1
Task
PSYCHIATRY
Taking a psychiatric history:
- ENSURE confidentiality
- IF uncooperative: I understand that you are going
through a bad time but please help me if you want me
to help you.
- HPI: when? How? Worsening or getting better? What
is the effect on your life because of the symptom?
What is the effect on your sleep?
- Mood: How is your mood? Have you noticed any
change in your sleep (in depression: early morning
awakening; anxiety: difficulty initiating sleep)?
Change in appetite? Change in weight? Did you
experience any weight loss or weight gain (typical:
vegetative sx go down; atypical: vegetative sx go up);
What is your energy level? Do you think life is worth
living? Have you thought of harming yourself or
anybody else (What, when, how)? Are there times
when your mood is high?
o anhedonia: loss of interest in activity which
used to be pleasurable.
o Psychomotor retardation: more common in
depression than agitation
- Psychosis: Im sorry if I have to ask questions which
may sound silly but I will need your cooperation. Do
you see/hear/feel things which others do not? Did you
have any strange experiences? Do you think
somebody is putting ideas in your head (thought
insertion)? Do you think your ideas are being
broadcasted everywhere/do you think people are after
your ideas (thought broadcasting)? Do you think that
people, TV, radio, newspaper is talking about you? Do
you hear voices telling you to harm
yourself/somebody?
- Insight: Do you think something is wrong with you? Do
you think you need help?
- Judgment: What will you do if there is a fire in this
room? What will you do if you find an envelope with a
name, ticket, everything?
- Cognition: do you know who you are? Where you are
and the time?
ORGANIC DISORDERS AND DEMENTIAS
Lifestyle Stress
Case: Margaret aged 35 years presents to your surgery on a
busy afternoon. She tells you she had about 6-8 weeks of
ongoing fatigue and tiredness. She denies any specific
symptoms but describes just fatigue, weariness, and feels as
cannot get out of her own way. Margaret is not your regular
patient but attended surgery on few occasions and you know
she had changed a couple of jobs but now tells you she is
working at 3 different places everyday starting from 8-7pm. She
was in a relationship but broke up recently and at present is
living with her extended family in suburban area of the city.
Margaret is smoker for the last 15 years and on average
smokes about 15-20 cigarettes per day and drinks 3-4 standard
drinks of red wine every day. She takes ASA for her occasional
tension headaches and takes no other OTC or prescribed
medications. she had not other significant PMHx. Margaret
describes some stress at work and finds hard to cope with the
manager at one of the jobs but still she is carrying on. She
requests you to prescribe her some medications for her stress
and mentions that few years ago one of the GPs of same
practice described her antidepressants medications which she
used for some time and thinks that maybe she needs those
meds again.
a. How will you manage Margaret (lack of sleep, good
appetite, no early morning awakening, mood is okay,
no psychosis)
History
- Consent
- I understand that you have tiredness and feeling
fatigue, can you tell me more about it? Do you have
any weather preference? Do you have palpitations?
Light-headedness or dizziness? SOB? Chest pain?
Weight loss? Night sweats? Headaches? Any lumps
and bumps on the body? Any cough? Any tummy pain
or change in waterworks or bowel motions? I
understand you smoke and drink alcohol, have you
tried using illicit drug use?
- Hows your mood? Has there ever been a time when
your mood was very high? Any problems with sleep?
Weight? Appetite? Do you still find things
pleasurable? Do you think life is worth living? Have
you thought about harming yourself or others? I
understand you were prescribed antidepressants
before, do you know why it was given?
- Psychotic symptoms: Do you feel/see/hear things that
other do not? Do you have any strange experiences?
- Hows your general health?
Management
- Consider quitting one of the jobs
- Consider moving out of the house
- DO NOT prescribe antidepressants
- Lifestyle modification
o Healthy diet
o Regular exercise
o Address alcohol and smoking
- Meditation and yoga
- Refer for stress management
Acquired Brain Injury and behavioral changes
Case: You are working in GP practice your next patient is a
health worker who looks after a house accommodation disable
people. He is here to talk to you about James who is one of the
residents of the house. James is 37-years-old and living in this
house for a long time. He has a downs syndrome. He had a
head injury which required surgery when he was young. And
then his family put him in this house as he needed a lot of
support. He is also having epilepsy which is well controlled with
the medication. The health worker is here to talk to you about
Jamess recent change in behavior.
Task
a. Talk to the health worker, Tim
b. Management
History: He was shouting at other residents and slams the door.
He hardly talks to anybody. Family talk to him but didnt come.
He respond but doesnt want to talk to anyone. No fever, Used
to work. From last 4 weeks he cannot get up in the morning,
become very abusive. Nothing happen at work.
Features:
- Acquired Brain Injury: Any type of the brain damage
that occurs after birth.
- The brain injury happens in two ways:
o Sudden onset: trauma, infection, lack of
oxygen to brain. (Near drowning), Stroke.
o Insidious onset: prolong alchol and
substances abuse, tumor or degenerative
diseases.
o How does it affect the person? Long term
effect of ABI are difficult to predict. Its
different in different people, the patient can

present with behavior and personality
changes. Thinking and learning abilities.
Increase fatigue.
History
- Can you tell me more about what happened? He is
violent, verbally abusive to staff, socially isolated, he
doesnt want to talk to anybody. They used to go to
work, but last 4 weeks he doesnt want to go to work.
- Hows his mood? Anhedonia? Sleep? Weight?
Appetite? try to self harm himself or somebody else?
No he doesnt.
- Psychotic symptoms:Talks bizarre? Delusions?
See/hear things others do not? Family support? SAD
- I understand he had brain injury years ago, do you
think something has happened recently (No)? How
about his epilepsy is it under control (Yes)?
Management:
- Alright Tim, Id like to see James. Id also organize
psychiatrist. Im concerned that the personality
changes might be because of the acquired brain injury
when he was young/in the past. We need to organize
some investigations. For example CT head, urine drug
screen, other blood tests.
- Can you give some medications for his behavior now?
No, not at this stage, psychiatrist needs to see him
first before give him medications. Id like to involve the
family. If he has self harm we need to admit him.
Psychiatric Patients Get Sick Too
Case: A 40-years-old man comes to ED in a district hospital
where you work as HMO. He had chronic schizophrenia for the
last 20 years and now complains of pain in the chest. The
tertiary care hospital where psychiatrist is available is 200km
away.
Task
a. History (chest pain since last 2 days, all over the chest
4-5/10 in severity; not taking medications for the last 1
year; I can see my girlfriend constricting my chest and
back; my dentist has inserted a magnet into my tooth
to spy on what Im doing; no suicidal ideations; lives
alone and nobody to take care of him)
b. Physical examination (normal)
c. Discuss diagnosis and management
History
- Is my patient hemodynamically stable?
- Confidentiality
- May I know a bit more about the chest pain? Since
when? Where exactly how severe is the pain? Do you
need any pain killer? What is the type of pain? Does it
go anywhere else? Is it for the first time? Did the pain
come with nausea/ vomiting, sweating, anxiety? Does
it come with any activity or walking? Do you feel any
SOB, any racing of heart? Any pain associated with
chest movement or breathing? Any recent URTI or
fever? Any injury or trauma to your chest? Any heart
burn or tummy pain?
- I understand you had schizophrenia for the last 20
years, are you taking your medications regularly?
When did you last see the specialist? What
medications were you on?
- Why did you stop your medications? Any side effects?
I would like to ask you some routine questions, do you
see/hear/feel things that other do not? How is your
mood? Any change is your weight, appetite, or sleep?
Do you think life is worth living? Have you thought of
harming yourself or others?
2
- PMHx: any history of heart condition? Hypertension?
SADMA? Whom do you live with? Do you have
enough support?
Physical Examination
- General appearance
- Vital signs
- Chest and heart examination
Diagnosis and Management
- I would like to admit the patient in the hospital now.
For the chest pain, we will do ECG and cardiac
enzymes and take blood for baseline investigations. I
would call in the medical registrar for further
assessment to rule out any organic cause.
- Secondly, he may have relapse of your schizophrenia
because he is not taking his medications and he has
nobody to take care of him at home. Based on these,
well arrange for transfer to tertiary hospital for
psychiatric assessment and management.
Dementia of Alzheimer Type
Case: A 35-year-old lady comes to your GP clinic asking about
her father who has recently been diagnosed with Alzheimer
disease. She is very concerned about her father and has many
questions from you. The daughter has the fathers permission to
inquire about his condition.
Task
- Explain about Alzheimer disease
- Answer her question
Counseling
- What is Alzheimer disease? It is a type of dementia
where there is wasting of brain cells which in turn
affect the function of the brain.
- The early features of this disease are:
o short-term memory loss (esp recent memory
where the person cannot remember what
has happened a few hours ago or even
moments earlier but may clearly remember
the events of the past)
o progressive decline in cognitive/mental
functioning
- Unfortunately, it can worsen slowly with time and can
lead to behavior changes and severe memory loss
where the person might even forget the names of
family members. It may also lead to self-neglect that
can further proceed to accidents at home or outside
and poor nutrition.
- Is the diagnosis 100% sure? It is a diagnosis of
exclusion. It is only after excluding the correctable
causes that we can diagnose Alzheimer disease. We
might see some changes on the CT scan of the brain.
However, the definitive diagnosis can only be known
after the person passes away and examining the
tissue of the brain under the microscope is done.
- Can it be depression? Depression by itself can
produce dementia and it is called pseudodementia. It
is important to exclude it before diagnosing dementia.
On the other hand, people with Alzheimer disease can
have depression, especially in the early stages of the
disease because they can recognize their disability.
- Do not worry so much. I will be visiting your father and
assess his condition and he will also be assessed by a
psychiatrist, and if required, will be given medications
for depression and he will also be followed-up on a
regular basis
- He will be assessed by age-care assessment team.
This team is composed of geriatrician, occupational
therapist, physiotherapist, social worker, myself as a
GP, psychologist and psychiatrist. The role of this

