Task
PSYCHIATRY a. How will you manage Margaret (lack of sleep, good
appetite, no early morning awakening, mood is okay,
Taking a psychiatric history: no psychosis)
- ENSURE confidentiality
- IF uncooperative: I understand that you are going History
through a bad time but please help me if you want me - Consent
to help you. - I understand that you have tiredness and feeling
- HPI: when? How? Worsening or getting better? What fatigue, can you tell me more about it? Do you have
is the effect on your life because of the symptom? any weather preference? Do you have palpitations?
What is the effect on your sleep? Light-headedness or dizziness? SOB? Chest pain?
- Mood: How is your mood? Have you noticed any Weight loss? Night sweats? Headaches? Any lumps
change in your sleep (in depression: early morning and bumps on the body? Any cough? Any tummy pain
awakening; anxiety: difficulty initiating sleep)? or change in waterworks or bowel motions? I
Change in appetite? Change in weight? Did you understand you smoke and drink alcohol, have you
experience any weight loss or weight gain (typical: tried using illicit drug use?
vegetative sx go down; atypical: vegetative sx go up); - Hows your mood? Has there ever been a time when
What is your energy level? Do you think life is worth your mood was very high? Any problems with sleep?
living? Have you thought of harming yourself or Weight? Appetite? Do you still find things
anybody else (What, when, how)? Are there times pleasurable? Do you think life is worth living? Have
when your mood is high? you thought about harming yourself or others? I
o anhedonia: loss of interest in activity which understand you were prescribed antidepressants
used to be pleasurable. before, do you know why it was given?
o Psychomotor retardation: more common in - Psychotic symptoms: Do you feel/see/hear things that
depression than agitation other do not? Do you have any strange experiences?
- Psychosis: Im sorry if I have to ask questions which - Hows your general health?
may sound silly but I will need your cooperation. Do
you see/hear/feel things which others do not? Did you Management
have any strange experiences? Do you think - Consider quitting one of the jobs
somebody is putting ideas in your head (thought - Consider moving out of the house
insertion)? Do you think your ideas are being - DO NOT prescribe antidepressants
broadcasted everywhere/do you think people are after - Lifestyle modification
your ideas (thought broadcasting)? Do you think that o Healthy diet
people, TV, radio, newspaper is talking about you? Do o Regular exercise
you hear voices telling you to harm o Address alcohol and smoking
yourself/somebody? - Meditation and yoga
- Insight: Do you think something is wrong with you? Do - Refer for stress management
you think you need help?
- Judgment: What will you do if there is a fire in this Acquired Brain Injury and behavioral changes
room? What will you do if you find an envelope with a
name, ticket, everything? Case: You are working in GP practice your next patient is a
- Cognition: do you know who you are? Where you are health worker who looks after a house accommodation disable
and the time? people. He is here to talk to you about James who is one of the
residents of the house. James is 37-years-old and living in this
ORGANIC DISORDERS AND DEMENTIAS house for a long time. He has a downs syndrome. He had a
head injury which required surgery when he was young. And
Lifestyle Stress then his family put him in this house as he needed a lot of
support. He is also having epilepsy which is well controlled with
Case: Margaret aged 35 years presents to your surgery on a the medication. The health worker is here to talk to you about
busy afternoon. She tells you she had about 6-8 weeks of Jamess recent change in behavior.
ongoing fatigue and tiredness. She denies any specific
symptoms but describes just fatigue, weariness, and feels as Task
cannot get out of her own way. Margaret is not your regular a. Talk to the health worker, Tim
patient but attended surgery on few occasions and you know b. Management
she had changed a couple of jobs but now tells you she is
working at 3 different places everyday starting from 8-7pm. She History: He was shouting at other residents and slams the door.
was in a relationship but broke up recently and at present is He hardly talks to anybody. Family talk to him but didnt come.
living with her extended family in suburban area of the city. He respond but doesnt want to talk to anyone. No fever, Used
Margaret is smoker for the last 15 years and on average to work. From last 4 weeks he cannot get up in the morning,
smokes about 15-20 cigarettes per day and drinks 3-4 standard become very abusive. Nothing happen at work.
drinks of red wine every day. She takes ASA for her occasional
tension headaches and takes no other OTC or prescribed Features:
medications. she had not other significant PMHx. Margaret - Acquired Brain Injury: Any type of the brain damage
describes some stress at work and finds hard to cope with the that occurs after birth.
manager at one of the jobs but still she is carrying on. She - The brain injury happens in two ways:
requests you to prescribe her some medications for her stress o Sudden onset: trauma, infection, lack of
and mentions that few years ago one of the GPs of same oxygen to brain. (Near drowning), Stroke.
practice described her antidepressants medications which she o Insidious onset: prolong alchol and
used for some time and thinks that maybe she needs those substances abuse, tumor or degenerative
meds again. diseases.
o How does it affect the person? Long term
effect of ABI are difficult to predict. Its
different in different people, the patient can
2
present with behavior and personality - PMHx: any history of heart condition? Hypertension?
changes. Thinking and learning abilities. SADMA? Whom do you live with? Do you have
Increase fatigue. enough support?
team is to assess your fathers condition, level of Due to poor Recall and Registration, patient might have
dependency, and eligibility for services that can be Alcohol-Induced Brain Injury
offered to him. Geriatrician might prescribe some
medications that can delay the progress but will not Wernicke-Korsakoff Syndrome
treat the illness. Occupational therapist can assess - Vision : Ophthalmoplegia
the home situation and his needs (eg fix lights, put - Ataxia
railings, remove loose carpets, etc) to keep your father - Memory Impairment (Amnesia)
safe. The social worker can arrange meals on wheels
if required, help him in washing the clothes and MMSE
cooking food, and can organize social support. - I will do MMSE which is a screening test to assess
Physiotherapist will assess his ability to walk and your cognitive or mental functioning. It is a simple test
might provide him with walking aids. Psychiatrist will that includes questions that assess you in a number of
assess his mental state and prescribe some areas and has thirty points in total. It will take
medications. approximately five minutes and I will guide you
- Is it better to put him in a nursing home? The aged- through it once we start. If you have any problem or
care assessment team will decide on it after questions, please dont hesitate to stop me. Can we
assessment and the options available are: do the MMSE?
o To stay home if he can cope (preferred
option due to familiar home environment). - Doing the MMSE.....(+) problem on registration and
He will be assessed regularly by team. recall.
o Living in the nursing home where a nurse - It can be Alcohol-induced Brain injury because of
will take care of him and I will also visit him chronic alcohol abuse. It can also be Wernicke-
regularly Korsakoff Syndrome.
o If at any time you want to take him back - What are you going to do with this patient? (by
home, you can do that and you can have Examiner)
access to respite care. It is a type of care - I will do complete medical evaluation and refer to
given by trained people on a temporary psychiatrist for further neuropsychological testing to
basis that help you take a break and have exclude more diffused impairment like dementia.
some rest. - Critical Error: Failure to identify short-term memory
- His vision and hearing will also be checked and his deficits; and a response that patient is delirious or
license may be suspended. It is very important for his demented.
safety and wellbeing.
- Will I get Alzheimer disease? It cannot be said at this CASE 109 Teaching Folstein MMSE
moment although there is a rare type of Alzheimer that
runs in families and occurs at an earlier age. But Case 1: You are a resident in Psychiatry Department. A 28-
because there is no family history, it may not be year-old was admitted with severe depression who is currently
possible. However, the specialist can explain more taking SSRIs. She is a secondary school teacher. A final year
about it. medical student did an MMSE and wants to discuss the results
which he shows on a small piece of paper.
Performing MMSE (Bookcase Condition 146)
Case 2: You are a resident in a large teaching hospital and you
Case: A 50-year-old barman comes to the GP clinic. He has a are asked by a final year medical student to teach you MMSE
history of consumption of up to 10 standard alcoholic drinks over and wants to discuss the results.
the last few weeks. His wife told you that he is quite forgetful
and unreliable for some months. You have completed the Orientation 5+5/10
history and now proceeding to test his cognitive function. Registration 0/3
Attention and Concentration 1/5
Task: Recall 0/3
a. Do MMSE Language 2+1+3+1 = 7/9
b. Explain what you are doing and why Did not write the sentence and copy the diagram : gave up
c. Summarize to the examiner the normal and abnormal Total 18/30
MMSE findings
d. Interpret the results to the examiner including what Tasks:
conditions these results signify a. Explain the results
b. Answer the questions that the student asks you
MMSE RESULTS of the patient: problem on registration and
recall therefore patient has short -term memory)
- ORIENTATION 5+5/10 MMSE (ORARLC) (total of 30 points)
- REGISTRATION 1/3 (3 tries) - Orientation (total of 10)
- ATTENTION AND CONCENTRATION (5/5) o 5 points: Year, Season, Date, Day, Month,
- RECALL 0/3 o 5 points: State City Suburb Hospital Floor,
- LANGUAGE Place
- Name two objects (2) - Registration (Immediate Memory; Total of 3)
- No, If's and or but (1) o Say three things and ask patient to repeat
- ask patient to close eyes (1) o Patient recalls three things
- write a sentence (1) o Patient can go for 6 tries
- hold paper with right hand, fold into half, put on lap (3) - Attention and Concentration (total of 5)
- CONSTRUCTION o WORLD Spell forward and Backward
- draw diagram (1) (easier to do and less time-consuming) or
o Subtract 7 starting from 100:
Patient is most likely not delirious because of intact orientation. - Recall (Short-term memory; Total of 3)
(Critical Error: if you say patient is delirious) o Reproduce three things that I have told you
Delirium is disorientation.... a while ago
4
Dementia (a diagnosis of exclusion; exclude causes by e.g. (At the EXAM, Two papers outside: 1st is the STEM, 2nd one is
Neuropsychological testing MMSE results)
- is slow, insidious and progressive
- No past history History
- Lack insight and confabulate. - How can I address you? (Why do you want to know
- Loss starts from recent then remote. my address?)
- Hide the deficits - Your wife is concerned about you. May I know why? (I
- No treatment have no problem)
- Did you notice any changes in behavior at home?
Counseling (No.) Any changes in your mood? Irritability? Any
- Do you have of any particular concern before I discuss problem with memory? Any problem with driving? Any
to you the result? problem in performing daily activities? Patient asks to
- MMSE is a bedside cognitive function screening test. repeat some questions.
