2014 PSYCH Case Report

Erica Schmidt, Andrea Paul & Kara Gilbert – Student Academic Support Unit (SASU) Monash University Faculty of Medicine, Nursing and Health Sciences 2008 – updated Feb 2014

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MED4171 Medicine of the Mind Student Academic Support Unit (SASU)

Psychiatric Written Case Report

Helpful Hints & Models


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MED4171 Medicine of the Mind

Psychiatric Written Case Report Helpful Hints & MODELS

Acknowledgements

The following was created with reference to the departmental guidelines for the report, as well as adapted from a lecture handout out given by Kara Gilbert, in collaboration with unit co-ordinators, in particular Ian Presnell, at Monash University given between 2003 & 2006. Special thanks to Sudha Rughanath and other student writers of prior reports who allowed examples of their work to be used in the development of this resource. Please note - these examples are a guide only, and the reader should look at them critically for both form and content, based on their own specific reporting needs. Some aspects of the examples have been modified for teaching purposes.

Expectations for the Report You have been given the marking criteria for this report as well as 3 exemplar case reports (not including how they were scored) by the Medicine of the Mind faculty (see Moodle MED4171 Psychological Medicine block). It is expected that you will follow the guidelines to ensure that you present a complete picture of the patient you interviewed and demonstrate your understanding of them and their problem(s). You should also refer to your recommended texts for guidance (Selzer & Ellen, Bloch & Singh 2007, and the DSM-5). This report should:

be clear and orderly be written in an academic narrative style (i.e. do not write as if you are speaking and do not

use contractions) except for selected sections described below where a note or dot-point style may be acceptable

indicate an awareness of any limitations in obtaining and/or presenting the material

de-identify the patient, psychiatric facility and caregivers

identify the source of your information (patient, relatives, case notes)

not use abbreviations or acronyms without first being written out in full (eg. Post-traumatic Stress Disorder (PTSD))

include section headings for ease of organization

NOT go over the word limit of 5000 words (including tables, footnotes & headings but

not reference list) – include word count on front page of report

not fabricate or embellish patient information, or plagiarize reports written by others

demonstrate your clinical reasoning and an awareness of diagnostic issues demonstrate your ability to make links between the symptoms and signs exhibited by the

patient as it relates to their health care and daily functioning We will now consider each section in turn with examples. For each example, and for your own report, consider the following:

Is is clear and understandable?

Is it well-organized?

Is the information contained in it relevant to the section heading it is under?

Is the information complete for its purpose?

What works and does not work? It is recommended that you first write out the information, note word count, and then revise to look for

efficient ways to present the information and avoid redundancies. It is ok to refer the reader to other sections of your report that provide more detail on a particular point.


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1. CASE HISTORY 1.1 Introduction This should be a brief, clear and concise opening that identifies the key issues of the case in a nutshell (i.e. set the scene at the very beginning of your report, giving some idea of the nature of the illness; for example, acute psychotic episode versus chronic illness exacerbation). Also include the circumstances

of your involvement as well as demographic information on the patient (de-identify the patient and others involved using pseudonyms, and explicitly indicate that you have done so via a footnote).

Framework Name

Demographic information (gender / age / marital status/ cultural and-or language background)

Occupation

Presenting symptom(s) and duration – without detail found in HOPC

Referral details, if applicable

Admission status (eg. voluntary or involuntary)

Sources of case information (and quality of information if relevant)

Point at which you assessed the patient

Example 1:

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. …

(Bloch and Singh, 2007:90)

Example 2:

Lisa Nguyen* is a 17 year old, unmarried, unemployed female of Vietnamese origin. Lisa migrated to Australia from Vietnam in 2006, and is currently studying year 11 at home through distance education. She presented to the emergency department of a metropolitan hospital after being referred by her general practitioner for depressed mood and increasing suicidal ideation. Lisa was transferred from the emergency department to an inpatient child and adolescent unit where she has been an involuntary patient for four weeks. Information for this report was gathered through two interviews with Lisa during the 4

th week of her admission along with patient notes,

observation of Lisa in groups, and discussion with treating physicians and nursing staff. …

* Pseudonyms have been used to protect patient confidentiality.

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. Start at the beginning of the current episode, including any precipitating events. It is useful to use the patient’s own words in your

description, and indicate this with quotation marks. In particular, it is important that you consider the following points in your discussion:

TIPS

Nutshell description of patient

Present the central problem facing the patient – eg. type of episode


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TIPS In this section,

emphasize the patient’s description of their symptoms at the time.

Be descriptive, but save analysis for later sections of the report

Include any information you want to discuss later

FRAMEWORK:

a. Discuss psychiatric symptoms:

Present a chronological narrative of the evolution of their symptoms for the current

episode. Start with when they began to feel unwell for the current episode – describe

any triggering events or prodrome. When presenting associated relevant symptoms,

attempt to group symptoms together in your discussion so that depressive, psychotic and

anxiety related symptoms appear next to each other in your text. (ie. make connections between the isolated symptoms that the patient may have revealed to you somewhat randomly in their interview; this will help your writing to develop logical sequences). Comment on relevant negative as well as positive symptoms (eg. ‘…patient admits to…patient denies…). Present

any relevant symptoms related to the differential diagnoses you will discuss later. Present the patient’s description of their symptoms contrasted with the description by other witnesses, if applicable.

b. Comment on the impact of the illness on the patient’s life:

work

social relationships

self-care

level of functioning & coping strategy

c. Note details of current treatment so far up to the point of your interaction if they have been under care for a significant amount of time

for the current episode (ie. weeks), or transferred in from elsewhere:

what

when

where

by whom If they are a new admission, this is not necessary. d. End this section with a comment on what their symptoms are currently like if they have had treatment. Example 3:

The patient describes an eight-month history of anxiety symptoms, which began two months after a car accident. 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. More recently she has had trouble concentrating on her work. Five days ago she was taken to her local GP after experiencing a typical attack in the supermarket. 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 day in an effort, she says, “to calm myself down and make things more bearable”.

