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PSYCHIATRY
HISTORY AND COUNSELLING STATIONS
No Topics Page
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Mental State Examination (MSE )

1. Psychosis (Schizophrenia) (Mania ) (MSE) - Only history taking

Mental State Examination (MSE ) and Suicide Risk Assessment ( SRA)

Depression - Suicide Attempt/Self Harm Risk Assessment

2 PCM overdose – Do MSE and Suicidal risk and give inference to

examiner)
3 Cut wrist – Hx and Mx to the examiner.

4 Cut wrist + OCP overdose – Only history

5 Pt had neck injury 5 days ago. Now has low mood. Take Hx and
discuss Mx with the examiner.
6 MMSE –only history
Alcohol
7 Gastroscopy shows gastric erosion – Hx only or Hx and Cx to pt
8 Nail infection – Hx only or Hx and Cx with pt.
9 Drug Dependence ( Heroin –assess drug dependency ) only history
10 Weight loss ( Anorexia Nervosa) – Only history
11 Insomnia – History and Cx to pt.
12 Panic attack – only history
13 SSRI – ( Paroxetine – Hx and Cx pt)
14 Bipolar disorder ( History and Diagnosis to the examiner)

Important – In almost every Psychiatric station – Suicidal thoughts is a must

( eg: Depression, Psychosis, Drug and Alcohol abuse, Bipolar disorders,
Anorexia nervosa, SSRI, Panic attack )

If the patient does not talk or hesitating to talk– you can offer confidentiality
“Whatever you say will be kept confidential within our team” and also gain
his trust by saying “We are here to help you”.
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THE MENTAL STATUS EXAMINATION

 It is a structured way of observing and describing a patient's current state of mind,
under the domains of appearance, behaviour, speech, cognition, mood, thoughts,
perception and insight.

( Pneumonic: ABS – MC – SHIT )

I. Appearance (observed)
II. Behaviour (observed)
III. Speech and Language (observed)

IV. Mood (inquired)

V. Cognition (Orientation) (inquired)

VI. Suicidality and Homicidality (inquired)

VII. Hallucination
VIII. Insight and Judgment (observed/inquired)
IX. Thought Process/Form (observed/inquired),
Thought Content (observed/inquired)

Components of the Mental Status Examination

I. Appearance (Observed) - Possible descriptors:
• Gait, posture, clothes, grooming.
 Apparent age
 Ethnicity
 Cleanliness & personal hygiene. Is there any evidence of self-neglect?
 Attire (is it appropriate for weather, surroundings etc... May be important sign in a
manic patient)
 Any abnormal involuntary movements e.g. tics, grimaces, tremors, stereotypies etc
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II. Behaviour (Observed) -

 Appropriateness of behaviour
 Level of eye contact
 Rapport
 Is patient easily distracted? (distractibility)
 Restlessness, anxiety
 Socially inappropriate e.g. embarrassing, over-familiar and sexually forward
behaviour (may be seen in manic patients)
 Aggression, violence etc.....

III.Speech and Language (Observed)

A. Quantity - Possible descriptors:

• Talkative, spontaneous, expansive, paucity, poverty.
B. Rate - Possible descriptors:
• Fast, slow, normal, pressured.
C. Volume (Tone) - Possible descriptors:
• Loud, soft, monotone, weak, strong.
D. Fluency and Rhythm - Possible descriptors:
• Slurred, clear, with appropriately placed inflections, hesitant, with good articulation,
aphasic.
 'Flight of ideas' does patient move quickly between subjects
 New or made up words (neologisms) or any other abnormal use of language?
 Logicality
 Is speech appropriate for the situation e.g. does patient answer questions
appropriately, is the content of speech appropriate to the situation?

IV. Mood (Inquired): A sustained state of inner feeling – Possible questions for patient:
• “How are your spirits?”
• “How are you feeling?”
• “Have you been discouraged/depressed/low/blue lately?”
• “Have you been energized/elated/high/out of control lately?”
• “Have you been angry/irritable/edgy lately?”
 Ask about depressed mood e.g. concentration, appetite, feelings of guilt, worry,
sleeping patterns, sexual relationships
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 Ask about self-harm e.g feelings about the future, 'have you ever thought that life was
not worth living?', thoughts of ending life, any preparations, any previous attempts at
self-harm/suicide?

How is your mood now? Can you please grade your mood in 1 to 10 scale where 1
being low and 10 being very happiest mood?

V. Cognition (Orientation) (Inquired) – Possible questions for patient:

• “What is your full name?”
• “Where are we at (floor, building, city, county, and state)?”
• “What is the full date today (date, month, year, day of the week, and season of the year)?”
• “How would you describe the situation we are in?”

VI. Suicidality and Homicidality

A. Suicidality – Possible questions for patient:
• “Do you ever feel that life isn’t worth living? Or that you would just as soon be dead?”
• “Have you ever thought of doing away with yourself? If so, how?”
• “What would happen after you were dead?”
Suicide Risk Assessment

If the station/task also states “perform a suicide risk assessment”, then you must also ask
the following 11 questions

Pneumonic : FAMISH ( 4 Fs – Family, Finance, Friends and Forensics, Alcohol,

Medications and illness, Insight, Suicidal thoughts, Hallucinations), ( Life - at present,
past and future)
 How do you feel about life at the moment?
 How do you feel about the future?
 Have you felt life is not worth living?
 Do you ever wish it would end?
 Have you thought about ending it?
 Have you thought how you would do this?
 Have you ever attempted to end your life before?
 How is your current social support, do you have many good friends?
 How are things with your family?
 Are you currently in financial trouble, are you working?
 Are you in trouble with the law?
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B. Homicidality – Possible questions for patient:

• “Do you think about hurting others or getting even with people who have wronged you?”
• “Have you had desires to hurt others? If so, how?”

VII. Hallucination
Assess the patient’s perception by asking appropriate questions. This may include questions
regarding,
 'I'd like to ask you a couple of questions about sometimes people have but may find
difficult to talk about. I ask everyone these questions?
 Then use questions such as ‘ Have you ever heard voices speaking when there seems
to be no-one around?”
 “Do you ever feel that people are discussing you negatively?” (If so, get context!)
 “Do you fear that people may be ‘out to get you’?”
 “Have you ever felt that something or someone is able to put thoughts into your
head?” (thought insertion)
 “Have you ever felt that something or someone can remove thoughts from your
brain?” (thought withdrawal)
 “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel
(tactile) things that are not really there, such as voices or visions?” (Hallucinations are
false perceptions)
• “Do you sometimes misinterpret real things that are around you, such as muffled
noises or shadows?” (Illusions are misinterpreted perceptions)

VIII. Insight and Judgment (Inquired/Observed) – Possible questions for patient:

• “What brings you here today?”
• “What seems to be the problem?”
• “What do you think is causing your problems?”
• “How do you understand your problems?”
• “How would you describe your role in this situation?”
• “Do you think that these thoughts, moods, perceptions, are abnormal?”
• “How do you plan to get help for this problem?”
• “What will you do when _____________ occurs?”
• “How will you manage if ____________ happens?”
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• “If you found a stamped, addressed envelope on the street, what would you do with it?”
• “If you were in a movie theatre and smelled smoke, what would you do?”

IX. Thought Processes or Thought Form (Inquired/Observed):

logic, relevance, organization, flow and coherence of thought in response to general
questioning during the interview. - Possible descriptors:
• Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive,
racing, blocking, perseveration, neologisms.
X. Thought Content (Inquired/Observed) – Possible questions for patient:
• “What do you think about when you are sad/angry?”
• “What’s been on your mind lately?”
• “Do you find yourself ruminating about things?”
• “Are there thoughts or images that you have a really difficult time getting out of your
head?”
• “Are you worried/scared/frightened about something or other?”
• “Do you have personal beliefs that are not shared by others?” (Delusions are fixed, false,
unshared beliefs.)
• “Do you ever feel detached/removed/changed/different from others around you?”
• “Do things seem unnatural/unreal to you?”
• “What do you think about the reports in papers such as Daily mirror?”
• “Do you think someone or some group intend to harm you in some way?”
• [In response to something the patient says] “What do you think they meant by that?”
• “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into
your head?
Does it ever seem like your own thoughts are broadcast out loud?”
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( Psychosis) (Schizophrenia) ( Mania)

MSE ( Mental state examination or Psychiatric assessment)

Causes of Psychosis
1) Depression,
2) Bipolar disorder (manic-depressive illness),
3) Puerperal psychosis
4) Drug abuse
5) Alcohol abuse.
6) Neurological conditions
7) Drugs not associated with abuse.

Exam question :
Mr James Smith, 25 years old man was brought to the hospital by police. According to the
police, Mr Smith went to the police station and was convinced that he has done something
wrong. After investigations, Police found that it was a false claim.

You are the FY 2 doctor in Psychiatry department, talk to the patient and do Mental state
examination and talk to him about further management.

Dr : Hello Mr Smith, I’m Dr …. One of the junior doctor in the Psych Dept. in this
hospital. I’m here to talk to you and help you. Can you please tell me what happened?
Mr Smith : Police are after me all the time…see they are standing by the door.
Dr : Do not worry Mr Smith they will not come inside. See I’m a doctor here and I’ll not
allow them to come inside. Please tell me why do you think they are after you?
Mr Smith : I did something wrong, So the police were after me.
Dr:I assure you that you are in safe place,and nobody will harm you.
Mr Simth: they have planted cameras in my room.
Dr:don’t worry mr smith,hospital is secure place,and nobody can see you outside this
room.
Dr : Do you know where you are now? ( Cognition)
Mr Smith : This is hospital.
Dr : Do you know who brought you here?
Mr Smith : The police brought me here.
Dr : Did the police catch you or did you go to them ?
Mr Smith : I was hiding from them for long time but I got tired and I turned myself in.
Dr: Have you been harmed in anyway?
Mr Smith: No
Dr: Since when are you feeling this way?
Mr smith: Since last few weeks
Dr: were you alright before?
Mr smith: yes
Dr: how do you feel in ur mood?can you please rate your mood on scale of 1-10,1 being
sad,low,and 10 being normal,happy?
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Mr smith:4-5
Dr: Are you able to eat/sleep well?carry out daily activities normally?
Mr smith:No/Yes
Dr : Do you ever see or hear things that are not really there, such as voices or visions?
( hallucination/perception)
Mr Smith : No
Dr : Do you feel that someone is plotting anything against you? Mr Smith : Yes.
Dr : Have people been interfering with your thoughts (thought insertion).
Mr Smith : No.
Dr: Do you think someone or some group intend to harm you in some way?
Mr Smith: yes,I feel Police will punish me.
Dr:Do feel like hurting urself/doing harm to self?
Mr smith:NO
Dr : Do you live with family or alone?
Mr Smith : I live on my own (sometimes he may say :I live with my mother).
Dr : Do you have any friends ? Mr Smith : No
Dr : Do you have any problem with finance? Mr Smith : No
Dr : Do you have any legal problems? Have you been in trouble with law
anytime?(Forensic history)Mr Smith : No.
Dr : Do you drink alcohol? Mr Smith : sometimes
Dr: do you smoke? Mr smith:yes/no
Dr:Do you use recreational drugs ? Mr smith:No
Dr : Do you think you have any problem, do you think you need any help? ( Insight)
Mr Smith : No
Dr:do you feel that this has affected your work/family life/social life?(Impact)
Mr smith:No/Yes
Dr : Do you have any medical conditions? Mr Smith : No
Dr : Did you have any mental health conditions before? Mr Smith : No
Dr : Any of your family members have any mental health conditions?
Mr Smith : No
Dr : Do you take any medications? Mr Smith : No
Dr: are you allergic to any medications? Mr smith:No
Dr : Do you have any medical problems at all? Mr Smith : No
Dr : Mr Smith why do you think all this is happening to you?
Mr smith:I don’t know
Dr : Thank you very much Mr Smith, we will try our best to help you.

DIAGNOSIS:From the information you have given me, you have a mental health condition
called Psychosis. Psychosis is a condition where in people loose touch with reality and
start to see,hear and believe things that are not true. It happens due to chemical imbalance
in the brain. It is not an uncommon condition, 1 in 100 people are affected by it. There are
many reasons why people can have this condition like life events, it runs in some families.
INVESTIGATIONS:We will admit you and do some tests to find the reason. This test
would include Blood tests and CT Scan of your brain.

MANAGEMENT:If the investigations are normal and symptoms persist for a long time it
could be a condition called Schizophrenia. We will treat that condition with medications to
help restore the chemical imbalance in the brain.( Risperidone or Olanzapine – no need to
tell the names of medications to the patient).
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We will provide all kinds of Psychological help and Social support.

[ The treatment could be Bio-psycho-social model]

Investigations for Psychosis

 Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse.
 Serological tests for syphilis should not be forgotten.
 Screening for AIDS should be preceded by counselling.
 Urine screen for drugs of abuse. Light recreational use of cannabis can produce a
positive test for the subsequent fortnight. Heavy and chronic use can produce a
positive result for months after the last use.
 CT brain scan may be contributory (eg, to exclude a space-occupying lesion or
cerebral atrophy) if focal signs are present but not otherwise.

