Condition 018 Advice on Smoking

You are working in a general practice. The next patient is a 30-year-old man who has returned to your
practice for follow-up following a recent chest infection. He is a smoker (20 cigarettes per day). On his
previous visit, you had told him that the 'best thing that he could do for his health would be to stop
smoking'. You have examined his chest which is clinically normal.
At this visit, you are expected to follow up his response to your previous advice and counsel
him further about tobacco cessation.

TASKS
1. Assess his motivation to stop smoking.
2. Counsel him appropriately.
3. Discuss treatment options and general resources.
4. Respond to any questions he may have.
APPROACH
 Hi John. How are you today?
 I've been thinking about your advice last time about my smoking. I would like to stop. What can
you do to help me?'
 John, I really appreciate that you are here to let me help you about quitting smoking. I think that
that is a really good thing that you are motivated to stop smoking. As I've told you before, the
best thing that you could do for your health is to stop smoking. Let me just ask you a few
questions about your smoking habits so we can appropriately make a plan for you, will that be
alright?
 Do you still smoke tobacco? How many cigarettes do you smoke every day? For how long have
you been smoking? What time of the day do you smoke more? How soon after you wake up do
you have your first cigarette? Do you find it difficult not to smoke in a non-smoking area? Is the
first cigarette of the day the hardest to give up? Do you smoke even when you are sick? Have
you tried to stop smoking for good in the past but found you could not? What happened? What
happens if you don’t smoke?
 How do you feel about your smoking at the moment? Are you ready to stop smoking now? How
motivated are you to quit smoking on a scale of 1 to 10, 1 being the least motivated, 10 being
the most motivated?
 So John, I can see that you are smoking for a long time, and you have been dependent on
smoking. But I am very happy and I congratulate you about your motivation and readiness to
quit.
 To encourage you more on your journey to quit, I would discuss with you the risks associated
with smoking and the benefits that you will experience when you quit smoking.
 Are you aware of the risks of smoking on your health? Tobacco smoke is made up of thousands
of chemicals and many of them are very harmful. Around 70 of them cause cancer. Also, these
chemicals when inhaled it takes the place of oxygen in your blood, starving your lungs, heart,
and other organs of the oxygen they need to function properly. Smoking thus increases the risk
of high blood pressure, heart disease, stroke and lung disease. The tar in cigarette also produces
a sticky brown substance that coats your lungs like soot in a chimney. Tar and smoke irritate
your lungs, increasing the amount of mucus in your chest and restricting your breathing thus it
 predisposes you to frequent upper respiratory tract infections. If you are smoking at home, it
can affect your partner or your children as well.
 Did you know that as soon as you stop smoking your body begins to repair itself? Once you quit
smoking, it will decrease the chance of having health issues related to smoking. Your food will
taste better and you will enjoy eating more and your sense of smell will improve. You will also
be able to save more money that you can use for your other hobbies or for your family. Even if
you have smoked for a long time, you will still be able to experience the benefits of quitting
smoking. It is never too late to quit smoking.
 Do you ever feel as if your smoking controls you? Has your mood ever been rattled when you
realise you’ve run out of cigarettes? When you start to regularly smoke more than 10 cigarettes
a day, most people will become addicted to nicotine. Nicotine levels drop every hour or so, so
often the urge to smoke is about your body recognising that it needs another hit – this is
another way smoking controls you. Regaining control over smoking feels good. This in turn can
make you feel more confident about tackling other positive goals, and shifting to a healthier,
happier lifestyle in other ways.
 The decision to quit smoking is a personal one and in the end you have to want to do it for
yourself. It’s important, though, to remember that your smoking also affects those around
you. A desire to protect loved ones from harmful smoke can be a good motivator to quit.
 I will suggest you to set a quick quit date within the next 2 weeks. This gives you enough time to
prepare but ensures you won't lose your motivation to quit. Choose an easy day to stop
smoking, one when you won’t be under much pressure and will have plenty to occupy you. Very
important is to stick to your quit date. If you have to change it set a new date straight away.
 Try to aim for total abstinence as it is more effective than cutting down.
 It is important for you to expect to have symptoms of nicotine withdrawal after starting to quit
smoking and to prepare for it. Withdrawal can be unpleasant especially in the first four days, so
it’s useful to think of the symptoms as signs that your body is recovering from smoking. Some
people only have a few mild symptoms but others have more severe symptoms that are harder
to deal with. It is common to have strong cravings, irritability, trouble concentrating,
restlessness, anxiety, low mood and trouble sleeping. Most people find that symptoms are gone
within two to four weeks though for some people they may last longer. Symptoms tend to rise
and fall over several weeks. Remember, it all passes if you hang on and stay quit.
 Focusing your attention on something that gives you pleasure or is relaxing can help with
withdrawal, such as exercise which can reduce cravings and withdrawal symptoms. It can also
lower stress and help keep your weight down. Get involved in new or favourite hobbies or
spend more time with supportive friends and family. Also focus on relaxation by getting a
massage or spa, try deep breathing exercises, listen to music, or take yoga or Pilates classes.
Remember the good things that are happening to your body as well. Now that you’ve stopped
smoking, your body can start to heal and reverse the damage from cigarettes.
 Inform your family and friends about your plan to quit.
 Take a healthy balanced diet, and take citrus fruits like orange, lemon which will reduce your
craving for smoking. Avoid alcohol, which is an important trigger for smoking, and similarly
reduce your caffeine intake.
 Based on my assessment, you may benefit from medications called nicotine replacement
therapy. It doesn’t contain chemicals that causes cancer, and you can use it as gum, patches or
inhaler to help you with your cravings.
  I will refer you to quit line, and support groups to keep you motivated. I will also review you
regularly and monitor your progress, and give you reading materials about this for further
insight.

 Counselling abilities.
 Awareness of principles of a tobacco quitting programme.
 Lack of awareness of the key elements of a nicotine quitting programme.
Candidates should have a broad knowledge of the content, and are expected to be aware of, and
incorporate most of the following key elements into their counselling.

KEY ELEMENTS OF CIGARETTE/NICOTINE WITHDRAWAL PROGRAMME

The key elements of a cigarette/nicotine withdrawal programme include:
Set a definite QUIT BY date (within two weeks of making the decision to quit).
Aim for total abstinence — not just 'cutting down'.
Review previous attempts at quitting and what went wrong!
Inform family and friends, particularly other smokers, of the plan,
Avoid alcohol, which is an important trigger for smoking, and similarly review coffee intake.
Anticipate and discuss likely individual pitfalls and difficulties (for example, weight gain or depression).
Practise problem solving as a way of dealing with 'what do I do if/when'.
Encourage the use of nicotine replacement therapy unless there are contraindications (e.g. coronary
artery disease or pregnancy).
Recommend starting or increasing physical activity and the importance of a balanced diet.
Schedule follow-up visits and supportive phone calls.

NICOTINE REPLACEMENT THERAPY (NRT)

The aim of nicotine replacement therapy (NRT) is mainly to ameliorate nicotine withdrawal. Neither
patches nor gum give the arterial 'high' concentration of cigarettes and the overall dose of nicotine they
provide is about 40% of that provided by cigarettes, but they are not accompanied by tar. carcinogens or
carbon monoxide. Smokers extract about 1 mg of nicotine per cigarette independent of the brand used,
although each cigarette may contain up to 14 mg of nicotine.
Costs of NRT may influence patient choice, but are generally cheaper than continuing to smoke.
Forms of NRT include:
NICOTINE GUM contains nicotine 2 or 4 mg per piece in a sugar-free resin base. The gum should be
chewed slowly, then left between cheek and gum before being repositioned and chewed intermittently
for up to 30 minutes, 10 times a day. Because nicotine is poorly absorbed from an acid environment,
acid drinks such as fruit juice should be avoided. Mouth soreness or dyspepsia may occur. Lozenges are
an alternative.
Condition 083 Medication changes
You are working in a general practice. A long-term patient of the practice has attended for a repeat
prescription of thioridazine (Melleril). The patient is a 35-year-old woman who has been receiving
thioridazine 200mg daily for chronic schizophrenia over the past 15 years. Due to recent adverse
publicity and concern about the effects of longterm thioridazine on cardiac conductivity (as reflected in
a prolongation of the corrected QT interval on the ECG), you wish to change her to a newer atypical
antipsychotic.

Before doing so, you will need to discuss with her the risks and benefits of her current treatment and
the risks and benefits of the commonly available atypical antipsychotics.

TASKS
1. Explain your concerns about continuing on thioridazine
2. Educate the patient about the risks and benefits of the newer atypical antipsychotics
3. Explain the side effects of the most common atypical antipsychotics
4. Respond appropriately to the patient's questions

5. There is no need for you to take any further history from the patient.

APPROACH
Good morning, I'm Dr.______. I will be one of the doctors who will look after you today. How can I
address you?
CONCERNS ABOUT THIORIDAZINE
I can see from your notes that you have been in thioridazine for the past 15 years. Do you have any side
effects to these mediation so far?
I am just concerned as this medication proved to develop life threatening side effects when used for a
long time, and with that I am just concerned about you. Is it okay if I explain these side effects to you?
Aside from the usual weight gain, dry mouth, constipation that it usually brings about, it was recently
proven that it also cause harmful effects to the heart. It tends to affect the manner of how the heart
beats, which will eventually cause irregular heartbeats that may possibly lead to a fatal heart attack.
And as you have said that you are having blurring of vision, this medication was proven to cause
opacities of the lens of the eye.
That being said, it seems that it is best that we shift to these newer antipsychotics, called the atypical
antipsychotics.
It has the same effect of controlling your symptoms, but these have lesser side effects compared to the
typical antipsychotics like thioridazine that was given to you. Examples of these atypical antipsychotics
are Olanzapine, Clozapine, Risperidone, and Quetiapine.
BENEFITS AND RISKS OF NEWER ATYPICAL ANTIPSYCHOTICS
As I have said earlier, these new atypical antipsychotics have the same effect as the older types.
These have lesser side effects on the heart, lesser effects on developing tremors or shakiness, or
problems in movement.
However, just as other medications, these drugs also have some risks of taking it. Generally, these
atypical antipsychotics are related to development of weight gain, development of metabolic
disturbances such as diabetes mellitus, high lipid levels in the blood or fat levels in the blood and
increasing a factor in the blood (hyperprolactinemia) causing disturbances in the periods, impotence,
leading to osteoporosis, and sedation.
SIDE EFFECTS OF MOST COMMON ANTIPSYCHOTICS
Specifically, these medications have these side effects:
Olanzapine: weight gain thereby increasing the risk of metabolic disease
Clozapine: agranulocytosis--or disturbance in the levels of the white blood cells in the blood which
protect us from infections.
Risperidone: postural hypotension causing light-headedness or dizziness, hyperprolactinemia leading to
development of milky discharge in the breasts
Quetiapine: lesser weight gain
In your case, if you agree to change your medications, I can create a management plan for you.
First, you need to adapt lifestyle modifications. You need to adapt a healthy well-balanced diet, and
engage in regular physical exercise as we need to keep your weight in the normal range to lessen the
possibility of developing metabolic disease once you start with these newer antipsychotics.
Next, we will arrange full investigations for you just to assess for your general health which include BMI
charting, BP monitoring, FBE, ECG, LFT, TFT, Prolactin.
I can arrange an admission to the hospital for you when we change antipsychotic medications as there is
what we call a "cross-over period"
[ILLUSTRATE] This is your drug now, thioridazine, we will try to taper your dose, while we introduce a
new drug called Olanzapine until these two drugs cross over. This process might take up to two weeks or
more, and during this period, relapse is very common and we will admit you in the hospital if ever you
develop these relapse symptoms.
Do you have any questions?

KEY ISSUES
 Explanation of risks of continuing current medication
 Explanation of benefits and side effects of recommended alternative medications
 Monitoring and follow-up during mediation change over

CRITICAL ERRORS
 None defined

IMPORTANT POINTS FROM THE COMMENTARY

 Thioridazine: prolongation of the QT interval, hence there is a danger of life-threatening
ventricular tachycardia
 Risk of progressing to polymorphic tachycardia (TORSADE DE POINTES) in patients with pre-
existing cardiac pathology, electrolyte abnormalities, thyroid disease, cerebrovascular disease
 May progress to ventricular fibrillation or sustained tachycardia
 Blockade of cardiac potassium channels may be the mechanism and genetic factors may play a
part. Women at greater risk
 Cause lenticular opacities when used in high dosage for long periods
 Anticholinergic effects which cause the most subjective discomfort: sedation, postural
hypotension, weight gain
 Extrapyramidal toxicity is uncommon, but not rare
 ATYPICAL ANTIPSYCHOTICS
 Not solely block CNS dopamine D2 receptors
 Less likely to cause tardive dyskinesia or other extrapyramidal syndromes
 Efficacy equivalent to conventional "typical" antipsychotics
 Side effects: weight gain, metabolic disturbances, hyperprolactinemia.
 Examples: RISPERIDONE, OLANZAPINE, AMISULPRIDE, QUETIAPINE
 Weight gain generally associated with RISPERIDONE, OLANZAPINE, AND QUETIAPINE
 Adolescents are particularly susceptible to this
 Not dose-dependent, but patients who were relatively underweight prior to treatment may put
on the most weight
 Mechanism: blockage of histamine H2 receptor and antagonism of 5HT2A receptors, as well as
impaired feedback of the adipose tissue-leptin loop
 There is an Increased risk of Type 2 DM in patients with Schizophrenia independent of
treatment, but weight gain and inappropriate dietary choice increase the risk further
 Atypical antipsychotics, particularly OLANZAPINE, heighten the prevalence of type 2 DM
especially in overweight or obese patients, by increasing insulin resistance
 Increased triglyceride levels are also associated with OLANZAPINE
 RISPERIDONE has the greatest risk of HYPERPROLACTINEMIA, and hence, amenorrhea,
galactorrhea, decreased libido, impotence, and anorgasmia
 Prolonged uninhibited prolactin release may cause hypogonadism and decreased estrogen and
testosterone secretion, which in turn increases cardiac morbidity and osteoporosis, and gives an
increased risk of breast cancer
 CLOZAPINE: atypical antipsychotic that has the MOST ADVERSE SIDE EFFECT PROFILE including
AGRANULOCYTOSIS
 AMISULPRIDE: most likely to cause extrapyramidal side effects, although it is claimed to
preferentially block limbic dopamine receptors rather than those in the striatum
 DECISION TO CHANGE ANTIPSYCHOTIC
 Depends on a risk/benefit ratio
 Increased risk of relapse requiring hospitalization during the changeover period
 PRE-SWITCH COUNSELLING
 Lifestyle, dietary advise, weight monitoring and an agreed exercise program are essential
elements of the pre-switch counselling process
 Baseline weight, BMI, BP must be measured
 Investigations: 12L ECG, thyroid function, fasting blood sugar and lipids, prolactin, full blood
count, electrolytes, urea, creatinine, and liver function tests
 CHANGING ANTIPSYCHOTICS
 Non-acute patients
 Cross-over period of 1-2 weeks is recommended by reducing the dose of the previous
medication and gradually increasing the dose of the new medication
 Caregivers must be informed of the 'early warning signs" of relapse
 Non-specific discontinuation symptoms may persist for several weeks after the changeover. This
include nausea, headache, restlessness, and influenza-like syndrome
 In this patient, because of the length of time he is on a typical antipsychotic, any change to a
newer atypical agent may require dose-titration over several weeks and doses towards the
higher end of the therapeutic range may be necessary.