team is to assess your fathers condition, level of
dependency, and eligibility for services that can be
offered to him. Geriatrician might prescribe some
medications that can delay the progress but will not
treat the illness. Occupational therapist can assess
the home situation and his needs (eg fix lights, put
railings, remove loose carpets, etc) to keep your father
safe. The social worker can arrange meals on wheels
if required, help him in washing the clothes and
cooking food, and can organize social support.
Physiotherapist will assess his ability to walk and
might provide him with walking aids. Psychiatrist will
assess his mental state and prescribe some
medications.
- Is it better to put him in a nursing home? The aged-
care assessment team will decide on it after
assessment and the options available are:
o To stay home if he can cope (preferred
option due to familiar home environment).
He will be assessed regularly by team.
o Living in the nursing home where a nurse
will take care of him and I will also visit him
regularly
o If at any time you want to take him back
home, you can do that and you can have
access to respite care. It is a type of care
given by trained people on a temporary
basis that help you take a break and have
some rest.
- His vision and hearing will also be checked and his
license may be suspended. It is very important for his
safety and wellbeing.
- Will I get Alzheimer disease? It cannot be said at this
moment although there is a rare type of Alzheimer that
runs in families and occurs at an earlier age. But
because there is no family history, it may not be
possible. However, the specialist can explain more
about it.
Performing MMSE (Bookcase Condition 146)
Case: A 50-year-old barman comes to the GP clinic. He has a
history of consumption of up to 10 standard alcoholic drinks over
the last few weeks. His wife told you that he is quite forgetful
and unreliable for some months. You have completed the
history and now proceeding to test his cognitive function.
Task:
a. Do MMSE
b. Explain what you are doing and why
c. Summarize to the examiner the normal and abnormal
MMSE findings
d. Interpret the results to the examiner including what
conditions these results signify
MMSE RESULTS of the patient: problem on registration and
recall therefore patient has short -term memory)
- ORIENTATION 5+5/10
- REGISTRATION 1/3 (3 tries)
- ATTENTION AND CONCENTRATION (5/5)
- RECALL 0/3
- LANGUAGE
- Name two objects (2)
- No, If's and or but (1)
- ask patient to close eyes (1)
- write a sentence (1)
- hold paper with right hand, fold into half, put on lap (3)
- CONSTRUCTION
- draw diagram (1)
Patient is most likely not delirious because of intact orientation.
(Critical Error: if you say patient is delirious)
Delirium is disorientation....
3
Due to poor Recall and Registration, patient might have
Alcohol-Induced Brain Injury
Wernicke-Korsakoff Syndrome
- Vision : Ophthalmoplegia
- Ataxia
- Memory Impairment (Amnesia)
MMSE
- I will do MMSE which is a screening test to assess
your cognitive or mental functioning. It is a simple test
that includes questions that assess you in a number of
areas and has thirty points in total. It will take
approximately five minutes and I will guide you
through it once we start. If you have any problem or
questions, please dont hesitate to stop me. Can we
do the MMSE?
- Doing the MMSE.....(+) problem on registration and
recall.
- It can be Alcohol-induced Brain injury because of
chronic alcohol abuse. It can also be Wernicke-
Korsakoff Syndrome.
- What are you going to do with this patient? (by
Examiner)
- I will do complete medical evaluation and refer to
psychiatrist for further neuropsychological testing to
exclude more diffused impairment like dementia.
- Critical Error: Failure to identify short-term memory
deficits; and a response that patient is delirious or
demented.
CASE 109 Teaching Folstein MMSE
Case 1: You are a resident in Psychiatry Department. A 28-
year-old was admitted with severe depression who is currently
taking SSRIs. She is a secondary school teacher. A final year
medical student did an MMSE and wants to discuss the results
which he shows on a small piece of paper.
Case 2: You are a resident in a large teaching hospital and you
are asked by a final year medical student to teach you MMSE
and wants to discuss the results.
Orientation 5+5/10
Registration 0/3
Attention and Concentration 1/5
Recall 0/3
Language 2+1+3+1 = 7/9
Did not write the sentence and copy the diagram : gave up
Total 18/30
Tasks:
a. Explain the results
b. Answer the questions that the student asks you
MMSE (ORARLC) (total of 30 points)
- Orientation (total of 10)
o 5 points: Year, Season, Date, Day, Month,
o 5 points: State City Suburb Hospital Floor,
Place
- Registration (Immediate Memory; Total of 3)
o Say three things and ask patient to repeat
o Patient recalls three things
o Patient can go for 6 tries
- Attention and Concentration (total of 5)
o WORLD Spell forward and Backward
(easier to do and less time-consuming) or
o Subtract 7 starting from 100:
- Recall (Short-term memory; Total of 3)
o Reproduce three things that I have told you
a while ago

- Language
o Name two objects (2)
o No, If's and or but (1)
o Ask pt to close her eyes (1)
o Can you write a sentence for me? (1)
o Hold paper in right, fold it into half, put it on
your lap (3)
- Construction
o Draw Diagram: Two overlapping hexagons
which are side by side (1) checks
neospatial orientation
o Depression may have pseudo-dementia
MMSE
Formula : ORARLC
Dementia: earliest symptom is lost of short-term memory
Registration and Recall is hallmark of dementia
Delirium: has poor orientation, something acute and patient is
confused; auditory hallucinations....
Patient came in with 18/30 and had problems with registration,
recall and language
Is this depression or dementia??
MMSE is a screening tool not a diagnostic test for Delirium,
dementia or head injury. It is a bedside test. It is affected by
many factors like Education, ethnicity, speech, age, physical
disabilities like hearing. Dementia is a Diagnosis of Exclusion.
Depression is pseudo-dementia
- Normal: 25 to 30.
- Mild-moderate impairment: 18-24
- Severe: less than 18
Depression
- is acute and past history.
- Patient is agitated and does not want to cooperate
because they are aware that something is wrong with
them. This patient gave up because she had insight.
- Recent and Remote affected
- They talk about their deficits
- Has treatment
- Repeat MMSE the following day? No, results will be
the same. Improvement will be seen in 4 to six weeks
- Is it dementia? Is it delirium? not delirium and not
dementia
- Is it depression? YEs, Depression is pseudo-
dementia.
Dementia (a diagnosis of exclusion; exclude causes by e.g.
Neuropsychological testing
- is slow, insidious and progressive
- No past history
- Lack insight and confabulate.
- Loss starts from recent then remote.
- Hide the deficits
- No treatment
Counseling
- Do you have of any particular concern before I discuss
to you the result?
- MMSE is a bedside cognitive function screening test.
Its purpose is not to make a diagnosis but to indicate
the presence of cognitive impairment due to delirium,
dementia, or head injury. The advantage of this test is
that it only takes 5 minutes which is therefore practical
to use repeatedly and routinely. It can be helpful to
monitor the progress or fluctuation in these disorders
that may benefit from intervention. The disadvantage
is that it can be affected by age, years of education,
socio-economic status, the background of the
patient/ethnicity and physical problems like hearing.
4
As an example, better educated people may score
well on the test despite having significant cognitive
impairment. Discuss MMSE scores...normal 25 to 30.
- Does the result show that the patient has dementia?
No dementia is a diagnosis of exclusion and requires
complete assessment with further neuropsychological
testing by the specialist before diagnosing it. In this
case, the patient was admitted with depression which
sometimes can be severe enough to cause pseudo-
dementia. The score of 18/30 is most likely because of
it. As you can see, the patients with depression gave
up even before finishing the examination; however the
patients with dementia will try hard to get a good score
and complete the examination.
- Can we repeat the test tomorrow? We can do it as it is
brief and easily conducted test but it is better to wait
until her mood symptoms get resolved. It can take
three to 4 weeks for the drugs to work and then we
can repeat the test and the score should improve with
the improvement of her depressive symptoms.
- Can we adjust the score because she gave up on the
latter part of the test? No, we don't change the scores
- What we do if she gets low score when her mood
symptoms are better? We will investigate her with full
dementia screening and further neuropsychological
testing by a specialist.
- Can it be delirium? No the patient's orientation is
normal and delirium has a rapid onset with a reduced
consciousness and a fluctuating course over the 24-
hour period. Delirium has a cause. They can have
hallucination but it is acute.
Frontal Lobe Dementia
Case: A 50-year-old man is in your GP clinic. His wife visited
you already and told you that he changes the lane while driving
without obvious reasons. He also has behavioral problems
recently. He is in your clinic because his wife insisted him for a
check up
MMSE is already done and no need to repeat it. In MMSE,
RECALL is 0/3, Language When patient is asked to hold paper
and fold and put on his lap: 0/3
Task:
a. Take a further history
b. Do at least 1 test to assess his cognitive function.
c. Discuss your provisional diagnosis with the examiner
and the reason for it.
(At the EXAM, Two papers outside: 1st is the STEM, 2nd one is
MMSE results)
History
- How can I address you? (Why do you want to know
my address?)
- Your wife is concerned about you. May I know why? (I
have no problem)
- Did you notice any changes in behavior at home?
(No.) Any changes in your mood? Irritability? Any
problem with memory? Any problem with driving? Any
problem in performing daily activities? Patient asks to
repeat some questions.
-
- Have you had head injury? How is your mood? History
of stroke, heart attack? Taking any medications?
Smoking? alcohol? Drugs?
History: (summary)
- Having short term memory problems and forgetting
many question. Patient had no insight. He was getting
irritated and agitated. His understanding of simple
language was impaired?