(Bloch and Singh, 2007:90)

Example 4:

Lisa experienced a prolonged prodrome of symptoms and events leading up to her current presentation. During Year 10 (last year), Lisa experienced a progressively increasing social and academic difficulty along with increasing depressive symptoms. She reports suffering bullying from both her peers and teachers. She was called “stupid and retarded” and feels a marked sense of injustice and maltreatment by her teachers. … Lisa had very few friends, and admits to having difficulty with social interaction. As the year progressed, Lisa became increasingly frustrated in class, was prone to yelling at teachers and began opting out of group participation in all her classes. There was a decline in her homework quality and amount handed in over time. She believed “nothing could help her”, withdrew significantly from her few friends, and found it increasingly difficult to attend school.


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Lisa was seen by three psychologists at school during Year 10. She shouted at the psychologists during most of her first assessment, however, stated that she was not angry but extremely anxious. Intellectual disability was suspected by her teachers, and testing was performed using the Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV). Results were inconclusive; though Lisa scored below average in most sections, this may have been due to poor English skills rather than cognitive deficits. However, Lisa did very well in perceptual reasoning. In October of last year, Lisa punched a student who bullied her, and suffered her first panic attack. She describes this as being an unexpected feeling of intense anxiety and distress associated with chest pain and breathlessness. Lisa claims that this display of aggression was very uncharacteristic of her. She deeply regretted it and attributes it to her extremely low mood at the time. At the conclusion of Year 10, Lisa failed every subject except mathematics. She was recommended to repeat Year 10, but instead opted to do Year 11 via distance education.

During distance education this year, Lisa has become increasing socially isolated, and has struggled to teach herself core material, especially Physics and English. She states that her only hope of passing these subjects is to get private tutors, which her family cannot afford. Lisa’s mother also cannot afford taking time off to support Lisa due to financial difficulties. Lisa felt overwhelmed, and said she was “confused by her thoughts at times”. Lisa’s depressive symptoms have also increased; her general practitioner suggested antidepressant medication, which she declined as she did not think it could help.

In terms of depressive symptoms, since the start of Year 10 Lisa has experienced decreasing mood, and a moderate degree of anhedonia. She has also had initial middle and terminal insomnia, with early morning wakening in the last two months, and regular nightmares about study and her sister. Lisa has had chronic fatigue and exhaustion, a paucity of concentration and short term memory, and frequent episodes of her “mind going blank”, especially over the last 6 months. She has gained 10kg over the last 2 years, which she attributes to studying more and exercising less. This year, she has had increasing feelings of guilt and hopelessness with suicidal ideation over the last month. She states suicide is her only option, and has plans to “jump in front of a car”. She has not written a suicide note, and has only informed her general practitioner of these plans. The only self harm reported is that she has started to bang her head into her wrists recently. Lisa denies any diurnal variation of mood, psychomotor retardation or anorexia.

Lisa also displays symptoms of anxiety; she has had three panic attacks, though she denies any persistent worry of having another attack or change in behaviour between the attacks. She has also had 12 months of irritability, and more recent muscle tension, though she denies restlessness. Lisa has also had substantial somatic symptoms. She has reported generalised pains (at times specifically in her chest and abdomen), and limb clumsiness at all times; no physical cause was found for these complaints. Lisa denies ever experiencing psychotic symptoms such as visual and auditory hallucinations and delusions. She also denies ever experiencing manic symptoms such as elevated mood, uninhibited behaviour, thoughts racing, impulsiveness and elevated energy levels.

Lisa was referred to the emergency department by her general practitioner in mid-March of this year. She was then transferred from the emergency department to an inpatient child and adolescent unit where she has been an involuntary patient for 4 weeks. Two weeks ago, Lisa was started on 75mg of Venlafaxine daily which has just been increased to 150mg daily. After starting the medication she experienced dizziness which subsided rapidly. Her depressive symptoms have improved dramatically though she still experiences some insomnia and occasional irritability, low mood, and feelings of guilt. In addition, she no longer has any suicidal ideation. She does not want to be discharged, not even into a day program or community service. She fears that she will get much worse if she leaves, and feels worse when she goes home from the unit on leave. Initially, she would not attend group activities in the unit, but now often enjoys them. However, she still gets very irritable and tearful when changes or long term solutions are discussed, such as a transition program. She feels helpless when asked to make decisions regarding her future.

QUESTIONS

1. How is clinical reasoning made evident?

2. What makes this section easily readable?


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1.3 Past Psychiatric History The following points are relevant in this section:

details of previous episodes of illness,

chronologically presented, even if undiagnosed – include main symptoms similar or different to the current presentation; for patients with multiple admissions for similar episodes each year, you may present a ‘typical’ episode and state how often they occur and their precipitants

previous psychiatric admissions and treatment – including diagnoses (which may

change) and management changes

outpatient/community treatment

suicide attempts

drug & alcohol abuse – use a sub-heading for this

an indication of pre-morbid and interval functioning - use a sub-heading for this

details of any forensic history – use a sub-heading for this

you may choose to have table of psych medications with dates and compliance issues here, or combine psychiatric and medical medications discussion under a separate heading.

Example 5:

KD first began using heroin in 1990, he claims initially as a social habit which quickly became his preferred means of escaping stress. By 1998, he was using it up to three times a week while still able to function and hold a full-time job. He denies a history of depressive, anxious or psychotic symptoms prior to the death of his son in 1998 (social aspects of this event are described in Developmental History).

