CASC Flash card

CASC FLASH CARDS NOTES 2011

Conducting interview. Stock phrases.

1. Introduction; good morning sir/madam-----my name is Dr – and your name is..?

2. I may need to interrupt you from time to time to get important information and it is not meant to be disrespectful in any way.

Conducting interview. Background information.

1. How old are you?

2. Where do you live?

3. What is your marital status?

4. How do you support yourself?

5. Where do you receive your mental health treatment?

6. How long have you been on the inpatient unit?

7. How did you get admitted: voluntary or involuntary?

Conducting interview. History of the present illness.

1. What led you to being hospitalised?

2. What is the reason for your receiving psychiatric care as an outpatient?

3. Would it be appropriate then for me to say that this…..is the reason for your being admitted/receiving treatment?

4. I am not sure that I understand, would you kindly clarify?

Q1.

ALCOHOL.

Patient with alcohol problem was admitted to orthopaedic ward after fall.

A. Take history and Mental state examination

B. Talk to nurse and discuss management plan.

Answer

A. Substance misuse history.

1. Onset and progression.

2. Typical daily drug use

3. Withdrawal symptoms

4. Poly substance use

5. Previous treatment

6. Complications: physical, psychological, social and family, occupation, finance, insight and motivation.

Q2. ALCOHOL. Assess motivation to change

Answer

1. Empathy

2. Avoid confrontation

3. Intention to change

4. Disadvantages of status quo.

5. Advantages of status quo

6. Advantages of change

7. Conclusion.

Q3. ALCOHOL. Perform physical examination.

1.Use hand gel before and after entering station.

2.Introduce yourself and state reason for the assessment/appointment (History).

3.Consent.

4.Ask for Chaperone.

5. Enquire about pain.

Two components: signs of withdrawal and signs of physical complications.

1.Signs of withdrawal. Include agitated, restless and fidgety; tremor, pulse respiration rate in 15 seconds.

2. Signs of physical complication.

a. Systemic complication. General signs; oedema, reduced body hair, bruises, abrasion and muscle wastage.

b. Arm and hand: elicit palmar erythema, clubbing, nicotine stains, Dupuytren’s contracture, liver flap, spider naevi and koilonychias.

c. Face: elicit pallor, icterus and spider naevi.

d. Abdomen exam and ascites.

e. External genitalia for testicular atrophy.

f. Eye movement: elicit nystagmus, lateral gaze.

g. cerebellar signs: Finger-nose test, Dysdiadochokinesia- heel shin test.

h. Reflexes in upper and lower limbs.

i. Gait.

j. sensory: Light touch, vibration and proprioception.

k. cardiovascular exam.

l. Respiratory exam.

THANK THE PATIENT

Q4. ANXIETY DISORDERS

Assess patient for anxiety disorder

Answer:

1. Communication

2. Presenting complaint and history

3. Background information

4. Diagnostic consideration

5. Co-morbidity

Communication: Non-judgmental; role of psychiatry in diagnosis and management; address concerns; invite corrections; ask consent to discuss with husband

History of presenting complaint: Explore main symptoms; triggers; evolution; avoidance; safety behaviours; levels of distress and functional impairment; risk assessment.

Demographics: Age;education;employment;medical history; psychiatric history; personality; social situation; linear relation with life event; psychosocial context; psychological.

Diagnostic considerations: Agoraphobia; with or without panic disorder; social phobia; specific phobia; general anxiety disorder; OCD; PTSD.

Co-morbidity: Medical; physical exam; alcohol and drugs; depression; psychosis; personality disorder.

Q5.ANXIETY DISORDERS

Explain diagnosis and management to Carer.

Answer.

1. Communication skills: Respond to carers questions.

2. Diagnosis.

3. Management.

4. Prognosis.

Management: Include the following- MDT approach;options;psychoeducation; pharmacological treatment; CBT; Psychiatric disorder treatment; role of carer in treatment plan; graded exposure with relaxation…

Q6. ANXIETY DISORDERS. AGORAPHOBIA. Explore psychopathology.

1.Do you avoid places or situations from which escape might be difficult or embarrassing or in which help may not be available in the event of having a panic attack or panic-like symptoms?

2. Tell me more about it.

Q7. ANXIETY DISORDERS. GENERALISED ANXIETY DISORDER. Assess psychopathology.

1.Do you worry all the time?

2. Tell me more about it.

3. Is this worry so bad that you find it difficult to relax?

4. When people worry they may also have the following symptoms…easily fatigued, difficulty concentrating, irritable, feeling tense, having difficulty sleeping….Have you had any one of these symptoms?

5. Tell me more about it.

Q8.

ANXIETY DISORDERS. OBSESSIONS. Assess psychopathology

1.Do you think certain thoughts or have images that go through your head over and over again?

2. Tell me more about it.

3. Do they bother you or cause any distress?

4. Do they affect your life in anyway?

5. Tell me more about it.

Q9. ANXIETY DISORDERS. COMPULSIONS. Assess psychopathology .

1.Do you have certain urges to do things over and over again?

2. Tell me more about it.

3. Do they bother you or cause any distress?

4. Do they affect your life in anyway?

5. Tell me more about it.

Q10. ANXIETY DISORDERS. Explore anxiety and Panic attacks.

Anxiety:

1.Would you describe yourself as an anxious person?

2. Tell me more about it.

Panic attack:

1.Do you have periods of intense apprehension, fearfulness, or terror that occur out of the blue?

