Case Presentation Format

In response to feedback from PCL users, we created the following outline that we hope will be helpful to use when preparing for your consultation and in presenting the case to the PCL psychiatrist. This format is meant as a guide that can help you get to the heart of the matter quickly and maximize time when you have the psychiatrist on the line. It mimics what many providers are taught in their formal training about presenting a clinical case. If it helps, download a PDF version to use like a worksheet.

Primary Information

Your clinical role with patient and practice setting:


Sex/Gender Identity: (cis, trans, male, female, non-binary, etc.)

Psychiatric History: (diagnoses; inpatient and/or outpatient; self-harm, etc.)

Medical History: (cardiac issues; diabetes; HTN)

Substance Use History: (present or history of; type(s) of substance(s) used; most recent use)

Current Medications: (psychiatric and/or medical)

Presenting problem(s)/symptom(s):

Case Presentation Flow

My role with the patient is _ and my question is about _. I am working with a _ year-old _ (cis, trans, male, female, non-binary, etc.) patient with a psychiatric history of _, a medical history of _, and a substance use history of _.  Their medications are _.  They are presenting with symptoms that include _. 

Clinical role with patient: You are a primary care doctor and met the patient for the first time today. A colleague in your clinic started the lamotrigine 3 weeks ago. 

Age: 35 year old

Sex/Gender Identity: cis-gendered female

Psychiatric History: Patient reports history of PTSD; denies history of mania or psychosis

Medical History: Hyperlipidemia. Taking Lipitor.  

Substance Use History: History of opioid use (heroin), alcohol and methamphetamines

Current Medications: Recently started on lamotrigine, now on 50mg a day, after unsuccessful trial of sertraline 100mg.

Presenting problem(s)/symptom(s): Patient scored high on the MDQ but did not have mania on sertraline and you are wondering what to ask the patient in order to determine whether bipolar is a better diagnosis and if so, what should be done with medications?

Clinical role with patient: You are a social worker in a primary care clinic, offering integrated behavioral health services. Your consulting psychiatrist is not available for the next week and the patient is seeing their primary care provider tomorrow.

Age: late 50s

Sex/Gender Identity: male

Psychiatric History: Diagnosed with anxiety, depression, and OCD since early 20s. Also has family history of depression. Patient denies current SI or HI.

Medical History: Unknown.

Substance Use History: Remote history of alcohol abuse; none in 20 years and attends AA meetings weekly

Current Medications: Tried sertraline initially years ago and unpleasant side effects but has successfully been on fluoxetine at 80 mg for 15 years. Buspirone 15 mg bid was added in 2018

Presenting problem(s)/symptom(s): Client is asking about which medications might be helpful for what they describe as intrusive thoughts.