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Mental status exam – the psychiatry interview

APCsee MAP TCIJ


Appearance Dressed Dishevelled: dressed and groomed
Groomed poorly
Given age matches his chronological age
Dressing matches the weather
Behaviour Psychomotor retardation vs. Psychomotor agitation
Eye contact
Cooperative
Hostile
Abnormal movements / jerks / tics / lip smacking (anti-psychotics)
Speech Volume (low / normal / loud)
(process of Tone (parkinsonism: monotonous)
talking) Articulation
Fluent
Pressured speech
Mood How is your mood? Write it in the patient “own words”
Affect Quality Elevated
Euthymic
Depressed
Anxious
Congruency
Others Stable / range / labile / flat
Perception Normal perception
Illusions
Hallucinations
Thought Processing (how does the Goal directed
patient connect ideas) Thought block
Flight of ideas
Loose association
Tangentiality
Circumstantiality
Contents Obsessions
Delusions
Suicidal / homicidal ideation
Cognition Mini mental exam
Insight
Judgement

ALWAYS clarify! What do you mean by that?

Brief comment: The patient is well dressed, well groomed; his appearance matches his
chronological age. His speech is not slurred, not pressured. There are no delusions or
hallucinations. There is no suicidal ideation or homicidal thoughts.

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Perception
Hallucinations:
- Visual:
o Usually organic (tumour / epilepsy / cocaine and amphetamine)
o Brain tumour /+/ alcohol intoxication / DT /+/ cocaine / hallucinogens
o Do you see objects / things that others do not see?
o Can you describe what do you see?
o Do they give you any messages?
o Are these messages asking you to harm yourself or anyone else?
- Auditory:
o Usually schizophrenia
o Do you hear voices / things that other people do not hear? When you are
alone, do you hear voices coming from your head?
o How many voices
o Are they familiar or not?
o Are they talking to you or about you? What are they telling you?
o Did they ever ask you to harm yourself or somebody else? What is
preventing you from doing this?
o How do you feel about these voices?
- Tactile:
o Cocaine chronic use (most probably) OR delirium tremens
o Do you feel ants / insects crawl on your body / skin?
- Smell: usually epilepsy

Though
Processing:
o How did you come here today?

Content:
+ Obsessions:
- Repeated intrusive thoughts that the patient knows it is wrong, and he can not
resist, if he resists ! ↑ anxiety ! take actions to try to ↓ anxiety (compulsions)
- Mostly regarding: cleanliness, contamination / order / checking / …
o Do you have any repeated thoughts or images that you find difficult to
resist? About what? What do you do?

+ Suicidal / homicidal ideation:


o Do you have any thoughts or ideas of harming yourself?
o Or harming other people?
o Any access to weapons?

- If the patient is suicidal ! admit, if he/she refuses ! form 1 (for involuntarily


admission – for 3 days – for psychiatric assessment – by another physician).
- Form 1 has to be filled within 1 week from seeing the patient.

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+ Delusions:
- False fixed believes, that do not match with the patient cultural and religious
background
- You can not convince the patient it is wrong, even with proof
- The ideas
o Believable (could be) – non bizarre
o Unbelievable (could never be) – bizarre
o Do you believe that other people would like to harm you? OR conspire
against you?
o Do you think that others would like to control you?
o Read your mind? Thought broadcasting
o Put thoughts into your head? Thought insertion
o Steal thoughts from your head? Thought withdrawal
o If you are watching the TV or reading the newspaper, do you believe that
they are talking about you? Delusion of reference
o Do you believe that you are a special person? With a special talents? Or
special power? Do you believe that you have a special mission to do in
life? Do you think you deserve to be treated specially?
o Do you feel other people are falling in love with you?
o Do you believe any part of your body is rotten?

Cognition:
- Are you becoming forgetful? Are you losing your staff?
- Assess abstract vs. concrete thinking!

Insight:
- Do you think that you are doing well? Or do you need help?

Judgement:
- If there is a fire in the building, what are you going to do?
- If you find a stamped and addressed envelop on the ground, near the mail box,
what would you do?

General screening:
- Depression:
o What is your mood? How do you feel?
o Did you lose interest in things that were interesting to you before (e.g.
certain hobby, playing something)?
- Anxiety:
o Are you the kind of person who worries too much?
o Do you have excessive fears or worries?
- Psychosis:
o Do you hear voices or see things that others do not?
o Do you think that someone else would like to hurt you?

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DSM-IV-TR – Diagnostic and Statistical Manual of Mental Disorders 4th Ed/2000 – Text Revision

Multi-axial system (5 axes)


The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to
different aspects of disorder or disability:
- Axis I: Clinical disorders, including major mental / psychiatric disorders, and learning
disorders, Substance Use Disorders
- Axis II: Personality disorders and intellectual disabilities (although developmental
disorders, such as Autism, were coded on Axis II in the previous edition, these disorders
are now included on Axis I)
- Axis III: Acute medical conditions and physical disorders
- Axis IV: Recent stressors, i.e. psychosocial and environmental factors contributing to the
disorder
- Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for
children and teens under the age of 18 (a questionnaire)

Example of a full proper psychiatric diagnosis:


- Bipolar I / Anti-social personality / DM+HTN / Divorce / global assessment was not
done because the patient was not cooperative

Diagnosis of diseases based on DSM-IV-TR is based on CRITERIA and TIME.


- Depression:
o MI PASS ECG or MIS GE CAPS
o You need to find at least 5 of the 9 for > 2 weeks, including at least one of the
Mode or Interest.
o If not fulfilling these criteria: non-specified mood disorder
o In teenagers: we do not need M or I, we can replace it with agitation OR drop in
school performance + other 4 criteria.
- Schizophrenia:
o 4 positive symptoms: hallucinations, delusions, disorganized speech,
disorganized behaviour.
o 1 other category; negative symptoms: mood, catatonia …
o At least 1 month of active symptoms (2 of 5) + 6 months of deterioration in
functioning.
o 1 active symptom (not 2) is accepted in the following cases:
" If the hallucinations are > 2 voices (commanding or commenting)
" The delusions are bizarre
- Anxiety:
1- Panic attack vs. panic disorder:
a. In panic disorder, there is at least ONE panic attack with at least ONE month
of worries and fears of having it again
b. Panic attack might be one or more attacks
c. If patient is avoiding going outside ! with agoraphobia
2- Phobias specific to certain objects
3- OCD
4- GAD: excessive unrealistic fears for more than 6 months PLUS other manifestations
5- PTSD (acute or chronic): Have you ever encountered a situation in which your
personal or mental safety and wellbeing were endangered? When? Do you have
flashbacks or nightmares?

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History taking – Psychiatry
MOAPS: mood / organic / anxiety / psychosis / serious conditions (self care, suicide, homicide, support) / HEADSSS
Major psychiatric illness Suicide Minor psychiatric illness
Personality disorder / Drinking /
S addiction / Eating / sleeping
Mood Anxiety Psychosis disorders / Somatic disorders /
A Cognitive (delirium / dementia) ...
" Low: MI PASS ECG 1- Panic attack vs. panic Criteria (1 month of 2-5 D Criteria
" High: DIG FAST + disorder active symptoms + 6 month
MI PASS ECG 2- Specific phobias of function deterioration) P
st
- 1 time or did you have it 3- OCD - 1st time or did you have E MOAPS
before? 4- GAD it before? R

xt
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T
- What about the opposite? 5- PTSD S
O
Dx: one of the mood disorders
N
Past psychiatric history Past psychiatric history
S
Organic:
1- SAD if IV drug use: check for liver (hepatitis) / constitutional symptoms (HIV)
2- PMH, including constitutional symptoms
3- Rule out medical conditions as DD, e.g. medications and specific diseases
xtxt
ext
TeTTTT constitutiona
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xtxtxt
e

Thyroid disease Mitral valve prolapse Brain tumour / HIV


e

Anxiety / psychosis Mood / psychosis Mood / anxiety


l

Serious conditions (red flags):


- Self care (are you eating / sleeping well?)
xt e T TTTT
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- Suicidal / homicidal ideation


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Social history:
xtxtxtxt
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- How do you support yourself financially?


