Psychiatry Handbook Cases

Contents
Condition 018 Advice on Smoking............................................................................................. 1

Condition 083 Medication changes ............................................................................................ 6
Condition 084 Body Dysmorphic Disorder .............................................................................. 12
Condition 085 Poor work performance..................................................................................... 19
Condition 086 Lifestyle stress .................................................................................................. 24
Condition 087 Binge drinking .................................................................................................. 31
Condition 088 Serotonin Syndrome.......................................................................................... 38
Condition 089 Collapse of a 30 year old .................................................................................. 46
Condition 100 Repeat benzodiazepine script ............................................................................ 51
Condition 106 Recent insomnia ................................................................................................ 57
Condition 109 Postnatal Depression ......................................................................................... 64
Condition 116 Cuts to the wrist ................................................................................................ 72
Condition 131 Major Depressive Disorder ............................................................................... 76
Condition 134 Delirium in a 25 year old .................................................................................. 84
Condition 146 Cognitive state assessment................................................................................ 91
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
Assess his motivation to stop smoking.
Counsel him appropriately.
Discuss treatment options and general resources.
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.
KEY ISSUES
Counselling abilities.
Awareness of principles of a tobacco quitting programme.
CRITICAL ERROR
Lack of awareness of the key elements of a nicotine quitting programme.
COMMENTARY
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
Explain your concerns about continuing on thioridazine
Educate the patient about the risks and benefits of the newer atypical antipsychotics
Explain the side effects of the most common atypical antipsychotics
Respond appropriately to the patient's questions
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
o disturbances in the periods,
o impotence,
o leading to osteoporosis
 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.
TASKS:
Establish rapport.
Take a sensitive, focused and relevant history.
Reach a diagnostic conclusion, and discuss this with the patient.
Discuss management briefly with the examiner.
APPROACH
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
Do you have any specific concerns?
Since how long have you had this?
Is it progressing?
How much hair have you already lost since this started?
Anything that you do to check the situation?
Do you think that this is interfering with your life to such an extent that you are dysfunctional?
Do you have concerns about any other body parts?
Any interventions done for this so far? (gone to massage and beauty parlour nothing has work,
wants to go under the knife, plastic surgeon)
Do you think about this all the time?
Does it ever seem that people are talking about you or taking special notice of you because of
this hair loss?
What do you think has caused you to have these beliefs?
Rule out medical causes
Thyroid problem: do you have weather preferences?
Did you have any recent infections?
Any recent stressors?
Any serious medical illness? Any chronic medical illness that requires treatment like
chemotherapy or radiotherapy?
Are you losing hair anywhere else?
How is this affecting your life?
Psychosocial history
How is your mood?
Do you think that life worth living?
How is your appetite? Any recent weight loss?
How is your sleep?
Do you think that anyone is spying on you or talking about you?
Sometimes under stress, people see, feel or hear things that others don’t, is this also true for
you at the moment?
HEADSSS
Who do you live with? How is your relationship with them?
How is your work?
Do you still enjoy your hobbies?
Do you still attend social activities?
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.
KEY ISSUES
Ability to take a focused psychosocial history and to come to an appropriate diagnosis.
Ability to communicate with a patient with body dysmorphic disorder.
CRITICAL ERRORS - none defined
COMMENTARY
'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.
TASKS
Take a focused history -- you have six minutes to do this
Inform the examiner of the three most likely diagnoses
Answer questions from the examiner about one or more of these diagnoses
APPROACH
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
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?
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?
I will just ask you some routine questions that I ask all of my patients for assessment. Will that
be okay?
DELUSIONS
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?
HALLUCINATION
Do you see, feel or hear things that others don’t?
Do you hear voices that command you to do something?
INSIGHT
Do you think you need help?
JUDGEMENT
If there’s a fire in this room, what will you do?
COGNITION
Where are you? What’s the date today? What is my name?
HEADSS
Aside from your stresses at work, I'd like to ask you how’s your home situation? Do you live
alone? Any stresses?
Do you have relatives who live nearby?
Do you have enough support?
Are you sexually active? Do you have a stable partner?
Do you still go out and meet up with friends and families?
SAD
Do you smoke?
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?
Any chance you're taking recreational/illicit drugs?
PAST MEDICAL HISTORY:

How is your general health?
Do you have any past history of mental illness? Any medical or surgical illness?
Are you on any medications?
Any allergies to food and drugs?
FAMILY HISTORY:
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
KEY ISSUES
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
CRITICAL ERRORS
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
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
1 standard drink = 10 grams of alcohol (equivalent to 12.5mL of pure alcohol)
For healthy men and women, drinking no more than 2 standard drinks on any day
For healthy men and women, drinking no more than 4 standard drinks on a single occasion
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
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.
TASKS:
Discuss his health condition and relevant matters with the patient.
Advise the patient of your diagnosis and proposed management.
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.
APPROACH
History
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?
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?
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?
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.