EXAMINATION:
DEMENTIA SCREENING TEST
- Clock face Drawing test (ask patient to draw a clock at
ten past eleven) patient is not able to do this
FRONTAL LOBE COGNITIVE TEST
- Verbal Fluency Test
o How many items can you buy from the
supermarket and name them in one minute
(Normal: >15; 15 or less is abnormal)
o Say as many words as possible in one
minute starting with letter F, A, S (normal is
15 words/letter or 30 words in all three)
o Or name as many vegetables. fruits, or
animals in one minute (10 or greater is
normal)
- Interpretation of Proverbs
o A stitch in time saves nine
o Time and tide wait for none
- Similarities and Differences: What's the difference
between a bird and plane or table and chair
- Motor Sequencing: Fist edge palm or rapidly
alternating movements
Patients with frontal lobe dysfunction perform poorly and
disorganized.
Diagnosis and Management
- Based on the history and assessment, my diagnosis is
frontal lobe dementia. This is because of the following
reasons:
o History given by his wife (irritability and
personality changes) which shows
personality and behavioral changes
suggestive of frontal lobe dementia
o MMSE reveals problems with registration
and recall and cannot do a simple task
which show problem in executive functioning
o My history shows that the patient had
problem with understanding and severe
short-term memory loss (forgets questions
and doesn't answer questions correctly),
lack of insight and cognitive impairment
o Specific Frontal Lobe Tests are poorly done.
- I would like to do investigations and look for reversible
causes. Secondly, I will refer this patient to a
psychiatrist for full medical assessment and
neuropsychiatric testing. On MRI, Frontal lobe atrophy
can be seen.
- There is no know curative treatment and supportive
care is essential. This condition is managed by
multidisciplinary care team including support groups.
Median Survival time is seven years and often occurs
between 40s and 50s.
- In Frontal lobe dementia, earliest manifestations are
personality changes and alterations of behavior
including social dysfunction.
Forgetfulness in a 56-year old man (Case 111)
Case: A 56-year-old man comes in your GP clinic with complaint
of forgetfulness but otherwise he is healthy.
TASKS:
a. Perform a history
b. Do MMSE
c. Explain to the patient the results and further
management
5
Mnemonic: DEMENTIAS - Things to rule out before Dementia
can be diagnosed
D - 3D's Dementia
Depression
Delirium
Drugs (medications and illicit drugs)
E - Emotions (Anxiety, loneliness, nervousness)
M - Memory (Benign Forgetfulness)
E - Endocrine (DM, Thyroid) Ears Eyes
N - Nutritional (B12 Deficiency - Self-Neglect); Neurological
problem (CVA, CVS)
T- Tumors, Trauma (Head Injury)
I - Infection (HIV, Syphilis)
A - Alcohol, Amenesia (WKS)
S - Chronic Schizophrenia
Common causes of dementia:
- Alzheimer - 60 % of dementias
- Frontal Lobe - 10%
- Lewy Body Dementia - 10%
- Alcohol - 5%
- Vascular - 15%
History
- Can you tell me more about it? (My family is
concerned that I am getting forgetful and that I am
afraid I have dementia.) Do you forget about the
recent things or the past events? Do you misplace
items like car keys or keep the stove open? Any
problem in performing daily activities? Do you find
difficulty in planning and decision making? Do you find
it difficult to remember the names of your friends and
family? Did you notice any change in your
personality? (like getting irritable or not being yourself
Frontal lobe dementia) Any episode of confusion?
(delirium)
- How is situation at home? Do you find it difficult to get
along with family? Any problems or issues at work?
Any difficulty in finding your way back home?
(tendency to wander) Any recent accidents? How
much is this affecting your personal and social life?
- Do you have any headaches? Any previous head
injury? episodes of falls? Problem with hearing?
Vision? Chest pain? Shortness of breath? What about
your diet? Any problems with waterworks? Bowel
movements?
- How is your mood? Do you enjoy the things that you
used to enjoy? Do you have any weather preference?
Past history of Heart Attack? Stroke? Mental Illness?
Infections like HIV or Syphilis? Are you on any
medications?
- Family history of Mental illness or dementia and other
serious conditions? SADMA?
- Is there anybody at home to take care of you?
Diagnosis and Management
- Dementia is only a diagnosis of exclusion and you
need complete medical evaluation and further
neuropsychological testing by a specialist.
- I will order the investigations and once the results are
back, I will refer you to the specialist
- Give the reading materials.
- Once the results are back, refer the patient.
- Red flags. Be careful of driving and avoid any falls.
Report any accidents at home.
Investigations
- FBE, LFTs, UEC, BSL, URine MCS, TFTs, BGL
- Vit B12 and Folate, Vitamin D, Calcium and
Phosphate,
- Syphilis and HIV (with patients consent)
- CT scan or preferably, MRI of the patient
 6

Dementia and Disclosure of patients condition (Book case 119 b. Physical examination/investigation results (FBE 140,
pg. 641) MCV 107, Plt 300, LFTs GGT increased, other
enzymes normal including albumin, RFTs normal, BP
Case: Michael aged 70 years had come to see you in your GP 150/100mmHg,
clinic. He is concerned about his wife Jenny who had increasing c. Management advice
forgetfulness over the past 6-12 months. She has misplaced her
bag and bank cards on numerous occasions. She is spending History:
very little time reading or knitting which were her favorite - Establish pattern of drinking: I know you are
hobbies. You had seen Jenny last week with URTI. Michael is concerned about your drinking. It is a very good
interested that if you can recommend Jenny for Nursing home decision to come and see me. I need to ask several
placement and is requesting for your approval letter. questions that may be personal. Is it alright? Since
how many years have you been drinking (years)? How
Task much do you drink per week? What type of alcohol do
a. Focused history you drink (spirit, beer, wine)?
b. Management advice o Safe drinking: 1 SD for female, 2SD for
males per day everyday
- Assess MMSE - Where do you prefer to drink? With family, friends? Is
- Draw clock test: it binge drinking or continuous? Are you aware of safe
o Circle: 3 points level of drinking? Have you noticed any ill effects of
o Number of the clock: 2 alcohol on you? Do you think you can drink heavily
o Right numbers: 2 without appearing drunk (tolerance)? Are you able to
o Put the time of the clock: 2 work as efficiently? How is it affecting your
- Investigations/Screening Test: relationships at work and in home? Have you ever had
o RFTs, LFTs, TFTs, FBE, Blood glucose, any accidents related to alcohol?
serum electrolytes, calcium and phosphage, - CAGE:
urinalysis, serum vitamin B12 and folate, o Have you ever thought of cutting down?
serum vitamin D, syphilis serology (HIV), o Do you feel annoyed when people criticize
CXR, CT/MRI, you?
o PET or SPECT scan for further information o Do you feel guilty for taking alcohol?
- Multidisciplinary assessment (aged care assessment o Do you take alcohol first thing in the
team/memory clinic): geriatrician, occupational morning?
therapist, psychologist, etc - How motivated are you on a scale of 1-10 to quit/cut
down on your alcohol?
Features Dementia Pseudodementia - Withdrawal Effects
Onset Insidious Clear-cut, often acute o How long can you go without alcohol? Not
Course over 24 Worse in evening or Worse in morning more than 1 day
hours night (sundown o How do you feel after a period of
effect)
abstinence?
Insight Nil Present
o Do you think you need to drink to sleep?
Orientation Poor Reasonable
Memory Loss Recent > remote Recent = remote
- Social effects
Responses to Agitated Gives up easily o Have you noticed any problems at work with
mistakes alcohol?
Response to Near-miss! Difficulty dont know; slow o How is your relationship with partner and
cognitive testing understanding and reluctant but children?
(question) understands words (if o How is your financial situation?
cooperative) o Have you had any accidents/fights because
of drinking
DRUGS, SUBSTANCES OF ABUSE AND ALCOHOL - Health problems
o Have you ever noticed heartburn, gastritis,
Alcoholic Counseling heart disease, liver disease, anemia,
hypertension, problem with memory, mood
Case: You are a GP and a 47-year-old businessman comes to changes, depression, change in sexual
you to discuss his alcohol consumption because he got pulled performance (thought it was related to age)
over by the police on his way to work. The blood alcohol level - SADMA
was 0.04. He was given a warning as it was near the legal limit - I will need to organize some investigations to see
and a sign that he had a lot of alcohol last night. He wants to effect of alcohol. FBE, anemia (macrocytic-vitamin
discuss the safe level of alcohol and the effect of alcohol on a b12), LFTs, Lipid profile, serum lipase, BSL, liver
person. USD, ECG,
- 1 SD = increase blood alcohol concentration by 0.01
Case 2: Jarrod aged 30 years is a new patient to your clinic. - Liver takes 1 hour to metabolize 1sd
Jarrod states that he has been drinking on average four SD per
day per week for the last six months since starting his new job. Counseling
Before this he was consuming on average 2SD drink two days - Feedback: History shows that you have been drinking
per week. Last night while drunk, he met a minor accident and more than normal. This is why I ordered some tests to
his girlfriend asked him to see you as she is not happy with his determine the effect of alcohol in your body. The high
drinking habit. Jarrod works in a local supermarket and is level of alcohol may cause HTN, cause tummy
otherwise fit and healthy. He is not on any regular medications problems (heartburn), increased weight, affects your
and had no known allergies. liver, heart, brain, loss of memory, gout, sexual and
social problem
Task - Listening: What do you think?
a. Further history - Aim for safe level of drinking: Advise on safe level of
drinking (1 30 ml spirit = 1SD; restaurant wine =
1.8SD)

