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PSYCHIATRY HISTORY AND COUNSELLING STATIONSNo Topics Page noMental State Examination (MSE )1. Psychosis (Schizophrenia) (Mania ) (MSE) - Only history takingMental State Examination (MSE ) and Suicide Risk Assessment ( SRA) Depression - Suicide Attempt/Self Harm Risk Assessment2PCM overdose – Do MSE and Suicidal risk and give inference to examiner) 3Cut wrist – Hx and Mx to the examiner.4Cut wrist + OCP overdose – Only history5Pt had neck injury 5 days ago. Now has low mood. Take Hx and discuss Mx with the examiner.6MMSE –only historyAlcohol 7Gastroscopy shows gastric erosion – Hx only or Hx and Cx to pt8Nail infection – Hx only or Hx and Cx with pt.9Drug Dependence ( Heroin –assess drug dependency ) only history 10Weight loss ( Anorexia Nervosa) – Only history11Insomnia – History and Cx to pt.12Panic attack – only history13SSRI – ( Paroxetine – Hx and Cx pt)14Bipolar 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”.THE MENTAL STATUS EXAMINATIONIt 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. HallucinationVIII. Insight and Judgment (observed/inquired)IX. Thought Process/Form (observed/inquired), Thought Content (observed/inquired)Components of the Mental Status ExaminationI. Appearance (Observed) - Possible descriptors:? Gait, posture, clothes, grooming.Apparent age EthnicityCleanliness & 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 etcII. Behaviour (Observed) - Appropriateness of behaviourLevel of eye contactRapportIs patient easily distracted? (distractibility)Restlessness, anxietySocially 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 subjectsNew or made up words (neologisms) or any other abnormal use of language?LogicalityIs 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 relationshipsAsk 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 HomicidalityA. 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 AssessmentIf 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? 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?”? “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?”( Psychosis) (Schizophrenia) ( Mania) MSE ( Mental state examination or Psychiatric assessment)Causes of PsychosisDepression,Bipolar disorder (manic-depressive illness), Puerperal psychosis Drug abuse Alcohol abuse.Neurological conditions 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: NoDr: Since when are you feeling this way?Mr smith: Since last few weeksDr: were you alright before?Mr smith: yesDr: 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?Mr smith:4-5Dr: Are you able to eat/sleep well?carry out daily activities normally?Mr smith:No/YesDr : Do you ever see or hear things that are not really there, such as voices or visions?( hallucination/perception) Mr Smith : NoDr : 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:NODr : 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 : NoDr : 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 : sometimesDr: do you smoke? Mr smith:yes/noDr:Do you use recreational drugs ?Mr smith:NoDr : Do you think you have any problem, do you think you need any help? ( Insight) Mr Smith : NoDr:do you feel that this has affected your work/family life/social life?(Impact)Mr smith:No/YesDr : Do you have any medical conditions? Mr Smith : NoDr : Did you have any mental health conditions before? Mr Smith : NoDr : Any of your family members have any mental health conditions? Mr Smith : NoDr : Do you take any medications? Mr Smith : NoDr: are you allergic to any medications? Mr smith:No Dr : Do you have any medical problems at all? Mr Smith : NoDr : 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). We will provide all kinds of Psychological help and Social support.[ The treatment could be Bio-psycho-social model]Investigations for PsychosisAbnormal 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 ASSESSMENTBackgroundDeliberate 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.AssessmentStep 1: History of Presenting Complaint- Elaborate the EventBefore: Prior events/Plan/Escape/Prep/Tell AnyoneDuring: Sequence/Expectations/Alcohol-DrugsAfter: Discovery/Anger-Regret/Lingering Thoughts/Insight/MoodExample of questions that may be askedElaborate 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?PastHave you tried this before?Do you keep having thoughts or keep making plans?Did you make arrangements and take care of your affairs?FutureHow does it feel to be alive?Do you regret for what you did?Would you try it again?How do you see the future?ManagementIf 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 PointsTake time to build a rapport with the patient.Explore triggers by asking about the 4FsWhen 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-Speech2. 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 tabletsDr - 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 wifeDr: Have you done anything like this before? ( Past) Mr Hick: Yes / NoDr: Did you plan it? Mr Hick: YesDr: Did you write suicide note? Mr Hick: YesDr: Did you inform anyone before doing it? Mr Hick: NoDr: 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: NoDr: “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: NoDr: 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 - 328 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 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, OccasionallyDr: 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: NoDr: Did you inform anyone about this? Isabella: NoDr: Did you write any suicide note? Isabella: NoDr: 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:NODr:Do you feel that somebody is trying to tell you to do things/or Is reading your mind?Isabella:NODr:do you smoke/do you use recreational drugs?Isabella:NODr:do you think that this will affect ur family life/work/social life?Isabella:NODr: 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.Dr: Do you have any medical condition? / are you taking any medication?/Allergic to any medications Isabella: NoDr:did you have any mental conditions in the past?Isabella:NODr:do you have any Family history of any mental conditions?Isabella:NODr: 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 examinerFrom 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 - 416 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,AFTERDr: 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 – NoDr: 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 wristDr: Who brought you to the hospital?Jessica: I came to the hospital myselfDr: Were you under the influence of alcohol when this happened? Jessica: NoDr: Did you plan to harm yourself ? Jessica: NoDr: Did you inform anyone about this? Jessica: NoDr: 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: NoDr: Do you have any medical condition?Jessica : NoDr: Are you taking any medication?Allergic to any medications? Jessica: NoDR:how do you feel in ur Mood?on scale of 1-10,1 being sad,gloomy and 10 being normal,happy?Jessica:7-8Dr:do you see/hear noises when nobody is around?Jessica:NoDr:do you feel that someone is telling you to do things?/or reading ur mind?/making you do things?Jessica:NoDr:do you smoke?/DRINK Alcohol?/use recreational Drugs?Jessica:NODr:do you feel that this has affected your family life/social life/work?