Following the death of his son in September 1998, he experienced severe guilt and blamed himsefl for not taking adequate care of him while under the influence of heroin. He also experienced insomnia, anhedonia, and depressed mood, with an inability to cope with day-to-day tasks. This culminated in a suicide attempt by overdose when he was barred from attending his son’s funeral by his then wife. He had an epileptic fit following the overdose and was admitted to hospital, but left four days later AMA. He does not recall medical or psychological treatment at the time.

In the years that followed, he experienced daily nightmares in which the accident would replay in his mind, and had panic attacks whenever he was reminded by cues such as screeching tyres, etc, and avoided visiting the place of the accident.

In 2000, when his wife officially divorced him, he became despondent and again attempted suicide by heroin overdose and was admitted and diagnosed with PTSD and Antisocial Personality Disorder (see Developmental History for a description of other personality traits) as well as Reactive Disorder. This prompted an ultimatum from his two remaining children to “clean up his act.” This initiated the successful completion of a 12-month residential rehabiltation program, and he has since been able to abstain from heroin use. …

Example 6:

Prior to the current admission, Lisa has had no previous psychiatric admissions, diagnoses or treatment. She has not attempted suicide previously though she reports having suicidal ideation during her childhood around the age of 10. Lisa had depressive symptoms during that period; similar to but less severe than her current episode. She is unsure if there were any stressors or precipitating factors for this episode and does not know how long it lasted. During the interval between episodes Lisa has been able to function quite well. She was able to keep up with school work and participated in extracurricular activities, though she made few friends. …

TIP In this section, you need to

build a picture of the pattern of illness

Chronicity

Severity

Coping strategies

Crisis triggers

Interval functioning This contributes to a complete discussion of the illness.


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Drug and Alcohol History (including presciption abuse, if any)

Example 7: Janice only drinks on special occasions a few times a year with her family and has less than a standard drink. She started drinking alcohol at the age of 17. She has never smoked or used any illicit drugs. However, she has required increasing doses of Oxycodone, and admits to taking them to calm herself sometimes (see Medical History for details of use).

Forensic History Example 8: John lost his license due to driving under the influence of alcohol for 6 months in 2006, and has had several drunk and disorderly charges brought against him.

1.4 Past Medical History This section is used to highlight any evidence of organic disease which may be influencing or be exacerbated by the current presentation, as well as to present other history for the reader to be aware of.

Emphasize medical conditions in the patient’s history that may bear some relationship to the psychiatric presentation (and avoid expanding your discussion of

medical details that are irrelevant to the psychiatric presentation), for example: o thyrotoxicosis → anxiety o hypothyroidism → depression

Systems most relevant include: cardiovascular, neurological and endocrine.

Similarly, demonstrate an understanding of the significance of drug therapy on psychological function by focusing on

medications taken by the patient that may influence the patient’s current psychological function. You may wish to have a separate sub-heading for this discussion.

Other medical and surgical history not directly related to their current psychiatric problem may be presented in note or dot point form if extensive.

Include a list of all medications (including dosage and schedule) taken by the patient prior

to admission, as well as any allergies. This can be in table form if you wish. You may wish to list current psychiatric medications with the past psychiatric history and medications for other chronic conditions in past medical history, or use one table for all. Any compliance issues or problems with medications should be discussed. Also include any over-the-counter medications used regularly or alternative therapies.

Example 9:

Two years ago Tom was diagnosed by his GP with leg ulcers due to peripheral vascular disease, exacerbated by the fact that he was sleeping upright in an armchair. This habit began after his wife left him, as he could not bear to sleep in the bedroom because of the memories. He also found that the only thing that could get his mind off ruminating about the separation was to watch old movies on the ABC at night – during this time he would doze off and manage to get some sleep. The problem of his leg unlcers and infective cellulitis has deteriorated over the two years and he now has decreased sensation bilaterally in his lower legs as well as large weeping wounds on sloughy skin. He has been admitted to hospital six times this year for exacerbations of this chronic condition. …

TIP 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.


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1.5 Family History This section showcases not only possible inheritable disorders, but also the psycho-social family dynamics and atmosphere, which influence learned behaviours and coping strategies.

Framework: Generations – at least parents and siblings, but may also

include grandparents, grandchildren or other extended family members; chronology of ages left to right (3 generations recommended)

Family members and their ages if known; may assign a letter, number, or pseudonym to identify persons referred to elsewhere in the report

Parents’ personality characteristics/ marital relationship

Current household atmosphere and relationship dynamics

Ego’s relationship with others in the family

Family history of psychiatric illness

May include other relevant family medical history (especially cardiovascular, neurological or endocrine disorders as risk factors for ego)

You must include a genogram (drawing of family tree). You may wish to indicate affected

individuals with different colours or cross-hatching. You need to include a key with your genogram,

particularly defining any non-standard symbols. Always indicate Ego on your genogram. Example 10: Genogram

Mick’s parents divorced when he was 10 years old. His mother has been in a relationship since 2005. Though not formally diagnosed, Mick says that he thinks his father has depression. Mick’s maternal uncle suffers from depression and has panic attacks. Mick reports that Jenny does not have any depressive symptoms, and that his grandparents do not have any mental health issues. …

Jenny (13)

Mick (17)

Father 38 – Depression?

49 –Depression/ Panic Attacks

Mother 38

TIP You need to give

relationship

information here as well

as diagnostic

information, unlike a

family history for other

medical purposes.