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- With whom do you live? Family support?


For teenagers, add: HEADSSS
Family history of psychiatric illness: suicide / depression / SAD / seen by psychiatrist
xt1
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xtxt
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TT
Mood disorders:

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PSYCHOSIS
Pt comes to the clinic complaining of strange feelings in his right hand

Clarify the CC 1- Is it pain, numbness, tingling?


OCD 2- Is it all the time, or on and off? Any specific
setting?
3- In you opinion, why do you have this?
Criteria : Any hallucinations: What? For how long?
" Hallucinations
" Delusions
st
1 time or did you have it
before?
Past psychiatric history
Organic Cover the following: head injury / trauma / vomiting
Mood / Anxiety
Serious conditions
Social history
Family history

Differential diagnosis:
- Brief psychotic disorder Schizoid Schizophrenia
- Post-partum psychosis Drug-induced Brain tumour

Difficult situations:
- If the patient with hallucinations tells you that he sees a radiation and gives you a
photo and asks: do you see it doctor? ! For me it does not look like radiation, but
I can understand that you see this as radiation
- At any time the patient starts to agitate and worries about special hallucinations!
o You are safe here, no body will harm you
- If the patient is away:
o Do not chase him/her around the room, stand by your chair
o I would like to assure you that you are safe here, no one will harm you
- I do not like “Egyptian people”, by the way, are you Egyptian doctor?
o Why are you concerned about that?
o Whether I am Egyptian or not will make no difference in this situation
- I do not like “gays”, by the way, did you see a gay patient today doctor?
o Why are you concerned about that?
o As a physician, I deal with all kinds of patients, regardless their race,
religion, sex, sexual orientation or anything else!
- Do you think I am crazy doctor?
o There is no medical term called “crazy”. However sometimes some people
have difficulties in the way they handle their thoughts and the way they
interact with and perceive reality, we call that schizophrenia. It is a mental
illness like any other illness that can affect the body, that we can treat with
medications

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SUBSTANCE ABUSE

Clarify the CC
OCD
Criteria : Any tactile hallucinations: cocaine until proven otherwise
Hallucinations
Delusions
1st time or did you have it
before?
Past psychiatric history
Organic Cover the following: head injury / trauma / vomiting
cocaine / amphetamine
Mood / Anxiety
Serious conditions
Social history
Family history

DD - Drug-induced psychosis
- HIV
- Schizophrenia
Investigations - CBC / urine / toxicology screen
- HIV / syphilis test
- CT / MRI brain

SCHIZOTYPAL PERSONALITY DISORDER

- Magical believes
- Limited number of friends that share the same believes
- Delusions

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PANIC ATTACK
Patient comes to the clinic complaining of dizziness

Common presentations: SOB / chest pain / heart racing / dizziness / numbness


Symptoms:
- ↑ cardiac: heart racing1 / chest pain tightness / excessive sweating
- ↑ respiratory: SOB / wheezing
- ↑ neurology: numbness / tingling / weakness / shaky / buzzing sounds / headache /
vision changes / difficulty balance
- ↑ GIT: nausea / vomiting / difficulty swallowing
- Depersonalization: you feel that you are out of your body
- Derealisation: feel things around you are strange / not real
- Excessive fears of: losing control / going crazy / dying

Clarify the CC When you say dizziness, do you feel:


- light headed
- Spinning
Analysis of CC Os Cf D
Criteria Analyze the attack: How did it end? How many attacks?
Are they similar? What were you doing?
" Associates symptoms: scan for the symptoms (above)
" Between attacks, do you have fears of having other
attacks? How does it affect you? Do you avoid going
out? (Relation to agoraphobia?)
MOAPS + Detail the anxiety screen questions
+ Cover the following: thyroid disease / SAD
(cocaine / caffeine / alcohol) / pheochromocytoma / MVP
Anemia (fatigue / light headedness / heavy menses / PMH anemia)
Past psychiatric history
Serious conditions
Social history / Family history
Detailed anxiety questions:
- Ask about the symptoms (cardiac, respiratory, neuro, GIT)
- Did you feel that you are out of your body? Or things are not real?
- Do you have excessive fears?
- Did you fear that you are: losing control / going crazy / dying?
- Between attacks: …
- Are you the kind of person who worries a lot? Excessive fear
- Are you under any stress in your life? How can you cope with this?
- Any special fears? High altitudes? Closed places? Talking in public?
- Have you ever encountered a situation in which your personal or mental safety
and wellbeing were endangered? When? Do you have flashbacks or nightmares?

1
Any heart racing, ask the patient “can you tap it for me”, then comment to the examiner: “it looks regular /
irregular for me”

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COUNSELLING

- Good day Mr … With what I heard from you today, the most likely diagnosis to
your symptoms is a medical condition that we call “panic attack”
o Now Mr … what do you know about “panic attacks”?
o Do you want me to explain this in details over the next few minutes?
- Inform the patient:
o Explain the pathophysiology: it is called sympathetic over-activity,
imagine you are crossing the road, and a speedy car is approaching you,
normally, our body reacts to this by enhancing the sympathetic nervous
system, which leads to some changes: increase in the heart rate, …
" The same reaction might happen without any external trigger, and
this would be stressful, and this is what we call a “panic attack”,
o Consequences: this might happen again / may cause limitations
o Investigations: I will still need to do physical exam, some blood works and
an electrical tracing of your heart (ECG), and if it is all negative, that will
be consistent with our diagnosis
- Preventive measure:
o Life style modification (↓caffeine and alcohol / better sleep hygiene)
o Relaxation techniques (e.g. breathing techniques)
- Treatment:
o Like many other conditions, it could be treated: 1/3 of cases will improve,
another 1/3 will remain the same, and the last 1/3 will deteriorate
o Treatment varieties include:
" Talk therapy
" Medications: 2 types
• Anti-anxiety: Lorazepam 0.5 mg qhs x 2 weeks
• SSRIs: Paroxetine 10 mg od x 4 weeks – similar to what we
usually use with depression.
• Like any other medication, they have their side effects;
• Follow-up 2-3 weeks
- Offer more information: brochures / web sites
- Whenever you suspect social problems ! involve the social workers

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TIREDNESS

Introduction
CC Tiredness
Clarify the CC - Is it weakness?
- Lack of energy?
- Decreased activity? Blocks …
- Not being refreshed after sleep?
Os Cf D Timing:
- Morning or all day: ?depression
- End of the day: organic
Ask about sleep - How many hours? And before?
- Find difficulty falling asleep?
- Do you wake up during night?
- When u wake up, do u need naps?