(ASK INDIVIDUAL QUESTIONS)Jessica:YES/NODr:Do you think you need any help from us for your stress or if you are feeling low?Jessica:I am OK NowDr: Do you have any mental health conditions? Jessica: NoDr: Any of your family members have any mental health conditions?Jessica: NoDr: were you ever in trouble with Law before?Jessica:NODr: 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 : NoDr: Do you have any financial problem? Jessica : NoDr: Do you have friends? Jessica : YesDr: 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 accordinglyScenario - 550 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: NoDr: 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 feelvery 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: NoDr: Have you ever had such low feeling before this 6 months ?Adam: NoDr: 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 : NoDr: Whom do you live with ?Adam: I live with my wife and children.Dr: Are they supportive Adam: YesDr; Do you have many good friendsAdam ; Not many.Dr: Have you have any trouble with the law ?Adam: NoDr: I would like to ask you a couple of questions about sometimes people have but mayfind difficult to talk about. I ask everyone these questions Have you ever heard voices speaking when there seems to be no-one around ? Adam: NoDr: Do you have personal beliefs that are not shared by others ? Aam : NoDr: Do you get any feelings to harm others? Adam: NoDr: Do you know where you are now. Adam : Yes doctor, I am in the hospital.Dr: Do you drink alcohol? Adam : NoDr: 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)BackgroundThe 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 PointsPerform your assessment for the entire 5 minutes. Offer sympathy and empathy. ( this is very important in this station)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 ASSESMENTCommon 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 abuseHypothyroidismSpace-occupying intracranial lesionsNormal pressure hydrocephalusSyphilisVitamin B12 deficiencyFolate deficiencyPellagraScenario - 6A 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. Dr. Hello Mr Adam Williams,Mynameis........ I am one ofthedoctorsinthe Psychiatrydepartment.Dr - Can you confirm your name for me Pt:- Mr Adam WilliamsDr - 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 youOrientationTimeYear/Season/ Month/ Day /Date---/ 5(one score for each right answer)PlaceCountry/ County City/town Street Building/ floor---/ 5(one score for each right answer)1. What country are we in now? 2. What county 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)Registration3 objectsAsk to repeat 3 words [allow one second between each word, repeat them up to 5 times]---/3(one score for each right answer)“ I am going to name 3 objects, I want you to repeat them. Please remember these words, I am going to ask you to name then again in a few minutes. These three 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).Attention and CalculationWORLDAsk to spell the word “world” and correct if wrong and ask to spell it back ward which gives score. Give one score for each correct answer until the order of the spelling is correct. Eg : D,L,R,W,O (score is 3 here)---/5Could you spell the word “world”? Now could you please spell backward?( you should not spell backwards to help him)Recall3 recallAsk to recall those 3 words--/3One score for each correct answer.Could you please repeat those 3 words I asked you to remember?( do not remind him the words)LanguageName 2 objectsAsk to name 2 objects--/2One score for each correct answer.Show 2 objects one by one, Could you please name this object?( eg – pen, paper)Repeat sentenceAsk to repeat NO IFS, ANDS, or BUTS--/1Give one score if the whole sentence is correct otherwise zero.I want you to repeat exactly what I sayNO IFS, ANDS, OR BUTS3 step commandAsk to perform a 3 steps act--/3One score for each right step.Ask pt which is his dominant hand. Ask him to do the 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)ReadRead and carry out the commandWrite a command on the paper and ask him to do that--/1Give one score if he closes his eyes not for reading.Please read this and do what it says.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.WriteWrite a sentence pleaseAsk to write a sentence,look for meaningful sentence--/1 One score for a meaningful sentence (ignore spelling errors).Could you please write a sentence in this paper?CopyCopythisdiagramAsktocopy2intersectingpentagonswhereintersectionboxhas4sidesonly.--/1 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.Can you pleasecopythisdesign.Total Score : 24-30 : Normal cognition20-23 : Mild cognitive impairment10-19 : Moderate cognitive impairment0 -9 : Severe cognitive impairmentAt 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 TeamALCOHOL ASSESSMENTYou must assess the following 6 steps and if required discuss your findings with the patient or the examiner.Step 1: Presenting ComplaintStep 2: History of Present ComplaintDaily Drinking Pattern: What/How Much/When/Where/Alone/ProgressionCAGE 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 OpenerStep 3: Features of Dependence TDW - Tolerance/Dependence/Withdrawal/Previous TreatmentStep 4: ConsequencesFriends/Family/Finances/ForensicStep 5: ComplicationsPhysical/Depression(Mood)/Psychosis/Self HarmStep 6: InsightManagementIf station/task states present findings/management/counsel, then as a rule, you should discuss:Referral to Alcohol Support WorkerLifestyle changesOutpatient Counselling Groups such as Alcoholics AnonymousOutpatient medication managementInpatient DetoxificationChange of occupation if requiredKey PointsBe 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 ernment Recommended AllowancesMale and Female:14 UNITS PER WEEK AlcoholExam 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 thatMrs 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 doctorDr: 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 itDr: Have you ever felt bad or guilty about your drinking?Mrs Parker: Yes, Doctor, SometimesDr: 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 : YesDr: 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 husbandDr : Do you have any financial problems?Mrs Parker : NoDr: 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 : NoDr:DO you feel that this has affected your work/family life/social life?(IMPACT)Mrs parker:NO/YESDr:DO you tend to drink alcohol to relieve ur stress?(STRESSOR)Mrs parker:NoDr: Do you have any health problem at all apart from the problem for which you had the procedure now? Mrs Parker : NoDr:did you have any mental health problems in ur past?Mrs parker:NODr:are you taking any medications?/are you allergic to any medications?Mrs parker:NODr:do you have family history of any mental health conditions?Mrs parker:NODr:Do you have any legal problems?Mrs parker:NODr: 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 – 8A 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. 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 ASSESSMENTAssessmentYou must assess the following 6 steps and if required discuss your findings with the patient or the examiner.Step 1: Presenting ComplaintStep 2: History of Present ComplaintDaily Drug Pattern: What/How Much/When/Where/Alone/ProgressionCAGE Questions: Cut Down/Annoyed/Guilty/Eye OpenerStep 3: Features of Dependence Tolerance/Withdrawal/Previous Treatment (Hep B)Step 4: ConsequencesFriends/Family/Finances/ForensicStep 5: ComplicationsPhysical/Depression(Mood)/Psychosis/Self HarmStep 6: InsightManagementIf station/task states present findings/management/counsel, then as a rule, you should discuss:Referral to Narcotic Support Worker and Lifestyle changesOutpatient Counselling Groups such as Narcotics AnonymousOutpatient medication management (Methadone/needle sharing)Inpatient DetoxificationScenario - 9You 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 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 : YesDr: 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?Mr Williams: Yes girlfriend who also uses opioids.Dr : Do you smoke or consume alcohol?Mr Williams: NoDr: 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:NoDr: 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: NoDr:Is there any Stress which is making you take this drug?