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Example 11: Family history

The patient, the eldest in a family of three daughters, still lives at home. Her mother, a 45-year-old primary-school teacher and her father, a 50-year-old electrician, are described as strict and intrusive, a pattern she ascribes to their strong Catholic beliefs. Their marriage is described as ‘over years ago; they never talk or touch’ and the atmosphere at home as tense. The patient is close to her younger sister in whom she confides. One sister has responded to a similarly distant relationship with both parents 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. (Bloch and Singh, 2007:92)

1.6 Personal History / Development This section can be useful for providing evidence for any Axis II condition. Use the headings in Bloch and Singh 2007 as a guide for organising the information in this section. In particular, note:

problems the patient may have experienced adjusting to

predictable stages of development

for each stage of life, describe significant life events and the patient’s responses

you may include other interests, social groups, religious experience, etc. in your discussion

the patient’s personality traits prior to their illness or

during remissions – how does the patient or others describe their basic personality

the patient’s coping strategies and patterns of behaviour

Example 12:

Lisa was delivered at 40 weeks gestation; the pregnancy was uneventful. She reached all milestones normally and was walking at 13 months. Lisa states that she had social difficulties even during early childhood, for example she could not understand jokes until she was 8 years old and always found the classroom more comfortable than the playground. Lisa had very few friends during childhood, was bullied and remembers it as an unhappy time. However, her mother reports no early concerns about her interpersonal skills. Lisa’s mother described her as an easygoing, obedient and honest child who enjoyed childcare and particularly liked drawing. Lisa also reports that she has always found change difficult even when she moved schools within Vietnam as a child.

Lisa is of Vietnamese ethnicity and was born in Japan as her family was living there due to her father’s studies. She moved to Australia at the age of two where Wendy was born, then moved back to Japan 4 months later. In 1997, when her parents divorced, Lisa moved back to Australia and has lived with her mother and Wendy since.

Lisa says that she was very close to her mother before the age of five, but as her mother began to work more she did not spend much time with her. They are no longer close, but they do get along. Lisa talks to her father on the phone once a week; she is not close to him. She gets along well with her mother’s boyfriend but only sees him rarely, about once a month.

Lisa’s relationship with her sister has always been turbulent as their personalities seem to clash. Lisa describes Wendy as “cranky, messy and lazy”. Since coming to Australia, these difficulties have escalated as Lisa has become increasingly irritable. Lisa seems to be jealous of Wendy who has assimilated into Australian culture better than she has. She reports that she intensely dislikes her sister and that her sister bullies her. Lisa has dreams about swearing at and hitting her sister, which she says she would never do but often wants to. As Lisa’s mother’s boyfriend lives in Castlemaine,

TIP If you think the patient

may have an Axis II

diagnosis, this is where

you will provide

evidence for it.

QUESTION

What

information is

inappropriate

for this section?

Where would it

be better

placed?


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she usually leaves Lisa and Wendy alone for the weekends to visit him. This upsets Lisa a lot; her main complaint with being at home is her sister. Lisa believes that if her sister was not living with her, life would be improved greatly. The few friends she has made she describes as “nerds and very friendly”. She does not confide in them when she feels upset and only engages in enjoyable activities with them; it appears that she does not have any close interpersonal relationships. Lisa still struggles with assimilating into the local culture.

Lisa values achieving a successful career above all other pursuits and therefore academic failure is not an option for her. She says “If I can’t get a degree, how can I face the world; I would rather be dead”. Prior to her migration to Australia, she passed all years of schooling undertaken. Lisa has never been employed.

Lisa’s menarche was at the age of 11. Her menstruation is very regular, occurring once a month for 5 days with normal flow. She reports a significant decrease in her mood prior to each period which she finds quite distressing. Since being in hospital, her menstruation has been delayed by a week. Lisa has never had sex or been a relationship.

Lisa plays the piano, which she is very passionate about and has continued to play throughout her illness. She practiced Tae Kwon Do for years, but withdrew recently due to academic stress and financial difficulties. Lisa also enjoys drawing though she has not been drawing often in the last year. Lisa’s family is Christian though she does not consider herself religious as she does not share any of their religious beliefs. However, she goes to church with them. …

Premorbid Personality and Coping Skills Example 13:

Lisa describes herself as introverted, diligent, determined, organised, and inflexible. She has trouble making friends; Lisa thinks that her main problem is she doesn’t understand people. She has particular difficulty in understanding people’s body language, tone and social cues. She tends to take things literally and have concrete thinking. Lisa values diligence and hard work above all else.

Lisa’s main coping skills are focused on distraction with activities. When feeling down or anxious she studies or switches to a different activity, often specifically playing piano. She has also tried deep breathing exercises for anxiety but these did not alleviate her symptoms. …

2. MENTAL STATE EXAMINATION (MSE) Use the headings in Bloch and Singh (2007) to organise your notes:

general appearance

rapport

behaviour

speech

mood

affect o quality o range o appropriateness/ congruence

thought o stream o form o content

perception

cognition (including MMSE)

judgement

insight

TIPS You must include an MSE YOU have done

State when the MSE was done (eg. day 3)

If points are lost on the Mini Mental State Examination or other cognitive test, be sure to state where the patient lost those points

Only if there have been significant changes in the MSE from the time of admission and when you interview the patient, recording this in two columns is valuable information – identify someone else’s MSE if used to compare

Otherwise, if there has been little change, use only your own MSE findings


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Example 14: Lisa’s mental state has improved significantly since her admission. Of note, her insight and mood have improved, she is no longer a guarded historian and has no suicidal ideation or depersonalisation. Detailed findings are as follows:

Current Mental State Examination (4 weeks after admission)

Appearance Lisa is a tall young girl who looks her age. She is casually and neatly dressed in a T-shirt, track pants and sneakers. She slouches in her chair.

Behaviour She is a good historian, answering in complete sentences and going into detail on all topics. Lisa is cooperative and maintains good eye contact. She displays no evidence of psychomotor retardation or agitation.

Speech

Lisa speech is accented, with normal volume and rate. She speaks spontaneously in a monotonous tone. Her English fluency is proficient enough to understand and answer all questions asked though she often asks for clarification. No aphasia or dysarthria is evident.

Mood Lisa describes her mood as “fine, not sad”. She rates it as a 5 out of 10; 10 being the most elevated.

Affect Lisa’s affect is blunted with a markedly reduced range of reactivity. She communicates her affect well and it is mood congruent.

