The discharge summary is potentially a very important and useful document. It may be referred to years later and it should be possible to gain a good idea of the patient's mental state and the degree of support for the diagnosis reached. It should also be helpful as a record of responses to different therapeutic interventions. The Part I summary should be completed within a week or two of admission (when it is easiest to do anyway) and can then serve as a useful summary for anyone called to see the patient, and as a basis for any reports which may need to be prepared. The Part II summary (which actually requires very little work once the Part I is completed) should be done within a week or two of discharge.
Organising the information in a psychiatric history and mental state examination can be quite difficult, but I hope the suggestions below may be of some use.
Dave Curtis, April 2011
It is important that this section provides an account of the time course of the presenting problem(s). If necessary bring together information obtained from a variety of sources and reorganised into chronological order. (If there are any physical symptoms that are volunteered or discovered on systematic enquiry, an account of these should also be given here.) Also document here all attempts at treatment of the current disorder, including effectiveness and side effects. Be sure to include any psychological treatments. Also document here interventions which form part of the Care Program Approach, such as support from a Community Mental Health Nurse and day centre attendance.
Some people use mood and affect to mean "climate and weather". The mood is the major pervasive emotional state, with the affect being more or less changeable around this "average". In any event I think both subjective and objective descriptions should be noted. (Tend to avoid using the term "depressed" descriptively, as it relates to a particular diagnosis.)
One fairly commonly used scheme places the past psychiatric history almost last. I think this is silly and that it should be presented early on. This can save the reader/listener a lot of unnecessary distraction while they try to weigh up different possible diagnoses based on just the acute presentation. In some patients it will be appropriate to incorporate the past psychiatric history into the history of the present condition, afer a brief account of the mode of presentation.
The biological and cognitive features of depression should always be noted, even as negatives. Logically, one might well put the biological features in the history of the present condition. Some people have a separate heading in the history called habits, which includes sleep, appetite, smoking, drinking, drug use, etc.
Recent and current suicidal intent must be noted somewhere. Conventionally it often goes under mood. Logically it could go under thought content, along with depressive cognitions.
It can be difficult to make a distinction between speech and thought form, and it might be allowable to subsume both under one heading (probably speech), provided all the features mentioned are included. However there are subjective aspects to thought, such as rate and the experience of block, which are not necessarily apparent in speech and need to be specifically enquired about.
In general mental state abnormalities should be described as objectively as possible with verbatim examples, rather than just giving the category of phenomenon they fall into. For example rather than say "he had thought-broadcasting..." say "he displayed thought-broadcasting, in that he believed the CIA could read his mind with a special computer". This means the reader can decide for himself what category the phenomenon falls into (in my view, the above would not be thought-broadcasting). Without examples, the reader is forced to rely on your judgement. This applies particularly to psychotic symptoms, including thought disorder and neologisms, and especially to first-rank symptoms which have diagnostic importance and are easy to get wrong. This does not mean that you should write down all abnormalities you elicit, just a clear example or two for each category.
Some authors write of four kinds of abnormality of thought: form, stream, content and possession. As you can see, I have subsumed these into the two main ones of form and content.
If there is any suggestion of high alcohol intake or alcohol-related problems then a separate heading of alcohol history should be given. This should contain quantity and pattern of present drinking, withdrawal symptoms, history of fits, DT's, blackouts, alcohol-related problems (physical/psychological/social), lifetime history of intake including previous dry periods, and perhaps family attitudes to drinking. It is crucial to include mention of morning withdrawal symptoms (shakiness, sweatiness, nausea) since these indicate physical dependency and the necessity for controlled detoxification (to avoid DT's and/or fits).
In the past and family psychiatric history, it is worth bearing in mind that one can usually make a very good stab at a diagnosis just by knowing the number and length of admissions, perhaps with some idea of the level of functioning in between. Of course, this isn't the actual diagnosis, just what somebody else thinks is the diagnosis. Thus somebody who has several very brief admissions is not thought to have major affective disorder, and somebody who has a few long admissions and is maintained on injections in between is probably thought to be schizophrenic, and so on.
For student case reports the discussion about differential diagnosis and aetiology would need to be expanded, and the account of the treatment would include an explanation of the aims of each intervention, and perhaps also a consideration of other treatments which might have been used but which were not.
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Dave Curtis (http://www.davecurtis.net/dcurtis.html)
Copyright Dave Curtis 1995-2011. You can distribute this material freely provided my copyright remains acknowledged.