2014 PSYCH Case Report

MED4171 Medicine of the Mind
Student Academic Support Unit (SASU)
Psychiatric Written Case Report

Helpful Hints & Models
Erica Schmidt, Andrea Paul & Kara Gilbert Student Academic Support Unit (SASU)
Monash University Faculty of Medicine, Nursing and Health Sciences
2008 updated Feb 2014
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MED4171 Medicine of the Mind
Psychiatric Written Case Report

Helpful Hints & MODELS
Acknowledgements
The following was created with reference to the departmental guidelines for the report, as well as adapted from a lecture handout
out given by Kara Gilbert, in collaboration with unit co-ordinators, in particular Ian Presnell, at Monash University given between
2003 & 2006.
Special thanks to Sudha Rughanath and other student writers of prior reports who allowed examples of their work to be used in
the development of this resource. Please note - these examples are a guide only, and the reader should look at them critically for
both form and content, based on their own specific reporting needs. Some aspects of the examples have been modified for
teaching purposes.
Expectations for the Report

You have been given the marking criteria for this report as well as 3 exemplar case reports (not
including how they were scored) by the Medicine of the Mind faculty (see Moodle MED4171
Psychological Medicine block). It is expected that you will follow the guidelines to ensure that you
present a complete picture of the patient you interviewed and demonstrate your understanding of them
and their problem(s). You should also refer to your recommended texts for guidance (Selzer & Ellen,
Bloch & Singh 2007, and the DSM-5).
This report should:
be clear and orderly
be written in an academic narrative style (i.e. do not write as if you are speaking and do not
use contractions) except for selected sections described below where a note or dot-point style
may be acceptable
indicate an awareness of any limitations in obtaining and/or presenting the material
de-identify the patient, psychiatric facility and caregivers
identify the source of your information (patient, relatives, case notes)
not use abbreviations or acronyms without first being written out in full (eg. Post-traumatic
Stress Disorder (PTSD))
include section headings for ease of organization
NOT go over the word limit of 5000 words (including tables, footnotes & headings but
not reference list) include word count on front page of report
not fabricate or embellish patient information, or plagiarize reports written by others
demonstrate your clinical reasoning and an awareness of diagnostic issues
demonstrate your ability to make links between the symptoms and signs exhibited by the
patient as it relates to their health care and daily functioning
We will now consider each section in turn with examples. For each example, and for your own report,
consider the following:
Is is clear and understandable?
Is it well-organized?
Is the information contained in it relevant to the section heading it is under?
Is the information complete for its purpose?
What works and does not work?
It is recommended that you first write out the information, note word count, and then revise to look for
efficient ways to present the information and avoid redundancies. It is ok to refer the reader to
other sections of your report that provide more detail on a particular point.
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1. CASE HISTORY
1.1 Introduction
This should be a brief, clear and concise opening that identifies the key issues of the case in a nutshell
(i.e. set the scene at the very beginning of your report, giving some idea of the nature of the illness; for
example, acute psychotic episode versus chronic illness exacerbation). Also include the circumstances
of your involvement as well as demographic information on the patient (de-identify the patient and
others involved using pseudonyms, and explicitly indicate that you have done so via a
footnote).
Framework
Name
Demographic information (gender / age / marital status/
cultural and-or language background)
Occupation
Presenting symptom(s) and duration without detail found in
HOPC
Referral details, if applicable
Admission status (eg. voluntary or involuntary)
Sources of case information (and quality of information if
relevant)
Point at which you assessed the patient
TIPS
Nutshell
description of
patient
Present the central
problem facing the
patient eg. type
of episode
Example 1:
Julie, a 25-year-old single accountant, and a practising Jehovahs Witness, lives with her retired
parents. She was referred by her family doctor with an abrupt onset of psychotic symptoms. This
followed two weeks of lowered mood after the break-up of her first ever relationship, which was
with a co-worker who unexpectedly left to travel overseas.
(Bloch and Singh, 2007:90)
Example 2:
Lisa Nguyen* is a 17 year old, unmarried, unemployed female of Vietnamese origin. Lisa
migrated to Australia from Vietnam in 2006, and is currently studying year 11 at home through
distance education. She presented to the emergency department of a metropolitan hospital after
being referred by her general practitioner for depressed mood and increasing suicidal ideation.
Lisa was transferred from the emergency department to an inpatient child and adolescent unit where
she has been an involuntary patient for four weeks. Information for this report was gathered
th
through two interviews with Lisa during the 4 week of her admission along with patient notes,
observation of Lisa in groups, and discussion with treating physicians and nursing staff.
* Pseudonyms have been used to protect patient confidentiality.
1.2 History of Presenting Complaint

This should be a detailed account of the patients central problem that you have already identified in
your opening statement. Put details about the problem and related symptoms in a chronological
order as this will help with the clarity of your writing. Start at the beginning of the current
episode, including any precipitating events. It is useful to use the patients own words in your
description, and indicate this with quotation marks. In particular, it is important that you consider the
following points in your discussion:
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FRAMEWORK:
a. Discuss psychiatric symptoms:
Present a chronological narrative of the evolution of their symptoms for the current
episode. Start with when they began to feel unwell for the current episode describe
any triggering events or prodrome. When presenting associated relevant symptoms,
attempt to group symptoms together in your discussion so that depressive, psychotic and
anxiety related symptoms appear next to each other in your text. (ie. make connections
between the isolated symptoms that the patient may have revealed to you somewhat randomly
in their interview; this will help your writing to develop logical sequences). Comment on relevant
negative as well as positive symptoms (eg. patient admits topatient denies). Present
any relevant symptoms related to the differential diagnoses you will discuss later.
Present the patients description of their symptoms contrasted with the description by other
witnesses, if applicable.
b. Comment on the impact of the illness on the patients life:
work
social relationships
self-care
TIPS
In this section,
level of functioning & coping strategy
c. Note details of current treatment so far up to the point of your

