Psych :

oCD (king)
ooks like OCD,things to confirm the diagnosis
1.how does she feel if she is unable to do it due to some reason?
2.does she feel relieved after taking pictures or counting numbers?
3.does she try to resist these compulsions?

Your doctor will provide the names of or arrange counsellors to help you cope with your
fear and stresses. This may include behaviour therapy, which will help you learn to confront
these fears, or cognitive behavioural therapy, which will teach you how to identify, evaluate,
control and modify your negative fearful thoughts and behaviours.

Life style stress

Parkinsonism Physcial exam

. Delerius patient in the ward 2 days after shoulder fracture fixation after fall with tremors
and hyperreflexia

Heavy alcohol drinker

MMS and DD

2. Talking with sister of a patient who has recent behavioural changes and forgetful he gave
permission to her CT with atrophic changes

Short term memory loss for DD could be frontal lobe dementia vs Alzheimer

I said I have to c the patient to do MMSE and to exclude organic causes ( dementia is a
diagnosis of exclusion)

6. I vaguely remember this: He had come to ur GP clinic a week ago, had some symptoms
like disturbed sleep, anhedonia, low mood, hopelessness. Your colleague prescribed
sertraline 50mg, to increase it to 100mg after a week and to be seen in the clinic after
2weeks or earlier if he had any issues. Tasks were 1)to assess his improvement?clinical
condition? (can't remember exactly, was something like that) 2)to address his concerns 3) to
manage accordingly (I dont remember the tasks too clearly but they were something along
this line)

Depressed pt was seen by colleague in GP 1 week ago. Gave Sertaline 50mg with plan to
increase its dose in few weeks.

Pt comes back after 1 week coz no better with symptoms.

History (On history did not want to take meds as his sister said it has lot of side effects also
he googled, ? Non compliance. Also he is alcoholic)

Management.

.pt with 8yrs history of schizophrenia brought in by his care worker with a lot of
delusions.Take relevent

history,management and why u want to do this.

8.Depression pt started on medications 2 weeks ago but came with same symptoms
again.Hiatory and management

Stressed out 42 yo, consultant in company, lots happening, long hoursMajor Depression • Hx •
Depression questions all positive • Insight was good • No suicide • Fraud at work- no flashbacks
• DDx with reasons • Major depression • Adjustment disorder • PTSD • GAD

. Student 22, lives by himself, parents were farmers, known to be tight, poor school
performance- repeats war and king- OCD • Hx • DDx

psych was domestic voilence and eating disorder

2017 march 2

Psych

15. Mania MSE

My first case mania typical case beautiful young girl but she didn't comb her hair probably
wearing shirt and pant walking around the room. I need to follow her and keep saying I want to
see the president you are wasting my time okay . My task MSE , present finding to the examiner,
PDx, ddx

Insight effect she keep saying you are wasting my time high energy no hallucination no suicide
when I ask her, she said do you think I am crazy normal cognition.
I said most likely mania. I need to exclude the rest such as drug, infection and space occupying
lesion need admission and check by psychiatrist

16. Request for breast reduction surgery, burst in to tears when asked for reason

Second psych case is body dysmorphic disorder. the patient want to do surgery as she said I
have very big breast and it effect my life a lot. I separated from my husband recently and my dad
passed a way 6 months a go. I try to asked her if there is any relation between her breast shape
and separation. she said no. I try to ask more questions about depression but there is non and
she start crying and said I miss my dad and we use to be very close. this case I didn't give dx
even though I know. I said we usually don't prefer to refer patient for cosmetic surgery if she
don't need there is risk for anaesthesia and surgery but if you insist, I will give you a refer for
second opinion. I will refer you to psychologist for CBT who help you to change this negative
feeling with positive one and if that doesn't work might be refer to psychiatry for medication.