Condition 084 Body Dysmorphic Disorder
You are the duty Hospital Medical Officer (HMO) in a busy city hospital clinic attached to the Emergency
Department. It is early evening.
The patient you are about to see is a neatly dressed, well-groomed 29-year-old man who has brought an
envelope containing some hair strands to the front desk, asking if they can be 'examined under a
microscope'. He appeared to be quite anxious and restless whilst waiting to be seen by you and the
triage nurse has told you that he has visited the toilet facilities for lengthy periods of time on several
occasions.
The triage assessment states that he is worried that he is suddenly going bald because he has begun to
lose his hair. He has brought some of his hair to the hospital to be examined to find out what the
problem is and have treatment urgently' because he believes that his hair loss is affecting his 'prospects
for promotion at work'. He is single and lives at home with his parents. He has worked as a financial
analyst in a merchant bank for the past six years. He admits to not having any social life and is a non-
smoker and non-drinker. He appears to have a normal full head of hair as illustrated below.

1. Establish rapport.
2. Take a sensitive, focused and relevant history.
3. Reach a diagnostic conclusion, and discuss this with the patient.
4. Discuss management briefly with the examiner.

 Good evening, I am Dr. Lea one of the HMOs here at the hospital. How may I address you?
 Hi John. It's very nice to meet you. How may I help you tonight?
 I see that you really suffer because you are so worried because of this hair loss. I understand your
concerns and I am so sorry that you are experiencing this. Let us work together to reduce this
distress. I see that you also have a sample of your hair that you want us to look at. Rest assured
we will do our best to look into this problem and help you.
 Let me also assure you that whatever we discuss today will be private and confidential between
you and me, unless it poses a harm to you or to someone else.
 History of present illness
o Do you have any specific concerns?
o Since how long have you had this?
o Is it progressing?
o How much hair have you already lost since this started?
 o Anything that you do to check the situation?
o Do you think that this is interfering with your life to such an extent that you are
dysfunctional?
o Do you have concerns about any other body parts?
o Any interventions done for this so far? (gone to massage and beauty parlour nothing has
work, wants to go under the knife, plastic surgeon)
o Do you think about this all the time?
o Does it ever seem that people are talking about you or taking special notice of you because
of this hair loss?
o What do you think has caused you to have these beliefs?
 Rule out medical causes
o Thyroid problem: do you have weather preferences?
o Did you have any recent infections?
o Any recent stressors?
o Any serious medical illness? Any chronic medical illness that requires treatment like
chemotherapy or radiotherapy?
o Are you losing hair anywhere else?
o How is this affecting your life?
 Psychosocial history
o How is your mood?
o Do you think that life worth living?
o How is your appetite? Any recent weight loss?
o How is your sleep?
o Do you think that anyone is spying on you or talking about you?
o Sometimes under stress, people see, feel or hear things that others don’t, is this also true
for you at the moment?
 HEADSSS
o Who do you live with? How is your relationship with them?
o How is your work?
o Do you still enjoy your hobbies?
o Do you still attend social activities?
o Do you smoke, drink alcohol, or take recreational drugs?
 Any family history of any medical or mental illness?

Diagnosis and Management

John, taking in your concerns and after careful evaluation, I have looked at your hair, and there is no
patch of baldness in your hair, and the amount of hair that you are losing can be just quite normal, I
think that what you're experiencing right now is not due to any medical cause.
I think that you may have a condition called Body Dysmorphic Disorder. This is a form of an obsessional
disorder, where you become overconcerned about your appearance, and your perception of your body
image is different from others. Becoming concerned about once appearance is quite a normal thing, but
in BDD, you become extremely concerned about a slight defect or a non-defect in your body then it
becomes difficult for you to control these thoughts which leads you to do repetitive and time consuming
behaviors like checking yourself every so often, until you wouldn't notice that it starts interfering with
your daily activities. If these thoughts and perception persists, it can lead to low self-esteem and fear of
rejection. I know that it is a very real experience and belief for you, that is why I want to help you
through this. We are here to help you, we’ll work as a team.
I will refer you to Psychologist for talk therapy where in your sessions, the psychologist will help you be
aware of your thoughts and how it controls your actions and then you work hand in hand with her to
understand and modify your thoughts so that in turn your actions become controlled. You will also
learn new ways of positive thinking and it will help you overcome your emotional disturbances. With
your consent, your family could also be involved in the psychoeducation. I will also refer you to a
psychiatrist who will start you on medications (SSRIs) for 3 months that will also help with your mood. It
would also probably be helpful for you to remove the mirrors in your room while you are recovering
from this. I will give you reading materials for further insight and I will review you in one month's time.

To the examiner:
I will refer my patient to the psychologist for cognitive behavioral therapy which include identifying
maladaptive thoughts, evaluating them, and generating alternative thoughts. Successful therapy will
create a change in thinking and behaviour patterns and create a positive attitude and improvements in
mood and wellbeing.
With the patient's consent, I would also involve the family to have family sessions since sometimes
working with families to improve their reaction to the BDD may help motivate the patient to change.
I will also refer my patient to a psychiatrist who will start him on medications such as SSRIs for 3 months
to help him with his mood.
I will advise him to remove mirrors in his room for the meantime to help curtail his obsession of
checking up himself every so often. And I will review him in one month's time after his sessions with the
psychologist and psychiatrist to check up on his progress.

 Ability to take a focused psychosocial history and to come to an appropriate diagnosis.

 Ability to communicate with a patient with body dysmorphic disorder.

'Body Dysmorphic Disorder, or dysmorphophobia, is a chronic preoccupation with an imagined defect in

one's appearance. Even if a slight physical anomaly is present, the person's concern is markedly
excessive. The preoccupation causes significant distress or impairment in the person's social,
occupational and other important areas of functioning.
Typical complaints commonly involve imagined or slight flaws of the face or head such as thinning hair,
acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, facial
asymmetry or disproportion or excessive facial hair.
Other common preoccupations include the shape, size or some other aspect of the nose, eyes, eyelids,
eyebrows, ears, mouth, lips, teeth, jaw, chin, cheeks or head. Any other body part may be the focus of
concern (the genitals, breasts, buttocks, abdomen, arms, hands, feet, legs, hips, shoulders, spine, overall
body size or body build and musculature).
The preoccupation may focus simultaneously on several body parts and although it may be often
specific: 'a hooked nose'; it may also be vague: 'a flat chest'; or general: 'I'm just ugly'.

From Diagnostic and Statistical Manual 4 - Text Revision

Most individuals with this disorder experience marked distress over their perceived deformities.
They find their preoccupations difficult to control and may make little or no attempt to resist them.
Many hours of the day may be spent thinking and worrying about their 'defect' and these thoughts may
dominate their lives, leading to significant impairments in functioning and avoidance of work, social and
public situations. Repetitive and time-consuming behaviours are undertaken to reduce their distress,
which have no or only minimal benefit. Reassurance that there are no visible defects has no lasting
effect on their abnormal beliefs. The core irrational belief in BDD is that the person is somehow
defective and unattractive and this is accompanied
by low self-esteem, shame, embarrassment and fear of rejection. The condition is common if it is looked
for and
asked about.
The most common associated behaviours are mirror-checking, touching, comparing the defect' with
other people's
body parts either directly or with pictures in magazines, excessive grooming, camouflaging, constantly
seeking
reassurance and questioning others about their alleged defects or ugliness and then seeking
dermatological or
cosmetic surgical treatments.
Social impairment is the norm. They are socially avoidant and will not willingly visit restaurants,
shopping centres,
beaches or go to parties or functions because of their self-consciousness about their appearance. Insight
is usually
poor or partial and their beliefs may become delusional. It is their self-referential ideas, i.e. that other
people are
taking special notice of their 'defect' and will talk and gossip and laugh about it, that contribute to their
social isolation and intensify their suffering to the point of despair, self-harm and sometimes suicide.
Psychiatric comorbidity is universal. Major depression is the most common (60%) but social
anxiety/phobia, obsessive compulsive disorder, substance abuse and avoidant personality disorder are
highly prevalent.
There is a roughly equal sex incidence and similar clinical features. Perhaps women are more likely to
focus on their
skins, lips, and weight, whereas men are more preoccupied with overall physique, their genitals and hair
loss or
excess. The condition typically begins in adolescence, but may not present or be diagnosed until the
thirties. The
course is chronic and relapsing.
Most patients with BDD seek costly dermatological or cosmetic surgical consultations and treatments,
but remain
dissatisfied with the results. They may then become litigious or violent. Rarely patients perform their
own
procedures after consulting internet web sites.

Management
The specific serotonin reuptake inhibitor antidepressants and clomipramine are often effective. The
dosages need
to be in the higher range and it may take three months to get a response, but 70% of patients report
improvement.
Augmentation with antipsychotics may increase the response rate. Treatment must be continued long-
term as
relapse is common if treatment is discontinued.
Cognitive behavioural treatments including psychoeducation, cognitive challenge and restructuring,
exposure and
response prevention, as well as anxiety management training, can supplement drug treatment and
increase response rates to over 80%. Severe comorbid depression may need hopitalisation and/or
lithium carbonate augmentation with antidepressants.
Trying to convince patients with entrenched ideas that their beliefs are irrational or that they look
normal is unlikely to persuade them to accept psychiatric treatment or referral. With the patient's
consent, family involvement in
psychoeducation and treatment planning and supervision of response prevention strategies and the
removal of mirrors from the family home may be valuable.
Condition 085 Poor work performance
You are working in a general practice. The patient is a 30 year old police officer who has been advised to
seek medical help by the human services officer (staff counsellor) for the State Police Service. The Police
Service has become concerned that she does not appear to be functioning as well in the workplace. She
has been having an increasing number of sick days, which are often on the first day of a new set of
rostered shifts.

1. Take a focused history -- you have six minutes to do this

2. Inform the examiner of the three most likely diagnoses
3. Answer questions from the examiner about one or more of these diagnoses

 Good morning, I'm Dr.____. I will be one of the doctors who will look after you today. How may I
address you?
 You look very distressed, how are you?
 Let me reassure you that whatever we talk about will remain between us, unless it will be harmful
to you or to others. Will that be okay?
 FOCUSED HISTORY
o I understand that you are here because you were asked by your supervisors to seek consult
as you have been having increasing number of sick days off. Could you tell me more about
this?
 What has been wrong so far? Why do you have days off when shift changes?
 When did this start?
 How are things at work? How is your relationship with your workmates? Any
particular concerns about them?
 What do you do to make you feel better?
 Do you have enough support?
o PSYCHOSOCIAL HISOTY
 How is your mood lately?
 How's your sleep and appetite? Have you lost weight?
 Do you think life is worth living?
 Do you have any passing thoughts of hurting yourself or others?
 Any definite plans of harming yourself? Do you have a weapon?
 Any previous attempts of suicide?
 Do you still enjoy the things you used to do? When you wake up in the morning, do
you have that interest to go out and do something for that day?
 Do you feel guilty about this?
 Do you feel more tired these days?
 Do you find yourself having difficulties in concentrating on your work?
 Have you noticed if you tend have slowed down on doing things?
 Are you generally an anxious person?
o I will just ask you some routine questions that I ask all of my patients for assessment. Will
that be okay?
 DELUSIONS
o Do you think some is spying on you?
o Do you think someone is trying to harm you?
o Do you think other people’s action is directed towards you?
 o Do you think someone is inserting thoughts in your mind?
o Do you think your thoughts are being broadcasted in the tv or radio?
HALLUCINATION
o Do you see, feel or hear things that others don’t?
o Do you hear voices that command you to do something?
INSIGHT
o Do you think you need help?
JUDGEMENT
o If there’s a fire in this room, what will you do?
COGNITION
o Where are you? What’s the date today? What is my name?
HEADSS
o Aside from your stresses at work, I'd like to ask you how’s your home situation?
Do you live alone? Any stresses?
o Do you have relatives who live nearby?
o Do you have enough support?
o Are you sexually active? Do you have a stable partner?
o Do you still go out and meet up with friends and families?
SAD
o Do you smoke?
o Drink alcohol?
 How much do you drink in one occasion? Do you drink everyday?
 Any problems with the law due to drinking?
 Have you ever felt you need to cut down on drinking?
 Have you ever felt annoyed of someone who criticizes your drinking?
 Have you ever felt guilty of drinking?
 Have you ever used alcohol as an eye opener in the morning?
o Any chance you're taking recreational/illicit drugs?
PAST MEDICAL HISTORY:
o How is your general health?
o Do you have any past history of mental illness? Any medical or surgical illness?
o Are you on any medications?
o Any allergies to food and drugs?
FAMILY HISTORY:
o Do you have any family history of Mental illness? Any family history of Cancer,
PCOS, Diabetes or Hypertension?
THREE MOST LIKELY DIAGNOSES (case flow may differ, but these are the possible diagnoses based
on the book)
Anxiety disorder: post-traumatic stress disorder, panic disorder, or generalized anxiety
disorder
Depressive disorders: adjustment disorder, major depressive disorder
Alcohol dependence/abuse: or just a problem with drinking
ANSWER EXAMINER'S QUESTIONS
What is a safe level of alcohol consumption for this patient?
Maximum of 20 grams per day (2 standard drinks) and 2 alcohol-free days per week
(NHMRC Levels for Women AND Men)
What are the short term risks associated with the patient's current level of alcohol use?
 Hangover effects - headaches, anorexia, tremor
Gastritis
Impulsive acts - including suicide attempts
Impaired decision making
Accidents, including with firearms
Worsening of mood/depression
Potentiation of anxiety or post-traumatic stress disorder symptoms, or social or
occupational problems

 Ability to take a focused history to define the potential cause of the current problem
 Knowledge of the causes of the problem
 Knowledge of the short-term effects of alcohol excess, and the NHMRC recommendations of
alcohol abuse

 Failure to identify the excess alcohol consumption

 Failure to ask about suicide

 Case is about severe work-related stress leading to alcohol abuse to help relieve a post-traumatic
stress syndrome with anxiety
 At risk of co-morbid depression and suicide
 She has a responsible job and failure to help her may result in the community being at risk
 Take adequate history of alcohol consumption
 Explore factors that led to the problem: fatal car accident and shooting of her work colleague the
next day
 Ask about key features of PTSD, assess subjective mood and risk of suicide, and access to firearms
 Identifying alcohol problem alone is insufficient for a pass
o Familiar with at least 4 short term risks/consequences of alcohol use
 Hang-over effects: headaches, anorexia, tremors
 Gastritis
 Impulsive acts: suicide attempts
 Impaired decision making
 Accidents, including with firearms
 Worsening of mood/depression
 Potentiation of anxiety or PTSD symptoms leading to social or occupational problems
 NHMRC GUIDELINES
o 1 standard drink = 10 grams of alcohol (equivalent to 12.5mL of pure alcohol)
o For healthy men and women, drinking no more than 2 standard drinks on any day
o For healthy men and women, drinking no more than 4 standard drinks on a single occasion
o For young people aged 15-17 years, the safest option is to delay the initiation of drinking for
as long as possible
Condition 086 Lifestyle stress
Thursday, 25 May 2017
2:47 PM

You are working in a general practice. The patient has come to see you after
having insurance medical examinations at work. It was recommended that he see
a general practitioner, to monitor his general health, and that he may be 'just
stressed'. He did not really think of being a 'stress type' before now, and has no
symptoms except for headaches towards the end of the day. Other family
members attend your practice, but this patient has not previously consulted you.
The patient has been told that cholesterol, blood sugar, and resting ECG are
normal, but on two occasions in the last month when tested by the insurance
doctor, the BP reading was high (160/80 mmHg) but eventually settled to normal
levels. On those days, the patient had come from particularly difficult meetings.
The patient is upset by these findings, believing that he has always been in perfect
health. The insurance doctor said 'there was nothing to be concerned about
really', but now he is worrying about having a heart attack and can't get that out
of mind over the past couple of nights. This worry has been reinforced by several
episodes of stabbing chest pain each lasting only a few seconds, unrelated to
exertion. Last night he took a sleeping tablet, normally only used on long plane
trips, to get some sleep, and feels much better now—the patient is now thinking
he may have been suffering from stress over the past couple of years.
You have obtained the information as listed below in the patient profile, and you
have just completed examining the patient, including performing an ECG. No
abnormality has been found. Blood pressure today is 130/70 mmHg.
 1. Discuss his health condition and relevant matters with the patient.
2. Advise the patient of your diagnosis and proposed management.
3. Answer any questions the patient asks you.

