Page 342 - tmp

Progress Notes Page 40 of 53

MSE
A6B: 37 year old male, mixed origin, slim build. He was wearing casual and dirty clothes. The conversation was one
sided with Simon keen to talk.

S: Pressured speech
M: Subjectively “fine, a bit elated”. Objectively elated
T: Thought disordered, tangential thinking, grandiose, persecutory delusions

C: Oriented to TPP
I: Limited insight - does not want any medications, never thinks he has had a mental health disorder

Risk
To self - low

Denies any thoughts of self-harm or suicide. Previous reports of suicide attempt as teenager.
To others - moderate
Denies thoughts or plans to hurt others. Has clearly documented history of aggressive behaviour and currently elated.
From others - low/moderate
At risk of reciprocal aggression

Physical examination:
Comfortable at rest

Nil abdo/chest/msk pain reported
HS I+11+0, pulse regular, CRT <3s

Chest chear, L=R, nil wheeze or cough
Abdomen SNT, bowel sound present
Neurology intact, normal power, normal gait

CN1-12 intact, PEARL
Obs last night BP 130/74, Temp.36.6, Sat 97% Res. 17, Pulse 86, BM. 6.0 Weight 78.4 Kg, Height 179.0cm - BMI 24.5

ECG: NSR 88bpm QTc 440ms

Impression:
Evidence of grandiose delusions and elated mood. In view of long term symptoms this is most likely consistent with a
Schizoaffective disorder. Does not currently have capacity for treatment or admission.

https://rio.beh-mht.cse.thirdparty.nhs.uk/rio/Reports/RiOReports.asp 08/01/2019
40