model case history is quite comprehensive | My Assignment Tutor

WRITING A PSYCHIATRIC CASE HISTORYGeneral Instructions:This model case history is quite comprehensive. Most case histories are under 10 pages(size 10 font). Number of pages do not necessarily translate to a better mark.Reading this model case history, one will have an excellent understanding of the patient’shistory, development, current situation and presentation. It also has an excellentdiagnostic formulation and exhaustive management plan.We do not expect most students to achieve this level of comprehension but it is helpful tosee an ideal case history written by another 4th year student.If you have problems with written English, we expect you to seek assistance in your casehistory. Ask assistance from the Student Learning Centre, friends or classmates.Microsoft word has spell check so please use it. Poor written English can affect yourmark.Medical records or clinic files cannot be taken home. Patients’ names, details or otheridentifying data should not appear in your report. Use pseudonyms or initials.Your case discussion should be your own.Do not “cut and paste” from medical records onto your case histories. It is much better toparaphrase information from medical records rather than copying them verbatim.Introductory statementThis should be one sentence to orientate the readers to the case and to provide focus fordiscussion. It proves to the examiners that you are not just presenting facts elicited butthat you have the skill to synthesise and make sense of a psychiatric presentation.Examples of introductory statements: – “ This case illustrates the complexity of diagnosisin a person with a first presentation of psychotic symptoms”, “ This case illustrates theclinical and ethical dilemmas of managing a woman with ongoing para suicidal behaviourand borderline personality traits”, This case illustrates the importance of a comprehensivepsychosocial rehabilitation assessment and strong treatment alliance in a man with atwenty year history of schizophrenia”. These statements should be based on what youbelieve to be the crux of the issue. If safety concerns are present it is important tohighlight this e.g “ This case illustrates the importance of managing suicide risk in anelderly man with an agitated depression.”DemographyAgain one or two sentences – you must put age, gender, occupation and ethnicity. Do notguess clients race or cultural affiliation ask this. You cannot practice psychiatry withoutunderstanding how the illness impacts on the individuals cultural world view or what itwould mean to them about themselves or what the implications are for treatment alliance.In demography you may also wish to put number of children or living circumstances e.g “Mr Pearce is a sixty year old Caucasian widower who is a retired bus driver and liveswith his only daughter”’ “ Mr Toto is a thirty year old Maori who lives with his wife andtwo year old son. He is a civil engineer.” Immediately with a demographic statement thereaders start to form a picture of the person as an individual.Mode of referralThis is a brief description of the context that you are seeing the person in e.g “ JanetJones has been a client of her community mental health centre for two years receivingtreatment for depression” “ Mr Smith was referred to the liaison psychiatry serviceyesterday by the inpatient cardiology team who were concerned about his bizarrebehaviour”History of presenting complaintThis is a description of the current complaints that the person has. This requires detailedelaboration often using the persons own words and supported by a relevant functionalenquiry. Quote the patient but in a selective way so that information is going to supportyour mental state and diagnosis and be consistent with the theme of the case e.g “ Johndescribes both male and female voices talking about him. They say insulting statementssuch as “ He has a hideous nose, no wonder everybody thinks he’s a freak”. With animportant piece of history like this you must tag on relative negatives e.g “ the voices donot tell or command John to do anything.”It would be helpful if the identified symptom (ie low mood, rapid speech, suicidalthoughts) are qualified in terms of a) onset b) duration c) precipitating or mitigatingfactors d) severity. For example, “Chris has had on and off thoughts of ending his life forabout 2 yrs now. It started after he separated from his partner. He noticed that everytimehe drinks alcohol, for the next 48 hours, these suicidal thoughts increase. On the otherhand, when he spends time with his kids, the thoughts seem to melt away.”If you have someone with psychotic symptoms you must present a relevant functionalenquiry e.g look for common delusions such as persecutory, mind reading and delusionsof reference. In history of presenting complaint this section should be detailed and mustinclude the patients attribution of their experiences e.g “ John believes the voices comefrom the devil as a result of a voodoo curse put on him by his neighbours.” Attributionshould also cover cultural understanding of illness.History of presenting complaint must also include impact of illness, e.g. “ Because ofJohn’s voices he has left home in fear and is now homeless. He has also dropped out ofhis Unitec course and has no contact with either family or friends.” This impactstatement shows the examiner that you are familiar with the concepts of disability andhandicap. A common criticism is that Drs can elicit symptoms but make no sense ofthem in terms of the individuals life experiences.Another key area is coping – how does the individual cope with their experiences – laterit can be discussed in the formulation whether this is protective or not e.g “ Jack copeswith the voices by drinking alcohol which he feels reduces their intensity” e.g “Janecopes with her feelings of being unreal by ringing her mother. If her mother is notavailable she cuts her wrist with a scalpel which she says helps her feel focused.”The other major area is safety. The most basic concepts of safety are suicidal risk andhomicidal risk. You have to make very clear emphatic statements on this “Jack presentsa very serious suicide risk. He has an active plan to kill himself by hanging. He hasbrought the rope and has selected a branch of a tree in his garden. He intended to hanghimself tomorrow on the anniversary of his wife’s death.” It is not enough to saysomeone is high or low risk, you must elaborate.