Its purpose is not to make a diagnosis but to indicate -
the presence of cognitive impairment due to delirium, - Have you had head injury? How is your mood? History
dementia, or head injury. The advantage of this test is of stroke, heart attack? Taking any medications?
that it only takes 5 minutes which is therefore practical Smoking? alcohol? Drugs?
to use repeatedly and routinely. It can be helpful to
monitor the progress or fluctuation in these disorders History: (summary)
that may benefit from intervention. The disadvantage - Having short term memory problems and forgetting
is that it can be affected by age, years of education, many question. Patient had no insight. He was getting
socio-economic status, the background of the irritated and agitated. His understanding of simple
patient/ethnicity and physical problems like hearing. language was impaired?
5
TASKS: Investigations
a. Perform a history - FBE, LFTs, UEC, BSL, URine MCS, TFTs, BGL
b. Do MMSE - Vit B12 and Folate, Vitamin D, Calcium and
c. Explain to the patient the results and further Phosphate,
management - Syphilis and HIV (with patients consent)
- CT scan or preferably, MRI of the patient
6
Dementia and Disclosure of patients condition (Book case 119 b. Physical examination/investigation results (FBE 140,
pg. 641) MCV 107, Plt 300, LFTs GGT increased, other
enzymes normal including albumin, RFTs normal, BP
Case: Michael aged 70 years had come to see you in your GP 150/100mmHg,
clinic. He is concerned about his wife Jenny who had increasing c. Management advice
forgetfulness over the past 6-12 months. She has misplaced her
bag and bank cards on numerous occasions. She is spending History:
very little time reading or knitting which were her favorite - Establish pattern of drinking: I know you are
hobbies. You had seen Jenny last week with URTI. Michael is concerned about your drinking. It is a very good
interested that if you can recommend Jenny for Nursing home decision to come and see me. I need to ask several
placement and is requesting for your approval letter. questions that may be personal. Is it alright? Since
how many years have you been drinking (years)? How
Task much do you drink per week? What type of alcohol do
a. Focused history you drink (spirit, beer, wine)?
b. Management advice o Safe drinking: 1 SD for female, 2SD for
males per day everyday
- Assess MMSE - Where do you prefer to drink? With family, friends? Is
- Draw clock test: it binge drinking or continuous? Are you aware of safe
o Circle: 3 points level of drinking? Have you noticed any ill effects of
o Number of the clock: 2 alcohol on you? Do you think you can drink heavily
o Right numbers: 2 without appearing drunk (tolerance)? Are you able to
o Put the time of the clock: 2 work as efficiently? How is it affecting your
- Investigations/Screening Test: relationships at work and in home? Have you ever had
o RFTs, LFTs, TFTs, FBE, Blood glucose, any accidents related to alcohol?
serum electrolytes, calcium and phosphage, - CAGE:
urinalysis, serum vitamin B12 and folate, o Have you ever thought of cutting down?
serum vitamin D, syphilis serology (HIV), o Do you feel annoyed when people criticize
CXR, CT/MRI, you?
o PET or SPECT scan for further information o Do you feel guilty for taking alcohol?
- Multidisciplinary assessment (aged care assessment o Do you take alcohol first thing in the
team/memory clinic): geriatrician, occupational morning?
therapist, psychologist, etc - How motivated are you on a scale of 1-10 to quit/cut
down on your alcohol?
Features Dementia Pseudodementia - Withdrawal Effects
Onset Insidious Clear-cut, often acute o How long can you go without alcohol? Not
Course over 24 Worse in evening or Worse in morning more than 1 day
hours night (sundown o How do you feel after a period of
effect)
abstinence?
Insight Nil Present
o Do you think you need to drink to sleep?
Orientation Poor Reasonable
Memory Loss Recent > remote Recent = remote
- Social effects
Responses to Agitated Gives up easily o Have you noticed any problems at work with
mistakes alcohol?
Response to Near-miss! Difficulty dont know; slow o How is your relationship with partner and
cognitive testing understanding and reluctant but children?
(question) understands words (if o How is your financial situation?
cooperative) o Have you had any accidents/fights because
of drinking
DRUGS, SUBSTANCES OF ABUSE AND ALCOHOL - Health problems
o Have you ever noticed heartburn, gastritis,
Alcoholic Counseling heart disease, liver disease, anemia,
hypertension, problem with memory, mood
Case: You are a GP and a 47-year-old businessman comes to changes, depression, change in sexual
you to discuss his alcohol consumption because he got pulled performance (thought it was related to age)
over by the police on his way to work. The blood alcohol level - SADMA
was 0.04. He was given a warning as it was near the legal limit - I will need to organize some investigations to see
and a sign that he had a lot of alcohol last night. He wants to effect of alcohol. FBE, anemia (macrocytic-vitamin
discuss the safe level of alcohol and the effect of alcohol on a b12), LFTs, Lipid profile, serum lipase, BSL, liver
person. USD, ECG,
- 1 SD = increase blood alcohol concentration by 0.01
Case 2: Jarrod aged 30 years is a new patient to your clinic. - Liver takes 1 hour to metabolize 1sd
Jarrod states that he has been drinking on average four SD per
day per week for the last six months since starting his new job. Counseling
Before this he was consuming on average 2SD drink two days - Feedback: History shows that you have been drinking
per week. Last night while drunk, he met a minor accident and more than normal. This is why I ordered some tests to
his girlfriend asked him to see you as she is not happy with his determine the effect of alcohol in your body. The high
drinking habit. Jarrod works in a local supermarket and is level of alcohol may cause HTN, cause tummy
otherwise fit and healthy. He is not on any regular medications problems (heartburn), increased weight, affects your
and had no known allergies. liver, heart, brain, loss of memory, gout, sexual and
social problem
Task - Listening: What do you think?
a. Further history - Aim for safe level of drinking: Advise on safe level of
drinking (1 30 ml spirit = 1SD; restaurant wine =
1.8SD)
7
condition (saw GP and gave pethidine)? Where do (persecution) do you think youre
you get the morphine from? Have you noticed any special? (grandeur) do you think
palpitation, agitation or sweating when youre not someone is putting thoughts on
taking morphine for your pain (if yes, means your mind? (control) do you think
addicted)? youve done something wrong?
- Depression questions: How is your mood? Do you still (guilt) do you think radio and TV
find things pleasurable? Any changes in your sleep, are talking about you? (idea of
appetite or weight? Do you think life is worth living? do reference)
you have any thoughts about hurting yourself or o Depression: how is your mood lately? Do
others? you enjoy the things you used to enjoy? Any
- Whom do you live with? Any stress at home or at problems with memory or concentration?
work? Any financial problems? Do you have enough Change in sleep, appetite or weight? Are
support? Do you have friends? SADMA? you interested in your sexual life? Do you
think life is worth living? Have you ever
Management thought of harming or killing yourself? Or
- Let me reassure you that I will try to manage your others? Have you ever tried this in the past?
pain. I understand that your pain is real. There is If you leave this room, what are you going to
something called brain-body axis. Anytime our mind is do?
stressed, our body starts reacting (e.g. diarrhea before o Anxiety: Do you feel nervous as a person
exams). In the same way, your body is reacting by most of the time? Tremors?
producing abdominal pain because of your stressors. Palpitation/pounding of the heart?
- Morphine is a short-term relief for the pain and has got - Social history
many side effects. It can affect your respiratory o Home situation: how are things going at
system, heart, and is highly addictive. At this stage, I home? Are you experiencing any problems?
will give you panadeine forte to start with and refer o Employment: do you work? Any problem at
you to the psychologist. He will do talk therapy (CBT) work? Any financial problems?
to relieve your stress and he will teach you how to o Social circle/friends?
overcome and handle your stress. If you need social o Hobbies? What do you do for relaxation?
support, I can organize a social worker. If you have - Past history: mental disorder? Depression?
financial issues, I can refer you to centerlink. There Psychoses? Medical illness? Thyroid problem?
are a lot of support groups available for you. You are Medications and side-effects?
not alone. - Family history: mental disorder? Thyroid?
- If dependent: Refer to psychiatrist for drug - SADMA!!!
dependence management
- Do you agree with me or do you have any other Mental Status Examination
questions? - Appearance: properly dressed? Unkempt?
Disheveled?
PSYCHOTIC DISORDERS - Behavior: cooperative/uncooperative; comfortable?
anxious? Restless? Irritable?
Paranoid Schizophrenia - Speech: coherent, fluent, understandable? High/low
volume? Monotonous/changing tones? Pressured
Case: A 35-years-old female is in your GP clinic and wants a speech?
letter to the Department of Housing Authority because she - Mood/affect (congruent)
wants to change her accommodation. She had schizophrenia for - Perception: hallucinations Psychosocial history
the last 10 years and she was on haloperidol. On examination, - Thought:
you can see some contact dermatitis on her hands. o Content: delusion/suicide
o Form: how contents of thought are
Task expressed (ie flight of ideas, loose
a. Psychosocial history (Neighbor wants to harm her and associations,tangentiality)
throws things into her home. She lives alone at Centre - Cognition (Orientation): Time? Date? Person?
link and believes the TV is talking about her. Didnt - Insight: do you think that you need help? Or medical
see the psychologist for 3 years and cut down dose by advice?
since 1 year. Wash excessively with cleaning - Judgment: what would you do if there is a fire in this
agents twice a day.) building?
b. Mental Status Examination (well-dressed, groomed,
mood/speech normal, delusions of reference, auditory
hallucination (hearing voices that neighbor is talking Differential diagnosis:
about her), delusion of persecution and husband is a. Organic causes (brain tumors)
involved, dermatitis (throw things at home), no insight, b. Drug-induced or substance abuse
good judgment, oriented, no suicidal ideation, stooped c. Anxiety disorder
medication by herself she thinks she's feeling well) d. OCD highly unlikely
c. Give your findings to the examiner
d. Diagnosis and differential diagnosis Management:
- I will need to refer her to the hospital because she is
- ENSURE Confidentiality! living alone, has ideas of reference, paranoid
- Psychosocial history: HEADSSS delusions and is lacking insight. I will need to contact
o Psychological: the specialist at the hospital to review her. This will be
Auditory/visual hallucinations: do for her safety.
you see or hear things that - Urgent referral to psychiatrist for possible admission: -
nobody else can see/hear? due to loss of insight, paranoid ideation, not taking
Delusions: do you think somebody medication, living by herself;
wants to harm you? Following - If patient refuses: involuntary admission
you? Spying on you?
10
Relapse of schizophrenia (Tardive Dsykinesia) ideas that are contrary to fact. There are many causes
for this condition. Schizophrenia which needs around
Case: A 40 year old lady with schizophrenia for the last 15 years 6 months to be diagnosed or schizophreniform or
comes to your GP clinic because she has movements of her delusional disorder. Some patients may have medical
face. conditions which we call organic-induced psychosis.