SUICIDE ATTEMPT/SELF HARM RISK ASSESSMENT

Background

 Deliberate self-harm is defined as an act with a nonfatal outcome in which an

individual deliberately did one or more of the following:
A behaviour (eg, self cutting the wrists) intended to cause self-harm.
Ingesting a substance in excess of the prescribed or recognised therapeutic dose.
Ingesting a non-ingestible substance or object.
 Deliberate self-harm is not an attempt at suicide in the vast majority of cases.
 It is usually an attempt to maintain control in very stressful situations or emotional
pressures - eg, bullying, abuse, academic pressure or work pressure.
 Self-harm is usually done in private and hidden from anyone else.

Assessment
Step 1: History of Presenting Complaint- Elaborate the Event
Before: Prior events/Plan/Escape/Prep/Tell Anyone
During: Sequence/Expectations/Alcohol-Drugs
After: Discovery/Anger-Regret/Lingering Thoughts/Insight/Mood
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Example of questions that may be asked

Elaborate the event
What did you do to harm yourself ?When ? Where ?
Were you alone? What time of the day was it?
Did you tell anyone ?Who found you?
Who brought you to the hospital?

Why did you try to harm yourself ?

Was there any particular event that pushed you into it?
Did you understand the fatality of the method used by you?

Did you prepare yourself for this incident?

How long have you been planning?
Do you normally consume alcohol? Where you intoxicated just before committing the act?

Did you write a suicide note?

Who did you address it to? What did you write on it?

How are you feeling now?

Past
Have you tried this before?
Do you keep having thoughts or keep making plans?
Did you make arrangements and take care of your affairs?

Future
How does it feel to be alive?
Do you regret for what you did?
Would you try it again?
How do you see the future?

Management
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If station/task states present findings/management, then as a rule, the patient with:

 Low suicide risk, regret and with a supportive home family unit should be discharged
with follow up. Any other patient should be admitted after consultation with senior
colleagues.

Key Points

 Take time to build a rapport with the patient.

 Explore triggers by asking about the 4Fs
 When presenting findings to the examiner, Comment on 3 important points first
1) Is the patient depressed (low mood easy Fatuguability, and Anhedonia) 2) High
or low suicidal risk 3) Admit or not then if you have time - comment on the
patient’s Appearance-Behaviour-Speech

2. Depression ( Suicidal attempts)

Scenario - 2 .

Mr Graeme Hick, 35 years old man was brought to the hospital because he had taken
overdose of Paracetamol Tablets. He was admitted and treated for this. His condition is
stable medically. You are the SHO in psychiatric department. Do Psychiatric Assessment
and discuss the Suicidal Risk for Mr Graeme with the examiner. (Question can be do
mental state examination / Please do MSE “OR” please do psychiatric assessment “OR”
please take detailed psychiatric history)

GRIPS ( Do ABS in your mind, Ask about – present, past and future ( Suicidal risk)

Dr: Hello Mr Hick. I am Dr ….. How are you feeling?

Mr Hick: Doctor, I do not want to live.
Dr: Mr Hick, Why do you not want to live?
Mr Hick: I have gone through a lot.
Dr: I am sorry to hear that. Did you try to harm yourself in any way ?
Mr. Hick – I took some paracetamol tablets
Dr - When did you do that?
Mr Hick: Today morning.
Dr: How many tablets did you take?
Mr Hick: I took about 40 tablets.
Dr: Was there anyone with you?
Mr Hick: No, Doctor.
Dr: Who brought you to the hospital?
Mr Hick: My wife
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Dr: Have you done anything like this before? ( Past)

Mr Hick: Yes / No
Dr: Did you plan it?
Mr Hick: Yes
Dr: Did you write suicide note?
Mr Hick: Yes
Dr: Did you inform anyone before doing it?
Mr Hick: No
Dr: Will you do it again? ( Future ) ( How do you see your future ?)
Mr Hick: As I told you, I don’t want to live. / I may do it again / I am not sure.
Dr: How is your mood nowadays? Mr Hick: Not good.
Dr: How would grade your mood, 1 being the saddest and 10 being the happiest?
Mr Hick: Very Sad, I would say 3/ 10.
Dr: It might sound bit irrelevant but I need to ask you few questions, Can you please tell
me what day is today? /Where are you now? ( Cognition)
Mr Hick: --- (He will give you correct answers )
Dr: Do you live with family? Mr Hick: Yes. (But I do not like my
family)
Dr: Do you have friends Mr Hick – No
Dr: Are you currently in financial trouble, are you working?
Dr: Do you have any problem with the law ?
Dr: Do you know why you are in the hospital? Do you need any help (Insight)
Mr Hick: Yes
Dr: 'I'd like to ask you a couple of questions about things sometimes people have but may
find difficult to talk about. I ask everyone these questions. “Have you ever had experiences
of hearing noises or voices when there was nobody around?”
Mr Hick: No
Dr: “Are your thoughts actually taken out or sent out of your mind? / Do there seem to be
thoughts in your mind which are not your own; which seem to come from somewhere
else?” “Do your thoughts seem to be somehow public; not private to yourself, so that
others can know what you are thinking?”

Mr Hick: No

Dr: Thank you, Mr Hick.

Give your inference to the examiner( stop Hx at 4 -1/2min and talk to the examiner): -
I will admit the patient. My patient very depressed and has high suicidal risk because
1) He planned to harm himself 2) He made a suicide note 3) he may do the same again in
the future and 4) His mood is very low.

Scenario - 3

28 years old Ms Isabella Jane was brought to the hospital because she has cut her wrist.
She was admitted and treated few hours ago. Her condition is medically stable. You are
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SHO in psychiatry department. You have been asked to do suicidal risk assessment, and
discuss your management (inference) with the examiner.

Dr: Hello Ms Jane. I am Dr … I am here you help you. Could you please tell me what
really had happened ?
Isabella: Doctor I cut my wrist.(IF PATIENT DOESN’T SPEAK,OFFER
CONFIDENTIALITY)
Dr: I am really sorry to hear that. How are you feeling now?
Isabella: I am okay.
Dr: Why did you try to harm yourself?
Isabella: I did it because I had some misunderstanding with my boyfriend. ( sometimes
she may say “ I had a row with my boy friend )”
Dr: When did this happen ?
Isabella: A few hours ago.
{DURING}Dr: Where were you when this happened ?
Isabella: I was in the bathroom when I cut my wrist. After that, I screamed. My
boyfriend was watching football downstairs. He heard me and then, he brought me to the
hospital.
Dr: Was there any one with you at that time?
Isabella: I was alone when I cut my wrist (sometimes she may say - my boyfriend/
mother was present in the other room and came into the room after I cut my wrist )
Dr: I am sorry to ask you, but do you drink alcohol?
Isabella: Yes, Occasionally
Dr: Were you under the influence of alcohol when this happened?
Isabella: I had couple of glasses of wine.
{BEFORE}Dr: Did you plan this?
Isabella: No
Dr: Did you inform anyone about this?
Isabella: No
Dr: Did you write any suicide note?
Isabella: No
Dr: Was the wound deep?
Isabella: No, it was not deep.
Dr: How is your mood now? Can you please grade your mood in 1 to 10 scale where 1
being low and 10 being very happy?
Isabella: My mood is okay. I would say 8/10.
Dr:do you feel /see/hear noises when nobody is around?
Issabella:NO
Dr:Do you feel that somebody is trying to tell you to do things/or Is reading your mind?
Isabella:NO
Dr:do you smoke/do you use recreational drugs?
Isabella:NO
Dr:do you think that this will affect ur family life/work/social life?
Isabella:NO
Dr: Have you ever tried to harm yourself before? Isabella: No
{AFTER}Dr: How do you see your future?
Isabella: Brilliant, I am very happy with my boyfriend, He is very helpful.
Dr: Are you going to do this again?
Isabella: No, Doctor. I am not happy about what has happened.
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Dr: Do you have any medical condition? / are you taking any medication?/Allergic to any
medications
Isabella: No
Dr:did you have any mental conditions in the past?
Isabella:NO
Dr:do you have any Family history of any mental conditions?
Isabella:NO
Dr: Do you live alone? Isabella: No, I live with my boyfriend.
Dr: What do you do for living? Isabella: I work in a coffee shop.
Dr: Did you have any problem with law? Isabella: No.
Dr: Thank you very much for all the information you have given me. We will try our best
to help you.

Tell your management to the examiner

From the history, Isabella has low suicidal risk (insight is present, mood is 8/10, regretful,
happy with boyfriend, has job). I will discharge her after discussing with my seniors and
arrange for follow-ups. ( No admission )

Scenario - 4

16 years old Ms Jessica Thompson was brought to the hospital because she cut her wrist
and took overdose of OCP pills. You are FY 2doctor in psychiatric department. Take
history from the patient and discuss the management with her.
(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK)
START WITH ONSET,DURATION,THEN DO BEFORE,DURING,AFTER

Dr: Hello Ms Thompson, Can you please tell me, what brought you to the hospital?
Jessica: I took pills and cut my wrist.
Dr: I am really sorry to hear that. How are you feeling now?
Jessica: I am okay.
Dr: can you please tell me why did you do this ?
Jessica: I was stressed because I missed my period and I was worried that I am pregnant.
So I took some OCP yesterday and I was hoping to have my periods today. Today also I
didn’t get the periods –so I told my boyfriend about it. He broke up with me because he
didn’t want me to be pregnant. I got upset and cut my wrist.
Dr: When was your last period?
Jessica: It was 5 weeks ago.
Dr: How many OCP pills did you take?
Jessica: I took 20 tablets.
Dr: Where did you take these tablets?
Jessica: In my room.
Dr - Was there any one with you at that time.
Jessica – No
Dr: Where were you when you cut your wrist this morning?
Jessica: I cut my wrist in bathroom.
Dr: Was there any one with you at that time ?
Jessica: I was alone when I cut my wrist
Dr: Who brought you to the hospital?
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Jessica: I came to the hospital myself

Dr: Were you under the influence of alcohol when this happened?
Jessica: No
Dr: Did you plan to harm yourself ?
Jessica: No
Dr: Did you inform anyone about this?
Jessica: No
Dr: Did you write any suicide note?
Jessica: No
Dr: Was the wound deep?
Jessica: No, it was not deep It is just a graze.
Dr: How do you see your future?
Jessica: Very bright. I am going to university for further studies.
Dr: Are you going to do this again?
Jessica: No, Doctor. I am not happy about what has happened. I am regretting what I did.
Dr: Have you ever tried to harm yourself before?
Jessica: No
Dr: Do you have any medical condition?
Jessica : No
Dr: Are you taking any medication?Allergic to any medications?
Jessica: No
DR:how do you feel in ur Mood?on scale of 1-10,1 being sad,gloomy and 10 being
normal,happy?
Jessica:7-8
Dr:do you see/hear noises when nobody is around?
Jessica:No
Dr:do you feel that someone is telling you to do things?/or reading ur mind?/making you
do things?
Jessica:No
Dr:do you smoke?/DRINK Alcohol?/use recreational Drugs?
Jessica:NO
Dr:do you feel that this has affected your family life/social life/work?(ASK INDIVIDUAL
QUESTIONS)
Jessica:YES/NO
Dr:Do you think you need any help from us for your stress or if you are feeling low?
Jessica:I am OK Now
Dr: Do you have any mental health conditions?
Jessica: No
Dr: Any of your family members have any mental health conditions?
Jessica: No
Dr: were you ever in trouble with Law before?
Jessica:NO
Dr: Do you live alone or with others?
Jessica: I live with my mother and brother.
Dr: Have you told your mother or brother about this?
Jessica : No
Dr: Do you have any financial problem?
Jessica : No
Dr: Do you have friends?
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Jessica : Yes

Dr: Thank you very much for all the information.

MANAGEMENT – Because you are at low risk to harm yourself, We would discharge
you. We would offer support for you in the community after discharge in 2 weeks time.
-we will refer you to a Gynecologist as regards the pregnancy
-We will also take a look at your wrist and treat accordingly
-We will also contact the poison information center if you need any treatment for the
tablets you have taken and would treat you accordingly

Scenario - 5

50 year old man Mr Adam Thompson had met with road traffic accident 5 days ago. He
was diagnosed with whiplash injury after the X Ray showed no fracture in his cervical
bones. He was treated with pain killers. He has come back now c/o pain in his neck. He has
low mood. Take history from the patient and discuss the management with the examiner.

Dr: Hello Mr Thompson, Can you please tell me, what brought you to the hospital?
Adam: I had met with an accident 5 days ago. I still have pain in my neck.
Dr: I am really sorry to hear that. Yes we have seen the X Ray of your neck and there were
no fracture in your neck bones. This pain will go away after some time on its own. Just
keep taking some pain killers until then.
Is there anything else bothering you ?
Adam: Doctor, I am feeling very low nowadays.
Dr: Is this after the accident?
Adam: No
Dr: Since when are you feeling low?
Adam: Since about last 6 months.
Dr: Any particular reason you are feeling low ?
Adam: I am not earning well. My wife is spending her money on me and our children.
I am feeling bad. ( Sometimes he may say he keeps having arguments with his wife).
Dr: Do you work ?
Adam: Yes I am a fire fighter but I don’t go to my work all the time.
Dr –Is there any other problems ?
Adam – No. It is just I have this financial problem.
Dr: How is your mood now? Can you please grade your mood in 1 to 10 scale where 1
being low and 10 being very happiest mood?
Adam: My mood is okay. I would say 3/10.
Dr: Some people get a feeling of harming themselves or ending their life when they feel
very low. Has this type of feeling crossed your mind?
Adam: I do feel like killing myself ?
Dr:Have you tried to do anything to end your life?
Adam: No
Dr: Have you ever had such low feeling before this 6 months ?
 17

Adam: No
Dr: How do you see your future?
Jessica: I am just living with my wife’s money. I don’t feel like living anymore.
Dr: Do you have any medical or mental health problem at all ?
Adam : No
Dr: Whom do you live with ?
Adam: I live with my wife and children.
Dr: Are they supportive
Adam: Yes
Dr; Do you have many good friends
Adam ; Not many.
Dr: Have you have any trouble with the law ?
Adam: No
Dr: I would like to ask you a couple of questions about sometimes people have but may
find difficult to talk about. I ask everyone these questions
Have you ever heard voices speaking when there seems to be no-one around ?
Adam: No
Dr: Do you have personal beliefs that are not shared by others ?
Aam : No
Dr: Do you get any feelings to harm others?
Adam: No
Dr: Do you know where you are now.
Adam : Yes doctor, I am in the hospital.
Dr: Do you drink alcohol?
Adam : No
Dr: Thank you very much for all the information.

