Highlights
Matthew a 43 year old male from regional Victoria visits your clinic after he was reviewed by his GP. He has a burn on his forearm from a wood heater and it requires regular dressing changes. This is your first encounter with Mathew. You begin the dressing change and are having an informal chat. He tells you about his son dying recently of lukaemia and the loss of his job. Matthew appears very low in mood and while grief about his son is evident and understandable; you begin to suspect that his presentation may be more serious. He tells you that he cannot talk to his mates about it and feels like a failure. He goes on to explain that he is having trouble sleeping and feels angry all the time. You can see on his file that he is on medication for depression and has been referred to a psychologist. You ask Matthew about the appointments with the psychologist, and he states that he never went because he felt he could handle his stuff on his own.
You have conducted a brief mental state assessment:
Appearance - short light brown hair, looks dishevelled in appearance unshaven and clothes looking unwashed
Behaviour- minimal eye contact
Speech- normal rate tone and volume
Mood- states “I feel terrible”, agitated & irritable,
Affect- congruent with mood
Thought form – no thought disorder evident
Thought content- see above scenario
Perception- nil perceptual disturbance
Cognition- orientated to time person and place
Insight – interact knows there is something wrong beyond just grief and engaging in some treatment
Judgement- intact
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