“Patrick has ongoing intent to assault and possibly kill his sister because he believes thatshe is interfering with his thoughts and that she has conspired to give him schizophreniaand put him in hospital. He assaulted her with his fists and an end of a hammer last nightin response to these beliefs and he poses a serious ongoing risk to this sister and possiblyothers.”Safety also includes self cares “ Mr Jones is at serious risk regarding his personal safetyas he frequently wanders the streets in a confused state, walks in front of traffic andforgets his home address.”There are also specific high risk groups e.g. young men with a recent diagnosis ofschizophrenia who have just been discharged from hospital and who have depressivesymptoms e.g. women with puerperal psychosis and risk of infanticide (5%).Current medication duration of treatment, efficacy and side effects should bedocumented.Current neurovegetative signs and symptoms have to be included. These are sleep,energy, concentration, ability to experience pleasure, appetite and libido.A common problem that medical students experience is how to write up the history ofpresenting complaint in the person seen in a community mental health setting. The key isto start with their current well being not when they were referred several years ago. Thedetails of referral several years ago is part of the person’s past psychiatric history.Past psychiatric historyIf this is extensive, summarise the pertinent points. Exact dates are less important buttreatments received, responses and serious events leading to hospital are. If no pastattempts at harming self or others say this if there, detail it e.g “John has had at least tenhospitalisations over the last six years with what sounds like an exacerbation of hisschizophrenia. On one occasion he had a serious suicide attempt where he jumped infront of a car and fractured his hip in response to command hallucinations. He tells mehe has been on a number of medications including chlorpromazine, haloperidol, pimozideand an injectable antipsychotic. He also describes frequent side effects such as tremor,impotence and akathisea. He does not believe that the medicine treats his voices onlydampens them down” .By presenting past psychiatric history in this way you have directed the key issues thatyou can raise both in formulation and management namely treatment resistant psychoticsymptoms and forming a therapeutic alliance with a disengaged high risk patient withrevolving door admissions.Forensic historyUseful to put here as it may relate to past psych history e.g “ Janet has had one arrest fordangerous driving when she was manic.” Always mention even if negative “There is noforensic history.”Substance abuse historyNeed to not only quantify amounts of substances but show the distinction between abuseand dependency by relevant positives and negatives. If the case is clearly a substanceabuse one, the substance abuse history should be presented in history of presentingcomplaint. e.g “ Jean drinks two bottles of wine a night. She has at least five episodesof blackouts in the last year and two DIC charges. In the last week she has started tohave shaking hands in the morning which go when she takes 5mg of diazepam prescribedby her GP for anxiety. Last year she went to one AA meeting after an ultimatum fromher partner but has had no help since.”Family psychiatric historyNot just psychiatric diagnosis and treatment but ask about family suicides and substanceabuse. E.g Alcoholic parents are relevant for a risk of alcoholism in children but alsovulnerability to personality or mood problems in children because of attachmentexperiences. This section can not only relate to genetic risk in formulation but also themeaning of the illness to the individual.Medical HistoryYou may wish to put this heading higher in your presentation e g if doing an elderlypatient. The order of the headings can be flexible but each must be clearly articulated.Use common sense to the most relevant parts e g don’t write in detail on anappendicectomy that is likely to be of no relevance. However, a diagnosis of diabetes ina woman with an eating disorder is highly relevant and would require detailed discussion.Key points are physical illness and their treatment either presenting as a mental illness orincreasing risk for a mental illness e g post CVA depression or the impact of a chronicillness on an individual’s personality development and mental well being e g majorimportance if you get a young person who has had a chronic severe physical illnessthroughout of their life. Clearly a psycho geriatric case requires detailed consideration ofmedical history.Social historyKey areas need to be covered but again select information that is relevant to the overallpresentation. This should cover family composition, what was childhood like e g majorevents like death of family member e g overall family atmosphere e g “John is the oldestof three sons. He describes a