2. Is it often associated with feelings of impending doom?

3. During these attacks, do you have shortness of breath, palpitation, chest pain or discomfort, choking or smothering sensation?

4. Do you fear that you are going crazy or losing control?

Q11.

ANXIETY DISORDERS. PTSD. Explore psychopathology of PTSD.

1.Have you ever experienced a situation in which your life or the life of anyone close to you was threatened?

2. Tell me more about it.

3. Increased arousal?

4. Avoidance of stimuli associated with the trauma?

Q12. ANXIETY DISORDERS. SOCIAL PHOBIA. Phenomenology assessment.

1.Do you feel anxious in certain types of social or performance situations?

2. Tell me more about it.

3. Do you avoid such situations?

Q13. ANXIETY DISORDERS. SPECIFIC PHOBIA. Assess pathophysiology.

1. Do you feel anxious in any specific situation or with a specific object or person?

2. Tell me more about it.

3. Do you avoid such situations?

Q14. ADHD

Take history from patient’s parent.

Answer.

1. History triad: Inattentive and short attention span; hyperactive at least 6 months for both; impulsive.

2. Associated behaviour problems.

3. Lifelong nature of symptoms.

4. Pervasiveness of symptoms in all environments.

5. Effect on function; family; peers; academic.

6. Co-morbidity: reading delay.

Q15. ADHD

Discuss management of ADHD to Parent.

Answer.

1. Acknowledge and address father’s concerns.

2. Explore what father already knows.

3. Nature of problem.

4. Education: coping methods; child, family and school.

5. Behavioural methods management: consistent Approach by parents and other adult carers.

6. Medication: type, benefit, side effect and length of use.

7. Limited role of diet manipulation.

Q16 ASPERGERS

Take developmental history from parent of Asperger’s child.

Answer:

1. Sensitivity.

2. Developmental delay.

3. Social play: spontaneity; reciprocity.

4. Peer relationship.

5. Communication.

6. Stereotypes and routines.

7. Areas of interest.

8. Abuse and bullying.

9. Behavioural issues.

Q17. BEHAVIOURAL DISTURBANCE.

An 80 year old woman had a recent fall. She became hostile to staff.

Task: A. Elicit psychotic symptoms and basic cognitive assessment.

B. Discuss diagnosis and management plan.

Answer.

A. Outline as follows.

1. Communication.

2. Circumstance of head injury.

3. Premorbid function.

4. Current difficulties: Risk; self-care; mood irritable; forgetful; apathy and social.

5. Behaviour associated with frontal lobe damage.

6. Cognitive assessment and frontal lobe examination:

a. Introduction.

b. Abstract thinking: proverb; similarities and estimates.

c. Alternate and sequence; Luria.

d. Verbal fluency: FAS (proper instruction).

e. Memory: List of words; digital span.

f. Calculation.

g. Alternate pattern drawing.

h. Primitive reflex; glabellar tap.

7. Management of head injury.

8. Need more information.

Q18. BEREAVEMENT.

Assess for grief and depression.

Answer:

1. Communication and sensitivity.

2. Chronology.

3. Grief.

4. Sadness and depression symptoms.

5. Guilt.

6. Hopelessness and helplessness.

7. Self-esteem.

8. Retardation.

9. Psychotic symptoms.

10. Family and social support.

11. Suicide risk.

12. Conclusion.

Q19. BLINDNESS.

TASK: Perform assessment to arrive at diagnosis and co-morbidity and perform physical examination.

Answer

Assessment:

1. Present complaint.

2. History of present complaint.

3. Temporal relation with stressors.

4. Medical complaints.

5. Illness in childhood.

6. Coping styles.

7. Offending history.

8. Illicit and legal drug use.

9. Effect on others.

10. Risks.

Diagnosis and comorbidity.

Conversion disorder; hypochondriasis; somatoform disorder; anxiety; depression; personality; substance misuse; etc.

Aetiology:

Predisposing, precipitating; perpetuating factors and secondary gain.

Physical exam:

Chaperone; consent; visual acuity; visual fields; eye movements and reflexes; fundoscopy.

Q20. BODY DYSMORPHIC DISORDER.

Task: Take history and nature of symptoms and perform mental state exam.

Answer:

1. Acknowledge his feeling about referral.

2. Sequential history of symptoms.

3. Assess nature of symptoms: overvalued idea; delusions.

4. Effect on personal and social life.

5. Comorbidity; current or past affective or anxiety disorder; social phobia.

6. Drug treatment for symptoms and comorbidity.

7. Do not argue.

8. Mental state.

9. Risk of self-harm.

10. Psychiatric treatment (persuasion).

Q21. BREAKING BAD NEWS.

1. Introduction.

2. Rapport and empathy.

3. Nonverbal and verbal communication with pause.

4. Use simple language and avoid jargons.

5. Professional approach.

6. Relatives concerns; respond appropriately.

7. Explain result of CT Brain and need for further investigation to clarify diagnosis.

8. Avoid giving false hope.

9. Control of interview.

Q22. CRANIAL NERVES EXAMINATION.

Remember the following five steps for all physical examination stations.

1.Use hand gel before and after entering station.

2.Introduce yourself and state reason for the assessment/appointment (History).

3.Consent.

4.Ask for Chaperone.

5. Enquire about pain.

CN1: Abnormal smell.

CN2: Visual acuity, visual fields and fundoscopy.

CN 3,4 and 6: H movement plus Nystagmus.