(STRESSOR)Mr Williams:NO/YesDr: 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 habitDr:did you suffer from any mental health conditions in the past?Mr Williams:NODr:do you have any other medical conditions? Mr Williams:NoDr:Are you allergic to any medications?are you taking any medicines?Mr Williams:NoDr:Do you have family history of any mental health conditions?Mr Williams:NoDr : Thank you Mr WilliamsManagement:? 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 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 NERVOSABackgroundPeople 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.AssessmentYou 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: SCOFFStep 3 : Mental state examination for depressionStep 4 : Interview parents and other informantsStep 5 : Assess family interaction in especially attitudes in relation to foodStep 6 : Physical examination ( Distribution for body hair, emaciation, vit. deficiency, Organic cause).History:OnsetTriggersDaily Diet Pattern: What/How Much/When/Where/Alone/ProgressionBinge eatingSelf Induced VomitingFeel fat/Fear of fatnessWeight lossFood dominationAmenorrhoeaMedical or psychiatric problemsPalpitations, faintingRole ModelsBaggy clothes4FsMoodRisk to themselves or othersStep 3: FAMISH History formatStep 4: Insight( Pneumonic – SCOFFS – 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 - 10Miss 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: YesDr: 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: YesDr: Could you please tell me, why are you losing weight?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 NoDr: Do you make yourself sick because you feel you are uncomfortably full ?Miss: Thompson: NoDr: 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 BeckhamDr: 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: NoDr: 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: NoDr 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 symptoms?Miss: Thompson NoDr: Thank you very much for all the information. Causes of insomnia?1Physical health?conditionslong-term painsleep disorders – such as snoring and sleep apnoea, restless legs syndrome, narcolepsy, night terrors and sleepwalkingproblems with the genital or urinary organs – such as urinary incontinence or an enlarged prostatejoint or muscle problems – such as arthritishormonal problems – such as an overactive thyroidneurological conditions – such as Alzheimer's disease or Parkinson's diseaserespiratory conditions – such as chronic obstructive pulmonary disease (COPD) or asthmaheart conditions – such as angina or heart failureIn women, childbirth can sometimes lead to insomnia.2Medicationas a side effect.certain?antidepressantsmedicines for?high blood pressure, such as?beta-blockersepilepsy?medicinessteroid medicationnon-steroidal anti-inflammatory drugs (NSAIDs)stimulant medicines used to treat?attention deficit hyperactivity disorder (ADHD)?or narcolepsysome medicines used to treat asthma, such as salbutamol, salmeterol and theophylline3Mental health conditionsmood disorders?– such as?depression?or?bipolar disorderanxiety disorders?– such as?generalised anxiety,?panic disorder?or?post-traumatic stress disorderpsychotic disorders?– such as?schizophrenia4Stress and anxietystressful event, such as a bereavement, problems at work, or financial difficulties.Having more general worries?–?for example, about work, family or health?–?are also likely to keep you awake at night.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.5Lifestyle factorsDrinking 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). These should be avoided in the evenings.Changes to your sleeping patterns can also contribute to insomnia?–?for example, because shift workchanging time zones after a long-haul flight?(jet lag).6Poor sleep routine and?sleeping environmentYou may struggle to get a good night's sleep if you go to bed at inconsistent times, nap during the dayA poor sleeping environment can also contribute to insomnia?–?for instance, an uncomfortable bed or a bedroom that's too bright, noisy, hot or cold.7Sometimes it's not possible to identify a clear cause.Exam Scenario for InsomniaYou are the FY2 doctor in the Rhuematology clinicMrs 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 concernsDr: Hello Mrs Johnson, I am Dr. … of the junior doctor in the medical department. How are you doing today ?Mrs Johnson: I am Ok doctorDr: 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 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 attackDr: 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: NoDr: Do you have any stress or worries ?Mrs Johnson: NoDr: Do you drink alcohol? / Do you smoke/Use recreational drugs?Mrs Johnson: I do not drink alcohol/NODr: 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: NoDr: 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 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 weeksHowever 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.PANIC ATTACKBackgroundAnxietyAnxiety 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 includingphobias?– an extreme or irrational fear of an object, place, situation, feeling or animalgeneralised anxiety disorder (GAD)?– a long-term condition that causes excessive anxiety and worry relating to a variety of situationspost-traumatic stress disorder?– a condition with psychological and physical symptoms caused by distressing or frightening eventsA 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.AssessmentYou must assess the following 4 steps as part of this station/task.Step 1: Presenting ComplaintStep 2: History of Present ComplaintOnsetSymptoms (explore above)DescriptionTriggersRecent change in circumstancesSeverityProgressionEffect on activities of daily living4FsMood (Score 1-10)RiskStep 3: FAMISH HistoryStep 4: InsightSuggested QuestionsHow 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 - 12Miss 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.[ 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: NoDr: Do u drink alcohol? Miss Jones: doctor, I am really worried about my heart.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 PointsIn this station, you must emphasise the importance of staying on the medications to achieve the best beneficial effect.Scenario - 13Mr 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.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 disorderBipolar 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 lethargicmania?–? 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.DepressionThe depression phase of bipolar disorder is often diagnosed first and manic episode later (sometimes years later).ManiaDuring 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.Dr: Hello Mrs Collins I am Dr… How can I help you ? Pt: I cut my wristsDr: 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: NoDr: 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: NoDr: 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 aroundPt: No doctorDr: Do you think you have any mental health problem?Pt: NoDr: Do you have any problems with the sexual life?Pt: NoD: Do you drink alcohol?Pt: NoDr: Do you use any recreation drugs?Pt: NoDr: Thank you very for all the information.Tell you diagnosis to the examiner: Bipolar disorder.GOOD LUCK History Taking, MSE and Management ProformaChief ComplaintHistory of present illness:1) Onset2) 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 Stressor10) Impact (On work, Family and Social life)11) Insight12) Past Psychiatry History: Similar or any other13) Past Medical History14) Family History15) Forensic HistoryMSE: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 AspectSociological Aspect: Lead by Consultant psychiatrist who gives medications.CPN/Care coordinator to monitor your mental health and medications in community.Social worker to look after your finances and accommodation.Occupational therapist to make the necessary changes in your house to maximise you potential in activities of daily living.