↑ sleep ↓ sleep

? organic ? depression
Constitutional symptoms Criteria : MI PASS ECG
All systems review (head to toe): 1st time or did you have it before?
- Cardiovascular What about the opposite?
- Lung Past psychiatric history
- GIT / liver Organic …/…/…
- Urinary Anxiety / psychosis
- MSK / skin Serious conditions
- Anemia ± LMP / periods hx Social history
- Endocrine (thyroid / DM) Family history
MI – mood / interest
PMH of cancer Counselling on depression
Social history – SAD
Family history

Diabetes Mellitus:
- Hx of DM - Blood sugar measured - Symptoms:
Fluctuations (acute) Emergencies Complications (chronic)
MICRO MACRO
- Eat more - Blurred vision DKA - Nephropathy - CAD
- Drink more - Tired Hypoglycemia - Neuropathy - CVS
- Pee more - Weight loss - Retinopathy - PAD /
impotence
Risk factors: weight / diet / family history / medications (steroids/beta blockers)
Counselling: I will need to do physical exam / laboratory to confirm diagnosis, but your
symptoms are likely due to …
Counsel on diet / weight Complications: high blood sugar

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NOTES

1- Sleep hygiene questionnaire:


- How many hours? How about before?
- How does this affect your life? ! empathy
Before - Find difficulty falling asleep? How long does it take you?
- Do you sleep in dark room? Lit room?
- Do you eat before sleeping? Heavy meals? Late meals?
- Do you drink before sleep? Alcohols? Coffee?
- Do you exercise before sleep?
- Do you read in bed? Watch TV?
During - Do you wake up during night? Any reason?
- Do you sleep alone? Or do you have sleep partner?
o Does he notice you are snoring? Do jerky movements?
o Does he snore? Does he do jerky movements?
- Do you have dreams? Nightmares?
After - Do you wake up early?
- When you wake up, do you feel non-refreshed? Do you need naps?
- Do you work on shifts?

2- Depression:
" Psychomotor question: do you think things take more time to do now?
Compared to before?
" Pancreatic cancer ! depression
" Whenever you find alcoholic patient ! check for complications:
i. Cancer pancreas
ii. Liver damage (↑ liver enzymes) / hepatitis / cirrhosis / carcinoma
iii. GIT: upper GIT bleeding / peptic ulcer perforation
iv. Depression (alcohol / depression / suicide) is common combination
" Treatment for depression (or most of the psychiatric diseases):
i. Life style modification
ii. Talk therapy
iii. Medications
Usually in combination

3- Domestic abuse presentations 4- Fatigue


- Headache - Depression / PTSD
- Abdominal pain - Domestic abuse
- Insomnia / sleeping pills - Hypothyroidism
- Vaginal bleeding - Fibromyalgia
- Fatigue - Anemia:
- Old person: think cancer & occult blood
- Young female: think menorrhagia
- Diabetes Mellitus, polyuria
- Anorexia nervosa

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INSOMNIA

A lady complaining of insomnia


Common presentation to: domestic abuse / depression / anxiety

Introduction
CC Insomnia / Tiredness
Clarify the CC - Difficulty falling sleep
- Waking up
Analysis CC: Os Cf D - More at certain time of the week?
- Did you try anything to help? Did it work?
Ask about sleep Sleep hygiene questionnaire
Anxiety - Do you have too many worries?
- What comes in your mind before falling asleep?
- Any changes / stresses in your life?
- Do you wake up with nightmares?
Depression - Screen with MI; if positive ! screen MI PASS ECG
PMH
Social - With whom do you live? Support?
! Screen for domestic violence or spouse abuse
- Children?
- Financial support?

N.B. did you ever think to hurt yourself? NO, my kids need me,
What about if they are not around? Maybe! This means: implicit yes to suicidal ideation

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DOMESTIC VIOLENCE – SPOUSE ABUSE

Screen for domestic violence or spouse abuse:


- ASSURE confidentiality: I would like to assure you that our conversation is
completely confidential, whatever you will tell me here, I will not release any
information, unless otherwise required by the law!
- With whom do you live? How do you describe this relationship? Supportive?
- How long have you been in this relation?
- Do you feel safe at home? In this relationship?
- Do you sometimes have conflicts? Arguments?
- Do you or your partner go through stressful times?
- Is there any chance that you partner drinks or uses drugs? When he drinks, does
he become angry? Lose control? When was the last time?
- How does this affect you?

Verbal / emotional:
- Does he start to shout at you? Swear at you?
- Does he call you names?
Physical:
- Did he ever get angry to the extent that he became physical?
- Does he try to put you down? Does he try to control you?
- Did he try to push you? Hit you? How many times?
- Any visits to the ER? When was the last time?
Financial:
- Who is controlling the spending at home?
- Do you have access to financials? Do you take permission?
- Did he ever to try to take you money against your wishes?
Sexual:
- Did he ever force you to sexual activity?

- Did he ever mistreat / abuse you in front of the children?


- Did he ever mistreat / abuse the children?
Fatality:
- Do you have access to weapons at home?
- Did you ever have thoughts to put an end to this all by ending your life or his life?
- Did you ever talk to anyone about this?

OUTCOME:
- The patient decides to end the relationship and leave ! you must provide support
and shelter
- The patient decides to continue: either with OR without police involvement

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Wrap-up:
- Based on what you have told me, what you are experiencing (or have gone
through) is called domestic violence or spouse abuse, and it is common. It is an
illegal crime, and it is against the law.
- It is not your mistake, and you should not feel guilty about that. It is unacceptable,
and nobody deserves to be treated in this way.
- We know from studies that the situation will not improve, on the contrary, it will
deteriorate, and you do not need to accept this. The studies show that the longer
you stay in this relationship, the higher the chance of abuse.
- It is important that you consider reporting the situation to the police for your
safety.

- If you like to end the relationship and leave:


o You can the police, they will come and arrest him, then they will
investigate the case, and may put charges against him, and you do not need
to worry that he might hurt you, the police can give a restraining order
o I will connect you with the social services and support groups, you do not
need to go through all of this by yourself, they will be able to help with
housing, financial support for both of you and the kids
- However, if you want to continue the relationship, you can still involve the police.
We know from the studies that if you involve the police, situation will improve,
they will come, speak with him, do some investigations, and then, by law, your
husband will be pushed to attend special training course:
o Anger management
o Relaxation techniques
o Drinking problem rehabilitation
o Marital counselling
- My concern is that if you go back without taking any measures, things might
deteriorate and get out of hand and one of you might lose his/her life, at least:
o You need to prepare an escape plan:
" A bag with essential belongings (e.g. IDs, bank documents, …)
" Easily accessible (you can pick it in second and leave)
o We will schedule a follow-up visit within few days
o Give social support group numbers

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CHILD ABUSE2

The child came to the ER with femur fracture, the skeletal survey showed multiple
healing fractures, counsel

Introduction … I assure you that he is ok, and after we finish I would


accompany you to see hi, is it ok with you. Before this I
would like to ask you some questions to know more about his
condition / fracture
Analyze the event - Can you describe what happened?
- When did this happen? When did you come to the ER?
- Who witnessed it? Anybody else?
- What he was doing?
Is it the first time? - Analyze the event
- Did you take him to the same hospital?
BINDE - E:
" Are you the biological mother?
" Is your current partner the biological father?
" SAD for both partners!
- Screen for the risk factors for child abuse:
" Was this pregnancy planned? Regular f/u visits?
" Was he a term baby? Did he need special attention?
" Has he had congenital anomalies?
" Do you think he is a difficult baby? Fussy baby?
- I: Are his shots up-to-date? If no, any reason?
- N: What is his weight? Do you know about his growth
charts? Regular f/u visits?
- D: Is he hyperactive baby? Challenges you most of time?
- E:
" How do you support yourself financially? Any support
from the biological father?
" Anybody at home seeing a psychiatrist? Illness?
" Tell me more about your childhood
Other children - Do you have other children?
- Repeated visits to ER?
PMH of the child

