Past psychiatric history examples

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Example 4:
Student's report
Lucy has a 4-week history of severe headache. Initially, Lucy reported a disturbance in her vision, saying that
she saw "purplish-black colour spots" in her vision. This was followed by the onset of a severe headache
located at the right frontal and temporal regions, radiating to the right occipital area. The headache commenced
as mild and dull pain then became severe and throbbing in nature. It was worsened by straining and coughing.
Lucy likened the pain to "being stabbed and squeezed by someone continuously" and described the headache
as the most horrible she had ever had. Lucy's GP prescribed her Panadol. The medication did not help and
Lucy started to experience nausea, vomiting, and mild photophobia. She also experienced pain at the nape of
her neck.
2 weeks after the headache commenced, Lucy was referred to an ophthalmologist. An angiogram showed
signs of venous blockage in the retinal veins. The headache persisted, and 3 weeks after it commenced, Lucy
was becoming more worried about it. She was experiencing (4)sleep disturbance, poor appetite and weight
loss (she reports losing 5kg over three weeks). At the time, Lucy resigned from work, thinking that her
symptoms were stress-related and she probably needed a break. Lucy also sought a second opinion from
another GP. A CT scan revealed a tumour in the right frontal lobe, which was causing oedema and a mid-line
shift. Lucy was immediately admitted to MMC for biopsy of the tumour. (The report commences with an account
of events in the past. In the first two paragraphs, events and experiences are predominantly expressed in the past
tense. The past tense is used to refer to:

Events in the patient's history that occurred prior to the interview and are squarely placed in the past.
Although related to the Presenting Complaint, the assumption of relevance to the current presentation is no
longer immediate (compare with the use of the present perfect tense, below)
"Initially, Lucy reported a disturbance in her vision..."
"Lucy's GP prescribed her Panadol. The medication did not helpand Lucy started to experience nausea,
vomiting, and mild photophobia.")

Since receiving the diagnosis of neural tumour, Lucy has felt depressed and anxious about her health. Lucy
has experienced two nights of restless sleep. She has lost enthusiasm for her usual activities, such as going
shopping and taking care of her son. She reports having no energy for maintaining her work or social life. She
has also become more irritable and aggressive, which is putting additional pressure on her family. She admits
to being preoccupied with thinking about her illness and is having trouble concentrating on daily activities. She
reports feeling tired but too scared to sleep for fear that she will not wake in the morning. ( The report moves
closer to present time. In the third paragraph, the present perfect tense predominates.
The present perfect tense is used to refer to events in the patient's history that occurred prior to the interview but still
bear current relevance.

In the history, you may describe signs and symptoms that began in the past and are still continuing.
"Since receiving the diagnosis of neural tumour, Lucy has feltdepressed and anxious about her health.
She has lostenthusiasm for her usual activities, such as going shopping and taking care of her son."
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)
"Lucy has experienced two nights of restless sleep."

You may describe completed events whose impact remains significant in the present situation.
"The physician has diagnosed a tumour in Lucy's right frontal lobe.")

In conjunction with her depressive symptoms, Lucy is also experiencing (The final paragraph brings the account
of events and experiences into present time.
The simple present tense is used to describe:

Events occurring at the time of the interview with the patient, including the patient's verbal reporting
"Lucy expresses concern..."

Habits and permanent states

"Lucy is a 34 year-old single mother who lives with her fiance and her 5 year-old son.")

excessive anxiety. Her anxiety is associated with restlessness, tiredness, irritability, insomnia, and difficulty in
concentrating. Other symptoms include palpitations, tachycardia and flushing. Lucy expresses concern over the
impending biopsy report, due sometime in the next two days, asking, "Am I going to die? Does the tumour
mean cancer?" Lucy also expresses concern over her son's welfare while she is hospitalised. In the last month,
her fiance and her mother have been looking after both her and her son. ( The progressive tense is used to
describe:

Temporary states (symptoms/signs) or situations, either in the past or present time:

"Lucy is experiencing excessive anxiety."
"Lucy was experiencing sleep disturbance, poor appetite and weight loss.")

(428 words)

Writing tip:
In reporting past events, your choice of English tense-aspect will allow you to add your perspective on the
current relevance of the patient's symptoms, signs, and experiences.
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 the example shown, note how the history is reported chronologically, starting with an account of most distant
past events and culminating in events and circumstances existing in the present time (i.e. at the time of the
interview). Note how the tenses shift through the report.