- Goals (short-term)
- Strategy:
o Dont drink daily
o Drink only with food
o Have a glass of water between drinks to
satisfy your thirst
o Switch to low alcohol drinks
o Mix alcoholic drinks with non-alcoholic ones
o Always check bottle for SD
o Avoid high-risk situations (with alcoholic
friends, going to the pub)
o If you are under pressure, tell them my
doctor told me to cut down
o When youre stressed, take a walk; explore
new interests, plan new activities
o Start with a period of abstinence to test the
presence of withdrawal symptoms. If you
want to drink, please report right away. We
can manage your symptoms
- If you consider cutting down to safe levels or quitting
alcohol, it will have a positive effect on your health,
save money, have less family problems, and more
time to spend with your family. I would also like to
recommend for you to join alcohol anonymous which
is a support group and recommend lifestyle
modification for weight reduction and control
hypertension, but it cannot be successfully done until
alcohol is taken cared of. Im always there with you to
help you and support you, but in the end, the decision
is yours.
- Offer to arrange for family meeting to discuss about
alcoholism
- Review once the tests come back
- Refer to DETOX unit if dependent! Alcohol withdrawal
scale: diazepam
- Red flags: Any other major concerns
Binge Drinking
Case: One of your patients David who is a single parent brought
his 10 years old son Simon to see you who got sprained ankle.
You examined his son and diagnosed him as having a sprained
ankle. On examination, apart from the sprained ankle, there Is
no other injury, bruises, or scars. The childs mother has left a
few years ago and the child was looked after by his father.
You have seen David 4 weeks ago in your clinic due to minor
head injury after he got drunk and fell in the pub. At that time,
you noticed he is a binge drinker of 24 pints on every weekend.
You told him about his overdrinking, and you asked him to come
back in 3 weeks time to discuss the issue, but he did not show
up on his appointment day. Today, he is here for his sons sake.
David is a delivery driver.
Task
a. Talk to the father about your concern
Strategies for Working with First Presentation of Alcohol Abuse
FLAGS Approach
- Feedback: tell patient your impression about his intake
level
- Listen to his reaction
- Advice about the benefits of quitting
- Goals setting: keep it with safe limits or stop
- Strategies: quench thirst with non-alcoholic drinks
before having an alcoholic one, avoid drinking on an
empty stomach, switch to low-alcohol beer, think of a
good explanation for cutting down on your drinking
Strategies for Working with Persistent Problem Drinker
- Continue to encourage a reduction or cessation of
alcohol intake
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- Provide regular feedback regarding the impact of
alcohol upon their physical, mental and social health
- Minimize the harms from polydrug use, by advising
against and offering treatment for other drug problems
- Monitor prescribed and complementary medications to
avoid predictable drug/alcohol interactions. Identify
and respond to problems of poor medications
adherence in heavy drinkers
- Use strategies to enhance patient engagement,
including approaches to overcome barriers posed by
cognitive disorders, language, and cultural issues or
physical disabilities
- Define and attend to any specific medical and
psychiatric conditions with relevant services that
communicate regularly
- Consider strategies to minimize the consequences of
specific medical complications such as CNS and
peripheral nerve damage, liver disease, cerebellar
damage, and/or peripheral neuropathy
- Engage psychosocial supports (meals on wheels,
welfare, employment support, community and
religious networks, financial or relationship
counseling) to reduce personal and family harms
- Empower family and close friends to reduce
availability of alcohol to encourage further
engagement with clinicians able to help with alcohol
problems
- Consider any medico-legal or ethical obligations,
including driving assessment, child protection, welfare,
guardianship and employment issues for use in
certain trades or professions
Smoking Counseling
Case: You are a GP and your next patient is a 30-year-old
female. She has been recently discharged from the hospital due
to recurrent attacks of bronchitis. She smokes 1 pack of
cigarettes per day since the age of 18. A few weeks earlier, you
saw her and advised her to stop talking. Now, she would like to
quit.
Task
a. Counsel her regarding smoking cessation
- You made a very good decision to come here to quit
smoking.
Assess the Motivation
- How motivated are you to stop smoking on a scale of
1-10? How confident are you that you will succeed (1-
10)?
Assess Dependency
- How many cigarettes a day do you smoke? How soon
after you wake up do you light your first cigarette (if
within 30 minutes of waking up high chances of
giving NRT, bupoprion or champix)? Do you find it
difficult not to smoke in a non-smoking area? Is it the
first cigarette that is hard to give up?
- What is the pattern (smoke it with friends or out on a
party or by self)? Do you smoke even when you are
very ill? Have you tried to quit smoking before? If yes,
why did you fail?
Advice on Nicotine Withdrawal
- Within 24 hours of stopping or reducing nicotine, you
may experience some symptoms such as depression,
insomnia, restlessness, irritability, anxiety, difficulty in
concentrating, drop in heart rate, increased appetite,
craving for sweets and cigarettes, but these symptoms
peak over a few days and will resolve after about a
month.

Benefits of quitting of Smoking
- Start to smell better
- Food tastes better
- Circulation of the blood improves
- Better immunity and less sick days at work
- Save money (2500 dollars/year for pack-a-day
smoker)
- More time to spend with family
- Set positive example for children
- Minimize risk for heart disease, lung cancer, stroke,
and gangrene
Plan
- Best way is COLD TURKEY. Decide the date to stop
smoking within 2 weeks of making a decision.
- Aim for TOTAL ABSTINENCE and not just cutting
down.
- Review your previous attempts at quitting and what
went wrong.
- Inform family, friends, and other smokers about your
plan
- Avoid alcohol and review coffee intake (triggers)
- To decrease cravings, drink plenty of water, gradually
increase other activities, avoid situations which could
restart your smoking, and eat more citrus fruits
(vitamin C helps reduce cravings).
- Nicotine replacement therapy
o Contraindications: pregnancy and CAD
o Nicotine patches: 40% nicotine; no tar and
other carcinogens;
o Nicotine gums (2 or 4 mg): chewed
intermittently for up to 30 minutes 10x a day;
poorly absorbed in acidic environment so
decrease fruit juices when youre chewing
gum; can also cause mouth soreness and
dyspepsia
o Transdermal patches (7 -21 mg used 16 0r
24 hours):applied every morning on a
rotational basis to non-hairy areas; can lead
to skin rash
o Nicotine inhalers (4mg): single use only; 10
or more per day for 6 months
o All are equally effective. Monotherapy is
preferred.
- Bupoprion (Zyban): atypical antidepressant with both
noradrenergic and dopaminergic activity. It works on
addiction pathways; 150 mg per day for 3 days then
increase to BD x 9 weeks. SE: nausea, insomnia, dry
mouth; CI: epilepsy, diabetes, pregnancy
- Varenicine (Champix): blocks the nicotine receptor
and dopamine (addiction) pathway as well; does not
contain nicotine and is not addictive; only available on
prescription; CI: mental illness, kidney problems,
pregnancy or breastfeeding; not yet studied on
epilepsy; if youre taking champix, not allowed to take
NRT or Zyban. Start 1-2 weeks before quit date
because champix needs time to build up in the body
and to allow it to start working; can smoke while taking
champix but make sure to quit by the date set; comes
as a white (0.5mg) or blue tablet (1mg).
o Days 1-3 0.5mg OD
o Days4-7:0.5mg BD
o Week 2-4: 1mg BD (give prescription for 4
weeks)
o 5-12 weeks: 1mg BD (give prescription for 8
the rest of 8 weeks)
o If patient has stopped smoking, recommend
another 12 weeks of treatment for the long-
term effect. Do not take double dose if you
missed the tablet for >6 hours. Dont share
medications. If you start smoking again, may
have nausea and vomiting.
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- Reading material.
- If partner is smoker, ask patient to come and see you.
- Quit Line number.
- Review after 1 week and see progress.
- Support groups.
Request for a Repeat Prescription of benzodiazepine (Drug
Dependence)
Case: Michael aged 22 years comes into your practice with no
appointment, seeking oxazepam to clam him down and sleep.
He looks a little unkempt, is agitated, fidgets and shakes his
legs while seated. The reception staff reports feeling
uncomfortable around him and note that he was insistent to be
seen today. There was no overt aggression. When you ask
about history of benzodiazepine use, Michael becomes irritated
and says he is asking for one script, but says he is been using
them for years, started when he was having difficulty coming off
speed and the he had then become dependent. He says his
current supply was stolen with car this morning which has left
him in anxious state with nothing to calm him down. He says he
usually gets them from a GP on the other side of the town but
unable to get there without car. He says he uses 5-6 tablets of
30mg oxazepam per day
Task
a. How will you address the request of the patient
- I am ready to help you. That is why I am here.
Because you are not my regular patient, I need to ask
a few more questions before I can help you.
- Why are you taking this medication? How long have
you been using this medication? How many times do
you take this in a day? Did you increase the doses by
yourself?
- Drinking, smoking and illicit drug use?
- General health? serious illnesses, injuries or accidents
(car accident)? Fits, falls, faints or loss of
consciousness? Did you ever feel depressed or
diagnosed with depression or other psychiatric illness.
Management
- Explain: period of monitoring your use and moods or
stress followed by graded reduction, along with
regular appointments, support and resource materials
or groups
- Diazepam (valium): long-acting I will change the
medication to the same medication but will work
longer. Pick up daily supply.
Morphine Request for Psychogenic Pain
Case: You are working as night shift HMO in ED and your next
patient is a young lady with abdominal pain. Investigations were
done and were found to be normal. She is requesting morphine
for her pain. This is not the first time she came with abdominal
pain.
Task
a. History (happening since 4 or 5 years;
b. Management
History
- I understand that you have this tummy pain and the
investigations we did came out to be normal. This
means that we could not find any organic cause for
your pain. I also understand that this is not the first
time. Since when is this happening?
- Confidentiality
- Do you think something happened in your life or a
stressor that initiated it (happened after getting
separated from partner)? How often does it happen?
Do you think these episodes are related to any
particular stress? Have you seen any doctor for this