Positive points in the history:

 Had two episodes of high BP readings which eventually settled to normal
levels. On both occasions, he came from difficult meetings
 More frequent headaches towards the end of the day
 Had several episodes of stabbing chest pain lasting for few seconds,
unrelated to exertion
 He enjoys being challenged by work and sports, and people coming to see
you for advice.
 He never takes a day off work, even with a bad cold or jetlagged from a trip,
and avoids taking tablets, even a Panadol® if he has a headache at the end of
the day.
 He works 12-15 hour days. Since he was promoted 18 months ago, he has
been taking work home on weekends more frequently and there is a lot
more pressure. He sometimes feel like escaping, but think of it only being a
few more years and anyway he feels happier at work than at home these
days. It is just too noisy with three teenage children, and he gets irritated
with his eldest son who dropped out of university last year, and 'just sits
around playing music with his mates'. He did not go on the family holiday this
year for the same reason, blaming work. His spouse is usually very
understanding, but got mad with him about that and things have been tense
the last few months. He has been more irritable at home, and his spouse
complains he criticizes the children too much.
 He normally gets on with a few hours sleep, often thinking through work
problems once he is in bed. He never feels tired, but the last year or so he
'catches up with naps' on weekends. The last couple of weeks, he has slept
badly, and feels tired in the morning. There is little time for sex, but he is sure
it is not his lack of interest that is the problem. He used to exercise regularly
at the gym and with weekly tennis but have not done so in the last few years
because he is just too busy at work, and running around with the children's
activities on weekends. Now, he walks up the stairs when he has time.
 He has gained a few kg over the past few years, but does not consider
himself overweight, or unfit. He has always eaten a balanced diet, except
when on overseas trips and at business lunches.
 History
o History of present complaint
 Hi John, before I discuss with you your health condition, would it be
alright if I ask you a few questions so I could better understand your
condition?
 I read from the notes that you have some concerns about some
chest pains that you've been experiencing, can you tell me more
about that?
 Since how long have you been experiencing this?
 How many times have you experienced these chest pains?
 Have you experienced something like this before?
 How severe is the pain?
 Is the pain going anywhere else?
 Have you noticed anything that triggers it or is it related to anything
like emotions?
 Does anything make it better or worse?
o Differential questions
 Cardiac: do you also experience sweating, cold clammy extremities,
nausea and vomiting?
 Respiratory: is the pain worse when breathing? Do you have
shortness of breath?
 Musculoskeletal: is the pain related to movement?
 Psychogenic: do you worry a lot about trivial things?
o Psychosocial history/HEADSS
 How is your mood?
 How is your sleep?
 How is your appetite?
 Have you had any recent weight changes?
 Do you think that life is worth living?
 Let me assure you that whatever we discuss today will be private
and confidential unless it poses a risk to you or to others?
 How is your home situation? Do you have any stress at home? How
are your relationship with your wife and three kids?
 Do you have a good support?
 I read that you are a finance manager, how are things at work? Do
you have any stress at work?
 Do you still enjoy the activities that you used to enjoy before?
  Do you still go out to meet with your friends and family?
o SADMAC
 I read that you've been smoking about 3-5 cigarettes daily. How
long have you been smoking? Do you have any plans of quitting
smoking? If you'll agree with me, I can arrange another consultation
with you to discuss about your smoking.
 I also read that you've been drinking whiskies and sherries on most
nights, have you tried cutting down on your drinking? We could also
talk about this on another consultation.
 Do you take any recreational drugs?
 How much coffee do you drink in a day?

 Discuss health condition

John, with the information that you have given me, most likely the physical
symptoms that you were experiencing is due to the different stress that you
are having in your life. When we feel under stress, our body kicks into
high gear to deal with the threat. Our heartbeat, breathing rate and
blood pressure all go up and the muscles tense. And
the longer we feel stressed, the greater the demand on our body.
The episodes of increase in blood pressure, frequent headaches, sleep
disruption, and chest pain, result from the body's response to the stress that
you face with your problems at home and the increased demands and
burden at work due to your promotion. On top of this, your lack of activities
of leisure and exercise, and your compensatory habits of smoking and
drinking increase your physical and emotional burden.
I understand that you are worried about the stabbing chest pain that you've
been experiencing, but based on the nature of the chest pain, it is most likely
just due to stress, and not due to an underlying cardiac pathology. But we
can do some screening investigations like ECG to check on your heart, if you
prefer.

 Diagnosis and Management

Because of the different stressors present in your life that we have identified,
and the way that it has been affecting your health, most likely you are having
lifestyle stress.
Stress occurs when a person feels that the demands made on them exceed th
eir ability to cope.
The more often we are placed under stress, the more often we have to use e
nergy to cope.
It is important for us to identify stressors early, and be able to manage it
because it can be detrimental to your health. There is growing
evidence that stress may contribute to physical illness such as cardiovascular
disease, and also,
untreated stress can turn into a mental illness such as an anxiety disorder or
depression. Some ways that you can manage stress are:
o Exercise regularly. You should do some form of exercise that causes you
to feel puffed afterwards. A leisurely stroll to the bus stop is not enough.
Have at least 30 minutes of exercise, at least three times a week.
o Give yourself some time to relax each day and try to spend time with
people who make you feel good about yourself. You can also try relaxing
activities like yoga and meditation to refresh your mind.
o Eat well as a nutritious diet is important. Eat plenty of fresh fruit and
vegetables and avoid sweet and fatty foods.
o A good sleep routine is essential. If you have difficulty falling asleep,
please follow these tips:
 Try to get up at the same time every day. Soon, this strict routine will
help to set your body clock and you'll find yourself getting sleepy at
about the same time every night
 Get enough early morning sunshine. Exposure to light during early
waking hours helps to set your body clock.
 Do not ignore tiredness. Go to bed when your body tells you it's
ready
 Don’t go to bed if you don't feel tired. You will only reinforce bad
habits such as lying awake.
 If you can't fall asleep within a reasonable amount of time, get out of
bed and do something else for half an hour or so, such as reading a
book.
 Improve your sleeping environment by investing in a mattress that is
neither too hard nor too soft, making sure that the room is at the
right temperature, it is dark enough, and it is quiet.
 Use your bedroom only for sleeping and intimacy.
 Avoid cigarettes and alcohol close to bedtime.
 Avoid caffeinated drinks like tea, coffee, cola or chocolate close to
bedtime. Instead, have a warm, milky drink.
 o It’s important to make time to have some fun and to get a balance in
your life. Take a break, go on a holiday, and give yourself some leisure
time.
o With your consent, I would also like to arrange a family meeting with
your spouse so she can support you as well in implementing these
lifestyle modifications, and we can talk about family issues and work
together to manage it.
o I will give you reading materials regarding lifestyle stress, and will
regularly review you for blood pressure monitoring and review of your
overall health.

 Patient counselling — explanation of diagnosis and patient education and

initial management plan.
 Provision of an adequate explanation about stress, its origins and its physical,
behavioural and psychological sequelae and complications, acute and
chronic.
 Reassurance about blood pressure and chest pain.

This patient has obsessional personality characteristics of perfectionism, mental

and interpersonal control, propensity to overwork, and inflexibility (not
personality disorder, on available information). As a coping style, it has brought
occupational and personal success, but in the context of promotion and
increasingly complex life, especially family demands, it is now being overused;
healthy compensatory mechanisms such as pursuit of fitness and competitive
sports have been discarded, and dysfunctional habits substituted. The degree of
dysfunction is sufficient to produce somatic and behavioural symptoms —
increased headache, chest pain, labile hypertension, increased intolerance and
isolation. The patient is stressed and does not have a psychiatric or physical
illness, but intervention is now needed to modify those behaviours which
increases the risk of cardiovascular disease and psychiatric illness, as well as
relationship breakdown. Recognition of the personality style enables realistic
intervention — brief,
behaviourally or physically mediated, with extension to include spouse for
interpersonal/family issues.

Management
The essential management is to provide this patient with appropriately focused
brief intervention to modify behaviours and lifestyle, after engagement through
adequate reassurance regarding physical illness, followed by education of the
physiological mechanisms and identification of stressors. Use of hypnotherapy
for sleep disturbance (short-term) is acceptable but other measures are
preferable, such as a regular sleep pattern, and progressive muscle relaxation.
Modification of lifestyle — restrain working hours, alcohol and cigarette
consumption. Resume exercise, increase leisure activities, including family
pursuits — these are the interventions most able to be implemented.
Include the spouse in supporting lifestyle modifications and enable discussion of
interpersonal and family issues.
Follow-up and ongoing monitoring of blood pressure and cardiovascular health is
indicated.
Condition 087 Binge drinking
You are working in a general practice. The patient is well known to you. He is a 25 year old sole parent of
a six-year old girl --- the mother left soon after the girl's birth and there has been no contact since. The
patient works full time as a local delivery truck driver.

 He regularly drinks heavily at the weekends.

 He intermittently presents on Monday "feeling seedy" requesting a certificate for the day off.
 He is otherwise in good health, but has had frequent presentations for minor sporting injuries.
 He is not taking any medication, smokes 10 cigarettes per day; there is no other drug history.
 He does not have any history of psychiatric illness.
 He is generally a good and caring parent---he has no other regular help with child-care.
 His relationship with his family is strained---they blame him for his wife leaving.
 His father was a violent, heavy drinker during the patient's childhood, and still drinks, but not to
excess.

The patient came to the practice today for the removal of sutures to a small scalp laceration, well-
healed, sustained eight days ago in a fall at the pub after the football. He was briefly unconscious.

He was taken, intoxicated to the emergency department of the local hospital at 1:00AM eight days ago,
the wound was repaired and he was discharged several hours later. Your nurse has just removed the
sutures. She has alerted you to discuss the patient's drinking and parental responsibilities.

1. Discuss with this patient his pattern of drinking and its harmful consequences
2. Make appropriate recommendations for dealing with the problem

PLEASE RE-CHECK!
According to the handbook , drinking is safe up to six standard drinks per day, no more than 3 days a
week in men.
But during the lectures, safe up to 4 standard drinks per occasion!

 REMEMBER THE 5A's: ASK, ASSESS, ADVISE, ASSIST, ARRANGE

 [ESTABLISH RAPPORT] I understand that you are here today to have your sutures removed. How
are you now? Do you have any pain at the moment? *OFFER PAIN KILLERS*
 Confidentiality: I will discuss personal matters with you today as I am very concerned about what
had happened with you recently. Let me reassure you that whatever we talk about will remain
between us, unless it will be harmful to you or to others.
 ASK
o If it is alright with your, could you please describe the incident to me?What exactly
happened at the pub last week?
o How are you feeling now? Any headache or blurring of vision?
o Is this the first time that this happened?
o If it is alright with you, could I ask you about your alcohol intake?
 ASSESS
o How long have you been taking alcohol?
o How much do you usually drink? Per day? Per occasion?
o What type of alcohol do you usually take?
 o Pattern of drinking: do you usually drink every day? Only on weekends? Throughout the
day? During the evenings?
o Have you increased your intake of alcohol recently?
o Have you had any blackouts?
o Is it affecting your relationships?
o Any financial problems because of this?
o Do you often have accidents?
o Any charges with the law due to your drinking habit?
o CAGE QUESTIONS
 Have you ever tried cutting down on your alcohol intake?
 What made you restart taking alcohol again?
 Were you ever been annoyed by criticisms of others of your drinking habits?
 Have you ever felt guilty about your drinking?
 Do you require intake of alcohol early in the morning as an eye opener?
o How's your mood?
o Do you think that your life is worth living?
o How's your appetite? Any changes in weight?
o How is your home situation? How is your daughter? Who is taking of her?
o What is your occupation? Any stresses at work recently? Are you able to work efficiently
despite having this habit?
o Do you also smoke? Take illicit drugs?
o Are you sexually active right now? Do you have a stable partner?
o How long can you go without alcohol? what happens if you don't drink alcohol?
o Do you think you need to drink to go to sleep?
o Do you want to quit drinking alcohol? From a scale of 1-10, 10 being the most motivated,
how motivated are you in quitting the habit?
o Any history of medical or surgical conditions? Have you ever been diagnosed with any
mental health conditions? Any intake of medications? Do you have any allergies?
o Does anyone in the family also drink alcohol heavily? Any family history of hypertension,
heart disease, diabetes? Any mental health illnesses?
 ADVISE
o Alcohol is toxic substance, and In excess it can cause harmful physical and psychological
effects. In your case, it seems that you are drinking a hazardous amount of alcohol every
occasion, it is called binge-drinking, or alcohol overuse. It is usually linked to increased risk-
taking activities, acute harm events such as road accidents, and troubles with other people.
Just like in your case, you have been in trouble in different bars for quite a while and I am
very concerned about this.
o It can lead to complications, like heart disease, stroke, memory problem, stomach ulcers.
Once you quit alcohol drinking, there will be less problems with your work and with your
relationship to other people, and lesser chances to have troubles with the law. You will be
able to save more money, and reduce the risk of any health problems, and more energy to
do your responsibilities everyday.
 ASSIST
o You may cut down your alcohol, or stop it completely.
o Please keep your alcohol within safe limits, which is 2 standard drinks per day, or a
maximum of 4 standard drinks per occasion. I can give you a chart for reference. Don't drink
daily, and keep at least two days alcohol-free per week. Drink it only with food, and don't
 drink in an empty stomach. Have a glass of water in between drinks to satisfy the thirst. You
can mix alcoholic with non-alcoholic drinks. Please avoid high risk situations, like going to
pubs, drinking with friends, driving while drinking.
 ARRANGE
o You should now adapt a healthier lifestyle. Please engage in regular physical exercise and
adapt a healthier diet as well. I can arrange another review with you to address your
smoking habits. Instead of going to the bar, you may try to just spend time with your
daughter.
o I will refer you to a support group called, Alcohol Anonymous, which can help you with your
progress.
o I will also arrange blood investigations for you so that we can check your current status,
which includes an FBE, UEC, Vitamin B12 and Folate levels, LFTs, Lipase, Lipid profile, BSL,
and ECG.
 COUNSELLING
o I know you are a good father and it is difficult to take care of the child alone. I need to
inform the child protection services to make sure your child is safe when you are working.
They will not take him away from you, but will provide support for you which will help you
to take better care of him.
o Please avoid driving when you're taking alcohol. If this happens again, I would have to talk to
the road licensing authority to check your license
o REASSURANCE: there is a lot of support available for you and for your child. We will do our
best to provide a plan that will help you become better. Here are reading materials to give
you more insight about your condition. I will arrange a review with you again once your lab
results are available.
 QUESTIONS THAT MAY BE ASKED
o Are you saying that I am an alcoholic?
 Candidate should indicate that there are ranges of consequential problems to
excessive drinking, and binge type drinking is associated with risk-taking and acute
harm events.
o Look at my father, he's always been a drinker and he's okay
 There are various responses including simply accepting the statement without
comment, to a reminder that his father's drinking was associated with violence and
family dysfunction, which the patient would want to avoid for his daughter
o How can I relax if I don't have a few drinks with my mates?
 The candidate could respond with an undertaking to discuss this further, or the option
of controlled drinking (less feasible with a binge drinking pattern), or some
introduction of relaxation techniques.