Past medical history examples

Example 4:
Student's report
Lucy has a set of medical conditions that are summarised as HERNS (Hereditary Endotheliopathy,
Retinopathy, Neuropathy and Stroke). 10 years ago, she experienced symptoms of proptosis, tachycardia,

thirst and vomiting and was diagnosed with Grave's disease. She was treated with Neomercazole. The
coexisting medical condition may be exerting an impact on Lucy's current anxious state. In addition, her
apparent poor coping mechanisms, which she has described as part of her personality trait, might also be
facilitating her anxious state.
In 1996, Lucy experienced a minor stroke, which caused temporary paralysis in her left arm. She was
monitored in hospital for three weeks and recovered.
3 years ago, Lucy was diagnosed as lupus carrier. Since the diagnosis, Lucy has been taking Warfarin and she
expects to maintain Warfarin therapy for life. Her condition has exacerbated a series of endotheliopathies,
predisposing Lucy to retinal microvascular occlusion.
2 weeks prior to her current hospital admission, Lucy was also diagnosed with hypercholesterolemia, a
suspected genetic disorder. She is currently taking Lipitol to manage this.

Writing tip 1:
Significant events in the Medical History are placed in chronological order, which helps with clarity of reporting.
Specific dates are used to help establish chronology clearly and succinctly.

Writing tip 2:
In this section, the simple past tense predominates but tenses shift when events bear significance to the
patient's present context.
Refer to earlier points made, under notes to Example 5, on the use of English tense in case presentations.
For example:

"Since the diagnosis, Lucy has been taking (present perfect continuous) Warfarin and
she expects (present) to maintain Warfarin therapy for life."

"Her condition has exacerbated (present perfect) a series of endotheliopathies.

She is currently taking (present continuous) Lipitol to manage this."

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Example 5:
Bloch and Singh, 2001:92
The patient, the eldest in a family of three daughters (Family size), still lives at home. Her mother, a 45-year-old
primary-school teacher and her father, a 50-year-old electrician (Parents' ages and occupations), are described
as strict and intrusive, a pattern she ascribes to their strong Catholic beliefs ( Parents' personality
characteristics). Their marriage is described as 'over years ago; they never talk or touch' ( Parents' marital
relationship) and the atmosphere at home as tense (Family atmosphere). The patient is close to her younger
sister in whom she confides (Special relationship). One sister has responded to a similarly distant relationship
with both parents (Parents' relationship with children) 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 (Family history of psychiatric illness).

Writing tip 3:

In Australian culture, when a person is married with children and living away from the parental home, we tend
to think of the family unit as comprising the couple and their children. In other words, the couple, as parents,
head the so-called nuclear family unit.
In some cultures, though, we place emphasis on one's own parents in family structures. Hence, even when a
person is married with children and living away from the parental home, we may think of the family unit as
incorporating the extended family and continue to emphasise an individual's parents as the head of the family
unit, which is larger than the nuclear family unit.
Obviously, your perspective on family unit will influence the way you report on the patient's family relationships.
As stated above, in Australian culture, while relationships with one's parents are integral to an individual, we
tend to view the family unit as consisting of principally the couple and their children. Hence, the couple is at the
head of the unit, while the couple's relatives, including their parents, comprise the extended family.
Consequently, in your report, in such a situation, you would focus immediately on discussing the patient's
relationships with their partner and children before moving on to discuss their relationships with their parents
and siblings. If the family unit is different, and larger, then you will need to consider your approach to reporting
on the patient's family relationships. Do not occupy unnecessary space by reporting on all the familial
relationships if the family is a large one and do not defer discussion of the patient's relationship with their
partner and children (it is probably one of the most influential).

Mental state examination examples

Example 11:
Student's report

General appearance and behaviour

Lucy is a 34 year-old Indian-Portuguese woman of average weight and height. At the
time of examination, she was well groomed and dressed. She was not confined to bed.
On appearance, were no signs of tremor or abnormal movements; however, Lucy
showed signs of proptosis, consistent with Grave's disease. Lucy was cooperative
throughout the interview. She maintained eye contact, except during the times when
recounting the history of her father's death and her previous marriage. Then, she
appeared depressed.
Speech
Lucy articulated herself clearly. She answered questions spontaneously, although at
slow rate and speed. She spoke softly throughout the conversation, particularly when
mentioning past unhappiness.
Affect and mood
Lucy's affect was depressed and her range of mood reduced. She also appeared
anxious and irritable.
Thought
a. Stream