CN 5: Sensory (3 divisions) and motor (clench jaws) and feel for masseter.

CN 7: Sensory taste and motor (raise eyebrows, smile, and blow out cheek, shut eyes against resistance.

CN8: Hearing; whispering behind patient.

CN 9, 10: Observe palate and uvula while patient says ‘aah’

CN11: Shrug shoulders against resistance. Deviate head against resistance.

CN 12: Protrude tongue and move to left and right side.

THANK THE PATIENT

Q23. MENTAL CAPACITY ASSESSMENT.

OUTLINE

1. Evidence of depression? Yes or no.

2. Evidence of other psychotic disorder? Yes or no.

3. CAPACITY

4. Evidence of consistency of his decision about the topic? Yes or no.

5. Evidence of coercion from family? Yes or no.

CAPACITY assessment

Two aspects are

1. Diagnostic test.

2. 2. Functional test.

Both diagnostic and functional test must be satisfied and linked before lack of capacity could be concluded.

Q24. CAPACITY. Assess consent to treatment and capacity.

Answer:

Consent to treatment involves the following:

1. Clear and full understanding of condition, procedures and their side effect.

2. Agree freely to receive treatment.

3. Competent (legal capacity) to take decision.

4. CAPACITY. Patient must be able to:

a. Understand the decision to be made.

b. Understand alternative courses available.

c. Weigh up pros and cons of each course of action.

d. Understand, retain and reach decision.

e. Communicate their intent.

5. Cognition: explore delirium, dementia, LD etc.

6. Active mental illness, emotional cognitive maturity.

Q 25. CAPACITY. Explain management plan to consultant.

Answer outline:

1. Communicate findings; be concise and professional.

2. Discuss reasoning for management plan.

3. Mental capacity Act 2005 application.

4. Consent; capacity and cognition.

5. Best interest check list:

a. Advance directive to refuse treatment.

b. Relevant substitute: Lasting power of attorney or court appointed deputy.

c. Involve person in decision as much as possible.

d. Persons past and present views, culture, religion and attitude.

e. Do not base on age, appearance, condition or behaviour.

f. Consult interested friends and family.

g. Least restrictive option.

Q26. CBT. Cognitive behaviour therapy. Assess suitability in patient with depression with cognitive distortion.

Answer:

1. Explain purpose of interview.

2. Explain cognitive distortion (inaccurate thoughts).

3. Elicit cognitive distortions.

4. Explain how CD can affect on-going depression.

5. Explain how CBT can help.

Q27. CONFUSION

A 60 year old man with history of confusion.

a. Assess the patient from carer interview.

b. Discuss presentation and management with consultant.

Answer outline:

1. Address carers concerns.

2. Diagnosis: ADL and risky behaviour regarding strangers and fire.

3. Alzheimer’s, visual hallucination (Dementia Lewy Body).

4. Psychotic symptoms in context of dementia.

5. Further assessment: collateral history, mental state, physical exam, blood test, CT brain, ADL and social support.

6. Carers assessment

Management:

1. Consider immediate, medium and long term management. Link with biological, psychological and social.

2. Treat superimposed delirium.

3. Risk management and mental state.

4. Sensory impairment and hearing.

5. Social isolation.

6. ADL support.

7. Psychological.

8. Resources available.

Question 28. DEMENTIA AND WANDERING: Assess risks.

Answer outline:

1. Assess seriousness of wandering.

2. Risks associated with wandering.

3. Previous episodes.

4. Causes of wandering.

5. Current risks.

6. Functioning at home.

7. Other risks at home.

8. Viability of returning home.

9. Possible intervention.

Question 29.DEMENTIA AND WANDERING. Discuss long term placement.

Answer outline.

1. Elicit their concerns.

2. Current level of support.

3. Carer stress.

4. Relative view on what patient wishes regarding placement.

5. Respect his autonomy.

6. Capacity to decide placement location.

7. Care, wellbeing and autonomy.

8. Options and pros and cons.

a. Home with increased package of care.

b. Sheltered housing.

c. Very sheltered housing.

d. Elderly mentally ill residential care.

e. EMI Nursing home.

f. Written information on above plan.

Question 30.DEMENTIA.Fronto temporal. Take collateral history.

Answer: Four clusters of symptoms are: Behaviour, Affective, Speech and physical.

1. Behaviour.

2. Affective.

3. Speech.

4. Physical.

5. Onset and progress.

6. Medical history and trauma.

7. Premorbid personality.

8. Provisional diagnosis.

9. Investigation.

Behaviour symptoms:

a. Self-neglect. Grooming.

b. Disinhibit ion. Sexual behaviour and aggression.

c. Distractibility and impulsivity.

d. Lack insight.

e. Risk assessment.

Affective symptoms:

a. Depression.

b. Anxiety.

c. Emotional unconcern and indifference.

d. Lack spontaneity.

e. Hypochondriasis and bizarre somatic preoccupation.

Speech symptoms:

a. Progressive reduction in speech.

b. Repetition.

c. Perseveration and echolalia.

d. Late mutism.

Physical symptoms:

a. Early incontinence.

b. Rigidity.

c. Tremor.

d. Akinesia.

Question 31.DEMENTIA.Fronto temporal. Examination.

Answer.