chaotic and traumatic family life where he often witnessedhis father assaulting his mother. Frequently John and his brothers would be taken fromthe house by different extended family members. He had been to ten different schools bythe age of fourteen and had difficulty forming friends and learning to read to write. Hefrequently got into trouble with the teachers and was expelled at fourteen for assaulting ateacher.”You also need to give a vocational and relationship history e.g Ann has worked for tenyears as a teller in the bank. She married her first boyfriend at the age of nineteen butdescribes the marriage as “loveless”. She finds she has little in common with herhusband and has never enjoyed sex as she finds it “dirty”. Her husband is 10yrs olderand tends to be controlling. They have no children and Ann has little social contactoutside the fundamentalist church she attends weekly.” Hobbies and religion are goodthings to present here as both are related to recovery.Premorbid personalityDon’t leave this out because its difficult. You get major clues from how people cope orappraise illness, forensic history, relationship and work history. Also from yourobservations in interviewing people e g the style of communication of someone who ishistrionic and flamboyant or with the overinclusive obsessional person who makes youparticularly irate in a setting which is time limited. Generally not good to label as“disorder” unless very clearly able to defend the case as such e g you may get a womanwith borderline disorder. Better to say “Sam has features (traits) of an obsessionalpersonality. He describes a need for orderliness and perfection and control over anumber of situations. Sometimes it also helps if you ask the patient (and or family) howthe patient was as a person prior to the onset of illness.Physical examinationGenerally brief and tailored – in psycho-geriatric cases may need more detail e gdetailing physical findings of Parkinsons. In eating disorders you will fail if you don’thave weight+height for BMI and look for features of anorexia or bulimia. In some onewith a primary substance abuse diagnosis look for this eg stigmata of alcoholism. Insomeone on long term anti-psychotics do an AIMS in someone on lithum look fortremor/hypothyroidism.“On physical examination Jane had a BMI of 16 her skin was dry and showed lanugo.Her teeth were chipped with dark staining. On cardiovascular examination she wasbradycardic with a pulse of 48/minute regular. Her BP was 110/60 and her heart soundswere dual with no murmurs. Her temperature was 36.5C. No further abnormalities weredetected on a brief examination.”Mental state examinationThis is the art and science of psychiatry. It must be organised, detailed and consistentwith what has been presented. Use the phenomenological terms and be sure you canjustify and define them. Do not leave out a section you cannot say “cognition was notassessed” unless you have an exceptionally good reason such as the patient walked out ofthe room.A Appearance, behaviour, eye contact and rapportPaint a picture of the person in front of you – its good psychiatry and it makes itinteresting to listen to eg “Paul was dressed in unevenly buttoned hospital pyjamas with aripped denim jacket on top. During the interview he remained curled into the corner ofthe couch and avoided eye contact. Rapport was difficult to establish as he seemedfrightened both of being in hospital and the experiences he was going through.”Comment on the quality of the rapport don’t just say good or bad elaborate on it.Describing why rapport was bad doesn’t mean that you are necessarily a bad Dr ratherthat you are a reflective Dr with a conception about dynamics. DO NOT BLAME THEPATIENT OR MAKE DEROGATORY REMARKS ABOUT THEIR APPEARANCE.Orientation/CognitionPresent a MMSE with frontal lobe extensions. If there are no abnormalities this can bedone quickly eg “ No abnormalities were detected on a Folstein Mini Mental StateExamination or on tests of frontal lobe function.” If there are any cognitive abnormalitiesthis is always relevant and you have to say what tests were abnormal.“Mrs Jones scored 27/30 on a Folstein Mini State Examination. She made two errors ontesting of attention and concentration and scored two out of three on short term memorytesting at five minutes. On frontal lobe testing she displayed several deficits. Sheperseverated on copying alternative patterns of w’s and m’s. She perseverated onalternative tapping testing and had a reduced verbal fluency only naming 8 wordsbeginning with’a’ in one minute with two repetitions.Her new word learning was impaired only recalling two out of four word pairs after twoattempts and her ability to describe similarities between an orange and a banana wasimpaired after saying they were both fruit she was unable to generate further ideas. Onproverb interpretation she was concrete to both simple and easy proverbs. When asked ameaning of “two many cooks spoil the broth” she told me she had a small kitchen wherenot many people would fit in.”A Speech –Comment on rate, rhythm, volume and intonationB Thought form –Is the thought form logical, irrational, loose?Giving examples helpsC Thought content –Comment on delusions, ruminations, obsessions or overvalued ideas if they are present.Describe what is the person actually saying to you, what is important e.g “Tom spoke in aself deprecatory manner outlining his many failures although this was neither delusionalor ruminatory in nature.”Be very clear on accurate terminology regarding delusions – especially highlightthreat/control/passivity as very relevant for dangerousness.I put SUICIDE/HOMICIDE here as well as judgement.D PerceptionIllusions, hallucinations, also know