Lucy's thought stream was decreased. It was also disturbed and Lucy's speech slowed
down and content reduced significantly when mentioning past unhappiness. b. Form
Lucy did not exhibit any formal thought disorders. She was able to answer questions
spontaneously and directly. She did not use any new or created words. Lucy did
experience thought block when exploring sensitivities in her past. No negative thought
disorder was detected. c. Content
Lucy was depressed and anxious about her health. She was obsessed with knowing
her biopsy result and was constantly asking the doctors and nurses for her result.
Thoughts that the tumour could be cancer were causing Lucy to lack motivation and
feel restless. Lucy was also feeling guilty for not being able to care for her son and
fiance since having the headache. Other than feeling obsession and guilt, Lucy has no
other positive symptoms, such as delusions, phobias or compulsions. Suicidal ideation
was not detected.
Perception
Lucy exhibits normal perception. Symptoms, such as illusions, misinterpretations,
depersonalisation, passivity phenomena, were not elicited.
Cognition
Lucy was alert and orientated to time and place. She was able to answer questions and
recall her past without difficulties.
Insight and judgement
When questioned about her condition, Lucy accepted the fact that she is ill and
requires treatment. She has cooperated with doctors and nurses and is compliant with
management.
Writing tips:
You may use the simple past tense to describe the patient's state at the time of the
MMSE, as in Example 11. This emphasises that the exam findings are specific to the
time of conducting the MMSE, but suggests that they are probably subject to change
if repeated.
Alternatively, you may use the simple present tense to report the findings of the
MMSE. This would contribute toward a consistent reference point for the report by
placing the activity of the MMSE at the same time as the interview, the findings of
which are forming the basis of this report. It would also grant the MMSE findings
more immediate perspective. Over multiple interviews it is important to state at which
point the MSE and MMSE were done, especially if the patient's mental state changes
or fluctuates.

Both approaches to reporting the findings of the MMSE are acceptable. It is important
to be consistent, though, in the approach you adopt.

Physical examination structure

3. Physical Examination
Emphasise signs relevant to both the patient's presenting and chronic problems and to differential diagnoses
where applicable.
Note signs of long-term psychotropic drug use.
Also attempt to identify signs that indicate the presence/absence of conditions that may present with psychiatric
complications (i.e. neurological and endocrine disorders, substance abuse).

Physical examination examples

Example 12:
Student's report
On general inspection, Lucy appeared to be tired. She showed a prominent sign of proptosis. She also had a
few bruises on her left arm, due to frequent cannulation and blood test, and a scar from her recent biopsy on
the right side of her forehead.
On cardiovascular, respiratory and abdominal examinations, no significant signs were detected. Blood pressure
was normal, 130/82. Pulse rate was 80 beats per minute and respiratory rate was 14 beats per minute.
On neurological examination, there were no signs of muscle wasting, abnormal movements or tremor. The
upper limbs showed full range of active and passive movements. On flexion and extension of the right arm,
however, pain was detected. The patient had normal tone, power, coordination and sensation in both arms.
Reflexes, however, were increased in both arms.
Examination of the lower limb showed normal tone, power, coordination and sensations. Plantar reflexes in
both legs, however, were decreased. There were no signs of abnormal gaits. Trendelenburg test, Pull test, and
Romberg's test all showed negative results.

Writing tips:
You may use the simple past tense to describe the patient's state at the time of the Physical Examination, as in
Example 12. This emphasises that the exam findings are specific to the time of conducting the Physical
Examination, but suggests that they are probably subject to change if repeated.
Alternatively, you may use the simple present tense to report the findings of the Physical Examination. This
would contribute toward a consistent reference point for the report by placing the activity of the Physical
Examination at the same time as the interview, the findings of which are forming the basis of this report. It
would also grant the Physical Examination findings more immediate perspective.
Both approaches to reporting the findings of the Physical Examination are acceptable. It is important to be
consistent, though, in the approach you adopt.

