1. Presenting complaint
This is a…….year old lady/man who presents today with ……….
This presenting complaint occurs on a background history of……….(insertrelevant
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 admissionis 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 psychiatrichx
This patient’s past medicaland 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.
Backgroundhx
Again this is not going to be complete butget a rough idea of what their childhood
was like, did they go to schooland what they do now.
This lady grew up in…. a single parent family and found schooldifficult. 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.
Socialhx
This 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 confidenceto go to the shop to get them.
FHx
DHx
Reportconcordance with medication.Attitude towards medicationif time!
Mentalstate 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.

2. Speech: She had normal speech(rate, rhythm, tone, content)
Mood and Affect: Her mood was subjectively very low and my objective finding
would supportthis. She reportedthoughtsof self harm but no currentsuicidal
ideation.
Thought: She did not have any apparent thought disorderor delusions.
Perception: Her perceptionwas normal.
Cognition: Cognition was not formally assessed butshe 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 beena 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 forthis 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.