Management with the examiner: I will admit him. My patient is very depressed. He has
suicidal thoughts.

MINI MENTAL STATE EXAMINATION (MMSE)

Background

 The MMSE is a brief 30-point questionnaire test that is used to screen for cognitive
impairment, memory impairment.
 It is commonly used in medicine to screen for dementia.
 It is also used to estimate the severity of cognitive impairment and to follow the
course of cognitive changes in an individual over time, thus making it an effective
way to document an individual's response to treatment.

Key Points

 Perform your assessment for the entire 5 minutes.

 Offer sympathy and empathy. ( this is very important in this station)
 18

 Take time to build a rapport with the patient.

 Do not rush the patient, but if he gets frustrated, support and encourage him.
 Use the pen and paper on the table and you can score if you wish ( eg 1 +2 + 3 + 2 ).

Dementia
MMSE/ MENTAL HIGHER FUNCTION ASSESMENT/ COGNITION
ASSESMENT
Common causes of dementia:

 Alzheimer's disease (about 50%). Degeneration of the cerebral cortex.

 Vascular dementia (about 25%). Brain damage due to cerebrovascular disease:
either major stroke, multiple smaller unrecognised strokes (multi-infarct) or
chronic changes in smaller vessels (subcortical dementia).
 Dementia with Lewy bodies (DLB) (about 15%). Deposition of abnormal protein
within neurons in the brain stem and neocortex.
 Frontotemporal dementia (less than 5%). Specific degeneration/atrophy of the
frontal and temporal lobes of the brain. One type of frontotemporal dementia is
Pick's disease, where protein tangles (Pick's bodies) are seen histologically.
 Mixed dementia.
 Parkinson's disease.
 Potentially treatable dementias (fewer than 5%):
 Substance abuse
 Hypothyroidism
 Space-occupying intracranial lesions
 Normal pressure hydrocephalus
 Syphilis
 Vitamin B12 deficiency
 Folate deficiency
 Pellagra

Scenario - 6
A 75 years old man has been brought to the hospital because he was found confused and
wandering. All blood investigations are done and results are normal. You are the doctor in the
Psychiatric department. Assess this patient and discuss the initial management with the
examiner.
 19

Dr. Hello Mr Adam Williams,Mynameis........ I am one ofthedoctorsinthe

Psychiatrydepartment.
Dr - Can you confirm your name for me Pt:- Mr Adam Williams
Dr - Do you know where you are now ?Pt: - Where am I ?
Dr - You are in the hospital, Do you know who brought you here?
Pt: Who brought me here ?
Dr - The police brought you herePt: Am I in trouble?
Dr - You're not in trouble. Do you know where do you live? Pt: I don’t know.
Dr: Ok Don’t worry. You are in a safe place now. Pt: Sure.
Dr: - I would like to ask you a few questions to know how well you remember things, is
that okay with you

Orientation Year/Season/ Month/ Day /Date

Time
---/ 5
(one score for each right answer)
Place Country/ County City/town Street Building/ floor 1. What country
are we in now?
---/ 5 2. What county
(one score for each right answer) are we in?
3. What city are
we in?
4. What
building are we
in?
5. What floor of
the building are
we in?
(When you ask
which floor you
are in – he may
step on the floor
and say “ I am on
this floor” – give
zero score)
Registra 3 objects Ask to repeat 3 words [allow one second between each “ I am going to
tion word, repeat them up to 5 times] name 3 objects,
I want you to
---/3 repeat them.
Please
(one score for each right answer) remember these
words, I am
going to ask you
to name then
again in a few
minutes.
These three
 20

objects are :
APPLE,
TABLE,
PENNY”.
Please repeat the
3 words for me.

(If the
patient
cannot say
correctly
then repeat
until learned
or up to
maximum 5
times).
Attentio WORLD Ask to spell the word “world” and correct if wrong and Could you spell
n and ask to spell it back ward which gives score. Give one the word
Calculat score for each correct answer until the order of the “world”? Now
ion spelling is correct. Eg : D,L,R,W,O (score is 3 here) could you please
---/5 spell backward?

( you should
not spell
backwards
to help him)
Recall 3 recall Ask to recall those 3 words Could you
--/3 please repeat
One score for each correct answer. those 3 words I
asked you to
remember?
( do not
remind him
the words)
Langua Name 2 Ask to name 2 objects Show 2 objects
ge objects --/2 one by one,
One score for each correct answer. Could you
please name this
object?
( eg – pen,
paper)
Repeat Ask to repeat NO IFS, ANDS, or BUTS I want you to
sentence --/1 repeat exactly
Give one score if the whole sentence is correct what I say
otherwise zero. NO IFS,
ANDS, OR
BUTS
3 step Ask to perform a 3 steps act Ask pt which is
command --/3 his dominant
One score for each right step. hand. Ask him
to do the
 21

following steps
in non-
dominant hand.
Please take
this paper
with in your
left hand ( if
he is right
handed),
fold it in
half once
with both
the hands
and put the
paper down
on the floor
.(don’t show
any gesture)
Read Read and Write a command on the paper and ask him to do that Please read this
carry out --/1 and do what it
the Give one score if he closes his eyes not for reading. says.
command Write on the
paper - [Please
close your eyes]

If the patient
just repeats
but does not
close the
eyes, you
can repeat
the
instruction 3
times, but
you do not
close your
eyes to
show him.
Write Write a Ask to write a sentence,look for meaningful sentence Could you
sentence --/1 please write
please One score for a meaningful sentence (ignore spelling a sentence in
errors). this paper?
Copy Copythisdia Asktocopy2intersectingpentagonswhereintersectionb Can you
gram oxhas4sidesonly. pleasecopythisd
--/1
esign.
Give one score if drawn correctly (Must have drawn
4 sided figure between two 5 sided figures).

Allow multiple attempts until Pt is finished and hands

it back to you.
 22

Total Score :

24-30 : Normal cognition

20-23 : Mild cognitive impairment
10-19 : Moderate cognitive impairment
0 -9 : Severe cognitive impairment

At the 6th minute bell :- Stop the assessment and discuss the management with the
examiner (SOMETIMES EXAMINER SAYS TO COMPLETE THE ASSESMENT)
DIAGNOSIS: From the above history and cognitive assessment the patient has impaired
cognition. He is able to PERFORM/NOT PERFORM most of the instructions. My
provisional diagnosis is dementia.(TELL THE SCORE/TYPE OF COGNITIVE
IMPAIRMENT)
INVESTIGATIONS& MANAGEMENT• I would like to admit the patient since he has
dementia so it is not safe to send him home and do investigations like CXR, urine test, A
brain CT scan to check for any cause for dementia and also find out more information
from GP about past history and Family about onset and progression of his condition.
.REFER TO DEMENTIA CLINIC/DEMENTIA Team

ALCOHOL ASSESSMENT
You must assess the following 6 steps and if required discuss your findings with the patient
or the examiner.
Step 1: Presenting Complaint
Step 2: History of Present Complaint
 Daily Drinking Pattern: What/How Much/When/Where/Alone/Progression

CAGE Questions: CAGE SCREENING TOOL

• “Have you ever felt that you should Cut down on your drinking?”
• “Have people Annoyed you by criticizing your drinking?”
• “Have you ever felt bad or Guilty about your drinking?”
• “Have you ever had a drink first thing in the morning to steady you nerves or get rid of a
hangover (Eye-opener)?”
• Scoring: Two or more positive responses correlate with substance abuse.


 Cut Down/Annoyed/Guilty/Eye Opener
Step 3: Features of Dependence
 23

 TDW - Tolerance/Dependence/Withdrawal/Previous Treatment

Step 4: Consequences
 Friends/Family/Finances/Forensic
Step 5: Complications
 Physical/Depression(Mood)/Psychosis/Self Harm
Step 6: Insight

Management
If station/task states present findings/management/counsel, then as a rule, you should discuss:
 Referral to Alcohol Support Worker
 Lifestyle changes
 Outpatient Counselling Groups such as Alcoholics Anonymous
 Outpatient medication management
 Inpatient Detoxification
 Change of occupation if required
Key Points

 Be honest and non-judgemental.

 Do not start station by discussing alcohol directly, mention that their test results may
be due to alcohol intake as well as many other causes and that you want to ask some
questions to rule alcohol out as a cause.
 Many patients drink in secret and may not want to discuss the issue.
 If patient denying drinking alcohol – you can offer confidentiality. ( Mr… “Whatever
you discuss with us will be kept confidential”
 The patient needs to accept that there is a problem before therapy can start.

Government Recommended Allowances

Male and Female:14 UNITS PER WEEK

Alcohol
Exam question: Mrs Tames Parker, 45 years old woman who had hysteroscopy. The
nurse noticed she has got a bad drinking habit and wants you to talk to her about it. You
are the SHO in the Psychiatric department. Take history for alcohol abuse from the patient
and talk to her about the management.
(GRIPS Followed by CAGE,T/D/W)
Dr: Hello, Mrs Parker, I am Dr………., one of the doctors in Psychiatric department. I am
here to talk to you and help you.
Dr: Can you please tell me how are you doing?
Mrs Parker: I am much better just a bit sore but I guess it’s expected.
Dr: I am sorry to hear that
 24

Mrs Parker: I am OK now.

Dr: Mrs Parker I want to talk to you about alcohol, is that okay ?
Mrs Parker: Yes, Doctor.
Dr: Do you drink alcohol Mrs Parker ?
Mrs Parker: Yes
Dr : For how long have you been drinking?
Mrs Parker : I have been drinking for last 20 years.
Dr: How much do you drink? (How frequently?)
Mrs Parker: Doctor, I drink 3 pints of beer and 1 shot whisky daily
( Then ask CAGETDW – cut down, annoyance, guilty, eye opener, tolerance, dependence,
withdrawal questions )
Dr:Have you ever felt you should try to cut down on your drinking?
Mrs Parker: Yes, Doctor, I went to Alcohol Anonymous (AA) Group 6 months ago to cut
down alcohol. But sometimes, I went for drinks because of my friends.
Dr: Does it mean that you still keep drinking.
Mrs Parker : Yes doctor
Dr: Can you please tell me why did you try to cut down drinking?(INSIGHT)
Mrs Parker : It is not good for health.
Dr: Have people annoyed you by criticizing your drinking?
Mrs Parker: Yes, My husband is really annoyed about it
Dr: Have you ever felt bad or guilty about your drinking?
Mrs Parker: Yes, Doctor, Sometimes
Dr: Have you ever had a drink in the morning (eye-opener) to steady your nerves or get rid
of a hangover?
Mrs Parker : Yes, Doctor.
(Patients with two or more positive responses are likely to be alcohol dependent).
Dr: Doyouthinkthatyouhavetotakemoreandmore alcoholto getthesameeffectasbefore?
(tolerance)
Mrs Parker: No, Doctor.
Dr : Do you feel you cannot do your daily activities without drinking alcohol? (dependence)
Mrs Parker : Yes
Dr: Howdoyoufeelwhenyoudo not drink alcohol for a long time ? ( withdrawal)
Mrs Parker: Doctor, when I do not drink, I feel restless, I start sweating and sometimes I
feel that my heart is racing. It happened to me 1 year ago.
Dr: What do you do for living? Mrs Parker: I own a winery ( a place where wine is made).

Dr: Do you live with your family?

Mrs Parker: Yes, with my husband

Dr : Do you have any financial problems?
Mrs Parker : No
Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1 being
low and 10 being very happiest mood? ( Mood)
MrsParker: My mood is fine (7/10)
Dr: At any point, THOUGHT of harming yourself or ending your life? ( Suicidal)
MrsParker: No, doctor.
Dr : Do you ever see or hear things that other people seem unable to see or hear?
( HALLUCINATION/PERCEPTION)
Mrs Parker : No
Dr:DO you feel that this has affected your work/family life/social life?(IMPACT)
 25

Mrs parker:NO/YES
Dr:DO you tend to drink alcohol to relieve ur stress?(STRESSOR)
Mrs parker:No
Dr: Do you have any health problem at all apart from the problem for which you had the
procedure now? Mrs Parker : No
Dr:did you have any mental health problems in ur past?
Mrs parker:NO
Dr:are you taking any medications?/are you allergic to any medications?
Mrs parker:NO
Dr:do you have family history of any mental health conditions?
Mrs parker:NO
Dr:Do you have any legal problems?
Mrs parker:NO
Dr: Thank you very much for all the information. We will try our best to help you.