condition (saw GP and gave pethidine)? Where do
you get the morphine from? Have you noticed any
palpitation, agitation or sweating when youre not
taking morphine for your pain (if yes, means
addicted)?
- Depression questions: How is your mood? Do you still
find things pleasurable? Any changes in your sleep,
appetite or weight? Do you think life is worth living? do
you have any thoughts about hurting yourself or
others?
- Whom do you live with? Any stress at home or at
work? Any financial problems? Do you have enough
support? Do you have friends? SADMA?
Management
- Let me reassure you that I will try to manage your
pain. I understand that your pain is real. There is
something called brain-body axis. Anytime our mind is
stressed, our body starts reacting (e.g. diarrhea before
exams). In the same way, your body is reacting by
producing abdominal pain because of your stressors.
- Morphine is a short-term relief for the pain and has got
many side effects. It can affect your respiratory
system, heart, and is highly addictive. At this stage, I
will give you panadeine forte to start with and refer
you to the psychologist. He will do talk therapy (CBT)
to relieve your stress and he will teach you how to
overcome and handle your stress. If you need social
support, I can organize a social worker. If you have
financial issues, I can refer you to centerlink. There
are a lot of support groups available for you. You are
not alone.
- If dependent: Refer to psychiatrist for drug
dependence management
- Do you agree with me or do you have any other
questions?
PSYCHOTIC DISORDERS
Paranoid Schizophrenia
Case: A 35-years-old female is in your GP clinic and wants a
letter to the Department of Housing Authority because she
wants to change her accommodation. She had schizophrenia for
the last 10 years and she was on haloperidol. On examination,
you can see some contact dermatitis on her hands.
Task
a. Psychosocial history (Neighbor wants to harm her and
throws things into her home. She lives alone at Centre
link and believes the TV is talking about her. Didnt
see the psychologist for 3 years and cut down dose by
since 1 year. Wash excessively with cleaning
agents twice a day.)
b. Mental Status Examination (well-dressed, groomed,
mood/speech normal, delusions of reference, auditory
hallucination (hearing voices that neighbor is talking
about her), delusion of persecution and husband is
involved, dermatitis (throw things at home), no insight,
good judgment, oriented, no suicidal ideation, stooped
medication by herself she thinks she's feeling well)
c. Give your findings to the examiner
d. Diagnosis and differential diagnosis
- ENSURE Confidentiality!
- Psychosocial history: HEADSSS
o Psychological:
Auditory/visual hallucinations: do
you see or hear things that
nobody else can see/hear?
Delusions: do you think somebody
wants to harm you? Following
you? Spying on you?
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(persecution) do you think youre
special? (grandeur) do you think
someone is putting thoughts on
your mind? (control) do you think
youve done something wrong?
(guilt) do you think radio and TV
are talking about you? (idea of
reference)
o Depression: how is your mood lately? Do
you enjoy the things you used to enjoy? Any
problems with memory or concentration?
Change in sleep, appetite or weight? Are
you interested in your sexual life? Do you
think life is worth living? Have you ever
thought of harming or killing yourself? Or
others? Have you ever tried this in the past?
If you leave this room, what are you going to
do?
o Anxiety: Do you feel nervous as a person
most of the time? Tremors?
Palpitation/pounding of the heart?
- Social history
o Home situation: how are things going at
home? Are you experiencing any problems?
o Employment: do you work? Any problem at
work? Any financial problems?
o Social circle/friends?
o Hobbies? What do you do for relaxation?
- Past history: mental disorder? Depression?
Psychoses? Medical illness? Thyroid problem?
Medications and side-effects?
- Family history: mental disorder? Thyroid?
- SADMA!!!
Mental Status Examination
- Appearance: properly dressed? Unkempt?
Disheveled?
- Behavior: cooperative/uncooperative; comfortable?
anxious? Restless? Irritable?
- Speech: coherent, fluent, understandable? High/low
volume? Monotonous/changing tones? Pressured
speech?
- Mood/affect (congruent)
- Perception: hallucinations Psychosocial history
- Thought:
o Content: delusion/suicide
o Form: how contents of thought are
expressed (ie flight of ideas, loose
associations,tangentiality)
- Cognition (Orientation): Time? Date? Person?
- Insight: do you think that you need help? Or medical
advice?
- Judgment: what would you do if there is a fire in this
building?
Differential diagnosis:
a. Organic causes (brain tumors)
b. Drug-induced or substance abuse
c. Anxiety disorder
d. OCD highly unlikely
Management:
- I will need to refer her to the hospital because she is
living alone, has ideas of reference, paranoid
delusions and is lacking insight. I will need to contact
the specialist at the hospital to review her. This will be
for her safety.
- Urgent referral to psychiatrist for possible admission: -
due to loss of insight, paranoid ideation, not taking
medication, living by herself;
- If patient refuses: involuntary admission

Relapse of schizophrenia (Tardive Dsykinesia)
Case: A 40 year old lady with schizophrenia for the last 15 years
comes to your GP clinic because she has movements of her
face.
Task
a. Psychosocial history
b. Diagnosis
c. Management
History
- Ensure confidentiality
- Tardive dyskinesia-- more with typical antipsychotics
- Can you stick out your tongue for me?
- Side effects: postural hypotension (giddiness, light
headedness with posture change),dry mouth? Bov?
Urinary retention? Constipation? Milky discharge on
breasts? Loss of libido? Decreased sexual drive?
Problem with periods
- EPSE: stiffness? Restlessness? Gait problems?
Bradykinesia? Cogwheel rigidity? Tremors?
- previous history of NMS? Fever, stiffness, confusion
- Medication: are you taking the drug? Did you change
your dose? When did you see your psychiatrist?
- Do psychosocial history?
- Do you think you need medical help?
Management
- Refer back to psychiatrist. Stop drug and change to
other medications.
- Risk of breakthrough psychosis
- May consider admission
Drug-Induced Psychosis
Case: An 18-year-old male who failed in one of his exams came
to your GP clinic for consultation. He felt depressed since then
and suffered insomnia. He came requesting for sleeping pills.
On assessment, you detected that he is suffering from
delusions, hallucinations, and other symptoms upon which you
settled with the diagnosis of acute psychosis. He also admitted
the use of illicit drugs. His parent came to the clinic to discuss
his case. The patient gave permission to discuss his case but
not to disclose his illicit drug use.
Task
a. Talk to the father
b. Explain current situation
c. Answer his question
Questions:
- Is my son using drugs?
- Is this condition due to depression? Can I take him
home?
- His auntie had schizophrenia, does he have this also?
Can he develop it?
Counseling
- Let me assure you that your son at the moment is
having a thorough assessment as we found him
suffering from a sort of psychiatric emergency that we
call acute psychosis. I have contacted a team called
CAT whos undertaking the assessment. This team is
the crisis assessment team. Psychosis is not a
specific disorder. This is a condition where a patient
has severe impaired sense of reality with emotional
and cognitive disabilities. The patient talks and acts in
a bizarre fashion and may suffer from hallucinations
wherein he can see or listen to voices or things which
are not real or cannot be experienced by others
around. Also, he can suffer from delusions which are
10
ideas that are contrary to fact. There are many causes
for this condition. Schizophrenia which needs around
6 months to be diagnosed or schizophreniform or
delusional disorder. Some patients may have medical
conditions which we call organic-induced psychosis.
Others may use illicit drugs which can experience it as
sequelae. We call this drug-induced psychosis. If any
patient is diagnosed with acute psychosis, it is an
emergency situation as the patient is not safe for
himself or for people surrounding him. They may have
suicidal ideation or any psychotic ideation which could
make them very aggressive and harmful to
themselves or others. Under the mental act, we
usually admit involuntarily all acutely psychotic
patients until we stabilize their condition and we do
further assessment to find out the cause. Usually,
many persons share the management of those
patients for short-term and long-term management.
Family will be notified and a meeting will be done to
discuss the management. We need lots of support
from you. The psychologist, psychiatrist, mental health
nurse, social workers can be part of this team as well
as myself as your GP. You can go to the hospital with
your son and you will be notified with the further steps.
- Do you think my son is using illicit drugs? As I have
mentioned before, there are many causes. We need
to assess him first. Our first priority is to stabilize your
son, then find out the cause and you will be informed
accordingly.
Ice-Induced Psychosis
Case: A 20-year-old man was brought to ED by his friends
where youre working as HMO. He had hallucinations and
delusions. He was aggressive and violent. You sedated him with
medications. He went to a party last night and you suspected he
used ICE. His father is here to see you. He knows about his
sons ICE usage.
Task
a. Relevant history
b. Advise further management
c. Answer his questions
History
- I understand you are here to talk about your son. Let
me assure you that he is in safe hands. Before I
explain the further management to you can you share
what you know about his condition? OR Do you know
what happened in the party? OR It can be quite
common at a young age and I understand that John
has a problem related to this. may I know a bit more
about it?
- Since when is he using it? any previous hospitalization
like this because of this? Any intervention done or
step taken regarding this issue? Are you a happy
family? How is your family life? Any particular issue?
Does he have any siblings? How is his relationship
with them? Anybody else in the family using drugs?
How much is this affecting the family? Does he go to
school or uni? How is his performance over there?
Any problems at uni or work? Any problems with the
law? Any of his friends having similar problems? Any
other hobbies or sports?
- How is his mood most of the time during the day?
Does he enjoy the things he used to enjoy? What
about his sleep? Did you notice any changes in his
weight or appetite? Did he have any previous attempts
to harm himself or somebody else? Did he ever talk
about seeing/hearing things/voices that nobody does?
Has he exhibited any strange behavior?

- Any previous medical problems such as thyroid
disease? Does he take any medications? Any
allergies? FHx of similar problems and psychiatric
illnesses? Smoking? Alcohol?
Management
- Most likely the condition that he is having is called ice-
induced psychosis. Psychosis is loss of contact with
reality that usually includes hearing/seeing things that
are not there and having abnormal beliefs. These are
called hallucinations and delusions. In simple words, it
is the changed and different way of thinking, speaking
and behaving that can make a person aggressive and
violent and unaware of his surroundings. This is what
John is going through at the moment and this is
because of his ice usage. It can change the chemicals
in the brain to produce these effects. Now he is safe
and stable.
- He will be assessed by the CAT for psychiatric
assessment. He will be admitted in the hospital under
care and supervision because in this condition he can
harm himself and others. Even if the patient refuses,
they can be admitted involuntarily and it is in the best
interest of their safety. They can give him
antipsychotic medications for short-term to treat his
intoxication. He will also undergo some investigations
such as FBE, U&E, LFTs, RFTs, BSL, TFTs including
urine and blood drug screen, alcohol concentration
and CT scan to r/o any organic cause.
- Once discharged, he will be followed up by
psychiatrist and GP. He can also be referred to a drug
rehabilitation center to help him stop drug usage and
develop new coping skills that make the relapse less
likely.
- Arrange family meeting.
- Support groups.
- Refer to psychologist if father is depressed.
- Is there any antidote available? No.
- Is ice addictive? It is a highly purified form of
amphetamine and thats why it is powerfully addictive.
- Will this lead to schizophrenia? Using this drug is a
risk factor for mental disorders.
- Will you report to authorities if drug test is positive? It
is a confidential issue. Once he is stable, we will talk
to him and discuss further plan of action with him.
Postpartum Psychosis
Case: You are an HMO and your next patient in ED is the
husband of a 25-year-old lady who had her first baby 2 weeks
ago. He is concerned about his wifes behavior but the patient is
not concerned about her problem. The husband has got the
consent to talk about his wife. Delivery was NSVD. She did not
want to come and see the doctor, so the husband came to talk
to you while waiting at the waiting room with the baby and the
nurse.
Task
a. History (doesnt take care of the baby and husband
too tired to take care; scared to leave baby with her;
behavior is odd; doesnt sleep much; lost weight, feels
like theyre both devils)
b. Management (immediate and long-term management)
History
- Confidentiality
- Could you tell me what you meant by change in
behavior in your wife? Is she breastfeeding at all? Is
she taking care of the child?
- Mood: How would you define her mood? How about
her sleep? Appetite? Weight? Do you think shes
weak and has no energy? Does she think that life is
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not worth living? Does she feel guilty about anything?
Any time that her mood is really high?
- Psychotic: does she hear/see things that others do
not? Does she have any strange feelings or
experiences? Does she tell you that somebody is
putting ideas on her head or that the TV or radio is
talking about her? Does she have strange
experiences or abnormal thoughts? Does she think
there might be something wrong with her?
- How is her general health? Has she been diagnosed
with any mental illness before? Family? SADMA?
- I can see that you are tired. Do you have enough
support? Whom do you live with? Are there any
financial problems at home?
Management
- From the discussion we have, your wife might be
suffering from a condition called postpartum
psychosis. It is not an uncommon condition but it
needs to be treated urgently. I am concerned about
you and your babys safety. I will need to admit your
wife and I will call the psychiatric registrar to come and
take a look. She will also be seen by the consultant.
- At this stage, they might start with ECT and
antipsychotic medications.
- How is your mood? Are you alright? I can organize a
social worker for you.
- Centerlink for financial problems.
- I dont think she will agree to be admitted. I am sorry
but she will be admitted involuntarily under the mental
health act and I will call on the crisis assessment
team.
- Dont worry. We will be here to take care of her.
Prognosis is good. If you need any help or you have
any other concerns, please dont hesitate to contact
us.
MOOD DISORDERS
Loneliness or Empty Nest Syndrome
Case: A middle-aged lady presented in your general practice.
She complains of feeling down and depressed for a few months.
You asked her to come for consultation a few weeks back but
did not come.
Task
a. History (poor appetite, lack of sleep, early morning
awakening, do not socialize, appetite okay but does
not find it pleasurable, no friends, dont feel like talking
to friends, stay-at-home, separated with husband but
not talking)
b. Provisional diagnosis
c. Management
Differential diagnosis
- Loneliness
- Depression
- Adjustment disorder
- Anxiety
- Bipolar disorder (depressive episode)
- Organic (menopause, hypothyroidism)
History
- Confidentiality
- How is your mood? Do you have low mood most of
the day? Do you still find the things you do
pleasurable? How is your sleep? Appetite? Weight?
How is your energy level? Do you think life is worth
living? Have you ever thought of harming yourself
- Who are you living with? Do you talk to each other?
How about your kids? Family?