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.Psychologist for the psychological input in the form of counselling.Risk: High - In patient admissionLow: GP, wellbeing services and Emergency numbers to contact.Heroine : Two type of management:Replacement (can be done in community or in ward)Methadone or Buprenorphine2. 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.IbuprofenBuscopanNalaxone=opioid antagonistMetaclopramide loperimideBZDMy 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.Alcohol:We can admit you for detoxification and it can be dine either in community by GP/ADS or as an in-patient. ChlordiazepoxideDisulfiramAcamprosatePabrinexRehabilitation: 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 wrist16 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, AFTERDr: 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 – NoDr: 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 wristDr: Who brought you to the hospital ? Jessica: I came to the hospital myselfDr: I see. Were you under the influence of alcohol when this happened Jessica ? Jessica: NoDr: 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 : NoDr: Okay Did you inform anyone about this? Jessica: NoDr: 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: NoDr: Do you have any medical condition? Jessica : NoDr: Are you taking any medication? Allergic to any medications? Jessica: NoDr: How do you feel in your Mood on scale of 1-10,1 being sad, gloomy and 10 being normal, happy? Jessica:7-8Dr: Do you see / hear noises when nobody is around ? Jessica: NoDr: Do you feel that someone is telling you to do things? or reading your mind? / making you do things? Jessica:NoDr: Do you smoke? / Drink Alcohol? / use recreational Drugs ? Jessica:NoDr: Do you feel that this has affected your family life/social life/work?(ASK INDIVIDUAL QUESTIONS)Jessica: YES/NODr: 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 NowDr: Do you have any mental health conditions? Jessica: NoDr: Any of your family members have any mental health conditions? Jessica: NoDr: were you ever in trouble with Law before? Jessica: NoDr: 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 : NoDr: Do you have any financial problem? Jessica : NoDr: Do you have friends? Jessica : YesDr: Has any one looked at your wound ? Jessica : Yes / NoDr: Did any specialist doctor talk to you about the chance of pregnancy to you ? Jessica: Yes/ NoDr: 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.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 ODYou are FY 2 doctor in Emergency department.18/20 years old Mr..... was brought to the hospital because he took over dose of Paracetamol tabletsTake 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, AFTERHe 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.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.VertigoYou 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. BPPVVestibular neuronitisMeniere’s diseaseMostly seen after the age of 50.Can be seen in young people.Precipitated by movementCan follow after injury to head or earLast only for few seconds or minutes. Episodic – happens on movement of head.Associated with nausea, usually no vomiting.No other symptoms like pain tinnitus or fullness in earIf Dix Halpike test is negative – then it is unlikely to be BPPV.Sudden oncet, lasts for hours. Not triggered by movement but movement can exacerbate symptom.Can happen after viral infections like flu.Can have nausea and also vomiting.There may be hearing lossNo other symptoms like pain, tinnitus,fullness in ear,.Hearing loss and tinnitus and fullness in ear present. Causes ofPeripheral vertigo Central vertigobenign paroxysmal positional vertigo (BPPV)head injurylabyrinthitisvestibular neuronitisMénière's diseasetaking?certain types of medicationmigraines?–?multiple sclerosis??acoustic neuroma?a?brain tumour?a?transient ischaemic attack (TIA)?or a?stroke?taking certain types of medicationDr: 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 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: NoDr: Are you taking any medications now? Pt: (No/Yes?)Examination: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:Warn the patient that transient vertigo may occur in any position.Ask the patient to keep their eyes open and stare at your nose.Prepare the couch so the headrest is down and the patient's head will overhang the end.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.Observe for nystagmus in each position (30 seconds) and then return the patient to the upright position.Repeat with the head turned to the right to test the right posterior canal.If positive:The patient experiences vertigo and rotary nystagmus in posterior canal BPPV. Purely horizontal nystagmus suggests horizontal canal BPPV.Nystagmus (fast component) will be upbeat and in the direction of the most affected ear. This has a limited duration, lasting <30 seconds (adaption).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: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.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).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.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 neuronitisDiagnosis: 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 neuronitisIf 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 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 lightstry to cut out noise and anything that causes stress from your surroundingsYou 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:supermarketsshopping centresbusy roadsPt: 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.Are you following me ? Pt Yes. Any other questions – NoWarning 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 HemoptysisDifferentials for cough for > 3 weeks :Bronchial carcinomaSmoking, weight loss. Haemoptysis.Mesothelioma – exposure to asbestosis, building worker ( roofer, plumber, carpenter) wt loss.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 blockers10. Psychogenic11. GORD – heart burn, regurgitation.Acute < 3 weeksForeign body – sudden onset.Infection. URTF/ Pneumonia/ Infective COPDExam questionYou are F2 in medicine60 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 patientDr: 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 wellDr: 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 coughDr: Have you had any shortness of breath? P: Yes.Dr: could you please tell me when that started? P: Around the same timeDr: Has it worsened since then? P: Yes/NoDr: 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)Dr: Fever? P: Yes/NoDr: Have you noticed any swellings in your neck or your armpits? P: NoDr: Do you have any trouble swallowing? P: NoDr: Do you have any pain in your calves? P: NoDr: 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 doctorDr: Do you have high BP? P: NoDr: Diabetes? P: NoDr: Thyroid related illnesses? P: NoDr: Are you on any medications? P: NoDr: What is your diet generally like? P: Balanced doctorDr: Do you smoke Mr...? P: Yes doctor.. I have been smoking for >20 yearsDr: Could you tell me what you smoke in a day? P: 1 pack of cigarettes/dayDr: Do you consume alcohol? P: Yes/NoDr: Do you have any allergies? P: NoDr: Do you have any family history of medical problems? P: NoDr: F/H of cancers? P: NoDr: 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.) 