interaction if they have been under care for a significant amount of time
for the current episode (ie. weeks), or transferred in from elsewhere:
what
when
where
by whom
If they are a new admission, this is not necessary.
d. End this section with a comment on what their symptoms are currently
like if they have had treatment.
emphasize the
patients
description of
their symptoms
at the time.
Be descriptive,
but save analysis
for later sections
of the report
Include any
information you
want to discuss
later
Example 3:
The patient describes an eight-month history of anxiety symptoms, which began two months
after a car accident. She experiences apprehensiveness when out of her home, inability to cope
with anything out of the ordinary, initial insomnia and irritability, and she has withdrawn socially. More
recently she has had trouble concentrating on her work. Five days ago she was taken to her local GP
after experiencing a typical attack in the supermarket. She has become housebound since, ruminating
that Im terrified of suffering a heart attack and dying suddenly like my mother. She has begun
drinking up to a bottle of wine a day in an effort, she says, to calm myself down and make things
more bearable.
Example 4:
Lisa experienced a prolonged prodrome of symptoms and events leading up to her current
presentation. During Year 10 (last year), Lisa experienced a progressively increasing social and
academic difficulty along with increasing depressive symptoms. She reports suffering bullying from
both her peers and teachers. She was called stupid and retarded and feels a marked sense of
injustice and maltreatment by her teachers. Lisa had very few friends, and admits to having
difficulty with social interaction. As the year progressed, Lisa became increasingly frustrated in class,
was prone to yelling at teachers and began opting out of group participation in all her classes. There
was a decline in her homework quality and amount handed in over time. She believed nothing could
help her, withdrew significantly from her few friends, and found it increasingly difficult to attend school.
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Lisa was seen by three psychologists at school during Year 10. She shouted at the
psychologists during most of her first assessment, however, stated that she was not angry but
extremely anxious. Intellectual disability was suspected by her teachers, and testing was performed
using the Wechsler Intelligence Scale for Children Fourth Edition (WISC-IV). Results were
inconclusive; though Lisa scored below average in most sections, this may have been due to poor
English skills rather than cognitive deficits. However, Lisa did very well in perceptual reasoning. In
October of last year, Lisa punched a student who bullied her, and suffered her first panic attack. She
describes this as being an unexpected feeling of intense anxiety and distress associated with chest pain
and breathlessness. Lisa claims that this display of aggression was very uncharacteristic of her. She
deeply regretted it and attributes it to her extremely low mood at the time. At the conclusion of Year 10,
Lisa failed every subject except mathematics. She was recommended to repeat Year 10, but instead
opted to do Year 11 via distance education.
During distance education this year, Lisa has become increasing socially isolated, and has
struggled to teach herself core material, especially Physics and English. She states that her only hope
of passing these subjects is to get private tutors, which her family cannot afford. Lisas mother also
cannot afford taking time off to support Lisa due to financial difficulties. Lisa felt overwhelmed, and said
she was confused by her thoughts at times. Lisas depressive symptoms have also increased; her
general practitioner suggested antidepressant medication, which she declined as she did not think it
could help.
In terms of depressive symptoms, since the start of Year 10 Lisa has experienced
decreasing mood, and a moderate degree of anhedonia. She has also had initial middle
and terminal insomnia, with early morning wakening in the last two months, and regular
nightmares about study and her sister. Lisa has had chronic fatigue and exhaustion, a
paucity of concentration and short term memory, and frequent episodes of her mind going
blank, especially over the last 6 months. She has gained 10kg over the last 2 years, which
she attributes to studying more and exercising less. This year, she has had increasing
feelings of guilt and hopelessness with suicidal ideation over the last month. She states
suicide is her only option, and has plans to jump in front of a car. She has not written a
suicide note, and has only informed her general practitioner of these plans. The only self
harm reported is that she has started to bang her head into her wrists recently. Lisa denies
any diurnal variation of mood, psychomotor retardation or anorexia.
Lisa also displays symptoms of anxiety; she has had three panic attacks, though
she denies any persistent worry of having another attack or change in behaviour between
the attacks. She has also had 12 months of irritability, and more recent muscle tension,
though she denies restlessness. Lisa has also had substantial somatic symptoms. She
has reported generalised pains (at times specifically in her chest and abdomen), and limb
clumsiness at all times; no physical cause was found for these complaints. Lisa denies ever
experiencing psychotic symptoms such as visual and auditory hallucinations and delusions.
She also denies ever experiencing manic symptoms such as elevated mood, uninhibited
behaviour, thoughts racing, impulsiveness and elevated energy levels.
QUESTIONS
1. How is clinical
reasoning made
evident?
2. What makes this
section easily
readable?
Lisa was referred to the emergency department by her general practitioner in mid-March of this
year. She was then transferred from the emergency department to an inpatient child and adolescent
unit where she has been an involuntary patient for 4 weeks. Two weeks ago, Lisa was started on 75mg
of Venlafaxine daily which has just been increased to 150mg daily. After starting the medication she
experienced dizziness which subsided rapidly. Her depressive symptoms have improved dramatically
though she still experiences some insomnia and occasional irritability, low mood, and feelings of guilt.
In addition, she no longer has any suicidal ideation. She does not want to be discharged, not even into
a day program or community service. She fears that she will get much worse if she leaves, and feels
worse when she goes home from the unit on leave. Initially, she would not attend group activities in the
unit, but now often enjoys them. However, she still gets very irritable and tearful when changes or long
term solutions are discussed, such as a transition program. She feels helpless when asked to make
decisions regarding her future.
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1.3 Past Psychiatric History
TIP In this section, you need to
The following points are relevant in this section:
build a picture of the pattern of

illness
Chronicity
Severity
Coping strategies
Crisis triggers
Interval functioning
This contributes to a complete
discussion of the illness.
details of previous episodes of illness,