- Are you sexually active? Stable partner? What do you
do?
- Do you hear or see things which others do not? Do
you have strange experiences?
- How is your general health? Do you have weather
preferences? Do you have swelling all over the body?
Weight gain? Lump in the neck?
- Menopausal symptoms: irritability? Dryness of
vagina? Hot flushes? Mood swings? Pap smear?
Mammography? SADMA?
Diagnosis
- From the discussion we have, you most likely have a
condition called loneliness or empty nest syndrome as
you have no one to talk to at home, your husband is
estranged to you and your children have grown up
and moved out. These are all contributing to it. There
are a lot of things we can do about it. You can join the
community clubs, or do voluntary work. Meet and
make new friends and create a social circle. You can
explore your interests and activities.
- I can arrange a social worker if you need a help. I will
refer you to a counselor with whom you can share and
talk about things. If you agree, I am happy to organize
a family meeting and tell them about your condition.
You can always give them a ring or talk to them via
skype to see them.
- Lifestyle modification. Review.
- Referral to psychologist. Reading material (Beyond
Blue).
Normal Grief
Case: You are a GP and 18 years old university student comes
to you with complaint of poor sleep since her father died. She
cant concentrate on her study and she is anxious as the exam
is approaching. She visited you 2 months ago with some flu.
She was alright at that time.
Tasks
- Focused history
- Management
Stages of Grief: (normal grief can go up to 3 months)
- Shock and disbelief
- Grief, anger, despair, self-blame, guilt
- Adaptation and acceptance of the loss
If the timing and severity increase, there is high risk of suicide
and psychosis.
History
- Sorry to hear what has happened. How are you
coping with this situation and your family? Is there
anything you want to share with me regarding your
dad?
- Confidentiality!
12
- Sleep problem? How is the problem? Hard to initiate
or wake up early? Night sweat? Do you feel fresh in
the morning? Any nap during the day
- How is your mood? Appetite? Daily enjoyment as
usual? Do you feel active or lethargic? Suicidal
ideation? Harming yourself or others? Do you think life
is worth living?
- Do you ever feel or hear things that other people
cannot? Do you feel someone is spying on you?
- Whom do you live with at home? How is your
relationship with your family? Since your fathers
death, have you talked to someone else about your
feeling
- SADMA?
- Tea and coffee drinking habit during in the evening?
- General health? Past history of thyroid problem or any
mental illness? Any family history of similar problems?
Any family history of mental illness?
- Insight and reliability
Management
- The most likely diagnosis at this stage is one of the
normal emotional reactions to people who lost
someone who is very close and emotionally bound. It
is normal to feel disbelief, anger, sadness.
- However, I can help you with some advice in many
ways.
o Socialize more talk to friends and family
o Approach religious resources according to
your beliefs to help your relax spiritually
o I can also organize a support group for you
and your family
o Sleep problems provide with written
materials regarding sleep hygiene and other
techniques
Avoid having tea or coffee in the
evening
Avoid having heavy meal before
sleep
A glass of warm milk before sleep
Try to maintain the room
environment being not too hot and
not too cool
Try to sleep in dark and quiet
room
Have a routine to go to bed at the
same time everyday
Avoid day time naps
Meditation before bedtime can
help you relax
I can arrange a referral letter to
psychotherapist who will teach
you relaxation technique.
- I can also organize social workers to visit you at your
place as required. It will be difficult for you to go to
exam right now, so a letter will be provided to your
principal of your school to reschedule your exam
- University counselor is also available for counseling of
such cases
o Sleep hygiene and life style modification
o Prescription short acting benzodiazepine
o If you feel very low at any time and you feel
stressed and frustrated with yourself, please
come to me and contact crisis control
center.
o Please do not stay alone and I will review
you in 3 days time about your progress

Anniversary Grief Reaction
Case: Your next patient in GP practice is a middle aged woman
who came for regular checkup regarding her BP. She had no
emotional problems before but during the last weeks, she was
tearful and often crying. Her husband died of heart attack 12
months ago.
Task
a. History (started 2 weeks ago, when I was cleaning the
closet and putting his clothes aside, and started to
smell his scent; I can feel his presence)
b. Diagnosis and Management
History
- I understand that you came to see me for review of
your blood pressure. Is everything alright? Have you
been checking your blood pressure? I also understand
that you have been tearful and crying. How do you
feel right now? (Patient starts crying Offer tissue and
Water). I know it is a very hard time for you. I am here
to help you. If you feel like talking to me, let me
reassure you that everything we talk about it
confidential. I will not breach this confidentiality.
- When did it start exactly? How did you cope after your
husbands death? Hows your mood? Do you still find
things pleasurable? Hows your sleep? Appetite?
Weight? Psychomotor retardation or agitation? Do you
think life is worth living? Do you feel guilty about your
husbands death? Have you thought of harming
yourself or anybody else? Do you hear or see things
that others do not? Do you have any strange
experiences?
- Whom do you live with? Have you got enough support
from friends and family? Do you go out with friends?
Are you working at the moment? Can you do your
day-to-day activities? SADMA?
Diagnosis and Management
- From the history, most likely what you are
experiencing is anniversary grief reaction. This is
normal, expected and understandable especially when
a close person/loved one passed away. Your mind
ventilates the feeling through crying. To feel your
husbands presence is a part of anniversary reaction
and it doesnt mean that you are getting insane. I
understand that you are going through a tough time.
What you are feeling is like a bruise. It will heal
without scarring. You will feel better once the
anniversary phase is better. But what you need at this
time is emotional support. We will manage your
condition with a multi-disciplinary approach
(Psychiatrist, Psychologist, Occupational Therapist,
Social Worker, Counselors, and Mental Health
Nurses). I will refer you to the psychologist whom you
can share your problems with and to help you cope
with the grief, social worker, and grief support group.
If you are happy, I can arrange a family meeting.
- Cant you just give me medications doctor? You do
not need any medications at this moment. All you
need is a lot of support during this hard time.
- I will need to see you in a weeks time to see your
progress.
- Referral. Review.
Major Depression with Psychotic Features
Case: You are a GP and a 42-year-old nurse comes to see you.
She had been accused of an incident at the hospital around 5
months ago where a patient had died. The nurse has been
cleared by the coroner and the case was adjourned. The patient
did not feel well after the incident and she was treated with
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SSRIs for some time. She did not show up for previous follow-
ups for the last 2 months. She is here today because the
receptionist has called her.
Task
a. Perform Mental state examination
b. Tell examiner diagnosis and management plan
Criteria:
- Anhedonia, depressed mood, suicidal ideation, sleep
problems (early awakenings), lack of energy,
problems with concentration and decision making,
lack of sexual desire and appetite
- Diagnosis depends upon the presence of 2 of the
above along with suicidal ideation, persisting for at
least 2 weeks or any 4 of the above without suicidal
ideation.
- Risks/criteria for admission: not eating/drinking
appropriately, suicidal ideation, lack of support at
home, not taking/responding to antidepressants
Counseling
- Show empathy. Confidentiality statement.
- From the notes I understand that you have been upset
since the incident five months ago. Can you please tell
me exactly what happened? I understand it is very
difficult for you to go through that experience one
more time, but it will really help me to understand the
situation. When exactly did you start feeling bad about
yourself? How was your mood before the incident?
Were you eating and drinking well? Were you able to
work? Have you ever been diagnosed with depression
or other illnesses like thyroid problems, diabetes,
infections? What happened after the incident? Did you
notice any changes in your weight or appetite? Were
you feeling guilty all the time? Any change in your
sleep pattern? Any early morning awakenings? Did
you feel like harming yourself or others? Do you think
your life is worth living? Have you thought about how
you are going to do it? Any plans? Did you buy
something for that plan? Please tell me, whom do you
live with him at home? Any partner? Kids? Relatives?
Friends? Neighbors to take care of you? Are you
working at the moment? When did you leave? Can
you tell me more about the medications that were
given to you? How long did you take them? Did they
help to improve your mood? Why did you stop?
- Do you see/hear things that others dont? Do you
have strange experiences? Do you think some people
are trying to harm or spy on you? Are there repetitive
thoughts that you cant get rid of? Do you think the TV
or radio talk to you?
- Can you please tell me your date of birth? Day?
- What would you do if there is fire in the room or
envelope on the street that has an address on it?
- Do you think you need medical help? May I ask why
youre here?
- What are your plans for the future? Are you planning
on anything?
MSE (ASEPTIC)
- Appearance (dress, posture, hygiene)
- Speech (rate, tone, volume)
- Emotion (affect and mood)
- Perception (hallucination, illusion, derealization)
- Thought (delusions, suicidal/homicidal ideations,
obsessions, logical/coherent)
- Insight and Judgment
- Cognition (orientation to time, place, and person;
memory; LOC)