1. Explain assessment.

2. Ability to hear, see and understand.

3. Relevant education and occupation history.

4. Frontal lobe tests

List of Frontal lobe tests:

1. Motor control. Initiate, plan and sequencing.

2. Perseveration: motor and verbal.

3. Finger nose test.

4. Go/no go .

5. Luria hand test.

6. Abstraction.

7. Cognitive flexibility.

8. Verbal fluency.

9. Category fluency.

10. Cognitive estimate.

11. Primitive reflexes.

12. Initiation, abstraction, response set inhibition.

Q32. DEPERSONALISATION. Assess

.

1.Do you have times in your life where you think that you cannot feel experiences or emotions?

2. Tell me more about it.

Q33. DEREALISATION. Assess

1.Do you have times in your life where you think that other people are lacking in feeling or emotions?

2. Tell me more about it.

1.

Q34. Depression. Elicit mood symptoms.

1.When people feel depressed they may also have the following symptoms…have you had any of these symptoms……?

2. If so which of the following symptoms have you had and for how long had you had them?

3. When people feel abnormally elevated or irritable they may also have the following symptoms…Have you had any one of these …? If so, which of the following symptoms have you had and for how long have you had them?

4. In many instances patients with depression also have symptoms of anxiety. Would you say that it was true in your case?

5. Tell me more about it.

6. Would you say that you are an anxious or a restless person?

7. Tell me more about it.

Q35 DEPRESSION. Elicit symptoms

Answer:

2. Introduction.

3. Mood; depression, anxiety, irritability, reactive.

4. Biological symptoms: sleep (early morning wakening). Appetite. Weight. Energy, libido.

5. other symptoms: concentration, anhedonia, motivation, interest, guilt, self-esteem.

6. suicide risk: hopeless, worthless, death wishes, suicide ideas, plans, preparation etc.

7. psychotic symptoms: nihilistic delusions, derogatory hallucination.

8. duration .causes.

9. Effect on personal, family, social and occupational function.

10. coping and supports.

11. insight.

12. Past history: depression, mania, hypomania.

13. diagnosis and treatment options.

14. Respond to nonverbal cues.

Q36. DEPRESSION AND PHYSICAL ILLNESS.

1.

introduction.

2.

chronology of depression and physical symptoms.

3.

differentiating symptoms: anhedonia, guilt, hopeless, self-esteem.

4.

psychotic symptoms.

5.

Effect of medication. Other treatment, hospital

6.

impact on occupation, relation, social and hobbies.

7.

suicide risk.

8.

past psychiatric history.

9.

summary and feedback.

Q37. DEPRESSION. RESISTANT DEPRESSION. Assessment.

1. Current symptoms and precipitants.

2. Treatment so far. Dose, duration, benefit. Side effect.

3. Reason for non-compliance.

4. Physical health; hypothyroidism.

5. Prescribed drugs: steroid, antihypertensive.

6. investigations.

7. psychotic symptoms. dementia

8. perpetuating factors: personality, work, relation, finance.

9. Immediate risks

10. optimism

Note the following:

a. concordance to treatment.

b. Treatment options.

c. Classes of antidepressants.

d. Antidepressant combination.

e. Lithium augmentation.

f. Other augmentations: SSRI and Buspirone, T3, nortriptyline. ; SSRI or venlafaxine and Mirtazapine.

g. ECT.

h. Star D trial: flexible approach, response not predicted by pharmacology or previous treatment.

Q38. EATING DISORDER. Elicit eating disorder history.

1. current eating pattern.

2. body image.

3. height and weight.

4. methods used to aid weight loss. Slimming pills, laxatives, binge and vomit.

5. period over which weight has been lost.

6. menstruation.

7. Physical complications; constipation, low BP, dizzy etc.

8. Co-morbid depression, OCD, suicide risk, drug and alcohol.

9. effect on life: studies and relationship.

Q39. EATING DISORDER. EXPLAIN MANAGEMENT.

1. Explain diagnosis, anorexia nervosa.

2. explain aetiology and family dynamics; family is not the cause.

3. Aims of treatment; weight, physical function optimise.

4. Outpatient: Dietician, food supplement, target weight, psychoeducation, CBT,family therapy.

5. Inpatient: Physical complication, psychiatric disorder.

6. Alleviate guilt feeling.

7. Offer support.

8. Allow questions.

9. Prognosis; chronic, relapsing, young has good prognosis, Low BMI <17, no bulimia and physical impairment are poor prognosis.

Q40. EVIL BABY. Assess and take history, do mental state and risk assessment.

Answer in three parts: History, Mental state and risk.

History:

1. Pregnancy, planned, delivery.

2. Giving birth and when symptoms started.

3. Level of support.

4. Previous pregnancies.

5. Relation with partner.

6. Past psychiatry history: mood, affective disorder.

7. Medical history: medication.

8. Substance use: alcohol and drug

9. Family history of mental illness.

Mental state exam:

1.Mood: labile.

2.sleep, appetite.

3. Routine as mother.

4. Perception: Hallucination

5. Thought: delusion about baby.

6. Insight into beliefs.

RISK:

1.To self: self-harm, suicide and neglect.

2. To others.

3. To baby: harm, neglect.

4. Husband, mother.

5. Outside family.

Q41. EVIL BABY Management. Discuss with husband (post-partum psychosis).

1.Acknowledge their distress. Sensitivity essential.

2.Relatives insight into current problem.

3.Explain your findings: Diagnosis and risk.

4.Management plan :

a.Inpatient or outpatient?

b.Mother and baby unit.

c.Pharmacological and psychological treatment. Lowest effective dose of haloperidol, chlorpromazine or trifluoperazine. Psychology includes supportive counselling, psychoeducation and relapse prevention.

d. counter risk. Risk management.