chronologically presented, even if undiagnosed
include main symptoms similar or different to the
current presentation; for patients with multiple
admissions for similar episodes each year, you
may present a typical episode and state how
often they occur and their precipitants
previous psychiatric admissions and
treatment including diagnoses (which may
change) and management changes
outpatient/community treatment
suicide attempts
drug & alcohol abuse use a sub-heading for this
an indication of pre-morbid and interval functioning - use a sub-heading for this
details of any forensic history use a sub-heading for this
you may choose to have table of psych medications with dates and compliance issues here, or
combine psychiatric and medical medications discussion under a separate heading.
Example 5:
KD first began using heroin in 1990, he claims initially as a social habit which quickly became his
preferred means of escaping stress. By 1998, he was using it up to three times a week while still able
to function and hold a full-time job. He denies a history of depressive, anxious or psychotic symptoms
prior to the death of his son in 1998 (social aspects of this event are described in Developmental
History).
Following the death of his son in September 1998, he experienced severe guilt and blamed himsefl
for not taking adequate care of him while under the influence of heroin. He also experienced
insomnia, anhedonia, and depressed mood, with an inability to cope with day-to-day tasks. This
culminated in a suicide attempt by overdose when he was barred from attending his sons funeral by
his then wife. He had an epileptic fit following the overdose and was admitted to hospital, but left four
days later AMA. He does not recall medical or psychological treatment at the time.
In the years that followed, he experienced daily nightmares in which the accident would replay in his
mind, and had panic attacks whenever he was reminded by cues such as screeching tyres, etc, and
avoided visiting the place of the accident.
In 2000, when his wife officially divorced him, he became despondent and again attempted suicide by
heroin overdose and was admitted and diagnosed with PTSD and Antisocial Personality Disorder
(see Developmental History for a description of other personality traits) as well as Reactive Disorder.
This prompted an ultimatum from his two remaining children to clean up his act. This initiated the
successful completion of a 12-month residential rehabiltation program, and he has since been able to
abstain from heroin use.
Example 6:
Prior to the current admission, Lisa has had no previous psychiatric admissions, diagnoses or
treatment. She has not attempted suicide previously though she reports having suicidal ideation
during her childhood around the age of 10. Lisa had depressive symptoms during that period; similar
to but less severe than her current episode. She is unsure if there were any stressors or precipitating
factors for this episode and does not know how long it lasted. During the interval between episodes
Lisa has been able to function quite well. She was able to keep up with school work and participated
in extracurricular activities, though she made few friends.
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Drug and Alcohol History (including presciption abuse, if any)

Example 7:
Janice only drinks on special occasions a few times a year with her family and has less than a standard
drink. She started drinking alcohol at the age of 17. She has never smoked or used any illicit drugs.
However, she has required increasing doses of Oxycodone, and admits to taking them to calm herself
sometimes (see Medical History for details of use).
Forensic History
Example 8:
John lost his license due to driving under the influence of alcohol for 6 months in 2006, and has had
several drunk and disorderly charges brought against him.
1.4 Past Medical History

This section is used to highlight any evidence of organic disease which may be influencing or be
exacerbated by the current presentation, as well as to present other history for the reader to be aware
of.
Emphasize medical conditions in the patients history that may bear some
relationship to the psychiatric presentation (and avoid expanding your discussion of
medical details that are irrelevant to the psychiatric presentation), for example:
o thyrotoxicosis anxiety
o hypothyroidism depression
TIP
Systems most relevant include: cardiovascular, neurological and

endocrine.
Similarly, demonstrate an understanding of the significance of

drug therapy on psychological function by focusing on
medications taken by the patient that may influence the patients
current psychological function. You may wish to have a separate
sub-heading for this discussion.
Other medical and surgical history not directly related to their

current psychiatric problem may be presented in note or dot point
form if extensive.
Include a list of all medications (including dosage and schedule) taken by the patient prior
to admission, as well as any allergies. This can be in table form if you wish. You may wish to
list current psychiatric medications with the past psychiatric history and medications for other
chronic conditions in past medical history, or use one table for all. Any compliance issues or
problems with medications should be discussed. Also include any over-the-counter
medications used regularly or alternative therapies.
You need to show that you:

a. understand the
relationship between
medical conditions and
psychiatric symptoms, and
b. can appreciate the
complexity of medical
problems that might be
exacerbated by psychiatric
conditions.
Example 9:
Two years ago Tom was diagnosed by his GP with leg ulcers due to peripheral vascular disease,
exacerbated by the fact that he was sleeping upright in an armchair. This habit began after his wife
left him, as he could not bear to sleep in the bedroom because of the memories. He also found that
the only thing that could get his mind off ruminating about the separation was to watch old movies on
the ABC at night during this time he would doze off and manage to get some sleep. The problem of
his leg unlcers and infective cellulitis has deteriorated over the two years and he now has decreased
sensation bilaterally in his lower legs as well as large weeping wounds on sloughy skin. He has been
admitted to hospital six times this year for exacerbations of this chronic condition.
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1.5 Family History

This section showcases not only possible inheritable disorders, but also the psycho-social family
dynamics and atmosphere, which influence learned behaviours and coping strategies.
TIP
Framework:
Generations at least parents and siblings, but may also

You need to give
include grandparents, grandchildren or other extended family
members; chronology of ages left to right (3 generations
relationship
recommended)
information here as well
Family members and their ages if known; may assign a letter,
number, or pseudonym to identify persons referred to
as diagnostic
elsewhere in the report
information, unlike a
Parents personality characteristics/ marital relationship
family history for other
Current household atmosphere and relationship dynamics
Egos relationship with others in the family
medical purposes.
Family history of psychiatric illness
May include other relevant family medical history (especially
cardiovascular, neurological or endocrine disorders as risk factors for ego)
You must include a genogram (drawing of family tree). You may wish to indicate affected
individuals with different colours or cross-hatching. You need to include a key with your genogram,
particularly defining any non-standard symbols. Always indicate Ego on your genogram.
Example 10: Genogram
49 Depression/
Panic Attacks
Father 38
Depression?
Mother
38
Mick
(17)
Jenny
(13)
Micks parents divorced when he was 10 years old. His mother has been in a relationship since
2005. Though not formally diagnosed, Mick says that he thinks his father has depression. Micks
maternal uncle suffers from depression and has panic attacks. Mick reports that Jenny does not have
any depressive symptoms, and that his grandparents do not have any mental health issues.
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Example 11: Family history
The patient, the eldest in a family of three daughters, still lives at home. Her mother, a 45-year-old
primary-school teacher and her father, a 50-year-old electrician, are described as strict and intrusive, a
pattern she ascribes to their strong Catholic beliefs. Their marriage is described as over years ago;
they never talk or touch and the atmosphere at home as tense. The patient is close to her younger
sister in whom she confides. One sister has responded to a similarly distant relationship with both
parents by getting married after a whirlwind romance, the other by moving to another city.
Her mother was hospitalised with post-natal depression twenty years ago. There is no other family
history of psychiatric illness.
1.6 Personal History / Development