Psych
10. borderline personality- risk assessment ( Ask intention during self harm, Previous attempt
to suicide, Any plans, Any weapon possession, future plan, Aseptic qs briefly, Headss q )
11. need to get rid of heroin addiction-

H/o & dx to examiner

6.BDD case is straight forward. Task :h/o, mx(she started to vomit because her boyfriend want
her to be thin before he went abroad trip, and want her to be thin when he comes back, no signs
of depression, stable, period normal,

. 30 yr old with repeated headaches. Diagnosed as tension headache and mri fine for that and
neck spasm which was normal. She is usual customer to your GP practice over the last10 years
with recurrent abdo pain & dysuria on and off. Task: find the cause for the current headache,
Tell her the likely cause and mx No organic stuff, Husband left 3/12 ago, she's angry stressed
and hurt because of that, no depression no anhedonia no psychotic feats no suicidal ideation. I
said tension headache and adjustment, but check Karen's maybe it's somatisation?????

11 - MSE
12-lady with black eye.fight with husband
PSYCHIATRIC
7.OCD
8.Depression. mse
Grief in a lady on the day of wife’s birthday -D & DD
15.Downs syndrome behavior changes- carrer came for advice.

Adjustment disorder with depression .

Care taker of boy having down syndrome concerned about behaviour change since his
roommate left .
Task
history
most likely diagnosis and differentials

Positive findings
1)Tearful, lack of sleep, tiredness,loss of appetite,anhedonia,loss of concentration and
psychomotor retardation ..for past 4 to 6 months since his roommate had left .

11) Anniversary grief reaction ;

patient feeling gloomy and tearful as it is his wife's birthday who has died 9 months ago and all
this time patient was fine but now close to her birthday he feels gloomy
Task
tell diagnosis and differentials
management
9-On lithium and suspects to be pregnant
19yo girl lives with her bf, she recently had two episodes of depression, was in the hospital or
not I forget. All her blood test r normal including lithium level. Except TFT. Today she comes to
you coz she thinks she is pregnant as in the history when you ask she said her LMP was 6 weeks
ago. Also, in history, using OCP but always forgot. HEADSSSS plus risk assessment was normal.
And she is worry what if she is pregnant and she is on lithium as remember.
lithium causes hypothyroidism and the effect of hypothyroidism is amenorrhea and thats the
reason she suspects herself to be pregnant. Lithium can cause ebstein's anomaaly, hypotonia
hyporeflexia. She wants to get pregnant.Is taking lithium so concerned.All tests were
normal.Assess her for mental status and tell management. Assess health state and explain the
management plan.

Refer her to psychiatrist.Lithium causes some fetal abnormalities so she needs adjustment of
the dose.I said that I will refer to psychiatrist he will decide better either to reduce the dose or
change it to other drug.
if already pregnant? The same thing.I searched on google.usually lithium is continued in
pregnancy with regular follow ups.still u can refer.I told about MDT.
3rd comment. explain the terotogenisity- fetal cardiac anomalies, the risk and the importence
of the drug continuation specially in the pregnancy to prevent relapses..TAKE the informed
concent to continue the drug,tell the best option is lithium than other available
moodstabilizers .Do the psychatry referral for dose adjustment as renal clearence of drug is high
during pregnacy,explain about ct follow up ,uss at 18weeks,monitoring drug dose,kidney
functions,doing foetal echo,and specialist managment accordingly

10- Bulimia nervosa

Psych:
11. Relapse of Schizo lack of compliance hearing god voices
so young guy,hearing God's voice,stopped his meds by himself 6 months back,now persecutary
and grandiosity delusion,auditory hallucinations,shifts b/w hostels,no intent to harm himself or
anyone else.
Hx and risk Mx

12. tummy pain young women lots of Ix done all normal Dx with IBS but not happy came to see
you very rude behavior from role
Player not very nice
Hx of Gatro sx
Tell causes !
?somatization
her hx was positive for work stress,personal relation disruption,she asked why is she having
these symptoms,couldn't judge from her expression that was she just acting or really pissed
off....
Psych:
1. Relapse of Schizo lack of compliance hearing god voices
Hx and risk Mx

2 tummy pain young women lots of Ix done all normal Dx with IBS but not happy came to see
you very rude behavior from role
Player not very nice

