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Clinical case presentation

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Anders Hverven

on 15 May 2014

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Transcript of Clinical case presentation

Mental State Exam
Case Summary
Mr. Elroy
Clinical case presentation
Appearance and Behavior
Mr. Elroy is pale-looking, underweight and his hygiene is has not been attended to.
In the interview he is cooperative, but unenthusiastic. Does not have eye contact.
He sits slouched in the chair.
His answer is polite but short.
A bandage is covering up the sutures on his necking restraining the motor function in his neck.
He also has a poor appetite.
Clinical Formulation
Mr. Elroy
Assessment task 2 (NSB023)
Anders Hverven
Ingvild Areng
Margrethe Bjørnstad
Martine Normann

76-year old male
Attempted to take his own life by swallowing a cocktail of tablets, and then to cut his own throat.
Has been suffering from depression in the past few months. He lost interest in life and lacks energy. Been living in isolation.
Has no family to attend to him.
Lives in a weathercottage he fully owns and is happy with.
Mood and Affect
Form of Thought
Thought Content
Sensorium and Cognition
Insight and Judgement
Therapeutic Relationship
Hoarse and halting
Low quantity of information
Slow rate
Low volume
Response and behavior shows a absence of emotional expression.
His face is immobile.
Voice is monotonous.
Mr Elroy's mood shows clearly signs of depression and apathy.
Mr. Elroy seems to have mostly negative thoughts.
He comes off as blank and empty.
Shows signs of depression yet again
Mr. Elroy displays no signs of delusional beliefs or thoughts.
His thoughts of himself are very negative and he does not seem to see a future for himself.
He has not talked about the suicide attempt but he is voicing suicidal thoughts.
Isolation himself from visiting neighbors shows an anti-social behavior.
Mr. Elroy displays no hallucinations or other perceptual disturbances.
Mr. Elroy is orientated of time, place and person.
He clearly understands new information he receives, but the does not retain much of it.
Mr. Elroy has bad insight to his own illness.
His judgement is very poor as he tried to commit suicide.
Maslows Hierarchy
Presenting factors
Major depression
Precipitating factors
Reminiscing about his past
Predisposing factors
Loss of his cat
No family
Perpetuating factors
Negative thoughts
No self esteem or confidence
Non engaging
Low insight regarding own illness
Protecting factors
Cultural Safety
Nursing care
Recovery Model
Basic needs
Regain appetite
Safety needs
Protection against self-harm.
Maintaining personal hygiene.
Social needs
Social network and interaction with others.
To feel belonging.
Be respected by others.
A sense of achievement
Top priorities

Risk assessment
Risk of infection and potential harm to himself.
No risk of harm to others, no risk of absconding.
Be respectful to the patient.
Do not discriminate.
Be aware of the social stigma attached to suicide.
Friends and social contact.
Animal aid
Meetings and Evaluation
To be needed by others
Feeling of matter and importance
Be a part of something bigger
By being taken care of
Participating in a program like Menshed or Animalaid
Regain once lost social life
Personal responsibility
Taking care of personal hygiene
Active sense of self
Build positive connections to
others and the community
Full transcript