Psychological Report of the Patient

3. Psychological Report

Background information: Patient has a wife and two children living in the city. He also has relatives living in a village. He is wealthy and educated, with high social status. He has been recently diagnosed with cancer. There is no history of substance abuse/mental problems and mental health care. He has denied help of a specialist in treating his cancer in New York and has decided to go back to the village, where he was raised. Patient seems, at some points depressed, constantly blanking out in space but is rather motivated. No medications were being taken at time of testing.

Mental status examination (MSE): Results of mental examination revealed a slightly depressed individual. He is distracted and does not follow conversation well sometimes. He often stared into space, usually for about a few seconds. The patient was casually dressed in expensive clothes. Posture was slightly hunched. Speech functions were normal. However, on topics related to his sickness, patient would stutter or stop speaking completely. Wide range of vocabulary and good grammar.

Patient was cooperative and spoke fondly of his family and childhood memories. He had said several times that he wants to go back to the village. His thought process was intact, but with no goals that were unrelated to his family. There was no obvious ideation about delusions, paranoia or suicidal/homicidal. He was unable to speak freely about his health. He interacted well with other people.

Results of evaluation: Patient is finding difficulty to deal with his physical health issues, and does not want medical attention. He has rejected medical care. Based on the MSE, he seems slightly depressed. He wants to go home, as he has indicated during the MSE. He believes that he is at a stage where it is impossible to regain full recovery.

Summary/recommendations: Results of psychological evaluation reveals a patient who is reluctant to seek medical attention and who strongly misses his childhood. He is depressed and wants to recollect all his childhood memories by going back to the village where he was from. He is still motivated by his immediate family and functions normally.

It is recommended that the patient have the support from his immediate family as well as his relatives, in order to help him maintain his current mental health. With the support of his family, the patient will feel encouraged and motivated. If the patient is reluctant to go to New York to receive treatment, I recommend that he receive treatment in his home, or back in the village, as he misses his childhood.

Please let me know if you need any additional information for the evaluation of this report.