
- Gather information about any previous mental health diagnoses or treatments.
- Ask about family history of mental illness.
- Inquire about substance use, including alcohol and drugs.
- **Conduct a physical examination to rule out any medical conditions.
- Preliminary Diagnosis and Treatment Planning:
- Based on the assessment, discuss potential diagnoses with R.B. and his family (if they're present).
- Explain the need for further evaluation and possible medication and/or therapy options.
- Address immediate safety concerns, such as suicidal or homicidal ideation.
- Develop a treatment plan that outlines goals, interventions, and follow-up recommendations.
Additional Points:
- It's crucial to treat R.B. with empathy and respect, acknowledging his distress and fear without judgement.
- Building trust and rapport is essential for encouraging cooperation and effective intervention.
- Safety is paramount, so assess any potential risk to himself or others and implement appropriate safety measures.
- Collaboration with mental health professionals, including psychiatrists, psychologists, and therapists, is crucial for comprehensive care.
Remember, this is just a preliminary assessment based on the limited information provided. A full diagnosis and treatment plan can only be developed after a thorough evaluation by qualified mental health professionals.
Sample Answer
Based on the presented information, there are several red flags suggesting R.B. may be experiencing a mental health crisis, potentially schizophrenia or another psychotic disorder. Here's a potential approach to his initial assessment:
1. Observation and Rapport:
- Maintain a calm and non-threatening demeanor.
- Introduce yourself clearly and explain your role.
- Respect his personal space and avoid sudden movements.
- Encourage communication, listen actively, and validate his concerns.
- Observe his behavior, including eye contact, posture, and speech patterns.
2. Mental Status Examination:
- Assess his mood, affect, and thought content: Look for evidence of depression, anxiety, paranoia, or delusions.
- Evaluate his perception and orientation: Check for any confusion or disorientation to time, place, or person.
- Assess his cognitive function: Test his memory, concentration, and ability to follow instructions.