Thought

Lisa’s thought stream is normal and she has no formal thought disorder. She is preoccupied with worry over the future especially discharge. Lisa also ruminates over past negative experiences such as bullying. She has no suicidal ideation, thought insertion/withdrawal, ideas of reference or any other delusions.

Perception Lisa denies experiencing any hallucinations or illusions, and reports no other perceptual abnormalities.

Cognition

A Mini Mental State Examination (MMSE) was conducted. Lisa scored 29 out of 30; she missed 1 point on recall. This is within the normal range. She reports poor short term memory and concentration (though she was very proficient at subtracting serial 7’s, continuing for longer than required).

Frontal/executive function is normal. This was tested by asking Lisa to compare objects (similarities and differences) and to draw a clock-face.

Insight Lisa has moderate insight. She knows that she has depression and needs treatment and understands the importance of compliance with medication but does not fully understand the symptoms of depression and how it affects her.

Judgment Lisa’s judgement is good. This is evident through general conversation and her sound reasoning through scenarios.

Rapport Lisa has good rapport, she was friendly and engaged. She even made jokes at times though they appeared awkward; her intonation often made it unclear whether she was joking without clarification.


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3. PHYSICAL EXAMINATION and INVESTIGATION RESULTS

Emphasize those aspects of the physical examination that will indicate the presence/absence of conditions that may present with psychiatric complications; i.e. consider the

symptoms/signs of conditions you will likely consider in your differential diagnosis discussion later: a. medical conditions, particularly neurological, cardiovascular and endocrine disorders b. substance abuse c. long-term psychotropic drug use d. evidence of self-harm

You may wish to organize your physical examination information by system or in a head-to-toe fashion. A table, note or dot-point format may be most appropriate for some parts of the physical examination. Fully describe your findings, with the most significant first. Do not forget to include pertinent negative findings. Example 15: On physical examination, no abnormalities were observed. Findings are summarised in the following table:

General appearance

- alert and responsive

- no obvious pain or respiratory distress

- appearance was not suggestive of any syndromic-type illness or endocrine abnormalities

- gait and posture normal

- no abnormalities in the neck, no goitre and no bruits – no other signs of thyroid disorder were found

Vital signs

- all normal

- heart rate – 68 bpm

- blood pressure – 110/70 mmHg

- respiratory rate – 14 bpm

- temperature – 36.5oC.

Cardio Vascular

- Dual heart sounds, nil else

- No pitting oedema

- peripheral pulses present

Lungs - Chest clear

Abdomen - Soft, non-tender, no abnormalities

Neurological

- Cranial nerves, sensory and motor functions of upper and lower limbs all unremarkable

- No abnormalities in hearing or eyesight

- No other abnormalities detected.

Lisa was extensively investigated. Bloods tests such as full blood examination (FBE), urea and electrolytes (U&E), renal function, liver function test (LFT), thyroid function test (TFT), urine toxicology, and blood sugar levels (BSL), were conducted. All values were within normal limits. Imaging studies such as MRI head and CT abdomen were unremarkable. (Note: If you have already included investigation results in your History of Presenting Complaint when describing treatment to date, no need to re-itemize here but refer the reader back to where you discussed it.)


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4. SUMMARY AND DIAGNOSIS (Who and What)

Framework:

Briefly summarise the patient, drawing on key

information you presented in earlier sections of the report

Include information on Axis I through Axis V

of the DSM classification system.

For Axis I, and if appropriate Axis II, also include a discussion of the differential diagnoses to be

considered for your case, from most likely to least likely. Do not include diagnoses that you

have no evidence for.

For each differential diagnosis, present evidence from the earlier parts of the report that serve to support/ discount the likelihood of the differential diagnosis. You

may wish to organize your information in prose (paragraphs) or as dot points. Draw links to

DSM diagnostic criteria.

A patient may have more than one co-morbidity or diagnosis on Axis I (eg. Alcohol Abuse and Major Depression). Present the primary diagnosis and co-morbidity for the current presentation first, then list differential diagnoses for the primary diagnosis.

Example16: Summary

KD is a 42 year-old married, recently unemployed man with a past history of IVDU and PTSD. He presents with suicidal ideation as a result of recurrent intrusive flashbacks and nightmares, representing an exacerbation of PTSD from when he witnessed his son’s death. This has occurred in the setting of a number of physical and psychosocial stressors such as suffering a stroke, the loss of his home and business, and an inability to resuscitate a dying man. He has a history of an abusive and emotionally deprived background. He also has an Antisocial Personality Disorder with limited maladaptive coping mechanisms, and minimal social supports apart from his immediate family. …

Example17: Axis I – V diagnoses and differentials

Multi-axial DSM-IV-TR Diagnosis (including differential diagnosis) Axis I

Diagnosis (most probable): Major Depressive Disorder o Lisa has had both depressed mood and anhedonia o Lisa has also had insomnia, fatigue, feelings of worthlessness and guilt, decreased

concentration, and suicidal ideation o Most of these symptoms have been present for 12 months, all of them for the last

1-2 months and they have been causing Lisa significant distress and impairment in functioning

o These symptoms are not better accounted for by the effects of a substance, general medical condition or bereavement

o The anhedonia, suicidal ideation and early morning wakening are indications that her depression is severe

o Lisa has somatic and anxiety symptoms associated with her depression o It is possible that this is Lisa’s first major depressive episode, as details of her

childhood episode are limited, in which case she would not yet be classified as

TIPS 1. The summary must draw on all areas in the

earlier parts of the report. Do not introduce new information here.

2. You must address the question “Why is one diagnosis more likely than another?” Include at least three Axis I diagnoses you considered.