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 rayScenario 1 – Lung cancerScenario 2 – MesotheliomaSHOW XRAY TO THE PATIENTScenario 1Lung CancerDr: Mr... I have your Chest Xray with me. Would you like to take a look at it?P: Ok doctorDr: 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: YesI 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 doctorDr: 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 2MesotheliomaDr: Mr... I have your Chest Xray with me. Would you like to take a look at it?P: Ok doctorDr: These are your lungs Mr.... and this is your heart. Can you see this white opacity over this lung? P: YesI 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 doctorDr: 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.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 Mesothelioma – Investigations – Chest X Ray, CY scan , Bronchosopy and biopsyLung Cancer Investigations – Chest X Ray, CY scan , Bronchosopy and biopsyTB – Chest X Ray, Sputum - AFB test, Gold quantiferon test, Mantoux test.Dry Cough - PCPExam questionYou 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?Dr: Do you get it throughout the day or any particular time?Pt: Throughout doctor.Dr: Anything makes it worse or better? Pt: NoDr: I see. Do you bring out any phlegm when you cough? Pt: NoDr: Do you cough up any blood ?Pt : NoDr: 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 doctorDr: 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 : NoDr: Dr: Have you noticed any change in your weight recently ( Lung cancer, Mesothelioma)? Pt: NoDr: Are you allergic to anything you know of ( Asthma)? Pt: NoDr: Have you ever came in contact with anyone who has similar symptoms ( TB, Pneumonia)? Pt: NoDr: Have you ever been contact with anyone who has TB do you know? Pt: NoDr: Have you travelled outside UK recently ( TB) ? PT: NoDr: Do you smoke? Pt: NoDr: Do you drink alcohol ?Pt: No/YesDr: 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.Dr: Are you sexually active ?Pt: YesDr: 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: NoDr: Do you have any other medical conditions ?Pt: NoDr: Do you have diabetes or high blood pressure? Pt: NoDr: Have been tested for HIV or Hepatitis infections anytime ? Pt : NoDr: Are you on any medications? Pt: NoDr: Are you allergic to any medications ? Pt : NoDr: Any of your family members has any medical conditions ?Pt: NoDr: 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 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.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 ? TBYoung man dry cough. History and managementDry 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.InvestigationsBlood tests for infection markers, Sputum test for bugs and chest X Ray – there was chest X Ray. May be normal or may show white shadowsDiagnosis: You may be having a condition called Tuberculosis. Do you know anything about it.I do not knowThis 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 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:tonsillar exudatetender anterior cervical lymph nodesabsence of coughhistory of feverpresence 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 treatmentabsence 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 necessaryin 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 unwellcentor criteria is not ideal, and will lead to some patients with bacterial pharyngitis not being treated and result in unnecessary antibiotic treatment for othersTiredness - Hypothyroidism Differentials Chronic heart disease – SOB, Ankle swellingLiver disease – bloated tummy, ankle swellingRenal disease – Facial puffiness, Problem passing urine, Less urine or more urine.Psychiatric illnesses – Mood, Any worries ?Thyroid disease ( hypothyroidism) – Weight gain, Constipation, Cold intolerance.Connective tissue diseases – Muscle pain, Rashes,Chronic anemia – SOB, tiredness, Neoplastic disease – weight loss, Lumps and bumps, cough, smoking, any cancers in family members.Chronic infections (eg, AIDS) – Have you tested for HIVDiabetes : increased thirst and hunger, Increased urination, family Hx of DMEndocrine diseases (eg, Addison disease) - Inflammatory bowel disease – tiredness, darkened skinDrug abuse – recreational drug use.Exam question : - 60 year old presents with tiredness. History and management with the patient.[Positive symptoms- Tiredness, weight gain, constipation, prefers hot weather]Dr: Hello Mrs. .. I am Dr…. one of the junior doctor in the medical department. How can I help you?Pt: I am feeling very tired for about 2 years.Dr: I am very sorry to hear that. Is there anything else you can tell me ? Pt: Like what ?Dr: Do you have any other symptoms like high temperature ( fever) ( TB) ? Pt : NoDr: Any headache ? Pt: NoDr: Body pain ( Fibromyalgia, CFS) ? Pt: NoDr: Any changes in the bowel habit ( Hypothyroidism, cancer) ? Pt: I am constipatedDr: Since when ?Pt: Since many months now.Dr: Have you noticed any bleeding from the back passage ( Bowel cancer) ? Pt: NoDr: What is the colour of the stool ( black colour – upper GI bleed – anaemia)? Pt: NoDr: Have you noticed bleeding from anywhere like nose, gums ( Anaemia) ? Pt: NoDr: Do you have SOB ( Anaemia, heart failure) ?Pt: NoDr: Palpitation ( anaemia) ? Pt: NoDr: Do you have any preference to any particular weather ?Pt: Yes I prefer warm weather.Dr: How about cold weather ( hypothyroidism) ? Pt: I don’t like it – I feel too cold can’t tolerate it.Dr: Have you noticed any swelling in the front of your neck? Pt: NoDr: Have you noticed any changes I your weight ( hypothyroidism, cancer) ?Pt: Yes I have gained weightDr: Can you please tell me how much weight did you gain in how much time? Pt :---Dr: Have you noticed any changes in your voice (hoarseness in Hypothryroidism) ?Pt: NoDr: Have you had any surgeries in the neck ( thyroidectomy can cause hypothyroidism) Dr: How is your mood ( hypothyroidism, depression) can you please rate in the scale of 1 to 10 one being very low and 10 being very happy ?Pt: It is low about 6 to 7.Dr: Any worries and stress making you feel low ?Pt: I lost my husband about 2 years ago. Dr: I am sorry to hear that. Do you think the tiredness started after that ? Pt : Yes / NoDr: How is your sleep ? Pt: Sleep is fine but I don’t get refreshed properly I the morning.Dr: Any lumps and bumps in the body? Pt: NoDo you feel your tummy distended ( heart, liver kidney failure) ? Pt: NoDr: Any swelling of feet ( heart failure)?Pt: NoDr: Did you have this type of problems before? Pt: NoPt: Do you have any medical conditions ?Pt: NoDr: Any heart kidney or liver problems? Pt: NoDr: Diabetes or High blood pressure? Pt: NoDr : Have you checked you cholesterol ( fat content in the blood) before ? Pt: NoDr: Are you taking any medications ( excessive thyroxin can cause hypothyroidism)Dr: Do you smoke? Pt: No Dr: Do you drink Alcohol? Pt: NoDr: Any medical conditions or any cancers in the family members ?Pt: NoDr: Any of your family members has any thyroid related conditions ?No/yes Dr: How much does this affects your life?Pt: It affects a lot doctor. I can’t work properlyDr: Is there anything else you think is important that we need to know? Pt: NoExamination :Dr: Mrs. I need to examine now and check your neck for any swelling and also examine your chest and tummy. (Examiner may not give any findings)Investigations:Dr: Mrs.. We need to do some tests to find out what exactly is causing these symptoms in you. There are lot of conditions which can cause tiredness like anaemia, diabetes, heart and liver failure, Vit D deficiency. We will do blood investigations to check whether you have any of these problems. Sometimes it could be due to underactive thyroid. So we need to do blood tests to check some hormones in called thyroid hormones. Do you follow me ?Pt: Yes. Dr: Is that OK. Pt: Ok[ Examiner may not give TFT result – In hypothyroidism TSH will be high and T4 will be low]What is a normal TSH level in a woman?Normal TSH levels for the average adult range from 0.4 4.0 mIU/L (milli-international units per