Summary and diagnosis structure

4. Summary and diagnosis
The summary must draw on all areas in the earlier parts of the report. New information cannot be introduced.
Essentially the summary will contain a brief outline of:

Who the patient is

What their problems are

What effects the problems are having on the patient

As well as a brief indication of:

Why the problems arose (precipitating factors)

How the problems arose (predisposing factors)

Factors influencing progression/ the course of the problems (perpetuating and protective factors)

Features may be drawn from all aspects of the history and examination, and should include relevant negatives
(features of the diagnosis and differential diagnoses that are not present).
The diagnosis will require you to synthesise signs and symptoms in the case report to identify core problems.
You should explicate your reasoning for drawing the links between signs and symptoms and diagnostic
decision-making. In other words, what important aspects in the History, Mental State Examination and Physical
Examination lead you to making the provisional diagnosis? Pick out the relevant pieces of these sections and
make links with the final diagnosis (and differential diagnoses).
One way to approach explaining your reasoning is for you to take each differential diagnosis and write down
the pros and cons evident in the earlier parts of your report that serve to support or discount the likelihood of
the differential diagnosis.

Summary and diagnosis example

Example 13:
Student's report
Lucy is a 34-year old single mother who has recently been diagnosed with a cranial tumour in the right frontal
lobe. The diagnosis explains her symptoms of persistent and worsening headache over the last four weeks,
which have led her to resign from work and rely more on her mother for support and care. Lucy has also
experienced symptoms of increased intracranial pressure, such as nausea, vomiting, and mild photophobia.
Hence, it is likely that the tumour is a space-occupying lesion, which is exerting the oedema effect and causing
the symptoms that Lucy is experiencing. Taking her age and sex into consideration, the lesion is most likely to
be a primary lesion, single and benign in nature. In addition, given that Lucy's father died 15 years ago of
stroke related causes, her mother and her sister both have cardiovascular illness, and Lucy has HERNS
syndrome, there is a high probability that the tumour has a vascular cause.
Lucy has become depressed and withdrawn since finding out that she has a brain tumour. In particular, she is
very anxious about the possibility that the biopsy results will show that the tumour is cancerous. Although

symptoms of depression and anxiety are not uncommon in patients threatened by a diagnosis of cancer, Lucy
has a history of feeling melancholy and, significantly, developed postnatal depression following the birth of her
son five years ago. Lucy's response to her current illness needs to be understood in this context, as it will help
to assess how well she will cope with the forthcoming diagnosis and future management of her illness.
Upon the mental state examination, Lucy exhibited sullen appearance and limited facial expression. Although
articulate, she spoke slowly and softly throughout the interview. Clearly, Lucy has a depressed affect. Her
history of childhood depression in conjunction with her recent history of poor appetite, sleep disturbance,
energy loss, reduced concentration and feelings of guilt indicate that Lucy is prone to developing a major
depressive disorder in response to her current medical condition.
From the information gathered in the history and examination, the following differential diagnosis can be
posited:
1) Major depressive disorder
Lucy's unhappy childhood and psychiatric history of depression support this diagnosis. In addition, she meets
at least five of the DMS-IV criteria on mental state examination.
2) Biological disorder
The tumour in Lucy's right frontal fossa might affect functions of the frontal lobe, which control thought and
personality. Consequently, Lucy's personality traits may be enhanced by such a biological disturbance, making
her more prone to stress and depression.
3) Anxiety
Lucy's sudden confinement in hospital, diminished ability to perform daily activities, and concerns about her
family and health, predispose her to experiencing anxiety, a potential trigger of depression.

Writing tips:
Links are made between symptoms and pathophysiological processes, which help explicate the reasoning for
arriving at a diagnosis:
Lucy has also experienced symptoms of increased intracranial pressure, such as nausea, vomiting, and mild
photophobia. Hence, it is likely that the tumour is a space-occupying lesion, which is exerting the oedema
effect and causing the symptoms that Lucy is experiencing.

The evidence supporting the diagnosis is provided from information gleaned earlier in the report.

Diagnosis: The tumour is a space-occupying lesion

Supporting evidence: Lucy's symptoms of increased intracranial pressure (nausea, vomiting, mild
photophobia)

Connections between the conclusions reached (diagnosis) and the supporting evidence (signs and symptoms)
are made with illatives, or argument indicators. There are two kinds of argument indicators. Either conclusion
indicators or premise indicators may be used in your text to link the evidence that supports the diagnosis.
Conclusion indicators are used to introduce a diagnosis after the evidence has been stated.
Conclusion indicators:

therefore

so

hence

thus

accordingly

and (so)

Example:
Lucy has also experienced symptoms of increased intracranial pressure, such as nausea, vomiting, and mild
photophobia. Hence, it is likely that the tumour is a space-occupying lesion.