 Discussion about binge drinking and consequential harm

 Highlight risk to daughter -- discuss potential referral to child protective services or equivalent

 Not addressing the issue of his daughter's well-being, protection and care management in any way

 Alcohol abuse and dependency are linked with genetic and developmental predisposition,
developmental environment, personality traits, and other psychiatric illness, especially mood and
personality disorders.
 Sociocultural factors are also significant.
 Hazardous drinking of excessive quantities of alcohol intermittently is a subtype of alcohol abuse,
less associated with withdrawal symptoms
o Associated with:
 injury
 Social and interpersonal sequelae of impaired judgement and poor impulse control
 Incidents of accidental injury to self or others, disinhibition, and sexual or aggressive acts, and
neglect of self or others are frequent reasons for intervention
 Episodic neglect of financial, occupational, and social responsibility is common, such as regularly
missing work after weekends
 Effective intervention includes
o Identification of the reason for the adverse consequences
o Sensitive but frank communication about the problem and appropriate offers of assistance
(education, assessment of psychiatric, medial, social, legal, interpersonal problems)
o Motivation for change
o On-going review
 This case: appropriately address the risk to daughter which must include his responsibility for
parental care and protection
 Statutory obligation to inform an authority of the daughter's situation as she is potentially at risk
of abuse by neglect. Check whether notification was made at the time of his presentation to the
ED
o Department of families
o Community services
o Indigenous affairs
 The authorities will be able to advise him about local child-care and parent support services.
 Inform about support groups
o Single-parent support groups, men-only support groups
o Give reading materials
Condition 088 Serotonin Syndrome
Your next patient is a 30-year-old bank clerk, who is consulting you in the Emergency Department of a
general hospital. She is complaining of severe nausea, headaches and the 'jitters'.
She attended here two days ago. Brief notes in the Emergency Department patient record state that she
was then complaining of back pain which was diagnosed as 'muscle pain'. The notes also state that she
had been taking the selective-serotonin-release-inhibitor (SSRI) Prozac® (fluoxetine) 20 mg daily for
depression for three weeks on the advice of her local doctor, without much improvement. An
alternative SSRI —Zoloft® (sertraline) 100 mg daily was prescribed when she attended the Emergency
Department.

1. Take a further focused history related to this situation.

2. Ask the examiner for the appropriate examination findings you require to assist in diagnosis.
3. Inform the examiner of your diagnosis.
4. Counsel the patient about the likely cause of her symptoms, their treatment, and what you
recommend with regard to further management of her depression.

Positive points in the history

 Chief complaint: nausea, headaches, jitters
 Takes Fluoxetine (SSRI) 20mg daily x 3 weeks
 Took Sertraline (SSRI) 100mg daily since 2 days ago
Positive points in the PE: high temperature, tachycardia, high blood pressure, muscle rigidity,
arrhythmias, dilated pupils

Differential Diagnosis:
 Organic
o Hypoglycemia
o Tension headache
o Excessive caffeine intake
o Drug-induced/Recreational drug use/Withdrawal
o Malignant hyperthermia
o CNS infection
 Psych
o Anxiety
o Serotonin syndrome

 History
I would like to know if my patient is hemodynamically stable? May I know the BP, heart rate,
temperature, and sats?
o If patient is unstable, proceed with DRSABC protocol. May give oxygen if sats are low, IV
fluids if hypotensive, benzodiazepines if agitated, nitroprusside if hypertensive, esmolol if
tachycardic, cooling measures if hyperthermic.
Good morning Mary, I am Dr. Lea, one of the HMOs here at the ED. I've been tasked to examine
you about the problem you are experiencing right now. Would you like to tell me more about it?
o History of present illness:
 When did the jitters, headaches and nausea start?
 Did these symptoms occur at the same time, or which one preceded which?
  Was the onset sudden or gradual?
 Are the symptoms there continuously or does it come and go?
 Jitters
 What do you exactly mean by jitters?
 Do you experience tremors or shakes?
 Do you feel any pins and needles in your hands or feet?
 Headache
 Where is the site of pain?
 Does it go anywhere else?
 What type of pain is it? Is it a sharp pain, a dull ache, a band-like pain?
 Anything that makes it better or worse?
 Did you notice anything that triggers it?
 Any associated symptoms like blurring of vision, vomiting, weakness of any part
of the body, neck stiffness?
 How severe is the pain from 1 to 10?
 Nausea
 Is your nausea associated with actual vomiting?
 Do you have tummy pain?
 Is it associated with a particular smell, sight, or any obvious trigger?
o Differential Diagnosis
At this point Mary, I would like to assure you that whatever we discuss today will be private
and confidential unless it poses a risk to you or to others.
 Hypoglycemia: By any chance, did you miss a meal before your symptoms started?
 Tension headache: Do you have any recent or ongoing excessive stress in your life?
 Excessive caffeine intake: How many cups of coffee do you consume in a day?
 Drug-induced: are you taking any over the counter or prescription medications, or are
you taking any type of recreational drugs?
 Anxiety:
 Are you worrying about something going on in your life right now?
 Serotonin syndrome:
 I read from the notes that you've been taking a medication called Prozac for the
past 3 weeks. Are you still taking them regularly?
 What was it prescribed for, and who prescribed it to you?
 Were you experiencing side effects from this medication?
 I also read from the notes that you also attended here at the ED two days ago
due to a back pain, and you were prescribed with another medication called
Zoloft. Were you able to take it as well?
 Were you still taking Prozac when you started taking Zoloft?
 Did you start experiencing the symptoms after taking the new medication?
 Signs and symptoms of Serotonin syndrome:
 Do you experience any agitation, confusion, seizures, tremors, shivering,
sweating, funny racing of the heart, fever, diarrhea?
o Psychosocial history
 How is your mood?
 Do you think that life is worth living?
 Do you have any passing thoughts of hurting yourself or others?
 How is your appetite?
 Did you have any recent weight loss?
  How is your sleep?
 Do you think that anyone is spying on you?
 Do you see, hear, or feel things that others do not?
 Do you think that thoughts are being inserted into your head?
 Do you think that your thoughts are being broadcasted in TV, radio, or social media?
 Do you think that you need help right now?
 If there is a fire in this room what would you do?
 Do you know that date today, where you are, who I am?
o HEADSS
 How is your home situation? Who do you live with? Any stress at home?
 Do you have relatives who live nearby?
 Do you have a good support?
 I see that you are a bank clerk. How is your job going so far? Any stress at work?
 Do you still enjoy the activities that you used to enjoy before?
 Do you still go out to meet your friends and family?
o SADMA
 Do you smoke?
 Do you drink alcohol?
 Do you have any known allergies?
o Any past history of a medical, surgical, or mental illness?
o Any family history of a medical, surgical or mental illness?

 Physical exam
o General appearance: is there any obvious sweating, tremors? Any pallor?
o Vital signs: BP, HR with regularity, RR with saturation, temperature?
o Eyes: any bloodshot eyes, dilated pupils or pinpoint pupils?
o CNS: I would like to know the tone, power, reflex, and sensation of the upper and lower
limbs
o I would like to do the rest of the systemic exam, CVS, Respiratory, Abdomen, Pelvic.
o Office tests: BSL, UDT

 Diagnosis and Management

Mary, based on my history and examination, most likely you are having a condition called
Serotonin syndrome. Do you have an idea what this is?
Serotonin syndrome is a serious adverse reaction to the use of certain medications. In your case,
you experienced this because of the interaction of the two medications that you were taking,
Prozac and Zoloft. Even though you have stopped taking Prozac when you took Zoloft, it would still
take about a week for it to wash out, that is why there was still an interaction between the two
drugs.
Signs and symptoms of this is agitation, confusion, seizures, tremors, sweating, increased tone and
reflexes of the limbs, high blood pressure, fast heart rate, increased temperature, diarrhea,
depending on the severity of the reaction. In your case, most likely it is just a mild reaction.
What we will do right now is to stop Zoloft and we'll keep you here for a few hours to observe you
and wait until the symptoms resolve, usually within 24 hours. But since we still need to manage
your depression, we still need to give you medications. However, we will wait for at least another
week before we reintroduce Zoloft at a lower dose. During this wash out period, I would like you
to seek support from your psychologist for a possible talk therapy.
 We will monitor you for the resolution of your symptoms so I would to follow you up after 24
hours here at the ED, or if you prefer you can follow-up with your GP. However, at any point that
your symptoms worsen, or you develop suicidal ideations, please report back immediately. I will
give you reading materials regarding Serotonin syndrome for further insight.
Do you have any other concerns?

 Ability to diagnose the serotonin syndrome due to side effects of a Selective Serotonin Reuptake
Inhibitor (SSRI) drug.

 Failure to recognise the need to stop the Zoloft® (sertraline) medication.

This scenario is a timely reminder about aspects of psychopharmacology. Side effects are common with
most psychotropics because they may be prescribed too enthusiastically and in dosages that are
inappropriately high, especially in management of 'depression' which is a complex multifactorial
complaint in our modern society. Not all patients with 'depression' or depressive symptoms need
antidepressants, but like antibiotics they are often prescribed reflexly by doctors under time pressure as
a ’quick fix – it can’t do any harm’ panacea for a patient in distress or in tears. Often it is the doctor's
helplessness that is being treated by the prescription because there is never enough time to establish
why this patient is depressed on this occasion.
Another common error is to start with too high a dose if the patient is really, really distressed {'more
must be better and will work faster'). Antidepressants and antipsychotics take 3-4 weeks to work. If the
patient's symptoms improve within that time there may be other factors which explain the
improvement, such as reduction in anxiety or insomnia or the benefits of a sensitive interview with the
discussion of issues and problems, or relief that the problem has been identified and that something is
being done.
Often it is not symptoms per se that cause patients or relatives to seek treatment. Patients present to
doctors when they are worried or anxious about symptoms or behaviours, or someone else is, who
influences the patient to attend the consultation. Anxiety intensifies ALL symptoms including
'depression' and is accompanied by typically exaggerated and catastrophic cognitions about the
consequences and outcome of whatever is causing their distress. ‘Is it fatal/terminal? Will I go mad/drop
dead etc?'
An effective initial consultation with a patient who is 'depressed which attempts a biological-
psychological-sociocultural approach and allows sufficient time for the patient to be listened to, to be
understood and to be taken seriously, will in itself relieve a major part of the intensity of the symptoms.
This will only enhance the effectiveness of whatever is subsequently recommended or prescribed.
Many people with 'depression' have mood fluctuations on a cyclical basis which are subthreshold or
relatively mild. These people are more likely to present at their peaks or troughs when they are
symptomatic in response to a life event or ongoing environmental stress. Their symptoms may be
naturally or temporally transient. If these people (as patients) are then prescribed psychotropics,
including antidepressants, when symptomatic (instead of being managed expectantly), and they
improve after a few days, they and their clinician may mistakenly attribute their response to the
medication. This may commit them to a future psychological dependence on medication rather than
learning to tolerate temporary oscillations in mood and biological symptoms by using nonchemical
coping strategies.
Some doctors and patients have become brainwashed by pharmaceutical companies into believing that
any degree of distress or suffering requires a chemical solution that is quick and effective (but frequently
expensive and unnecessary). When a patient has been started on an antidepressant and is appropriately
reviewed a week later and reports no improvement, the inexperienced or unaware clinician may
recommend doubling the dose and seeing the patient a week later. At two weeks, when there is still no
major improvement or cure, the dose will be increased or doubled again. By the third week when the
patient reports some improvement at last, this is wrongly attributed to the increase in dosage and not
the latent response to the initial dose.
SSRIs are potent drugs even in low dosage. Once the dosage increases then side effects and toxicity will
increase significantly. Most patients take such medications erratically or in fits and starts (i.e. if they are
having ' a good day' they will skip a dose: if it's a bad day', then they will double the dose). Some
patients are extremely somatically focused and will develop toxicity just by reading the package inserts
about product information.
This patient feels aggrieved that she has been mismanaged and ill-served by the doctors who have
unknowingly contributed to her serotonin syndrome. Patients deserve better and clinicians must ensure
that they are aware of both the risks and benefits of the drugs they prescribe. As patients become better
informed, they will not tolerate scenarios like this one lightly. Neither will their legal advisers.
The serotonin syndrome is caused by excess serotonin in the central nervous system, commonly
because of drug-drug interaction, in this case inadequate washout between a long half-life agent
(fluoxetine) and a high starting dose of a second SSRI (sertraline). The syndrome usually presents with
changes in mental state (confusion, irritability, labile mood), restlessness, myoclonus, hyperreflexia,
fever, sweating, shivering and tremor and diarrhoea.
Hypertension, convulsions, and death have been reported. Treatment is to cease the medication and
provide symptomatic care (e.g. cooling blankets). Referral to an emergency specialist may be necessary
in more severe cases.
Condition 089 Collapse of a 30 year old
This patient was brought to the Emergency Department complaining of a sudden inability to walk. She
had collapsed on the way to court where her husband was due to appear on fraud charges. The charges
related to embezzlement to cover the husband's gambling debts.

She is a 30 year old housewife who was fully active yesterday and carrying out her everyday life up until
this morning. You have reviewed the case and found the patient presented with a similar condition a
year ago at the time the fraud was first alleged. At that time, she was admitted to hospital, and
investigation including computed tomography of the spine and head were reported as normal. After two
weeks in hospital she recovered the ability to walk.

1. Examine the lower limbs with attention to the neurological system --- you have six minutes to
complete your examination
2. Report your findings to the examiner as you proceed. Also take note of the patient's general
behavior and demeanor.
3. Answer the questions which the examiner will ask you about this problem.
4. Provide a likely diagnosis to the examiner, and give your reasons for selecting the diagnosis.

 Wash your Hands.