Screen for domestic violence or spouse abuse

2
Good TWO screening questions: immunization (not up-to-date) / weight (FTT or under nutrition)

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Wrap-up:

- How do you feel your child has so many fractures? …


- I know that you are concerned about your son, sometimes it is challenging to look
after a child, especially if you do not have enough support.
- On the other hand, children at that age have flexible bones, and it is difficult to
explain the nature of his fracture(s) only by jumping from a couch.
- In these situations we usually involve the children aid society (CAS), this is a kind
of social services devoted to the safety and well being of children
o Please do not do this? Why?
o They will take my son! Why r u saying so? Any experience with them?
o Not necessarily that they take your child, this is not their first priority
- Their first concern is the safety of your child, what will happen is that they will:
o Ask you some questions about what happened!
o Come to visit you at home
o Talk with your partner
Then they will take their next step based on the results of these meetings
- I am sure you are sharing my concerns about … (the child name) safety!

If there is spouse abuse / domestic violence:


- Also, based on what you have told me, what you are experiencing (or have gone
through) is called domestic violence or spouse abuse, and it is common. It is an
illegal crime, and it is against the law.
- It is not your mistake, and you should not feel guilty about that. It is unacceptable,
and nobody deserves to be treated in this way.
- We know from studies that the situation will not improve, on the contrary, it will
deteriorate, and you do not need to accept this. The studies show that the longer
you stay in this relationship, the higher the chance of abuse.
- It is important that you consider reporting the situation to the police for your
safety.

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DOMESTIC ABUSER

You are bout to see a 55/60 years old gentleman, whose wife is recovering in the ER, she
has bruises, and he asked to speak with you. In the next 10 minutes counsel him

Introduction
Analysis
SH / Safety
Counsel " Domestic violence
" Drinking rehabilitation
" Stress management and anger control
" Family marital counselling
" Offer social support if there is a need

Introduction:
" If the patient asked to see you: I understand that you are here because you are
accompanying your wife, she has bruises and my colleagues are taking care of her
right now. How can I help you today?
" If the patient is inquiring about her status: I can assure you that she is stable and in
safe hands now.
" If the patient asks to see her: After we will finish, I will ask her, if that is ok with her,
I can take you there.

Analysis:
" Do you have any idea how did she end up having all these bruises?
" Was there any argument / disagreement / shouting? Did you lose control? Did it end
up that you physically hurt her?
" Is this the first time or happened before? Any repeated visits to the ER before?

Social history:
" How long have you been together? What is the nature of your relationship? Stable?
Was there and significant conflicts before?
" Was there any recent change or stressor in your life? How do you support yourselves
financially? Do you have enough resources?
" Do you have anybody else at home? Any family support? Do you have children?
How is the relation with them?
" SAD

Safety:
" Criminal record / access to weapons at home
" If you go home now and face the same situation, how would you react?
" Any chance that you might hurt yourself or any other one?

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Counselling:

" I can see that you are going through stressful period of time. It must be difficult for
you and your wife. Sometimes this stress might present by changes in behaviour
and/or personality.
" If you do not have enough support at home, things might get out of control.
" What happened is what we call “domestic violence”; it is a kind of “physical abuse”.
It is not acceptable, and it is considered illegal crime. However, this is your wife
decision. If she chooses to report you, that is her right, and nobody can prevent her.
She can press charges against you, and they will take you to the court, in this case you
might need legal help, this might have serious consequences.

" On the other hand, if she decides not to take any measure, may be you should try to
improve the situation by taking steps to decrease the stress in your life, and you can
consider reducing your alcohol drinking. Drinking alcohol might leads to what we
call “disinhibition” in which one might lose control on his reactions and usually this
leads to violent and serious consequences.
" I can help you by referring you to attend:
o Alcohol rehabilitation programs
o Stress management and anger control programs

" I recommend also that you consider attending family marital counselling; they have
good experience in dealing with couples going through difficult times.

" Finally, I can help you to contact the social services. They might be able to help; you
can speak with them and see what they might be able to do! Is that ok with you?

2011-09- Psychiatry.doc Page 19 of 40


DEPRESSION

Management:
- Suicidal patient: ! hospitalization
From what you have told me, you are meeting the criteria of what we call “…”
and I have concerns about your safety, because you have more than THREE risk
factors for suicide as per the screening test. Do you mind to stay with us in the
hospital for few days, so we can do the required investigations and start the
medications, until you feel ok, what do you think about that?

- Outpatient: ! SSRIs
o Cipralex 10 mg PO od x 3 weeks (side effects include: headache, nausea,
ejaculation disorder, somnolence, insomnia, diarrhea, fatigue, anorgasmia)
o Follow up visit after 2-3 weeks
o Contract: sometimes when the anti-depressant starts to work, the energy
level improves while the mood is still low, that is why sometimes there is
increase in suicidal ideation. Usually happens 2-3 weeks, if this happens
with you, call 911 or call me immediately and come to see me.

2011-09- Psychiatry.doc Page 20 of 40


DEPRESSION COUNSELLING

1. Inform the patient


a. The medical condition is called “depression”, what do you know about
depression? Did you read anything about it? It is the most common mood
disorder. And it is a common problem
b. Explain the pathophysiology: it is related to the chemical in our brain,
most likely to decreased serotonin
c. Consequences / complications of the condition: it affects functionality,
leads to decreased concentration and ability to work, and in severe cases in
susceptible persons, it might lead them to suicide
2. Treatment:
a. Talk therapy
b. Medications: (side effects / alternatives / consequences)
i. SSRIs
ii. TCA
3. Offer more info: brochures / web sites
4. Break every 30-60 seconds and ask the patient: does that make sense? Is this
acceptable? Reasonable? Is it clear?

2011-09- Psychiatry.doc Page 21 of 40


DYSTHYMIA

Depression presentations: sad (low mode), weight loss, insomnia, tired

" Scale the sadness 0 – 10


" If good days ! ask for periods (check for gaps ≤ 2 months)

" Screen MI,


o If positive ! MI PASS ECG
o Then assess functionality; what do you do?!
Also:
" Indecisiveness: difficulty making decisions
" Low self esteem ! how do you feel about yourself?