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 their ability to
cope.
The more often we are placed under stress, the more often we have to use energy 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:
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.
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.
Eat well as a nutritious diet is important. Eat plenty of fresh fruit and vegetables and avoid
sweet and fatty foods.
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.
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.
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.
I will give you reading materials regarding lifestyle stress, and will regularly review you for
blood pressure monitoring and review of your overall health.
KEY ISSUES
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.
CRITICAL ERROR - none defined
COMMENTARY
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.
TASKS
Discuss with this patient his pattern of drinking and its harmful consequences
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!
APPROACH
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
If it is alright with your, could you please describe the incident to me?What exactly happened at
the pub last week?
How are you feeling now? Any headache or blurring of vision?
Is this the first time that this happened?
If it is alright with you, could I ask you about your alcohol intake?
ASSESS
How long have you been taking alcohol?
How much do you usually drink? Per day? Per occasion?
What type of alcohol do you usually take?
Pattern of drinking: do you usually drink every day? Only on weekends? Throughout the day?
During the evenings?
Have you increased your intake of alcohol recently?
Have you had any blackouts?
Is it affecting your relationships?
Any financial problems because of this?
Do you often have accidents?
Any charges with the law due to your drinking habit?
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?
How's your mood?
Do you think that your life is worth living?
How's your appetite? Any changes in weight?
How is your home situation? How is your daughter? Who is taking of her?
What is your occupation? Any stresses at work recently? Are you able to work efficiently
despite having this habit?
Do you also smoke? Take illicit drugs?
Are you sexually active right now? Do you have a stable partner?
How long can you go without alcohol? what happens if you don't drink alcohol?
Do you think you need to drink to go to sleep?
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?
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?
Does anyone in the family also drink alcohol heavily? Any family history of hypertension, heart
disease, diabetes? Any mental health illnesses?
ADVISE
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.
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
You may cut down your alcohol, or stop it completely.
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
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.
I will refer you to a support group called, Alcohol Anonymous, which can help you with your
progress.
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
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.
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
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
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.
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
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.
KEY ISSUES
Discussion about binge drinking and consequential harm
Highlight risk to daughter -- discuss potential referral to child protective services or equivalent
CRITICAL ERRORS
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
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
Identification of the reason for the adverse consequences
Sensitive but frank communication about the problem and appropriate offers of assistance
(education, assessment of psychiatric, medial, social, legal, interpersonal problems)
Motivation for change
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
Department of families
Community services
Indigenous affairs
The authorities will be able to advise him about local child-care and parent support services.
Inform about support groups
Single-parent support groups, men-only support groups
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.
TASKS:
Take a further focused history related to this situation.
Ask the examiner for the appropriate examination findings you require to assist in diagnosis.
Inform the examiner of your diagnosis.
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
Hypoglycemia
Tension headache
Excessive caffeine intake
Drug-induced/Recreational drug use/Withdrawal
Malignant hyperthermia
CNS infection
Psych
Anxiety
Serotonin syndrome
APPROACH
History
I would like to know if my patient is hemodynamically stable? May I know the BP, heart rate,
temperature, and sats?
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?
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?
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?
How is your mood?
Do you have any passing thoughts of hurting yourself or others?
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?
HEADSS
How is your home situation? Who do you live with? Any stress at home?
Do you have relatives who live nearby?
I see that you are a bank clerk. How is your job going so far? Any stress at work?
Do you still go out to meet your friends and family?
SADMA
Do you smoke?
Do you drink alcohol?
Do you have any known allergies?
Any past history of a medical, surgical, or mental illness?
Any family history of a medical, surgical or mental illness?
Physical exam
General appearance: is there any obvious sweating, tremors? Any pallor?
Vital signs: BP, HR with regularity, RR with saturation, temperature?
Eyes: any bloodshot eyes, dilated pupils or pinpoint pupils?
CNS: I would like to know the tone, power, reflex, and sensation of the upper and lower limbs
I would like to do the rest of the systemic exam, CVS, Respiratory, Abdomen, Pelvic.
Office tests: BSL, UDT