- I would like to address my MS findings to the
examiner. The patient looks appropriately dressed for
the weather. She looks gloomy, tearful, and avoiding
eye contact. She is sitting with a drooping posture.
The affect appears constricted, although the mood is
depressed and irritable at times. The patient speaks
with a monotonous voice, sometimes with long pauses
in between where she avoids answering. I also found
that the patient has delusions of guilt. She feels
helpless and has suicidal ideations although no
particular plan is present at the moment. Her cognition
is distracted where the patient is not able to
concentrate adequately although her memory is intact.
Her insight and judgment is impaired.
- Based on the examination findings my most likely
diagnosis is major depression with psychotic features.
It is obvious that the patient is neglecting herself. She
needs to be evaluated appropriately by the psychiatric
team so I will need to refer her to the hospital if
required under the mental health act. The most likely
management is anti-depressants with or without ECT
followed by CBT later on.
Postpartum/Postnatal Blues
Case: Your next patient in GP practice is a 25-year-old Jane
who is 7 days postpartum. She feels exhausted, and has lack of
energy, and gets quite irritable at times. She is wondering if she
is lacking some vitamins and seeks your advice.
Task
a. History (1st baby, feels very tired; planned pregnancy;
takes care of the baby; complicated labor prolonged
for 14 hours, eclampsia; cannot sleep at night
because baby is crying all the time; husband needs to
travel a lot; needs help; I love my baby; no past
history of depression)
b. Diagnosis
c. Management
Risk factors
- Prolonged or difficult labor
- First baby
History
- Congratulations! How was the pregnancy? How was
the labor? Is it your first baby? Is everything okay
now? How is the baby? Did you start breastfeeding?
Any problems with that?
- I understand that you have tiredness and youre
irritable?
- Confidentiality
- Any SOB or did you have a lot of blood loss? Do you
think youre pale? Any weather preferences? How are
your waterworks? Hows your discharge? Any
offensive smell? Hows your diet?
- Mood: How is your mood? Do you still find things
pleasurable? Hows your weight? Appetite? Sleep?
Have you ever thought of harming yourself or the
baby? Do you think life is worth living? Do you
hear/see things that others do not? Do you have any
strange experience? SADMA?
- How are things at home? Do you have enough
support from friends, family and husband? How is
your relationship with husband? Any financial
problems?
Diagnosis and Management
- Most likely you have a condition called postpartum
blues. It is more common during the first pregnancy
and basically, it happens because of hormonal
imbalance. There are also contributory social factors.
In your case, it is the lack of social support.
14
- Youre doing a good job as a mother. Dont worry. I do
understand that it is difficult to be a mother for a first
time and you need support. I will organize a social
worker to help you. If you like, I can organize a family
meeting and talk to your husband about the issue. I
would also like to refer you to a counselor to teach you
how to cope with stress.
- I would organize basic investigations especially FBE,
ESR/CRP, urine MCS, BSL, and TFTs.
- Do not worry. You are not alone. These blues or mood
swings should be fine in around 1-2 weeks (1 month
maximum).
Postnatal depression with psychosis/melancholic features
Case: 30-year-old woman came to your GP clinic. She has 2
children 30 months and 2 months. She presented with 2 weeks
history of tiredness, weight loss, and inability to sleep. Shes
always worried about her baby as she thinks baby will die from
SIDS. You arranged some investigations for her 1 week ago and
all the tests are normal. Today, shes here to collect the report.
Task:
a. History
b. Diagnosis
c. Management
History
- I understand from your notes that you are here
because you have trouble sleeping, has lost weight
and are always tired? Can you tell me more about it?
Can you describe me your sleep pattern? I know you
are tired (anemia, chronic illnesses, psychological),
but do you have any SOB, palpitations, fever?
- How is your mood? Sleep? Weight? Appetite? Have
you lost interest in the activity which used to be
pleasurable before? Do you think life is worth living?
Have you thought of harming yourself or anybody
else? Have you ever thought of harming your baby?
- Psychosis: do you see, hear, feel things which others
do not? Do you have any strange experiences? Do
you think someone is putting thoughts into your head?
Or think something/someone is after your thoughts?
Do you think tv/radio/newspaper is talking about you?
Do you think youre a good mother?
- Insight
- Judgment
- Cognition
- HEADSSS
- PMHx/FHx/SADMA
Risk factors for postpartum depression
- Previous history of postnatal depression
- Previous history of any mental illness
- Unplanned pregnancy
- Difficult marriage/lack of support
- Social isolation
- Complication during pregnancy
- Abused childhood
Management
- You have a condition called postpartum depression
with some psychotic features. Our body and mind are
interconnected. When our mind is too stressed our
body starts showing symptoms and thats the reason
why youre having tiredness, weight loss and sleep
changes. We did some investigations and all the tests
are normal which means that there is no organic
cause for your symptoms.
- I have to admit you to the hospital. I will call the
ambulance. In the hospital you will be reviewed by a
 15

- psychiatrist. They will start you with lithium, anti- - Thought:

psychotic medications, and antidepressant
medications as well. If you dont get better with this
management, the specialist might also consider doing
ECT.
- I would also like to speak to your partner and other
family members because you need a lot of support. In
the hospitals, we have mother and child unit so you
can stay with your children. I would organize a social
worker to help you. Most likely, the breastfeeding will
be terminated (bromocriptine dopamine agonist).
- Later on, you will also be seen by a psychologist and
they will consider doing CBT.
- According to the mental health act, I need to go for
involuntary admission. I am sorry.
- Prognosis is good once treatment is administered but
there is a chance of relapse in the future.
- Consider lithium prophylaxis in future pregnancies.
- OFFER BABY CHECK!
Mania
Case: You are GP and a 35-year-old David comes to your clinic
as his wife has some concerns about his behaviors.
o Stream: amount and speed of thinking
o Form: how patient puts his thoughts across;
loose association/derailment, tangentiality,
flight of ideas, circumstantiality (over-
inclusiveness or beating around the bush)
content: delusion, thought
broadcasting/insertion/ideas of
reference/suicidal ideation
perception: hallucination and illusions
- Cognition/Insight and Judgment
Examination Findings
- My patient's general appearance is okay. She is
casually dressed and well-groomed. Her behavior is
restless and agitated. Volume of speech is low and
language is good. She describes her mood as "okay".
Her affect is congruent with the mood. Her thought
streaming is okay. She exhibits flight of ideas and has
delusions of grandeur. She believes that the president
is going to die and she needs to save him. Perception
is alright. She does not have hallucinations or
delusions. She is oriented to time, place and person
and has impaired insight.

Case 2: Your next patient is 24-year-old university student Differential Diagnosis

brought by parents who are concerned because of his change in - Mania
behavior for 2 weeks. He seems to have been hyperactive, - Drug-induced
sleeps less and has slept with 3 girls in the last 2 days. He has - Acute psychosis
been drinking a lot of alcohol and are worried he might get into - Hypomania
an accident.
Diagnosis and management
Task - Urine drug screen
a. History (6 minutes) - Admit patient
b. Explain to examiner differential diagnosis - Call psychiatric registrar: they might start him on mood
stabilizers
Differential Diagnosis
- Bipolar Mood Disorder ANXIETY DISORDERS
- Schizoaffective Disorder
- Personality disorder Generalized anxiety disorder (JM 1259/1260)
- Hyperthymic personality (no treatment unless they
come with mania or depression) Case:
- Alcohol/drug dependence - R/O drug dependence/withdrawal, hyperthyroidism,
- Anxiety disorder cardiac arrhythmias, pheochromocytoma, depression,
- Hyperthyroidism Diabetes

Treatment
- Admit - Do ECG, BSL and Urine at the office during his first
- Lithium carbonate, sodium valproate visit
- Anti-psychotic - DSM criteria:
- Anti-depressant (need to used with caution with mood o UNREALISTIC worries
stabilizer) o Uncontrollable worries
- Psychiatrist review and long-term followup o Symptoms are not the direct result of any
- Mental health care plan organic or psychiatric disturbances
o 3 or more symptoms:
Mania MMSE Irritability
Restless, keyed up or on edge
Case: Your next patient is a young uni student brought in by Easily fatigued
their concerned parents. She is insisting to fly to US to meet the Difficulty concentrating or mind
president. going blank
Muscle tension
Task Sleep disturbance
a. Mental state examination - Management:
b. Present findings to examiner o Relaxation techniques: YOGA AND
MEDITATION
MSE o Lifestyle modification: Diet
- Confidentiality o Physical activity: 30 minutes brisk walking
- General appearance and behavior: restless and most days of the week
agitated o Refer to psychologist for CBT
- Speech and language: rate, volume, quantity; fluency, o Sleep problems: sleep hygiene; may give
range of vocabulary short-term benzodiazepines (up to 2 weeks
- Mood and affect: congruent/incongruent; but usually 2 days to prevent drug
appropriate/inappropriate (related to situation) dependence)