5.Address concerns of relative.

6. Follow up by CPN, health visitor, postnatal women group.

Q42. EXTRAPYRAMIDAL SYMPTOMS EXAMINATION... EPSE

Remember the following five steps for all physical examination stations.

1.Use hand gel before and after entering station.

2.Introduce yourself and state reason for the assessment/appointment (History).

3.Consent.

4.Ask for Chaperone.

5. Enquire about pain.

In addition: Explain what you know.

Clarify complaint and their history.

Medication and any changes.

Effect of the symptoms on their function.

Proceed as follows;

1.Patient sitting:: Elicit abnormal movement, hypokinesia, finger tapping, and tremors. Moth exam for dentures, tongue movement. Head and neck for rigidity, glabellar tap.

On couch patient to swing legs.

2.Patient standing: Elicit truncal unsteadiness, dropping of hands from shoulder level.

3.Walking: Gait.

Conclusion

4.Explain the findings.

5. Explain management options:

a.Reducing medication

b. changing medication.

capacity Act 2005 application.

4. Consent; capacity and cognition.

5. Best interest check list:

a. Advance directive to refuse treatment.

b. Relevant substitute: Lasting power of attorney or court appointed deputy.

c. Involve person in decision as much as possible.

d. Persons past and present views, culture, religion and attitude.

e. Do not base on age, appearance, condition or behaviour.

f. Consult interested friends and family.

g. Least restrictive option.

Q26. CBT. Cognitive behaviour therapy. Assess suitability in patient with depression with cognitive distortion.

Answer:

1. Explain purpose of interview.

2. Explain cognitive distortion (inaccurate thoughts).

3. Elicit cognitive distortions.

4. Explain how CD can affect on-going depression.

5. Explain how CBT can help.

Q27. CONFUSION

A 60 year old man with history of confusion.

a. Assess the patient from carer interview.

b. Discuss presentation and management with consultant.

Answer outline:

1. Address carers concerns.

2. Diagnosis: ADL and risky behaviour regarding strangers and fire.

3. Alzheimer’s, visual hallucination (Dementia Lewy Body).

4. Psychotic symptoms in context of dementia.

5. Further assessment: collateral history, mental state, physical exam, blood test, CT brain, ADL and social support.

6. Carers assessment

Management:

1. Consider immediate, medium and long term management. Link with biological, psychological and social.

2. Treat superimposed delirium.

3. Risk management and mental state.

4. Sensory impairment and hearing.

5. Social isolation.

6. ADL support.

7. Psychological.

8. Resources available.

Question 28. DEMENTIA AND WANDERING: Assess risks.

Answer outline:

1. Assess seriousness of wandering.

2. Risks associated with wandering.

3. Previous episodes.

4. Causes of wandering.

5. Current risks.

6. Functioning at home.

7. Other risks at home.

8. Viability of returning home.

9. Possible intervention.

Question 29.DEMENTIA AND WANDERING. Discuss long term placement.

Answer outline.

1. Elicit their concerns.

2. Current level of support.

3. Carer stress.

4. Relative view on what patient wishes regarding placement.

5. Respect his autonomy.

6. Capacity to decide placement location.

7. Care, wellbeing and autonomy.

8. Options and pros and cons.

a. Home with increased package of care.

b. Sheltered housing.

c. Very sheltered housing.

d. Elderly mentally ill residential care.

e. EMI Nursing home.

f. Written information on above plan.

Question 30.DEMENTIA.Fronto temporal. Take collateral history.

Answer: Four clusters of symptoms are: Behaviour, Affective, Speech and physical.

1. Behaviour.

2. Affective.

3. Speech.

4. Physical.

5. Onset and progress.

6. Medical history and trauma.

7. Premorbid personality.

8. Provisional diagnosis.

9. Investigation.

Behaviour symptoms:

a. Self-neglect. Grooming.

b. Disinhibit ion. Sexual behaviour and aggression.

c. Distractibility and impulsivity.

d. Lack insight

e. Risk assessment.

Affective symptoms:

a. Depression.

b. Anxiety.

c. Emotional unconcern and indifference.

d. Lack spontaneity.

e. Hypochondriasis and bizarre somatic preoccupation.

Speech symptoms:

a. Progressive reduction in speech.

b. Repetition.

c. Perseveration and echolalia.

d. Late mutism.

Physical symptoms:

a. Early incontinence.

b. Rigidity.

c. Tremor.

d. Akinesia.

Question 31.DEMENTIA.Fronto temporal. Examination.

Answer.

1. Explain assessment.

2. Ability to hear, see and understand.

3. Relevant education and occupation history.

4. Frontal lobe tests

List of Frontal lobe tests:

1. Motor control. Initiate, plan and sequencing.

2. Perseveration: motor and verbal.

3. Finger nose test.

4. Go/no go .

5. Luria hand test.

6. Abstraction.

7. Cognitive flexibility.

8. Verbal fluency.

9. Category fluency.

10. Cognitive estimate.

11. Primitive reflexes.

12. Initiation, abstraction, response set inhibition.

Q32. DEPERSONALISATION. Assess

.

1.Do you have times in your life where you think that you cannot feel experiences or emotions?

2. Tell me more about it.

Q33. DEREALISATION. Assess

1.Do you have times in your life where you think that other people are lacking in feeling or emotions?

