Professional Documents
Culture Documents
Q1. Mrs. Kate is a 32 year old patient presenting with low mood. Her husband passed away a few
months ago. Please take patient history and counsel her.
Q2. Mr. Brown has been suffering with Rheumatoid Arthritis and now presents with complaints of
Insomnia. He is on medications, please take patient history and counsel.
Hello Mrs Kate My name is Samson; I am one of the junior doctors in this department
I can see that you are feeling bit low Mrs Kate
Is there anything bothering you?
Express your concern and ask her if anything else is bothering her.
In RA ask her if she is okay with her medicine.
Ask her if her joints are bothering her despite medications.
Ask her if its alright to start talking to her about her problem?
Presenting complaints of depression
S - Suicidal thoughts, plans or attempts
U - Unexplained feelings of guilt or worthlessness.
I - Inability to function (psychomotor agitation/retardation)
C - Concentration impaired.
I - Impaired appetite and libido (Appetite/=wt/ by 5%)
D - Disturbed sleep (early morning awakening/hypersomnia)
E - Energy levels low.
These are the core symptoms. The mandatory symptoms are: low mood & Anhedonia is lack of
pleasure in life.
For Diagnosis, low mood and Anhedonia must be present + at least 2 symptoms from the core of
symptom list. They must be present everyday for at least 2 weeks.
Questions to Ask
Start asking from low mood and Anhedonia and stop with suicidal risk.
If you were to rate your mood in a scale of 1 to 10, 1 being the lowest and 10 being your
best, how would you fair?
Do you enjoy going out with friends? What do you normally do for fun? Do you still enjoy it?
Do you feel fatigued most of the time?
How long have you been feeling this way?
Do you notice any change during the day?
How is your sleep?
How about your appetite and weight?
Hows your concentration level?
Hows your sex drive?
Do you feel slowed down or restless and agitated all the time?
Are you feeling hopeless and worthless? Do you have any guilty feelings? Weighing you
down?
At such times people tend to hurt themselves. Has such thought ever crossed your mind?
Do you drink Alcohol? (If yes, does low mood make her drink more?)
How about smoking cigarettes and drugs?
S - Stress at work/home
Where do you work? Is there any stress at work? How about home?
Do you hear any voices when nobody is around you? Do you think any voice? Is anyone
commenting on your thoughts and actions?
Do you have any firm belief that others do not agree with?
COUNSELLING:
From what youve told me, there is a possibility that you are suffering from depression. However
well have to rule out other problems that may sometimes present similarly. For this we will have to
request a few investigations. However, do not be alarmed. We shall provide you with all the
support we can.
Try to tell people who are close to you how you feel. It is not weak to cry or admit that you
are struggling.
Do eat regularly, even if you do not feel like eating. Try to eat healthy diet.
Dont drink too much alcohol. Drinking alcohol is tempting to some people with depression
as the immediate effect may seem to relieve the symptoms.
Dont make any major decisions whilst you are depressed.
Do tell your doctor if you feel that you are getting worse.
EXERCISE
In addition to the above to the above treatments, regular exercise is thought to help to improve
symptoms (if you are able to do some work exercise).
PSYCHOLOGICAL TREATMENTS (Talking treatment)
Various psychological treatments have been shown in research trials to be good for depression.
ANTIDEPRESSANT MEDICINES
An antidepressant does not usually work straight away. It can take 2-4 weeks before the effect
builds up fully. So you need to give it time.
LEAFLETS, WEBSITES, SUPPORT GROUP.
FOLLOW UP IN CLINIC.
DRUG ABUSE
Q1. A young man comes to you with the intentions of stopping drug abuse. You are the junior
doctor; assess him for drug abuse/dependency.
Q2. The police have brought in a young man; please assess him for drug abuse dependency.
GRIPS
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Depending on how he comes to you, on this own or brought by the police, you have to talk
likewise
If he comes on his own, he is going to be very receptive to you but if not, you will have to
calm him down, reassure and make him understand that the questions you are asking him
are for his own good
Questions
Do you do drugs?
What type of drug do you use?
How long have you been using it?
How do you use it? Do you use needles too? Do you know of the Needle Exchange
Programme?
How much do you use in a day?
How often do you use it?
Do you need to use more of it to get the same effect as time passes?
What happens if you do not use it for a day or two? Do you have any problems? What are
they?
Where do you work? How much do you spend in a day on drugs? If not sufficient, how do
you procure the money for the drugs?
