Case history structure

Case history structure

1. Case History

1.1 Introduction

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)
• Age
• Marital status
• Occupation
• Referral details
• Central problem

 

1.2 History of Presenting Complaint

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

 

1.3 Past Psychiatric History

"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 rational for describing the past psychiatric history immediately after the present illness."

Bloch and Singh (2001: 91)

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.

 

1.4 Past Medical History

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.

 

 

1.5 Family History

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).

 

1.6 Personal History/Development

Use the list in Bloch and Singh (2001:93) as a guide for selecting and organising the information in this section:

• Early development
• Childhood
• School
• Adolescence
• Occupation
• Menstrual history
• Sexual history
• Marital history
• Children
• Social network
• Habits
• Leisure
• 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).

Introduction examples

Example 1:

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.

Example 2:

Student's report

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 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.

Example 2:

Student's report

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.

Writing tips:

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).