2. Tell me more about it.

1.

Q34. Depression. Elicit mood symptoms.

1.When people feel depressed they may also have the following symptoms…have you had any of these symptoms……?

2. If so which of the following symptoms have you had and for how long had you had them?

3. When people feel abnormally elevated or irritable they may also have the following symptoms…Have you had any one of these …? If so, which of the following symptoms have you had and for how long have you had them?

4. In many instances patients with depression also have symptoms of anxiety. Would you say that it was true in your case?

5. Tell me more about it.

6. Would you say that you are an anxious or a restless person?

7. Tell me more about it.

Q35 DEPRESSION. Elicit symptoms

Answer:

2. Introduction.

3. Mood; depression, anxiety, irritability, reactive.

4. Biological symptoms: sleep (early morning wakening). Appetite. Weight. Energy, libido.

5. other symptoms: concentration, anhedonia, motivation, interest, guilt, self-esteem.

6. suicide risk: hopeless, worthless, death wishes, suicide ideas, plans, preparation etc.

7. psychotic symptoms: nihilistic delusions, derogatory hallucination.

8. duration .causes.

9. Effect on personal, family, social and occupational function.

10. coping and supports.

11. insight.

12. Past history: depression, mania, hypomania.

13. diagnosis and treatment options.

14. Respond to nonverbal cues.

Q36. DEPRESSION AND PHYSICAL ILLNESS.

1.

introduction.

2.

chronology of depression and physical symptoms.

3.

differentiating symptoms: anhedonia, guilt, hopeless, self-esteem.

4.

psychotic symptoms.

5.

Effect of medication. Other treatment, hospital

6.

impact on occupation, relation, social and hobbies.

7.

suicide risk.

8.

past psychiatric history.

9.

summary and feedback.

Q37. DEPRESSION. RESISTANT DEPRESSION. Assessment.

1. Current symptoms and precipitants.

2. Treatment so far. Dose, duration, benefit. Side effect.

3. Reason for non-compliance.

4. Physical health; hypothyroidism.

5. Prescribed drugs: steroid, antihypertensive.

6. investigations.

7. psychotic symptoms. dementia

8. perpetuating factors: personality, work, relation, finance.

9. Immediate risks

10. optimism

Note the following:

a. concordance to treatment.

b. Treatment options.

c. Classes of antidepressants.

d. Antidepressant combination.

e. Lithium augmentation.

f. Other augmentations: SSRI and Buspirone, T3, nortriptyline. ; SSRI or venlafaxine and Mirtazapine.

g. ECT.

h. Star D trial: flexible approach, response not predicted by pharmacology or previous treatment.

Q38. EATING DISORDER. Elicit eating disorder history.

1. current eating pattern.

2. body image.

3. height and weight.

4. methods used to aid weight loss. Slimming pills, laxatives, binge and vomit.

5. period over which weight has been lost.

6. menstruation.

7. Physical complications; constipation, low BP, dizzy etc.

8. Co-morbid depression, OCD, suicide risk, drug and alcohol.

9. effect on life: studies and relationship.

Q39. EATING DISORDER. EXPLAIN MANAGEMENT.

1. Explain diagnosis, anorexia nervosa.

2. explain aetiology and family dynamics; family is not the cause.

3. Aims of treatment; weight, physical function optimise.

4. Outpatient: Dietician, food supplement, target weight, psychoeducation, CBT,family therapy.

5. Inpatient: Physical complication, psychiatric disorder.

6. Alleviate guilt feeling.

7. Offer support.

8. Allow questions.

9. Prognosis; chronic, relapsing, young has good prognosis, Low BMI <17, no bulimia and physical impairment are poor prognosis.

Q40. EVIL BABY. Assess and take history, do mental state and risk assessment.

Answer in three parts: History, Mental state and risk.

History:

1. Pregnancy, planned, delivery.

2. Giving birth and when symptoms started.

3. Level of support.

4. Previous pregnancies.

5. Relation with partner.

6. Past psychiatry history: mood, affective disorder.

7. Medical history: medication.

8. Substance use: alcohol and drug

9. Family history of mental illness.

Mental state exam:

1.Mood: labile.

2.sleep, appetite.

3. Routine as mother.

4. Perception: Hallucination

5. Thought: delusion about baby.

6. Insight into beliefs.

RISK:

1.To self: self-harm, suicide and neglect.

2. To others.

3. To baby: harm, neglect.

4. Husband, mother.

5. Outside family.

Q41. EVIL BABY Management. Discuss with husband (post-partum psychosis).

1.Acknowledge their distress. Sensitivity essential.

2.Relatives insight into current problem.

3.Explain your findings: Diagnosis and risk.

4.Management plan :

a.Inpatient or outpatient?

b.Mother and baby unit.

c.Pharmacological and psychological treatment. Lowest effective dose of haloperidol, chlorpromazine or trifluoperazine. Psychology includes supportive counselling, psychoeducation and relapse prevention.

d. counter risk. Risk management.

5.Address concerns of relative.

6. Follow up by CPN, health visitor, postnatal women group.

Q42. EXTRAPYRAMIDAL SYMPTOMS EXAMINATION... EPSE

Remember the following five steps for all physical examination stations.

1.Use hand gel before and after entering station.

2.Introduce yourself and state reason for the assessment/appointment (History).

3.Consent.

4.Ask for Chaperone.

5. Enquire about pain.

In addition: Explain what you know.

Clarify complaint and their history.