liter). However, many organisations agree that a reading of 2.5 or less is truly ideal, with anything 2.5 – 4.0 mIU/L considered “at risk”. For those on thyroxine, goal TSH level is?between 0.5 to 2.5?mU/L.What is the normal range for T3?Typically,?normal?results range from 100 to 200 nanograms per deciliter (ng/dL). What is a normal t4 level?Normal results?are generally from 4.5 to 11.2 micrograms per deciliter. Diagnosis: Mrs... with the information you have given me, I think you have condition what we call as Hypothroidism otherwise called underactive thyroid. Do you know anything about it? Pt: NoDr: We have a butter fly shaped gland in front of the neck called thyroid gland which normally produces some hormones called thyroid hormones.These hormonesregulate the body's metabolism - the process that turns food into energy.?An underactive thyroid gland (hypothyroidism) is where your thyroid gland doesn't produce enough hormones. Many of the body's functions slow down when the thyroid doesn't produce enough of these hormones. Are you following me ?Pt : Yes. Why am I having this problem?Dr: Most cases of an underactive thyroid are caused by the immune( body’s defence) system attacking the thyroid gland and damaging it. Sometimes it can be due to deficiency of Iodine in the diet or previous treatment for overactive thyroid or sometimes it can be due to tumour ( growth) of the thyroid gland.Do you follow me ? Pt: YesIf we do not treat this condition then it can lead to other complications – it can increase cholesterol( bad fat) levels in the blood leading to heart problems. Sometimes it causes swelling in the front of the neck. So it is very important to treat the condition. Pt: How will you treat me doctor? Dr: We will treat you with a medication called Levothyroxine. This replaces the thyroid hormones in the body. Initially we need to keep checking your blood levels of thyroid hormone regularly to find out the proper dose of the medicine you require. We will start with the low dose and increase it gradually until the proper required dose is reached. Usually you will have to take one tablet per day either morning or night. Some people start to feel better?soon after the treatment,?while in others?it may take months to see the improvement.Are you following me? Pt: Yes, how long should I take this medicine?Dr: An underactive thyroid is a lifelong condition, so you will usually need to take this medicine for the rest of your life.The effectiveness of the?tablets can be changed by other medications, supplements or foods, so you should swallow the tablet with water on an empty stomach, and you should avoid eating for 30 minutes afterwards.[ mention only if asked - If you're prescribed levothyroxine because you have an underactive thyroid, you're entitled to a medical exemption certificate. This means you don't have to pay for your prescriptions].?Pt:Are there any side effects doctor ?Dr: It doesn't usually cause any side effects.Side effects usually only occur if you're taking too much of this medicine. This can cause problems including?sweating,?chest pain,?headaches,?diarrhoea?and vomiting.Are you following me ?Pt: Yes Dr: Any other concerns ? Pt: No Dr:Thank you very much. Drug Addict wants a Self-DischargeYou are FY2 Doctor in acute medical care unit. A 27 year old lady, Miss.… has been admitted to the acute medical care unit. Patient is a known drug addict and a diagnosed case of Infective Endocarditis. Patient has been started on intravenous antibiotics. To complete treatment, patient needs IV antibiotics for several weeks as an inpatient. Nurse has come to you and informed you that patient wants self-discharge.Talk to the patient, inquire why does she want self-discharge and address her concerns. Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you Miss…? Patient: Yes doctor. Dr: How are you doing Miss…?Patient: I do not like this hospital doctor. I want to go home. Dr: Miss… could you please tell me why you do not want to stay in the hospital?Patient: The nurses are very rude to me. Dr: I am really sorry if someone misbehaved with you. I will look into this matter. Please do not be upset. Could you please tell me what really happened?Patient: No doctor, I do not want to stay in this hospital any more. I want to get discharged. Please discharge me.Dr: Well, Miss… could you please explain to me why you do not want to stay in the hospital. If you tell me what is bothering you, I will be able to help you.Patient: No doctor, nurses have been very impolite with me. They are calling me drug abuser. I want to go home.Dr: Well, Miss… I can clearly understand that you are very much offended by what happened and I apologize to you for such behavior but it is very important for you to stay admitted in the hospital as we need to give you medicines through your veins. However, I want to reassure you that if you can tell me what happened, all the information you give me will be kept confidential within our team. Could you please open up to me about the matter? Patient: Doctor, you see, it is also because nurses object that I cannot smoke cigarettes in the hospital. Dr: I see. I can understand that you must be very troubled by all this. I apologize to you again. However, I would like to tell you that it is important for you to stay admitted. Could you please tell me how much do you know about your condition?Patient: I have been told that I have infection in heart. Dr: Yes, you have been told right Miss… You have a condition called Infective Endocarditis. This is an infection that affects the tissue that lines the inside of the heart chambers. This results in significant damage to heart valves. Also, it can cause other serious complications if it is not treated quickly with antibiotics. Are you following me?Patient: Yes, doctor. But I do not want to stay in the hospital. Why should I stay in the hospital?Dr: You see, Miss… it is a very serious infection and can be even life-threatening if not treated in time. The earlier the condition is treated, the better the likely outcome. Patient: But you can give me antibiotic tablets doctor I can take them at home. Dr: Miss…Unfortunately this condition cannot be treated with just antibiotic tablets. Tablets are not as effective as injections into veins. That is why we want you to stay in the hospital so that we can give this antibiotics through your veins.Pt: I can’t stay here. Nurses don’t let me smoke and it is not bearable for me to continue without it. Can’t I just pop out and smoke ?Dr: I can understand why you are so upset. It must really be very distressing for you. Well you can pop out and smoke but it is not advisable at all. If you do not mind, I will be asking you some questions about your general health, if that alright with you. Patient: Okay. Dr: Could you please tell me how much do you smoke? Patient: 20 cigarettes per day. Dr: I see, and for how many years? Patient: ?Dr: Do you take any recreational drugs? Patient: I take heroin. Dr: How much? Patient: Dr: For how long have you been taking it? Patient: Years/monthsDr: How do you take it? Patient: I inject it through my veins. Dr: And do you exchange needles? Patient: No doctor. Dr: That’s good. And have you ever tried to cut it down or stop it altogether?Patient: No doctor, I cannot.Dr: I see. Could you please tell me how has been your mood lately?Patient: I feel very alone doctor/feel very lowDr: And why is that? Patient: I do not have any friends. Dr: I am really sorry about that. Could you please tell me what work do you do?Patient: I am jobless. Dr: And where do you live? Do you live with your family?Patient: I am homeless doctor. I have no family. Dr: It must be really upsetting for you Miss… I can recognize that you have a very stressful life. However, I’d like to tell you that a lot of help