Psychiatry Clinical Case Proforma

For Ward Presentation — Department of Psychiatry

| Date:

1. Identification & Presenter Details

Patient Name

Age / Sex

IPD / Bed No.

Occupation

Address

Date of Admission

Presenting Student & Roll No.

History given by

Patient Attendant

2. Chief Complaints

Tick all that apply, as reported by patient and/or informant.

✓	Chief Complaint	Side	Site	Duration (since)
	Persistent low mood
	Excessive anxiety / worry
	Sleep disturbance
	Irritability
	Hallucinations (hearing/seeing things others do not)
	Poor concentration
	Substance use / withdrawal symptoms
	Suicidal ideation
	Excessive fear (phobia)
	Behavioural change
	Other:

3. History of Present Illness

Mode of Onset & Course

Acute onset Gradual / insidious onset Following a stressful life event Episodic (with symptom-free intervals) Continuous / persistent course Following substance use Other:

Character of Pain / Key Symptom — SOCRATES

Not routinely applicable in psychiatry — use the narrative box below to describe the presenting symptom in the patient/informant’s own words, onset, precipitating factors and course.

S — Site
O — Onset
C — Character
R — Radiation
A — Associated symptoms
T — Timing
E — Exacerbating / relieving factors
S — Severity (0–10)

4. Past, Personal, Family & Treatment History

5. General Physical Examination

Build

Nutrition

Consciousness

Vitals

PR (/min)

BP (mmHg)

RR (/min)

Temp

SpO2 (%)

RBS

GCS

6. Mental Status Examination (MSE)

A. General Appearance & Behaviour

B. Speech

Rate

Volume

Tone

Relevance & coherence

C. Mood & Affect

Subjective mood (patient's own words)

Objective affect

D. Thought

Stream & form
Content

Standard safety assessment — tick Present/Absent for each; if Present, document the clinical detail and safety plan in the notes field. This is a routine part of every psychiatric assessment.

E. Perception

F. Cognitive Function

Orientation (time/place/person)
Attention & concentration
Memory (immediate/recent/remote)
Abstract thinking
General intelligence

G. Insight & Judgement

Insight (grade / description)

Judgement (test / social)

7. General Physical & Systemic Examination (Medical Clearance)

8. Investigations

✓	Investigation	Findings
	Complete blood count
	Thyroid function test
	Blood sugar
	Liver function test
	Renal function test
	Serum electrolytes
	Urine toxicology screen
	ECG (baseline, before psychotropics)
	Standardized rating scale used (specify)
	Other:

9. Diagnosis

Provisional Diagnosis

Differential Diagnosis

10. Treatment Plan

Pharmacotherapy planned Psychotherapy / counselling planned Psychoeducation to family given Safety plan established (if risk identified) Inpatient admission planned Outpatient follow-up planned

11. Summary

Auto-generated from ticks & entries above, in the fixed order of the sections — edit freely before presenting.

Presenting Student's Signature

Countersigned by Faculty / Resident

Psychiatry Clinical Case Proforma — for teaching purpose · not a legal medical record

Sign	Absent	Present	Details (site / grade)
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Edema

Risk item	Absent	Present	Clinical detail / safety plan
Suicidal ideation
Self-harm history
Risk of harm to others

System	Normal	Abnormal	Details
Cardiovascular System
Respiratory System
Neurological (gross)