Others may use illicit drugs which can experience it as
Task sequelae. We call this drug-induced psychosis. If any
a. Psychosocial history patient is diagnosed with acute psychosis, it is an
b. Diagnosis emergency situation as the patient is not safe for
c. Management himself or for people surrounding him. They may have
suicidal ideation or any psychotic ideation which could
History make them very aggressive and harmful to
- Ensure confidentiality themselves or others. Under the mental act, we
- Tardive dyskinesia-- more with typical antipsychotics usually admit involuntarily all acutely psychotic
- Can you stick out your tongue for me? patients until we stabilize their condition and we do
- Side effects: postural hypotension (giddiness, light further assessment to find out the cause. Usually,
headedness with posture change),dry mouth? Bov? many persons share the management of those
Urinary retention? Constipation? Milky discharge on patients for short-term and long-term management.
breasts? Loss of libido? Decreased sexual drive? Family will be notified and a meeting will be done to
Problem with periods discuss the management. We need lots of support
- EPSE: stiffness? Restlessness? Gait problems? from you. The psychologist, psychiatrist, mental health
Bradykinesia? Cogwheel rigidity? Tremors? nurse, social workers can be part of this team as well
- previous history of NMS? Fever, stiffness, confusion as myself as your GP. You can go to the hospital with
- Medication: are you taking the drug? Did you change your son and you will be notified with the further steps.
your dose? When did you see your psychiatrist? - Do you think my son is using illicit drugs? As I have
- Do psychosocial history? mentioned before, there are many causes. We need
- Do you think you need medical help? to assess him first. Our first priority is to stabilize your
son, then find out the cause and you will be informed
Management accordingly.
- Refer back to psychiatrist. Stop drug and change to
other medications. Ice-Induced Psychosis
- Risk of breakthrough psychosis
- May consider admission Case: A 20-year-old man was brought to ED by his friends
where youre working as HMO. He had hallucinations and
Drug-Induced Psychosis delusions. He was aggressive and violent. You sedated him with
medications. He went to a party last night and you suspected he
Case: An 18-year-old male who failed in one of his exams came used ICE. His father is here to see you. He knows about his
to your GP clinic for consultation. He felt depressed since then sons ICE usage.
and suffered insomnia. He came requesting for sleeping pills.
On assessment, you detected that he is suffering from Task
delusions, hallucinations, and other symptoms upon which you a. Relevant history
settled with the diagnosis of acute psychosis. He also admitted b. Advise further management
the use of illicit drugs. His parent came to the clinic to discuss c. Answer his questions
his case. The patient gave permission to discuss his case but
not to disclose his illicit drug use. History
- I understand you are here to talk about your son. Let
Task me assure you that he is in safe hands. Before I
a. Talk to the father explain the further management to you can you share
b. Explain current situation what you know about his condition? OR Do you know
c. Answer his question what happened in the party? OR It can be quite
common at a young age and I understand that John
Questions: has a problem related to this. may I know a bit more
- Is my son using drugs? about it?
- Is this condition due to depression? Can I take him - Since when is he using it? any previous hospitalization
home? like this because of this? Any intervention done or
- His auntie had schizophrenia, does he have this also? step taken regarding this issue? Are you a happy
Can he develop it? family? How is your family life? Any particular issue?
Does he have any siblings? How is his relationship
Counseling with them? Anybody else in the family using drugs?
- Let me assure you that your son at the moment is How much is this affecting the family? Does he go to
having a thorough assessment as we found him school or uni? How is his performance over there?
suffering from a sort of psychiatric emergency that we Any problems at uni or work? Any problems with the
call acute psychosis. I have contacted a team called law? Any of his friends having similar problems? Any
CAT whos undertaking the assessment. This team is other hobbies or sports?
the crisis assessment team. Psychosis is not a - How is his mood most of the time during the day?
specific disorder. This is a condition where a patient Does he enjoy the things he used to enjoy? What
has severe impaired sense of reality with emotional about his sleep? Did you notice any changes in his
and cognitive disabilities. The patient talks and acts in weight or appetite? Did he have any previous attempts
a bizarre fashion and may suffer from hallucinations to harm himself or somebody else? Did he ever talk
wherein he can see or listen to voices or things which about seeing/hearing things/voices that nobody does?
are not real or cannot be experienced by others Has he exhibited any strange behavior?
around. Also, he can suffer from delusions which are
11
- Any previous medical problems such as thyroid not worth living? Does she feel guilty about anything?
disease? Does he take any medications? Any Any time that her mood is really high?
allergies? FHx of similar problems and psychiatric - Psychotic: does she hear/see things that others do
illnesses? Smoking? Alcohol? not? Does she have any strange feelings or
experiences? Does she tell you that somebody is
Management putting ideas on her head or that the TV or radio is
- Most likely the condition that he is having is called ice- talking about her? Does she have strange
induced psychosis. Psychosis is loss of contact with experiences or abnormal thoughts? Does she think
reality that usually includes hearing/seeing things that there might be something wrong with her?
are not there and having abnormal beliefs. These are - How is her general health? Has she been diagnosed
called hallucinations and delusions. In simple words, it with any mental illness before? Family? SADMA?
is the changed and different way of thinking, speaking - I can see that you are tired. Do you have enough
and behaving that can make a person aggressive and support? Whom do you live with? Are there any
violent and unaware of his surroundings. This is what financial problems at home?
John is going through at the moment and this is
because of his ice usage. It can change the chemicals Management
in the brain to produce these effects. Now he is safe - From the discussion we have, your wife might be
and stable. suffering from a condition called postpartum
- He will be assessed by the CAT for psychiatric psychosis. It is not an uncommon condition but it
assessment. He will be admitted in the hospital under needs to be treated urgently. I am concerned about
care and supervision because in this condition he can you and your babys safety. I will need to admit your
harm himself and others. Even if the patient refuses, wife and I will call the psychiatric registrar to come and
they can be admitted involuntarily and it is in the best take a look. She will also be seen by the consultant.
interest of their safety. They can give him - At this stage, they might start with ECT and
antipsychotic medications for short-term to treat his antipsychotic medications.
intoxication. He will also undergo some investigations - How is your mood? Are you alright? I can organize a
such as FBE, U&E, LFTs, RFTs, BSL, TFTs including social worker for you.
urine and blood drug screen, alcohol concentration - Centerlink for financial problems.
and CT scan to r/o any organic cause. - I dont think she will agree to be admitted. I am sorry
- Once discharged, he will be followed up by but she will be admitted involuntarily under the mental
psychiatrist and GP. He can also be referred to a drug health act and I will call on the crisis assessment
rehabilitation center to help him stop drug usage and team.
develop new coping skills that make the relapse less - Dont worry. We will be here to take care of her.
likely. Prognosis is good. If you need any help or you have
- Arrange family meeting. any other concerns, please dont hesitate to contact
- Support groups. us.
- Refer to psychologist if father is depressed.
- Is there any antidote available? No. MOOD DISORDERS
- Is ice addictive? It is a highly purified form of
amphetamine and thats why it is powerfully addictive. Loneliness or Empty Nest Syndrome
- Will this lead to schizophrenia? Using this drug is a
risk factor for mental disorders. Case: A middle-aged lady presented in your general practice.
- Will you report to authorities if drug test is positive? It She complains of feeling down and depressed for a few months.
is a confidential issue. Once he is stable, we will talk You asked her to come for consultation a few weeks back but
to him and discuss further plan of action with him. did not come.
- Are you sexually active? Stable partner? What do you - Sleep problem? How is the problem? Hard to initiate
do? or wake up early? Night sweat? Do you feel fresh in
- Do you hear or see things which others do not? Do the morning? Any nap during the day
you have strange experiences? - How is your mood? Appetite? Daily enjoyment as
- How is your general health? Do you have weather usual? Do you feel active or lethargic? Suicidal
preferences? Do you have swelling all over the body? ideation? Harming yourself or others? Do you think life
Weight gain? Lump in the neck? is worth living?
- Menopausal symptoms: irritability? Dryness of - Do you ever feel or hear things that other people
vagina? Hot flushes? Mood swings? Pap smear? cannot? Do you feel someone is spying on you?
Mammography? SADMA? - Whom do you live with at home? How is your
relationship with your family? Since your fathers
Diagnosis death, have you talked to someone else about your
- From the discussion we have, you most likely have a feeling
condition called loneliness or empty nest syndrome as - SADMA?
you have no one to talk to at home, your husband is - Tea and coffee drinking habit during in the evening?
estranged to you and your children have grown up - General health? Past history of thyroid problem or any
and moved out. These are all contributing to it. There mental illness? Any family history of similar problems?
are a lot of things we can do about it. You can join the Any family history of mental illness?
community clubs, or do voluntary work. Meet and - Insight and reliability
make new friends and create a social circle. You can
explore your interests and activities. Management
- I can arrange a social worker if you need a help. I will - The most likely diagnosis at this stage is one of the
refer you to a counselor with whom you can share and normal emotional reactions to people who lost
talk about things. If you agree, I am happy to organize someone who is very close and emotionally bound. It
a family meeting and tell them about your condition. is normal to feel disbelief, anger, sadness.
You can always give them a ring or talk to them via - However, I can help you with some advice in many
skype to see them. ways.
- Lifestyle modification. Review. o Socialize more talk to friends and family
- Referral to psychologist. Reading material (Beyond o Approach religious resources according to
Blue). your beliefs to help your relax spiritually
o I can also organize a support group for you
Normal Grief and your family
o Sleep problems provide with written
Case: You are a GP and 18 years old university student comes materials regarding sleep hygiene and other
to you with complaint of poor sleep since her father died. She techniques
cant concentrate on her study and she is anxious as the exam Avoid having tea or coffee in the
is approaching. She visited you 2 months ago with some flu. evening
She was alright at that time. Avoid having heavy meal before
sleep
Tasks A glass of warm milk before sleep
- Focused history Try to maintain the room
- Management environment being not too hot and
not too cool
Try to sleep in dark and quiet
room
Have a routine to go to bed at the
same time everyday
Avoid day time naps
Meditation before bedtime can
help you relax
I can arrange a referral letter to
psychotherapist who will teach
you relaxation technique.
- I can also organize social workers to visit you at your
place as required. It will be difficult for you to go to
exam right now, so a letter will be provided to your
principal of your school to reschedule your exam
- University counselor is also available for counseling of
Stages of Grief: (normal grief can go up to 3 months) such cases
- Shock and disbelief o Sleep hygiene and life style modification
- Grief, anger, despair, self-blame, guilt o Prescription short acting benzodiazepine
- Adaptation and acceptance of the loss o If you feel very low at any time and you feel
stressed and frustrated with yourself, please
If the timing and severity increase, there is high risk of suicide come to me and contact crisis control
and psychosis. center.
o Please do not stay alone and I will review
History you in 3 days time about your progress
- Sorry to hear what has happened. How are you
coping with this situation and your family? Is there
anything you want to share with me regarding your
dad?
