Case history structure.doc

Case history structure1. Case History1.1 IntroductionAn introduction is necessary to establish the focus of your case and provide orientation to your reader. It should consist of a few clear and concise opening statements, which typically include information on: 摘要介绍必要建立把精力集中在你的情况和你的读者提供方向。它应该包括一些清楚和简洁的开场讲话,通常包括信息: Name (pseudonym) Age Marital status Occupation Referral details Central problem名字(化名)年龄婚姻状况的职业转诊中心问题。细节Sample text and writing tips 1.2 History of Presenting Complaint 历史展示投诉This should be a detailed account of the patients 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. 这应该是一次详细介绍对病人的中心问题是,你已经确定在你公开的声明。关于这个问题,把细节和相关症状的顺序,这将帮助你清晰的写作。Identify common psychiatric symptoms 确定共同的精神症状You should make connections between the isolated symptoms that the patient may have revealed to you somewhat randomly in their interview by grouping the symptoms together (i.e. depressive, psychotic, anxiety). This will help your writing to develop logical sequences. It may be necessary to comment on relevant negative as well as positive symptoms. 你应该联系,孤立的症状病人可能揭示了他们你有点随机分组的面试症状一致(例如,精神压抑、焦虑)。这将帮助您的文字发展的逻辑序列。也许有必要评论有关负面以及积极的症状。Comment on the impact of the illness on the patients life 评论病因的影响患者的日常生活Consider work, social relations and self-care. 认为工作、社会关系、进行自我护理。Note details of previous treatment 以前的治疗附注细节Include information on who administered management (when and where), what the treatment was (and preferably the dose and duration of treatment), and the patients responses to treatment. 谁管理包括信息管理(何时何地),治疗是(最好是剂量和疗程),以及患者对治疗的反应。 Integrate current problem and psychiatric issues Consider the relationship between the patients psychiatric state and concurrent medical conditionsSample text and writing tips 1.3 Past Psychiatric History Many psychiatric illnesses are recurrent or have an acute-on-chronic course, so that the link between the present illness and past psychiatric history may be strong. This is the rational for describing the past psychiatric history immediately after the present illness. Bloch and Singh (2001: 91)The following points are relevant in this section: details of previous episodes of illness previous psychiatric admissions/treatment outpatient/community treatment suicide attempts/drug and alcohol abuse interval functioning (what is the patient like between episodes/when well)By including this sort of information, you will build a picture of the pattern of illness (chronicity, severity, coping strategies, crisis triggers, etc.), which will contribute toward a complete discussion of the illness.Sample text and writing tips 1.4 Past Medical History In this section of the report, 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. Record medications. Demonstrate an understanding of the significance of drug therapy on psychological function and, if appropriate, focus on medications taken by the patient that may influence the patients psychological function.Sample text and writing tips 1.5 Family History Include details of: Parents and siblings, nature of the relationships between family members Any family tensions and stresses and family models of coping Family history of psychiatric illness (incl. drug/alcohol abuse, suicide attempts)Include a geneogram (drawing of family tree).1.6 Personal History/DevelopmentUse the list in Bloch and Singh (2001:93) as a guide for selecting and organising the information in this section: Early development Childhood School Adolescence Occupation Menstrual history Sexual history Marital history Children Social network Habits Leisure Forensic historyKeep notes for each subsection brief. In particular, note a) any problems the patient may have experienced with adjusting to predictable stages of development (e.g. - but not restricted to - effect of med