2011-09- Psychiatry.doc Page 22 of 40


ABDOMINAL PAIN / HEADACHE

Abdominal pain for few weeks, and was seen by a surgeon last week, comes to your
office (± to have MRI OR to renew medication).
Headache for 7 months, young man, comes to renew Tylenol 3

Chief complain ± a request (investigations OR medication renewal)

Introduction
Analyze the previous visits Is the pain different?
Analyze the CC Os Cf D / PQRST / ↑↓ / 1st time
AS " Constitutional symptoms
" GIT / liver
" Genito / urinary

Medical problem Somatisation


PMH Other pains / headache
FH Impact/cause: how does it affect your life?
How are you coping? Are you under stress?
SH MOAPS screening
FH of psychiatric disease

Physical examination Counselling

Notes:
- Somatisation disorder: (4 pains / 2 GIT / 1 neuro / 1 sexual) complains
- If the pain is only during the day, and not nights ! mostly non-organic

Actions for Tylenol 3:


- If using it for few weeks ! stop it / do not worry about withdrawal symptoms
- If using it for long time ! counsel / renew
- If using it for depression ! start SSRIs / taper Tylenol 3 (decrease gradually)
- If drug seeker ! DO NOT give any narcotics / rehabilitation

2011-09- Psychiatry.doc Page 23 of 40


Counselling for somatisation disorder:
- I understand that you are here because of …, and to (renew medication / do MRI /
…) and we will discuss that, but before discussing this, I would like to explain the
findings in your case.
- Based on the symptoms (± and the surgeries you had) the most likely explanation
to your pain (headache) is a medical condition called “somatisation disorder”.
- What do you know about “somatisation disorder”? Would like me to explain?
- It is not uncommon condition, and we do not know the exact explanation for it,
but we believe that because some patients are more sensitive to pain than others,
or may be due to patients difficulty in handling stresses in their lives, these
stresses may manifest as painful experiences (symptoms).
- Do you have a family doctor?
" YES
o I will explain some points for you now, and then you can arrange a
meeting with your family physician and discuss the follow up with him, in
these situations, it is important to have only one physician dealing with all
the investigations so that he can get better understanding of the whole
situation.
" NO, I do not have a family physician!
o I can be your family physician, if you would like to. That means we will
set a follow-up visits every 4 weeks, during which we will review
underlying symptoms, to make sure we are not missing any serious
condition.
o We will review the stress in your life and see how we can help you with it:
" I can refer you to psychiatrist to help you deal better with any
stress / conflict in your life
" And we can consider some medications (Amitriptyline), it belongs
to a family of medications called TCA (tri-cyclic anti-depressants)
but we use it for pain control

Counselling if the patient is depressed:


- I understand that you are here because of …, and to renew medication and we will
discuss that, but before that, I would like to explain the findings in your case.
- Based on what you have told me, the most likely explanation to your symptoms is
a medical condition called “depression”.
- We need to treat the depression with [talk therapy, behavioural modifications, and
medications (SSRIs, TCA)] ! depression counselling
- For Tylenol 3 we will not stop it suddenly, I will renew it for you, but we will
agree that you will gradually cut it down, over the next few days, till the other
medication (SSRIs) kicks in.

If there was a suicidal attempt:


- However, because of the suicidal attempt 2 days ago, we would like you to stay
with us in the hospital for few days so that we can start the treatment

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DRUG SEEKER

If you find a man searching in the drawers of the hospital, firmly ask him to stop, tell him
this is private property and he is not allowed to go through these medical stuff

Introduction Why are you taking it? What was the diagnosis?
Analyze the CC Os Cf D / PQRST / ↑↓ / 1st time
AS - Constitutional symptoms
- Red flags for headache:
" Nausea / vomiting
" Bothered by light
" Neck pain / stiffness
" Weakness / numbness / tingling in body
Analyze Tylenol 3
Other medications In addition to Tylenol 3, do you take any other meds?
Sleeping pills?
MOAPS
PMH If teenager: HEAD SSS
SH SAD (if not done with PMH)

Analyze Tylenol 3
- So you told me you are taking it for …
- Who prescribed it to you?
- Who renewed it to you? Why?
- When was the last renewal? Can you show me your last bottle?
- How many tablets do you use now? And before? When did you start to ↑ the use?
- When you take it, aside for the headache relief, how do you feel? What if you do
not take it, how do you feel? Start shaking? Heart racing? You feel you are on the
edge?
- Do you renew it from the same doctor or different doctors? Why you did not go to
him this time? Is it ok that I contact him?
- Do you renew it from the same pharmacy or different pharmacies? Is it ok that I
contact the pharmacy?
- Did you ever obtain the medication from the street?

Counselling:
- I understand that you are here to renew your Tylenol 3, we will discuss that, but
before that let me ask you what is your understanding of Tylenol 3?
- Tylenol 3 is a good medication when it is used for particular indication.
- Do you know what does it contain? It contains 2 medications:
o One of them is the regular Tylenol as you buy it from the pharmacy
o The other one is codeine

2011-09- Psychiatry.doc Page 25 of 40


- Tylenol itself is a safe and effective drug, and can be used for long time, however,
if there is no strong indication to use it, it is better to ↓ it as it might cause liver
and kidney injury.
- On the other hand, the other medication “codeine” it is a drug belongs to the
family we call “narcotics” which is similar to morphine. It is an excellent pain
killer if used for short term, but, if it is used for long term, this is concerning for
us, do you know why?
o First of all, people need to keep increasing the dose in order to obtain the
same effect, we call that tolerance
o Also, if you stop using it suddenly, you will have “withdrawal” symptoms,
similar to that you have now; sweats, shaking, and heart racing
- For these reasons, people got hooked easily on Tylenol 3, and can not stop it. Not
only that, they will need to keep increasing the dose. We call that “a habit forming
medication”.
- If I renew your medication, I will not be helping you, it will be like a vicious
circle, the more I renew your medication, the more dependent you will be on it,
the more you will need it. For that reason it is not the right step to renew it.
o Can you give me just few pills; I have a very important interview?
o Even if I give you few pills, this is not the solution, this will be
temporarily, and the problem will keep increasing. I can help you with
“sick” or “leave” note. And a better idea, I can give you another
medication that can help you with your pain.
- If you like help, I can refer you to a detoxification center, where they will help
you to quit.

2011-09- Psychiatry.doc Page 26 of 40


LITHIUM DISCONTINUITY

Introduction Have been diagnosed with bipolar 3 years ago, and would
like to discontinue the lithium
Tell me more Why would you like to stop your medication?
I am glad you came here to discuss it, any other concerns
Mania History " When were you diagnosed? How?
" Any serious consequences? Were you hospitalized?
For how long?
" Were you seen by a psychiatrist? Regular f/u?
Today Do you feel: DIG FAST (distractibility, impulsiveness,
grandiosity, flight of ideas, activity, sleep, talkative)
Scan for MI PASS ECG
depression
Lithium History " Do you renew your medications on regular basis?
" How much lithium do you take? From the beginning?
" Are you taking it regularly?
" Do you measure lithium level? On regular basis? When
was the last time? What was it? What is your target?
" Are you still taking it? Did you stop?
" How do you feel about lithium?
Side " Hypothyroidism: do you have your thyroid hormone
effects measured? Do you feel cold? Dry skin? Constipation?
" Diabetes insipidus: do you feel thirsty? Drink more?
Pee more? Got your urine checked? ttt: thiazides
" Abdominal pain? Nausea / vomiting?
" Neuro – shaking/tremors: β-blockers
" Neuro – ataxia/balance/seizure: stop it
MOAPS I know that you have been asked all these questions before,
let me ask it for another time!

Do you feel: DIG FAST (distractibility, impulsiveness, grandiosity, flight of ideas,


activity, sleep, talkative)
D Do you have a lot of projects? Were you able to finish it to the end? Can you focus
on multiple projects?
I " Are you spending more money than before? Are you borrowing money that you
can not pay back?
" With whom do you live? Many sexual partners?
" SAD: what started 1st; feeling high or talking drugs?
" Have you had problems with the law? Fighting? Arrest? Speeding tickets?
G Do you feel very special? Have special mission?
F Do you feel a lot of thoughts? Ideas?
A How much time do you spend on your projects?
S How many hours do you sleep? Any changes?
T Did anybody mention that you are talking fast?

