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Diagnostic Formulation

This document provides guidelines for creating a diagnostic formulation, including presenting the patient's demographic information and chief complaints, examining their mental status and medical history, developing a differential diagnosis, discussing contributing factors and prognosis, and outlining a management plan. A diagnostic formulation assesses the case through clinical judgment, while a summary concisely restates the key facts.

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arshia chatterjee
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232 views12 pages

Diagnostic Formulation

This document provides guidelines for creating a diagnostic formulation, including presenting the patient's demographic information and chief complaints, examining their mental status and medical history, developing a differential diagnosis, discussing contributing factors and prognosis, and outlining a management plan. A diagnostic formulation assesses the case through clinical judgment, while a summary concisely restates the key facts.

Uploaded by

arshia chatterjee
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Diagnostic formulation

Dr. Jayati Simlai M.D.


Additional Prof & Head
Dept of Psychiatry
• Introductory comments:

• Present the salient socio-demographic features of the patient (e.g. ‘Mrs. R is a 30-
year-old married school teacher living with her husband and a 4-year-old son’).

• Presenting problems:
• This section should be brief; state the main problems excluding irrelevant details
(e.g. ‘Over the past two months she has become increasingly depressed, with loss
of energy, self- reproaches and self-depreciating ideas’).
• Briefly mention how the patient's life has been affected by the problems (e.g. ‘She
has not been going for work and has also been unable to do the housework or take
care of her child’)
• Mention events closely related to the onset or exacerbation (e.g. ‘The onset of
symptoms was preceded by a medical termination of pregnancy about which
patient was very ambivalent’).
• Avoid long lists of minor or transient symptoms and negative findings except those
that will help in the differential diagnosis
• Past history of psychiatric disorder, its
treatment and outcome: (e.g. ‘Mrs. R had had
similar symptoms soon after her son's birth;
she was treated with antidepressant
medication and became completely well in
about two months’).
• Positive medical history of significance: (e.g.
‘The patient was detected to be hypothyroid a
year ago and is on treatment’).
Mental status examination:

• Mention important findings only.


• Use labels for psychopathological findings at this
stage, for example, use terms such as ‘delusions of
guilt’, ‘third person auditory hallucinations’ etc. Details
of these findings should have already been described
during the detailed presentation prior to the
formulation and if helpful, could be mentioned again
during the discussion of the differential diagnoses.
• Differential diagnosis:
• If there is little doubt about the diagnosis, say so and say why.
• Do not present an irrelevant differential diagnosis for the sake of giving one.
• If diagnosis is not clear, embark on a careful discussion of the possibilities in
the order of likelihood, and discuss points in favor of and against each of
them.
• This is done using descriptive psychopathology (e.g. first-rank symptoms)
elicited during history taking and mental status examination.
• Details of symptoms collected earlier could be used to support a diagnosis
(e.g. content of auditory hallucinations to differentiate between
schizophrenia and depressive illness).
• Information on the course of illness is also useful (e.g. ‘Though the acute
psychotic symptoms are remitted with medication, the patient never
reached his premorbid level of functioning at work or in social interactions’).
• Differential diagnosis tests one's ability to make a discriminating
clinical judgment.
• Do not give a long list of differential diagnoses that cover the
whole of ICD-10;
• Think twice before giving more than three or four.
• If a patient's history and findings justify diagnosing two or more
conditions that co-occur, mention those with supporting
evidence (e.g. Depressive disorder in a person with alcohol
dependence syndrome).
• End the discussion with a conclusion on the most likely diagnosis.
If that is not possible at all, mention the major possibilities.
• Aetiological factors:
• These could be considered from different perspectives
for example based on nature or based on chronology.
• Nature Biological Factors - e.g. Genetic, physical illness,
drugs Psychological Factors - e.g. Obsessive personality
traits Sociocultural Factors - e.g. Poor social support,
unemployment
• Chronological Predisposing Factors - e.g. Family history
of mood disorders Precipitating Factors - e.g. Child birth
• Perpetuating Factors - e.g. Husband‘s alcohol abuse
• Management:

• a. Further investigations
• Includes information from key relatives/employer/teachers Review of past case records
• Laboratory investigations :Psychometry and clinical tests
• In each case specify which procedure/tests you would organize and its justification
• b. Immediate management plans
• Is the patient to be treated as an inpatient or outpatient? If as an inpatient, why?
• Management of suicide risk/violence - where indicated Medication - specify
type/justification/dosage/route/expected response/side effects and their managements.
• c. Long-term management plans
• i. Somatic: Medication - type/dosage/duration
• ii. Psychological: Psychotherapy - indications/type/focus
• iii. Social: Involvement of the family/rehabilitation measure
• Prognosis:

• This should not be a general pronouncement, based merely on


the type of disorder (such as schizophrenia).
• Discuss instead the good (e.g. acute onset; affective symptoms)
and poor (e.g. poor drug compliance in the past; poor social
support) prognostic factors.
• Prognosis can also be described under the headings of short
term (e.g. ‘Chances of recovery from the present episode is good
with antidepressant treatment’) and long term (‘risk of relapse
and recurrence is high because of the significant marital discord
and patient's reluctance to take medicines on a long-term basis’).
• Come to a reasonably firm final conclusion rather than using
vague terms like ‘guarded’.
HOW IS A SUMMARY DIFFERENT FROM A
DIAGNOSTIC FORMULATION?
• The terms ‘summary’ and ‘diagnostic formulation’ are often used
together and cause confusion to many candidates who take them
to be synonymous. However, there are subtle but important
differences and being aware of them is helpful in making a good
diagnostic formulation.
• Summary is a concise description of all the important aspects of
the case, whereas formulation is an assessment of the case rather
than a restatement of facts. The best example of a summary is the
Discharge Summary, given on discharge after an inpatient
treatment. This should be written in such a way that it provides all
the necessary information that will assist in the follow-up care of
the patient by the same, or other medical team.
The summary should include:

• Demographic data like name, age, gender


• Reasons for referral to psychiatry
• History of present illness
• History of previous illnesses
• Family history
• Personal history - birth and development, childhood,
• Education, occupation, sexual and marital history
• Premorbid personality
• Physical examination
• Investigations - physical and psychological
• Diagnosis
• Treatment and progress Prognosis'
• Plans for further management
Standardized multi-axial diagnostic formulation

• Axis I a. This comprises mental disorders including


personality disorders and developmental disorders as well
as Axis general medical conditions.
• b. Axis II: This addresses disabilities in (i)personal care (ii)
occupational functioning (iii) functioning with family and(iv)
social functioning
• c. Axis III: Contextual factors. Problem areas such as
housing, education, work, finance, legal and interpersonal
are included here.
• d. Axis IV: Quality of life. This is scored from 1(poor) to 10
(excellent) and reflects patient’s own perception.

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