DIAGNOSIS:Mrs parker ,ur experiencing soreness and withdrawal symptoms because of

ur ALCOHOL use. From the information I think you have alcohol dependence.
*Cause and effect : From what you told me Mrs Parker, You seem to be taking too much
alcohol which is dangerous to you. This can damage your liver and risk your life.
 MANAGEMENT:Stop alcohol : If you stop drinking, it will not only help you in
this problem, but also in your overall health. We can help you on that.
 Medications : We can give medications to prevent withdrawal effects (anti
withdrawals - chlordiazepoxide) and also to help you stop drinking alcohol (anti-
craving medications – disulfiram, Acamprosate).
 Counselling : You can try to attend Alcohol anonymous, or we can help by
counselling sessions ( CBT) or
 Rehabilitation: if needed we can admit for rehabilitation (Job, Finances and
accommodation)
 Avoid going to the winery, triggers ( seeing other people drinking): may be you can
try to change your job ( if he is a bar tender ) or try to avoid going to the bar floor (If
he is a bar owner).

Scenario – 8
A 60 year old man, Mr Smith, was admitted in the hospital because of ingrowing toe nail
infection. Medical Investigation has been done : MCV ↑, LFTs : deranged. Talk to the
patient, take Hx and advice patient to stop drinking.
[ This is a history and counselling station]

Dr : Mr Smith we have done some blood investigations because you have

infection in your toe nail. The results show there is some abnormalities in
your blood picture. This could be due to several reasons lack of some type of
food in your diet or drinking alcohol.
 26

Dr: Do you think that you eat a healthy balanced diet? (Vit B12 deficiency
causes high MCV)

Mr Smith : Yes.

Dr: Do you drink alcohol?

Mr Smith : Yes.
The rest is similar approach as previous Task.

DRUG ABUSE ASSESSMENT

Assessment
You must assess the following 6 steps and if required discuss your findings with the patient
or the examiner.
Step 1: Presenting Complaint
Step 2: History of Present Complaint
 Daily Drug Pattern: What/How Much/When/Where/Alone/Progression
 CAGE Questions: Cut Down/Annoyed/Guilty/Eye Opener
Step 3: Features of Dependence
 Tolerance/Withdrawal/Previous Treatment (Hep B)
Step 4: Consequences
 Friends/Family/Finances/Forensic
Step 5: Complications
 Physical/Depression(Mood)/Psychosis/Self Harm
Step 6: Insight
Management
If station/task states present findings/management/counsel, then as a rule, you should discuss:
• Referral to Narcotic Support Worker and Lifestyle changes
• Outpatient Counselling Groups such as Narcotics Anonymous
• Outpatient medication management (Methadone/needle sharing)
• Inpatient Detoxification

Scenario - 9
You are the FY 2 doctor in the Psychiatry department.

30 year old, Mr Henry Williams, has been referred to the hospital from his GP because he
 27

is opioid dependent and he wants to quit the habit.

Take history from Mr Henry and discuss the further management with him.

{GRIPS-CAGE,T/D/W,Which DRUG,DOSAGE,ROUTE OF INJECTION}

Dr: Hello Mr Williams, I am Dr… one of the junior from the Psychiatry Dept. How can I
help you Mr Williams?
Mr Williams: Dr I use drugs and I want to stop and I need help.
Dr: It is really good to know that you wish to quit drug habit. I am really glad that you have
come to us. We can surely help you with that.
Can you please tell me, which drugs doyou use?
Mr Williams: Doctor, I use Heroin.
Dr: For how long have you been taking it?
Mr Williams: It has been 10 years; I started taking it when I was 20 years old.
Dr: How much do you take it?
Mr Williams: about 1 gram.
Dr: How often do you take it?
Mr Williams: I take it two times daily.
Dr: How do you use it?
Mr Williams: I inject in my blood channels nowadays, before I used to snort it.
Dr : Do you know of the needle exchange programme?
Mr Williams: Yes, I am aware of it.
Dr: Apart from heroin, do you take anything?
Mr Williams: No doctor ( sometimes he may say - I use cocaine, marijuana and
amphetamine).
(Ask CAGETDW questions)
Dr: Have you thought of Cutting down or quitting them?
Mr Williams: I tried to quit it two times before (5 months and 7 months before) , but it did
not work as I had serious withdrawal symptoms
Dr: Why did you try to Cut down before?
I was having some health problems. I had some infections on my arm where I used to inject
myself.
Dr: Do you sometime get Annoyed when people talk about your habit?
Mr Williams: No (sometimes yes, because of my wife/ girlfriend)
Dr: Do you have any sort of Guilt feeling that you are using opioid?
Mr Williams: Yes, Doctor, Sometimes I feel guilty in front of my wife/ girlfriend.
Dr: Do you take them in the morning as well?(EYE OPENER)
Mr Williams: Yes, Doctor. First thing I do in the morning is to take these drugs.
Dr: Doyouthinkthatyouhavetotakemoreandmore drugsto
getthesameeffectasbefore?(TOLERANCE)
Mr Williams: No, Doctor.
Dr : Do you feel you cannot do your daily activities without taking drugs? (Dependence)
Mr Williams : Yes
Dr: Howdoyoufeelwhenyoudo not take these drugs?(WITHDRAWAL)
Mr Williams: Doctor, when I do not take these drugs, I feel restless, I start sweating and
sometimes I feel that my heart is racing. It happened to me 1 year ago.
Dr: What do you do for living?
Mr Williams: I am on benefits
Dr: Do you live with your family?
 28

Mr Williams: Yes girlfriend who also uses opioids.

Dr : Do you smoke or consume alcohol?
Mr Williams: No
Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1 being
low and 10 being very happiest mood?
Mr Williams: My mood is fine (8/10)
Dr:do you ever feel that someone is telling you to do things/or controlling your mind?
Mr Wiliams:No
Dr: At any point, thought of harming yourself or ending your life?
Mr Williams: No, doctor.
Dr: At any point, you have gone to wrong side of the law?(FORENSICS)
Mr Williams: No ( sometimes he may say - I was arrested when I was young for pick
pocketing).
Dr : Do you ever see or hear things that other people seem unable to see or hear?
( hallucination)
Mr Williams: No
Dr:Is there any Stress which is making you take this drug?(STRESSOR)
Mr Williams:NO/Yes
Dr: Do you think this is affecting your health or social life /Family life?(Impact)
Mr Williams: Yes doctor.
Dr : Do you think you need help? (Insight)
Mr Williams: Yes Doctor.
Dr : How do you see your future?
Mr Williams: Good if I can stop this habit
Dr:did you suffer from any mental health conditions in the past?
Mr Williams:NO
Dr:do you have any other medical conditions? Mr Williams:No
Dr:Are you allergic to any medications?are you taking any medicines?
Mr Williams:No
Dr:Do you have family history of any mental health conditions?
Mr Williams:No
Dr : Thank you Mr Williams

Management:

• As you know it is not good for health as well as for your social life.
We can help you to quit the habit if you are willing to do so.
•We have a Drug de-addiction(DETOXIFICATION)programme which can help you where
we can Admit and rehabilitate.WE will Give you drug called LOFEXIDINE,TO HELP
You with the withdrawal effects.
*We will also treat you symptomatically.For example:METACHLOPARAMIDE for
Nausea,LOPERAMIDE for Loose Motions,BENZODIAZEPAMS for
Palpitations.*REPLACEMENT THERAPY:We have some medications called
Methadone or Buprenorphine ( tell the names of the medications to the patient) we can
give you to help you.
*We have talking therapies, such as counselling, can help you to understand and overcome
your addiction and plan for your future.
*We can refer you to a support group( self help group -Narcotics Anonymous ) where
 29

you can meet other people with similar problems and share your experiences which can
help you.
*Talk about NEEDLE EXCHANGE PROGRAM
*Advise about his girlfriend – if your girlfriend wishes to stop her drug habit we can help
her too.
Do you follow me? Any questions ?

ANOREXIA NERVOSA
Background

 People with anorexia nervosa have extreme weight loss as a result of very strict
dieting.
 In spite of this, they believe they are fat and are terrified of becoming what is, in
reality, a normal weight or shape. They do not accept that they are losing weight and
they do not believe they need any help.
 Distorted body image and abnormal attitudes to food and weight.
 Amenorrhoea and often other signs of starvation are present.
 Bulimia nervosa – They usually accept they have a problem and they recognise the
need for treatment.

Assessment
You must assess the following 6 steps for assessment of eating disorder in real life.
In the exam only first 3 steps.
Step 1: History of development of the disorder and patient’s ideas (Body Image distortion,
Compensatory mechanisms, Daily diet and exercise)
Step 2: SCOFF
Step 3 : Mental state examination for depression
Step 4 : Interview parents and other informants
Step 5 : Assess family interaction in especially attitudes in relation to food
Step 6 : Physical examination ( Distribution for body hair, emaciation, vit. deficiency,
Organic cause).

History:
• Onset
• Triggers
• Daily Diet Pattern: What/How Much/When/Where/Alone/Progression
• Binge eating
• Self Induced Vomiting
 30

• Feel fat/Fear of fatness

• Weight loss
• Food domination
• Amenorrhoea
• Medical or psychiatric problems
• Palpitations, fainting
• Role Models
• Baggy clothes
• 4Fs
• Mood
• Risk to themselves or others
Step 3: FAMISH History format
Step 4: Insight
( Pneumonic –
SCOFF
S – Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry that you have lost Control over how much you eat?
O – Have you recently lost more than One stonein a three month period? ( one stone = 6.3
kilos or 14 pounds)( 1 kilo = 2.2 pounds)
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life ?
If the patient has 2 or more positive answers it indicates a likely case of Anorexia or
Bulimia).

Scenario - 10
Miss Jessica Thompson, 20 years old girl was brought to the hospital by her parents. On
her recent visit to GP, GP noticed that Miss Jessica has lost some weight and he referred
her to the hospital for this reason. Her Parents are not with her now in the hospital. You are
the SHO in psychiatry department, Take history from Miss Thompson.

[ This station is only history taking]

Dr: Hello are you Miss Jessica Thomson ?

Miss: Thompson: Yes
Dr: I am Dr… one of the junior doctor in the psychiatry department. Can you please tell me
what brought you to the hospital?
Miss: Thompson: I am here because of my parents; they think that I have been losing
too much weight.
Dr: Can you please tell me, how much weight did you lose?
Miss: Thompson I have lost about 15 pounds ( more than one stone, 6.8 kg) in the last 3
months.
Dr: Have you been trying to lose weight?
Miss: Thompson: Yes
Dr: Could you please tell me, why are you losing weight?
 31

Miss: Thompson: Dr, I want to be like my friend.

Dr: Can you please tell me, why do you want to be like your friend?
Miss: Thompson: She is slim and good looking. My friend has found boyfriend.
Dr: Do you think that you are fat?
Miss: Thompson Yes doctor.
Dr What do you do ? Do you work or you are a student ?
Miss: Thompson: I am a university student.
Dr: Can we talk about your general life style?
Miss: Thompson of course, Doctor.
Dr: What is your diet like? / What do you eat in breakfast/ lunch/ dinner?
Miss: Thompson: In breakfast, I eat banana. In lunch, generally I do not eat anything. I just
have water. I take light snacks like biscuits at night.
Dr: Have you any time eating too much food and could not have any control on eating.
(Binge eating)
Dr: Do you do any exercise?
Miss: Thompson Yes, doctor. I enjoy running (doing exercise).
Dr: How often do you do exercise?
Miss: Thompson I do it every day for about 2 hours.
Dr: Do you take any medications to lose weight ?
Miss: Thompson No
Dr: Do you make yourself sick because you feel you are uncomfortably full ?
Miss: Thompson: No
Dr: Do you have any preference for clothes?
Miss: Thompson: Yes, Doctor, I like to wear baggy clothes.
Dr: Do you have any role models?
Miss: Thompson I am very big fan of Victoria Beckham
Dr: Can you please tell me, do you like looking yourself in the mirror repeatedly?
Miss: Thompson : No doctor.
Dr: Do you keep checking your weight frequently?
Miss: Thompson: Yes doctor.
Dr: How has been your mood? Can you please grade it, 1 being the saddest and 10 being
the happiest?
Miss: Thompson: It has not been good. (3/10)
Dr: Have you ever thought of harming yourself?
Miss: Thompson: No
Dr: do you think that you have been losing too much weight?
Miss: Thompson: No, dr. / I feel uncomfortable when I do not follow my daily routine of
diet and exercise.
Dr: How is your general health?
Miss: Thompson Dr, I feel weak nowadays, I want to sleep most of the time.
Dr: How you ever had any mental health problem before?
Miss: Thompson: No.
Dr: Are the family members supportive?
Miss: Thompson: Yes they are supportive.
Dr : Any problems with your colleagues in the university? ( Bullying ?)
Miss: Thompson: No
Dr How is your periods?
Miss: Thompson: I am waiting for my periods; it has not come for last 8 weeks. I am
worried about it.
Dr: Do you have any health symptoms like palpitation, Feeling faint or any other
 32

symptoms?
Miss: Thompson No
Dr: Thank you very much for all the information.