is available for you to cope with this state of affairs. Do you know why this condition would have happened to you ? Patient: Why doctor?Dr: Miss…. unfortunately, people who inject street drugs may also inject bugs/germs into their bloodstream if they use dirty or contaminated needles. These bugs may then settle on a heart tissue. The infection can damage heart valves and may spread to other areas of heart tissue. Unfortunately, this might have happened and lead you to develop this infection in the heart. Pt: But doctor I just want to go home. Dr: Miss … If you do not get treated now serious complications usually develop -for example, it can lead to problems such as heart failure. Sometimes the infection can spread to other organs and can cause damage to the other organs too. It can life threatening too if you do not stay in the hospital and get treated. That is why it is very important that you stay in the hospital and get treated. Patient: But I can’t smoke can’t do anything here.Dr: I would sincerely advice you to consider quitting smoking. Smoking is not only hazardous to your lungs but to your heart also. It can worsen your condition in the heart. I know that it must be really unbearable for you to not smoke. We can give you help to cut it down and quit it. However, for now if you really want it we can give nicotine patches. Is that Ok? Pt: May be yes.Dr: Also, I would like to tell you that we can provide you help to cut down on drugs. We have a lot of medicines available to help you cope this. Pt: You will only give Methadone!Dr: Miss… We have many different options to help you cut down on using drugs. I will tell you what your options are. In order to reduce the craving of the drug, we can give you medicines. Also, in order to decrease withdrawal symptoms we can give you another medicine called Lofexidine. Also, we might later on refer you to some support groups to help you quit drugs. Would you consider it? What do you think about it?Patient: Well I will think about it.Dr: So would you consider staying in the hospital for getting this infection cleared off from you?Patient: Yes, doctor I would.Dr: Is there anything else you want to know?Patient: No doctor, you are very kind. Dr: Thank you very much Miss… If the patient still not convinced. Dr: I am sorry that I wasn’t able to convince you about the importance of you staying in the hospital for the treatment. You do have the right to refuse any treatment what we advise. However, I will talk to my seniors and may be they will be able to convince you about it. If you still do not want to stay in the hospital you can sign a “self - discharge form” and then you can go home. Thank you very much for talking to me. I really wish all the good health for you Miss.. Anorexia NervosaYou are the F2 in the psychiatric dept. 16/25yr old female referred by her GP on account of weight loss. BMI of 17. Has no symptoms of depression. Take history and discuss further management with her.patient doesn't believe she has problems, losing weight intentionally and still believes she is overweight.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.??AssessmentYou 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:? SCOFFStep 3 : Mental state examination for depressionStep 4 : Interview parents and other informantsStep 5 : Assess family interaction in especially attitudes in relation to foodStep 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?????????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 othersStep 3: FAMISH History formatStep 4: Insight( Pneumonic –SCOFFS – 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 stone in 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).?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 and discuss further management.?Dr: Hello are you Miss Jessica Thomson ????? Miss: Thompson: YesDr: 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: YesDr: Could you please tell me, why are you losing weight?????? 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 ----. In lunch, generally I do eat ---- I take ---- 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 NoDr: Do you make yourself sick because you feel you are uncomfortably full ??????? Miss: Thompson: NoDr: 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 -----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: NoDr: 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: NoDr 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 symptoms??????? Miss: Thompson NoDr: Thank you very much for all the information.Miss .. We have measured your height and weight. Your weight is far lesser than what it should be for your height. I think you have lost too much weight. This is not good for you. In medical terms we call this condition as Anorexia Nervosa.Do you know anything about this at all? NoAnorexia nervosa is a serious?mental health condition.?It's?an eating disorder where a person keeps their body weight as low as possible. If it continues like this it can lead to lot of other conditions like depression and medical problems like Osteoporosis and sometimes people with this condition may not be able to conceive children. Do you follow me? YesWe can help you to treat this condition.TreatmentWe can help you by combination of psychological therapy and supervised weight gain. We have a team of specialists like Psychiatrists, Psychologists, dieticians and specialist nurses here to help you We as Psychiatrists can help you by Psychotherapy otherwise we call as Cognitive analytic therapy and Cognitive behavioural therapy. We can involve your family members also if do not mind to help the treatment. Our dieticians can teach you what type of food you can eat to gain weight. We do not need to admit you at this moment. We can do all these as an outpatient and see how things goes. Is that OK? What do you think about this?Information about treatment of Anorexia NervosaPsychological treatmentA number of different psychological treatments can be?used to treat anorexia. Depending on the severity of the condition, treatment will last for at least?6 to 12 months or more.Cognitive analytic therapy (CAT)Cognitive analytic therapy (CAT) is based on the theory that mental health conditions such as anorexia are caused by unhealthy patterns of behaviour and thinking developed in the past, usually during childhood.CAT involves a three-stage process:reformulation??– looking at past events?that may?explain why the unhealthy patterns developedrecognition??– helping people?see how these patterns are contributing towards?the anorexiarevision??– identifying changes?that can break these unhealthy patternsCognitive behavioural therapy (CBT)Cognitive behavioural therapy (CBT) is based on the theory that how we think about a situation affects how we act and, in turn, our actions can affect how we think and feel.In terms of anorexia, the therapist will attempt to?show how the condition is often associated with unhealthy and unrealistic thoughts and beliefs?about food and diet.The therapist will?encourage?the adoption of?healthier, more realistic ways of thinking that should lead to more positive behaviour.Interpersonal therapy (IPT)Interpersonal therapy (IPT) is based on the theory that relationships with other people and the outside world in general have a powerful effect on mental health.Anorexia may be associated with feelings of low self-esteem,?anxiety?and self-doubt caused by problems interacting with people.During IPT, the therapist will explore?negative issues associated with your interpersonal relationships and how these issues can be resolved.Focal psychodynamic therapy (FPT)Focal psychodynamic therapy (FPT) is based on the theory that mental health conditions may be associated with unresolved conflicts that occurred in the past, usually during?childhood.The therapy?encourages?people with anorexia to think about how early childhood experiences may have affected them. The aim is to find more successful ways of coping with stressful situations and negative thoughts and emotions.Family interventionsAnorexia doesn't just impact on one individual?