Medication and any changes.

Effect of the symptoms on their function.

Proceed as follows;

1.Patient sitting:: Elicit abnormal movement, hypokinesia, finger tapping, and tremors. Moth exam for dentures, tongue movement. Head and neck for rigidity, glabellar tap.

On couch patient to swing legs.

2.Patient standing: Elicit truncal unsteadiness, dropping of hands from shoulder level.

3.Walking: Gait.

Conclusion

4.Explain the findings.

5. Explain management options:

a.Reducing medication

b. changing medication.

c. start antimuscarinic.

d. Assess mental state.

e. Look at patient s notes.

f. Speak to GP, CPN and others.

g. Thank the patient.

Q43. FIRE SETTING assessment

1.Fire setting; possible cause.

2. psychotic symptoms: delusions of control.

3. cognitive function: orientation and recent memory.

4. Previous psychosis.

5. Reasons for stopping medication, compliance.

6. Insight: View of symptoms and causes. View of fire setting and causes.

7. Medication: oral or depot.

Q44. FITNESS TO PLEAD. Assessment.

1.Give reason for your visit.

2.Information is part of report; confidentiality is not guaranteed.

3. Details of index offence and charge.

4. Relevant factors and mental state at time of offence.

5. Establish fitness to plead as follows:

1.Mental disorder.

2. Impact of disorder on ability to understand six points:

a. Nature of charge.

b. Plea guilty or not guilty.

c. consequence of guilty.

d. instruct a solicitor.

e. proceedings in court.

How to challenge juror.

Q45. Fitness to plead. Discuss with solicitor.

1.Explain findings: diagnosis and risk.

2. intended content of your report.

3. Avoid medical jargon.

4. Deal with queries and differences professionally.

5. Duties and responsibility: availability of report and case law precedence.

Q46. FUNDOSCOPY EXAMINATION.

Remember the following five steps for all physical examination stations.

1.Use hand gel before and after entering station.

2.Introduce yourself and state reason for the assessment.

3.Consent.

4.Ask for Chaperone.

5. Enquire about pain.

Proceed as follows;

1.Turn off light and draw curtain.

2. Sit opposite patient.

3. Check focus is set to zero and light is working.

4. Patient to look at particular point.

5. Approach from one side 15-30 degrees.

6. Elicit red reflex (pink pupil) and opacities (cataract floaters).

7. Focus ophthalmoscope.

8. Check optic disc for: papilloedema, optic atrophy and deep optic cup.

9. Retinal vessels. Diameter of arteries, arteriovenous junctions and patterns of blood vessels.

Retinal background and adjacent vessels in four quadrants, nasal and temporal, upper and lower.

Q47. HALLUCINATION. Explore range and depth of hallucinations.

1.Have you had any experience where you were hearing , seeing, feeling or smelling strange things?

2. Tell me more about it.

3. do you have these experiences when you are alone?

4. Have you checked it out with other people if they too are having these experiences?

Q48. HEAD INJURY. Take history from informant.

1.Introduction and setting the reason for the interview.

2. Premorbid function.

3. Mechanism and severity of injury.

4. Current problems and behaviour associated with frontal lobe.

5. Mood, irritability, impulsivity, multitasking, ,apathy and motivation.

6. forgetful.

7. Self-care

8. Risk: driving, kitchen, fire, strangers.

Q49. HYPOCHONDRIASIS. Assess patient.

1.Communication: Address Patient concerns and role of psychiatry.

2. History: Demography, age, education, job, medical history, childhood illness, linear relation.

3. Diagnosis: preoccupation with an organ, patient desire for diagnosis, ,hypochondriasis, somatisation, conversion disorder.

4. Co morbidity. Body dysmorphic disorder, somatisation, Delusion of nihilistic or somatic nature, Depression, anxiety and substance misuse.

5. Physical examination.

Q50. Hypochondriasis. Explain to the carer the diagnosis, management and prognosis.

1.Diagnosis.

2. Management: Multidisciplinary, psychological link, psychiatric disorder, CBT, Pharmacology.

3. Prognosis.

Q51. INTERPERSONAL THERAPY. Explain

There are 16-20 sessions. Weekly sessions last one hour.

There are 4 stages

1.Interperesonal conflict or dispute.

2. Role transitions.

3. Grief.

4. Interpersonal deficit.

Q52. Learning Difficulty and indecent exposure. Take history

1.Aetiological possibilities: Life event.

2. History of depression in the past.

3. Personal history: Education difficulty, bullying at school, employment, ability.

4. Index offence.

5. Offending history.

6. Psychiatry history.

7.Current support.

8. Recent stresses.

9. Mental state examination.

Q53. Learning Difficulty and indecent exposure. Discuss management with Carer.

1.Clarify : Past psychiatry history, treatment, police, risk to self and others.

2. Depression, bereavement.

3. Further assessment by MDT.

4. Increased support or admission, pros and cons. Support in residential placement. Social worker involvement.

5. Risk: self-neglect, children, others.

Q54. LIMB EXAMINATION. Examine Upper limb.

Remember the following five steps for all physical examination stations.

Use hand gel before and after entering station.

Introduce yourself and state reason for the assessment.

Consent.

Ask for Chaperone.

Enquire about pain.

Two parts of the exam;

1. Sensory and

2. Motor

Motor exam:

a.Inspection of whole body and upper limbs for tremors, muscle wasting, fasciculation and deformity.

b.Palpation.