Hx of Gatro sx
Tell causes !
?somatization

Psychiatry.
1. Serotonin syndrome.
Was on 2 antidepressants. Gp started a new one I think 2 days ago. Diaphorsis, irritable and
restlessn. Increased BP, high pulse. Other obs forgot.
Task history.
Most likely diagnosis and management.
Said Serotonin syndrome and emergency hospital admission. Mentioned about what they will
do. When I said both drugs will be stopped for the time. He said my symptoms will come. I said
MDT will monitor you and will re introduce medications once symptoms will settle down.
2. PTSD.
8 months of sleep problems. Symptoms started after she came from Turkey 8 months ago.
Because of sleep have to take days off.
History. Has some flash backs and gets up at night. Unable to sleep afterwards. Nothing
happened in Turkey.army officer. Stopped working in army 10 years ago. Was posted in
Afghanistan ( war zone).
Give most likely diagnosis and D/D.
Alcohl counselling n hsitory

10. Mse post domestic violence(rescued) lady with depression

24 april

7. A carer from a social service wanted to know the condition of one of their resident Peter .
Peter had Down syndrome . Now he's developed major depression with moderate severity. Task:
explain patient's condition about major depression. ( carer got the consent to b informed, carer
was a young lady , she asked if peter need medication, she could pursued peter for his further
management.).
8. Around 60 yrs old lady Jill . She forgot taking her hypertension medication. She was alcoholic,
however she recently had reduced her drinking.now she drank intermittently. Task:what is mmse,
perform it, tell patient the significance of mmse n causes of forgetfulness. Physical examination:

Psychi
1. Craer of Down’s syndrome pt (pt has physical disability) coming with concerns….(as in Karens)
a. Explain depression features to the carer
b. B. further mx
2. Alcoholic lady with memory impairment
a. MMSE (Recall, reg, orientation for time impaired)
b. DX

c. 1. A young lady who had some event at work. Initially she was given sleeping tab for 5
days but her symptoms got worse and she is feeling tired and sad and having sleep
issue
Depression
Task : 1. Take history 2. Most likely diagnosis 3. Discuss management
I think in this case there is delusion of guilt not sure
d. . Risperidone induced tremor- examiner and patient was gud in this case-
they gave in stem he is psychotic and now he don't have symptoms he has
given risperidone and now he came for prescription renewal and tremors - he
was gud actor resting tremors he gave- asked focused hx- after this
medication u got this periods then he said yes. Smoker- no , alcoholic- no.
Examination only hand , wrist and arm exam - asked to walk him examiner
said no need neurological exam then I checked temperature, pulse, crt, tone-
rigidity was there.. told him to write I am great he wrote no micrographia they
were laughing for it.. then tap on the table he did well no bradykinesia I said
and forgot reflexes and did them again was normal.. then said this shakes are
due to medication so I will refer u to specialist they will reduce or change the
medication called atypical antipsychotics which have same affect like typical
ones with less side affects and asked him is it ok he said yes.. then don't
worry once we stopped this medication u will be fine.. thanked both of them
and came out. They were happy only.
e.
f. 4. Domestic violence - she acted well in stem they gave she is ur patient in
last visit u told her u will help her as her husband is doing physical abuse to
her..but she didn't agree to leave him and now she came for ur help.. hx for 5
mins and management to patient.. I asked hx she said he is doing too much
some bruises now and mood questions not gud she said I asked she told this
days it's not worth living, appetite not gud, sleep after he sleeps only she
sleeps.. she is cleaner.. friends she is not allowed to go with them.. she is
behaving like depressed patient even telling confidentiality she is behaving
the same ..I asked about family she said they live near by but cannot go to
them..I said don't worry I will help u.. u want me to tell police she said
whatever u want u do I came to u.. I said don't worry I think ur going in to
depression please don't worry we have shelter homes where u can stay and I
don't want to send u home it's not safe and admit u.. psychologist will come
and talk to u to cope up wth this situation.. she was ok .. but she don't have
suicidal plans.. and I said will talk to her husband she said no.. and came out
thanking them.. I should have said her marriage counsellor and all.
g.
h. 13-27 y/o female has had colonoscopy because of recurrent
abdominal pain which was normal.after that she is given
midazolam because of pain.
You are working as an intern in GI department.the nurse told
you that the patient "has remembered something " that wants
to talk to someone.
 Task:
1-take further history from the patient
2- explain the most probable diagnosis for the patient

Patient says that can hear the sound of her neighbour in her
childhood period that asks her sex
i.
Schizophreniform history 18months ago. Now brought by parents, task history, explain DXwith
reason to patient.