This section can be useful for providing evidence for any Axis II condition. Use the headings in Bloch
and Singh 2007 as a guide for organising the information in this section.
In particular, note:
problems the patient may have experienced adjusting to
TIP
predictable stages of development
If you think the patient
for each stage of life, describe significant life events and
the patients responses
you may include other interests, social groups, religious

experience, etc. in your discussion
the patients personality traits prior to their illness or
during remissions how does the patient or others describe
their basic personality
the patients coping strategies and patterns of behaviour
may have an Axis II

diagnosis, this is where
you will provide
evidence for it.
Example 12:
Lisa was delivered at 40 weeks gestation; the pregnancy was uneventful. She
reached all milestones normally and was walking at 13 months. Lisa states
that she had social difficulties even during early childhood, for example she
could not understand jokes until she was 8 years old and always found the
classroom more comfortable than the playground. Lisa had very few friends
during childhood, was bullied and remembers it as an unhappy time. However,
her mother reports no early concerns about her interpersonal skills. Lisas
mother described her as an easygoing, obedient and honest child who enjoyed
childcare and particularly liked drawing. Lisa also reports that she has always
found change difficult even when she moved schools within Vietnam as a child.
QUESTION
What
information is
inappropriate
for this section?
Where would it
be better
placed?
Lisa is of Vietnamese ethnicity and was born in Japan as her family

was living there due to her fathers studies. She moved to Australia at the age
of two where Wendy was born, then moved back to Japan 4 months later. In 1997, when her parents
divorced, Lisa moved back to Australia and has lived with her mother and Wendy since.
Lisa says that she was very close to her mother before the age of five, but as her mother
began to work more she did not spend much time with her. They are no longer close, but they do get
along. Lisa talks to her father on the phone once a week; she is not close to him. She gets along well
with her mothers boyfriend but only sees him rarely, about once a month.
Lisas relationship with her sister has always been turbulent as their personalities seem to
clash. Lisa describes Wendy as cranky, messy and lazy. Since coming to Australia, these difficulties
have escalated as Lisa has become increasingly irritable. Lisa seems to be jealous of Wendy who has
assimilated into Australian culture better than she has. She reports that she intensely dislikes her
sister and that her sister bullies her. Lisa has dreams about swearing at and hitting her sister, which
she says she would never do but often wants to. As Lisas mothers boyfriend lives in Castlemaine,
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she usually leaves Lisa and Wendy alone for the weekends to visit him. This upsets Lisa a lot; her
main complaint with being at home is her sister. Lisa believes that if her sister was not living with her,
life would be improved greatly. The few friends she has made she describes as nerds and very
friendly. She does not confide in them when she feels upset and only engages in enjoyable activities
with them; it appears that she does not have any close interpersonal relationships. Lisa still struggles
with assimilating into the local culture.
Lisa values achieving a successful career above all other pursuits and therefore academic
failure is not an option for her. She says If I cant get a degree, how can I face the world; I would
rather be dead. Prior to her migration to Australia, she passed all years of schooling undertaken. Lisa
has never been employed.
Lisas menarche was at the age of 11. Her menstruation is very regular, occurring once a
month for 5 days with normal flow. She reports a significant decrease in her mood prior to each period
which she finds quite distressing. Since being in hospital, her menstruation has been delayed by a
week. Lisa has never had sex or been a relationship.
Lisa plays the piano, which she is very passionate about and has continued to play throughout
her illness. She practiced Tae Kwon Do for years, but withdrew recently due to academic stress and
financial difficulties. Lisa also enjoys drawing though she has not been drawing often in the last year.
Lisas family is Christian though she does not consider herself religious as she does not share any of
their religious beliefs. However, she goes to church with them.
Premorbid Personality and Coping Skills
Example 13:
Lisa describes herself as introverted, diligent, determined, organised, and inflexible. She has trouble
making friends; Lisa thinks that her main problem is she doesnt understand people. She has
particular difficulty in understanding peoples body language, tone and social cues. She tends to take
things literally and have concrete thinking. Lisa values diligence and hard work above all else.
Lisas main coping skills are focused on distraction with activities. When feeling down or anxious she
studies or switches to a different activity, often specifically playing piano. She has also tried deep
breathing exercises for anxiety but these did not alleviate her symptoms.
2. MENTAL STATE EXAMINATION (MSE)

Use the headings in Bloch and Singh (2007) to organise your notes:
general appearance
rapport
behaviour
speech
mood
affect
o quality
o range
o appropriateness/ congruence
thought
o stream
o form
o content
perception
cognition (including MMSE)
judgement
insight
TIPS
You must include an MSE YOU have done

State when the MSE was done (eg. day 3)
If points are lost on the Mini Mental State
Examination or other cognitive test, be sure to
state where the patient lost those points
Only if there have been significant changes in
the MSE from the time of admission and when
you interview the patient, recording this in two
columns is valuable information identify
someone elses MSE if used to compare
Otherwise, if there has been little change, use
only your own MSE findings
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Example 14:
Lisas mental state has improved significantly since her admission. Of note, her insight and mood have
improved, she is no longer a guarded historian and has no suicidal ideation or depersonalisation.
Detailed findings are as follows:
Current Mental State Examination (4 weeks after admission)
Appearance
Lisa is a tall young girl who looks her age. She is casually and neatly dressed in a
T-shirt, track pants and sneakers. She slouches in her chair.
Behaviour
She is a good historian, answering in complete sentences and going into detail on
all topics. Lisa is cooperative and maintains good eye contact. She displays no
evidence of psychomotor retardation or agitation.
Speech
Lisa speech is accented, with normal volume and rate. She speaks spontaneously
in a monotonous tone. Her English fluency is proficient enough to understand and
answer all questions asked though she often asks for clarification. No aphasia or
dysarthria is evident.
Mood
Lisa describes her mood as fine, not sad. She rates it as a 5 out of 10; 10 being
the most elevated.
Affect
Lisas affect is blunted with a markedly reduced range of reactivity. She

communicates her affect well and it is mood congruent.
Thought
Perception
Cognition
Lisas thought stream is normal and she has no formal thought disorder. She is
preoccupied with worry over the future especially discharge. Lisa also ruminates
over past negative experiences such as bullying. She has no suicidal ideation,
thought insertion/withdrawal, ideas of reference or any other delusions.
Lisa denies experiencing any hallucinations or illusions, and reports no other
perceptual abnormalities.
A Mini Mental State Examination (MMSE) was conducted. Lisa scored 29 out of 30;
she missed 1 point on recall. This is within the normal range. She reports poor
short term memory and concentration (though she was very proficient at subtracting
serial 7s, continuing for longer than required).
Frontal/executive function is normal. This was tested by asking Lisa to compare
objects (similarities and differences) and to draw a clock-face.
Insight
Judgment
Rapport
Lisa has moderate insight. She knows that she has depression and needs
treatment and understands the importance of compliance with medication but does
not fully understand the symptoms of depression and how it affects her.
Lisas judgement is good. This is evident through general conversation and her
sound reasoning through scenarios.
Lisa has good rapport, she was friendly and engaged. She even made jokes at
times though they appeared awkward; her intonation often made it unclear whether
she was joking without clarification.
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3. PHYSICAL EXAMINATION and INVESTIGATION RESULTS