FAMISH
F Do you live alone? Do your friends and family know of your dependency? If he has come
to you for help are they going to stand by you as you go in for a de-addiction programme?
How are your finances?
Have you any trouble with the law?
A Do you smoke or consume alcohol?
M Medical illness and medications?
I Interest in life
Is there any particular event in your life that forced you into this?
Do you feel better when you indulge in your habit?
How do you see your future?
Do you suffer from low moods?
Any thought of self harm?
S Is there any stress at home or work?
H Any voices commenting on you or any buzzing/ringing noises in your ears? Any beliefs you
hold that others do not agree with
COUNSELLING
ANOREXIA NERVOSA
Miss Catherine is a 16 year old patient, take patient history and assess.
GRIPS
MANAGEMENT:
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Catherine, from what you have told me you do not have sufficient amount of food. I know you feel
well and I am sure you are doing well but sometimes when you tend to eat less and when this goes
on for sometimes there is a condition called Anorexia Nervosa that people suffer. They tend to eat
less to lose weight. Would you like to have a leaflet to read about it?
We feel you are exercising a lot. We will fix an appointment with our gym instructor who would
advice you.
You may go home now but if there is a problem like pain, dizziness come to us.
D/Ds:
Infections
Diabetes Mellitus
Malignancy
Mal absorption
Hyperthyroidism.
INSOMNIA
Mrs. Janet is a 60 year old lady who has come in with complaints of difficulty sleeping. This has been
present since past 4 months. She also complains of irritability and confusion. She has been suffering
with Rheumatoid Arthritis since last 7 years. Please take detailed patient history and council her
(remember not to take medicine history).
GRIPS
Offer confidentiality
Empathy/ eye contact/ make the pt. Talk
Ask about sleeping pattern or sleeping schedule.
D/Ds:
Shift worker
Living environment
Depression
Mania/Anxiety
Grief
Nocturia (BPH), ( DM)
Nocturnal cough (asthma)
Medication
Pain( joint problems)
Negative history (questions for)
Panic attack
OCD
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PTSD
Psychosis
Insight
Past history of any psychiatric illness
Family history of any psychiatric illness
Social History: What do you do for your living?
Are your family and friends supportive?
Personal History:
Smoking
Drinking
Drug abuse
Any problem with police or law
Suicidal risk
Counselling bio/psycho/social
Effective plan but need your co-operation
ADVICE
ANY QUESTIONS?
RIPSOUR
R Repititive
I Intrusive
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P Persistent
S Senseless
O derived from his own thoughts
UR Unable to resist
COUNSELLING:
Tell her whatever she has said makes you feel she suffers from OCD.
Offer her support and encourage her
Counselling and psychotherapy
Behavioural therapy and relaxation therapies
Medications if necessary
Leaflets on problems and management
D/Ds:
OCD
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Phobias
Panic attacks
Generalised Anxiety Disorder
MANAGEMENT
Support groups
OPC
Leaflets, website
Crisis card
COUNSELLING
Insomnic
Depression
Psychotic
Anxiety
Try to take amitriptylline at the same time(s) each day to avoid missing any doses.
If you do forget to take a dose, take it as soon as you remember unless it is nearly time for
your next in which case leave out the missed dose. Do not take two doses together to make
up for a forgotten dose.
You may feel that Amitriptylline is not working for you straightaway. It can take a week or
two after start of this treatment before the effect builds up and 4-6 weeks before you feel
the full benefit. Do not stop after a week or so, thinking it is not helping.
Try to keep your regular appointments with your doctor. This is so your doctor can check on
your progress.
Do not try to drink alcohol while you are being treated with Amitriptylline. Taking
Amitriptylline and alcohol increase the chance that you experience side- effects.
If you buy any medicines, check with a pharmacist that they are safe to take with
Amitriptylline.
There are several types of antidepressants and they differ in their possible side-effects.
While you feel depressed or are taking amitriptylline, you may have thoughts about harming
yourself ending your life. It is very important that you tell your doctor about this if it
happens.
Amitriptylline may cause your skin to become more sensitive to sunlight than usual. Avoid
strong sunbaths and sunbeds until you know how your skin reacts.
Do not stop taking Amitriptylline unless your doctor tells you to do so. Stopping treatment
suddenly sometimes causes problems.
If any of the above becomes troublesome, speak with your GP for advice. If you experience any
other symptoms which you think may be due to this medicine, speak with your GP or pharmacist.