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?
KEY ISSUES
Ability to diagnose the serotonin syndrome due to side effects of a Selective Serotonin
Reuptake Inhibitor (SSRI) drug.
CRITICAL ERROR
Failure to recognise the need to stop the Zoloft® (sertraline) medication.
COMMENTARY
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.
TASKS
Examine the lower limbs with attention to the neurological system --- you have six minutes to
complete your examination
Report your findings to the examiner as you proceed. Also take note of the patient's general
behavior and demeanor.
Answer the questions which the examiner will ask you about this problem.
Provide a likely diagnosis to the examiner, and give your reasons for selecting the diagnosis.
APPROACH
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.
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.
Romber’g test: Can you close your eyes for me?
REPORT: The Romberg’s test is negative.
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.
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.
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.
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.
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
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?
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
What would you expect to find on sensory examination given your findings thus far?
Normal sensation
What is your likely diagnosis?
Somatoform conversion disorder
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.
KEY ISSUES
Ability to conduct an appropriate focused neurological examination of the lower limbs and
identify a somatoform conversion disorder with abnormal illness (Sick Role) behavior
CRITICAL ERRORS
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.
TASKS:
Evaluate the situation by taking a focused history.
Outline to the patient the nature of the problem you have identified and proposed
management.
Answer any questions the examiner asks you.
APPROACH
History
Good morning John, I am Dr. ____, your GP today, how may I help you today?
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?
Let me assure you that whatever we discuss today will be private and confidential, unless it
poses a risk to you or to others.
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?
How is your mood?
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 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?
HEADSS
How is your home situation? Who do you live with? Any stress at home?
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?
SADMA
Do you smoke?
Do you take recreational drugs?
Aside from this medication, are you taking other over the counter or prescription medications?
Have you been diagnosed of any medical or mental illness in the past?
Do you have a family history of any medical or mental illness in the past?

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?
KEY ISSUES
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.
CRITICAL ERROR - none defined
COMMENTARY
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.
TASKS
Take a focused and relevant history, to enable you to diagnose the cause of the insomnia
Develop a management plan
Counsel the patient
APPROACH
DDx
Depression
Anxiety disorder
Post-traumatic stress disorder
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?
When did this start?
Finding it hard to fall asleep?
How long does it take you to fall asleep (>15mins = abnormal)
Once you fall asleep, do you have to wake up multiple times?
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?
Do you wake up early in the morning?
Do you sleep in between the day? Take some naps?
Do you feel fresh in the morning? Do you feel drowsy in class?
Do you snore?
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?
PSYCHOSOCIAL HISTORY (complete depression screening, >2 weeks, 5/9 symptoms = MAJOR
DEPRESSION)
How is your mood?
Do you still enjoy doing the activities you used to do?
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 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
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.
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
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
I will organize psychologist referral, where he might start you with a relaxation therapy
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)
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.
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.
I will arrange counselling for your & your family. I’ll see you in one week time to see how you’re
coping with that.
If you drive, please drive carefully.
Here are some reading materials that can give you insight about your condition.
Are you happy with this plan?
KEY ISSUES
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
CRITICAL ERRORS
Prescribing antidepressants at this stage
Omitting supporting interaction

Grief: emotional cost after the loss of someone or something precious and meaningful
Painful and causes psychological anguish, waves of unpleasant dysphoria, and distress
Physiological arousal and mixture of physical symptoms
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
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)
For people who cannot afford daytime fatigue or somnolence even for a few days after a
restless night
Given for up to 2 weeks only
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.
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.
TASKS
Take a further appropriate history to evaluate the possible causes of her symptoms. You do not
need to perform a physical examination.
Provide a likely diagnosis to the examiner and give your reasons for selecting this diagnosis.
Outline briefly your management approach to the examiner.

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.
Major Depression
Hemochromatosis, Hepatitis
Hypothyroidism
Diabetes Mellitus
Adrenal Insufficiency
Malignancy
Infections
Chronic Fatigue Syndrome
Anemia
Drug-induced/Medication-induced
Sleep oapnea
Celiac disease
APPROACH
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?
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?
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?
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?
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?
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 others' actions are directed towards you?
Do you think that someone is inserting thoughts into your head?
Do you think that someone is extracting thoughts from your head?
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?
HEADSS
How is your home situation? Who do you live with? Is there any stress at home?
Are you working? Any stress at work?
How do you describe yourself as a person?
Do you still go out to meet your family and friends?
SADMA
Do you smoke?
Do you take any prescription or over the counter medications?
Any past history of any medical or mental illness?

