Outline for a student psychiatric case report
Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.
- 1General patient data
Age (not date of birth), sex, profession/occupation without organization name, admission date and time, department, referral source/delivery method, referring institution diagnosis, admitting diagnosis. Do not include full name, address, or document numbers: use "Patient N.". Admission status (voluntary / involuntary): without information that could identify the patient.
- 2Complaints
Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.
- 3Subjective history of present illness (Anamnesis morbi)
Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.
- 4Objective history
Information from relatives and medical records: onset and course of the disease, behavior, hospitalizations, treatment efficacy.
- 5Past Medical History (Anamnesis vitae)
- Development, education, work, family
Early development, academic performance, personality traits in childhood and adolescence, professional path, marital status, social adaptation.
- Past medical history, surgeries, injuries
Past medical history, traumatic brain injuries, neuroinfections, seizures, surgeries.
- Psychoactive substance use
Alcohol, drugs, smoking: duration of use, amounts, signs of dependence.
- Medication history
Regular medications taken by the patient (name, dose, frequency).
- Allergic history
Drug, food, and household allergen intolerance; type of reaction.
- Family history
Psychiatric disorders, suicides, and substance dependencies in relatives.
- Obstetric and gynecological history
For women: menarche, menstrual cycle characteristics, menopause, pregnancies/childbirth/abortions.
- 6Somatic and neurological status
Brief overview by systems: general condition, skin (signs of self-harm), cardiovascular and respiratory systems, abdomen; neurological status (pupils, reflexes, focal symptoms, tremor).
- 7Mental status (Status psychicus)
- Appearance, behavior, rapport
Grooming, facial expressions, motor activity, accessibility for contact, attitude toward the interview, speech rate and characteristics.
- Consciousness and orientation
Clarity of consciousness, orientation in place, time, and own personality.
- Perception
Illusions, hallucinations (true, pseudohallucinations), psychosensory disturbances, objective signs of perceptual distortions.
- Thinking
Form: rate, coherence, sequence; content: delusions, overvalued ideas, obsessions.
- Emotional Sphere
Mood baseline, appropriateness, lability, anxiety, diurnal fluctuations.
- Will and drives, suicidal risk
Activity, drives (sleep, appetite, libido), suicidal thoughts and intentions, aggression.
- Attention, memory, intellect
Concentration and switching of attention, memory for current and past events, level of knowledge and judgment.
- Critique and insight into treatment
Understanding of the morbid nature of experiences, attitude towards hospitalization and treatment.
- 8Leading psychopathological syndrome and its justification
Identify syndromes based on mental status and medical history, justify the leading syndrome.
- 9Preliminary diagnosis and its rationale
Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.
- 10Examination plan
Experimental psychological testing, laboratory and instrumental examinations (EEG, neuroimaging as indicated), consultations: purpose of each.
- 11Results of laboratory and instrumental studies
All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".
- 12Differential diagnosis
At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).
- 13Clinical diagnosis and its rationale
ICD-10 formulation (Class F) with code: nosology, form, course type, leading syndrome, comorbid conditions; justification.
- 14Etiology and pathogenesis
Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).
- 15Treatment and its rationale
Psychopharmacotherapy (INN, dose, route, frequency, side effect monitoring) with reference to clinical guidelines, psychotherapy, psychosocial rehabilitation; prescriptions in Latin for 2–3 drugs.
- 16Observation notes
prescriptions).
- 17Stage (discharge) epicrisis
Briefly: patient, age, date of admission, reason for admission, main examination results, clinical diagnosis, treatment performed and its effect, condition at the end of curation, recommendations.
- 18Prognosis and recommendations
Clinical and socio-occupational prognosis with justification, discharge recommendations, psychiatric follow-up.
- 19References
formatted according to GOST R 7.0.100-2018.
How a psychiatric case history differs from other subjects
There are almost no physical findings confirming the diagnosis here, so evidence is provided by descriptions of the patient's behavior and statements. The diagnosis is made in two steps: first the leading psychopathological syndrome, then the nosological form with the ICD-10 code from Class F (e.g., F20 schizophrenia, F32 depressive episode, F10 mental and behavioral disorders due to psychoactive substance use).