He has a diagnosis but maybe no explanation yet or maybe schizophrenia has developed because
symptoms persisted for longer then 1 -6month . As schizophreniform is prodomal or provision
diagnosis is many patients And family need to understand the difference. It has better prognosis
then schizophrenia and usually less social emotional deficits . But likely good that schizophrenia
might develop. as well as thy will pick on early signs of relapse and contact the MHS.
She stopped meds,now in depression plus hears voices.asked in detail what voices are telling
her,harmful ideation for herself or others,sleep appetite,illicit drugs,thyroid etc.needs urgent
admission coz of loss of contact with reality and severe depression.will b seen by
psychiatrist,baseline investigation and meds will be started

Naima Ahmad She told her doc stopped as she was good.but now relapse so I told urgent admission
n review.also rule illicit drug thyroid baseline tests etc to rule out any other cause for psychotic
features

27 yo male recently fought with his brother very badly. His brother didn't injured. Father is
concerned about hismarijuana addiction.
Tasks: take relevant Hx, assess Pt's intake of marijuana, counsel Pt/give advice
Anyone had this station? Advice welcome!
You are a GP and a 24 year old patient Nathan. Who is a known marijuana dependent came in your clinic. He won’t
seem to quit. He tried cutting it down a little bit.
•Recently, he had a fight with his brother.
•Task:
1.Assess his dependency on marijuana
2.Counsel the patient accordingly
Loading…
Task 1:
•Introduce
•Confidentiality
•5 A’s
•Psychosocial History
•SADMA
•PMH/FH

Task 2: Counsel
•Marijuana
•Harmful effects
•Benefits of Quitting
•Talk about the AIM
•Withdrawal Symptoms: SSRI and Buspirion
•Referral to Psychologist
•Motivational enhancement Therapy
•Contingency Management Therapy
•Drug Rehabilitation Center if not coping
•4R’s

Task 1: History/Ask and Assess

•I read from the notes that you’ve been taking marijuana and it’s good that you are trying to cut it down.
•Ensure confidentiality
•Do you have any specific concerns?
•How’s your relationship with your brother?
PATTERN:
1.Since how long have you been taking marijuana?
2.How many times do you smoke marijuana per day?
TOLERANCE
●Have you increased the amount after starting to take marijuana?

DEPENDENCE and WITHDRAWAL

1.Do you think you are dependent on marijuana?
2.How long can you go without taking marijuana?
3.Have you ever tried giving up marijuana?
4.Why did you stop taking marijuana?
5.Any withdrawal symptoms when you cut it down?
a.Anxiety
b.Irritability
c.Aggressiveness
d.Angry beahaviour
e.Sweating
f.Chills
g.Tremors
h.Restless sleep
i.Nightmares

PHYSICAL EFFECTS:
a.Did you notice any problems with your memory?
b.Or any frequent episode of coughing?
PSYCHOSOCIAL EFFECTS:
MOTIVATIONAL SCALE:
From 1-10, how motivated are you to give up marijuana?
PSYCHOSOCIAL: mood, suicidal risk, delusions and hallucinations
SADMA
PMH/FH

Task 2: Counsel/ADVISE,ASSIST AND ARRANGE

•Marijuana is an illicit drug at the time of its use, you could feel happy and elated, relaxed and confident and more
talkative but these are just the immediate effects of marijuana.
EFFECTS ON HEALTH
•Used of marijuana can result in long term harmful effects which are more predominant than the immediate effects.
•So smoking marijuana could lead to damage of the lungs resulting in asthma, bronchitis and even cancer.
•It can lead to loss of memory, decreased attention span, learning and performance difficulties.
•It can also result in mental health problems like mood swings and schizophrenia.
•It also decrease the sex drive, can cause subfertility or infertility.
•Can also have problems at work, social and financial problems
•And you can end up having trouble with law
•So more than the physical addiction that marijuana causes it is the psychological addiction that predominates which
makes you feel that you need to take marijuana to act normally

BENEFITS OF QUITTING:
•The benefits of quitting marijuana are immense
•It can avoid physical and psychological symptoms at the same time save money
•And can improve your relationships