2011-09- Psychiatry.doc Page 27 of 40


Counselling:
- I understand you are here because you would like to discontinue the lithium,
however before we discuss that; I would like to know your understanding about
mania and mood disorders!
- Mood disorders are common, and the most common of them is depression where
people feel low and do not concentrate and its treatment include the talk therapy
and medications that could be used for 6-12 months and could be stopped if the
condition improved and in some times we need to give the treatment for longer
periods of time.
- This is not the case for mania/bipolar. We can treat and control it, but we can not
cure it, may be one day in the future we will be able to do this.
- Your chance of relapse if you stop it is 60% and after the second time this goes
up to 80%, and after the third time it goes higher to 90%. You can see it is
increasing.
- Based on your lithium level, which is within therapeutic target, we can measure it
today and we can try to decrease it gradually to check if you are feeling good and
closely monitor you. But you have to promise me that at anytime you feel high
mood, start to spend too much, talk fast or start not to sleep well, you have to
come to see me or go to the nearest ER and inform them.
- Regarding your inability to write, this is not related to lithium, thought block is
not a side effect of lithium. You may try some relaxation techniques to help you
concentrate more.

2011-09- Psychiatry.doc Page 28 of 40


MANIC PATIENT

If the patient is psychotic:


First step is to detect early what is his mood?
- If high mood: manic attack, with psychotic feature
- If no high mood: brief psychotic disorder / schizophreniform

Introduction
Ask about the mood
Assure the patient Assure the patient: you are safe here, you are in the hospital
and no one will hurt you
Red flags Fever / headache / nausea & vomiting / head injury
HPI " OCD
" Mania (DIG FAST)
" Depression (MI PASS ECG)
" Suicide (SAD PERSONS)
" If you leave what will happen? What would you like to do?
MOAPS Screen
" SAD: substance abuse
" Medical conditions; hyperthyroidism: history of thyroid
problems, symptoms (heart racing, sweating, heat
intolerance, neck swelling, visual field changes)
PMH / FH Psychiatric disease
SH

N.B. if any patient has mood disorder; go through DIG FAST and MI PASS ECG

Management:
From what you have told me, you are meeting the criteria of what we call “manic
episode” and I have concerns about your safety, because you have more than THREE
risk factors for suicide as per the screening test. Do you mind to stay with us in the
hospital for few days, so we can do the required investigations and start the medications,
until you feel ok, what do you think about that?

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SUICIDE

LOTS OF EMPATHY

SAD PERSONS
S A D P E R S O N S
Sex Age Depression Previous Ethanol Rational Suicide Organized NO Serious
Male > 65 attempts thinking in the plan support illness
lost family
SAD HEAD PMH
SSS
3-4 Release if enough support
>5 Hospitalize

Introduction - … And to see what should be the next step, first, I


would like to know how you feel about being saved.
o If happy, I am glad for that
o No!
Analyze the event - Assure confidentiality
- Can you tell me more about what happened
- Why did you do that?
- Assess the plan here, was it organized? Or it was an
impulse? Did you leave a note? Recently, have you
been giving your belongings away?
Is it the first time? - Were you seen by a psychiatrist? Were you given a
diagnosis? Do you see your psychiatrist? Take meds?
Analyze SAD PERSONS
After - If you leave the hospital, what are your plans? What do
you want to do?
Decision
Conclusion / Counselling

Analyze SAD PERSONS


E - SAD
R - What did you think will achieve by ending your life?
- Sometimes people hear voices asking them to end their life, did you hear this?
N - HEAD SSS
- H: With whom do you live? … Anybody else? … Anybody else? If there is a
step-parent in the image, ask about the relations with him and with other parents.
Do you feel safe at home? Then ask gradually, if there is a chance that this
parent might get angry when he drinks? May shout, may swear at, may push, and
may hurt?
S - PMH

2011-09- Psychiatry.doc Page 30 of 40


Decision:
- If still depressed and/or SAD PERSONS (>3-5) ! admit
- It she is ok, regrets the accidents, no SAD PERSONS ! release

Conclusion / Counselling:
HOSPITALIZE
- Based on our interview, I have concerns about your safety, because you have
more than THREE risk factors for suicide as per the screening test. Do you mind
to stay with us in the hospital for few days, so we can do the required
investigations and start the medications, until you feel ok, what do you think
about that?
RELEASE
- Based on our interview, it is ok if you would like to leave, but you have to arrange
a follow up meeting with your family doctor within 3 days.
- However, I would like you to know that life sometimes could be challenging, and
you may face challenges in the future. It is important that you learn how to deal
with challenges.
- I would also like you to promise me that if at any time you want to harm yourself
or end your life, you will seek medical help immediately; you can come to my
office or call 911.

Notes:
- If no eye contact, wasting time, no pt interaction ! assure confidentiality
- Whenever you hear “car accident” ! show empathy / did you hurt yourself / ask
about who was in the car / was any one injured?
- If the person driving was < 18 and was driving alone ! be curious ! this must
be an important meeting / person that you really did not want to miss!
- The girl asks you to tell her mother that she crashed mother’s new car! She does
not want to directly (herself) inform the mother!
o I can not do this.
o Why do you think this would help? “She will not be angry”
I see, however, life is full of challenges, it is better that you try to learn
how to deal with challenges yourself.
o We can help you to tell your mother by yourself, we can arrange a meeting
with your mother, I can be present, or we can ask a nurse or a social
worker to be there.
- The girl does not want to inform her parents that she did attempt suicide!
o You assess her and if she is to be released, e.g. she regrets what happened,
she is happy to be saved, no SAD PERSONS risk factors ! she is
competent ! respect her wishes.

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EATING DISORDER

Young female, her parents brought her because they have concerns about her weight

Anorexia nervosa Bulimia nervosa


Restrictive Binge-purge
Under weight Average low weight
Distorted self image
Amenorrhea
Disturbed perception ! loss of insight ! Binge-purge (> 3 times / week) > 3 months
incompetence ! inform parents and admit Lose control ! over-eat ! react (purge)
involuntarily

Introduction Your parents brought you …. How do you feel about that?
I am glad that you came:
- To figure it out (if she is ok)
- To assure your parents (if she is not ok)
Analyze her weight
Diet
Exercise
Extra measures
Impact / consequences
MOAPS S: HEAD SSS
FH Eating disorder / psychiatric illness / suicide
Conclusion

Weight analysis:
- What is your weight today?
- When did you start to lose weight? What was your weight at that time? How
much did you lose? What was your highest weight? What is your target weight?
- Why are you losing weight?
- Are you losing weight alone? Or someone else is encouraging you?
- When do you look at yourself in the mirror, how do you perceive yourself? How
do you perceive your weight?
- Do you like to dress in baggie?
- It looks like you lost a lot of weight in short period of time; I would like to know
how did you achieve that?

Diet:
Let us talk about your diet;
- How many meals do you eat per day? How about snacks?
o What do you eat in breakfast? How about the amount?
- Do you calculate calories? How much calories do you eat per day?
- Do you eat alone or with other people?
- Do you like to collect recipes? To cook?

2011-09- Psychiatry.doc Page 32 of 40


Exercise
- How about exercise? Do you exercise?
- How many times a week?
- Do you dance? Practice any sports?