Causes of insomnia
long-term pain
sleep disorders – such as snoring and sleep apnoea, restless legs
syndrome, narcolepsy, night terrors and sleepwalking
problems with the genital or urinary organs – such as urinary
incontinence or an enlarged prostate
joint or muscle problems – such as arthritis
Physical
health conditions hormonal problems – such as an overactive thyroid
1
neurological conditions – such as Alzheimer's disease or
Parkinson's disease
respiratory conditions – such as chronic obstructive pulmonary
disease (COPD) or asthma
heart conditions – such as angina or heart failure

In women, childbirth can sometimes lead to insomnia.

certain antidepressants
medicines for high blood pressure, such as beta-blockers
2 Medication epilepsy medicines
as a side effect. steroid medication
non-steroidal anti-inflammatory drugs (NSAIDs)
stimulant medicines used to treat attention deficit hyperactivity
disorder (ADHD) or narcolepsy
some medicines used to treat asthma, such as salbutamol,
salmeterol and theophylline
mood disorders – such as depression or bipolar disorder
3 Mental health anxiety disorders – such as generalised anxiety, panic
conditions
disorder or post-traumatic stress disorder
psychotic disorders – such as schizophrenia
stressful event, such as a bereavement, problems at work, or
financial difficulties.
4 Stress and Having more general worries – for example, about work, family or
anxiety health – are also likely to keep you awake at night.
 33

These can cause your mind to start racing while you lie in bed,
which can be made worse by also worrying about not being able to
sleep.
Drinking alcohol before going to bed and taking certain recreational
drugs,
stimulants such as nicotine (found in cigarettes) and caffeine (found
in tea, coffee and energy drinks).
5 Lifestyle factors
These should be avoided in the evenings.
Changes to your sleeping patterns can also contribute to
insomnia – for example,
because shift work
changing time zones after a long-haul flight (jet lag).

You may struggle to get a good night's sleep if you go to bed at

6 Poor sleep inconsistent times,
routine nap during the day
and sleeping
environment A poor sleeping environment can also contribute to insomnia – for
instance,
an uncomfortable bed or a
bedroom that's too bright, noisy, hot or cold.
7 Sometimes it's not possible to identify a clear cause.
Exam Scenario for Insomnia
You are the FY2 doctor in the Rhuematology clinic

Mrs Sarah Johnson, 60 years old lady, has come to the Rheumatology clinic for the
follow up because she was diagnosed with Rheumatoid arthritis. She is on
Paracetamol and Methotrexate and Folate for RA. She complains of unable to sleep.

Talk to her and address her concerns

Dr: Hello Mrs Johnson, I am Dr. … of the junior doctor in the medical department.
How are you doing today ?
Mrs Johnson: I am Ok doctor
Dr: What brought you to the hospital?
Mrs Johnson: I have difficulty in sleeping.
Dr: I am really sorry to hear that. When did it start?
Mrs Johnson: It started 6 months before.
Dr: Can you please tell me about your difficulty in sleeping? Do you find it difficult to sleep
when you go to bed or difficulty in maintaining sleep or you wake up early in morning?
Mrs Johnson: I get into bed at 9 or 10 o’clock but I can sleep only after 3 o’clock.
Dr: Has anything happened recently which might be the cause of this problem - like any
 34

sad or shocking news ?

Mrs Johnson: Yes doctor, Mr Johnson died.
Dr: I am really sorry to hear that. How did he die?
Mrs Johnson: He Died of heart attack
Dr: How was your mood after your husband died?
Mrs Johnson: I was depressed initially but now I am Ok. Only sometimes when I get into
bed I think about him and I miss the time which we spent together. My mood is very low if I
don’t get sleep ( this is not depression).
Dr: You keep thinking of him in the night ! Is this what is causing lack of sleep?
Mrs Johnson: No doctor.
Dr: Do you have any medical or mental health problems ?
Mrs Johnson: I am diagnosed with Rheumatoid Arthritis.
Dr: Are you in pain nowadays because of this condition?
Mrs Johnson: No doctor. Pain is well controlled with Paracetamol, methotrexate and
Folate. ( non of these drugs cause insomnia)
Dr: Do you take any other medication apart from these medications?
Mrs Johnson: No doctor.
Dr: Do you have any other symptoms like – shortness of breath in the night, have to go to
the loo many times in the night ( incontinence) ?
Mrs Johnson: No doctor.
Dr: How is the sleeping condition at your home? Is there any noise? Too bright lights
disturbing you ?
Mrs Johnson: No problem at all. ( Sometimes she may say neighbours are very noisy
in the night.
Dr: Is the bedroom too hot or cold?
Mrs Johnson: it is fine.
Dr: Are you working?
Mrs Johnson: No
Dr: Do you have any stress or worries ?
Mrs Johnson: No
Dr: Do you drink alcohol? / Do you smoke/Use recreational drugs?
Mrs Johnson: I do not drink alcohol/NO
Dr: Do you drink tea/ coffee before going to bed?
Mrs Johnson: No. (sometimes she says - 2 cups of coffee in the morning), ( sometimes
she says she drinks coffee in the night)
Dr: Is the bed or pillow uncomfortable?
Mrs Johnson: No
Dr: Do you sleep in the day time ?
Mrs Johnson: No ( sometimes she may say -Yes because I do not get sleep in the night I
 35

take a short nap in the afternoon).

Dr: Do you keep watching TV or computer until late in the night ?
Mrs Johnson: No.
ASK QUESTIONS RELATED TO
THOUGHTS,PERCEPTION,IMPACT(Work,Family,Social Life)

Diagnosis & Management:

Counselling:
Dr: Mrs Johnson -
There are many reasons why people do not get sleep. In your case though the cause is
not very clear sometimes people who have Rheumatoid arthritis do have this problem -
sometimes due to pain, but sometimes it can happen without any known reasons in
patients with this condition.

However you can I improve my sleep by what we call sleep hygiene

• use a sleep diary to keep track of your sleeping habits

If she is doing any of the following then advise accordingly:-

• avoid sleeping during the day ( sometimes she is sleeping in the day time)
• avoid tea, coffee and any other products that contain caffeine after midday
( sometimes she drinks too much coffee in the night time)
• don’t eat or drink large amounts just before bedtime
• avoid drinking alcohol if your sleep is disturbed
• don’t smoke before bedtime or during the night
Sometimes she may say – her neighbours are too noisy – you can request them not
to make too much noise if they do not listen – you can report to the council)

• exercise regularly (but not within three hours of going to bed)

• keep the bedroom dark, quiet and at a comfortable temperature
• check that your mattress and pillows are comfortable
• set up a relaxing routine – try to go to bed and wake up at the same time each day
• take a warm bath before going to bed.

Relaxation techniques and Talking therapy (CBT) may also be help you. We will refer
you to the Psychiatrists who are experts in this.

Mrs Johnson: Doctor will you give me sleeping pills ?

Dr: There are many sleeping pills but they have side effects and they may cause
addiction and also medications may not help in the long term. Medications are not
recommended for more than four or five weeks
However if nothing else helps we can consider giving you sleeping pills
Is it OK ?
Mrs Johnson : Ok doctor I will try.
Dr: We will keep following you up. Thank you very much.
 36

PANIC ATTACK
Background

Anxiety
Anxiety is a feeling of unease. It can range from mild to severe and can include
feelings of worry and fear.

There are several conditions that can cause severe anxiety including
 phobias – an extreme or irrational fear of an object, place, situation, feeling or
animal
 generalised anxiety disorder (GAD) – a long-term condition that causes
excessive anxiety and worry relating to a variety of situations
 post-traumatic stress disorder – a condition with psychological and physical
symptoms caused by distressing or frightening events

 A panic attack is a severe attack of anxiety and fear which occurs suddenly, often
without warning, and for no apparent reason. In addition to the anxiety, various other
symptoms may also occur during a panic attack. These include one or more of the
following:
 Palpitations.
 Sweating and trembling.
 Dry mouth.
 Hot flushes or chills.
 Feeling short of breath, sometimes with choking sensations.
 Chest pains.
 Feeling sick , dizzy, or faint.
 Fear of dying or going crazy.
 Numbness, or pins and needles.

Assessment
You must assess the following 4 steps as part of this station/task.
Step 1: Presenting Complaint
Step 2: History of Present Complaint
 Onset
 Symptoms (explore above)
 Description
 Triggers
 Recent change in circumstances
 Severity
 37

 Progression
 Effect on activities of daily living
 4Fs
 Mood (Score 1-10)
 Risk
Step 3: FAMISH History
Step 4: Insight

Suggested Questions
How long have you been having problem?
What happens to you ?
Do you have heart racing, feeling dizzy and numb,
Do you have breathing problems and have a sense impending doom(You feel as though
something extremely bad is going to happen but you are not sure what. You may also feel as
though your world is coming to an end)?
What brings it on?
How long has this been going on?
Does it occur only when you are faced with such a situation or at any time?
Can you go out of the house at all ?
Are you afraid of crowds and people?
Any special fear?
Is this hampering your daily life?
What do you do to subside them?
Is your family and friends supportive?
Is there stress at work /family?
Do you enjoy your daily activities /interest/otherwise?
Is this problem making you suicidal?
Any other medical /mental condition you wish us to know of? Are you on any medications?

Scenario - 12
Miss Sarah Jones, 25 years old lady has been referred to the hospital by her GP. She went
to GP because she thinks that she is very anxious nowadays. All investigations have been
done and are normal. You are SHO in the hospital. Take history from Miss Jones.
 38

[ This station is only history taking]

Dr: Hello Mrs Jones, I am Dr… one of the junior doctor in the Psychiatry department. How
are you doing ?
Miss Jones: I am very worried doctor.
Dr : What are you worried about ?
Miss Jones: Dr, I become anxious nowadays. I Feel like my heart is racing and mouth is
dry. Sometimes, I even have choking sensation.
Dr: When did it start?
Miss Jones: It started few months ago.
Dr: When was the last time you had symptoms?
Miss Jones: I had these symptoms two weeks ago when I went to the party and I met my
family members.
Dr: Can you please tell me, how did it start at first time?
Miss Jones: It started when I was at shopping centre. And I started having symptoms.
Dr: Do you have any idea what can be the cause of these symptoms, any recent
change/incident in your life?
Miss Jones: Yes doctor. My husband left me 8 months ago, and I got divorced after that.
Dr: Is there any particular thing which makes you anxious?
Miss Jones: No doctor. However, it happens when I go out.
Dr: Does it affect your daily life?
Miss Jones: Yes.
Dr: How does it affect your life?
Miss Jones: I cannot go out nowadays as I am afraid that if I go out I might get these
symptoms.
Dr: Do you have any concerns about your life, any responsibility?
Miss Jones: Yes, Doctor, I am concerned about my three kids.
Dr: Do you have any family to support you?
Miss Jones: Yes, Doctor my sister supports me.
Dr: What do you do for living?
Miss Jones: I am not working right now; I lost my job 4 months ago.
Dr: How has been your mood?
Miss Jones: It has been good
Dr: Have you ever thought of harming yourself?
Miss Jones: No
Dr: Do u drink alcohol?
Miss Jones: doctor, I am really worried about my heart.
 39

Dr: Don’t worry, my GP colleague did all the investigations and fortunately everything is
fine and there is nothing wrong with your heart. ( Mention this only if the patient ask you
this question, otherwise just say “thank you very much for all the information”).
[This is only history taking station]

SSRI Counselling ( Fluoxetine) ( Antidepressant)

Key Points

 In this station, you must emphasise the importance of staying on the medications to
achieve the best beneficial effect.

Scenario - 13

Mr Jeremy Williams 30 years old man has been referred to you from GP. This man was
prescribed paroxetine. Talk to the patient and address patient’s concern.

Dr. Hello Mr Williams I am Dr… One of the junior doctor in the Psychiatry department.
How are you doing today?
Pt: The medicine what you gave me is useless doctor.
Dr: Why do you say that?
Pt: They are not at all helping me.
Dr: Which medication are you talking about ?
Pt: I was prescribed this medication 10 days ago because I was feeling very low.
Dr: Do you take it regularly?
Pt: Yes.
Dr: Are you still taking the medication or have you stopped taking them.
Pt: I am still taking them.
Dr: Mr Williams, unfortunately you may not see the effect of this medication within 10
days. It takes 4-6 weeks to build up its best effects so please continue your medication
regularly. Please do not stop taking this medication on your own. You will see the effect in
the next few weeks.
Dr: Do you have any other concerns about this medication ?
Pt : I heard that it can cause problems with sex life. Is that true ?
Dr: It is true. It can very rarely cause sexual dysfunction like low sex drive or erectile
problems. However we will keep monitoring the medication. Any other concerns ?

Pt: Do they have any other side effects ?

Dr: Yes, Common ones are headache, vomiting, diarrhoea or constipation and sometimes
stomach ache.It can either make you very sleepy or you may not get good sleep at all. This
medication might cause poor sleep. So please don’t take it in night, take it early morning.
 40

Pt: Doctor is it addictive?

Dr: It is not addictive. We will not stop this medication suddenly. We will gradually
decrease the dose of medication. So you will not experience any side effect.

Dr: Do you have the feeling of harming yourself or ending your life ?
Pt: No ( is he says yes – admit him)
Dr: If at all you get these feelings any time later please do come back to us. We will keep
following you up.

Bipolar disorder
Bipolar disorder, formerly known as manic depression, is a condition that affects
moods, which can swing from one extreme to another.
There will be periods or episodes of:
 depression – feeling very low and lethargic
 mania – feeling very high and overactive

Unlike simple mood swings, each extreme episode of bipolar disorder can last for several
weeks (or even longer), and some people may not experience a "normal" mood very often.

Depression
The depression phase of bipolar disorder is often diagnosed first and manic episode later
(sometimes years later).