•ASSIST
1.The aim complete abstinence but withdrawal symptoms can occur like:
a.Anxiety
b.Aggresiveness
c.Restless sleep
d.Nightmares
e.Tremors
2.But these will be effectively dealt with, antidepressants like Fluoxetine or Buspirone
Loading…
•ARRANGE
1.I will refer you to a drug rehabilitation center
2.They will start you on CBT which will help you to stop your drug use, enhance your self control, and also addresses
other problems that often co occur with this.
here in counselling mostly it should start with history taking about drug use and dependency plus other factors like
smoking and alcohol abuse? then we should rule out the severity of dependence like how often, have u tried quitting
and symp, etcc...then psycho social history as long term use can cause prob with mental health..Final management
will be investigations like urine drug test etc and referra

What I have studied regarding this case -

1)ask the boy whether he wants to have the consultation alone or not.
2)congratulate if he is willing to give up marijuna
3)Confidentiality and ask what happened with brother.
4)then u assess his condition.Dependence questions,method of taking,with whom he takes,since when,any other
recreational drugs,alcohol,smoking(u know all the questions)
5)how this addiction is affecting his life-physically,mentally,socially,financially.
6)motivation questions.How confidence he is.
7)talk about all the harmful effect of marijuana.
Emphasise on lung problems like breathing problem,Bronchitis,Even risk of Lung CA.
8)benefits of quitting .
9)refer to drug rehab.talk about what they will do.Physical symptoms he may have after stopping and how it can be
minimised.CBT and psychologist.
Buspirone and SSRI will be given
10)regular checks,family meetings etc

Dependance
Did you ever think your use of cannabis was out of control?
4 Did you wish you could stop?
Did the prospect of missing a smoke make you very anxious or worried?
Did you worry about your use of cannabis?
Did you wish you could stop?
How difficult would you find it to stop or go without

The important steps are: • to assess frequency of cannabis use • if more than weekly, assess
dependence • feedback to the patient their levels of use, dependence status and any other
concerns they may raise during the consultation e.g. “you tell me you are using cannabis most
days of the week”, “your score indicates you are moderately dependent on cannabis”,
“you’ve told me that you are sick of your partner nagging you about smoking and you’ve
always got this cough” • be positive, non-judgemental and support the patient’s capacity to
change their cannabis use • explore willingness to make those changes
• provide appropriate information sheets which contain NCPIC web address for further
resources and the free national 1800 30 40 50 Cannabis Information and Helpline if they have
any questions
• refer to other services as required e.g. local ADIS for specialist referral • monitor and
follow-up at subsequent visits
At this stage, there are no medications available to help specifically with cannabis
withdrawal, although your GP may recommend medication for other issues like low mood or
sleeping difficulties. This will depend on your individual situation. The good news is that
withdrawal from cannabis ceases in a relatively short time period and most symptoms will
subside within two weeks.

22 year old boy after argument with brother brought in by his father. Marijuana addict
Had to take history and advice about marijuana.

April 24

2 assessment of change in behavior

Young lady brought in by Dad,staying alone in room with herself.not interacting with family,not
going to Uni.previously treated for schizo,meds stopped by consultant on improving.on history
she told about hearing voices,not telling to harm anyone.no suicide idea.I told urgent
admission,rule out organic cause illicit drug thyroid etc.psychiatrist review,anti psych
meds.provisional diagnosis schizophreniform as less than six months duration

20 april
Station no 7
Lady with cognitive impairment (alcoholic + forgot to take her medicine for DM)
Task- Do MMSE(chart already provided) + Explanation
AMC's feedback- cognitive impairment- pass
Station no 8 (rest)
ation no 19
Need to talk with caretaker of residence
About one of the residents who had Down syndrome and recently dx with moderate to severe
depression

25 August 2017
Psyc.
1) Benzo dependence but patient wants to stop. Regular GP on leave. Patient stressed because
son has cancer – trouble sleeping. Taking diazepam 1 tab b.d
2) Borderline personality cutting self to feel better. No suicidal tendencies. Has been in hospital
before in and out. Initial line of management.
3) Uni student brought by parents for erratic behavior. Manic case wants to see prime minister.
MSE

28 August 27, 2017 retest

6- Psych
Anniversary grief reaction