Case Presentation

Warning

For Case Presentations, think about using the SBAR communication tool:

  • Situation
  • Background
  • Assessment
  • Recommendation

Below are some points to cover when presenting your case:

Give a summary of the history.


Discuss possible predisposing, precipitating and maintaining factors.  Discuss any protective factors noted in the patient’s history. 


Discuss potential risks (including suicide, self-harm, alcohol, drugs, absconding, driving, any children involved, and harm to others).


Give likely diagnosis (with reasons for this) and differential diagnosis.


Suggest further investigations (e.g. bloods, ECG, imaging), and further history required (e.g. collateral history from family, friends or health workers, and history from previous case notes)


Discuss management, both long-term and short-term (e.g. immediate admission or crisis team follow-up).  Use a bio-psycho-social approach.


Discuss likely prognosis, both for this acute episode, and lifelong. 

Last reviewed: 05/07/2023

Next review date: 05/07/2024

Reviewer name(s): NHS GGC MyPsych team.