Emphasize those aspects of the physical examination that will indicate the presence/absence of
conditions that may present with psychiatric complications; i.e. consider the
symptoms/signs of conditions you will likely consider in your differential diagnosis discussion later:
a. medical conditions, particularly neurological, cardiovascular and endocrine disorders
b. substance abuse
c. long-term psychotropic drug use
d. evidence of self-harm
You may wish to organize your physical examination information by system or in a head-to-toe fashion.
A table, note or dot-point format may be most appropriate for some parts of the physical examination.
Fully describe your findings, with the most significant first. Do not forget to include pertinent negative
findings.
Example 15:
On physical examination, no abnormalities were observed. Findings are summarised in the following
table:
General
appearance
Vital signs
Cardio
Vascular
Lungs
Abdomen
Neurological
- alert and responsive

- no obvious pain or respiratory distress
- appearance was not suggestive of any syndromic-type illness or
endocrine abnormalities
- gait and posture normal
- no abnormalities in the neck, no goitre and no bruits no other
signs of thyroid disorder were found
-
all normal
heart rate 68 bpm
blood pressure 110/70 mmHg
respiratory rate 14 bpm
o
temperature 36.5 C.
- Dual heart sounds, nil else

- No pitting oedema
- peripheral pulses present
- Chest clear
- Soft, non-tender, no abnormalities
- Cranial nerves, sensory and motor functions of upper and lower
limbs all unremarkable
- No abnormalities in hearing or eyesight
- No other abnormalities detected.
Lisa was extensively investigated. Bloods tests such as full blood examination (FBE), urea and
electrolytes (U&E), renal function, liver function test (LFT), thyroid function test (TFT), urine toxicology,
and blood sugar levels (BSL), were conducted. All values were within normal limits. Imaging studies
such as MRI head and CT abdomen were unremarkable.
(Note: If you have already included investigation results in your History of Presenting Complaint when
describing treatment to date, no need to re-itemize here but refer the reader back to where you
discussed it.)
Page 12
4. SUMMARY AND DIAGNOSIS (Who and What)

Framework:
Briefly summarise the patient, drawing on key

information you presented in earlier sections of
the report
Include information on Axis I through Axis V

of the DSM classification system.
For Axis I, and if appropriate Axis II, also include a

discussion of the differential diagnoses to be
considered for your case, from most likely to
least likely. Do not include diagnoses that you
have no evidence for.
TIPS
1. The summary must draw on all areas in the
earlier parts of the report. Do not
introduce new information here.

2. You must address the question Why is one
diagnosis more likely than another?
Include at least three Axis I diagnoses you
considered.
3. If you have considered an Axis II diagnosis or

traits, also provide evidence for this.
For each differential diagnosis, present evidence from the earlier parts of the report
that serve to support/ discount the likelihood of the differential diagnosis. You
may wish to organize your information in prose (paragraphs) or as dot points. Draw links to
DSM diagnostic criteria.
A patient may have more than one co-morbidity or diagnosis on Axis I (eg. Alcohol Abuse and
Major Depression). Present the primary diagnosis and co-morbidity for the current presentation
first, then list differential diagnoses for the primary diagnosis.
Example16: Summary
KD is a 42 year-old married, recently unemployed man with a past history of IVDU and PTSD. He
presents with suicidal ideation as a result of recurrent intrusive flashbacks and nightmares,
representing an exacerbation of PTSD from when he witnessed his sons death. This has occurred in
the setting of a number of physical and psychosocial stressors such as suffering a stroke, the loss of
his home and business, and an inability to resuscitate a dying man. He has a history of an abusive and
emotionally deprived background. He also has an Antisocial Personality Disorder with limited
maladaptive coping mechanisms, and minimal social supports apart from his immediate family.
Example17: Axis I V diagnoses and differentials

Multi-axial DSM-IV-TR Diagnosis (including differential diagnosis)
Axis I
Diagnosis (most probable): Major Depressive Disorder
o Lisa has had both depressed mood and anhedonia
o Lisa has also had insomnia, fatigue, feelings of worthlessness and guilt, decreased
concentration, and suicidal ideation
o Most of these symptoms have been present for 12 months, all of them for the last
1-2 months and they have been causing Lisa significant distress and impairment in
functioning
o These symptoms are not better accounted for by the effects of a substance,
general medical condition or bereavement
o The anhedonia, suicidal ideation and early morning wakening are indications that
her depression is severe
o Lisa has somatic and anxiety symptoms associated with her depression
o It is possible that this is Lisas first major depressive episode, as details of her
childhood episode are limited, in which case she would not yet be classified as
Page 13
having major depressive disorder

