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PS1.1-3 | Introduction to Psychiatry — Assignment
CLINICAL SCENARIO
This assignment requires you to conduct a structured psychiatric history and mental status examination (MSE) on a simulated or real (consented) patient, and to produce a formal clinical write-up. The exercise integrates all three competencies of this cluster: applying psychiatric classification frameworks (PS1.1), eliciting a comprehensive history (PS1.2), and systematically documenting the MSE across all eight domains (PS1.3). You will also briefly formulate a provisional diagnostic impression using ICD-11 or DSM-5 classification criteria, with a reflective commentary on the process.
Instructions
You may use any one of the following patient sources:
1. A simulated patient scenario provided by your faculty (role-play with a peer or a standardised patient).
2. A consented patient in your psychiatry posting (with faculty supervision and appropriate ethical safeguards; identifying details must be anonymised in the write-up).
Your write-up must follow the structured format below. Do not use bullet points — write in clear clinical prose appropriate for a case record. Anonymise all identifying information (use initials or a pseudonym). Submit a single document of 600–900 words covering all sections.
Length: 600-900 words
What to Submit
1. Presenting Complaint and History of Presenting Illness
Describe the patient's presenting complaint in their own words (one sentence in quotes). Then narrate the history of the presenting illness in chronological order: onset, duration, course (episodic/continuous/progressive), severity, precipitating factors, and any previous episodes or treatment. Note any informant history obtained and its significance.
2. Relevant Background History
Summarise the following domains as relevant to this case: past psychiatric and medical history; family history of psychiatric illness; personal and developmental history (key childhood events, educational and occupational trajectory); premorbid personality; social history (living situation, support system, occupation, stressors); and substance use (alcohol, tobacco, cannabis, other substances — type, quantity, duration, current use).
3. Mental Status Examination
Document the MSE systematically across all eight domains. For each domain, describe your finding and note its clinical significance where applicable:
(a) Appearance and Behaviour — dress, grooming, psychomotor activity, eye contact, rapport.
(b) Speech — rate, rhythm, tone, volume, quantity, spontaneity.
(c) Mood — patient's own words describing their subjective emotional state; numerical self-rating if obtained.
(d) Affect — observed emotional expression (range, reactivity, congruence with mood).
(e) Thought Form — coherence, goal-directedness, any formal thought disorder (loosening of associations, flight of ideas, tangentiality, blocking).
(f) Thought Content — presence or absence of delusions (type), obsessions, phobias, suicidal or homicidal ideation (direct question must be documented).
(g) Perceptions — presence or absence of hallucinations (modality, content), illusions, depersonalisation/derealisation.
(h) Cognition — orientation (time, place, person), attention and concentration, memory (immediate, recent, remote), and any other relevant cognitive finding.
(i) Insight and Judgement — level of insight into illness and need for treatment; social judgement.
4. Provisional Diagnostic Formulation
State your provisional diagnosis using ICD-11 or DSM-5 criteria. Specify which system you are using and why the clinical features meet (or do not yet meet) diagnostic criteria. Apply the relevant classification axes: Is this neurotic or psychotic? Organic or functional? If organic features are present, explain what further investigations would be needed. State the differential diagnosis (at least one alternative).
5. Reflective Commentary
Reflect on the process of conducting this assessment (150–200 words). Address: (a) What was most challenging about eliciting the history or performing the MSE — and why? (b) One clinical pearl you learned from this encounter that you would apply differently next time. (c) How did the principles of empathy, respect, and non-judgement shape the interview? Be honest and specific — generic reflections will not score well.
Grading Rubric — Structured Psychiatric History and MSE Assessment Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Completeness and accuracy of psychiatric history (PS1.2) | 10 pts | All standard history domains covered comprehensively (presenting complaint, HPI with chronology and severity, past history, family history, personal/developmental history, premorbid personality, social history, substance use). Informant history appropriately incorporated where applicable. |
| Systematic and accurate MSE documentation across all eight domains (PS1.3) | 10 pts | All eight MSE domains documented with accurate terminology and clinically meaningful description. Mood and affect differentiated correctly; insight assessed across all three components (awareness, attribution, treatment acceptance). Suicidal ideation directly addressed and documented. |
| Accuracy of provisional diagnostic formulation and application of ICD-11/DSM-5 classification (PS1.1) | 10 pts | Correct provisional diagnosis stated with explicit ICD-11 or DSM-5 criteria cited. Classification framework applied accurately (neurotic/psychotic, organic/functional). Duration thresholds and required symptom criteria correctly referenced. At least one differential diagnosis offered with reasoning. |
| Quality of clinical writing and appropriate use of psychiatric terminology | 5 pts | Clinical prose is clear, structured, and uses accurate psychiatric terminology throughout. The write-up reads as a professional case record with no lay-language substitutions for technical terms. |
| Depth and honesty of reflective commentary | 5 pts | Reflection is specific, honest, and identifies a genuine challenge in the process with concrete learning. The role of empathy and non-judgement is addressed with a real example from the encounter. Shows meaningful self-awareness. |
PEER REVIEW
Read your peer's write-up carefully before completing this review. Use the rubric criteria above to guide your feedback. For each of the five criteria, provide: (1) one specific strength you observed (with a direct reference to the text), and (2) one specific, actionable suggestion for improvement. Your feedback should be constructive, specific, and grounded in the rubric — vague praise ('good work') or vague critique ('needs more detail') are not acceptable. Your peer review will itself be assessed on the quality and specificity of the feedback you provide.