rarer ones and comment if present . Always discusscommand hallucinations in detail.E Mood –eg Apathetic, euthymic, dysphoric, despondent, depressed elevated, angry fearful etcYou can also ask mood directly – and quoting the patient’s response “Mark says he isfeeling grumpy.”F AffectBe clear that this is a different concept to mood – discuss range, reactivity, mobility,intensity and congruence.G InsightThis has several parts1. Does the person think that something different is going on ie they see the symptomsas different to usual self?2. Do they see symptoms as illness?3. Do they see symptoms as part of mental illness?4. What is their attitude to help seeking/treatment?5. Do they see impact of illness?6. In people with personality disorders concept of psychological insight important.Always relate insight to the appropriate other part of the MSE ie is it the persons’s mood,psychosis or cognition for example that makes insight less than full. It is inadequate tosay “insight is impaired” “insight is partial” without adequate exploration of thecomponents insight.H JudgementHow does all the mental state you have presented impact on decision making regardingaction. Clearly key ones = suicide, risk to others and ability to self care. Again don’tmake global statements without discussion – not adequate to say “ judgement isimpaired” without saying why and how.WHAT IS A FORMULATION?A formulation is more than a summary. It is your opportunity to define how youunderstand why this person is presenting in this way at this time. The art of formulatingis a skill that psychiatrists continue to develop throughout their careers. As medicalstudents the key aspects to appreciate is that a formulation contains three core parts.1. DSM IVA formulation using the 5 Axis system. This should be included in the write up as part ofthe student’s diagnostic formulation.2. a) DescriptiveA formulation starts with a brief statement about the case. This should link to yourintroductory statement.For example “Mr Jones has had multiple admissions for treatment refractoryschizophrenia and has significant disability and a range of rehabilitation needs”b) ExplanatoryThe models of understanding discussed in the explanatory aspect of the formulation canvary according to the individual’s presentation and the field of interest of thepsychiatrist. In general a biopsychosocial framework is the most appropriate one for amedical student to use. How does the biology of the individual relate to theirpsychological and social world? Even in a “very biological” condition such asAlzheimer’s Dementia the persons psychological coping style and family structure andsupport create a unique aspect to understanding the situation.The developmental stage of the individual is a key aspect of the explanatory componentof a formulation. For example what is the difference between a person developingschizophrenia at age 14yr compared with age 30yr? Clearly there is a marked difference.The fourteen-year-old will have a significant disruption to the tasks associated with thatage – education, peer relationships, becoming aware of their sexuality. The tasks for athirty-year-old that would be disrupted by the illness would be consistent withdevelopmental areas such as employment and developing or sustaining a family networkof their own.c) PrognosisThis is not a statement merely relating to a statistical likelihood of a cure. A prognosticstatement needs to include factors related to the individual, both protective and riskrelated. It also needs to consider factors that may relate to the ease or difficulty offorming a therapeutic alliance. For example:“Although I have emphasised the need foradequate antidepressant therapy a key issue remains the ability for health services toengage with this man in a culturally appropriate manner as his religious beliefs leave himwith fear regarding taking medication”MANAGEMENT PLAN COMPONENTS1.SafetyWhat are the current safety concerns? Priority lies with immediate risk to self fromsuicidality or diminished self cares and risk to others. Be aware of risk factors e.g age,gender, substance abuse and of course significant past events and personality style. Anaccurate and thorough mental state examination will identify features which specificallyincrease risk e.g command hallucinations, delusions of threat/control, an irritable andelevated mood or suicidal ideation. Long term risk relates to ongoing factors either in theindividual’s mental state or environment.Psychiatry has moved away from predicting dangerousness to managing risk. Strategiesfor managing risk include engagement with the individual, frequency of contact andeducation around early warning signs for illness relapse. Increase in nursing and medicalsupervision, respite admissions and or acute in-patient hospitalisations are options inmanaging unwell and unsafe patients. On some occasions the mental health act may berequired to ensure appropriate medication use or inpatient care at times of acute crisis.An active plan to address substance abuse issues may be part of managing safety as mayattention to environmental stress such as housing stability.2. Clarifying diagnosis and differential diagnosisIs it clear what the individual’s diagnosis is? It is surprising how many consumers aretreated within the system for years with an unclear or inconsistent diagnosis. Too oftendiagnoses like schizo-affective disorder are used in a loose and meaningless way tojustify unfortunate poly-pharmacy. Management addressing differential diagnosisincludes reviewing old notes both psychiatric and medical, obtaining a thoroughlongitudinal history from the individual and meeting with family members forclarification3 Cultural issuesThe individual