–?it can have a big impact on the whole family. Family intervention is an important part of treatment?for young people with anorexia.Family intervention should focus on the eating disorder, and involves the family discussing how anorexia has affected them.?It can?also help the family understand the condition and how they can help.Gaining weight safelyThe care plan will include advice about how to increase the amount eaten so weight is gained safely.Physical health?– as well as weight?– is monitored closely. The height of children and young people will also be regularly checked to make sure they're developing as expected.To begin with, the person will be given small amounts of food to eat, with the amount gradually increasing as their body gets used to dealing with normal amounts.The eventual aim is to have a regular eating pattern, with three meals a day, possibly with vitamin and mineral supplements.An outpatient target is an average gain of 0.5kg (1.1lbs) a week. In a specialist unit, the aim will usually be to gain an average of around 0.5-1kg (1.1-2.2lbs) a pulsory treatmentOccasionally, someone with anorexia may refuse treatment even though they're severely ill and their life is at risk.In these cases, as a last resort doctors may decide to admit the person to hospital for compulsory treatment under the Mental Health Act. This is sometimes known as sectioning or being sectioned.Treating additional problemsAs well as the main treatments mentioned above, other health problems caused by anorexia will also need to be treated.If you make yourself vomit regularly, you'll be given?dental hygiene?advice to help prevent stomach acid damaging the enamel on your teeth.For example, you may be advised not to?brush your teeth soon after vomiting to avoid further abrasion to tooth enamel, and to?rinse out your mouth with water instead.Avoiding acidic foods and mouth washes may be recommended. You'll also be advised to visit a dentist regularly so they can check for any problems.If you've?been taking?laxatives?or diuretics in an attempt to lose weight, you'll be advised to reduce them gradually so your body can adjust. Stopping them suddenly can cause problems such as?nausea and?constipation.MedicationMedication alone isn't usually effective in treating anorexia. It's often? only used?in combination with the measures mentioned above to?treat associated psychological problems, such as?obsessive compulsive disorder (OCD)?or?depression.Two of the main types of medication used to treat people with anorexia are:selective serotonin reuptake inhibitors (SSRIs)?– a type of?antidepressant medication?that can help people with co-existing psychological problems?such as depression and?anxietyolanzapine?– a medication that can help reduce feelings of anxiety related to issues such as weight and diet?in people who haven't responded to other treatmentsSSRIs tend to be avoided until a person with anorexia has started to gain weight because the risk of more serious side effects is increased in people who are severely underweight. The drugs are?only used cautiously in young people under the age of?18.Shoulder and thigh pain – Polymyalgia RheumaticaExam questionElderly lady C/o shoulder and thigh pains – 3 weeksHistory and management.Shoulder and thigh ( may show around pelvis also) pains since 3 weeks. Oncet – Sudden or gradual [ in PMR – it is usually sudden but can be gradual too]Worse in the morning. [in PMR it is worse in the morning].Any swelling in shoulders - ? NoAny other joint pains ? No, Other joint swellings ( osteo arthritis) ? No, Swelling and pains in the hand joints ( rheumatoid arthritis) ? NoAny changes in the bowel habits like loose stools diarrhoea ? No Fever – No, Trauma ? NoSoreness in eyes?– No, Skin rashes ( SLE) – NoDifficulty using shoulder ? can she lift weight? Difficulty in walking ?Pain on the side of the head ? Any vision problems? Any pain in jaw while chewing? [ to r/o GCA] – NoPMHx – GORD on Omeprazole for 20 years Any other medicationsAllergy?Family historyAnything else important?ExaminationI want to examine your shoulder joints and other joints and also examine your thighsExaminer may say – shoulder movements restricted( abduction limited).I want to examine for any swellings or muscle wastings ? Examiner may say – No[ In PMR – joints movements may be restricted]Provisional diagnosis Mrs,,, I need to check whether the medication Omeprazole what you are taking is causing this problem. Is it OK? check BNF for side effects – it may show long term use of Omeprazole causes Vit D and B 12 deficiencies which may cause body aches).Mrs.. If one takes Omeprazole for long term it may cause vit deficiencies which in turn can cause body pains but they usually do not cause the pains to be worse in the morning and restriction movements of the joints.I think you have a condition what we call as Polymyalgia Rheumatica. Do you know anything about this? NoPolymyalgia rheumatica is a form of arthritis – joint condition. It causes pain in the joints and muscles of the lower back, thighs, hips, neck, shoulder and upper arms, and other parts of the body.The condition occurs when the lining surrounding the joints and tendons near the shoulders and hips becomes inflamed.The disease is centered on the joints (especially the shoulders and hips). But the discomfort is felt in the upper arms and thighs. This type of pain is called referred pain. It arises in one area but causes symptoms in another.Do you follow me? YesTypically, polymyalgia rheumatica affects people older than 55. If not treated, it can lead to stiffness and significant disability. In some cases, symptoms do not get worse. They may even lessen in a few years.In a minority of cases, polymyalgia rheumatica is associated with another condition called giant cell arteritis (temporal arteritis). This is a condition in which blood vessels are inflamed, especially in the neck and head. If not treated giant cell arteritis can cause blindness or stroke.Do you follow me ? YesWe need to do some blood tests called ESR and CRP to check whether there are any possibilities of this condition. {The ESR and CRP tests may be used both to diagnose the condition and to check whether treatment is working}.TreatmentWe will refer you to the specialist called Rheumatologists.We can give you pain killer medication like NSAIDS but they are not very helpful.We can give you medications called Corticosteroids, such as?prednisolone. We will give you low doses of that like 10 mg to 20 mg per day and they are highly effective.Long term use of steroids can cause Osteoporosis that is thinning of bones. We can give you medications to prevent osteoporosis like calcium, vitamin D and alendronate (Fosamax).If you have serious side effects of steroids and if we cannot just treat with low doses of steroids then we may give some other medications called?methotrexate?We will also refer you to Physiotherapists. Physical therapy may help to control discomfort. It can also help maintain the ability to move the joints and function.PrognosisTreatment may be required for years. But the outlook for people with polymyalgia rheumatica is excellent.Warning signs:If you develop any headaches on the sides of the head or vision problems or jaw pain while chewing please come to us immediately because these are the signs of serious condition called Gaint cell arteritis as I mentioned earlier. We may need to treat to you urgently with high dose steroids. ................
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