- Confidentiality!
13
Anniversary Grief Reaction SSRIs for some time. She did not show up for previous follow-
ups for the last 2 months. She is here today because the
Case: Your next patient in GP practice is a middle aged woman receptionist has called her.
who came for regular checkup regarding her BP. She had no
emotional problems before but during the last weeks, she was Task
tearful and often crying. Her husband died of heart attack 12 a. Perform Mental state examination
months ago. b. Tell examiner diagnosis and management plan
Task Criteria:
a. History (started 2 weeks ago, when I was cleaning the - Anhedonia, depressed mood, suicidal ideation, sleep
closet and putting his clothes aside, and started to problems (early awakenings), lack of energy,
smell his scent; I can feel his presence) problems with concentration and decision making,
b. Diagnosis and Management lack of sexual desire and appetite
- Diagnosis depends upon the presence of 2 of the
History above along with suicidal ideation, persisting for at
- I understand that you came to see me for review of least 2 weeks or any 4 of the above without suicidal
your blood pressure. Is everything alright? Have you ideation.
been checking your blood pressure? I also understand - Risks/criteria for admission: not eating/drinking
that you have been tearful and crying. How do you appropriately, suicidal ideation, lack of support at
feel right now? (Patient starts crying Offer tissue and home, not taking/responding to antidepressants
Water). I know it is a very hard time for you. I am here
to help you. If you feel like talking to me, let me Counseling
reassure you that everything we talk about it - Show empathy. Confidentiality statement.
confidential. I will not breach this confidentiality. - From the notes I understand that you have been upset
- When did it start exactly? How did you cope after your since the incident five months ago. Can you please tell
husbands death? Hows your mood? Do you still find me exactly what happened? I understand it is very
things pleasurable? Hows your sleep? Appetite? difficult for you to go through that experience one
Weight? Psychomotor retardation or agitation? Do you more time, but it will really help me to understand the
think life is worth living? Do you feel guilty about your situation. When exactly did you start feeling bad about
husbands death? Have you thought of harming yourself? How was your mood before the incident?
yourself or anybody else? Do you hear or see things Were you eating and drinking well? Were you able to
that others do not? Do you have any strange work? Have you ever been diagnosed with depression
experiences? or other illnesses like thyroid problems, diabetes,
- Whom do you live with? Have you got enough support infections? What happened after the incident? Did you
from friends and family? Do you go out with friends? notice any changes in your weight or appetite? Were
Are you working at the moment? Can you do your you feeling guilty all the time? Any change in your
day-to-day activities? SADMA? sleep pattern? Any early morning awakenings? Did
you feel like harming yourself or others? Do you think
Diagnosis and Management your life is worth living? Have you thought about how
- From the history, most likely what you are you are going to do it? Any plans? Did you buy
experiencing is anniversary grief reaction. This is something for that plan? Please tell me, whom do you
normal, expected and understandable especially when live with him at home? Any partner? Kids? Relatives?
a close person/loved one passed away. Your mind Friends? Neighbors to take care of you? Are you
ventilates the feeling through crying. To feel your working at the moment? When did you leave? Can
husbands presence is a part of anniversary reaction you tell me more about the medications that were
and it doesnt mean that you are getting insane. I given to you? How long did you take them? Did they
understand that you are going through a tough time. help to improve your mood? Why did you stop?
What you are feeling is like a bruise. It will heal - Do you see/hear things that others dont? Do you
without scarring. You will feel better once the have strange experiences? Do you think some people
anniversary phase is better. But what you need at this are trying to harm or spy on you? Are there repetitive
time is emotional support. We will manage your thoughts that you cant get rid of? Do you think the TV
condition with a multi-disciplinary approach or radio talk to you?
(Psychiatrist, Psychologist, Occupational Therapist, - Can you please tell me your date of birth? Day?
Social Worker, Counselors, and Mental Health - What would you do if there is fire in the room or
Nurses). I will refer you to the psychologist whom you envelope on the street that has an address on it?
can share your problems with and to help you cope - Do you think you need medical help? May I ask why
with the grief, social worker, and grief support group. youre here?
If you are happy, I can arrange a family meeting. - What are your plans for the future? Are you planning
- Cant you just give me medications doctor? You do on anything?
not need any medications at this moment. All you
need is a lot of support during this hard time. MSE (ASEPTIC)
- I will need to see you in a weeks time to see your - Appearance (dress, posture, hygiene)
progress. - Speech (rate, tone, volume)
- Referral. Review. - Emotion (affect and mood)
- Perception (hallucination, illusion, derealization)
Major Depression with Psychotic Features - Thought (delusions, suicidal/homicidal ideations,
obsessions, logical/coherent)
Case: You are a GP and a 42-year-old nurse comes to see you. - Insight and Judgment
She had been accused of an incident at the hospital around 5 - Cognition (orientation to time, place, and person;
months ago where a patient had died. The nurse has been memory; LOC)
cleared by the coroner and the case was adjourned. The patient
did not feel well after the incident and she was treated with
14
- I would like to address my MS findings to the - Youre doing a good job as a mother. Dont worry. I do
examiner. The patient looks appropriately dressed for understand that it is difficult to be a mother for a first
the weather. She looks gloomy, tearful, and avoiding time and you need support. I will organize a social
eye contact. She is sitting with a drooping posture. worker to help you. If you like, I can organize a family
The affect appears constricted, although the mood is meeting and talk to your husband about the issue. I
depressed and irritable at times. The patient speaks would also like to refer you to a counselor to teach you
with a monotonous voice, sometimes with long pauses how to cope with stress.
in between where she avoids answering. I also found - I would organize basic investigations especially FBE,
that the patient has delusions of guilt. She feels ESR/CRP, urine MCS, BSL, and TFTs.
helpless and has suicidal ideations although no - Do not worry. You are not alone. These blues or mood
particular plan is present at the moment. Her cognition swings should be fine in around 1-2 weeks (1 month
is distracted where the patient is not able to maximum).
concentrate adequately although her memory is intact.
Her insight and judgment is impaired. Postnatal depression with psychosis/melancholic features
- Based on the examination findings my most likely
diagnosis is major depression with psychotic features. Case: 30-year-old woman came to your GP clinic. She has 2
It is obvious that the patient is neglecting herself. She children 30 months and 2 months. She presented with 2 weeks
needs to be evaluated appropriately by the psychiatric history of tiredness, weight loss, and inability to sleep. Shes
team so I will need to refer her to the hospital if always worried about her baby as she thinks baby will die from
required under the mental health act. The most likely SIDS. You arranged some investigations for her 1 week ago and
management is anti-depressants with or without ECT all the tests are normal. Today, shes here to collect the report.
followed by CBT later on.
Task:
Postpartum/Postnatal Blues a. History
b. Diagnosis
Case: Your next patient in GP practice is a 25-year-old Jane c. Management
who is 7 days postpartum. She feels exhausted, and has lack of
energy, and gets quite irritable at times. She is wondering if she History
is lacking some vitamins and seeks your advice. - I understand from your notes that you are here
because you have trouble sleeping, has lost weight
Task and are always tired? Can you tell me more about it?
a. History (1st baby, feels very tired; planned pregnancy; Can you describe me your sleep pattern? I know you
takes care of the baby; complicated labor prolonged are tired (anemia, chronic illnesses, psychological),
for 14 hours, eclampsia; cannot sleep at night but do you have any SOB, palpitations, fever?
because baby is crying all the time; husband needs to - How is your mood? Sleep? Weight? Appetite? Have
travel a lot; needs help; I love my baby; no past you lost interest in the activity which used to be
history of depression) pleasurable before? Do you think life is worth living?
b. Diagnosis Have you thought of harming yourself or anybody
c. Management else? Have you ever thought of harming your baby?
- Psychosis: do you see, hear, feel things which others
Risk factors do not? Do you have any strange experiences? Do
- Prolonged or difficult labor you think someone is putting thoughts into your head?
- First baby Or think something/someone is after your thoughts?
Do you think tv/radio/newspaper is talking about you?
History Do you think youre a good mother?
- Congratulations! How was the pregnancy? How was - Insight
the labor? Is it your first baby? Is everything okay - Judgment
now? How is the baby? Did you start breastfeeding? - Cognition
Any problems with that? - HEADSSS
- I understand that you have tiredness and youre - PMHx/FHx/SADMA
irritable?
- Confidentiality Risk factors for postpartum depression
- Any SOB or did you have a lot of blood loss? Do you - Previous history of postnatal depression
think youre pale? Any weather preferences? How are - Previous history of any mental illness
your waterworks? Hows your discharge? Any - Unplanned pregnancy
offensive smell? Hows your diet? - Difficult marriage/lack of support
- Mood: How is your mood? Do you still find things - Social isolation
pleasurable? Hows your weight? Appetite? Sleep? - Complication during pregnancy
Have you ever thought of harming yourself or the - Abused childhood
baby? Do you think life is worth living? Do you
hear/see things that others do not? Do you have any Management
strange experience? SADMA? - You have a condition called postpartum depression
- How are things at home? Do you have enough with some psychotic features. Our body and mind are
support from friends, family and husband? How is interconnected. When our mind is too stressed our
your relationship with husband? Any financial body starts showing symptoms and thats the reason
problems? why youre having tiredness, weight loss and sleep
changes. We did some investigations and all the tests
Diagnosis and Management are normal which means that there is no organic
- Most likely you have a condition called postpartum cause for your symptoms.
blues. It is more common during the first pregnancy - I have to admit you to the hospital. I will call the
and basically, it happens because of hormonal ambulance. In the hospital you will be reviewed by a
imbalance. There are also contributory social factors.
In your case, it is the lack of social support.
