Psychiatry Case Report template
Content
Psychiatry Case Report
History
1. Intro
o
o
o
Initials:
Age:
Gender:
o
o
o
Marital status:
Occupation:
Location:
Date:
o
2. Presenting complaint + background history
3. History of presenting complaint
4. Past psychiatric history
o
o
Previous contacts with psychiatric services:
o Diagnosis:
o Who made the diagnosis:
o Age at diagnosis:
o Follow up:
o
o
Admission history:
o Year:
o Reason:
o Length of admission:
o Involuntary/voluntary
ECT history:
Self-harm
o How many times:
o When the first episode:
o When the most recent:
o Forms of self harm:
Stitches / Medical attentions
after self-harm:
o
5. Family history
5.1. Parental history
Father (age & occupation):
Mother (age & occupation):
Relationship:
5.2. Siblings
Number:
Age range:
Relationship:
5.3. Family psychiatric history:
6. Past medical and surgical history
7. Alcohol and substance misuse history
Age when fist consume:
Changes in level of consumption:
How much per week:
Illicit drugs:
Smoking:
8. Current medications ( name, dose, frequency, compliant )
9. Personal history
9.1.
Birth and development
Full term?:
Complications:
Breastfed/bottlefed
Dev. Milestone:
9.2.
Childhood and adolescence
9.3.
Education and literacy
Age start:
Age
finish:
9.4.
Bullying/truancy?:
Qualification/certificate:
Academic performance:
Read/write
Last work:
Disability allowance?
Occupational history
Age start:
Type of jobs:
Problems?:
9.5.
Relationship history
9.6.
Psychosocial history
10.
Forensic history
11.
Premorbid personality
Mental state examination
1. Appearance and behavior
2. Speech
3. Mood and affect
4. Thought
Self-harm or harming others
Obsession / Overvalued idea / Delusions
Thought Insertion / Withdrawal / Broadcasting + Made Acts / Movements / Emotions
Thought Blocking / Fusion / Substitution / Circumstantiality / Tangentiality / Flight of ideas / LoA
5. Perception
Hallucinations / Depersonalization / Derealization
6. Cognition
Year
Season
Date
Day
Month
7. Insight
Apple
Table
Penny
D
L
Floor
Hospital
Town/city
County
R
O
W
Apple
State
Table
Penny
Wristwatch
Pen
No ifs, ands, or buts
Take the paper in your right
hand
Fold it in half
Put it on the floor
Read this and do what it says
Make up and write a
sentence
Please copy this picture
Total (30)
Believe: suffering a mental illness / needs treatment / needs to be in
hospital
History
1. Intro
o
o
o
Initials:
Age:
Gender:
o
o
o
Marital status:
Occupation:
Location:
Date:
o
2. Presenting complaint + background history
3. History of presenting complaint
4. Past psychiatric history
o
o
Previous contacts with psychiatric services:
o Diagnosis:
o Who made the diagnosis:
o Age at diagnosis:
o Follow up:
o
o
Admission history:
o Year:
o Reason:
o Length of admission:
o Involuntary/voluntary
ECT history:
Self-harm
o How many times:
o When the first episode:
o When the most recent:
o Forms of self harm:
Stitches / Medical attentions
after self-harm:
o
5. Family history
5.1. Parental history
Father (age & occupation):
Mother (age & occupation):
Relationship:
5.2. Siblings
Number:
Age range:
Relationship:
5.3. Family psychiatric history:
6. Past medical and surgical history
7. Alcohol and substance misuse history
Age when fist consume:
Changes in level of consumption:
How much per week:
Illicit drugs:
Smoking:
8. Current medications ( name, dose, frequency, compliant )
9. Personal history
9.1.
Birth and development
Full term?:
Complications:
Breastfed/bottlefed
Dev. Milestone:
9.2.
Childhood and adolescence
9.3.
Education and literacy
Age start:
Age
finish:
9.4.
Bullying/truancy?:
Qualification/certificate:
Academic performance:
Read/write
Last work:
Disability allowance?
Occupational history
Age start:
Type of jobs:
Problems?:
9.5.
Relationship history
9.6.
Psychosocial history
10.
Forensic history
11.
Premorbid personality
Mental state examination
1. Appearance and behavior
2. Speech
3. Mood and affect
4. Thought
Self-harm or harming others
Obsession / Overvalued idea / Delusions
Thought Insertion / Withdrawal / Broadcasting + Made Acts / Movements / Emotions
Thought Blocking / Fusion / Substitution / Circumstantiality / Tangentiality / Flight of ideas / LoA
5. Perception
Hallucinations / Depersonalization / Derealization
6. Cognition
Year
Season
Date
Day
Month
7. Insight
Apple
Table
Penny
D
L
Floor
Hospital
Town/city
County
R
O
W
Apple
State
Table
Penny
Wristwatch
Pen
No ifs, ands, or buts
Take the paper in your right
hand
Fold it in half
Put it on the floor
Read this and do what it says
Make up and write a
sentence
Please copy this picture
Total (30)
Believe: suffering a mental illness / needs treatment / needs to be in
hospital