 Good morning, I am Dr ____and I will look after you today. How can I address you?
 Today I’m going to do a physical examination of your legs, I’m will have a look, feel and I’ll ask you
to do some movements. Is that alright with you?
 Can you expose your leg up to your mid-thigh please?
 Before I start. Are you in pain? Where exactly is the pain? Do you need any painkillers? if I hurt
you or you feel uncomfortable, during the examination, just let me know so that I could stop.
o GAIT: Can you please take a few steps for me? Then turn around an please walk back.
 Can you please walk in one foot in front of the other? (cerebellar testing)
 Walk in tip toes.
 Walk in heels.
 REPORT: The gait is normal. The speed, symmetry and arm swing were all normal. The
power of dorsiflexion and plantarflexion were all normal.
o Romber’g test: Can you close your eyes for me?
 REPORT: The Romberg’s test is negative.
o Tone: Can you please lie down on the bed and let your leg be floppy or relax your leg for
me?
 Leg roll (internal and external rotation of the femur)
 Knee:
 Pull knee upward then let go
 Flex and extend knee (feel for any resistance)
 REPORT: The tones of both lower legs were normal.
o Clonus:
 Ankle Clonus: Rotate ankle then dorsiflex the foot.
 Can you bend your knee? (Thigh externally rotated). The ankle clonus is
negative.
 Knee: Can you straighten your leg? (sharply move patella down, hand on lower part of
Quadriceps)
  REPORT: The knee clonus is negative. There is no sustained rhythmical contraction of
the quadriceps.
o Power:
 Can you please lift your leg up?: Hip flexion: L2-3
 Can you please push against the bed?: Hip extension L5, S1-2
 Can you please push your leg together?: Adduction L2-4
 Can you please pull you leg apart?: Adduction: L4-5, S1
 Can you please bend your knee? Knee flexion L5-S1
 Knee Extension L3-L4
 Push toes against my hand Dorsiflexion L4-5
 Plantarflexion S1-2
 Ankle inversion L5, S1
 Ankle eversion L5-S1
 REPORT: the motor power of the lower limbs are normal.
o Reflexes: This is a neurohammer, and I will tap gently on parts of your leg and feet to test
your reflexes. This won’t hurt, please bear with me.
 Knee jerk: L3-4
 Ankle reflex: L5-S1
 Plantar jerk L5, S1-S2
 REPORT: the lower limb reflexes are normal, no clonus, or hyporeflexia noted.
o Sensation:
 BLUNT OR SHARP ENDS: This is a neuropin, this is what it feels like. Please close your
eyes and let me know if you can feel it.
 L1: Inguinal area (pocket area)
 L2: Upper medial thigh
 L3: lower thigh (mid area)
 L4: knee / outer lower leg
 L5: Big toe
 S1: Small toe
 VIBRATION: This is a vibration fork. This is what it feels like. Please let me know if you
can feel it. Please close your eyes.
 PROPIOCEPTION: I’m gonna test your position sense. This is down, up, and neutral.
Now I would ask you to please close your eyes, and tell me if it is down, up, and
neutral.
 LIGHT TOUCH: This is what it feels like. Please close your eyes and let me know if you
can feel it.
 REPORT: There are no sensory deficits on light and sharp touch, intact vibration and
position sense
o Coordination: REPORT: The coordination tests were all normal.
 Heel to shin test.
 Toe Finger test.
 Can you tap your feet against my hand as quick as you can?
o To complete my examination, I will do the cranial nerve exam, the upper limb neurological
exam and the cardiovascular system examination.
 ANSWERS TO THE EXAMINER
o What would you expect to find on sensory examination given your findings thus far?
 Normal sensation
o What is your likely diagnosis?
  Somatoform conversion disorder
o What has lead you to that conclusion?
 The physical examination findings are all normal, and are not congruent with a
possible organic illness. Moreover, the patient seems to have a bland disconcern
(belle indifference) about her condition, as well. These are consistent findings present
in a somatoform conversion disorder, as the physical problem that she developed
occurred as a response to the overwhelming stress that she is currently undergoing
now. The symptoms that she presented tend to be her defenses against an
overwhelming emotion such as anxiety, anger, or shame, for the emotional conflicts
brought about the impending fraud charges that she is currently facing.

 Ability to conduct an appropriate focused neurological examination of the lower limbs and identify
a somatoform conversion disorder with abnormal illness (Sick Role) behavior

 Failure to conduct a thorough neurological examination

 Unacceptable for the candidate to do an incomplete neurological examination of the lower limbs,
and unacceptable to conclude that the problem is "an anxiety disorder" or other such ill-defined
diagnosis.
 Hysterical conversion, abnormal illness behavior, and sick role behavior can be acceptable
 Stronger candidates may present a more sophisticated diagnosis with formulation, thus correctly
linking the conversion disorder to the unresolved emotional conflicts around the impending fraud
charges, and the patient's extreme shame and anxiety in regard to this.
Condition 100 Repeat
benzodiazepine script
You are working in a general practice. You saw this patient for
the first time one week ago and provided a prescription for his
usual sleeping tablet, the benzodiazepine oxazepam (Serepax®)
30 mg daily, 25 tablets. At that time, you were satisfied there
were no comorbid problems such as depression. The patient
has returned today for another prescription. The patient's
mental state is unchanged.

1. Evaluate the situation by taking a focused history.

2. Outline to the patient the nature of the problem you have
identified and proposed management.
3. Answer any questions the examiner asks you.

 History
o Good morning John, I am Dr. ____, your GP today, how

may I help you today?

o I understand that you want a refill of your tablets now,

but would it be alright if I ask you a few questions

before we make a decision?
o Let me assure you that whatever we discuss today will

be private and confidential, unless it poses a risk to you

or to others.
o History of medication use

 How long have you been on this medication?

 Who saw you on your initial consultation and

prescribed this medication?

  When did you last see your specialist? Do you go for
regular check-ups?
 Why have you been put on this medication?

 How many tablets and how often was the

prescription for you?

 Have you been taking it at the prescribed dosage

and frequency?
 Is there any time that you have taken extra tablets?

 May I ask why you took extra tablets?

 Do you feel better when you take the medication?

 Do you think you need this medication to feel that

way?
 I understand your reasons for taking extra tablets,

but we have to discuss that in a little while as I have

some concerns about it.
 Do you experience jitteriness or shakiness, or have

problems with sleep and concentration when you

don’t take the pill?
o Psychosocial history
 How is your mood?

 Do you think that life is worth living?

 Do you have any passing thoughts of harming

yourself or others?
 How is you appetite?

 Did you notice any recent weight loss?

 How is your sleep?

 Do you think that someone is spying on you?

 Do you see, hear, or feel things that others do not?

 Do you think that you need help?

  If there is a fire in this room, what would you do?
 Do you know where you are right now, what date it

is, and who I am?

o HEADSS
 How is your home situation? Who do you live with?

Any stress at home?

 Do you have a good support?

 Do you work or go to Uni? Any stress at work or at

Uni?
 Do you still enjoy the activities that you used to

before?
 Do you still go out to see your friends and family?

o SADMA
 Do you smoke?

 Do you drink alcohol?

 Do you take recreational drugs?

 Aside from this medication, are you taking other

over the counter or prescription medications?

 Do you have any known allergies?

o Have you been diagnosed of any medical or mental

illness in the past?
o Do you have a family history of any medical or mental
illness in the past?

 Diagnosis and Management

Thank you for those information that you shared with me
John. I understand that you want a script for a refill of your
tablets, but as I mentioned a while ago, I want to discuss
some things as I have some concerns about it. Is that alright
with you?
I understand that you have had stressful experiences in
your life, and there has been extra pressure at work lately,
and you feel that this medication is helping you cope with it.
However, this medication is usually only helpful if used for a
short duration, usually 1 to 2 weeks. If used more than that,
usually it leads to dependence.
If you're happy to cooperate with me, I would like to discuss
a management plan with you.
I would like to replace your current medication with
another medication of the same group, but with a longer
duration of effect. You will still get the same relief from it.
Initially, I will give you an equivalent dose, but we will
gradually taper the dose based on your response, until you
can be off the medication. In this way, we would minimize
the occurrence of withdrawal symptoms( like fits, agitation,
exacerbation of anxiety) and maximize treatment success.
During this period, I would like to make a regular (meet with
you ) follow up with you so we can monitor your mood and
response to the medication, and we can discuss your
concerns if there are any. It may take a while for us to
eventually take you off the medication, but as long as you
stay and cooperate with our plan, that would be okay. For
now, I will give you a script for 1 week with daily dispensing.
With your consent, we can also involve your family and
arrange a family meeting so they can as well provide you
support.
I can also refer you to a psychologist for talk therapy , give
you resources materials,support group.
To help you with your sleep problem, please follow these
tips:
 Try to get up at the same time every day. Soon, this

strict routine will help to set your body clock and you'll
find yourself getting sleepy at about the same time
every night
 Get enough early morning sunshine. Exposure to light

during early waking hours helps to set your body clock.

 Do not ignore tiredness. Go to bed when your body tells

you it's ready

 Don’t go to bed if you don't feel tired. You will only

reinforce bad habits such as lying awake.

 If you can't fall asleep within a reasonable amount of

time, get out of bed and do something else for half an

hour or so, such as reading a book.
 Improve your sleeping environment by investing in a

mattress that is neither too hard nor too soft, making

sure that the room is at the right temperature, it is dark
enough, and it is quiet.
 Use your bedroom only for sleeping and intimacy.

 Avoid cigarettes and alcohol close to bedtime.

 Avoid caffeinated drinks like tea, coffee, cola or

chocolate close to bedtime. Instead, have a warm, milky

drink.
Adopt healthy lifestyle modifications. Avoid smoking, do not
drink excessive amounts of alcohol—that is, a maximum of
two standard drinks a day, eat a sensible amount of food,
 and pick foods rich in vitamins, maintain a healthy weight,
exercise regularly at least 30 minutes per day, 5 times per
week, and allot time for relaxation.
Just in case you develop symptoms such as irritability,
tremors, sweating, confusion, seizures, nausea, vomiting,
and abdominal pain, please report immediately. I will give
you reading materials for further insight and I will see you
again in a week. Do you have any other concerns right now?
 Identification and preparedness to address the issue of
dependency and overdose.
 Appropriate language and attitudes in taking the history and
discussing the problem.
 Knowledge of biological and psychosocial management of
benzodiazepine dependency.
 Awareness of the risks of sudden cessation, such as acute
withdrawal states, fits, agitation, exacerbation of anxiety
and treatment failure.

This station assesses the candidate's ability to identify inappropriate

benzodiazepine use and dependency, and to
counsel a patient appropriately. The doctor is presented with the
problem of being drawn into maintaining a long-term benzodiazepine
use habit, with clear evidence of over-use (approximately 75% greater
consumption than the
prescribed dose). Benzodiazepines are recommended for short-term
use only. While they have some place in the
Long-term management of chronic severe anxiety, other treatments,
including antidepressant medication and
psychological treatments (relaxation techniques, cognitive behavioural
or interpersonal therapies) must be applied
first. Long-term prescription needs are to be closely supervised and
monitored for over-use, such as in this case.
This case challenges candidates in a number of ways. Chiefly, it requires
them to actively and constructively
intervene, not just to provide the prescription (with or without advice)
or to just refuse the prescription, thus provoking the patient to seek out
another source, or risking precipitating a withdrawal state. The
satisfactory candidate, in addition to managing the immediate
consultation needs, will be aware of community support and self-help
groups.
Candidates should demonstrate that they understand the problems of
both prescribing further medication without any review or plan for
reduction, and also suddenly stopping the medication. Thus, simply
advising the patient that they will 'talk next time', or refusing to
prescribe with no other measures put in place, are both unsatisfactory.
Similarly, referring the patient immediately to a substance abuse unit
would be unsatisfactory and counterproductive.
Condition 106 Recent insomnia
You work in a family medical center. You are seeing the son of a
recently deceased patient. You have known the family for many years,
and have seen the son on many occasions before with childhood
illnesses. You saw him last six months ago (prior to him taking flying
lessons) at which time a full general examination was normal.

The son is now 25 years old, single and a university student. He is

consulting you because of difficulty sleeping over the past month since
the unexpected death of his father. Prior to the death there had been
no problems sleeping, except immediately prior to the university
examinations. There is no relevant past history and his general health
previously has been excellent.

1. Take a focused and relevant history, to enable you to diagnose the

cause of the insomnia
2. Develop a management plan
3. Counsel the patient

 DDx
o Depression

o Anxiety disorder

o Post-traumatic stress disorder

o Normal grief

 Good morning, I'm Dr ___, I will be looking after you today.

How may I address you?
 I'm sorry to hear about your father. How are you so far?
 Let me reassure you that whatever we talk about will just
remain between us unless it will be harmful to you or to
others.
 I understand that you are here because you have been
having difficulty sleeping. Can you tell me more about it?
o When did this start?

o Finding it hard to fall asleep?

 How long does it take you to fall asleep (>15mins =

abnormal)
o Once you fall asleep, do you have to wake up multiple

times?
o Why do you wake up multiple times?

 Do you have any thoughts racing in your mind, what

makes you wake up? (ANXIETY)

 Do you have any nightmares or flash backs?

 Once you wake up, how long does it take you to fall

asleep?
o Do you wake up early in the morning?

o Do you sleep in between the day? Take some naps?

o Do you feel fresh in the morning? Do you feel drowsy in

class?
o Do you snore?

o EXPLORE FATHER'S DEATH

 Is it okay if I ask you some questions about your
father?
 What happened to him?
 Where were you at the time when it happened?
Could you tell me more about what happened
during that day?
 How are you and your family coping so far? Do you
have support?
o PSYCHOSOCIAL HISTORY (complete depression screening,
>2 weeks, 5/9 symptoms = MAJOR DEPRESSION)
 How is your mood?

 How is your appetite?

 Do you still enjoy doing the activities you used to

do?
 Do you think that life is worth living?

 Sometimes when very stressed, some people

tend to think of doing harm to themselves or

others. Is this applicable to you?
 Do you feel guilty of anything? Guilty of your father's

death?
 Do you feel more tired these days?

 Do you have difficulty concentrating?

 Have you slowed down on things?

 I will just ask you some questions that I routinely ask

my other patients for assessment. Will that be okay?

 Do you think someone is spying on you?

 Do you think someone is trying to harm you?

 Do you see, feel, hear things that others don't?

 Do you think you need help?

 If there's a fire in this room, what will you do?

 Where are you right now? What is the date today?

Who am I?
 HEADSS

 How are things at home? How is your

relationship with your mom? Do you talk about

your feelings with one another?
  DO you have relatives nearby? Do you have
enough support?
 How is your schooling? How long have you been

off studying? When is your exam?

 Have you talked to anyone in the faculty or in

school about your situation?

 Are you sexually active? In a stable relationship?

 Do you go out and meet up with friends and

families?
 SADMA
 Do you smoke?

 Drink alcohol?

 Take recreational drugs?

 Do you take any tea, coffee, or alcohol before

going to bed?
 Are you on any medications?

 Any allergies to food and drugs?

 PMH
 Do you have any past history of mental illness?

Any medical or surgical illnesses?

 FH
 Do you have any family history of mental illness?

Any history of cancer, diabetes, hypertension?

 MANAGEMENT PLAN AND COUNSELLING
o It’s normal to feel down especially when you lose
someone close to you but it’s good that you’ve come to
me to discuss. Most likely you’re having a Grief
Reaction. Grief is part of the nature response to an
emotional wound, it’s not an illness. It will go away with
 time, like a bruise. To help you with it, let me make a
management plan for you.
o There are some things that you can do to relax or to feel
good:
 Be close with your family members and friends,

don’t think you’re alone or lonely.