Extra measures:
- Do you take anything else to help you to lose weight?
- Do you take stool softeners? Do you take water pills?
- Did you try before to induce vomiting?
- Do you sometimes exceed the amount of food you intended to eat? How many
times a week?
- How do you feel after that? How do you compensate?

Impact / consequences:
Because you have lost a lot of weight, I would like to know the impact of this on you!
- Do you have amenorrhea? When was the LMP? Regular?
- Do you feel cold / tired / swelling in your legs?
- Pigmentation on your skin? Fine hair growth? Skin changes?
- Any bony pains? Fractures?
- Muscle cramps?
- Heart racing? Light headedness, dizziness, fainting?

MOAPS:
- Mood: scan for depression
- Organic: hyperthyroidism / constitutional symptoms (for cancer)
- HEAD SSS
- Screen for anxiety / psychosis

Family history:
- Eating disorder / psychiatric illness / suicide

Conclusion:
- Anorexia patient is to be admitted if BMI < 18 or body weight is < 85% of ideal
body weight

Management of anorexia nervosa:


- ………………………………………………………………………………………

Notes:
- So doctor do you agree with me that I am overweight? Or do you see me like my
parents I am not good?
o I will share your parents concern, it looks like you lost significant weight
in short period of time, and this is concerning.
- If the patient lost interest ! slow down ! summarize and start again slowly

2011-09- Psychiatry.doc Page 33 of 40


MINI MENTAL STATUS EXAM:

Introduction: Mr … Now, we will do a mental exercise, in which I am going to ask you


some questions. Some of these questions are easy, and some questions are difficult,
please do as much as you can!
" Prepare this list before you go to the room in cases of delirium / dementia / post-
concussion. Then you can mark the correct or the wrong ones
1 2 3 4 5 5 Orientation to place
6 7 8 9 10 5 Orientation to time

11 12 13 3 3 words recall – immediate


14 d 15 l 16 r 17 o 18 w 5 world – backwards
19 20 21 3 3 words recall – delayed

22 23 24 3 3 steps command
25 26 2 Aphasia (pen / watch)
27 Close your eyes! 1 Read / execute
28 1 Write
29 1 Copy
30 No ifs, ands or buts 1 Repeat

1-5 / Orientation to place: do you know which country we are in? Province? City?
Hospital (or street) name? Which floor (or suit number)?

6-10 / Orientation to time: do you know which year we are in? Season? Month? Day of
the month? Day of the week?

11-13 / 3 words recall – immediate: I am going to tell you 3 objects, and I would like
you to repeat after me and memorize it, and I will ask you about it later! (penny/ tree/ car)

14-18 / Concentration: can you spell the word “world” backwards? He gets -1 for each
non-matching letter

19-21 / 3 words recall – delayed: can you tell me the 3 words that I told you before

22-24 / 3 steps command: give all the instructions at once; are you left or right handed?
Can you please take this paper by the … hand / fold it into halves / give it back to me?

25-26 / Aphasia (pen / watch): what is the name of this? What is this?

27 / Read and execute: can you read this sentence and do what is written in it!
28 / Write: can you write a sentence for me!
29 / Copy: can you copy these two shapes!
30 / Repeat: can you repeat after me; “no ifs, ands, or buts”!
MMS score < 24 ! incompetent

2011-09- Psychiatry.doc Page 34 of 40


DEMENTIA
Difficulty with memory for 6 months

Introduction I would like to ask some questions; then we will do a mental exercise
Analysis of CC Memory assessment
Behavioural " Did anybody tell you that you have changes in your personality? Being
changes short temper? More arguments?
" If there is a fire in this building; what are you going to do?
" How about your sleep? (dementia: fragmented sleep /+/ delirium:
reversed sleep cycle; sleep at day, awake at night)
MMS
Let us take a day of your life; I would like to see how did it affect your life?
DEATH
SHAFT
MOAPS Organic in details and screen the rest (especially mood for pseudo-dementia)

Memory assessment: Can you tell me more about this difficulty! OCD +
- Any fluctuations in memory level?
- This deterioration is gradual slowly progressive, or is it you feel ok for a while
then you have attack then you are fine then you have another attack? (step ladder)
- Are you having difficulty memorizing numbers?
- Do you have difficulty finding words?
- Do you have difficulty reading? Writing? Calculating?
- Do you lose your stuff?
- Do you make lists to remind you to do things you used to do on regular basis? Do
you have difficulty organizing your schedule?
- Do you have difficulty doing tasks you used to do before; like tying a tie?
- Do you feel difficulty for new events, or old events?
o Recent: What did you have for breakfast? Confirm from partner!
o Remote: Who was the USA president during WWII?

DEATH:
- Dressing: difficulty dressing and undressing yourself?
- Eating: do you remember to get all your meals? Or do you skip meals?
- Ambulatory: do you have difficulty moving around?
- Toileting: how about urination? Have you ever lost control or wet yourself?
- Hygiene: any difficulty having showers?

SHAFT:
- Shopping: who is responsible for shopping? You or your wife?
- House keeping: how about house keeping, are you able to help your wife?
- Accounting: who is responsible for banking at home?
Did you ever give cheque without balance?
- Food: do you cook? Did you ever forget the stove on?
- Traffic: do you drive? Difficulty driving? Have you ever lost your way?

2011-09- Psychiatry.doc Page 35 of 40


MOAPS screening:
Mood:
- Depression – pseudo-dementia?
Organic:
- Do you have nay long term disease? Kidney? Lung? Heart?
- History of stroke? Difficult with vision / hearing? Weakness / numbness?
- Medications? OTC? Sleeping pills?
- Any history of thyroid disease? Symptoms of hypothyroidism?
- Hx of surgeries? In stomach?
- Are you vegetarian? For how long? Do you take supplements?
- Head trauma? Injury?
- SAD
Anxiety
Psychosis
Self care / suicide

Dementia cases:
- 69 years old man comes to your clinic because he is keeping forgetting for the last
few months. In the next 5 minutes; take history and assess (this is too long for 5
minutes, but during taking history, and if you mention: I would like to do the
MMS exam, the examiner will give you the score).
- 55 years old patient comes to your clinic because he has difficulty in memory. His
MMS score is 21. In the next 5 minutes, take history.
- 67 years old man, comes to your clinic complaining of difficulty with memory. In
the next 10 minutes take history and assess (make MMS exam).

The cases could be:


- Thyroid disease (especially if pt is younger than 60 years)
- Dementia
- Alzheimer disease

N.B. If the patient has difficulty in AT of the “DEATH”; i.e. falls due to ataxia and
urinary incontinence; consider normal pressure hydrocephalus.

2011-09- Psychiatry.doc Page 36 of 40


DELIRIUM
Delirium cases:
- A middle aged gentleman comes to your clinic because his dad is not himself for
the last 3 days. Take history by proxy
- A middle aged gentleman comes to your clinic because his mom is in seniors
home; they gave her 15 units of insulin instead of 5 units, and she is not herself.
Counsel him! (insulin induced hypoglycemia ! stressful event ! decompensate
a border line delirium)
- Patient has surgery 3 days ago, not feeling himself. Patient will be aggressive.
- Patient has surgery 3 days ago, not feeling himself. Patient will keep repeating: “I
do not know”!