Subjective and objective medical history
The subjective history is recorded in the patient's own words, the objective history from relatives and medical documentation: discharge summaries, outpatient records. The department checks whether both are present and whether they match. Heredity (mental disorders, dependencies, and suicides in relatives), early development, education and work, premorbid personality traits, trauma and infections, alcohol and substance use, onset of the disease, episodes and remissions, hospitalizations, treatment response, and suicide attempts are required.
Mental status in order
- Appearance and behavior: neatness, posture, facial expressions, motor activity.
- Consciousness and orientation in place, time, and own personality.
- Contact: whether they answer willingly, to the point, how they interact with the physician.
- Perception: illusions, hallucinations (true or pseudo-hallucinations), cenesthesias; if absent, indicate that behavior does not suggest them.
- Thought form (pace, coherence, goal-directedness) and content (delusions, overvalued ideas, obsessions) with patient quotes.
- Emotions: mood background, appropriateness, diurnal fluctuations.
- Will and drives: activity, interests, sleep, appetite, craving for alcohol and psychoactive substances.
- Attention, memory, and intellect considering age and education.
- Insight into condition and illness.
- Suicidal thoughts, intentions, and plans: asked directly and the answer is recorded.
Somatic and neurological status
They are not reduced to a single line: organic and somatogenic origins of the disorder must be ruled out, and ECG, body weight, and laboratory parameters assessed before prescribing psychopharmacotherapy.
Ethics and confidentiality
Mental health information is particularly sensitive: in addition to medical confidentiality under Federal Law No. 323-FZ, the Law of the Russian Federation «On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision» dated July 2, 1992, No. 3185-1 applies. Write the biographical section anonymously, and use non-stigmatizing language in the text: «a patient with schizophrenia» rather than labeling them by their diagnosis. It is convenient to cross-check controversial treatment points using clinical guidelines.
Example of a psychiatric case history: depressive episode
Fragments of a model case history. The patient is fictional, data are for educational purposes.
Mental status (fragment)
Patient N., 36 years old, ill for about 5 weeks. Dressed neatly, sits slumped in a monotonous posture; facial expressions are impoverished and sorrowful, movements slowed. Consciousness is clear, orientation in place, time, and own personality is correct. Makes contact, answers after a pause, in a quiet voice, briefly and to the point. No perceptual disturbances revealed, behavior does not suggest them. Thought process is slowed in pace, consistent, goal-directed; no delusions expressed. Mood is depressed, with anguish, worse in the mornings: «in the morning I have no strength to get up, by evening it's a bit easier». States that nothing brings joy and she no longer feels like knitting as she used to. Tires quickly, struggles to concentrate on work. Wakes up at 4 a.m. and cannot fall back asleep, appetite is decreased, lost 5 kg in a month (was 68 kg). Suicidal thoughts, intentions, and plans are denied upon direct questioning, no history of attempts. Memory and intellect correspond to age and education. Insight into her condition is preserved, agrees to treatment.
Syndromal diagnosis
Leading syndrome: depressive syndrome, characterized by depressed, melancholy mood, slowed thinking, and psychomotor retardation (depressive triad), loss of interests, and increased fatigue. Somatic syndrome features: loss of interests, early morning awakenings, worse mood in the mornings, psychomotor retardation, decreased appetite, and a weight loss of more than 5% over a month. No delusions or hallucinations are present, therefore the syndrome is non-psychotic.
Nosological diagnosis
Duration is more than 2 weeks; all three main symptoms of a depressive episode according to ICD-10 are present (depressed mood, loss of interest, increased fatigue) along with three additional symptoms (impaired concentration, sleep disturbance, decreased appetite). Based on the number and severity of symptoms and the fact that the patient can only work with great effort, the episode is of moderate severity. According to the patient and her husband, there have been no previous depressive, manic, or hypomanic episodes, thus recurrent depressive disorder (F33) and bipolar affective disorder (F31) are ruled out. Organic and somatogenic etiologies are excluded based on somatic and neurological status as well as laboratory tests (including TSH); the patient denies alcohol and psychoactive substance use, which is confirmed by her husband.