 Go out with your friends or anyone close to you

 If you want, I can give you some address of religious

sources, they’re spiritual, you can talk with them

personally
 I can refer you and your family to support groups

who underwent the same thing as what you and

your mom had
 Social worker who will help you and your family -

Nurses, crisis center

o Your difficulty of sleeping is most probably linked to the
grief reaction that you're having. And as of now, there
are many other ways to improve your sleep (sleep
hygiene):
 Avoid alcohol, tea or coffee before going to bed,

that will help you to maintain your sleep

 Avoid heavy evening meal before going to bed

 Avoid day time nap

 Take one glass of warm milk before sleep

 Take regular daytime exercise

 Need to maintain suitable room

 Need to make your room noise-free, don’t put bright

lights inside your room

  I can give you reading materials about this sleep
hygiene list which you can follow every day
o I will organize psychologist referral, where he might
start you with a relaxation therapy
o If all measures fail, then I’d like to give you sleeping
tablet like Temazepam 10 mg orally at night for 2 weeks,
not more than 2 weeks. (Can prescribe it now)
o I understand it’s hard to take the exam right now
because you can’t concentrate on studying. I think it’s
wise to talk to your course coordinator regarding this
situation. It’s possible to postpone your exam consider
this special circumstance. I can give you a medical
certificate for it.
o And since your dad developed a heart attack, I can do
baseline investigations for you as well just to check you
for some risks. I will do FBE, lipid profile, and an ECG. I
can also refer you to a cardiologist for a full review after
you have recovered from your current condition.
o I will arrange counselling for your & your family. I’ll see
you in one week time to see how you’re coping with
that.
o If you drive, please drive carefully.
o Here are some reading materials that can give you
insight about your condition.
o Are you happy with this plan?
 Displaying empathy with the patient
 Appropriate history to determine diagnosis of the cause of
insomnia
 Displaying appropriate counselling skills when advising the patient
about the management of this problem, including other common
problems which can occur

 Prescribing antidepressants at this stage

 Omitting supporting interaction

 Grief: emotional cost after the loss of someone or

something precious and meaningful
o Painful and causes psychological anguish, waves of

unpleasant dysphoria, and distress

o Physiological arousal and mixture of physical symptoms

o NORMAL function of the human condition

 Insomnia in the early days and weeks following a loss is part

of the adjustment process, and managed expectantly
o Grief is part of the natural response to an emotional

wound, and like a bruise, it will resolve, given time.

 Short term treatment with a hypnotic (short acting
benzodiazepine--temazepam, oxazepam, lorazepam, or a
non-benzodiazepine such as Zolpidem or Zopiclone)
o For people who cannot afford daytime fatigue or

somnolence even for a few days after a restless night

o Given for up to 2 weeks only

o Rebound insomnia may still occur if these are tapered

off
 Grief-associated insomnia treated with hypnotics may be
the start of chronic or lifelong psychological dependence on
a benzodiazepine and requests for repeat prescriptions
should be declined
  It is normal to feel diminished and bereft when someone
revered dies, but not to feel personally worthless, useless
and hopeless with lowered self-esteem and irrational guilt
or shame.
 Suicidal ideation is not part of normal grief, but deliberate
self-harm afterwards may be cultural, or an expression of
extreme dysphoria and not indicative of an
intention to die.
o Marked functional impairment, prolonged anorexia and

weight loss, persistent insomnia, significant

psychomotor retardation, hypomania or manic behavior
or frank psychosis are all indications for antidepressant
treatment, mood stabilizers including lithium carbonate,
or atypical antipsychotics. Specialist referral may be
necessary once grief overlaps with psychiatric illness.

STAGES OF BEREAVEMENT
 Shock or disbelief: feelings include numbness and
emptiness, anxiety, fear, and suicidal ideation
 Grief and despair: feelings of anger, guilt, self-blame, and
yearning. Social withdrawal and memory impairment may
occur. Feeling of intense grief usually lasts about 6 weeks
and the overall stage of grief and despair for about 6
months.
 Adaptation and acceptance: significant feelings of apathy
and depression. Physical illness is common and includes
problems such as insomnia, asthma, bowel dysfunction,
headache, and appetite disturbances
Condition 109 Postnatal Depression
You are working in a general practice. The patient is a 28-year-old mother of two
children who presents with a two-week history of broken sleep, fatigue and
exhaustion. She is accompanied by her husband. Peter, who is a 30-year-old
manager of a travel agency. They live locally with his parents whilst they save for
a house. They have a 10-week-old son, Thomas, who is breastfed, and 30-month-
old daughter. She is a non-smoker and non-drinker.
Your practice records show that both pregnancies and deliveries were normal and
uneventful.

1. Take a further appropriate history to evaluate the possible causes of her

symptoms. You do not need to perform a physical examination.
2. Provide a likely diagnosis to the examiner and give your reasons for selecting
this diagnosis.
3. Outline briefly your management approach to the examiner.

Positive points in the history:

Chief complaint: broken sleep, fatigue, exhaustion x 2 weeks
 Mother of two children: 10 week old son who is breastfed, and 30

month old daughter

 Husband is a manager of travel agency
 Lives with parents
 It was a planned pregnancy
 Have been constantly afraid that Thomas may stop breathing and

suffer a sudden infant death, so have forced herself to sleep for

only brief periods. She has become increasingly worried that
Thomas is not feeding properly and is failing to thrive because of
her insufficient supply of breast milk. So you have been weighing
him at every opportunity, at the clinic, at home and weekly at the
local hospital Emergency Department. Even though his weight
appears to be increasing, she has become convinced that the
various weighing scales are wrong and that, as his mother, she
KNOWS that he is not gaining weight.
  She has come to believe that she is a bad mother and a failure and
that as a result her son and daughter will be taken away from her
and that her story will be highlighted in the media.
 She has begun to think that life is not worth living and that the
shame and gossip from neighbours and friends which she is SURE is
going on, would be stopped if she just went away somewhere and
kill herself. Then her family will be better off, because that will
prove to them how much she loved your son, as his health
problems are her entire fault.
 Increasingly over the last two weeks, she has not been sleeping
well. Her appetite has diminished and she has been losing weight
since Thomas was born. She has lost 6 kg in the past ten days. She
is tired all of the time, she feels terrible inside and she feels
anxious, agitated, unhappy, guilty and desperate. Her anxieties
about her son's health and wellbeing have not been allayed by
reassurances
from her husband, her extended family, the clinic nurses or the
hospital Emergency Department. Now she are worried that her
husband's insistence on her coming to see the doctor means that
he is planning to divorce her, because she have failed as a mother
and a wife and brought shame to his family name.
 Describes herself as a quiet, placid, socially anxious. Very home and
family orientated -- obsessional and conscientious.

Differential Diagnosis
 Major Depression
 Hemochromatosis, Hepatitis
 Hypothyroidism
 Diabetes Mellitus
 Adrenal Insufficiency
 Malignancy
 Infections
 Chronic Fatigue Syndrome
 Anemia
 Drug-induced/Medication-induced
 Sleep oapnea
 Celiac disease
 History
Good morning Mary, I am Dr. _______ your GP for today. I read
from the notes that you are having problems with your sleep and
are feeling a bit fatigued. Could you tell me more about it?
o History of present illness

 How long have you been experiencing these symptoms?

 Did you experience this suddenly, or did it happen

gradually?
 How did it start? Is it becoming worse, or it's just the same?
 Is it always there, or it just comes and goes?
 Anything that makes it worse or better?
 Did you notice anything that might have triggered this?
 Is this the first time that you have experienced this, or was it

the same with your first pregnancy?

o Postpartum questions

 How are you coping with the birth of your second child?
 Was it a planned pregnancy?
 Are you enjoying your motherhood?
 Any concerns or problems that you are experiencing so far?
 Why do you think so?
 Did anyone tell you this?
 Did anything happen that made you think this way?
 How is your baby doing?
 Would it be alright if I ask your husband some questions as

well?
 How are your children doing? Are they healthy and

well? Any problems with the wellbeing of your

children?
o Differential Diagnosis
  Hemochromatosis: Any pigmentation in your skin or your
mouth?
 Hepatitis: Any yellowish discoloration of urine or eyes? Any

travel history?
 Hypothyroidism: Do you have any weather preferences? Any

changes in your bowel habits?

 Diabetes Mellitus: Any increased urination or feel

excessively thirsty?
 Malignancy: Any weight loss? Any lumps and bumps? Any

unexplained fever?
 Infections: Any recent infections? Any recent history of

recent surgery including tooth extraction?

 Anemia: Does your diet include a lot of meat and green leafy

vegetables? Any diarrhea? Any excessive blood loss during

periods? Bleeding from any sites of the body?
 Any medications that you are on?
 Sleep apnea: Do you snore? Are you excessively sleepy

during the day?

 Celiac disease: Any special diet you are on?
o Psychosocial history
 How is your mood?
 How long have you been having this low mood for?
 On a scale of 1 to 10, how would you rate your mood?

(1 is lowest, 10 is highest)
 Do you mind if I ask you the reason why you are feeling

low? I assure you that whatever you tell me will be

kept private and confidential unless it causes harm to
you or to others.
 I'm really sorry about that. I can only imagine how

terrible this must be for you. Please don't worry, let

me assure you that we are here to look after you and
we'll help you to sort it out.
 Sleep: Is all this affecting your sleep?
  What sort of sleep problems are you having?
 Do you find it hard to fall asleep?
 Do you have to wake up multiple times?
 What is it that makes you wake up?

Do you have thoughts racing in your

mind?
 Are you having any nightmares, or any

flashbacks?
 Once you wake up, how long does it

take you to fall back asleep?

 Do you wake up early in the morning?
 Energy: Do you feel tired even when you are at

rest, or is it just with exertion? Any associated

symptoms like shortness of breath, chest pain,
weakness, fever, nausea and vomiting?
 Appetite: Are you eating well? Any weight loss or

weight gain?
 Intrust/Anhedonia: Do you still enjoy the things

that you used to enjoy before?

 Guilt: Do you feel guilty for anything?
 Concentration: Do you find it hard to concentrate

on things?
 Psychomotor retardation: Have you slowed down

on things?
 Do you think life is still worth living?
 Do you have passing thoughts of harming yourself or others?
 What is your intention? Do you want to end your life,

or you just wanted to harm yourself?

 Do you mind if I asked you why you want to end

your life?
 Are you a very impulsive person?
 Do you have any organized plan for suicide?
 Do you think that someone is spying on you?
  Do you think that others' actions are directed towards you?
 Do you see, hear, or feel things that others do not?
 Do you think that someone is inserting thoughts into your

head?
 Do you think that someone is extracting thoughts from your

head?
 Do you think that your thoughts are being broadcasted in

TV, radio, or social media?

 Do you think that you need help?
 If there is a fire in the room, what would you do?
 Do you know where you are, what date it is today, and who I

am?
o HEADSS
 How is your home situation? Who do you live with? Is there

any stress at home?

 Do you have a good support?
 Are you working? Any stress at work?
 Do you still enjoy the activities that you used to enjoy

before?
 How do you describe yourself as a person?
 Do you still go out to meet your family and friends?
o SADMA
 Do you smoke?
 Do you drink alcohol?
 Do you take recreational drugs?
 Do you take any prescription or over the counter

medications?
 Do you have any known allergies?
o Any past history of any medical or mental illness?
o Any family history of any medical or mental illness?

 Diagnosis and Management

Diagnostic Criteria for Postnatal depression:
Women must exhibit five or more symptoms for at least two
weeks with at least one symptom from the first two symptoms
listed below:
o Depressed mood AND/OR
o Anhedonia (no interest or pleasure or enjoyment)
o Significant change in weight or appetite
o Markedly increased or decreased sleep
o Psychomotor agitation or retardation
o Fatigue or loss of energy
o Feelings of worthlessness or guilt
o Reduced concentration
o Recurrent thoughts of death or suicide

In addition, these symptoms must be accompanied by significant

impairment in capacity to engage and function in usual activities
e.g. parenting, occupational, social and other roles.

Based on the history, most likely you are having postnatal

depression with melancholic features. PND is a depression that
comes on within 12 months of having a baby, usually during the
first few weeks or months. Around 16% of women experience
postnatal anxiety and/or depression.
The exact cause of this is unknown but it may be related to the
physical, emotional, and social changes that comes on with
pregnancy and having a new baby. Even a relatively easy birth is an
overwhelming experience for a woman’s body, and adapting to
parenthood could be daunting. You have to deal with the constant
demands of your baby, a different dynamic in your relationship
with your partner and the loss of your own independence. Such
changes would be hard at the best of times, but are even more
overwhelming when you are still physically recovering
from childbirth and coping with broken sleep. Moreover, society
puts lots of demands and expectations on a new mother, which you
may feel that you need to live up to.
 Because of this, you develop a low mood, develop a low self-
esteem and lack of confidence, you have feelings of inadequacy
and guilt, you have negative thoughts, feel that life is meaningless
and have recurrent thoughts of harming yourself, you feel unable
to cope, and have difficulty sleeping, you feel fatigued, and have
loss of appetite, which are symptoms of postnatal depression.
I know that this must be a tough time for you, and I would like to
help you manage your situation. I will refer you to the hospital,
where you will be admitted. Are you okay to be admitted? (If
patient does not agree to be admitted, "I understand that you are
worrying about your children, but under that Mental Health Act,
with your current situation, I have to refer you for admission. I will
call the CAT team and arrange for a social worker to support your
children and family while you are away.")
Once in the hospital, you will be admitted to a secure unit, and will
be seen by the psychiatric team composed of the psychiatrist who
might do electroconvulsive therapy, which is a treatment which
induces controlled seizures by placing small electrodes at specific
locations on the head, and start you on a medication called Lithium,
and the psychologist who will initiate a talk therapy with you.
While you are admitted, you will not be able to breastfeed your
son, so you might be given medications to reduce breast
enlargement. I will arrange for a social worker to support your
children and family while you are away. Your family will be
accompanied to see you on a daily basis. You do not need to stay in
the hospital for a long time, once you feel better, you may be
discharged home.
With your consent, we can also arrange a family meeting so they
can support you as well.
Do you have other concerns at this point?

 Diagnosis of postnatal depression.

 Potential suicidal ideation requiring urgent intervention.
  Failure to diagnose severe postnatal depression.
 Failure to appreciate urgency of situation (including possible
suicide) requiring hospitalisation

The diagnosis is postnatal depression with melancholia features, in a

woman with premorbid anxious and obsessional traits. Her beliefs
about her infant and her competence as a mother could be interpreted
as overvalued ideas (and therefore not psychotic): or delusions (fixed,
irrational false beliefs not amenable to evidence or persuasion to the
contrary) which would suggest severe depression with psychotic
features.
Her depression began with hypochondriacal anxiety about her son's
wellbeing and this progressed to affect her view of herself as a mother
and as a wife. She has comorbid anxiety symptoms, but her primary
diagnosis is depression.
Her suicidal ideation and her cognitions of guilt, shame, failure and
inadequacy are of serious concern and require urgent intervention.
This is not dysthymia, obsessive-compulsive disorder, post-traumatic
stress disorder or schizophrenia.
Condition 116 Cuts to the wrist
You are working in a general practice setting. Your patient is a 25 year old full time university student
living at home with his parents who are both teachers, and three younger siblings.