15
Treatment
- Admit - Do ECG, BSL and Urine at the office during his first
- Lithium carbonate, sodium valproate visit
- Anti-psychotic - DSM criteria:
- Anti-depressant (need to used with caution with mood o UNREALISTIC worries
stabilizer) o Uncontrollable worries
- Psychiatrist review and long-term followup o Symptoms are not the direct result of any
- Mental health care plan organic or psychiatric disturbances
o 3 or more symptoms:
Mania MMSE Irritability
Restless, keyed up or on edge
Case: Your next patient is a young uni student brought in by Easily fatigued
their concerned parents. She is insisting to fly to US to meet the Difficulty concentrating or mind
president. going blank
Muscle tension
Task Sleep disturbance
a. Mental state examination - Management:
b. Present findings to examiner o Relaxation techniques: YOGA AND
MEDITATION
MSE o Lifestyle modification: Diet
- Confidentiality o Physical activity: 30 minutes brisk walking
- General appearance and behavior: restless and most days of the week
agitated o Refer to psychologist for CBT
- Speech and language: rate, volume, quantity; fluency, o Sleep problems: sleep hygiene; may give
range of vocabulary short-term benzodiazepines (up to 2 weeks
- Mood and affect: congruent/incongruent; but usually 2 days to prevent drug
appropriate/inappropriate (related to situation) dependence)
16
b. Diagnosis and management Melbourne, recently divorced 3 weeks ago, not on any
contraceptives, regular with pap smear, no bleeding
History disorder; drinking alcohol 3-4 glasses of wine to help
- When did it start? Any previous episodes? Did it occur with sleep)
after the motor vehicle accident? Any triggering b. Physical examination (looks well without eye contact,
factor? Any associated features such as chest pain or VS normal, all PE normal)
sweating? How is your general medial health? Any c. Investigation
serious medical problems in the past? d. Diagnosis and Management
- I know you had a car accident, Im sorry about it. Im
not asking you to recall the event, but can you please Differential Diagnosis
tell a few words about it? Was somebody with you at - Major depression
that time? How is she? Do you have any contact with - Acute stress disorder
her? Do you experience any sudden images of the - PTSD
event? Do you try to avoid driving or the place where
the incident took place? Do you have any nightmares? Stressors:
Do you feel irritated, angry or guilty about anything - Death of a loved one
pertaining to the incident? - Divorce or problems with relationship
- How is your mood? Sleep? Appetite? Weight? - General life chages
Anhedonia? Suicidal ideation: do you think life is worth - Illness or other health issues in yourself or a loved one
living? Have you thought of harming yourself or - Moving to a different home or city
anybody else? Do you see/hear/feel things others - Unexpected catastrophes
cannot or have you had any strange experiences? - Worries about money
- Whom do you stay with? Do you have a lot of friends? - In teenagers: family problems or conflict, school
SADMA? problems, sexuality issues
- ENCOURAGE patient by nodding and showing
concern Features:
- 5 symptoms for 2 weeks daily: SAGECAPS (in
Diagnosis and Management depression)
- From the chat we had, I think you have a condition o Sleep
called post-traumatic stress disorder. Have you heard o Anhedonia
about it? It is a type of anxiety disorder where the o Guilt
patient experiences various symptoms and behaviors o Energy (lack of)
like recollection, flashbacks, avoidance, sleep o Concentration
problems following a psychologically distressing event o Appetite
which in your case is the MVA you had 3 months o Psychomotor retardation
before. o Suicidality
- The symptoms usually come immediately after the - Criteria
event but can be delayed for months or years. o Development of emotional or behavioral
- I will refer you to a psychiatrist. He will talk and listen symptoms in response to an identifiable
to you and will use some techniques to help you come stressor within 3 months of the onset of the
out of this situation cognitive behavioral therapy. stressor
As you havent slept for a few days, he may offer you o Symptoms or behaviors are clinically
sleeping pills for a short time but I would advise you to significant as evidenced by:
start with sleep hygiene. marked distress that is in excess
- At this stage, you might not need any medication, but of what would be expected from
if required, the specialist might offer SSRIs. exposure to the stressor
- I would like to do a family meeting if its okay with you. Significant impairment in social or
Family support is very important at this stage. occupational functioning
- Safe level of drinking. o Stress-related disturbance does not meet
- Review. Reading material about PTSD and sleep criteria for another specific axis I disorder
hygiene. and is not merely an exacerbation of pre-
- Differentials: anxiety disorder (GAD, adjustment existing axis I or II disorder
disorder, panic attacks, substance abuse) o Symptoms do not represent bereavement
o Once stressor has terminated, the
ADJUSTMENT DISORDERS symptoms do not persist for more than an
additional 6 months
Adjustment Disorder - Treatment
o CBT
Case: Your next patient in GP practice is 32-year-old Shirley o Relaxation technique (yoga and meditation)
Coombs complaining of SOB. She has recently moved from o Healthy diet and exercise, reduce caffeine
Sydney to Melbourne with prolonged travel time. o Stress management (dont bottle things up!)
o Sleep hygiene
Case 2: lady with chest tightness and pain and normal o Short-term course of drug treatment is
investigation husband died recently; necessary in persistent or severe case
Case 3: sad woman anniversary grief Developmental Disability with Adjustment Disorder
Task Case: You are a GP and your next patient is a 26-year-old with
a. Focused history (started 2 days ago, comes and go, Down Syndrome living in a support home. There is change in
does not change with position, started 4 weeks ago, behavior recently and he is very tired. He is afraid to coming to
present at rest, not feeling comfortable, no fever, feels the GP and that is the reason he hasnt come today as well.
tired, and breathless, drove from Sydney to Instead, there is a legal carer who has come to see you.
20
- Consider ENT referral to rule out organic pathology - Dont worry. You made a decision to come up and talk
- Review after couple of weeks about it. At this stage, I would like to refer you to a
psychiatrist who will do talk-therapy. He may also put
Critical Errors you on some medications (SSRI and antipsychotics)
- Not sympathetic for your anxiety and concern.
- Did not rule out organic causes - I would advise you to remove the mirrors in your
- Does not know the diagnosis home.
- Offer family meeting/support/social workers
Body Dysmorphic Disorder - Review, reading material, referral.
Case: You are an HMO and your next patient is a 29-year-old Case 2:
male who came to see you. He brought an envelope containing
hair and he asked you to examine it under the microscope. He is History
worried that he is getting bald and he believes that this hair loss - Confidentiality
will affect his promotion. - History: patient information HPI
- Family history
Task - Personal and social history
a. Focused history - MSE
b. Diagnosis o Appearance: eye contact; psychomotor
c. Management agitation, how patient dresses,
o Speech: pressured, normal, soft, loud,
Case 2: Female wants to have a breast reduction surgery monotonous
o Affect
Case 3: Man concerned about penis size o Thought: Form and Content
o Cognition
Case 4: You have a 24-year-old male student coming to your o Suicidal Risk
GP clinic asking for referral to plastic surgeon because he thinks o Insight/Judgment
his nose is too big. On examination, you find that his nose is
completely normal. Management
- I think you have what we call BDD. This means that
Task you have a preoccupation with a certain part of your
a. Further focused history body even though it is normal and this is causing you
b. Examination not necessary distress and anxiety.
c. Advise patient - I can give you a referral to a plastic surgeon if you
want, for a second opinion, but honestly at this point, I
Features dont find it necessary.
- Preoccupied - I would, however, like to refer you to a psychologist for
- Try to HIDE it cognitive behavioral therapy so that he can talk things
- Frequent mirror checking through and identify any stressors and help you cope
with them.
History
- I can see from the notes that you have hair in this Somatization Disorder with Agoraphobia
envelope and you want me to take a look at it under
the microscope? Why? Is it the first time? How is it Case: You are seeing a 26 year old female, Nardia, who comes
affecting your life? Apart from hair loss, are you to you for review of the result of MRI brain which was requested
concerned about any other part of your body? Does by the neurologist specialist. Nardia did the MRI as she has
this concern preoccupy you? Do you try to hide it? headache associated with severe neck spasm. Nardia has past
- How is your sleep? Restless? How is your mood? history of abdominal pain and nausea. Investigation with blood
Appetite? Weight? Anhedonia? Guilt? Do you think life tests, CT and U/S were all normal. Colonoscopy and upper GI
is worth living? Have you thought of harming yourself endoscopy were normal too. Past history revealed she had a
or others? Do you have any strange experiences? feeling that she had a breast lump on investigation that was
- Social history: how are things at home and at work? normal as well, history of chest pain investigation ECG stress
Do you have a lot of friends? Do you socialize? test echo and Holter were all normal. Nardias MRI results are
- SADMA? all normal
- Appear before the age of 30 - I will give you some reading material about this
- Criteria: 4 pain symptoms, 2 GIT, 1 sexual, 1 disorder medically named somatization disorder with
pseudoneurologic symptom agoraphobia.
- Please understand that this treatment will take some
History time to work. Meanwhile, you can take some OTC
- May I ask more about the pain? How bad is it? Does it painkillers to relieve the pain.
go anywhere? Has it changed over the past few
hours? Is it the first time for you to have neck pain? Hypochondriasis
- I understand from the notes that you have had
previous treatments for different symptoms like Case: Suzanne aged 45 years presents to your surgery in a
headache, tummy pain, etc. any complaints now? busy afternoon. She tells you that she had right sided abdominal
What treatments were given? Did it help? At the pain for a few years and she bad been investigated in detail with
moment, how is your mood? Are you enjoying daily negative results. She describes pain is not present all the time
life activities? Are you socializing with family or and she thinks she has colon cancer and maybe doctors are
friends? Do you work? Are you able to concentrate unable to diagnose. On further questioning she denies weight
well on your work? Any difficulties in making loss, change in bowel habits or any history of melena or
decisions? How is your appetite these days? Sleep? hematemesis. Her appetite is good and is well otherwise. She
Weight? Are you in a stable relationship at the requests you to do another ultrasound and colonoscopy.
moment? Sexually active? Are you still interested in Suzanne lives independently in a flat and had no known medical
sex? or any surgical problems.
