Examining a Patient with Mental Illness – Disorder Example

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"Examining a Patient with Mental Illness" is a great example of a paper on the disorder. In this assessment of mental disorder on a patient named Lucy, the approach entailed evaluating aspects such as general appearance and behavior, speech, affect and mood, thought, stream, perception, cognition, insight, and judgment. On appearance, I would observe Lucy in search of any signs of shiver or atypical movements and after lacking such symptoms, I would discover the prevalence of proptosis (a condition with characteristics relating to Grave’ s disease). During the interview, Lucy’ s reactions and responses played a significant role as part of the assessment; in addition to her history.

Speech assessment focused on her ways of articulation, answering questions, rate, and speed. Moreover, I also paid attention to her conversational tone and its relation to different situations. According to my summary findings and observations, Lucy was a victim of depression (affect) and had an abridged mood, which resulted in anxiety and a short-temper. Under thought assessment, the main aspects were stream, form, and content, which I used to make conclusions such as the source of her unhappiness, prevalence of formal thought disorders, nature of her thought block, and the basis of her mental illness.

Moreover, from discussions and evaluation of her past relative to her condition, I was able to determine that Lucy gave extended concern to her condition, probably worrying about her condition worsening. This was the main source of her obsession and guilt. Relative to perception and cognition assessments, I was able to determine the seriousness of Lucy’ s condition as this helped eliminate the prevalence of some of the serious symptoms such as misinterpreting, illusions among others; moreover, she was aware of the time and place of the interview.

Finally, the results of her insight and judgment were positive since this section mostly entailed identifying whether the patient acknowledges and accepts their condition. Example Two                       The second health assessment mainly focuses on historical information relative to the condition of a patient. Typically, every detail about the history is essential in the assessment and I use most of this information to make summary findings of a patient’ s mental illness. However, this form of assessment is extensively effectual when combined with others such as the one in the first example.

Dealing with patient history starts with the identification of information concerning the patient, the main reason that led to their visit. Normally, I have to record or quote the reason as indicated by the patient. Following this should be their history of mental illness i. e. past disorders or diagnosis. However, the assessment should entail all past illnesses; the sole focus on psychiatric history is less effective.                       Additionally, family history is a prevalent aspect in healthcare provision hence it should also play a role in the assessment even though most patients are reluctant to give this information.

Listing this information as part of the assessment is significant as it could apply immediately or later during treatment. Mostly, when a relative has a past linking them to the same illness but recovered, similar treatment and interventions could apply as an option for the recent victim. Summary Findings                       Typically, a comprehensive assessment of a mental illness patient should entail observing certain characteristics altogether as the foundation for establishing the best available treatment for them (Bates, 2002).

The five elements to consider as part of the assessment are background, affect, trouble, handling, and empathy. The background assessment brings into light potential circumstances and historical illnesses that directly relate to the patient’ s condition. Affect assessment focuses on the patient’ s sentiments and knowledge about their condition. Trouble relates to affecting evaluation since it fixates on establishing the perceptions that follow the patients acknowledging their condition. Handling focuses on the thought process and any potential functions directly linked to the mental illness. Finally, empathy, as the name suggests, creates a firm link between the patient and doctor as a way of understanding each other’ s conceptions and approaches towards treatment. Subjective, Objective, Assessment and Plan (SOAP) Note Mental Health Illness Subjective: The patient’ s reason and understanding about their mental illness e. g.

experiencing depression and anxiety Objective:   Identification of treatment options and interventions but after having a clearer understanding of the problem i. e. could opt for further assessment and under what basis Assessment: Formulating questions aiming to understand the probable source of the depression and anxiety e. g. asking about family history, recent perplexing events (Bates, 2002) Plan: Using the provided and gathered information, develop the best available form of treatment and intervention i. e.

which will achieve the set objectives and goals


Bates, E. (2002). Assessment and Health History: Cultural Medicine, Stanford Education, Retrieved from http://culturalmeded.stanford.edu/pdf%20docs/Bates_Chapter_2.pdf
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