and family’s cultural identification must be established on first contact.This is so the family and individual can have access to culturally appropriate support andthe staff can receive advice on how to work with the consumer and appreciate their worldview. It is essential to utilise the interpreting service when the consumer requests this orwhen English is not their first language.4 Biological Managementa) Pertinent diagnostic tests and examinationsConsideration of the physical health of the individual is essential. This is becausephysical conditions may present with an altered mental state e.g. delirium. Anotherimportant reason is because of the possible medication interactions with pre-existingmedicines taken for a physical condition. It is important to establish baseline blood testsprior to prescribing many medications eg renal function and thyroid function prior tolithium.In certain populations, a comprehensive physical examination and investigation isparticularly important as in potentially life threatening conditions such as anorexianervosa. It is important to remember that consumers with schizophrenia have poorergeneral physical health than the general population and often do not access GeneralPractitioners. A physical examination on someone prescribed anti psychotic medicationmust include an examination for tardive dyskinesia and extrapyramidal side effects.b) MedicationThe other major component of biological management is medication. What does theevidence tell us about which medications are effective for someone with this condition?Clearly the attitude of the consumer and their family to medication is important. Adiscussion of the advantages and disadvantages of medication and possible side effects isobligatory in good management. It is also important to discuss the dosing regime, theexpected time for effect, the need for any special monitoring and practical issues such aswhat to do if a dose is missed. There should also be a statement on how often the personwill be reviewed. Written information sheets in the appropriate language are important.Directing patients to websites which detail medication side effects can be helpful(www.medsafe.govt.nz).5 Psychological managementPsycho-education (discussing what the individual’s condition is and potential treatmentstrategies) and exploring the patients coping style and aggravating stressors arecomponents of general psychological management. Additionally specific psychologicaltherapy may be indicated such as cognitive behavioural therapy for depression or anumber of anxiety disorders. Psychological management may include specialassessments such as neuropsychological testing. As with all management, psychologicalstrategies should be a planned intervention with specific goals and outcomes to beevaluated.6 Social and Family issuesA major criticism of mental health services has been the lack of communication withfamily members. Family members are not only a valuable source of information but areoften a major support in the individual’s recovery process. Families may experience theirown stress from seeing a member unwell and community organisations such as the“Supporting Families” can be invaluable. Family support groups from the CMHC’s andinpatient units are also useful resources. Specific interventions involving the family suchas Integrated Mental Health Care or Family therapy may be indicated. The individual’sfamily or major social support person should be involved in developing a wellness planwith early warning signs and contact numbers.Social issues often relate to housing, money, education and employment. There is clearevidence that for people with ongoing mental illness the quality of their housing relates totheir ability to maintain wellness in the community. Hopefully as a service we can movepast the language of “placement “ to working together with the consumer to find a stablehome. Assessment of living skills may alert the team to specific needs for the individualfor example budgeting or cooking. Management of employment issues may range fromproviding a letter to employers supporting a gradual return to the workplace to a referralto specialist agencies.7 Rehabilitation ManagementThis is of more relevance to consumers with the more severe and enduring mentaldisorders. Rehabilitation is not concentrating solely on symptoms but rather looks at theimpact of the illness on the individual’s ability to function within and as part of thecommunity. Establishing goals with the individual and their family and looking at thesteps needed to achieve these are important. A rehabilitation plan identifies areas forskill retrieval, skill development and community integration.8 Critique of ManagementIn asking the students to write case histories, we do not just expect them to be “scribes”.We encourage critical thinking and reflection. In this section of the Case History , wewant you to comment on the overall management of the case. Were there areas ofengagement or treatment that could have improved? Were medication used properly?Was there effort to involve families? Were non-medication treatments utilized? If not,why?Marking Criteria for Case Study Reports 4Well structured, logical with discussion significantly above expectedstandard (and handed in on time.)3The expected standard for Year 4. Meets all general standards(accurate, referenced, legible, dated and named), complete in allareas, basic management plan outlined and short discussion (1-2pages plus references) presented which relates to the patient.2Below expected standard but has remediable features.1A very poor report that is unacceptable.0Not handed in.N/ANot assessed this attachment

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