HOW TO STORE AMITRIPTYLLINE
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PANIC ATTACK
FEATURES
Tremors
Breathing difficulty and tachycardia
Tingling and numbness in hands and feet
Dryness of the mouth
Palpitations
Choking sensation in throat
Feeling of impending doom
Butterflies in stomach
GRIPS:----------------- h/o presenting complaints
D/Ds:
Panic attacks
Generalised anxiety disorder
Hyperthyroidism
Pheochromocytoma
MANAGEMENT:
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CBT
Rebreathing into a paper bag
Medications
Counselling in psychotherapy is rarely necessary
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Scores of 25-30 out of 30 are considered normal; NICE classify 21-24 as mild, 10-20 as moderate
and <10 as severe impairment.
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I gathered from your notes that you are feeling a bit low.
Can you tell me more about your mood?
Are you having this low mood since the birth of your baby?
Was it a planned pregnancy?
Did you see your GP regularly during your pregnancy?
Were there any problems during your Pregnancy?
Was the child birth difficult?
How is your sleep and appetite?
How many children do you have?
How do you feel about your baby?
Do you breast feed the baby?
Whom do you live with?
Are your family and friends supportive?
Do you have any thoughts of harming the baby or yourself?
Do you drink at all or take other illicit drugs?
Do you have any other medical illness?
Have you ever seen a psychiatrist before?
Does anyone in your family suffer from mental illness?
Have you ever heard any voices or noises or seen any visions when you were all alone in the
room?
How do you see your future?
FAMISH
COUNSELLING
Reassure her and tell her to confide in people whom she trusts and seek help from her family and
social services. Tell her to pursue her hobbies.
Keep time for herself.
MANAGEMENT
Counselling
Support groups and social groups
Help lines and crisis lines
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D/Ds:
Baby blues
PND
Post partum psychosis.
which means it blocks some chemicals in the brain and by so doing it improves the mood of people.
Ask few questions
Take paroxetine exactly as your doctor has told you. It is usually taken once each day in the
morning.
Take paroxetine with a snack or after eating a meal.
If you are taking paroxetine tablets, swallow them whole with a drink of water. Do not crush
or chew the tablets.
If you are taking paroxetine oral liquid, do not take indigestion remedies for the two hours
before and the two hours after you take the medicine.
Try to take your doses at the same time each day as this will help you to avoid missing any.
If you do forget to take a dose, take it as soon as you remember. If you do not remember until
the following day, skip the missed dose. Do not take two doses together to make up for a
forgotten dose.
You may feel that paroxetine is not working for you straightaway. It can take a week or two
after starting this treatment before the effect begins to build up, and 4-6 weeks before you feel
the full benefit. Do not stop taking it after a week or so, thinking it is not helping.
You are advised not to drink alcohol while you are being treated with paroxetine. Taking
paroxetine and alcohol may increase the chance that you experience side-effects.
Paroxetine may cause your skin to become more sensitive to sunlight than usual. Avoid
strong sunlight and sunbeds until you know how your skin reacts.
If you buy any medicines, check with a pharmacist that they are safe to take with paroxetine.
There are several types of antidepressants and they differ in their possible side-effects. If you
find that paroxetine does not suit you then let your doctor know, as another may be found that
will.
Do not stop taking paroxetine unless your doctor tells you to do so. Stopping treatment
suddenly can cause problems and your doctor will probably want you to reduce your dose
gradually if this is necessary.
While you feel depressed or are taking paroxetine, you may have thoughts about harming
yourself or ending your life. It is very important that you tell your doctor about this if it
happens.
If you are taking paroxetine for depression, you should expect that a normal course of
treatment will last for around six months after your symptoms have eased.
Dry mouth
Headache
Constipation
Increased sweating, yawning, blurred vision,
your doctor
Important: if you develop any of the following, contact your doctor straightaway or go to the
accident and emergency department of your local hospital:
If you experience any other symptoms which you think may be due to this medicine, speak with your
doctor or pharmacist.
How to store paroxetine
Never take more than the prescribed dose. If you suspect that someone has taken an overdose
of this medicine go to the accident and emergency department of your local hospital at once.
Take the container with you, even if it is empty.
If you are having an operation or dental treatment tell the person carrying out the treatment
which medicines you are taking.
This medicine is for you. Never give it to other people even if their condition appears to be
the same as yours.
Never keep out-of-date or unwanted medicines. Take them to your local pharmacy which will
dispose of them for you.
If you have any questions about this medicine ask your pharmacist.
Eye contact
Rapport
Appropriateness of behaviour
Level of motor activity
Anxiety levels
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3. Mood
1. Subjective how is your mood? On a scale of 1 to 10, 1 being the lowest 10 being the
highest, what is the score of your mood?