Differential Diagnoses:
o Adjustment Disorder (with depressed mood)
Lisa does have several stressors such as academic difficulties, bullying,
relationship problems (especially with her sister), financial difficulties at
home, and cultural dissonance
It is likely that these stressors precipitated her symptoms but the distress
does not seem to be excess of what one would expected from the
exposure to these stressors combined
In addition, most of these stressors either occurred after, or more than 3
months before, the onset of symptoms
Although this mood disturbance is likely to be stress related it is better
accounted for (and meets the criteria) by major depressive disorder
o Panic Disorder (without agoraphobia)
Lisa has had three panic attacks however she has never had any
persistent concern, worry or change in behaviour between attacks (though
it is possible that she is minimising any distress caused by the attacks)
The attacks have been at times where her depressive symptoms have
been the most severe, and have subsided since treatment and
improvement of her depressive symptoms
o Generalised Anxiety Disorder
Although Lisa does have symptoms of anxiety (irritability, fatigue, poor
concentration, insomnia, muscle tension) which she has had most days for
6 months, they have been occurring exclusively during a mood disorder
o Bipolar Disorder
Lisa has not had any manic or hypomanic episodes, though this diagnosis
is important to consider as she is quite young and may in the future
o Pain disorder (Chronic, associated with psychological factors)
Lisa experiences pain in her chest and abdomen along with limb
clumsiness of sufficient severity to warrant clinical attention and with no
physical causes found
However, these symptoms are better accounted for by a mood disorder
o Aspergers Syndrome
Although Lisa does not fit the DSM-IV criteria for Aspergers Syndrome she
does have a marked qualitative impairment in social interaction especially
nonverbal behaviour which does cause her significant impairment
Axis II
Obsessive Compulsive Personality traits:
o Although Lisa does not fully meet the criteria of obsessive-compulsive personality
disorder she does exhibit some emerging traits
She can become quite preoccupied with rules, order, organisation and
schedules
Lisa can be excessively devoted to work to the exclusion of all other
activities; when doing home school on most days she studies from 9am
10pm , with no breaks, eating while she studies
She can be quite rigid and stubborn (describes herself as inflexible)
o However, these traits may also be due to a pervasive development disorder
(specifically Aspergers Syndrome)
Possible Mental Retardation
o This is most likely mild due to her level of functioning
o Lisa was tested for intellectual disability by a school psychologist after concerns
from teachers due to her poor school performance
o Although she performed below average in many areas testing, results are
inconclusive as they may be due to her English skills
Axis III
None
Axis IV
Problems with primary support group: mother often absent and doesnt get along with sister
Page 14
Problems related to social environment: difficulty making friends, bullied at school

Educational problems: academic difficulties
Economic problems: mother has financial difficulties
Still having difficulty adapting to new culture and language
Axis V
55 on Childrens Global Assessment Scale [CGAS] - used instead of Global Assessment
of Functioning [GAF] for people under the age of 18
o Lisa has variable functioning with sporadic difficulties in several but not all social
areas (does have some friends and some normal parent interaction)
o These would be apparent to those who encounter her in a dysfunctional time or
setting but not in other settings
5. Risk Assessment
Your risk assessment must include the day of assessment, as the risk assessment changes over time.
Include your assessment of the patients risks of harm to self and/or others, risk of neglect of self and/or
others (including non-compliance), risk of absconding, risk of exploitation, risk of homelessness and
other safety risks. Although you may use a standardized form on your placement for risk assessment,
do not include the form with your report, although you may use it as a guide for sub-section headings.
Quantify each risk and provide evidence from earlier sections of the report as appropriate.
Example 18: Risk Assessment on day 2 of admission
Suicide: Lisa had suicidal ideation for a month before admission and had made plans.
Currently she denies suicidal ideation, her mood has improved and she no longer has
feelings of hopelessness so she is at low risk of suicide. She has made no previous
suicide attempts.
Self-Harm: At the present time, Lisa denies any thoughts of harming herself though
previously she has by banging her head into her wrists so she is at low risk.
Harm to others: Lisa does get quite irritable and annoyed at staff and occasionally raises
her voice though she has never harmed staff; her risk is low to moderate.
Self-Neglect (including compliance): Lisa is at no apparent risk of self-neglect as

throughout her admission she has always taken care of her personal hygiene and
nutrition. She is also very compliant with her medication and believes it is improving her
condition significantly so her risk of non-compliance is low.
Risk of exploitation: Lisa has a moderate risk of exploitation as she seems quite trusting
of friendly people and as she has a lot of trouble understanding people she is unlikely to
be able to know their intentions and may be easily led.
Absconding: Lisa has no apparent risk of absconding because she likes being an
inpatient and feels safe and happiest when she is in the unit; she does not like going
home on leave and is always eager to return.
Financial: Lisa is at no apparent financial risk as she spends very little and as a teenager
is not given the means to spend large amounts.
Sexually Inappropriate Behaviour: Lisa is at no apparent risk of sexually inappropriate

behaviour.
Page 15
6. FORMULATION (How and Why)

In this part, you should attempt to tie together the information you have provided in the earlier parts of
your report in an attempt to explain the aetiological basis of the patients illness. In other words,
consider the importance of the following factors in relation to the patients illness:
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors
Attempt to define the psychological, biological and social forces that have contributed towards
the development of the above-mentioned factors in your discussion. You need to be able to draw on
relevant pieces of information from earlier parts of your report in your discussion and analysis.
You can also integrate evidence and concepts from the wider literature, although a literature review
is not the primary task of this report. This is where you need to demonstrate your understanding
of the patient and their problems by making links between the information you have presented.
Regardless of whether you include it or not in your final report (if you have word space), it is useful to
draw up a table as in example 19 for yourself to help you identify and classify all your information before
you write your final version. Remember that psychological evidence relates to the patients
thinking or view of themselves and the outside world, while social evidence relates to relationships,
interactions, and observed behaviour.
Example 19 (table):
Biological
Psychological
Social
Predisposing
Precipitating
Perpetuating
Protective
- FHx of mood and