3. If you have considered an Axis II diagnosis or traits, also provide evidence for this.


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having major depressive disorder

Differential Diagnoses: o Adjustment Disorder (with depressed mood)

Lisa does have several stressors such as academic difficulties, bullying, relationship problems (especially with her sister), financial difficulties at home, and cultural dissonance

It is likely that these stressors precipitated her symptoms but the distress does not seem to be excess of what one would expected from the exposure to these stressors combined

In addition, most of these stressors either occurred after, or more than 3 months before, the onset of symptoms

Although this mood disturbance is likely to be stress related it is better accounted for (and meets the criteria) by major depressive disorder

o Panic Disorder (without agoraphobia) Lisa has had three panic attacks however she has never had any

persistent concern, worry or change in behaviour between attacks (though it is possible that she is minimising any distress caused by the attacks)

The attacks have been at times where her depressive symptoms have been the most severe, and have subsided since treatment and improvement of her depressive symptoms

o Generalised Anxiety Disorder Although Lisa does have symptoms of anxiety (irritability, fatigue, poor

concentration, insomnia, muscle tension) which she has had most days for 6 months, they have been occurring exclusively during a mood disorder

o Bipolar Disorder Lisa has not had any manic or hypomanic episodes, though this diagnosis

is important to consider as she is quite young and may in the future o Pain disorder (Chronic, associated with psychological factors)

Lisa experiences pain in her chest and abdomen along with limb clumsiness of sufficient severity to warrant clinical attention and with no physical causes found

However, these symptoms are better accounted for by a mood disorder o Asperger’s Syndrome

Although Lisa does not fit the DSM-IV criteria for Asperger’s Syndrome she does have a marked qualitative impairment in social interaction especially nonverbal behaviour which does cause her significant impairment

Axis II

Obsessive Compulsive Personality traits: o Although Lisa does not fully meet the criteria of obsessive-compulsive personality

disorder she does exhibit some emerging traits She can become quite preoccupied with rules, order, organisation and

schedules Lisa can be excessively devoted to work to the exclusion of all other

activities; when doing home school on most days she studies from 9am – 10pm , with no breaks, eating while she studies

She can be quite rigid and stubborn (describes herself as inflexible) o However, these traits may also be due to a pervasive development disorder

(specifically Asperger’s Syndrome)

Possible Mental Retardation o This is most likely mild due to her level of functioning o Lisa was tested for intellectual disability by a school psychologist after concerns

from teachers due to her poor school performance o Although she performed below average in many areas testing, results are

inconclusive as they may be due to her English skills Axis III

None Axis IV

Problems with primary support group: mother often absent and doesn’t get along with sister


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Problems related to social environment: difficulty making friends, bullied at school

Educational problems: academic difficulties

Economic problems: mother has financial difficulties

Still having difficulty adapting to new culture and language Axis V

55 on Children’s Global Assessment Scale [CGAS] - used instead of Global Assessment of Functioning [GAF] for people under the age of 18

o Lisa has variable functioning with sporadic difficulties in several but not all social areas (does have some friends and some normal parent interaction)

o These would be apparent to those who encounter her in a dysfunctional time or setting but not in other settings

5. Risk Assessment Your risk assessment must include the day of assessment, as the risk assessment changes over time. Include your assessment of the patient’s risks of harm to self and/or others, risk of neglect of self and/or others (including non-compliance), risk of absconding, risk of exploitation, risk of homelessness and other safety risks. Although you may use a standardized form on your placement for risk assessment, do not include the form with your report, although you may use it as a guide for sub-section headings.

Quantify each risk and provide evidence from earlier sections of the report as appropriate. Example 18: Risk Assessment on day 2 of admission

Suicide: Lisa had suicidal ideation for a month before admission and had made plans.

Currently she denies suicidal ideation, her mood has improved and she no longer has

feelings of hopelessness so she is at low risk of suicide. She has made no previous

suicide attempts.

Self-Harm: At the present time, Lisa denies any thoughts of harming herself though

previously she has by banging her head into her wrists so she is at low risk.

Harm to others: Lisa does get quite irritable and annoyed at staff and occasionally raises

her voice though she has never harmed staff; her risk is low to moderate.

Self-Neglect (including compliance): Lisa is at no apparent risk of self-neglect as

throughout her admission she has always taken care of her personal hygiene and

nutrition. She is also very compliant with her medication and believes it is improving her

condition significantly so her risk of non-compliance is low.

Risk of exploitation: Lisa has a moderate risk of exploitation as she seems quite trusting

of friendly people and as she has a lot of trouble understanding people she is unlikely to

be able to know their intentions and may be easily led.

Absconding: Lisa has no apparent risk of absconding because she likes being an

inpatient and feels safe and happiest when she is in the unit; she does not like going

home on leave and is always eager to return.

Financial: Lisa is at no apparent financial risk as she spends very little and as a teenager

is not given the means to spend large amounts.

Sexually Inappropriate Behaviour: Lisa is at no apparent risk of sexually inappropriate

behaviour.


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6. FORMULATION (How and Why) In this part, you should attempt to tie together the information you have provided in the earlier parts of your report in an attempt to explain the aetiological basis of the patient’s illness. In other words, consider the importance of the following factors in relation to the patient’s illness:

Predisposing factors

Precipitating factors

Perpetuating factors

Protective factors

Attempt to define the psychological, biological and social forces that have contributed towards

the development of the above-mentioned factors in your discussion. You need to be able to draw on relevant pieces of information from earlier parts of your report in your discussion and analysis.

You can also integrate evidence and concepts from the wider literature, although a literature review

is not the primary task of this report. This is where you need to demonstrate your understanding

of the patient and their problems by making links between the information you have presented. Regardless of whether you include it or not in your final report (if you have word space), it is useful to draw up a table as in example 19 for yourself to help you identify and classify all your information before

you write your final version. Remember that psychological evidence relates to the patient’s

thinking or view of themselves and the outside world, while social evidence relates to relationships,

interactions, and observed behaviour.

