Summary formulation

The summary of a new case includes the following:

• the positive features of history and examination

• any relevant negative features, such as absence of a family history

• differential diagnoses, starting with the most likely possibility, and giving evidence for and against each one. A definite diagnosis cannot always be made from the first interview, so listing two or three possibilities is quite acceptable.

• aetiology, considering predisposing, precipitating, and perpetuating factors, and the question of why the disorder has developed at this stage in the patient's life

• plan of investigation; for example, interview with informant, selected laboratory tests

• plan of management

• comments on prognosis.

Case example 1

A single man aged 26, who has been unemployed since he dropped out of art college 5 years ago, and who lives with his mother, was admitted to the psychiatric hospital under Section 2 of the Mental Health Act 1983, after trying to jump from an Underground platform but being pulled back by another passenger. He did this because he kept hearing two voices talking to each other, saying 'foul things' about him. He says his problems began 6 months ago when he saw the girl he wanted to marry (though he had never spoken to her) going into a pub with another man. Since then, he has felt low in mood, lost interest in everything, stayed in his room most of the day, had both early and late insomnia, and not wanted to eat because the food tasted different. He admits to smoking cannabis several times a week for several years.

On examination, he was a thin man, casually dressed. He seemed suspicious, and several times he suddenly stopped talking in midsentence and looked round as if he had heard something behind him. He described depressive symptoms and third-person auditory hallucinations as above.

The differential diagnosis includes schizophrenia; depressive illness; and drug-induced psychosis.

Predisposing factors include genetic loading for psychiatric disorder, because the patient's father has had several admissions to a mental hospital and now has injections from a community nurse.

Further investigations should include a physical examination, urine screen for drugs, an interview with the patient's mother, and perusal of his father's notes. Initial management will include close observation in the ward setting, bearing in mind a possible continuing suicide risk.

Case example 2

A 37-year-old married man was referred to psychiatric outpatients from the gastroenterology clinic where he has been attending for 2 years with a diagnosis of irritable bowel syndrome. Recent physical investigations have not shown any new pathology. His symptoms of abdominal pain and diarrhoea have been worse over the past 6 months since he was made redundant from work. During this time, he has also developed low mood, poor appetite with weight loss, loss of libido, and insomnia with early waking. On mental state examination, he appeared anxious and depressed; borbo-rygmi were audible during the interview, and the patient had to leave at one point to visit the lavatory.

The most likely diagnosis is depressive illness, with associated anxiety symptoms, and exacerbation of his functional bowel disorder. The diagnosis of anxiety disorder alone would not cover his 'biological' symptoms of depression. Another possibility is organic bowel disease, but this seems unlikely in view of his recent normal investigations. He appears predisposed to psychological disorder by an anxious personality, and this present episode appeared precipitated by his redundancy and perpetuated by his continuing unemployment.

An interview with his wife confirmed the likely diagnosis of depression, and suggested that the patient had been particularly affected by his loss of role as breadwinner for the family, because his wife had recently been promoted in her own work.

Further physical investigation seems unnecessary, and might even prove unhelpful by adding to the patient's worries about his physical health. Antidepressant medication would be the quickest way to help this man, and amitriptyline would be suitable with its additional sedative, anxiolytic, and hypnotic properties. He could also be offered training in psychological techniques of anxiety management.

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