You have just seen this young man, previously unknown to you, to deal with cuts to his left wrist and
hand. He told you he did not know how he sustained his injuries. You did a limited psychiatric
assessment in the suture room, and established:

 He has been upset over the past three days, and has barely slept, having quite atypically failed his
semester exams
 He is convinced he had an infallible method of predicting the questions to be asked in the exams,
only studied those questions and cannot understand how it did not work
 He denies any suicidal thoughts or impulses, and deliberate self-harm
 He told you that he had not been "doing some drugs" but no other details were able to be elicited
 He denies any past history of psychiatric illness
 His general health is good, and he is not taking any medication of any kind
 You noted he is actively hallucinating and thought-disordered and concluded he was acutely
psychotic
 He does not consider himself unwell, and just wants to go home to sleep
 The practice nurse has dressed his wounds and you are now going to see him and address the
psychiatric management

1. Inform the patient of your evaluation of his problem and treatment recommendations
2. Inform the examiner of the reasons for your proposed management and other possible options
3. Explain your decision to the patient

 Good morning, I'm Dr.____. I am one of the doctors who will look after you today. How can I
address you?
 I understand that you are very distressed recently, and we acknowledge the pain that you are
feeling. Let me reassure you that we will provide you with all the support you need, and we will
help you get through this.
 Do you have someone with you right now?
 Most likely you are having a condition called acute psychosis. Have you heard about it? Let me
explain the condition to you.
 Sometimes when there are too much stressors that surround us, our mind tends to respond
differently by having an impaired sense of reality. Patients who are suffering from acute psychosis
may tend to see or hear things which others don’t. At certain times, even though they don't tend
to mean it, they tend to think of or even eventually do hurt themselves and as well as others.
There are several causes that leads to this condition. Sometimes it can happen due to head
injuries, metabolic disturbances, or sometimes substance abuse. And in your case, we need to
identify the cause for your safety.
 This is an emergency situation, and I need to refer you to the crisis assessment team for full
evaluation of your condition. Don't worry, you will be taken cared of by an experienced team until
you get better.
 I am really concerned about you, as you can see that you have these injuries to your wrists, and
that you have been really stressed because of your exam results. Again, let me reassure you that
we will provide you with all the support you need during these times.
 If the CAT team decides to admit you in the hospital, you will be assessed by a multidisciplinary
team, (psychiatrist, psychologist, mental health nurse), who will work together to help you with
your condition. We will identify the cause of what you are feeling right now, as we are going to
arrange blood and urine or even imaging of the brain for investigations.
 I will be your GP from now on, and I will help you get better. I will regularly review you once you
get discharged from the hospital.
 If he refuses to get admitted, or gets agitated
o Call for help, calm him down
o Under the mental health act, I am obliged to admit you to the hospital, as based on my
careful evaluation, you are having this acute psychosis, which may pose harm to yourself or
to others.
o Oral diazepam 5-10mg and/or olanzapine 5-10mg would be appropriate initial choices for
sedation by the general practitioner.
o Diazepam must never be given intramuscularly

 Ability to understand and directly address the fact of serious mental illness, risk of harm, and need
for treatment
 Knowledge of psychiatric crisis treatment options including involuntary treatment
 Ability to communicate and negotiate with the patient, including flexibility and inclusiveness of
significant others, such as parents, without neglecting duty of care

 Not ensuring urgent referral for psychiatric assessment and crisis care

 This is a management station---to implement crisis care for a young man with an acute psychosis
and injury of unknown origin
 Patient presents with a minor injury in the setting of an acute psychosis
o Injury may be accidental or due to deliberate self-harm, or driven by a psychotic phenomena
(by command hallucinations or delusions)
o Specific mechanism is important in understanding and management of each individual case
 Potential for further harm is the overriding principal determinant requiring further action
 Early intervention in psychotic illness plays a vital role in diminishing chronicity and severity of
outcome in a range of biopsychosocial areas
 Appropriate doctor response entails the ff:
o Deciding the level of risk to the patient and others based on obtained information and
observation
o Preparedness to act on the decision within the framework of the mental health legislation
and crisis psychiatric resources
o Applying knowledge of psychopharmacology and skill in chemical restraint
 Undertaking to ensure the patient has sleep relief whilst his condition is further
assessed is important
o Using communication skills to manage a difficult-to-engage patient, in this case responding
positively to the patient's requests for sleep relief and assistance with his academic
 problems is therapeutic, whereas aggressively pursuing the possibility of illicit drug use at
this time is not acceptable
o Self-harm or unexplained injury in the context of acute psychosis is a serious psychiatric
emergency
 Receives emergent specialist mental health/psychiatric assessment
 Continuously supervised until he has that assessment
o The risk of further self-harm may be exaggerated once the patient becomes aware he has a
serious mental illness
o Mental health crisis team or the police and ambulance need to be summoned to the
doctor's general practice as soon as practicable rather than allowing him to be taken to the
clinical/assessment center/hospital in a private car accompanied by a friend or with his
parents
o Oral diazepam 5-10mg and/or olanzapine 5-10mg would be appropriate initial choices for
sedation by the general practitioner.
o Diazepam must never be given intramuscularly
Condition 131 Major Depressive Disorder
The 45-year-old patient whom you are about to see is consulting you in a general practice with a
presenting complaint of being tired. You have not seen this patient before. The patient was advised to
see a doctor by the workplace Health and Safety Officer. As you greet the patient, you notice that he is
middle aged, neatly dressed in a professional mode, looks worried, smells of alcohol, has a fine tremor
on handshake and has nicotine staining of fingers of his right hand.

1. Take an appropriately detailed and focused history.

2. After six minutes, the examiner will inform you of the physical examination findings.
3. Inform the examiner of your provisional diagnosis and what further tests you will order to aid
confirmation.

Positive points in the history:

Chief complaint: tiredness
 Smells of alcohol, has fine tremor on handshake
 Has nicotine staining of fingers of his right hand
 Reports feeling drained and awful, especially in the mornings. He wishes that he did not have to
go to work, because he has so much trouble concentrating, but he doesn't feel any better on
weekends either. He has felt this way for about six months, and it is getting worse.
 He is not sleeping well. His sleep is broken, and over the past few weeks, he wakes up at 4 am,
feeling restless and bothered by all kinds of thoughts, and does not get back to sleep. He often
takes a Panadeine® (paracetamol/ codeine) to aid sleep. He feels better later in the day and after
he has had a glass of wine. He has started drinking at lunchtime now.
 He cannot be bothered with other people, and has given up his regular tennis. He has no interest
in sex.
 He thinks that his life is not worth living. He has had passing thought of taking an overdose or
gassing himself. He has no active plans or suicidal impulses. He misses his children a lot, and
worries about his and his children's future.
 He has had weight loss of about 5 kg in six months; no previous episodes of weight loss or gain.
Poor appetite. Constipation is a problem, for the first time in his life.
 His wife left him six months ago, taking the children, and he has not had any regular contact with
them since.
 His boss has had talks with him in recent weeks about his work performance, and yesterday he has
received a written warning from the company regarding his performance which he understands
means dismissal is under consideration.
 He is a habitual smoker of about 35-40 cigarettes daily
 He is a habitual drinker of ½-1 bottle of wine daily, increased over the past few weeks to 1-2
bottles.
 He drinks at least 8 cups of coffee daily
 No current medication, apart from self-administered Panadeine®, 2-4 to help him sleep, most
nights for several months.
 He had a previous episode of depression when aged 20, when he failed his university exams, the
same year his father disappeared. He refused a psychiatric referral, and the local doctor gave him
Valium® (diazepam); he got better after about a year, when he met his wife.

 History
Good morning John, I am Dr. _______ your GP for today. I read from the notes that you are feeling
tired lately. Could you tell me more about it?
o History of present illness
 Tiredness
 How long have you been experiencing this?
 Did you experience this suddenly, or did it happen gradually?
 How did it start? Is it becoming worse, or it's just the same?
 Is it always there, or it just comes and goes?
 Do you experience it only on exertion, or does it also occur at rest?
 Anything that makes it worse or better?
 Did you notice anything that might have triggered this?
 Is this the first time that you have experienced this?
 Alcohol
 Do you drink alcohol?
 What type of alcohol do you usually drink?
 For how long have you been drinking?
 How much do you usually drink in one session? Did you increase your intake
recently? Why?
 Do you drink alone or only when you are with friends?
 Do you do binge drinking?
 Do you experience any side effects of alcohol drinking like heartburn, mood
change, problem with memory and concentration?
 Do you think you can drink heavily without being drunk?
 Are you able to work efficiently? Is it affecting your relationships? Any financial
problems due to alcohol spending? Do you often have accidents? Any charges
with law due to your drinking habits?
 Cutting down: have you ever thought of cutting down on your alcohol intake?
 Annoyed: do you feel annoyed when people criticize your alcohol drinking?
 Guilt: do you feel guilty about your alcohol drinking?
 Eye opener: do you take alcohol first thing in the morning?
 Smoking
 Do you smoke?
 For how long have you been smoking?
 How many sticks do you consume in a day?
 How soon after you wake up do you have your first cigarette?
 Do you find it difficult not to smoke in a non-smoking area?
 Is the first cigarette of the day the hardest to give up?
 Do you smoke even when you are sick?
 Have you tried to stop smoking for good in the past but found you could not?
What happened?
 What happens if you don’t smoke?
o Differential Diagnosis
 Hemochromatosis: Any pigmentation in your skin or your mouth?
 Hepatitis: Any yellowish discoloration of urine or eyes? Any travel history?
 Hypothyroidism: Do you have any weather preferences? Any changes in your bowel
habits?
 Diabetes Mellitus: Any increased urination or feel excessively thirsty?
 Malignancy: Any weight loss? Any lumps and bumps? Any unexplained fever?
  Infections: Any recent infections? Any recent history of recent surgery including tooth
extraction?
 Anemia: Does your diet include a lot of meat and green leafy vegetables? Any diarrhea?
Any excessive blood loss during periods? Bleeding from any sites of the body?
 Any medications that you are on?
 Sleep apnea: Do you snore? Are you excessively sleepy during the day?
 Celiac disease: Any special diet you are on?
o Psychosocial history
 How is your mood?
 How long have you been having this low mood for?
 On a scale of 1 to 10, how would you rate your mood? (1 is lowest, 10 is highest)
 Do you mind if I ask you the reason why you are feeling low? I assure you that
whatever you tell me will be kept private and confidential unless it causes harm
to you or to others.
 I'm really sorry about that. I can only imagine how terrible this must be for you.
Please don't worry, let me assure you that we are here to look after you and
we'll help you to sort it out.
 Sleep: Is all this affecting your sleep?
 What sort of sleep problems are you having?
 Do you find it hard to fall asleep?
 Do you have to wake up multiple times?
 What is it that makes you wake up? Do you have
thoughts racing in your mind?
 Once you wake up, how long does it take you to fall
back asleep?
 Do you wake up early in the morning?
 Do you take anything to help you fall asleep?
 Energy: Do you feel tired even when you are at rest, or is it just with
exertion? Any associated symptoms like shortness of breath, chest pain,
weakness, fever, nausea and vomiting?
 Appetite: Are you eating well? Any weight loss or weight gain?
 Intrust/Anhedonia: Do you still enjoy the things that you used to enjoy
before?
 Guilt: Do you feel guilty for anything?
 Concentration: Do you find it hard to concentrate on things?
 Psychomotor retardation: Have you slowed down on things?
 Do you also have moments when you feel that you are on top of the world?
 Do you think life is still worth living?
 Do you have passing thoughts of harming yourself or others?
 What is your intention? Do you want to end your life, or you just wanted to
harm yourself?
 Do you mind if I asked you why you want to end your life?
 Are you a very impulsive person?
 Do you have any organized plan for suicide?
 Do you think that someone is spying on you?
 Do you think that others' actions are directed towards you?
 Do you see, hear, or feel things that others do not?
 Do you think that someone is inserting thoughts into your head?
  Do you think that someone is extracting thoughts from your head?
 Do you think that your thoughts are being broadcasted in TV, radio, or social media?
 Do you think that you need help?
 If there is a fire in the room, what would you do?
 Do you know where you are, what date it is today, and who I am?
o HEADSS
 How is your home situation? Who do you live with? Is there any stress at home? How do
you feel about that?
 Do you have relatives that live nearby?
 Do you have a good support?
 Are you working? Any stress at work?
 Do you still go out to meet your family and friends?
o SADMAC
 Do you take recreational drugs?
 Do you take any other medications?
 Do you drink coffee? How much do you drink in a day?
o Any past history of any medical or mental illness?
o Any family history of any medical or mental illness?

 After six minutes, the examiner should inform the candidate that physical examination shows no
abnormality, and ask: What is your provisional diagnosis and differential diagnosis? What tests will
you now order?'

 Diagnosis and Differential Diagnosis

Based on the history, most likely the patient is having a major depressive disorder with substance
abuse and risk for suicide. He manifests with a depressed mood, lack of interest in activities, sleep
disturbances, loss of appetite, fatigue, reduced concentration, thoughts of suicide, which is
impairing his capacity to engage and function in his usual activities at home and at work, for 6
months, which meets the criteria for a major depressive disorder. On top of this, he is consuming
excessive amounts of alcohol, cigarettes, coffee, and Panadol. He also has passing thoughts of
harming himself by overdose or gassing himself, so there is potential suicidality risk.
However, we also need to rule out other differentials for tiredness like organic causes such
hemochromatosis, hepatitis, endocrine disorders such as hypothyroidism, malignancy, infections,
chronic fatigue syndrome, anemia, effect of medications, sleep apnea and celiac disease, and
psychiatric causes such as adjustment disorder, dysthymia, bipolar disorder, or substance abuse.
To do this, I will arrange for investigations such as FBE and possible iron studies to check for
anemia and hemochromatosis, ESR/CRP to check for infections, UEC, LFT and lipid profile to check
for analgesic abuse, effects of alcohol abuse, and hepatitis, and TFT to check thyroid disorders.

 Identification of major depression as primary illness.

 Appropriate history-taking skills.
 Risk assessment of suicide.
 Recognition of excessive alcohol intake.
 Appropriate investigations for complications of alcohol abuse and for organic causes of
depression.
 Recognition of potential suicidality risk.
 Failure to diagnosis major depression.
  Failure to identify excess alcohol consumption.
 Failure to ask about suicidal thoughts or plans.