Example 19 (table):

Predisposing Precipitating Perpetuating Protective

Biological

- FHx of mood and personality disorders - Female - IBS symptoms provided negative reinforcement to eat - Fear of food making her teeth ‘filthy and yellow’ when she had bands

- Peak onset of anorexia nervosa is in adolescence - Menarche

- Desires to remain ‘little’ and associates ‘dirty’ menstruation and secondary sexual characteristics with weight gain

- Age of onset associated with better likelihood of remission than if Eve had developed anorexia nervosa later in life

Psychological

- Schizoid and obsessive-compulsive personality traits - Low self-esteem and a sense of powerlessness

- Sleep disturbance - Pervasive fear of ‘failure’, particularly not achieving a high enough VCE score for admission to law course

- Losing weight gives Eve a sense of control, security and accomplishment - Desire for ‘control’ over life - Desire for independence from her family

Social

- Parents had an acrimonious divorce when Eve was 5 yrs old - Absent and idealised father - Ambivalent relationship with ‘controlling’ and

- Began dieting as a New Year’s resolution to ‘gain control over her life’ and be ‘like the popular girls’

- Controlling mother - Famiy dysfunction - Media promotes a slender physique - An overweight body is

- Close relationship with paternal grandmother and school teachers


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unaffectionate mother - Poor coping styles exhibited by her role models (mother’s nervous breakdowns, substance abuse by father, ascetic maternal grandmother) - Poor social integration and no close relationships with peers (feels like an outsider and a ‘charity case’ in their company)

considered as an expression of weak willpower and laziness by many subcultures of Australian society, including Eve’s peer group

Example 20 (prose):

...

Predisposing Factors

In this case, KD’s witnessing of his child’s death was a significant enough event to signal his unconscious to utilise defences and coping mechanism to deal with the stress. KD’s personal history and antisocial personality traits have resulted in him having a very limited range of maladaptive coping techniques, which were inadequate to deal with the stress of the situation. His main method of problem solving and dealing with conflict is through physical aggression and anger This was probably adapted from his harsh adolescence living on the streets and amongst gangs, time spent in jail, and also through modelling from his father’s own violence towards KD.

A most significant aspect of KD’s life is the childhood trauma he suffered as a result of both his mother’s abandonment, and also his father’s physical and emotional abuse. According to Freud, it is possible that the trauma of his son’s death symbolically reactivated the previously quiescent, unresolved psychological conflict of his childhood abuse. As a result it is postulated that the ego relives, and thereby tries to master and reduce the anxiety associated with the earlier trauma (Sadock & Sadock 2003: 1472-3).

…

Example 21

Leo has several factors which predispose him to schizophrenic psychosis. The primary biological factor,

given he has no reported family history, is being male. Males have a slightly higher prevalence of the

disease and slightly poorer prognosis.(3) Factors, likely psychosocial in nature, which also predispose

him to this condition are early loss of a parent(5), urban upbringing(3), and being born in winter(6).

The time period “15-20 years ago” appears a number of times in his history. This may have been the

onset of his disease or more likely a crisis period where his disease worsened significantly. During this

period, Leo’s first son committed suicide, Leo’s house burned down and he was severely injured in the

blaze, Leo retired from the workforce, and Leo’s marriage broke down. Leo’s retirement is most likely

a result of this crisis rather than a precipitating factor, and similarly it is most reasonable to assume

the suicide of his son was a precipitating factor rather than a consequence of his disease. The fire was

allegedly due to electrical fault and thus could have been a traumatic precipitating factor, or it also


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may have been set by him, though this makes it no less traumatic and it clearly still affects him in one

way or another. Finally the breakdown of his marriage is likely a consequence of his disease rather

than a precipitating factor, but were it to be true his wife did leave him for another man (or even

simply left as a result of the son’s suicide) this could have been a precipitant to a crisis in his condition.

7. MANAGEMENT On the basis of your formulation, you will need to outline an appropriate management plan, including:

a. further investigations and why they are indicated

b. immediate plans (during hospital stay)

c. short-term goals (post-discharge plans and interventions)

d. long-term goals (on-going plan)

e. consider appropriate medications, psychological therapies, other non-pharmacological treatments, referrals, and on-going monitoring

Include pharmacological and non-pharmacological methods of treatment/ intervention and reasons for

them, referrals, and follow up plans. If an involuntary patient, indicate the criteria for release.

Also give an indication of the prognosis for the patient if possible and on-going expected risk

assessment, including relapse prevention and rehabilitation. Example 22:

Investigations

No further investigations are necessary unless there is a change in the physical symptoms Lisa experiences or her physical exam findings.

Short term

Although it is currently low, it is important that Lisa’s risk is continuously reassessed, especially in regards to suicide and self-harm. The critical points for reassessment are whenever her situation changes as this is likely to precipitate symptoms and change her risk; for example change in room, schedule, medication or discharge. It is also vital to monitor her daily for side effects of venlafaxine and continued improvement of symptoms. As IQ testing was inconclusive due to Lisa’s English difficulties her English proficiency must be tested and then her IQ must be tested again, if necessary in Vietnamese. It is important to determine if she has mental retardation as management must be altered accordingly since this would not only affect her functioning but her current illness.

As Lisa now has some insight into her condition and is willing to be treated she should be made a voluntary patient as this would empower her and encourage a more therapeutic relationship with her treating team. It is also important to encourage Lisa to participate in group activities with the other inpatients.

Intermediate and Long Term

Lisa should continue the venlafaxine for 12 months to prevent relapse and allow time for psychological therapies and social supports to take effect; it should then be gradually withdrawn. It is also important to encourage compliance and continue to monitor for side effects and improvement while Lisa is on the medication. If improvement is not sufficient an increase in dosage may be considered as the medication is unlikely to be having a noradrenergic effect at the current dose (150mg daily). In addition, it is vital to continue to assess her risk, though less frequently.