Mania
During a manic phase of bipolar disorder, patient may feel very happy and have lots of
ambitious plans and ideas. They may spend large amounts of money on things they cannot
afford and would not normally want.
Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also
common characteristics of this phase.
They may feel very creative and view the manic phase of bipolar as a positive experience.
However, they may also experience symptoms of psychosis (where they see or hear things
that are not there or become convinced of things that are not true).

Scenario - 14
( This station assesses your ability to take history in a patient with elevated mood).

Miss Sarah Collins 30 year lady was brought into the hospital with cuts on her wrists.
Medical management has been done and she is medically stable.While she was in the
hospital nurse noticed strange behaviour. You are the SHO in the Psychiatric department.
Talk to the patient and tell your diagnosis to the examiner.
 41

Dr: Hello Mrs Collins I am Dr… How can I help you ?

Pt: I cut my wrists
Dr: I am sorry to hear that. How did this happen?
Pt : Doctor, I have a very nice dress and I wanted to buy a matching shoe. When I went
for shopping for the shoe shop was closed. I saw a pair of perfectly matching shoe on the
glass window of the shop, so I smashed the window to get the shoe and I got hurt on my
wrist.
Dr: I am very sorry to hear that. But why did you smash the window?
Pt: Oh doctor I was in a very good mood.
Dr: Has this happened to you before.
Pt: Doctor I am very happy since the last two weeks.
Dr: Is there any particular reason why you are so happy?
Pt: Nothing special.
Dr: Has this happened to you before ?
Pt: No doctor in fact some time ago I was very depressed and I left going to the
University.
Dr: When was that ?
Pt: This happened about a month ago.
Dr: Why were you so depressed ?
Pt: I do not know why.
Dr: How is your mood now in the scale of one to ten, one being lowest mood and 10 being
the happiest mood ?
Pt: 10 out of 10 doctor.
Dr: Have you ever had low mood ?
Pt: I was feeling very low about a month ago.
Dr: Do have any thoughts of harming yourself or ending your life ?
Pt: No doctor. I used to have that feeling before but now I am very happy.
Dr: Have been treated for depression or any other mental health problems before?
Pt: No
Dr: What do you do for living ?
Pt: I work as a waitress in hotel.
Dr: Are you financially stable.
Pt: No doc. I am almost bankrupt.
Dr; Have you ever been involved in any legal problems?
Pt: No
Dr: Who do you live with?
Pt : My parents but we don’t have good communication.
Dr: Do you hear any noises when no one else is around
Pt: No doctor
Dr: Do you think you have any mental health problem?
Pt: No
Dr: Do you have any problems with the sexual life?
Pt: No
D: Do you drink alcohol?
Pt: No
Dr: Do you use any recreation drugs?
Pt: No
Dr: Thank you very for all the information.
 42

Tell you diagnosis to the examiner: Bipolar disorder.

GOOD LUCK

History Taking, MSE and Management Proforma

Chief Complaint

History of present illness:

1) Onset
2) Duration
3) Progression (clinical Features including ICD 10, risk and differentials
4) Mood(sleep,appetite,Anhedonia)
5) Thought(Insertion,Broadcasting,Withdrawal)
6) Perception(Hallucinations)
7) alcohol and drug
8) risk(To self,To others)
9) Current Stressor
10) Impact (On work, Family and Social life)
11) Insight

12) Past Psychiatry History: Similar or any other

13) Past Medical History

14) Family History

15) Forensic History

 43

MSE:

Appearance: and Behaviour:

Speech:

Mood:

Thought:

Perception:

Risk:

Insight:

Management

Inpatient admission if risks are high and then Community mental health, (which is
a MDT) after discharge

(Bio-Psycho-Social Model)

Biological aspect: Medications (Anti depressant, Anti psychotics, Mood stabiliser)

Psychological Aspect

Sociological Aspect: Lead by Consultant psychiatrist who gives medications.

1. CPN/Care coordinator to monitor your mental health and medications in
community.
 44

2. Social worker to look after your finances and accommodation.

3. Occupational therapist to make the necessary changes in your house to
maximise you potential in activities of daily living.
4. Mental health support workers support to adapt to ordinary life within the
community. Including individual support and counseling via such activities as
shopping with people who need care and support, taking them to
appointments, developing everyday skills such as how to make a cup of tea or
prepare and cook a meal safely, or simply being with them in their home
environment.
5. Psychologist for the psychological input in the form of counselling.

Risk:
1) High - In patient admission
2) Low: GP, wellbeing services and Emergency numbers to contact.

Heroine : Two type of management:

1. Replacement (can be done in community or in ward)

Methadone or Buprenorphine
2. Detox (can be done in community or in ward)
Impotent admission is needed for detox:
 Lofexidine= treatment for withdrawal symptoms like
chills, sweating, muscle pain, stomach cramps,
runny nose and difficulty in sleeping.
 Ibuprofen
 Buscopan
 Nalaxone=opioid antagonist
 Metaclopramide
 loperimide
 BZD

My consultant will be taking the final decision but I can let you know about
the treatment options.
(No single detox is the same, varies individually i.e. each programme is
tailored to meet a meet a person’s individual needs)
Community drag team-worker will tell you when and how often to take the
medicine.
Firstly, we would be stabilising the patient by admitting him and we will
detoxify him.
 45

Alcohol:
We can admit you for detoxification and it can be dine either in community
by GP/ADS or as an in-patient.
 Chlordiazepoxide
 Disulfiram
 Acamprosate
 Pabrinex

Rehabilitation: After detox (both Heroin and alcohol, we refer to rehab

centre for 12-16 weeks for psychotherapy and also help you stabilise
socially, financially by looking for job placements)

Self Harm –OCP overdose and cut wrist

16 years old Ms Jessica Thompson was brought to the hospital because she cut her wrist
and took overdose of OCP pills. You are FY 2 doctor in psychiatric department. Take
history from the patient and discuss the management with her.
(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK)
START WITH ONSET, DURATION, THEN DO BEFORE, DURING, AFTER

Dr: Hello Ms Thompson, I am Dr... one of the junior doctor in the Psychiatry department.
How can call you ?
Jessica: You can call me Jessica.
Dr: Jessica Can you please tell me, what brought you to the hospital?
Jessica: I took pills and cut my wrist.
Dr: I am really sorry to hear that. How are you feeling now?
Jessica: I am okay.
Dr: Alright... can you please tell me why did you do this ?
Jessica: I was stressed because I missed my period and I was worried that I am
pregnant. So I took some OCP yesterday and I was hoping to have my periods today.
Today also I didn’t get the periods – so I told my boyfriend about it. He broke up with me
because he didn’t want me to be pregnant. I got upset and cut my wrist.
Dr: I am very sorry hear about this Jessica. When was your last period?
Jessica: It was 5 weeks ago.
Dr: How many OCP pills did you take? Jessica: I took 20 tablets.
Dr: Where did you get these tablets. Jessica: It is my mom’s pills.
Dr: Where did you take these tablets? Jessica: In my room.
Dr - Was there any one with you at that time. Jessica – No
Dr: Where were you when you cut your wrist this morning?
Jessica: I cut my wrist in bathroom.
Dr: Was there any one with you at that time ?
Jessica: I was alone when I cut my wrist
Dr: Who brought you to the hospital ?
Jessica: I came to the hospital myself
 46

Dr: I see. Were you under the influence of alcohol when this happened Jessica ?
Jessica: No
Dr: Did you plan to harm yourself at all ?
Jessica: No. It just happened. I was not thinking properly at that time.
Dr: I am sorry to ask this - Did you think of ending your life at all ? Jessica : No
Dr: Okay Did you inform anyone about this? Jessica: No
Dr: Was the wound deep ? Jessica: No, it was not deep It is just a graze.
Dr: How do you see your future ?
Jessica: Very bright. I am going to university for further studies.
Dr: Are you going to do this again ?
Jessica: No, Doctor. I am not happy about what has happened. I am regretting what I did.
Dr: Have you ever tried to harm yourself before? Jessica: No
Dr: Do you have any medical condition? Jessica : No
Dr: Are you taking any medication? Allergic to any medications? Jessica: No
Dr: How do you feel in your Mood on scale of 1-10,1 being sad, gloomy and 10 being
normal, happy? Jessica:7-8
Dr: Do you see / hear noises when nobody is around ? Jessica: No
Dr: Do you feel that someone is telling you to do things? or reading your mind? / making
you do things? Jessica:No
Dr: Do you smoke? / Drink Alcohol? / use recreational Drugs ? Jessica:No
Dr: Do you feel that this has affected your family life/social life/work?(ASK
INDIVIDUAL QUESTIONS)
Jessica: YES/NO

Dr: Is she student what is she studying, any financial problems, Any other worries.

Dr: Do you think you need any help from us for your stress or if you are feeling low?
Jessica: I am OK Now
Dr: Do you have any mental health conditions? Jessica: No
Dr: Any of your family members have any mental health conditions? Jessica: No
Dr: were you ever in trouble with Law before? Jessica: No
Dr: Do you live alone or with others?
Jessica: I live with my mother and brother.
Dr: Have you told your mother or brother about this? Jessica : No
Dr: Do you have any financial problem? Jessica : No
Dr: Do you have friends? Jessica : Yes
Dr: Has any one looked at your wound ? Jessica : Yes / No
Dr: Did any specialist doctor talk to you about the chance of pregnancy to you ?
Jessica: Yes/ No
Dr: Thank you very much for all the information.

MANAGEMENT – Jessica, I am very sorry you have to go through this problem. Do not
worry we are here to help you.
-we will refer you to a Gynecologist as regards the chance of pregnancy ( if not already
sorted out)
-We will also take a look at your wrist and treat accordingly ( if not already sorted out)
-We will also contact the poison information center if you need any treatment for the
tablets you have taken and would treat you accordingly.
 47

However since you said you are regretting for what you have done and you are sure that
you are not going to do this again, I don’t think we need to admit you for any Psychiatric
reasons. I will talk to my seniors and then you can go home.

I sincerely advise you to talk to your mother about this. I am sure she will understand your
problem and support you in the future. What do you say - will you talk to your mother ?
Jessica : Yes doctor. [ If she says no - ask her - Can we talk to your mother and explain
about you. I am sure she will understand your problem – what do you say? Jessica – OK.
If she still says no – then mention that your seniors will talk to her before we discharge her]

We are also here to support you if need any time. We will give the telephone number of a
help line to call if you feel very stressed out like this any time in the future and they will
advise you of what you can do. Also will have a follow up in the community clinic after 2
weeks. Is that OK ?
Jessica : Ok
Dr: Thank you very much.

Self Harm – Gay man PCM OD

You are FY 2 doctor in Emergency department.
18/20 years old Mr..... was brought to the hospital because he took over dose of
Paracetamol tablets
Take history from the patient and discuss the management with him
-------------------------------------------------------------------------------------------------

(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK)

START WITH ONSET, DURATION, THEN DO BEFORE, DURING, AFTER

He took 16 tablets of paracetamol 2 hours ago.

Boy friend brought him to the hospital.

He had an argument with his mother because mother was very upset because she found out
that he is gay.
He is regretting for that now. Not going to do it again. Sees future bright.
Lives alone.

Dr: Is he working what is his job, any financial problems, Any other worries.

MANAGEMENT –Mr.. I am very sorry you have to go through this problem. Do not
worry we are here to help you.

Mr… Unfortunately overdose of Paracetamol can damage and kidneys.

First of all we need to do some blood tests to see if you have any damage to the liver and
kidneys.
 48

Also we need to check whether you need any treatment with antidote medicine for
overdose of Paracetamol. For that we need to test the level of Paracetamol in your blood
after 2 hours ( 4 hours after the ingestion).
I will talk to my seniors about it. Also we will refer you to the Psychiatry specialist. They
will help you further.

Pt: Do I need to be admitted.

Dr: At the moment yes you need to be in the hospital because we need to do the test to see
whether you need any treatment for the overdose of the tablets you have taken.
However if the level of paracetamol is not very high or if there is no damage to the organs
then you do not need to be admitted here.