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:
Depressed mood AND/OR
Anhedonia (no interest or pleasure or enjoyment)
Significant change in weight or appetite
Markedly increased or decreased sleep
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Reduced concentration
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?
KEY ISSUES
Diagnosis of postnatal depression.
Potential suicidal ideation requiring urgent intervention.
CRITICAL ERRORS
Failure to diagnose severe postnatal depression.
Failure to appreciate urgency of situation (including possible suicide) requiring hospitalisation
COMMENTARY
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
TASKS
Inform the patient of your evaluation of his problem and treatment recommendations
Inform the examiner of the reasons for your proposed management and other possible options
Explain your decision to the patient
APPROACH
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
Call for help, calm him down
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.
Oral diazepam 5-10mg and/or olanzapine 5-10mg would be appropriate initial choices for
sedation by the general practitioner.
Diazepam must never be given intramuscularly
KEY ISSUES
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
CRITICAL ERRORS
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
Injury may be accidental or due to deliberate self-harm, or driven by a psychotic phenomena
(by command hallucinations or delusions)
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:
Deciding the level of risk to the patient and others based on obtained information and
observation
Preparedness to act on the decision within the framework of the mental health legislation and
crisis psychiatric resources
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
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
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
The risk of further self-harm may be exaggerated once the patient becomes aware he has a
serious mental illness
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
Oral diazepam 5-10mg and/or olanzapine 5-10mg would be appropriate initial choices for
sedation by the general practitioner.
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.
TASKS
Take an appropriately detailed and focused history.
After six minutes, the examiner will inform you of the physical examination findings.
Inform the examiner of your provisional diagnosis and what further tests you will order to aid
confirmation.

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.
APPROACH
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?
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
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?
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?
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 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 others' actions are directed towards you?
Do you think that someone is inserting thoughts into your head?
Do you think that someone is extracting thoughts from your head?
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?
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?
Are you working? Any stress at work?
Do you still go out to meet your family and friends?
SADMAC
Do you take any other medications?
Do you drink coffee? How much do you drink in a day?
Any past 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.
KEY ISSUES
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.
CRITICAL ERRORS
Failure to diagnosis major depression.
Failure to identify excess alcohol consumption.
Failure to ask about suicidal thoughts or plans.
COMMENTARY
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)
TASKS
Determine the cause of the sleeping problem by taking a relevant focused history, and
performing an appropriate psychiatric (mental state) assessment
Explain to the patient the nature of the problem and what can be done to help
APPROACH
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?
Finding it hard to fall asleep?
How long does it take you to fall asleep (>15mins = abnormal)
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 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]
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?
ORIENTATION (10 POINTS) - may do only 3 to screen (time, place, person)
Do you know what year it is?
What is the current season?
What is the day today?
What is the date?
What month are we currently in?
What country are we in right now?
What state are we currently in?
What town?
Which hospital or GP clinic are we currently in?
What floor are we currently in?
REGISTRATION** checks immediate memory

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
Please remember these three words, I will ask them to you again later.
ATTENTION & CALCULATION

SERIAL 7s = need to subtract 7 from 100 backwards
WORLD: spell the word "WORLD" backwards
If all correct = 5/5 = DLROW
DRLOW = 1/5
Score is given until the first mistake is made
RECALL - Checks short term memory

Can you repeat the three words that I have mentioned to you a while ago?
LANGUAGE
I will show you two objects, please name these for me. 2/2
Can you repeat this phrase for me "No ifs, ands or buts" 1/1
3-step command: take this paper, fold it in half, and put it on the table 3/3
Write on a paper: CLOSE YOUR EYES
Can you read this, and then follow this command 1/1
Can you please write a sentence? 1/1
CONSTRUCTION/COPYING (DIAGRAM)
Can you copy this diagram for me?
DIAGNOSIS AND MANAGEMENT