As many psychological, behavioural and social factors contribute to Lisa’s condition, non-pharmacological treatment plays a large role. It is important to educate both Lisa and her family on depression, its treatment and effects. Counselling should be offered to Lisa’s family as Lisa’s depression can affect them and they can aid her recovery. Family therapy would be constructive as Lisa’s mother needs to be encouraged to spend more time with her. In addition Wendy and Lisa’s


Page 19

relationship needs to worked on especially in regards to jealousy and bullying issues. It is also worthwhile to assess Wendy for depression as she has many of the same risk factors as Lisa and in addition has a depressed sibling who she lives with, adding to her predisposition. Lisa’s counselling must focus on explaining the need for discharge and the temporary nature of inpatient stay along with the support she will receive after being discharged and that she will not “be on her own” as this thought greatly distresses her when discharge has previously been brought up. Lisa’s history needs to be examined to determine her early warning signs of relapse including irritability, insomnia and anxiety. Lisa and her family need to be educated on detecting these signs and seeking help.

Mindfulness based Cognitive Behaviour Therapy would be of benefit for her to work on both her obsessive-compulsive traits and to challenge any negative thoughts associated with her depression. Acceptance and commitment therapy may also be of use to help Lisa manage her feelings by increasing her psychological flexibility. Lisa has trouble initiating leisure activities and tends to only study if left alone unless she has appointed scheduled activities to attend. Therefore a schedule could be made to help her plan periods of leisure.

A day program, for a few weeks at the inpatient unit, can be considered to ease Lisa’s transition. To aid her studies and encourage socialising Lisa could join a study group at a local library. In addition, Lisa may be able to get financial assistance for private tutors or free tutoring through one of the various community support groups catered towards adolescents. Lisa should be encouraged to resume group social activities such as Tai Kwon Do and possibly additional activities in her areas of interest such as a drawing class. Lisa may benefit from joining a local Vietnamese cultural group as she could meet and learn from teenagers of her own culture who have adjusted well to Australian culture. Community groups and online resources for teens who have suffered depression may also be of use for Lisa.

Lisa is unsure whether her insomnia begun before or after her depression. If it does not resolve with her depressive symptoms any sleep hygiene issues should be explored and advice should be given. This issue along with her ongoing risk assessment and medication monitoring can be managed by Lisa’s general practitioner. Lisa’s case manager should also be liaised with especially in regards to referral to available community services.

References: Bloch, S., and B.S. Singh (2007). Foundations of Clinical Psychiatry (3rd Ed.). Melbourne: Melbourne

University Press. Especially, Chapter 16, available online via Voyager Catalogue: http://images.lib.monash.edu.au/med1022/04118932.pdf

Psychiatry Year 4 MBBS 2012 Metro Student Guide, Monash University

DON’Ts use an acronym without first

identifying it in long form (e.g. Obsessive-Compulsive Disorder (OCD))

abbreviate headings

include information or discussion which does not belong within that section

repeat information unnecessarily

forget to re-read your report to double-check for clarity and meaning

forget your cover sheet

DOs use headings and subheadings

to help organize your report

provide the appropriate information under each heading

use an academic style

de-identify the patient and others involved

stay within the word limit – tables and diagrams are included in the word count


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Writing Tips 1 – English tense and aspect: 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 addition, 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. Verbs are words which describe actions and states of being. In English, the time that these actions or states of being (let’s call them events) occur must be encoded in the use of verb tense. English also uses verb aspect to describe whether the action or state should be viewed as a whole event (a point in time) or as an ongoing experience (a period of time). Time is viewed as linear in English, and the most common reference point used is NOW. The simple tenses encode whether events occur at the time of NOW (present tense), before NOW (simple past tense), or after NOW (simple future tense). The default aspect for the simple past and future tenses is as a complete whole at a point in time, while the default aspect for the present tense is as an ongoing, incomplete experience across a period of time. The perfect tenses reference events to a point in time other than NOW, with past and future events relevant to that alternative reference point.

Time ----------------------l---------------------------l------------------------l--------------------- past NOW future The present tense is used to describe:

Events and ongoing beliefs occurring NOW, including the patient’s verbal reporting. This tense is used frequently in the introduction and history of presenting complaint when describing symptoms, and may also be used in the summary, risk assessment, formulation and management discussions. (1) KD reports that nightmares of his son’s accident began recurring in January, 2005. (2) …he attributes this to having nightmares about his son

Habits and permanent states (3) KD is a chef who lives with his wife and supports two children from previous marriages.

The simple past tense is used to refer to:

Events in the patient’s history that happened in the past, before NOW. This tense is used in most history sections of the report to describe completed events. (4) In December, 2004, KD suffered a stroke, which caused temporary right hemiparesis. (5) The financial problems caused him and his wife to be evicted from their apartment.

The present perfect tense is used to refer to events in the patient’s history that started or happened prior to NOW but still bear current relevance.

In the history, you may describe signs and symptoms that began in the past and are still continuing. (6) Following the stroke, KD’s mood has been “down” and irritable… (7) The increased arousal and nightmares have resulted in significant sleep disturbance

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) (8) In the last four days, KD has experienced two nights of no sleep.

You may describe completed events whose impact remains significant in the present situation. (9)…and has decided to present himself to hospital to get help for the sake of his wife and children.

The progressive tense is used to describe:

Ongoing or temporary states (symptoms/signs) or situations, either in the past or present time, when you want the event to be viewed across a period of time: (10) Now, KD is experiencing excessive tiredness and anxiety… (11) Prior to the resuscitation attempt four days ago, KD was feeling “quite good”.

http://www.monash.edu.au/lls/sif/Tutorials/Grammar/grammar.html

http://www.monash.edu.au/lls/sif/Tutorials/Grammar/grammar.html

Documents

2014 PSYCH Case Report