- I need to ask you some strange questions. Do you
see/hear things that others dont? Do you think that Task
someone is trying to harm you at any way? Have you a. How will you manage Suzannes request
ever thought about harming yourself or ending your
life? Have you thought of a plan? Have you bought Features
something to carry out that plan? Do you feel
excessively anxious about things? Do you feel SOB, Somatoform disorder
dizzy, or fainting at any time? Are you happy with your - DSM IV Criteria
life? Do you feel guilty about anything? Any bad o Preoccupation with fears of having or the
memories for you? Any childhood incidents that you idea that one has a serious disease based
cant forget? Any repetitive thoughts? Any other on the persons misinterpretation of bodily
medical or surgical conditions that I should be aware symptoms
of? Have you ever been diagnosed with depression or o Preoccupation persists despite appropriate
other psychological illnesses? FHx of psychiatric medical evaluation and reassurance
illnesses? SADMA? How do you support yourself? o Belief (A) is not of delusional intensity and is
Financial issues for you? not restricted to a circumscribed concern
about appearance
Diagnosis and Management o Preoccupation causes clinically significant
- I understand that you have pain in the neck along with distress or impairment in social,
stiffness. On the other hand, it seems like you are occupational, or other important areas of
unhappy and depressed. Im wondering if we can link functioning
the two conditions. In my opinion, the mind and body o Duration of disturbance is at least 6 months
are connected deeply. Whenever there is stress upon o Not better accounted for by GAD, OCD,
the mind, the body reacts by producing symptoms like Panic disorder, major depressive episode,
nausea, vomiting diarrhea before exams. Just like separation anxiety or another somatoform
that, you are having pain in your neck. This pain is disorder
quite real; however, the CT scan shows that there is
nothing physically wrong with the structures in the History
neck. - r/o organic disease
- We have a management plan which involves a - risk assessment: mood, and suicidal ideation
multidisciplinary approach. First, lets deal with your
pain. We can refer you to a pain management clinic Counseling and Management:
and give you a stronger medication. o Group psychotherapy and CBT
- Sometimes, talking about the stress and emotional o Lifestyle modification
conflicts within the mind can help to relieve these o Relaxation techniques
symptoms. So I would recommend for you to see a o SSRIs
psychologist for a type of treatment we call as
cognitive behavioral therapy/talk therapy. They might PERSONALITY DISORDERS
give you some medications like SSRIs or certain
anxiolytics. Antisocial Personality Disorder
- This problem in your neck can go away. I will see you
in two weeks to see how you are going. There are a Case: You are an HMO in ED when a police brings a 27-year-
few things you can do to reduce your anxiety: old Michael from a boarding house where he had been in a fight
breathing slowly, hyperventilation will make symptoms with another resident which he seems to have started and he
of panic attack worse, use relaxation technique, dislocated her middle finger. The police want him to be
exercise and swimming. Make a change in your life medically checked before they take him to the police station to
style. Reduce caffeine intake and alcohol. Exercise charge. Michael is well known to your hospital.
regularly.
- Refer to Anxiety recovery center Victoria or Metal
health organization of Australia
25
taking? Was it regular? Did you have any other side - Can you describe to me what exactly do you mean by
effects from this medication (abnormal movement dizziness? In what position do you feel dizzy? Did you
around the mouth or the body?noticed any shaking of lose consciousness at any time? Did you fall down
your hands? Restless? Sleepy more? Dizziness and hurt yourself?
especially on getting up in the morning? Any - I understand you went to your GP recently. What
complaints of dry mouth, headache, blurred vision? symptoms did you have at the time? Do you think you
How are your periods? Are they regular? LMP? can see or hear things that others dont? Do you think
- May I ask how is your mood? Sleep? Appetite? the TV or radio is talking to you or about you? How is
Energy level? Do you feel interested in daily life your mood these days? Any ideas about harming
activities? Have you ever thought of harming yourself yourself?
or others? I need to ask you some questions that - What medication was prescribed to you and in what
might sound strange or funny. Do you ever dose? Were you able to follow the instructions
see/hear/feel things or voices that other cant? Do you properly? Who looks after your medications for you
think the TV/radio are talking to you or about you? Do (wife)? What dose did you take? Do you have the
you think someone is spying on you? Do you think you prescription with you? Or do you have the bottle?
have special powers? Any past medical or surgical Which medication were you on previously? What was
history that I should be aware of? SADMA? Have you the name? dose? Any side effects? At the moment do
ever had your blood sugar checked? Any family you have any complaints of N/V/blurred vision/dry
history of psychiatric illness. Are you on a mouth? Any abnormal movements around the mouth?
relationship? What methods of contraceptive do you Do you feel restless all the time? Have you noticed
use? What contraception do you use? Any chance any tremors or shakes of your hands? When was your
you might be pregnant at the moment? last visit to the specialist psychiatrist? Any past
medical or surgical history? Any hospital admissions
Management previously? Have you ever suffered from high or low
- I would like to organize some blood tests on the BP before? SADMA (medication interaction: antifungal
patient. FBE with PBS, BSL, TFTs, LFTs, lipid profile, and SSRIs inhibit liver breakdown of risperidone
serum prolactin, U/E/C, ECG, CXR increase blood levels)?
- Most probably what you have is a side effect of - Am I able to talk to the carer or the wife?
olanzapine (zyprexa). All medicines have some side
effects but they are important to control your Physical examination
symptoms of schizophrenia. At the moment, I need to - General appearance: LOC (alert, confused, drowsy),
talk and liaise with the psychiatrist. They might decide pallor, jaundice, dehydration; any visible abnormal
to change this medication but before that, I want you movement of the face or the body? Tremors?
to try some dietary and lifestyle changes. Please try - Vital signs
regular exercise 30 minutes a day for most of the - Neck for LAD
week, check your weight regularly, and choose a - Chest/heart/abdomen
healthy diet. The dietitian can help by making an - BSL and Dipstick
appropriate diet chart for you. This weight gain puts
you at a high risk to develop DM, HPN, and heart Management
disease, depression (obesity can cause non- - You have a condition called postural hypotension.
compliance of medications) This condition is characterized by a change of your
- You need to have regular followup with me and the blood pressure while standing up from a sitting
psychiatrist. If they decide to change the medication, position that gives you dizziness. There are two
you will need to be admitted to the hospital during the possibilities: either you are having a side effect of
crossover period which usually takes around 2 weeks risperidone or a higher than normal dose has been
(tapering previous medication slowly and introduce the taken. The side effect is quite commonly seen within
new one while observing for side effects). the first week of treatment even at a normal dose
- Diet and lifestyle should be done until she has seen (usual starting dose: 1mg BD gradually increasing to
psychiatrist. 3mg BD).
- Is it the doctor who has done some mistake? Your
Postural Hypotension (Side Effect of Risperidone) doctor has prescribed what is best for you. I would
prefer to take a look at the prescription and if possible,
Case: You are an HMO and a 25-year-old male came in to the I will talk with your wife who takes care of your
ED due to dizziness since this morning. He has been diagnosed medication.
with schizophrenia for the last 10 years and his symptoms are - What we need to do now is to keep you in the ED to
usually controlled with medications. Recently, his wife noticed observe your BP and to do some blood tests (FBE,
that he had typical symptoms again, so she sent him to the GP Risperidone blood level). I will call in the psychiatric
who changed his medications to risperidone. team to review your condition. They might adjust the
dose of your current medication or they might decide
Task to switch to another one. If they decide to change,
a. History (haloperidol x 10 years risperidone; can then you will need to stay in the hospital for the
talk to his dead brother recently; dizziness on standing crossover period which takes around 2 weeks.
and sitting; - Meanwhile, I would like you to be aware of general
b. Physical examination (oriented to person, place and rules to be followed when taking an antipsychotic
time; no pallor, dehydration, jaundice, BP sitting medications:
120/80 100/60, BMI N) o Take medication exactly as prescribed
c. Diagnosis and Management o Have a routine to take at the same time
everyday
History o If you forget to take a dose, take it within the
- Is my patient hemodynamically stable? next few hours. Otherwise, skip the dose.
Please do not double the dose.
29
o You need to continue taking the medications o When ECT has been successful in the past
even if you feel well o Last resort to treatment-resistant OCD,
o Never stop the drug abruptly Parkinson disease, tourette syndrome
o Inform your doctor if you develop any side - Contraindications: raised ICP is the absolute
effects, other symptoms, and before taking contraindications.
any other medications - Some specialists believe that it is more effective than
o Half-minute rule (30sec): when you get up in drug therapy. It is amongst the least risky medical
the morning, sit up slowly and stay for 30 procedure carried under GA.
seconds, put the legs over the side of the - Extra caution is required in a number of clinical
bed for 30 seconds and slowly get up and situations according to the medical history of your
walk prevent any dizziness in the future mother (recent MI, cardiac arrhythmia, pace makers,
hypertension, intracranial pathology, epilepsy,
Counseling on ECT osteoporosis, aneurysm, skull defect, retinal
detachment
Case: A 55-year-old lady has been admitted to the hospital for - Pre-ECT evaluation:
severe depression with suicidal ideation. Her son has come to o Full medical history, physical examination,
your GP clinic to discuss about ECT as the psychiatrist has routine investigations including fundoscopy
recommended it as the best choice of therapy for his mom at will be done to make sure ECT is safe for
this stage. your mother.
o Anesthetic consultation for risk of
Task anesthesia
a. Discuss about ECT o Explain of procedure and informed consent
b. Answer questions o Patient should be fasted for 6-8 hours
before the procedure
- Painless - The procedure is carried out under the supervision of
- Under GA and with muscle relaxants a consultant psychiatrist and anesthetist. Patient is
- Indications given general anesthesia and muscle relaxant to keep
- Contraindication: her relaxed and unaware of seizures. Small devices
o Increased ICP called electrodes will be placed on specific locations of
- Side effects: her head to give a series of brief electrical pulses.
o Anesthesia SE Patients vital signs are continuously monitored and it
o Muscle relaxant SE takes about 10-15 minutes for the procedure to
o Memory loss and transient confusion complete and patient is taken to recovery area for
- Drug Interactions post-anesthetic care.
o Non benzodiazepines for anxiety - Duration of treatment: typically3x/week for 6-9
zolpidem, zolpidone, zolfresh treatments depending on the patients condition and
o No antidepressants and antiepileptics response to treatment. It can be performed as an OP
o Mood stabilizers may result to postictal procedure or when the patient is hospitalized. The
confusion but does not interfere with efficacy symptoms start improving after 2-3 treatments.