But the Psychiatrist has to see you and then they will tell you about the further
management. However since you are regretting for what you have done and you are sure
you are not going to do such things again they may not admit you. They may advise you
about the help what they can provide and follow up with you later. Is that OK ?
Pt : Ok Dr Any other concerns ? Pt : No
Dr: Thank you very much.
 49

Vertigo
You are FY2 doctor in Emergency Department.
25 years old female has been brought to emergency room with complaint of Vertigo.
Take history from the patient, talk to her and discuss further management with her.
BPPV Vestibular neuronitis Meniere’s
disease

Mostly seen after the age of 50. Sudden oncet, lasts for hours. Hearing
Can be seen in young people. Not triggered by movement but loss and
Precipitated by movement movement can exacerbate symptom. tinnitus and
Can follow after injury to head or Can happen after viral infections like fullness in
ear flu. ear present.
Last only for few seconds or Can have nausea and also vomiting.
minutes. There may be hearing loss
Episodic – happens on movement
of head. No other symptoms like pain, tinnitus,
Associated with nausea, usually no fullness in ear,.
vomiting.
No other symptoms like pain
tinnitus or fullness in ear
If Dix Halpike test is negative –
then it is unlikely to be BPPV.
Causes of
Peripheral vertigo Central vertigo
 benign paroxysmal positional vertigo  migraines –
(BPPV)  multiple sclerosis

 head injury  acoustic neuroma

 a brain tumour
 labyrinthitis
 a transient ischaemic attack
 vestibular neuronitis
(TIA) or a stroke
 Ménière's disease  taking certain types of
 taking certain types of medication medication

Dr: Hello Miss I am Dr…. How may I call you? Pt: You can call me ....
Dr: What brings you to hospital Miss..? Pt: I am having vertigo doctor.
Dr: I am sorry to hear that. Could you please tell me what exactly do you mean to as
vertigo?
Pt: Doctor every time I turn my head, I feel like my head is spinning.
Dr: It must be very distressing for you. Can you tell me more about it?
Pt: I was shopping in the market doctor and I just turned my head to have a look at
something and it felt like the whole world just spun around me. I fell down suddenly doctor.
Could you imagine?
Dr: I can understand, it must be very upsetting for you.
Pt: It is. I was brought by ambulance to the hospital.
Dr: Could you please tell me if this feeling is being provoked by any specific movements of
head or your body? (Like sitting up or leaning forward or turning the head in a horizontal
 50

plane?)
Pt: Yes, doctor my symptoms are worsened when I tilt my head to a side. (Patient might
describe the position) (BPPV)
Dr: Can you tell me whether the feeling of head spinning is triggered by the head movement
or is exacerbated by movement? (Labrynthitis is not triggered by movement but may
be exacerbated by it vs. BPPV which is triggered by movement).
Pt: ? Doctor I get the feeling only when I move my head. (BPPV)
Dr: Could you please tell me how long do these episodes last?
(20-30 seconds in BPPV vs. >20 min in Meniere’s disease)
Pt: It lasts for a few seconds doctor but it is unbearable.
Dr: It must be. Does anything relieve it?
Pt: Yes doctor, it resolves if I keep my head stable. (BPPV)
Dr: Is there any other symptoms other than head spinning?
Pt: Yes doctor, I have been feeling sick. (Patient is holding a cup in her hand as if about to
vomit)
Dr: Have you vomited? Pt: No doctor. But I am afraid I might vomit any time.
Dr: Please do not worry. We mightbe giving you some medicine for this complaint. Are you
comfortable to talk to me? Pt: (Yes, I can bear it/No?)

Dr: Did you lose consciousness during this time period? (Syncope/TIA/Vertebrobasilar
Ischemia))
Pt: No, I didn't lose consciousness but I fell down doctor.
Dr: Did you stand up suddenly from the sitting position at the moment you fell down in the
market? (Orthostatic Hypotension) Pt: No.
Dr: Did you experience any weakness in arms or legs during this time period?
(TIA/Vertebrobasilar Ischemia) Pt: No.
Dr: Did you lose hearing from one or both ears? (Labrynthitis/Meniere's
Disease/Vestibular Neuroma) Pt: No.
Dr: Do you have pain in this ear? Pt: No.
Dr: Do you have any fever ? (Otitis Media) Pt: No.
Dr: Do you hear any hissing or ringing sounds in the ear? (Tinnitus -
Labrynthitis/Meniere’s disease/Acoustic Neuroma) Pt: No.
Dr: Do you have any balance problem while walking? (Balance Problems - Meniere’s
disease/Acoustic Neuroma) Pt: No.
Dr: Do you feel any fullness in your ear? (Aural Fullness-Meniere's Disease) Pt: No.
Dr: Have you been feeling unsteadiness in walking and/or hand movement? (Ataxia -
Acoustic Neuroma) Pt: No.
Dr: Have you been feeling any one sided headaches lately? (Vestibular Migraine/Acoustic
Neuroma) Pt: No.
Dr: Did you have injury to the ears or head recently? (Trauma) Pt: No.
Dr: Is it the first time it is happening? (Multiple Sclerosis) Pt: Yes.
Dr: Did you have any infections like flu in the recent past?
Pt: Yes, doctor I have had a flu like illness a few days before. (Viral Post-viral illness
(Viral Neuronitis) a cause of BPPV)
Dr: How long ago was that? Pt: Almost ten days ago doctor.
Dr: Have been diagnosed with any medical conditions in past? Pt: No
Dr: Are you taking any medications now? Pt: (No/Yes?)

Examination:
 51

 I need to examine your ear. Examiner may say: Ear examination is normal.

 I will like to perform a test called Dix-Hallpike Test.

 [ Do the test unless the examiner stops you or gives the findings]
This will involve you sitting on the couch. I will have to ask you to lie back and move your
head in certain directions. These set movements will usually trigger an episode of vertigo. It
will help us confirm the diagnosis of what we are suspecting in you. Are you following?
Pt: Yes.

(Rule out contraindications of performing the test)

Dr: could you please tell me if you have any neck or back related disease or injury? No.
Dr: Any bone problems like Rhumatoid Arthritis? Pt: No.

Procedure of Hallpike Test:

1. Warn the patient that transient vertigo may occur in any position.
2. Ask the patient to keep their eyes open and stare at your nose.
3. Prepare the couch so the headrest is down and the patient's head will overhang the
end.
4. Begin with the patient sitting with their head turned 45° to the left to test the left
posterior canal. With their head in this position, quickly lay the patient down until
the head is dependent 30° below the level of the couch.
5. Observe for nystagmus in each position (30 seconds) and then return the patient to
the upright position.
6. Repeat with the head turned to the right to test the right posterior canal.
7. If positive:
8. The patient experiences vertigo and rotary nystagmus in posterior canal BPPV.
Purely horizontal nystagmus suggests horizontal canal BPPV.
9. Nystagmus (fast component) will be upbeat and in the direction of the most affected
ear. This has a limited duration, lasting <30 seconds (adaption).
10. On sitting, there is more vertigo, experienced as the room spinning in the opposite
direction (with reversal of the nystagmus).

 Rhomberg's Test - this is used to identify instability of either peripheral or central

cause of vertigo:

1. The patient stands up straight with feet together (or at a distance for them to be
steady) with arms outstretched. Then ask them to shut their eyes.
2. If they are unable to maintain their balance with their eyes closed, the test is positive
(usually fall to the side of the lesion so stay close by to prevent them falling).
3. A positive test suggests a problem with proprioception or vestibular function.
Romberg's test can also be positive in neuromuscular disorders and may not be
reliable in very elderly people.

[ stop the examination by 6 minutes]

Diagnosis:

Pt: From the information I have gathered, I suspect that you might be suffering from a
condition called as BPPV. Do you know anything about it? Pt: No doctor.
 52

Dr: BPPV is a condition of the inner ear. It is a common cause of intense dizziness or
vertigo. I will tell you what it means. It is short for Benign Paroxysmal Positional Vertigo.

Benign means that it is not due to serious cause. Paroxysmal means symptoms comes in
episodes, Positional means that the symptoms are triggered by certain positions. In the case
of BPPV, it is certain positions of the head that trigger symptoms. Vertigo is dizziness with a
sensation of movement. Are you following?

Pt: Yes doctor but why has it happened to me?

Dr: Our inner ear has some fluid filled structures called semi circular canals which maintains
balance of our body. If any broken off fragments of the inner ear structures gets inside that
fluid it causes vertigo when we move the head in certain directions.
Sometimes this problem can be triggered if there is any injury or infections in the head or ear
previously. Are you following?

Pt: Yes doctor. Are you going to do any tests ?

Dr: There is no need to do any investigations to diagnose this condition. However if the
condition does not resolve or gets worse then we may need to do some tests like CT scan or
MRI scan to exclude any other conditions. However, I would like to refer you to Ear Nose
and Throat specialist. Is that alright? Pt: Alright.

Pt: Yes doctor. But how are you going to treat me?

Dr: This condition usually resolves itself in few days or in few weeks. There is no need for
hospital admission. We have a special technique called The Epley manoeuvre. This
manoeuvre is usually very successful in stopping symptoms with just one treatment. If the
first treatment does not work, there is still a good chance that it will work in a repeated
treatment session a week or so later.
We will give you medication called Proclorperazine and antihitamines this will help to
improve your symptoms of nausea vomiting and vertigo.
Dr: Can I ask if you drive? Pt: Yes doctor.
Dr: Please do not drive until this problem is resolved and please inform the DVLA.
Pt: Do I need to be careful about anything?

Dr: [ warning signs]However if you have any symptoms like hearing loss, hearing any
abnormal hissing sounds in the ear, headache vision problem please do come back because
these could be due to some other serious conditions.
Pt: Yes doctor.

Dr: Do you have any concerns? Pt: No, you have been very kind.

Vertigo – Vestibular neuronitis

 53

Diagnosis:

You have a condition called Vestibular neuronitis.This is an inner ear condition that causes
inflammation ( swelling) of the nerve connecting the labyrinth ( an organ which helps
maintaining our body balance) to the brain.

The condition is usually caused by a viral infection. It usually comes on suddenly.

Are you following me ?

Pt : Yes Is this a serious condition ?

Dr: This is not a serious condition. It will subside by itself in few weeks time.

Treating vestibular neuronitis.

This condition subsides on its own in about 3 to 6 week time without any treatment.

There is no need to be admitted to the hospital for treatment.

We can give you medications to reduce the severity of your symptoms but they do not
speed up recovery.

We will also give you anti- sickness medication called Prochlorperazine – which can help
with symptoms of nausea and vomiting.
[Antibiotics – if it is caused by a bacterial infection ( do not mention in the exam because
patient did not have fever so not bacterial infection)]

However, there are some self-help measures you can take to reduce the severity of your
symptoms and help your recovery.

Self-help for vestibular neuronitis

If you're feeling nauseous, drink plenty of water to avoid becoming dehydrated. It's best to
drink little and often.

If you have quite severe vertigo and dizziness, you should rest in bed to avoid falling and
injuring yourself. After a few days, the worst of these symptoms will go away and you will
 54

not feel dizzy all the time.

You can do several things to minimise any remaining feelings of dizziness by

 Avoiding drinking alcohol ( if the patient drinking)

 avoiding bright lights
 try to cut out noise and anything that causes stress from your surroundings
You should also avoid driving, using tools and machinery, or working at heights if
you're feeling dizzy and unbalanced.

Once the dizziness is starting to settle, you should gradually increase your activities
around your home. You should start to have walks outside as soon as possible. It may help to
be accompanied by someone, who may even hold your arm until you become confident.

You won't make your condition worse by trying to be active, although it may make you feel
dizzy. While you're recovering, it may help to avoid visually distracting environments such
as:

 supermarkets
 shopping centres
 busy roads
Pt: Will there be any problem in the future ?
Dr: A small number of people experience dizziness and vertigo for months or even
years.This is calledchronic vestibular neuronitis.

It happens when the vestibular nerve fails to recover and the balance organs can't
get messages through to your brain properly.

The symptoms aren’t usually as severe as when you first get the condition, although even
mild dizziness can have a considerable impact on your quality of life, employment and other
daily activities.

If this happens then we have something called vestibular rehabilitation therapy (VRT) to
treat this condition.

VRT attempts to "retrain" your brain and nervous system to compensate for the abnormal
signals coming from your vestibular system.

VRT is usually carried out under the supervision of a physiotherapist.

 55

Are you following me ? Pt Yes. Any other questions – No

Warning signs

Dr: Miss. You can go home now. However if you develop headache, hearing loss, double
vision, slurred speech, balance problem while walking or weakness or numbness in arms or
legs you should come back because these are the signs that it could be some other serious
conditions.

Dry Cough and Hemoptysis

Differentials for cough for > 3 weeks :

1. Bronchial carcinoma
- Smoking, weight loss. Haemoptysis.
2. Mesothelioma – exposure to asbestosis, building worker ( roofer, plumber,
carpenter) wt loss.
3. Infection T.B – Haemoptysis, night sweat, wt loss, contact with any one with
TB.
4. P.E – SOB, chest pain, haemoptysis, calf pain, travel, surgery. Recent immobilization.

5. Asthma – allergy to pets – wheeze, pollen, exercise.

6. COPD - > 3 month for 2 consecutive years, wheeze.

7. CCF – ankle swelling, orthophnoea, PND.

8. Diffuse parenchymal lung disease.

9. Drugs – ACE inhibitors, Beta blockers

10. Psychogenic
 56

11. GORD – heart burn, regurgitation.

Acute < 3 weeks

1. Foreign body – sudden onset.

2. Infection. URTF/ Pneumonia/ Infective COPD

Exam question

You are F2 in medicine

60 y/o man presents with complaints of cough since few months. He has coughed up
blood few times in the last week.

Take history, examine and discuss management with the patient

Dr: Hello Mr... my name is Dr... I'm one of the junior doctors in the medicine department.
What brings you to the hospital today?

P: Doctor.. I have been having this bad cough for a few months now.. And for the last few
days I have coughed up some blood as well

Dr: I'm sorry to hear that Mr... Could you please tell me when this problem started?

P: It has been over 6 months now.

Dr: Is the cough associated with any sputum/phlegm?

P: No it is a dry cough

Dr: Have you had any shortness of breath? P: Yes.

Dr: could you please tell me when that started? P: Around the same time

Dr: Has it worsened since then? P: Yes/No

Dr: You mentioned that you had coughed up some blood few times this week. Could you
please tell me more about it? How much of blood did you cough up?

P: _________________________

Dr: Do you have any chest pain? P: No (Might say yes if mesothelioma)
 57

Dr: Fever? P: Yes/No

Dr: Have you noticed any swellings in your neck or your armpits? P: No

Dr: Do you have any trouble swallowing? P: No

Dr: Do you have any pain in your calves? P: No

Dr: Have you noticed any change in your weight? P: Yes (assess quantity)

Dr: Do you have any other complaints that you wish to report Mr...?

