Case Presentation

By London Deanery | September 24, 2018

Case Presentation

This is an assessment task to test your ability to present a psychiatric assessment and BASIC plan (e.g.presenting to a consultant on ward round or over the phone to your registrar when on call or handing over to a colleague).

You need to include the relevant components of the history, mental state examination and any risk factors. You may want to include any positive findings on physical examination.

You may want to include a brief formulation looking at aetiological (The 4 P’s: predisposing, precipitating, perpetuating and protective) factors (using a bio-psycho-social model).

You should include a differential diagnosis and then state your preferred diagnosis

You should offer a BASIC management plan – as you are at the start of your training you only need to demonstrate you can make long-term plans for patients but to offer a sensible short-term plan that addresses cases you may have to manage out-of-hours e.g. offer a short term plan for a suicidal patient or a plan for a psychotic patient who presents in A&E and who does not want to be admitted.


When making a management plan you may want to consider:

  1. Is a corroborative history needed/notes needed?
  2. Are further investigations needed? e.g. Alcometer, urine drug screen, blood tests
  3. Are they medically cleared? Have organic causes been excluded?
  4. Are they safe to be discharged or should admission be considered?
  5. If they are discharged what is the follow up plan? When? Where? By who?
  6. If considering admission – consider capacity, mental health legislation
  7. If admitted, what is plan on ward? – Think level of observation, any medication they may need,any children/pets to consider • Never forget to ask yourself - Do I need senior support?

Form to sign off the Competency

Note: You can either fill this PDF form on a computer (preferably together with your assessor) and print it out for the assessor to sign, or you can just print the page and fill it out by hand together with the assessor. In any case after the form is signed, you will need to scan it to upload to your portfolio, just like you would with any paper-based evidence form. If you fill the form on your computer you need to SAVE it with a different name - so that the text you typed into the form gets preserved. A form filled on a computer probably, will be easier to read.

If the form opens directly in your browser you probably will not be able to type in the form fields - for that you need to open the form with your system PDF viewer - which likely will be Adobe Reader.

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