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.
[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.
[SPECIFICS of the management]
There can be multiple causes of acute confusion, but we will do it a complete delirium screen
which includes
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
URINE: Urine MCS (infections), Urine drug screen, Urine sodium
IMAGING: CXR, Cranial CT
SPECIFICS OF MANAGEMENT
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)
Stop ketamine.
Low stimulus Environment: minimal lighting and noise, one nurse looking after him per shift
Continuous patient observation: by family member or acquaintance. Photos in the wall to make
patient feel he is in a familiar environment
Low dose benzodiazepines ONLY if symptoms persist
For agitation
Haloperidol in low dosage twice daily and can be safely used parenterally
Olanzapine as intramuscular alternative
Sedatives for use at night and in patients with liver disease
Short acting benzodiazepines: lorazepam, oxazepam, alprazolam
Are you happy with this plan?
KEY ISSUES
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
CRITICAL ERRORS
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
Hypoxia - post-operative and post-traumatic patients, and those with atelectasis
Drug intoxication or withdrawal - sedatives, analgesics, and opiates, anesthetics or neuroleptic
agents such as ketamine, and from alcohol withdrawal
Sepsis - chest, wound, and urinary infections
Metabolic disturbances - water and electrolyte (hyponatremia, hyper natremia), hypo or
hyperglycemia, anemia, uremia, hyperthyroidism, or hypothyroidism, hepatic disease
Vulnerability to the above - produced by underlying CNS or psychiatric disorder (Alzheimer,
cerebral tumor, psychosis
Key features
Disturbed consciousness and confusion with disorientation in time and place, fluctuating within
a 24 hr period with lucid intervals
Perceptual abnormalities
Sleep-wake cycle abnormalities (inverted pattern: awake all night and dozing briefly during the
day)
Mental sluggishness
Poor attention and concentration with distractibility
Affective lability: fear, anxiety, depression, grandiosity, aggression
Ideas of reference and misinterpretations leading to paranoid or suicidal/nihilistic ideation and
delusions
Psychomotor disturbance: restless agitation, or somnolent retardation
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
Advancing age
Cerebral insufficiency
Drug/alcohol effects
Brain injury or infection
Any condition requiring intensive care
Treatment
Recognition of diagnosis and identifying and correcting the contributing factors
Assigning same staff each shift to care for the patient
Encouraging family and friends to sit with them are helpful
Place in a quiet room with familiar objects from home nearby
Subdued lighting at night assists in orientation and reduces the likelihood of misinterpretations
For agitation
Haloperidol in low dosage twice daily and can be safely used parenterally
Olanzapine as intramuscular alternative
Sedatives for use at night and in patients with liver disease
Short acting benzodiazepines: lorazepam, oxazepam, alprazolam
Diazepam may prolong or worsen daytime confusion
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.
TASKS
Examine the cognitive state using the modified Folstein Mini-Mental State Examination (MMSE)
provided.
Explain to the patient what you are going to do and why.
Summarise for the examiner, the normal and abnormal MMSE findings.
Tell the examiner your interpretation of the results, including what condition these results
signify.

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:
Orientation: Gave correct information on name, year, day and date, season and location of
consultation.
Registration: Took 3 attempts to learn all 3 objects
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
Recall: only remembers 1 of the 3 objects
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
Construction: able to copy the design accurately
APPROACH
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?
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?
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.
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
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)
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?
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.
KEY ISSUES
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.
CRITICAL ERROR
Failing to identify the specific short-term memory deficit.
COMMENTARY
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.

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Contents

Condition 018 Advice on Smoking............................................................................................. 1

Condition 018 Advice on Smoking

KEY ELEMENTS OF CIGARETTE/NICOTINE WITHDRAWAL PROGRAMME

NICOTINE REPLACEMENT THERAPY (NRT)

Condition 083 Medication changes

BENEFITS AND RISKS OF NEWER ATYPICAL ANTIPSYCHOTICS

IMPORTANT POINTS FROM THE COMMENTARY

Diagnosis and Management

CRITICAL ERRORS - none defined

From Diagnostic and Statistical Manual 4 - Text Revision

PAST MEDICAL HISTORY:

ANSWER EXAMINER'S QUESTIONS

IMPORTANT POINTS FROM THE COMMENTARY

Condition 086 Lifestyle stress

Positive points in the history:

Discuss health condition

Diagnosis and Management

CRITICAL ERROR - none defined

Condition 087 Binge drinking

He regularly drinks heavily at the weekends.

IMPORTANT POINTS FROM THE COMMENTARY

Positive points in the history

Diagnosis and Management

IMPORTANT POINTS FROM THE COMMENTARY

Diagnosis and Management

IMPORTANT POINTS FROM THE COMMENTARY

Positive points in the history:

Diagnosis and Management

IMPORTANT POINTS FROM THE COMMENTARY

Positive points in the history:

Diagnosis and Differential Diagnosis

REGISTRATION** checks immediate memory

ATTENTION & CALCULATION

RECALL - Checks short term memory

DIAGNOSIS AND MANAGEMENT

IMPORTANT POINTS FROM THE COMMENTARY

Positive points in the history:

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