Case 1: Dad has not been himself / not sleeping well


Introduction I will ask some questions in order to reach a working plan
Analysis of the CC " How old is he? What are your concerns?
" Tell me more! Any recent stress? OCD
" Does it look like your dad is seeing things do not exist? Hearing
voices? Complaining of insects crawling on his skin?
" Did you notice if your dad is angry / aggressive?
" Does he sleep during night? What a bout during the day?
" Is he eating? Taking care of himself?
" With whom does he live? How is he capable of keeping life?
How does this affect his / their life?
" Is it first time?
Causes " Constitutional symptoms
DD " Any headache / vomiting / neck pain / skin rash / red eyes / any
ear discharge / runny nose / teeth pain / diff swallowing / SOB /
Infection cough / urine changes / abd pain / calf pain / swelling
Trauma " Head trauma? Injury?
Surgery " Recent surgeries? Pain at site of injection? Dressing change?
SAD " SAD
Medications " What about medications, do you have a list with medications?
Go one by one!
- Is he hypertensive? Controlled? Regular measurements?
- I can see that he is diabetic; for how long? Controlled?
Regular f/u and measurements? HbA1c?
- Cholesterol / Water pills / Anti-depressants
- Sleeping pills; if more than 1; ask if it was prescribed by
the same doctor
- Erythromycin!!! Why was he taking it? Pneumonia!
Conclusion It looks like your dad has a medical condition called “delirium” it is
a serious condition. Your dad needs to be seen by a doctor ASAP,
can you bring him to see me. If he is too far, he needs to be taken to
the nearest ER; we will need to decrease or stop some of his
medications, and restart them gradually.

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Case 2: DT

Patient is agitated, delirious and uncooperative

Introduction I can assure you that are safe here, you are in the hospital and no
one will hurt you, we would like to help you
" I can see that you are looking to the wall, do you see anything?
Do you see anything else?
" Doctor, do you see the spiders I see? For me, it does not look
like spiders, however, I understand that you can see them at the
moment, but I can assure you that nothing will hurt you!
Analysis of CC " I can see you are scratching; do you feel anything? Do you hear
/ see anything?
" Do you think any one would like to hurt you? Assure safety!
" When did that start? OCD?
Full MMS exam
Causes " Constitutional symptoms
DD " Any headache / vomiting / neck pain / skin rash / red eyes / any
ear discharge / runny nose / teeth pain / diff swallowing / SOB /
Infection cough / urine changes / abd pain / calf pain / swelling
Trauma " Head trauma? Injury?
Surgery " Recent surgeries? Pain at site of injection? Dressing change?
SAD " SAD: any shaking / sweating
Medications " What about medications, do you have a list with medications?
Any sleeping pills?
" Do you have nay long term disease? Kidney? Lung? Heart?
Conclusion

Notes:
- It the patient is not cooperative, keeps repeating “I do not know”; start to ask the
questions of the MMS exam, they will go with you. After you finish, you can
continue the rest of your exam
- If the patient is starring at the wall; ask him: I can see that you are looking to the
wall, do you see anything there?
- Mental status exam = psychiatric interview
- For delirium; we do the MMS exam daily until he improves
- For dementia; we do the MMS exam every 3-6 months; for follow-up

2011-09- Psychiatry.doc Page 38 of 40


Counselling – Smoking Cessation
1- Congratulations, … We will speak in details about how we can work together to achieve this
healthy goal, but first let me ask you some questions, I need to have the bigger picture about your
smoking, and this will help us to figure out the best plan to achieve our goal
2- Smoking history:
" When did you start smoking? For how many years?
" How many cigarettes per day?
3- Reasons (motivations): to seek smoking cessation
4- Previous attempts: How many times? Why did you fail? When was the last time?
EMPATHY: “failure” is a normal part of trying to stop
5- Is there any other smoker in your home? Is she/he willing to quit? It will be a great idea if
both of you tried to quit at the same time, this will increase the success rate of your trial.
If she/he would like to know more information or need help, I will be more than happy to
meet her/him, we can arrange a meeting
6- Complications of smoking:
" Cancer (lung, tongue, nasopharynx, urinary bladder, other cancers)
" Cardio vascular hazards (myocardial ischemia)
7- Risk factors (personal history or family history) of:
" Heart disease / attack
" Diabetes mellitus / hyper-cholesterolemia
" Weight loss / hemoptysis
8- Plan:
" STAR:
i. Set a quit date, print papers with this date and stick it under your vision
so that you see it frequently during the day
ii. Tell your family, friends, they will be your support
iii. Anticipate the challenges you will face (nicotine-withdrawal effects:
headache, nausea and a craving for tobacco, insomnia, irritability,
anxiety, and weight gain)
iv. Remove cigarettes and other tobacco products (e.g. ashtrays) from your
home, car, and work
" Nicotine Replacement Therapy:
i. Nicotine patch [21 mg (if smoking > 25 cig/day), 14 mg, 7 mg]
ii. Nicotine gums
iii. Nicotine inhaler
" Psychological support for smoking cessation (to ↓ the craving):
i. Zyban (Bupropion):
+ used with tapering smoking for 2 weeks, then stop smoking and use
with patch
+ 150 mg qAM x 3 days then 150 mg bid x 7 – 12 weeks
+ Contra-indications: epilepsy, seizure disorder, eating disorders, patients
undergoing abrupt discontinuation of ethanol or sedatives
ii. Champix (Varenicline): ↓ urge to smoke and ↓ withdrawal symptoms
+ 0.5 mg qAM x 3 d then 0.5 mg bid x 4 d then 1 mg bid x 12 wks
" Investigations:
i. CBC / urinalysis / lipid profile
ii. If there is risk factors for heart diseases: stress ECG test
iii. If patient is worried, or if there is hemoptysis: chest x-ray

2011-09- Psychiatry.doc Page 39 of 40


REFUSAL TO TREATMENT – COUNSELLING

Mrs … 56 yrs old, was recently diagnosed with lung cancer, counsel her.
Introduction I understand you were diagnosed recently with lung cancer
How do you feel? How are you coping?
Support - With whom do you live?
- Any family support?
- How do you support yourself financially?
Brief history - SAD
- Fm Hx of lung cancers
Lung cancer - What do you know about lung cancer?
- Do you know which type you have?
- Available treatment
- Now, I would like to explain the treatment options we have,
- Once diagnosed, usually surgery is late to be done, so we have
radio and chemo therapies
- Based on your condition and stage of cancer, the surgeon thinks
that “chemo” and/or “radio” therapy are the best line of treatment
for you, this is based on the many clinical trials and evidence-
based medicine.
Treatment refusal No doctor, I do not want to contaminate my body with chemicals, I
am going for spiritual therapy!
Why you do not want to be treated?
Assess Rule out depression:
competency - I want to ask you some questions to know more about your
health! MI PASS ECG
- How is your mood? Do you find yourself cry easily? …
If depressed ! assess suicide and psychiatric consult
Counsel In not depressed ! she is competent, she can refuse treatment
- After all this is your decision; I just want to make sure you know
the available treatments that were proved to be beneficial in
treating lung cancer.
- Why not to try both? We start the medical therapy that we are
sure it works, and you go for spiritual therapy!
- Explain the condition, the available treatments
- The side effects of treatments and the complications of not
getting treatment
- What about arranging a meeting with some one who has had the
same medical condition, and speak with him/her. You will get
better insight into the disease and you will see the results of
treatment.
- How about arranging a meeting for your and your family
members (if you wish) with the surgeon, so that he can explain
the process in more details?

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