The main clinical reasoning in this case is the ability to take an accurate history of depressive symptoms
and recognise depression as a primary diagnosis, and not solely an associated symptom of substance
abuse, or solely a temporary response to work/family problems. In taking the history the candidate
needs therefore to elicit the key symptoms of major depression, including psychomotor retardation and
slowing with fatigue, sleep disturbance, early morning wakening, weight loss, poor concentration,
anhedonia and suicidal thoughts. The candidate must also obtain the history of present alcohol abuse,
habitual and excess consumption, details of other substance misuse, and a relevant systems review. The
candidate must take some psychosocial history, namely the marital breakdown and social isolation as
these are highly relevant to the case and further management. Suicide risk assessment is critical. A
formal extended cognitive state examination is not possible but the candidate should be able to
comment on cognitive state and memory as reflected in the history provided. The case also involves
consideration of relevant investigations. These include physical problems that may present as
depression (e.g. hypothyroidism, frontal lobe impairment, anaemia, or malignancy) and physical
consequences of alcohol abuse (particularly hepatic and gastrointestinal disease).
At first glance this may seem a complicated case, but both depression and alcohol abuse are very
common mental health problems, with high levels of disability; and they often coexist.
Condition 134 Delirium in a 25 year old
You are a night intern in a general hospital. The patient you are about to see is a 25 year old male
student who was admitted 24 hours ago with 20% partial thickness burns sustained when throwing fuel
over a camp fire. The burns, involving all the limbs, are being managed conservatively and have been
dressed under intravenous ketamineneuroleptanalgesia. You have been called because the patient is
unable to sleep, restless, and distressed and has pulled out the intravenous line delivering patient-
controlled analgesia (morphine 1mg/hour)

1. Determine the cause of the sleeping problem by taking a relevant focused history, and performing
an appropriate psychiatric (mental state) assessment
2. Explain to the patient the nature of the problem and what can be done to help

 HEMODYNAMIC STABILITY
 RAPPORT: Good evening, I'm Dr ___, I am one of the doctors who will be looking after you tonight.
I'm sorry to hear about your injuries. How are you feeling now?
 Let me reassure you that whatever we talk about will just remain between us unless it will be
harmful to you or to others.
 I understand that you have been having trouble sleeping. Could you tell me more about it?
o Finding it hard to fall asleep?
 How long does it take you to fall asleep (>15mins = abnormal)
o Once you fall asleep, do you have to wake up multiple times?
 Could you tell me more about what you are feeling right now?
 I will be asking you some routine questions that I usually ask all of my patients. Will that be okay?
 How’s your mood like these days?
 Is life worth living for you?
 Or you want to harm yourself or others?
 Appetite? Weight? Sleep?
 DELUSIONS AND HALLUCINATIONS
 Do you think some is spying on you?
 Do you think someone is trying to harm you?
 Do you think other people’s action is directed towards you?
 Do you think someone is inserting thoughts in your mind?
 Do you think your thoughts are being broadcasted in the tv or radio or social
media?
 Do you see, feel or hear things that others don’t?
 Do you hear voices that command you to do something?
 Insight*
 Judgment*
Examiner, can I have a copy of the Folstein Mini-mental state examination? [VERY IMPORTANT TO
CHECK ORIENTATION, ATTENTION, CONCENTRATION to check for delirium]
o I am going to do a simple test called mini-mental state examination which is basically a
screening test to check your memory and mental function. During the test I'm going to ask
you a few questions. And will be asking you to follow some simple commands. Don't worry, I
will guide you throughout the procedure. Don't hesitate to ask me if you have any
questions. Will that be okay with you? Shall we start?
o ORIENTATION (10 POINTS) - may do only 3 to screen (time, place, person)
 o Do you know what year it is?
o What is the current season?
o What is the day today?
o What is the date?
o What month are we currently in?
o What country are we in right now?
o What state are we currently in?
o What town?
o Which hospital or GP clinic are we currently in?
o What floor are we currently in?

o REGISTRATION** checks immediate memory

o I'm going to tell you three objects and I want you to repeat them to me after I say all of
these to you.
 Apple Table Coin = 3
 Can repeat for 3-5 times
 I will repeat them for you again
 SCORING is based on the first trial
o Please remember these three words, I will ask them to you again later.

o ATTENTION & CALCULATION

o SERIAL 7s = need to subtract 7 from 100 backwards
o WORLD: spell the word "WORLD" backwards
 If all correct = 5/5 = DLROW
 DRLOW = 1/5
 Score is given until the first mistake is made

o RECALL - Checks short term memory

o Can you repeat the three words that I have mentioned to you a while ago?

o LANGUAGE
o I will show you two objects, please name these for me. 2/2
o Can you repeat this phrase for me "No ifs, ands or buts" 1/1
o 3-step command: take this paper, fold it in half, and put it on the table 3/3
o Write on a paper: CLOSE YOUR EYES
 Can you read this, and then follow this command 1/1
o Can you please write a sentence? 1/1

o CONSTRUCTION/COPYING (DIAGRAM)
o Can you copy this diagram for me?

 DIAGNOSIS AND MANAGEMENT

 o From your history and examination findings, it seems that most likely you have a condition
we call delirium, or an acute confusional state. This is a common complication of major
injuries and their treatment, such as your burn. In your case, most likely the cause of your
delirium is emergence phenomenon secondary to ketamine, because this medication has
the effects of disturbed sleep and vivid and concerning dreams as what you have
experienced.
o [GENERAL SCRIPT] It will most likely get better along with your recovery, but there are some
common problems which need to be checked, like infection, changes in your fluid balance,
and it may be a side effect of your pain relief. We will do a complete delirium screen which
consists of blood, urine, and imaging investigations which can help us identify the cause of
your condition. The visions and fears you have are part of the delirium, and do not mean
you have a psychiatric illness such as schizophrenia. If the nursing staff knows about your
fears, they can take extra care to explain their treatments to you, and they will also be
careful about lighting, noise etc, as those environmental matters can be irritating. In the
meantime, there are things that can be done to relieve your symptoms, such as additional
sedation, and changing your analgesic.
o [SPECIFICS of the management]
o There can be multiple causes of acute confusion, but we will do it a complete delirium screen
which includes
o BLOOD: FBE, CRP (signs of infection), Blood culture (fever) UEC, Ca, Mg, P, Urinary
sodium and osmolality, serum osmolality to find out the exact cause of low salt levels
in the blood, TFTs, Vit B12 and folic acid, Blood sugar levels, ABG, VBG (too much/less
acid in the blood), troponins, liver function tests (liver failure can contribute), blood
alcohol levels
o URINE: Urine MCS (infections), Urine drug screen, Urine sodium
o IMAGING: CXR, Cranial CT
o SPECIFICS OF MANAGEMENT
o For now, what we can do for you is to Control of Pain and give you alternative
medications for pain than morphine (after burn injuries further analgesia usually do
not require opioids, as this may worsen the delirium)
o Stop ketamine.
o Low stimulus Environment: minimal lighting and noise, one nurse looking after him per
shift
o Continuous patient observation: by family member or acquaintance. Photos in the wall
to make patient feel he is in a familiar environment
o Low dose benzodiazepines ONLY if symptoms persist
o For agitation
 Haloperidol in low dosage twice daily and can be safely used parenterally
 Olanzapine as intramuscular alternative
o Sedatives for use at night and in patients with liver disease
 Short acting benzodiazepines: lorazepam, oxazepam, alprazolam
o Are you happy with this plan?

 Ability to make a diagnosis of delirium, by taking both an adequate history and performing an
adequate mental state examination
 Ability to formulate and communicate an initial management plan, which includes addressing the
cause of the delirium, and relieving the symptoms
 Failing to make a diagnosis of delirium/acute brain syndrome
 Telling the patient he has schizophrenia or like illness

 Delirium (acute brain syndrome) is an acute confusional state associate with acute impairment of
consciousness: disorientation, restlessness, agitation, illusions, and hallucinations are common.
 Delirium and confusion may be precipitated by change from a familiar home environment to the
unfamiliar and disturbing environment of the hospital. Confusion is often worse at night
 Rapidly obtain as adequate a history is as possible from the patient, relatives, nursing staff
 Focused clinical examination looking for possible precipitating factors and identifiable disorders
 Common causes of delirium in hospitalized patients
o Hypoxia - post-operative and post-traumatic patients, and those with atelectasis
o Drug intoxication or withdrawal - sedatives, analgesics, and opiates, anesthetics or
neuroleptic agents such as ketamine, and from alcohol withdrawal
o Sepsis - chest, wound, and urinary infections
o Metabolic disturbances - water and electrolyte (hyponatremia, hyper natremia), hypo or
hyperglycemia, anemia, uremia, hyperthyroidism, or hypothyroidism, hepatic disease
o Vulnerability to the above - produced by underlying CNS or psychiatric disorder (Alzheimer,
cerebral tumor, psychosis
 Key features
o Disturbed consciousness and confusion with disorientation in time and place, fluctuating
within a 24 hr period with lucid intervals
o Perceptual abnormalities
o Sleep-wake cycle abnormalities (inverted pattern: awake all night and dozing briefly during
the day)
o Mental sluggishness
o Poor attention and concentration with distractibility
o Affective lability: fear, anxiety, depression, grandiosity, aggression
o Ideas of reference and misinterpretations leading to paranoid or suicidal/nihilistic ideation
and delusions
o Psychomotor disturbance: restless agitation, or somnolent retardation
o On recovery, most patients have no recall of their period of delirium, or sometimes they
experience features of so-called "near death experiences"
 Factors contributing to confusion
o Advancing age
o Cerebral insufficiency
o Drug/alcohol effects
o Brain injury or infection
o Any condition requiring intensive care
 Treatment
o Recognition of diagnosis and identifying and correcting the contributing factors
o Assigning same staff each shift to care for the patient
o Encouraging family and friends to sit with them are helpful
o Place in a quiet room with familiar objects from home nearby
o Subdued lighting at night assists in orientation and reduces the likelihood of
misinterpretations
o For agitation
  Haloperidol in low dosage twice daily and can be safely used parenterally
 Olanzapine as intramuscular alternative
o Sedatives for use at night and in patients with liver disease
 Short acting benzodiazepines: lorazepam, oxazepam, alprazolam
o Diazepam may prolong or worsen daytime confusion
o Hypoalbuminemia may mean the dosage of all protein-bound drugs must be reduced,
including psychotropics, to limit medication toxicity from free drug in the circulation
 Psychotropics should be reduced gradually and not stopped abruptly
Condition 146 Cognitive state
assessment
This 50-year-old man works as a barman and is attending an
appointment at a general practice, which you arranged after a
conversation with his wife. He has a history of consumption of up to 10
standard alcoholic drinks on most days, over the last 10 years.
In attempting to contact the patient at home, you spoke with his wife
who said that the patient has been quite forgetful and unreliable for
some months, causing family and work colleagues to be irritated and
concerned.
The patient is in your consulting room. You have completed your
history and you are now proceeding to test his cognitive function.

1. Examine the cognitive state using the modified Folstein Mini-

Mental State Examination (MMSE) provided.
2. Explain to the patient what you are going to do and why.
3. Summarise for the examiner, the normal and abnormal MMSE
findings.
4. Tell the examiner your interpretation of the results, including what
condition these results signify.

Positive points in the history:

 Consumes up to 10 standard alcoholic drinks on most days over the

last 10 years
 According to wife, patient has been quite forgetful and unreliable

for some months

 On examination:
o Orientation: Gave correct information on name, year, day and

date, season and location of consultation.

o Registration: Took 3 attempts to learn all 3 objects
o Attention and Calculation:
  On serial 7s, able to do correctly for 5 successions, but then
asks what he was subtracting again
 Spells the word "WORLD" backwards correctly
o Recall: only remembers 1 of the 3 objects
o Language:
 Able to name the watch and pen correctly
 Able to repeat "no ifs and buts"
 Able to follow the 3-step command
 Able to read and follow the command "close your eyes"
 Able to write a coherent sentence
o Construction: able to copy the design accurately

 Mini Mental State Examination

I am going to do a simple test called a mini mental state
examination, which is basically a screening test to check your
memory or mental function. During the test, I am going to ask you a
few questions, and I will be asking you to follow some simple
commands. Don’t worry, I will guide you throughout the procedure,
it will take only approximately 5 minutes. Please don't hesitate to
ask me if you have any questions. Are you alright to start?
o Orientation (10 points)

 Year: do you know what year it is?

 Season: do you know what season it is?
 Day: do you know what day it is?
 Date: do you know what date it is?
 Month: what month is it now?
 State: what state are you in?
 Country: what country are you in?
 Town: what town are you in?
 Which hospital or GP clinic are you in?
 Which floor are you on?
 What is your name?
o Registration: (3 points) --checks immediate memory loss
  I am going to tell you 3 objects, you need to repeat them to
me after I tell you the 3 objects
(Give 1 second pause in between the 3 objects)
(Can repeat up to 3 times if the patient does not remember
it in the previous attempts, BUT the score will be the first
try)
 Please remember these three words, I will ask them to you

later again.
o Attention and Calculation (5 points)
 Can you please subtract 7 serially starting from 100?
 WORLD: Can you please spell the word "world" backwards?
 Give score until the first mistake has been made
 DLROW = 5 points
 DLRWO = 3 points
 DRLOW = 1 point
o Recall (3 points) -- checks short-term memory
 Please tell me the three words I told you a while ago.

(DO NOT REPEAT the words for the patient again. If he

cannot remember, score him 0)
o Language (2 points)
 Show 2 objects, could you please tell me what it is?
 Please repeat this sentence to me: "No ifs and or buts"
 3-step command: Please take this paper, fold it into half, put

it in your lap
 Write on a paper: "Close your eyes"
 Can you read this, and then follow this command.
 Can you please write any sentence for me?
o Construction
 Can you please draw this diagram?
 Interpretation of test
I examined a 50 year old man, John, who his wife has complained
of having symptoms of forgetfulness.
On examination, I found that he is able to perform correctly the
tests for orientation, attention and calculation, language, and
construction. However, he had trouble with the tests for
registration and recall, indicating that he most likely has problems
with his immediate and short term memory. This is most likely due
to an acquired brain injury because of chronic alcohol abuse since
John has been consuming 10 standard drinks nightly for the past 10
years. A diffuse chronic brain syndrome like dementia of whatever
kind or an acute brain syndrome/delirium or acute confusional
state is unlikely in this patient since the patient is fully oriented and
alert, and able to perform the other tests correctly, apart from the
tests for registration and recall. However, I would also arrange for
investigations called the delirium/dementia screen composed of
FBE, CRP, UEC, Ca, Mg, Phosphate, serum osmolality TFT, Vit B12,
folate, BSL, ABG/VBG, troponins, LFT, blood alcohol levels, urine
Na, urine osmolality, urine MCS, urine drug screen, CXR, CT of the
brain, ECG to exclude a more diffuse impairment, and a possibility
of Wernicke's encephalopathy which is a common complication of
chronic alcoholism.

 Skill in using a screening tool for cognitive impairment.

 Ability to interpret the results — and to identify there is a focal
problem of short-term memory impairment.
  Knowledge that this is likely to be an acquired brain injury as a
complication of hazardous alcohol use.

 Failing to identify the specific short-term memory deficit.

The Folstein MMSE is a screening tool assessment of cognitive function

impairment — broadly speaking, delirium/acute brain syndrome/acute
confusional state and chronic brain syndrome/dementia. Abnormal
results indicate the need for further neuropsychiatry/
neuropsychological and medical evaluation to make an exact diagnosis.
The cognitive performance deficits as scripted are in (2) Registration
and (4) Recall —these are short-term memory functions; the deficits
are almost certainly due to acquired brain injury from chronic alcohol
abuse. The cognitive deficits are confined to short-term memory
functions. It is very relevant that all other responses are correct, and
that there are no indications with this screening tool of a diffuse
chronic brain syndrome/dementia of whatever kind, or an acute brain
syndrome/delirium/acute confusional state. In particular this patient is
fully oriented and alert, and hence he does not have an acute brain
syndrome/concentration deficit in answering the doctor's questions;
the candidate is expected to know this.
This short-term memory deficit picture, with preservation of long-term
memory and other intellectual function, in the absence of an acute
brain syndrome, is a focal cognitive impairment of an amnestic (Greek
— without memory) type, and is one type of the cognitive decline
found with chronic alcohol abuse. Further neuropsychological testing is
required to exclude more diffuse impairment (e.g. dementia). It is
possible the patient has or has had an episode of Wernicke
encephalopathy, and the knowledgeable candidates will appreciate
this.