Summarises findings in order that some meaningful conclusions can be drawn from the experience.
Argues the pros and cons in establishing a differential diagnosis
Helps both in the process of communicating with other mental health professionals and establishing the care plan for the patient.
Introduces the patient and the important demographical details
Summaries the relevant positive and negative findings from the history in a way that leads towards differential diagnosis.
Lists sensible differential diagnoses based on the logical conclusions drawn from the presented formulation.
Mr X is a 25 year old unemployed father of two currently separated from his partner referred for the first time by his GP because of a four week history of depression and alcohol problems following the break up of his relationship. He complains of low mood, loss of energy, no pleasure in life and is experiencing anxiety and a tremor along with sleep disturbance, principally early morning wakening. He denies suicidal thought. He has been drinking approximately 48 units of alcohol per week but answered negatively to the CAGE questionnaire. In his family history his mother suffers from depression and his maternal grandfather had alcohol problems. His personal history reveals the death of a close friend in a motorcycle accident recently and the break up of his relationship. He has no other history of substance misuse or forensic history. Previously he has coped well with pressure at work. He is off sick.
The differential diagnosis includes
- depressive episode and
- depression associated with problem use of alcohol
Evidence for the former includes
- the duration and severity of symptoms
- family history
Evidence favouring the latter includes
- onset of drinking at the onset of the depression
- its intensity
- family history.