personality disorders
- Female
- IBS symptoms
provided negative
reinforcement to eat
- Fear of food making
her teeth filthy and
yellow when she had
bands
- Schizoid and
obsessivecompulsive
personality traits
- Low self-esteem
and a sense of
powerlessness
- Peak onset of
anorexia nervosa
is in
adolescence
- Menarche
- Desires to
remain little and
associates dirty
menstruation and
secondary sexual
characteristics
with weight gain
- Age of onset
associated with
better likelihood
of remission than
if Eve had
developed
anorexia nervosa
later in life
- Sleep
disturbance
- Pervasive fear of
failure,
particularly not
achieving a high
enough VCE
score for
admission to law
course
- Began dieting as
a New Years
resolution to gain
control over her
life and be like
the popular girls
- Losing weight
gives Eve a sense
of control, security
and
accomplishment
- Desire for
control over life
- Desire for
independence
from her family
- Controlling
mother
- Famiy
dysfunction
- Media promotes
a slender
physique
- An overweight
body is
- Parents had an
acrimonious divorce
when Eve was 5 yrs
old
- Absent and
idealised father
- Ambivalent
relationship with
controlling and
- Close
relationship with
paternal
grandmother and
school teachers
Page 16
unaffectionate
mother
- Poor coping styles
exhibited by her role
models (mothers
nervous breakdowns,
substance abuse by
father, ascetic
maternal
grandmother)
- Poor social
integration and no
close relationships
with peers (feels like
an outsider and a
charity case in their
company)
considered as an
expression of
weak willpower
and laziness by
many subcultures
of Australian
society, including
Eves peer group
Example 20 (prose):
...
Predisposing Factors
In this case, KDs witnessing of his childs death was a significant enough event to signal his
unconscious to utilise defences and coping mechanism to deal with the stress. KDs personal history
and antisocial personality traits have resulted in him having a very limited range of maladaptive
coping techniques, which were inadequate to deal with the stress of the situation. His main method of
problem solving and dealing with conflict is through physical aggression and anger This was probably
adapted from his harsh adolescence living on the streets and amongst gangs, time spent in jail, and
also through modelling from his fathers own violence towards KD.
A most significant aspect of KDs life is the childhood trauma he suffered as a result of both his
mothers abandonment, and also his fathers physical and emotional abuse. According to Freud, it is
possible that the trauma of his sons death symbolically reactivated the previously quiescent,
unresolved psychological conflict of his childhood abuse. As a result it is postulated that the ego
relives, and thereby tries to master and reduce the anxiety associated with the earlier trauma (Sadock
& Sadock 2003: 1472-3).
Example 21
Leo has several factors which predispose him to schizophrenic psychosis. The primary biological factor,
given he has no reported family history, is being male. Males have a slightly higher prevalence of the
disease and slightly poorer prognosis.(3) Factors, likely psychosocial in nature, which also predispose
him to this condition are early loss of a parent(5), urban upbringing(3), and being born in winter(6).
The time period 15-20 years ago appears a number of times in his history. This may have been the
onset of his disease or more likely a crisis period where his disease worsened significantly. During this
period, Leos first son committed suicide, Leos house burned down and he was severely injured in the
blaze, Leo retired from the workforce, and Leos marriage broke down. Leos retirement is most likely
a result of this crisis rather than a precipitating factor, and similarly it is most reasonable to assume
the suicide of his son was a precipitating factor rather than a consequence of his disease. The fire was
allegedly due to electrical fault and thus could have been a traumatic precipitating factor, or it also
Page 17
may have been set by him, though this makes it no less traumatic and it clearly still affects him in one
way or another. Finally the breakdown of his marriage is likely a consequence of his disease rather
than a precipitating factor, but were it to be true his wife did leave him for another man (or even
simply left as a result of the sons suicide) this could have been a precipitant to a crisis in his condition.
7. MANAGEMENT
On the basis of your formulation, you will need to outline an appropriate management plan, including:
a. further investigations and why they are indicated
b. immediate plans (during hospital stay)
c. short-term goals (post-discharge plans and interventions)
d. long-term goals (on-going plan)
e. consider appropriate medications, psychological therapies, other non-
pharmacological treatments, referrals, and on-going monitoring

Include pharmacological and non-pharmacological methods of treatment/ intervention and reasons for
them, referrals, and follow up plans. If an involuntary patient, indicate the criteria for release.
Also give an indication of the prognosis for the patient if possible and on-going expected risk
assessment, including relapse prevention and rehabilitation.
Example 22:
Investigations
No further investigations are necessary unless there is a change in the physical symptoms Lisa
experiences or her physical exam findings.
Short term
Although it is currently low, it is important that Lisas risk is continuously reassessed, especially in
regards to suicide and self-harm. The critical points for reassessment are whenever her situation
changes as this is likely to precipitate symptoms and change her risk; for example change in room,
schedule, medication or discharge. It is also vital to monitor her daily for side effects of venlafaxine
and continued improvement of symptoms. As IQ testing was inconclusive due to Lisas English
difficulties her English proficiency must be tested and then her IQ must be tested again, if necessary
in Vietnamese. It is important to determine if she has mental retardation as management must be
altered accordingly since this would not only affect her functioning but her current illness.
As Lisa now has some insight into her condition and is willing to be treated she should be made a
voluntary patient as this would empower her and encourage a more therapeutic relationship with her
treating team. It is also important to encourage Lisa to participate in group activities with the other
inpatients.
Intermediate and Long Term
Lisa should continue the venlafaxine for 12 months to prevent relapse and allow time for
psychological therapies and social supports to take effect; it should then be gradually withdrawn. It is
also important to encourage compliance and continue to monitor for side effects and improvement
while Lisa is on the medication. If improvement is not sufficient an increase in dosage may be
considered as the medication is unlikely to be having a noradrenergic effect at the current dose
(150mg daily). In addition, it is vital to continue to assess her risk, though less frequently.
As many psychological, behavioural and social factors contribute to Lisas condition, nonpharmacological treatment plays a large role. It is important to educate both Lisa and her family on
depression, its treatment and effects. Counselling should be offered to Lisas family as Lisas
depression can affect them and they can aid her recovery. Family therapy would be constructive as
Lisas mother needs to be encouraged to spend more time with her. In addition Wendy and Lisas
Page 18
relationship needs to worked on especially in regards to jealousy and bullying issues. It is also
worthwhile to assess Wendy for depression as she has many of the same risk factors as Lisa and in
addition has a depressed sibling who she lives with, adding to her predisposition. Lisas counselling
must focus on explaining the need for discharge and the temporary nature of inpatient stay along with
the support she will receive after being discharged and that she will not be on her own as this
thought greatly distresses her when discharge has previously been brought up. Lisas history needs
to be examined to determine her early warning signs of relapse including irritability, insomnia and
anxiety. Lisa and her family need to be educated on detecting these signs and seeking help.
Mindfulness based Cognitive Behaviour Therapy would be of benefit for her to work on both
her obsessive-compulsive traits and to challenge any negative thoughts associated with her
depression. Acceptance and commitment therapy may also be of use to help Lisa manage her
feelings by increasing her psychological flexibility. Lisa has trouble initiating leisure activities and
tends to only study if left alone unless she has appointed scheduled activities to attend. Therefore a
schedule could be made to help her plan periods of leisure.
A day program, for a few weeks at the inpatient unit, can be considered to ease Lisas
transition. To aid her studies and encourage socialising Lisa could join a study group at a local
library. In addition, Lisa may be able to get financial assistance for private tutors or free tutoring
through one of the various community support groups catered towards adolescents. Lisa should be
encouraged to resume group social activities such as Tai Kwon Do and possibly additional activities in
her areas of interest such as a drawing class. Lisa may benefit from joining a local Vietnamese
cultural group as she could meet and learn from teenagers of her own culture who have adjusted well
to Australian culture. Community groups and online resources for teens who have suffered
depression may also be of use for Lisa.
Lisa is unsure whether her insomnia begun before or after her depression. If it does not
resolve with her depressive symptoms any sleep hygiene issues should be explored and advice
should be given. This issue along with her ongoing risk assessment and medication monitoring can
be managed by Lisas general practitioner. Lisas case manager should also be liaised with
especially in regards to referral to available community services.
DOs
DONTs
use headings and subheadings

