Presenting complaintThis is a…….year old lady/man who presents today with ………. This presenting complaint occurs on a background history of……….(insert relevant past medical history here but always be concise e.g. suicidal ideation on a background of diagnosed clinical depression). Hx of presenting complaint:The history leading up to this admission is as follows…….(here is where you need to get the facts in a list e.g. in the last 6 weeks this lady has been feeling gradually lower in mood. She has stopped taking her medication and this was all initially triggered by the loss of her beloved spaniel!) Once again this is clear and concise and easy for the listener to understand quickly. Past psychiatric hxThis patient’s past medical and psychiatric history includes….any previous admissions/diagnoses, a short list of medical problems if you get to that during the clerking but really don’t worry if you don’t this is a psychiatry station.

Background hxAgain this is not going to be complete but get a rough idea of what their childhood was like, did they go to school and what they do now. This lady grew up in…. a single parent family and found school difficult. She did not have many close friends and did not go on to higher education. She spends her days mostly on her own and finds her spaniel is really her only reason to live for. Social hxThis lady lives alone in a council flat and smokes 20 cigarettes a day. She drinks alcohol rarely. Her appetite is poor and her diet consists of microwave meals when she has the confidence to go to the shop to get them.FHx

DHxReport concordance with medication. Attitude towards medication if time!

Mental state examination:Appearance and Behaviour:On examination of this lady’s mental state I found that she was…..dressed appropriately. She had difficulty maintaining eye contact and was wringing her fingers anxiously.

 Speech: She had normal speech (rate, rhythm, tone, content) Mood and Affect: Her mood was subjectively very low and my objective finding would support this. She reported thoughts of self harm but no current suicidal ideation. Thought: She did not have any apparent thought disorder or delusions. Perception: Her perception was normal. Cognition: Cognition was not formally assessed but she was orientated in time, place and person Insight: She showed good insight, she is aware that her mood is low and that this is causing her to find normal day to day tasks very challenging.

Formulation:This is a 45 year old lady presenting today with low mood and associated thoughts of self harm. This has been a 6 week decline in her mood and is her first presentation to mental health services. She lives alone and does not venture out of the house very much.

After ruling out any possible organic causes for this lady’s presentation such as hypothyroidism, substance misuse, or prescribed drugs; my primary differential would be of a depressive episode. Then list maybe 1-2 less likely differentials.