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Mr. Peter Mendel DOB 01/06/1958 Male Situation Peter has presented with acute episode of chest pain which has triggered his underlying anxiety. Biological factors ( Physical ) Borderline Type 2 Diabetes Chronic stable angina Hypertension 2 beers per night Recent weight loss ( 5kgs) Smoker – occasional cigar Undiagnosed anxiety Reported “exhaustion, insomnia “. Cognitive Undiagnosed anxiety Difficulties concentrating Psychosocial factors Has been having trouble sleeping. Irritable Has lost interest in food. No history of suicide, very sad after friends’ death. No history of violence Social factors Lives with wife and teenage children’s girls 16 and 19 Good support Employed – works long hours. No time for recreational activities Previous Medications GTN Spray PRN MSE Appearance/Behaviour – looks tired but well kept. Good eye contact, co-operative Rapport was easily established. Speech- normal rate, rhythm, and volume. Mood is stated as 5/10, Affect: (emotional State) is congruent (is matching or appropriate to verbal communications ). Thought form is normal amount of thought production that flows continuously and logically. Thought content – Finds it difficult to concentrate Perception – Nil perceptual disturbances. Insight: he realizes that he is unwell has feelings of sadness and well as his acute chest pain. Orientation – Peter is orientated to time and place. “Social ,Psychological, Cognitive and Physical factors are associated with mental health. For each factor , identify one important aspect of Peter’s history that should be prioritised . Explain your rationale.”

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