An introduction is necessary to establish the focus of your case and provide orientation to your reader. It should consist of a few clear and concise opening statements, which typically include information on:
- Name (pseudonym)
- Marital status
- Referral details
- Central problem.
Writing tip 1
The Introduction is different to the Summary that comes at the end of the report. It is much briefer (2 - 5 sentences) and is designed to set the scene for your reader. In it, you will establish the current presenting complaint and emphasise likely causal elements.
You may specify a diagnosis, especially if this is relevant to the presenting complaint and is established prior to the current presentation or is known at the time you conduct the interview with the patient. It is less likely to include data from sections other than the history of the presenting complaint (and past psychiatric history if relevant).
This should be a detailed account of the patient's 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.
Identify common psychiatric symptoms
You should make connections between the isolated symptoms that the patient may have revealed to you somewhat randomly in their interview by grouping the symptoms together (i.e. depression, psychosis, anxiety). This will help your writing to develop logical sequences. It may be necessary to comment on relevant negative as well as positive symptoms.
Comment on the impact of the illness on the patient's life
Consider work, social relations and self-care.
Note details of previous treatment
Include information on who administered management of the treatment (when and where), what the treatment was (and preferably the dose and duration of treatment), and the patient's responses to treatment.
Integrate current problem and psychiatric issues
Consider the relationship between the patient's psychiatric state and concurrent medical conditions.
Read the example and lecturer's comments.
Bloch et al., 2017, Chapter 6, p. 104
 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out of her home, inability to cope with anything out of the ordinary, initial insomnia and irritability, and she has withdrawn socially.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 "I'm 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".
 Central problem
 Common psychiatric symptoms
 Effect on work
 This is the precipitant
 Impact of illness on work, social relations, and self-care
Writing tip 2
You may choose to commence this section of the report with a summary of the key issues that you will address, as in the example.
The central problem is identified promptly in the first sentence, and relevant key symptoms are outlined immediately in the second sentence. This is important information in an objective diagnostic report.
Information on the impact of illness is placed next, helping to contextualise the patient's experience of the central problem and related symptoms. This information will contribute toward a more sophisticated diagnosis that accommodates the patient's experience and response to illness.
Note that in the example all symptoms (whether present or not) relevant to a diagnosis of anxiety and the differential diagnosis) have not been included. This is OK for an introduction but not for the history of the presenting complaint.
Writing tip 3
Chronology is established using three techniques.
The opening sentence not only identifies the central problem but also informs the reader of when the problem first started. This establishes a temporal perspective on the patient's current problem, which is relevant for framing the events when describing the course of the problem. Remember, in this instance, we are referring to the patient's current problem or episode, which may or may not be related to an underlying chronic condition. This means that, having alerted the reader to the fact that this presentation/episode is part of a longer-standing problem, the current episode is described first and then the remainder of the illness course beginning with the first onset of symptoms. This would usually be put in the history of the presenting complaint.
Events are placed in chronological order, which is regularly marked by the use of specific temporal markers, highlighted in the example ( e.g. “an eight month history...”, “began two months after”, “more recently”, “five days ago”, “since”). This is preferable to a specific date (as the reader then has to calculate the duration).
Temporal perspectives on actions, events, and states of affairs are also marked grammatically by appropriate use of English verb tense forms (see notes on Example 5.)
Many psychiatric illnesses are recurrent or have an acute-on-chronic course, so that the link between the present illness and past psychiatric history may be strong. This is the rationale for describing the past psychiatric history immediately after the present illness.
Bloch & Singh (2017), Chapter 6, p. 104
The following points are relevant in this section:
- details of previous episodes of illness
- previous psychiatric admissions/treatment
- outpatient/community treatment
- suicide attempts/drug and alcohol abuse
- interval functioning (what is the patient like between episodes/when "well').
By including this sort of information, you will build a picture of the pattern of illness (chronicity, severity, coping strategies, crisis triggers, etc.), which will contribute toward a complete discussion of the illness.
Writing tip 4
In reporting past events, your choice of verb tense 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.
In this section of the report, you need to show that you
- understand the relationship between medical conditions and psychiatric symptoms, and
- can appreciate the complexity of medical problems that might be exacerbated by psychiatric conditions.
Make or keep a record of medications. Demonstrate an understanding of the significance of drug therapy on psychological function and, if appropriate, focus on medications taken by the patient that may influence the patient's psychological function.
Writing tip 5
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 6
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 verb tense in case presentations.
Bloch et al., 2017, Chapter 6, p. 106
 Melody, 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 is tense.  Melody 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.  Melody’s mother was hospitalised with post-natal depression twenty years ago. There is no other family history of psychiatric illness.
 Family size
 Parents' ages and occupations
 Parents' personality characteristics
 Parents' marital relationship
 Family atmosphere
 Special relationship
 Parents' relationship with children
 Family history of psychiatric illness
Writing tip 7
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.
Your perspective on what a family unit means 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 principally of 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).
Include details of:
- Parents and siblings, nature of the relationships between family members.
- Any family tensions and stresses and family models of coping.
- Family history of psychiatric illness (including drug/alcohol abuse, suicide attempts).
Use the list in Bloch et al., 2017, Chapter 6, to assist you in selecting and organising the information in this section. As the authors note, the list is only a guide:
- Early development
- Menstrual history
- Sexual history
- Marital history
- Social network
- Forensic history.
Keep notes for each subsection brief. In particular, note
- any problems the patient may have experienced with adjusting to predictable stages of development (e.g. - but not restricted to - effect of medical and psychiatric illnesses on development), and
- how they responded to stressful life circumstances.
If possible, comment on the patient's personality traits prior to their illness (i.e. premorbid personality).