Clinical diagnosis: Moderate depressive episode with somatic symptoms.
ICD-10 code: F32.11 (F32.10 if somatic syndrome is absent).
Examination Plan (Key Points)
- Complete blood count, comprehensive metabolic panel, TSH, ECG.
- Consultations with a general practitioner and neurologist.
- Experimental psychological assessment, tracking depression severity using a clinical scale over time.
- Reassessment of suicide risk at every examination.
Common mistakes in psychiatric case histories
- Mental status is replaced by a retelling of the anamnesis or complaints.
- Evaluative words instead of observations: "strange", "inappropriate" without describing what the patient is doing and saying.
- Lack of patient quotes where they specifically demonstrate delusions, ideas of guilt, or thought disorders.
- Suicidal thoughts are not documented, although every patient must be asked about them.
- Nosology assigned immediately without a syndromal diagnosis and its justification.
- Unspecified code (F32 without severity, F20 without subtype) or code does not match the formulation.
- Lack of collateral history, leading to missed episodes of hypomania, for instance, which the patient does not notice herself.
- Somatic and neurological status omitted; organic cause of the disorder not ruled out.
- Stigmatizing wording and real patient data in the biographical section.
Compile your psychiatric case history
The patient can be simulated for a specific condition, or you can upload your own clinical notes (text, handwritten photos, audio). Cross-checked with clinical guidelines, ICD-10 coding, and export to Word and PDF. 2 case histories per month for free.
Frequently asked questions
How to write a psychiatric case history?
Collect a subjective history from the patient's words and a collateral history from relatives and documentation, then sequentially describe the mental, somatic, and neurological status. Identify the leading syndrome, justify the nosological diagnosis with an ICD-10 code from chapter F, perform a differential diagnosis, and outline an investigation and treatment plan. The work concludes with progress notes and the epicrisis.
What is the structure of a psychiatric case history?
Biographical data, complaints, subjective and collateral history, somatic and neurological status, mental status, syndromal diagnosis, investigation plan, differential and clinical diagnosis, treatment, progress notes, epicrisis. The generator compiles the history according to the standard psychiatric structure, but if your department has its own structure, you can upload its template.
How to describe mental status?
Follow a fixed order: appearance and behavior, consciousness and orientation, rapport, perception, form and content of thought, emotions, volition and drives, attention, memory, intellect, insight, suicidal thoughts. Write observations and patient quotes rather than evaluations. If there are no abnormalities, state so for each item.
How does a schizophrenia case history differ?
The anamnesis provides a more detailed description of the onset of the disease, exacerbations and remissions, and the progression of personality changes. The status covers positive symptoms (delusions, hallucinations) and negative symptoms (emotional flattening, reduced activity), while the diagnosis specifies the subtype and course type, such as paranoid schizophrenia (F20.0). It is best to check the exact formulation requirements with your department.
Where to find an example of a psychiatric or depression case history?
A model fragment for a moderate depressive episode was reviewed above: mental status, justification of the syndrome, and diagnosis formulation with the ICD-10 code. The generator will compile a full history from your patient encounter notes or based solely on the condition; in the latter case, the patient is simulated. Missing data are marked as "not specified".
Can a neural network write a psychiatric case history?
You can draft one: the generator will assemble the history from clinical notes (text, file, handwritten photo, audio), cross-check the diagnosis and treatment against Russian Ministry of Health clinical guidelines, and assign the ICD-10 code. However, you will need to defend the mental status and diagnostic logic during your exam. Do not insert real names or other patient identifiers: in addition to Federal Laws No. 323-FZ and No. 152-FZ, mental health information is protected by the Psychiatric Care Act. Two case histories per month are free on any account, and the "Maximum" plan adds five more.
Case histories for other subjects
How the generator works and how to check its output: case history with AI. All tools: AI for medical professionals.