1. Case history
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
Bloch and Singh, 2001:90
Julie, a 25-year-old single accountant, and a practising Jehovah's 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.
Lucy is a 34 year-old single mother who is living with her fiance and her 5 year-old son. Lucy was referred to the Monash Medical Centre by her general practice with a 4-week history of headache, the symptoms of which were so bad that she was forced to resign from work. A subsequent CT scan indicated the presence of a tumour in the right frontal lobe. Upon the CT diagnosis, Lucy experienced symptoms of depression and anxiety, which have progressively worsened. She is now awaiting the results of a cranial biopsy.
Mrs P, a 68 year-old married housewife, lives with her husband on a farm. She presented to the Emergency Department at the Monash Medical Centre with diarrhoea and moderate dehydration following bowel resection two weeks earlier to remove carcinoid tumours. This follows a two-and-a-half year history of diarrhoea and weight loss, which has seen Mrs P become increasingly housebound and more dependent on her husband, who suffers Tourrett's syndrome and depression, for care. Her current critical state follows closely on the suicide of her youngest daughter (aged 39 years) in March this year.
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 where 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. depressive, psychotic, 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 (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
Bloch and Singh, 2001:90
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The patient describes an eight-month history of anxiety symptoms, which began two months after a car accident.Lecturer's comment 1:
Central problem. 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.Lecturer's comment 2:
Common psychiatric symptoms. More recently she has had trouble concentrating on her work.Lecturer's comment 3:
Effect on work. Five days ago she was taken to her local GP after experiencing a typical attack in the supermarket.Lecturer's comment 4:
This is the precipitant. 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 dayLecturer's comment 5:
Impact of illness on work, social relations, and self-care. in an effort, she says, "to calm myself down and make things more bearable".Lecturer's comment 6:
The history is documented from the patient's perspective. The facts recorded must be based on the patient's description. Where appropriate, incorporate the patient's own words into the report.
Writing tip 1
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 shown.
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 work-up.
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 presenting complaint.
Writing tip 2
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 marked grammatically by appropriate use of English verb tense forms (see notes on Example 5.).
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.
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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.Show/hide lecturer's comment 1
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.Lecturer's comment 1:
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 help and 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.Lecturer's comment 2:
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 felt depressed and anxious about her health. She has lost enthusiasm 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 excessive anxiety.Lecturer's comment 3:
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." 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.Lecturer's comment 4:
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."
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.
In this section of the report, 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.
Record 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.
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.
- "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."
Bloch and Singh, 2001:92
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The patient, the eldest in a family of three daughters,Lecturer's comment 1:
Family size. still lives at home. Her mother, a 45-year-old primary-school teacher and her father, a 50-year-old electrician,Lecturer's comment 2:
Parents' ages and occupations. are described as strict and intrusive, a pattern she ascribes to their strong Catholic beliefs.Lecturer's comment 3:
Parents' personality characteristics. Their marriage is described as 'over years ago; they never talk or touch'Lecturer's comment 4:
Parents' marital relationship. and the atmosphere at home as tense.Lecturer's comment 5:
Family atmosphere. The patient is close to her younger sister in whom she confides.Lecturer's comment 6:
Special relationship. One sister has responded to a similarly distant relationship with both parentsLecturer's comment 7:
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.Lecturer's comment 8:
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).
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 (incl. drug/alcohol abuse, suicide attempts)
Include a geneogram (drawing of family tree).
Use the list in Bloch and Singh (2001:93) as a guide for selecting and organising the information in this section:
- Early development
- Menstrual history
- Sexual history
- Marital history
- Social network
- Forensic history
Keep notes for each subsection brief. In particular, note a) 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 b) how they responded to stressful life circumstances.
If possible, comment on the patient's personality traits prior to their illness (i.e. premorbid personality).