P: No doctor

Dr: Do you have high BP? P: No

Dr: Diabetes? P: No

Dr: Thyroid related illnesses? P: No

Dr: Are you on any medications? P: No

Dr: What is your diet generally like? P: Balanced doctor

Dr: Do you smoke Mr...? P: Yes doctor.. I have been smoking for >20 years

Dr: Could you tell me what you smoke in a day? P: 1 pack of cigarettes/day

Dr: Do you consume alcohol? P: Yes/No

Dr: Do you have any allergies? P: No

Dr: Do you have any family history of medical problems? P: No

Dr: F/H of cancers? P: No

Dr: What do you do for a living Mr...?

P: I work as a plumber/carpenter/roofer (or) Patient might not give a significant

occupational history.

Dr: Have you travelled anywhere recently? P: Yes/No (look for travel to TB endemic areas)

Dr: Ok Mr... I would like to examine your neck, chest and hands.

( Examiner may give findings of clubbing and /or swelling in the supraclavicular area; and
decreased or reduced air entry in the left or right lung.)
 58

Dr: Mr...Do you have any idea what may be happening to you ? Pt: No doctor.

D: Mr… It looks like you have some serious condition. Do you want to know about it?

Pt : Yes doctor.

Dr: Based the information what you told me it looks like you have cancer in your lungs or
lining of the lung. Pauce

Pt: Oh …. Really … I didn’t expect doctor.

[ Pt may say “ my friend who was working with me had been diagnosed with
mesothelioma. Do I also have the same doctor”.

Dr: I wish it was not true but unfortunately you are right that it is possible that you too may
be having the same problem. ]

Dr: However we will need to do some tests to confirm that. First we will do a chest X ray.

Examiner might show you the chest x ray

Scenario 1 – Lung cancer Scenario 2 – Mesothelioma

SHOW XRAY TO THE PATIENT

Scenario 1
 59

Lung Cancer

Dr: Mr... I have your Chest Xray with me. Would you like to take a look at it?

P: Ok doctor

Dr: These are your lungs Mr.... and this is your heart. Can you see this round opaque
shadow at the top of your lung here? P: Yes

I am sorry to say that I do not have very good news for you. Mr...

Unfortunately this looks like cancer of the lung...

Dr: We will have to do further tests to confirm the diagnosis, like a CT scan of your chest.
We will also refer you to a specialist... a pulmonologist... who will do a procedure called a
bronchoscopy, where we will have to pass a flexible tube with a camera through your
mouth into your airways to get a better view of the problem. If needed, he might take a
tissue sample and send it for further analysis. Are you following me Mr....?

P: Yes doctor. Why did this happen to me?

Dr: There are few factors that can increase the risk of developing lung cancer.

This condition is common in those people who smoke for long time.

P: Is it treatable doctor?

Dr: Mr... the treatment depends upon the diagnosis. If it is cancer, then it will depend upon
the stage of the cancer.. how far it has progressed and also the type of cancer. If it is an
early stage, we may be able to offer surgical options to remove the growth. But if the
cancer has advanced too much or if it is a more aggressive type of cancer, I'm afraid there
are no curative options. We might be able to offer treatment measures like radiotherapy or
chemotherapy to prolong life and relieve the symptoms. Are you with me Mr...?

P: Yes doctor I understand. You can go ahead with the tests..

Dr: Ok Mr... I will speak with my consultant and arrange for them right away. Do you have
any other concerns?

P: No doctor

Dr: Once again, I'm sorry I don't have better news for you at the moment... If you have any
doubts, please feel free to ask for me.

Scenario 2
 60

Mesothelioma

Dr: Mr... I have your Chest Xray with me. Would you like to take a look at it?

P: Ok doctor

Dr: These are your lungs Mr.... and this is your heart. Can you see this white opacity over
this lung? P: Yes

I am sorry to say that I do not have very good news for you. Mr... Unfortunately this looks
like cancer of the lining of your lung... called mesothelioma.

We will have to do further tests to confirm the diagnosis, like a CT scan of your chest. We
will also refer you to a specialist... a pulmonologist... who might try to take a biopsy.... or a
tissue sample from the lining of your lung and send it for further analysis. Are you
following me Mr....?

P: Yes doctor. Why did this happen to me?

Dr: There are few factors that can increase the risk of developing mesothelioma. Exposure
to elements like asbestos which was used extensively in the construction of old houses and
buildings can affect the lining of the lung and cause this condition.

P: Is it treatable doctor?

Dr: Mr... Unfortunately this is a serious type of cancer. I'm afraid there are no definitive
curative options. We might be able to offer treatment measures like radiotherapy or
chemotherapy to prolong life and relieve the symptoms, but I am afraid there is no
permanent cure if you are indeed diagnosed with mesothelioma. Are you with me Mr...?

P: Yes doctor I understand. You can go ahead with the tests..

Dr: Ok Mr... I will speak with my consultant and arrange for them right away. Do you have
any other concerns?

P: No doctor

Dr: Once again, I'm sorry I don't have better news for you at the moment.. If you have any
doubts, please feel free to ask for me.
 61

Patient with dry cough – Take history for the patient and tell your
differentials and investigations to the examiner.
Pt will give the same story as above

Also he may say that his son lives in Tanzania and visited him few months ago and both of them
started to having cough at the same time.

Differentials

1) Mesothelioma – Investigations – Chest X Ray, CY scan , Bronchosopy and biopsy

2) Lung Cancer Investigations – Chest X Ray, CY scan , Bronchosopy and biopsy
3) TB – Chest X Ray, Sputum - AFB test, Gold quantiferon test, Mantoux test.

Dry Cough - PCP

Exam question

You are the FY 2 doctor in the medical department.

30 year old homeless man presented with cough and shortness of breath.

Take history and examine the patient.

[ Positive findings – dry cough, exertional dyspnoea, night sweat, bisexual, does not
practice safe sex, shares needles, homeless)

Dr: Hello Mr… I am Dr … one of the junior doctor in the medical department. How can I
help you Mr..

Pt: Doctor I have been having cough for the last few weeks.

Dr: I sorry to hear that. Can you please tell me anything more about it ?

Pt: Like what doctor?

 62

Dr: Do you get it throughout the day or any particular time?

Pt: Throughout doctor.

Dr: Anything makes it worse or better? Pt: No

Dr: I see. Do you bring out any phlegm when you cough? Pt: No

Dr: Do you cough up any blood ?Pt : No

Dr: Do you have fever? Pt: No, but I feel a bit hot in the evening and I get sweating.

Dr: Do you have any chest pain? Pt: No ( if yes – explore chest pain – since where, when,
type)

Dr: Do you have shortness of breath ? Pt: Yes doctor

Dr: Since when? Pt: Since last few weeks?

Dr: When do you get breathlessness is it on exertion or even at rest do you feel short of
breath?

PT: When I exert my shortness of breath gets worse doctor.

Dr: Do you have any pain or swelling in your calf (PE) ? Pt : No

Dr: Dr: Have you noticed any change in your weight recently ( Lung cancer,
Mesothelioma)? Pt: No

Dr: Are you allergic to anything you know of ( Asthma)? Pt: No

Dr: Have you ever came in contact with anyone who has similar symptoms ( TB,
Pneumonia)? Pt: No

Dr: Have you ever been contact with anyone who has TB do you know? Pt: No

Dr: Have you travelled outside UK recently ( TB) ? PT: No

Dr: Do you smoke? Pt: No

Dr: Do you drink alcohol ?Pt: No/Yes

Dr: Do you do recreational drugs? Pt: Yes.

Dr: What drug do you use ?Pt: I inject heroin.

Dr: Do you share needles with others? Pt: Yes.

 63

Dr: Are you sexually active ?Pt: Yes

Dr: Do you have a regular partner? Pt: No regular partner.

Dr: Whom do you have sex with - males or females or both? Pt: I have male and female
partners. I am a bisexual doctor.

Dr: Do you practice safe sex? Pt: No

Dr: Do you have any other medical conditions ?Pt: No

Dr: Do you have diabetes or high blood pressure? Pt: No

Dr: Have been tested for HIV or Hepatitis infections anytime ? Pt : No

Dr: Are you on any medications? Pt: No

Dr: Are you allergic to any medications ? Pt : No

Dr: Any of your family members has any medical conditions ?Pt: No

Dr: What job do you do? Pt: I am jobless doctor.

Dr: Where do you live ?Pt: I do not have a home doctor.

Dr: Sorry to hear that. We will try to help.

Dr : Is there anything else you think is important that we need to know?

Pt: I do not know doctor.

Dr: Mr .. I need to examine your chest and also check your pulse, Blood pressure and your
temperature. ( examiner may or may not give any findings)

Dr: Mr… with what you told me I think you have a condition what we call as
Pneumocystis Pneumonia. This is infection of the lungs by some kind of fungus type of
bugs. Do you follow me?

Pt: OK. But why did I get this doctor?

Dr: This type of infection happens in those kind of people whose body resistance is low for
example people who have HIV infection. There could be chance of you having this
infection because this type of infection common in those people who do not practise safe
sex or shares needles with others when they use drugs. This infection can spread easily this
 64

way. This is quite a serious condition if you have HIV infection also.

Are you following me Mr…

Pt: Yes. So what will happen now?

Dr: We need to do some investigations to confirm whether you have this condition. We
need to do some blood test to check for infection markers and also do chest X Ray.

[ Examiner says – chest X Ray shows bilateral basal consolidation or fluffy shadows].
Thank you to the examiner.

Dr: Mr… Your chest X Ray shows that you do have chest infection. We need to do some
more tests to check what kind of bugs may be causing this this. For this we need to test
your sputum( silver staining) if you can get some sputum – if not we do a procedure called
bronchoscopy where we put some fluid into the wind pipe and take it out with some
instruemnts and then we test that for the presence of the bugs. We may also take some
tissue sample from the lungs. We may do a test called PCR ( polymerase chain reaction) to
check for these bugs. Also we may do CT scan of the chest.

Are you following me? Pt: Yes doctor.

Dr: It is better to check whether you have HIV infection also. We can treat the HIV
infection if you have it? Is that OK / Pt : Ok doctor.

Dr: Any questions? Pt: How will you treat me doctor?

Dr: To treat we will admit you in the hospital. We will give medications called Co-
trimoxazole through your vein and another medication called Dapsone as a nebuliser -
something like steam inhalation. We may also give steroid medication to treat this bugs.

We may also need to treat the HIV infection if you have.

I sincerely advise you to practice safe sex in the future and also stop using recreational
drugs. If not at least do not share needles with others. We have something called needle
exchange programme. You can get new needles for free.
 65

Are you following me? Pt: Yes. Dr: Is that OK? Pt : Ok doctor.

Dr Any other questions ?Pt : No.

Dr: We will talk to the social services and see if they can help you with shelter when we
discharge you. Thank you very much. Hope you recover soon.

Dry cough ? TB
Young man dry cough. History and management

Dry cough since 3 months, has night sweats, has blood in sputum, has weight loss, Has been to
south Africa 3 months ago. No known contact with any one with TB or similar symptoms. Chronic
smoker. Had SOB, able to talk.

Take Hx for other differentials like other dry cough stations.

Risk factor of immunosuppression HIV ( rec drugs and sexual Hx)

Works in community group with many people.

Examine the chest and hands, examiner may not give any findings. I need to check your pulse, BP
and temperature. Check for NEWS chart.

Investigations

Blood tests for infection markers, Sputum test for bugs and chest X Ray – there was chest X Ray.
May be normal or may show white shadows

Diagnosis: You may be having a condition called Tuberculosis. Do you know anything about it.

I do not know

This is an infection of your lungs by bacterial kind of bugs called Mycobacterium Tuberculosis.

This condition is very common in Asian and African countries. This infection can spread from
person to person by droplets while coughing or sneezing. So since you went to Arica - may be you
came into contact with someone with TB and you would have got this from that person.

This condition can cause infection in the lung for long time including months and can damage the
lungs. Sometimes it can spread to other areas of body like brain and kidneys and cause serious
dame to those organs. Do you follow me?

We will admit you now and treat you, We will give medication like rifampicin, ethambutol,
Isoniazid, and pyrazinamide. These are like tablets which you need to take daily. Usually you need
to take all these 4 medications for first 2 months and then take only isoniazid and rifampicin for
 66

further 4 months. My Consultant will decide how long you may need to take this medicine.

We will discharge once you feel better. We may need to keep you in a separate room while we
treat you because this infection can spread to others if you are very close to others.

It may be better to check whether you have any other medical conditions like HIV because if
someone has HIV then they can easily get TB also. We can treat HIV also if you have it. Is that OK.

Centor criteria to aid diagnosis of Group A beta-haemolytic streptococcus

(GABHS)as a cause of presentation with a sore throat:

o tonsillar exudate
o tender anterior cervical lymph nodes
o absence of cough
o history of fever
 presence of three or four of these clinical signs suggests that the
chance of the patient having GABHS is between 40% and 60%, so
the patient may benefit from antibiotic treatment
 absence of three or four of the signs suggests that there is an 80%
chance that the patient doesn't have the infection, and antibiotics
are unlikely to be necessary
 in patients with tonsillitis who are unwell, and have three out of four
of these criteria, the risk of quinsy is 1:60 compared with 1:400 in
those who are not unwell
 centor criteria is not ideal, and will lead to some patients with
bacterial pharyngitis not being treated and result in unnecessary
antibiotic treatment for others