2. Objective this is what you as a doctor think of his mood.
4. Speech
1. Rate is it fast, slow or normal?
2. Volume is it too high, low or normal?
3. Tone- is it too high, low or normal?
4. Flight of idea is he jumping from one topic to the next. If yes then he has fight of ideas.
5. Thought
1. Thought broadcasting do you think other people can hear your thoughts?
2. Thought withdrawal do you think people are taking away your thoughts?
3. Thought insertion do you think other people are putting thoughts in your head?
6. Perception
1. Hallucination - do you hear voices when there is nobody around you?
2. Delusions do you have beliefs which other people disagree with?
7. Insight
Do you think you need any help?
8. Cognition
1. What date is it today?
2. Do you know where you are now?
3. What is the name of the building you are in?
4. Can you say Aplle, Penny, and Paper please.
5. Can you count from 20 backwards please?
9. Suicidal risk
1. Do you have thoughts of harming yourself?
2. How do you feel now?
Example of summary
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Mr. Brown appears to be a gentleman of white origin, 28 years old. He is dressed appropriately and
appears clean. His behaviour is appropriate and he maintains proper eye contact. He developed a
good rapport and his mood is low though he denies it. He has got normal speech volume with good
tone and no flight of ideas. He has got no signs of psychosis, his cognition is intact and he has
insight to the problem. He has no risk of committing suicide.
NB if patient regrets about the action and has no thoughts of harming himself then he is a low risk
patient.
Management
Always admit even if low risk
1. Needs psychiatric assessment
2. Needs medical treatment of paracetamol overdose.
DRUG ABUSE
A 25 year old gentleman with history of drug abuse has come in with an intention to stop using
drugs. Take history and counsel the patient.
Hello my name is Samson, I am one of the junior doctors.
I just wanted to assure you that what all we discuss is confidential.
1.
2.
3.
4.
5.
DRUG ABUSE-PSYCHOSIS
A 25 year old gentleman Mr. Webber has brought in by the police as he was found on the street.
Please assess the patient for drug abuse or dependency.
Hello Mr. Webber
Patient: Police, Police, Police, Police Doctor.
Doctor: my name is Johnson I am one of the doctors here, do not worry Mr. Webber there is no
police here.
I am here to help you.
The police will not come here do not worry.
Nobody will come in here, you are safe here now.
We would like to help you.
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Now that you are with us this is a very good chance for you to stop using recreational drugs and get
your life back.
As you can see you are here now, this is what drugs can do. Drugs cannot do anything better than
destroying your life.
As for now we need to examine you and run few tests to make sure you are medically okay.
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Alcohol History
Mr Williams is a known alcohol drinker. Take Hx
C Cut down
A Annoyed
G Guilty of drinking
E Eye opener
T Tolerance
W Withdrawal
C Have you ever felt that you need to cut down on your drinking?
A Have you ever got annoyed because other people are concerned of your drinking?
G Have you ever felt guilty because of the way you drink?
T Do you feel that you have to increase the amount of alcohol you drink to achieve the same
effect?
W What happens if you do not drink for a day or two?
PSYCHOSIS
1) Do you have any belief which other people do not agree with?
2) Do you hear voices when there is no one around you?
3) Do you think other people are hearing your thoughts?
4) Do you think other people are putting thoughts in your mind or they are taking away your
thoughts?
SOCIAL CIRCUMSTANCES
1) Who do you live with?
2) Where do you live?
ALCOHOL Related CONDITION
1) Paracetamol
2) Liver problems
3) Per-rectal bleed
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ALCOHOL COUNCELLING
1) The level of alcohol intake is too much and is very dangerous for your health
2) You can develop serious conditions like:
a. Damage your liver
b. Bleeding from the blood channels in your stomach and people die from this
condition
3) If your liver is damaged you can experience things like
a. Low blood sugar levels and die from it.
b. Your brain can get damaged due to toxic substances in your body, since your liver is
not working to prevent this.
4) With the levels you are drinking you cannot build a family properly your family can break
Do you have a family?
5) With the level you are drinking you cannot sustain a job for long time.
6) I strongly recommend that you stop drinking Mr Williams. We have alot of help to offer to
help you quit
a. We have alcohol anonymous group where you can meet people who also are
trying to quit and people who have successfully stopped drinking.
b. We have medications to help you stop to have the desire to drink.
c. I can refer to these services and you will get a lot of help, so many people have
managed to stop drinking using these services
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