to help organize your report
provide the appropriate
information under each heading
use an academic style
de-identify the patient and
others involved
stay within the word limit
tables and diagrams are
included in the word count
use an acronym without first

identifying it in long form (e.g.
Obsessive-Compulsive Disorder
(OCD))
abbreviate headings
include information or
discussion which does not
belong within that section
repeat information unnecessarily
forget to re-read your report to
double-check for clarity and
meaning
forget your cover sheet
References:
Bloch, S., and B.S. Singh (2007). Foundations of Clinical Psychiatry (3rd Ed.). Melbourne: Melbourne
University Press. Especially, Chapter 16, available online via Voyager Catalogue:
http://images.lib.monash.edu.au/med1022/04118932.pdf
Psychiatry Year 4 MBBS 2012 Metro Student Guide, Monash University
Page 19
Writing Tips 1 English tense and aspect:

Incorrect use of tenses and time markers impacts on temporal sequences, which influences the logical
structure of the text and may even influence clinical interpretations of illness. In addition, in reporting past
events, your choice of English tense-aspect will allow you to add your perspective on the current relevance
of the patients symptoms, signs, and experiences.
Verbs are words which describe actions and states of being. In English, the time that these actions or
states of being (lets call them events) occur must be encoded in the use of verb tense. English also uses
verb aspect to describe whether the action or state should be viewed as a whole event (a point in time) or
as an ongoing experience (a period of time).
Time is viewed as linear in English, and the most common reference point used is NOW. The simple tenses
encode whether events occur at the time of NOW (present tense), before NOW (simple past tense), or after
NOW (simple future tense). The default aspect for the simple past and future tenses is as a complete whole
at a point in time, while the default aspect for the present tense is as an ongoing, incomplete experience
across a period of time. The perfect tenses reference events to a point in time other than NOW, with past
and future events relevant to that alternative reference point.
Time
----------------------l---------------------------l------------------------l---------------------
past
NOW
future
The present tense is used to describe:

Events and ongoing beliefs occurring NOW, including the patients verbal reporting. This tense is used
frequently in the introduction and history of presenting complaint when describing symptoms, and may
also be used in the summary, risk assessment, formulation and management discussions.
(1) KD reports that nightmares of his sons accident began recurring in January, 2005.
(2) he attributes this to having nightmares about his son
Habits and permanent states
(3) KD is a chef who lives with his wife and supports two children from previous marriages.
The simple past tense is used to refer to:
Events in the patients history that happened in the past, before NOW. This tense is used in most
history sections of the report to describe completed events.
(4) In December, 2004, KD suffered a stroke, which caused temporary right hemiparesis. (5) The
financial problems caused him and his wife to be evicted from their apartment.
The present perfect tense is used to refer to events in the patients history that started or happened
prior to NOW but still bear current relevance.
In the history, you may describe signs and symptoms that began in the past and are still continuing.
(6) Following the stroke, KDs mood has been down and irritable
(7) The increased arousal and nightmares have resulted in significant sleep disturbance
You may describe signs and symptoms that no longer exist but that have an impact still felt in the
present (i.e. they were experienced a short time ago)
(8) In the last four days, KD has experienced two nights of no sleep.
You may describe completed events whose impact remains significant in the present situation.
(9)and has decided to present himself to hospital to get help for the sake of his wife and children.
The progressive tense is used to describe:
Ongoing or temporary states (symptoms/signs) or situations, either in the past or present time, when
you want the event to be viewed across a period of time:
(10) Now, KD is experiencing excessive tiredness and anxiety
(11) Prior to the resuscitation attempt four days ago, KD was feeling quite good.
http://www.monash.edu.au/lls/sif/Tutorials/Grammar/grammar.html
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MED4171 Medicine of the Mind

Student Academic Support Unit (SASU)

Psychiatric Written Case Report

MED4171 Medicine of the Mind

Psychiatric Written Case Report

Expectations for the Report

1.2 History of Presenting Complaint

level of functioning & coping strategy

c. Note details of current treatment so far up to the point of your

1.3 Past Psychiatric History

TIP In this section, you need to

The following points are relevant in this section:

build a picture of the pattern of

details of previous episodes of illness,

Drug and Alcohol History (including presciption abuse, if any)

1.4 Past Medical History

Systems most relevant include: cardiovascular, neurological and

Similarly, demonstrate an understanding of the significance of

Other medical and surgical history not directly related to their

You need to show that you:

1.5 Family History

Generations at least parents and siblings, but may also

Example 10: Genogram

Example 11: Family history

1.6 Personal History / Development

the patients responses

you may include other interests, social groups, religious

may have an Axis II

Lisa is of Vietnamese ethnicity and was born in Japan as her family

2. MENTAL STATE EXAMINATION (MSE)

You must include an MSE YOU have done

Lisas affect is blunted with a markedly reduced range of reactivity. She

3. PHYSICAL EXAMINATION and INVESTIGATION RESULTS

- alert and responsive

- Dual heart sounds, nil else

4. SUMMARY AND DIAGNOSIS (Who and What)

Briefly summarise the patient, drawing on key

Include information on Axis I through Axis V

For Axis I, and if appropriate Axis II, also include a

introduce new information here.

3. If you have considered an Axis II diagnosis or

Example17: Axis I V diagnoses and differentials

having major depressive disorder

Problems related to social environment: difficulty making friends, bullied at school

Self-Neglect (including compliance): Lisa is at no apparent risk of self-neglect as

Sexually Inappropriate Behaviour: Lisa is at no apparent risk of sexually inappropriate

6. FORMULATION (How and Why)

- FHx of mood and

pharmacological treatments, referrals, and on-going monitoring

use headings and subheadings

use an acronym without first

Writing Tips 1 English tense and aspect:

The present tense is used to describe:

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