Tone: Flex wrist (rolling wave), flex and extend elbow active and passive.

Power: Hold hand in front and close eyes. Elicit Weakness of shoulder abduction; sensory wandering. Elicit weakness in other muscle groups of small and large joints.

Reflex; Supinator and biceps and triceps.

Sensory:

Coordination: Finger – nose test (both hands); touch their fingers with thumb of same hand (bradykinesia); Dysdiadochokinesia. Patients’ handwriting.

Light touch (cotton wool).

Tuning fork vibration

Q55. MENTAL DISORDER DEFINED: The existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder.

Q56. MENTAL HEALTH ACT SECTIONS

1.Section 47/49: Post conviction. Sentenced prisoners e.g. in RSU

2. Section 48/49: preconviction. In prison health care wing and acutely unwell and needs emergency mental hospital admission in PICU.

3. Section 35: Remand to hospital for 28 days assessment (cf. Section 2 MHA).

4. Section 36: Assessment and treatment.

5. Section 37: Similar to section 3 MHA.

6. Section 38: Transfer to hospital as interim hospital order.

Q57. PARANOIA. Explore the psychopathology.

1.Have you had any experience where you felt that for some reason people were trying to hurt you or harm you?

2. Tell me more about it.

3. Have you had any experience where you felt that your thoughts were not your own and someone else was controlling them?

4. Tell me more about it.

5. Do you feel other people can read your thoughts?

6. Tell me more about it.

Q58. Pathological or Morbid jealousy. Assess patient.

Outline

1. Nature , effect and insight of delusion.

2. Underlying disorders.

3. Risk to self.

4. Risk to others.

Detail.

1.Nature , effect and insight of delusion.

a.onset and progression.

b. relationship history.

c. his reasons for her infidelity.

c. degree of conviction.

d. willingness to consider alternative explanation

d. evidence seeking behaviour.

e. evidence available.

f. Time spent to think about it.

f. Aggression; verbal and physical.

g. partner confession and circumstance.

h. Restrict partner movement.

2. Underlying disorders.

a.personality.

b. affective disorder

c. psychotic.

d. paranoid.

e. Alcohol and drug.

f. obsessions.

3. Risk to self. Self-harm.

4. Risk to others. Confirmatory behaviour. Identity of lover. Violent fantasies against lover, history of violent behaviour. Target e.g. . wife, children, alleged lover, objects. Reaction of potential victims. Thoughts , Plans, Use of weapons; alcohol and Forensic history. insight.

5.Amenable to management suggestion

Q59. PARKINSONISM. Perform physical examination.

Remember the following five for all physical examination stations.

Use hand gel before and after entering station.

Ask for Chaperone.

Introduce yourself and state reason for the assessment.

Consent.

Enquire about pain.

Then perform Five categories as follows:

1.inspection: look for tremor of hands reduced by movement; expressionless face; excessive salivation; slow movement.

2. Tone: Elicit lead pipe rigidity or cogwheel rigidity.

3. Fine movement: Patient to tap thumb with index finger rapidly; polishing movement; to undo and do up button.

4. standing and walking.

Stand without using hands.

Walking. Elicit slow initiation, stooped posture, shuffling gait, reduced arm swing, turn ‘as one’

5.Writing: Elicit micrographia.

Q60. Pathological or Morbid jealousy. Discuss with partner.

1.Reasons for interview.

2. Establish jealousy is the central problem.

3. Confirmatory behaviours: Interrogation, restriction movement, following partner, searching.

4. Partner: coping strategies. Mental state. Role in arguments.

5. Risks determinants.

6. Risk management. Reducing risks, improving self-protection.

7. Treatment for morbid jealousy is that of the underlying cause. CBT, Alcohol and drug treatment.

8. Prognosis: Depends on developing insight and concordance with treatment.

Q61. Pregnancy and resistant depression. Discuss treatment.

1.Risk of lithium and venlafaxine.

2. What to do if she chooses to continue lithium and venlafaxine.

3. Risk of stopping lithium and or venlafaxine.

4. Breast feeding on lithium or venlafaxine.

5. Substitute drugs.

6. Other forms of treatment. ECT.

7. What to do next:

a. Meet couple and CPN.

b. Discuss risks and options.

c. care plan.

Q62. PREGNANCY and OPIATE USE. Take a history of substance misuse.

1.Onset and progression.

2. Typical daily drug use.

3. Withdrawal symptoms.

4. Polysubstance misuse.

5. Previous treatment.

6. Complications: Physical, psychological, social, financial, family, insight and motivation.

7. Patients ideas, concerns and expectations.

Q63. PREGNANCY and OPIATE USE. Discuss management.

1.Empathise.

2. Address questions and concerns

3. Psycho education: effect of substance misuse in pregnancy and implications for unborn child.

4. Management options.

a. Treat any physical complications of substance use.

b. Role of opiate replacement treatment.

c. Other harm minimisation e.g.. Needle exchange, safer injecting practices

d. psycho education intervention includes: Motivational interviewing and Fellowship e.g. narcotic Anonymous.

e. Inpatient options. Detoxification, rehabilitation if patient determined to be drug free prior to delivery.

f. treat co-morbid psychiatric disorders.

g. Sensitively explain the role of child and family social services.

Q64. Pregnancy and substance misuse . complications.

OPIATES

CRACK COCAINE

BENZODIAZEPINE

TOBACCO

Intra uterine growth retardation

Intra uterine growth retardation

Neonatal abstinence syndrome