- Consent: - Side effects:
o Normal MMSE o Immediate: Headache, muscle pain, nausea
o Not under effect of drugs/alcohol and drowsiness are benign and should
o Age respond to symptomatic treatment
o Post-ECT delirium needs close supervision
- Is the son permitted to discuss the condition of his and supportive treatment and IV
mother? I understand that you are here to discuss psychotropics if required.
about ECT: its indications, contraindications, o Memory impairment that usually resolves by
procedure, side-effects and post ECT management 4-6 weeks following treatment
- Any particular concern? Please dont hesitate to stop - Maintenance treatment: ongoing treatment will be
me if you have questions. required to prevent a recurrence in the form of ECT,
- It is a medical procedure in which a series of low- antidepressants, psychotropics, CBT or
frequency electrical pulses are passed through the psychotherapy.
brain to produce brief-controlled fits. It can provide
rapid and significant improvements in severe CHILD AND ADOLESCENT BEHAVIORAL DISORDERS
symptoms of a number of mental health conditions
and doesnt cause any structural brain damage. Autism
- Indications
o Psychogenic depression Case 1: You are GP and your next patient is a 3-1/2 year old girl
o Melancholic depression unresponsive to with her mother who comes to you because she is concerned
meds about her destructive behavior. She has been contacted by
o Psychosomatic depression (Life-threating childcare who says she is different from other kids. A hearing
refusal to food or severe psychomotor test has already been done.
disturbance)
o Severe postpartum depression and Task
psychosis a. History play for hours, specific game, likes TV
o Catatonic schizophrenia cartoon, energetic; doesnt want to sleep; looks fine;
o Severe mania talked late; lack interaction to other kids; not hearing
o Pregnancy when medications cannot be mom; lacks social input
given as they can cause harm to fetus b. Explain diagnosis
o Elderly people who cannot tolerate drug side c. Counsel accordingly
effects
30
Case 2: You are a GP, a 5-years-old girl was brought to you by please understand that there is a lot we can do to help
mom because childcare complained that she has destructive her. The actual cause of autism is not known, but
behavior and claims she is different from other kids. She has a there is a genetic tendency. It is associated later on in
6-year-old brother with whom she does not interact well. Her life with epilepsy, OCD, sometimes intellectual
speech was delayed by 1 year. Her hearing and vision tests are disability and Tourette syndrome. This condition is
normal. She has been to the specialist who diagnosed her with more common in males. Around 1:1000 australians
autism. The mom is not clear about the diagnosis. suffer from autistic spectrum disorder (autistic
disorder, high-functioning autism, asperger syndrome,
Task pervasive developmental disorder). Autism is very
a. Explain the diagnosis to the mom difficult to diagnose under the age of 3. If any
b. Counsel accordingly suspicion is raised, it is important to establish the
diagnosis to help with treatment. The earlier the
History treatment is started, the better is the outcome. I want
- Please explain what you mean when you say that you to be aware that your daughter might exhibit
shes different from other kids. Is she aggressive? temper tantrums or obsessions. She will be resistant
How is her interaction with the other kids and with the to a change of daily rituals. She might be sensitive to
childcare workers? Does she exhibit any repetitive some colors, textures or smell. Otherwise, physically,
behavior? Does she become upset when her routine she will be a healthy and well-developed child. We do
is changed? Do you think she is particularly attached not expect for her to have the same emotions and
to a certain toy/object? Does she prefer to play alone? moods as everyone else. In a multidisciplinary team
Is she able to initiate play with other kids? How does approach, we will start an interventional program
she respond when you or someone else call her? Any which includes a. behavior modification therapy, b.
repetitive use of a word or sentence? Is she able to speech therapy, c. education, sensory and motor
maintain eye contact? How many friends does she program, d. regular medical checkups e. regular
have? Does she respond appropriately to changes in hearing and vision checks. You and your family need
your mood? to be involved throughout the program. Most of her
- BINDS: Please tell me more about your pregnancy? behavioral problems can be improved with this
Any complications? Mode of delivery? Any problems program and 5% of these kids go on to live an
like breathing? Did she require resuscitation? Can you independent life. However, the majority will require
tell me when she started to speak? When did she start life-long support.
babbling (6-8 mos)? Proper words (10-12mos)? Can - No special school except for asperger (do not want to
you tell me how much she can speak now stigmatize patient)
(words/sentences)? Developmental milestones: walk,
eat, drink independently? Does she smile socially? Behavioral Problem (ADHD)
Immunization? Any other medical or surgical
conditions? Case: You are a GP and a 6-year-old boy was brought to you
- Any family history of mental retardation? Autism? Or by his mom because she says the child is very active and the
other developmental disorders? teacher has complained that the child is loud and disruptive in
class. He is in grade 2.
Differential Diagnosis:
- ADHD Task
a. Focused history
Diagnosis b. Diagnosis and management
- Most likely, your child has some kind of a behavioral
disorder. The most common one to present this way is Differential Diagnosis for Hyperactivity
called autistic spectrum disorder. - ADHD
- It is characterized by: - Asperger Syndrome
o impaired social interaction - Oppositional defiant disorder
o speech and language problems - Visual and hearing problems
o abnormal repetitive behavior - Trauma (head injury)
- It is important to confirm this diagnosis preferably by a - Developmental problems
specialist. Unfortunately, it is a lifelong condition that - Previous infections (meningitis,
cannot be cured, but it can be very well controlled with - Home/school problems
appropriate interventions. I will refer you to the speech - Physical or congenital lesions
pathologist once the diagnosis is confirmed. Autism is
associated with a high risk of epilepsy and OCD so History
there is a possibility she might develop fits or seizures - Can you tell me more about the problem? What do
later on. There is no medical treatment but regular you mean when you say that he is disruptive and loud
checkups are important because these kids never at school? Is he aggressive towards his classmate? Is
complain. You will have all the support from me as it difficult for him to wait in lines? Is he pushing around
your GP, pediatrician, child psychologist, speech other kids? How is his academic performance?
pathologist, centrelink, and Autism Association of - Please tell me more about his behavior at home. Do
Australia. Please come back once the diagnosis is you think that he is able to concentrate on a given task
confirmed and we can talk about it in more detail. for at least a few minutes? Does he pay attention to
what goes around? Does he pay attention to
- Case 2: I can see from the notes that your child has commands? Does he talk rapidly without finishing
been diagnosed with a developmental disorder called sentences? Do you think he is able to finish a task
autism. It is a lifelong condition where the childs skills given to him? How long can he play with a particular
of social interaction and communication are affected. new toy? Do you think hes impulsive? How many
She will show repetitive behavior. She might have hours does he sleep at night?
speech problems. I understand that it might be
shocking and distressing for you to hear all this, but
31
- How is his relationship with you or with his family? - These kids might later on develop conduct disorder.
How is your home situation? Any recent changes at The usual age is preschool.
home? Who takes care of him most of the time? Does - Criteria
he go to child care? How is your relationship with your o Persistence of stubbornness
partner and other kids? Any new relationship for you? o Refusing to comply with instructions
How many kids do you have apart from this one? o Unwilling to compromise
Hows the behavior of the other kids? How is the o Deliberately testing the limits
relationship between them? Any family history of o Failure to accept responsibility
similar problems? Do you think he was diagnosed with o Blaming others for their own wrongdoings
a medical condition? How is he doing now? o Deliberately annoys mothers
- How was your pregnancy with this child? Any o Frequently losing temper
problems with delivery? Any history of head trauma or - Management:
brain infections or any other illnesses? Has he ever o Improved parenting skills (conflict resolution,
had a formal hearing or visual test done? How is his communication and problem solving with the
immunization? Are you happy with his growth and child)
development at this time? Are you happy with his diet o Anger management skills for the child
or nutrition? o Family counseling
o Classroom strategies (social skills
Management development sessions)
- Most likely, because of your concern and because of - Appear well in front of other people such as doctors
the teachers complaint, I do suspect that your childs except people they know well and whom they consider
behavior is different from others. I still need to have as authorities
his vision and hearing checked by a specialist. Before
labeling a child as having a behavioral problem, it is Differential diagnosis
important to obtain assessment reports from school as - Oppositional defiant disorder - argumentative,
well as from the family. This is called psychosomatic stubborn, picks up a fight
testing best done by the specialist child psychologist. - ADHD
- The most common behavioral problem in this age - Conduct disorder - extreme; gets into physical fights,
group is called ADHD (attention deficit hyperactivity theft/fire, cruel to animals and people, no remorse; no
disorder). It is a developmental disorder that results in relationship
poor concentration and lack of impulse control. Please
understand it is not a physical illness, but it can affect Features:
the childs learning and social skills. Usually, there are - Easily lose temper
associated problems with family function. - Refuse to follow rules
- Once the diagnosis is confirmed, we will start - Deliberately annoy others
treatment that includes behavioral modification that is - Blame others for their own mistakes
done by the psychologist. There are classroom - Can be verbally hostile but not physically
strategies to help with his learning and concentration - Acts are usually directed to those who are well known
span. There are special teachers who are qualified to to them
run these programs. Family counseling is also - Parents are facing numerous arguments
required. The fourth aspect is medications. These
medications are usually prescribed by the pediatrician VS Conduct disorder
only and are basically stimulants (methylphenidate - Aggressive
ritalin, dexamphetamine or atomexetine). The - Involve in bullying, fighting, theft, fire-setting,
single most effective treatment for ADHD is - Do not follow rules
methylphenidate. They stimulate areas of the brain for - Property destruction
impulse and concentration. Side effects are reduced - Antisocial
appetite and growth problems. - Can be cruel to animals
- Don't have any remorse
Oppositional Defiant Disorder - Refer to adolescent mental health service
Case: A mother brought his 8-year-old son with problems in Management: Behavior modification and family assistance
behavior.
History
Task - Can you tell me a bit more about it? (I'm concerned
a. History for 8 minutes (problem with School about his behavior. He is argumentative and stubborn
performance, argumentative, disobedient, picks up and is getting more difficult for me to handle him). For
fight with other kids and has problems getting along how long has he been having this problem? it's been
with them, doesn't listen to teacher's commands and an ongoing problem since he's very young but
does what he wants to do; has a sister who is fine; increasing with age). Does he lose temper very
fights with sister; no bullying in school noted; full-term quickly? Yes he gets annoyed with his siblings while
planned pregnancy; no complications; immunization playing with them. Does he listen to what you say to
up to date; separated from husband 4 years ago but him? No. He is disobedient and when I ask him to do
dad visits regularly and has good relationship with something he gets angry and does not do his work.
dad) Does he have any other siblings? Any problem with
b. Most likely diagnosis them? No. He has 2 other siblings without problems.
Des he go to school? Did you talk to his teacher about
DSM IV Criteria it? Teacher has similar complaints. He doesn't listen
- Repetitive persistent pattern of opposition, to teachers and difficult to settle him down. Does he
disobedience, and disruptive behavior towards have friends in school? He has but he doesn't
authority figures persisting for at least 6 months. have good relations with them. How is his
32
No, but remember, your parents love you and worry Risk Assessment
about you. Eventually, you should tell them or at least - Static Factors
explain that you are going through a difficult stage. o Age (elderly or very young age groups)
They are here to support you. o Past history of suicide
- I want to refer you to Family Planning Victoria. They o Past history of any medical illness including
are specialized in sexuality and reproductive health. depression and psychosis
There is a lot of help and support for you. o Child abuse
- I would also like to see you in a weeks time. - Changing Factors/Circumstances
- Doctor whats wrong with Johnny? Johnny is going o Patient living alone
through a difficult stage. There are physical and o Stressor (uni, work, family)
mental changes in adolescence which often create o Relationship
inner conflict which we will try to help Johnny to solve. o Access to means
I will see him in a week time. o Drugs/intoxication disinhibited and leads
to patient being impulsive
RISK ASSESSMENT
- Ask about the INTENTION while patient was cutting
Suicidal Attempt herself. Was it to commit suicide or to get physical
pain?