Premise indicators are used to introduce the evidence that supports a diagnosis:
Premise indicators:

because

since

for

given that

for the reason that

granted that

Example:
It is likely that the tumour is a space-occupying lesion because Lucy has experienced symptoms of
increased intracranial pressure, such as nausea, vomiting and photophobia.
Example:
Given that Lucy's father died 15 years ago of stroke related causes, her mother and her sister both have
cardiovascular illness, and Lucy has HERNS syndrome, there is a high probability that the tumour has a
vascular cause.

Formulation structure
5. Formulation
In this part, you should explore in more depth the aetiology of the patient's illness.
You will need to draw on the precipitating, predisposing and perpetuating factors identified earlier in your
summary to define the biological, psychological and social forces that have contributed towards a) the
development of the patient's illness and b) their response to their illness.
A major difference between a summary and a formulation is that the latter seeks to link the pieces of
information as opposed to listing them.
You should draw on relevant pieces of information from earlier parts of your report and consider the patient's
presenting problem in the context of their history of chronic illness. You can also integrate evidence and
concepts from the wider literature; however, your statements should be an understanding of the patient, not of
the literature.

Formulation example
Example 14:
Predisposing factors
Lucy has a set of medical conditions, which can be summarised as Hereditary Endotheliopathy Retinopathy
Neuropathy and Stroke (HERNS). The syndrome affects the endothelial vessels of the eyes and brain. Damage
of the endothelium affects the biological functions of organs and leads to vascular disturbance and build-up of
necrotic tissue. Lucy is also a lupus carrier - the antibody, lupus anticoagulant, is associated with arterial and
venous thrombosis. Lucy also has high hypercholesterolemia, a genetic trait. Taking into account all of these
biological factors, Lucy is predisposed towards developing a brain tumour. The fact that her father died of a
stroke in his late 40s increases the likelihood that Lucy's signs and symptoms are genetically linked.
It is perfectly normal for healthy individuals to feel depressed when threatened with a diagnosis of cancer.
However, Lucy's history of depression, 'fragile' personality, and poor coping mechanisms when faced with
emotional problems make her more likely to be predisposed towards developing more serious forms of
depression compared with otherwise healthy individuals.

Precipitating factors
Obviously, the diagnosis of a neural tumour may be directly linked to Lucy's recent onset of anxiety and
depression. The co-current lack of stability in Lucy's life, including concern over the welfare of her son while
she is ill and the loss of her job, may also be contributing towards her recent depressive symptoms. The timing
of her illness is not especially good for Lucy, who is on the verge of committing herself to a secure relationship,
by marrying and providing a 'family' for her son.

Perpetuating factors
Lucy's experience of one illness after another has left her feeling insecure and with a sense of defeat, reflected
in her personality. Lucy has a weak character in that she has poor frustration tolerance and coping
mechanisms, causing her to emotionally collapse in stressful situations. Her weak personality is, therefore, a
perpetuating factor contributing towards the worsening of her current condition.

Writing tips:
Predisposing factors are the factors in the patient's history that make the patient susceptible or inclined toward
presenting with, where applicable, an underlying diagnosis, and has "these symptoms" in this current situation.
Precipitating factors are the immediate factors or events that have caused the patient to present with or
experience symptoms now. Depending on their backgrounds, life experiences, supports, coping strategies, and
current circumstances, we might expect or even predict that two different people would react differently to the
same (precipitating) event.
Perpetuating factors are the factors that are causing the patient's symptoms to continue or progressively
worsen.
Some students find it helpful to use these headings in the formulation. Other students are able to write more
freely without them. Note that most students appear to benefit from structuring the factual information in the
history and mental state using headings.

Management structure
6. Management
On the basis of your formulation, you will need to outline appropriate management plans, including:

Investigations

Short-term goals

Long-term goals

Management example
Example 15:
The appropriate management for Lucy will really depend on the precise nature of the tumour. However, it will
be crucial to monitor her in hospital and provide symptomatic relief for her headache, neck pain and
depression. A review of her co-existing medical conditions, Grave's disease, lupus, and hypercholesterolemia,
will need to be undertaken. In addition, it will be necessary to provide counselling and support to help Lucy
come to terms with her illness and so prevent the likelihood of her becoming clinically depressed.

Writing tips:
The future tense is adopted at this stage of the report, as management decisions for the patient are still to be
implemented.
Most lecturers would prefer students to provide more detail, especially of who is doing what. The expected
outcomes described briefly above are a start. Many students will just refer the patient to counselling without
stating why or what the expectations are.