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

Sample text and writing tips

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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

Sample text and writing tips

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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.

Sample text and writing tips

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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.

Sample text and writing tips

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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).

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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).