Case: Your next patient in ED is a 45-year-old man who was - When to admit
involved in a high speed single car crash earlier today. Other o Suicidal ideation
drivers reported that he was speeding along the highway and hit o Psychiatric diagnosis (depression or
a tree. Air ambulance was deployed and he sustained minor psychotic)
injuries with Colles fracture. He was brought by ambulance and
was assessed by the trauma team. His injuries have been taken Management
cared of and they have put a plaster for the fracture. Now the - Ensure confidentiality
resident is handing this patient over to you for final checkup - Appreciate that the patient is in stress
before discharge. - I understand that you are going through a tough
phase, can you please talk more about it. I know I am
Task sorry to hear that. Sometimes, we are very frustrated
a. History (intended to kill herself; divorced 6 months and some people do make us sad, but did you have
back and lost her job; worked as an accountant any intention to kill yourself by cutting your thigh (no
before; had repeated attempts; overdosed before; doctor, it just makes me feel better)? Have you done
generally a sad person) this before? Have you ever thought of harming your
b. Talk to patient and management boyfriend or any body else?
- How is your mood? Do you feel sad? Do you think you
Highlights: have lost interest in things that you used to enjoy
- CONFIDENTIALITY before? Any sleep problems? Change in appetite or
- What was the patients INTENTION? Did you intend to weight? Do you think life is worth living? Have you had
kill yourself or was it to do self-harm? problems with your relationship in the past as well?
- Have you had any previous attempts at self-harm? Are there any times when your mood is really high?
- Have you ever been diagnosed with any mental - Ill ask some questions which might seem funny but do
illness? you feel/see/hear things that others do not? Do you
- Have you seen any psychiatric services before? have any strange experiences?
- Did you regret doing it? (If intention was suicidal) - Do you think Im crazy? Sorry, I didnt mean that, but
- Past, present and future! these are routine questions for all patients who are in
your situation.
Risk Assessment (Borderline Personality Disorder) - Whom do you live with? Do you get along with them?
No issues? How about your parents? Do you have
Case: You are an HMO in the ED and your next patient is a24- friends? Do you socialize with them? Do you work or
year-old lady who has a history of repeated self-harm. She has are you a student? Any problems at work or at the
been diagnosed with borderline personality disorder. She cut uni? Is there anything else that is bothering you
her thigh this time. She was found intoxicated and was brought (financial, relationship, etc)?
to the hospital. Now she is okay. The wound has been taken - SADMA?
cared of and she wants to go home. - Ask about insight, cognition and judgment.
Task o Do you think there is something wrong? Do
a. Risk assessment you think you need professional help?
b. See if shes ready to go home o Fire/envelope question
o Do you know where you are, date, and time.
Case 2: A 16-year-old girl was at a party and had - PMHx: thyroid diseases?
benzodiazepine overdose yesterday after having a fight with her - Just let me go home! I know that you are really
boyfriend. She lost consciousness and was brought to you by stressed. I am here to help you, so please just bear
her friends. Now, she is ready to be discharged and your task is with me and help me so I can help you.
to do the risk assessment. - You can go home Mary. How would you go home?
(on history she takes tablets from mom to be able to sleep in When you go home, what will you do? What are your
this case advise on sleep hygiene!!!!). plans tomorrow? I would recommend you to call your
family or friend to come and pick you up. I would not
Case 3: You are an HMO in the ED and a 22-year-old female recommend that you drive now. I am really concerned
has been admitted with a number of wounds in her arms and with the way you are coping up with stress, so I will
legs. Most of them were superficial cuts. She has been treated refer you to the psychiatrist and psychologist. They
by the registrar. The wounds have been sutured and she wants will do talk therapy and will teach you techniques on
to go home. how to handle stress without harming yourself.
- About alcohol we need to discuss about the safe
level of drinking.
34
- If you agree to it, I would be happy to arrange a talk refer you to a counselor or psychologist with whom
with your friends or family. There is also a 24/7 hotline you can talk about things and teach you how to handle
number 1800187263 (1-800-18-SANE). Anytime you stresses of your life. I would also like to refer you to a
feel stressed, you can give them a call and you can psychiatrist for formal assessment.
talk to them. - At this stage, you can go home but I would like to give
- If you have financial problems centerlink you advice on sleep hygiene:
- Organize social worker if you need support o Have a regular pattern of sleep
o Dont have coffee, tea, or heavy meals
Benzodiazepine Overdose o Hot shower or milk
o Dont watch TV before going to bed
Case: You are an HMO in ED and a 16-year-old girl comes who o Bed should be used for 2 purposes: sleep
overdosed with mothers benzodiazepine tablets. Her mother and sex
found her and brought her to you. She has been resuscitated - If you are stressed or upset, then talking with a
and now is stable. Her mother is waiting outside. counselor might help
- Regarding your alcohol, please book an appointment
Task with your GP so he can advise you on the safe level of
a. Talk to the patient (started when parents got divorced; drinking
had difficulty sleeping for a few months, did not have - Social support.
intention to kill herself; school performance or grade;
mood is okay, I dont need help, why would I need ABUSE AND VIOLENCE
help. Doesnt think the TV is talking about her;
b. Decide on further management Child (Sexual) abuse
Risk Assessment You are a GP and a 4-year-old girl was brought in by mom who
- Dynamic: says she has a rash in the genital area. Her mom is divorced
o Patient: mental state, diagnosed mental and mom lives with a new boyfriend for the last 5 months. The
illness (depression, psychosis, mania), girl usually spends weekends with her dad. This weekend, she
intention/remorse, has refused to go to dad.
o Context/circumstance: access to
means/weapons, accommodation, family Task
support and friends, stressors (financial, a. Counsel the mom
personal)
- Static: History
o Time: history (have you done it before), Hx - I have been told you are worried that your daughter
of mental illness, developmetal history (child has a rash in the genital area. I need to ask you a few
abuse, conduct disorder, personality more questions if its alright with you.
disorder) - Mention confidentiality
o Place: culture - Can you please tell me more about what happened?
When did you notice the rash? Is it getting worse? Did
Counseling your child tell you what happened? Why do you think
- I understand you took some of your moms tablets, she refuses to go to her dad? Have you noticed any
how are you feeling now? Are you feeling better? behavior that is different than usual in your child (e.g.
- I am sorry to hear that. nightmares, irritability, refusing to eat or drink, refusing
- Confidentiality to talk to you)? Have you noticed her in an abnormal
- Was it accidental or did you take it with intention? Did position (like knee chest position)? Do you think she is
you have any intention to harm or kill yourself? How is enjoying the usual activities or is she withdrawn?
your mood? Do you still find things pleasurable? Do - Waterworks? Does she cry when she passes urine?
you go out with your friends? How are things with Bowel habits? Allergies? Itching down below?
school or uni? How is your school performance? I Bleeding? Discharge? Any possibility of trauma or
understand you have sleep problems. Is it difficulty foreign body? Is this the first time to have this rash?
getting to sleep or waking up in the morning? Hows - I need to ask you some questions regarding your
your appetite? Any changes in your weight? Do you home situation that will help me to better understand
think? What do you think about life? Do you think it is your childs condition. How is your relationship with
worth living? Have you ever thought of harming or your ex-husband and with your new partner? Any
killing yourself? Are there any times when your mood stress? Any violence at home? How often does she
is very high? Whom do you live with at home? Do you spend time with your boyfriend? Did you call your ex-
have enough family support? Are you a happy family? husband to ask him what happened? Do you know
Have you tried reaching out to your mom? If youre about his family situation now? Are you aware if he
happy I can arrange for a family meeting. Any other smokes, drinks, or uses recreational drugs? Do you or
stressors like financial or school/work? your partner smoke, drink or recreational drugs?
- How is your general health? Do you have any weather
preference? Differential diagnosis
- Do you hear/see things that others do not? Do you - Child abuse
have any strange experiences? SADMA? - Foreign body
- Allergy
Management - Trauma
- At this stage, Im glad you dont have intentions to - Vulvovaginitis
harm yourself, but you are upset because of your
parents divorce. If you like, I am happy to arrange a
family meeting and talk about things. I would like to
35
Management unplanned pregnancy. The father left before she was born. Now,
- At the moment, I do have a few differentials in mind they live with her new boyfriend who is unemployed. The mom
like vulvovaginitis which is an infection of the genital works part time and the boyfriend looks after the child. You
area, or skin allergies, but because you are worried examined the child and found a bruise on her left cheek, a
about possible abuse, it makes me concerned as well. painful swelling of her right upper arm. An xray was done that
I will notify the child protection authority as well as shows a spiral fracture of the right humerus.
VFPMS (Victorian Forensic Pediatric Medical
Services) or pediatric department of the local hospital. Task
- It is better for them to come and talk to your child as a. Explain diagnosis to mom
they have a special way of doing it. If required, they b. Discuss appropriate management
will do a genital examination preferable by an
experienced pediatrician. They might take necessary Problem list:
swabs and samples. Please dont talk to your child a. Identify child abuse. Exclude organic causes.
about any of this (mental trauma/might influence the b. Assure confidentiality
child). It is a long process to find out what happened. c. Assessing the psychosocial status
You and your daughter will have all the help and d. Delicate, empathetic explanation of the situation.
support throughout the way. Convince her for hospital admission
- They might admit the child to the hospital for
investigations as well as possible treatment of the Differential diagnosis:
rash. She will be seen by a child psychologist as well - ITP
as the social worker. We will involve the police if - Pancytopenia
required, but the Child Protection Authorities will be - Leukemia
the first one to be notified. - Bleeding disorders
History Task
- I understand that youre getting injured quite often and a. Counsel accordingly
now you have an injury on your forehead. How did it
happen?
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- Sally I definitely will try to help you with the pain and Task
make you as comfortable as possible. How bad is a. Respond to Sallys question
your pain? My abdominal pain is progressively b. Answer examiners questions
worsened, pain med made me nauseated.
- Do you know what youre getting for pain relieve at the - What is it that you want me to do for you? I
moment? No, I dont know. Sally I will find out and I understand that you are in a lot of pain and I can only
will involve pain team, or palliative specialist to adjust imagine what you are going through right now, but
your medication. Effective analgesia is possible in up there is still a lot we can do for you. I am sorry but I
to 90% of cases. In general we use analgesic ladder am legally not allowed by Australian laws to help you
approach start from simple pain killer and move to end of life.
weak opioids to strong opioids - Patient does not have the right to stop basic life
o Simple pain killer: Paracetamol, aspirin, support such as pain management, oxygen, and
NSAIDs. parenteral feeding.
o Weak Opioids: Tramadol, codine. - Are there any other concerns you have? I can
o Strong Opioids: Morphine, Hydromorphine organize a counselor for you. If youre a spiritual
(5times stronger than morphine), Fentanyl, person, I can arrange someone to come and talk to
Oxycodone. you. The motive of palliative care is to make your end-
of-life as comfortable for you as possible.
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