o SSRIs after 3 months of lifestyle
modification and CBT
Panic disorder with Agoraphobia
Case (Panic disorder): A 30-year-old female came in to your GP
attack saying she had a heart attack 4 months ago when she
was visiting a postnatal class. All PE and investigations at that
time were normal. Patient does not understand her condition,
hence came to you for explanation.
Task
a. Focused history (cant breath, heart beating fast,
fainted; anxious, stressed, other investigations normal;
given sleeping pills but did not take it; no longer going
out because she is scared of recurrence; worry about
a lot of things says husband but she does not believe)
b. No further examination
c. Diagnosis
d. Management
Case 2 (Panic attack): Sheila aged 35 years presents to your
GP clinic with history of sudden onset of palpitations, trembling,
sweating and chest tightness. She also had numbness and
tingling feeling in her arms, legs, and around the lips. She had
similar episodes in the last few months and was investigated in
the hospital with negative results.
Task
a. Focused history (2nd attack, was sitting in the staff
room and started feeling palpitations, trembling,
sweating and chest tightness; lasted about 30
minutes, blood tests; ECG normal; coffee 5-6 cups,
father with HPN and angina; works as assistant
teacher; feels stressed but able to manage it;
relationship with partner is okay; no financial
constraints; mood is okay; sleep and appetite is good;
life is still worth living; smokes 5-10 cigarettes/day;
drinks 2-3 SD/day)
b. Physical examination (looks anxious but well; PR 74,
BP 110/70, thyroid normal; chest and heart normal;
abdomen normal)
c. Differential diagnosis and management
Features (DSM IV)
- Panic Attack Criteria
o Discrete period of intense fear or discomfort
in which four or more symptoms develop
abruptly and reach a peak within 10 minutes
SOB or smothering sensations
Dizziness, unsteady feelings, light
headedness or faintness
Palpitations or accelerated heart
rate
Trembling or shaking
Sweating
Feeling of choking
Nausea or abdominal distress
Depersonalization or derealization
Numbness or tingling sensations
Flushes or chills
Chest pain or discomfort
Fear of dying
Fear of going crazy or of doing
something uncontrolled
o Organic disorders that stimulate a panic
attack are hyperthyroidism,
pheochromocytoma and hypoglycemia
o Management:
Reassurance and explanation
Support
16
Breathing techniques to help
control panic attacks and
hyperventilation
Breathe in and out of paper bag
Acute attack: benzodiazepine
Lifestyle modification
CBT: teach patients to
identify,evaluate and control and
modify their negative fearful
thoughts and behavior
SSRIs
- PANIC Disorder: Presence of both:
o Believes having heart attack
o Recurrent panic attack in which the onset is
not associated with a situational trigger
o At least 1 of the panic attacks has been
followed by one month of one or more of the
following
Persistent concern about having
additional attacks
Worry about implications of the
attack or its consequences
Significant change in behavior
related to attacks
o Presence or absence of agoraphobia
o Panic attack are not due to the direct
physiological effects of a substance,
medication, general medical condition or
another mental disorders
Differential Diagnosis
- Panic attack
- Anxiety disorder
- Conversion disorder
Agoraphobia: extreme anxiety about being in a place where
escape might be difficult or embarrassing. Extreme cases lead
to a situation where the person rarely leaves home
History
- Confidentiality
- Please tell me more about what happened 4 months
ago? Where were you at the time? Can you describe
the environment? How many people were in that
room? Was it a crowded place? Where was the baby
at that time? What symptoms exactly did you feel?
Was that the first episode? What happened
afterwards? Did you lose consciousness? I
understand from the notes that you had a lot of tests
done and the results were all normal.
- During the last 4 mos, have you had similar symptoms
(e.g. palpitation, chest tightness, DOB, dizziness)?
Where? What situations? Environment?
- Can you describe yourself in terms of your
personality?
- Are you worried about having a similar episode again?
- Did you attend more classes afterwards?
- Do you think you are evading public spaces/closed
spaces since then?
- How is your mood/appetite/sleep? Are you able to
perform daily household activities?
- Have you thought about harming yourself or others?
- Hows the baby doing at the moment? Are you coping
well? Are you breastfeeding? Do you have enough
support at home?
- PMHx: thyroid, heart, mental illness; SADMA
Physical Examination
- General appearance
- Vital signs
- Thyroid examination
- Chest and heart
- Abdomen

Management
- Most likely you have a condition called panic disorder
with agoraphobia. It is a feeling of excessive anxiety
that causes symptoms like palpitations, sweating, etc.
Usually, there is no cause for this problem.
- I will refer you to a psychologist. We will try and help
you to overcome this problem as it makes it difficult for
you to go out in public. We will teach you to how to
avoid these attacks and what to do if you have one.
This treatment is called CBT.
- We will also teach you some breathing techniques that
will help whenever you are stressed and anxious.
- If your symptoms are not relieved by CBT, the
specialist might start you with SSRIs. Also, if you
develop recurrent attacks with increased severity,
SSRIs are required.
- I can ask a social worker to come and visit you at
home.
- Reading materials; Review materials and followup
with psychologist
Obsessive Compulsive Disorder (OCD)
Case: a 30-year-old nurse came in to your GP clinic. She was
seen by your colleague a week ago. She has repetitive,
frequently intrusive thoughts of washing her hands very
repeatedly because she thinks her hands might be
contaminated and transmits infection to patient. Investigations
were done and she was diagnosed with OCD. Shes feeling
anxious and frustrated and now thinks whether she can take
some time off from work.
A university student comes and when someone tells king, he
starts to walk.
Task
a. History (patient wearing gloves)
b. Management plan
History
- Confidentiality!
- Can you talk a bit more about it? Do you think it is
rational to keep washing hands? How is it affecting
your life? Do you have any other repetitive thoughts?
Since when? Are you a perfectionist?
- Mood: I know this is a frustrating time for you but how
is your mood these days? Sleep? Appetite? Weight?
Anhedonia?
- Have you ever thought of harming anybody or
yourself? Are there any times when your mood is
really high?
- Do you see/hear/feel things which others dont? any
strange experiences which others find hard to
believe?
- Insight: do you think you need help?
- Judgment: fire or envelope question
- Social history: how is the situation at work (stressed)?
Home? Whom do you stay with? Financial issues?
Happy family?
- SADMA
Management
- You have a problem called OCD. Do you know what it
is? OCD is one of the anxiety disorders. It is a
common condition. People experience recurrent and
persistent thoughts (obsession) leading to anxiety and
compulsion.
- I would like to refer you to a psychiatrist and
psychologist. They will do Behaviour Modification
Therapy (Exposure and Response Prevention) which
means the therapist will expose you to the obsession
and will teach you how to overcome your anxiety.
17
- The psychiatrist may also consider giving SSRIs to
relieve your anxiety and maybe some short-term
benzodiazepines to help you with your sleep.
- Do not worry. The prognosis is good.
- Am I crazy? No. this is an anxiety disorder. Most likely
because you are too stressed at work. Take things
lightly and do not bottle up things.
- If you want to take time off, it is a very good decision.
- Relaxation and Meditation
- Review and reading materials
Obsessive Compulsive Disorder
Case: A university student came to see you at a GP clinic. He
failed his exam recently.
Task
a. Take a history
b. Diagnosis
c. Management
History
- I understand that you have come here because you
worried about failing your exams. I am sorry about
this. Why do you think it happened (I have trouble
studying because of my thoughts)? Can describe
these thoughts for me? (I study history and whenever I
READ THE WORD KING, I feel anxious and I need to
go around the room once). When did it happen? Since
when did you start having this condition? How often
does it happen? How do these thoughts make you feel
(They are unwanted thoughts. It distresses me and
makes me anxious.)? Have you tried to resist these
thoughts (Yes, I tried but failed)? Do you think that
these thoughts are unreasonable and excessive?
Apart from walking around the table do you have any
other habits or rituals which you need to carry out
every day (He needs to wash hands 10 times a day).
Does it cause any trouble? Hows your mood? Hows
your appetite? Do you enjoy the things you used to
like? Are you in a stable relationship? Are you
sexually active?
- Risk assessment: Have you ever thought about
harming yourself or others? Do you see/hear things
when no one else is around? Do you think somebody
try to put thoughts in your mind or steal from your
mind? Have you excessively worried about simple
things? Are you perfectionist?
- Past History: Any medical condition? Particularly
thyroid. Any mental or behavioral problems in the
past? SADMA? Who do you live with? Do you have
many friends? Hows your family? Apart from study do
you have other interest? Are you financially secured?
- Family History: Any medical or mental condition runs
in the family?
Diagnosis and Management
- Andrew, from my history I think most likely you have
an anxiety disorder called obsessive compulsive
disorder. Have you ever heard about it? It is a
common condition often starting in early adolescence.
People with this OCD experience recurrent and
persistent thoughts, images or impulses that are
intrusive and unwanted. They also perform repetitive
and ritualistic actions that are excessive, time
consuming and distressing.
- I would like to refer you to a specialist for assessment.
Often the first step in treatment is psychotic treatment.
CBT (cognitive behavior therapy): The important part
of this therapy is gradual exposure to situations which
trigger obsession plus teaching behavior techniques to
reduce compulsion and anxiety.
 18

- Medical treatment from psychiatrist: SSRIs o Psychological component: constantly

- Would you like me to organize family meeting? Do you worried, sleeplessness, restless, lack of
need any support for studying? concentration
- Prognosis: - Constellation of symptoms that persist for 1 month
o 20-30% will improve significantly. after exposure:
o 40-50% will have moderate improvement. o Acute PTSD: duration of symptoms <3
o 20-40%, they have chronic OCD or months
worsening symptoms. o Chronic PTSD: duration of symptoms >
- People who can have a good prognosis: 3months
o Good social environment o Delayed onset PTSD: onset at least 6
o Clear precipitating event months after stressor
o Episodic symptoms - Experienced or witness a traumatic event (death,
near-death experience, rape, earthquake, natural
Delayed-Onset PTSD calamities) with situation with feeling of helplessness
and extreme fear
Case: Paul is 55-years of age and a father of four. He presents - Typical distressing recurrent symptoms
with difficulties sleeping and concentration. He says that he o Recurrent intrusive features recollection,
wakes up in a cold sweat every night after a nightmare and he nightmares, flashbacks
finds it difficult to sleep because of anxiety. The nightmare is o Avoidance of events that symbolize or
always the same: a car accident like the one he experienced 10 resemble the trauma, detachment, feelings
years ago. Paul was driving from the hardware shop with his of numbness or withdrawal, guilt
then 8 year old son and suddenly hit on the side of the car and o Hyperarousal phenomena: exaggerated
swerved onto the side road. He remembers time slowly down startle response, irritability, anger, difficulty
as the car was sliding off the road, thinking this is it and turning with sleeping and concentrating,
to see his son leaning towards the window. He had wanted to hypervigilance
reach out and grab him but had to keep his hands on the wheel - Management
and regain control of the car. He said it was probably the most o Meditation and yoga
intense and scariest few seconds of his life. No one was injured o Lifestyle modification (smoking cessation,
and at the time Paul felt relieved, thinking for some time after decrease alcohol intake, healthier food, and
how lucky they were that the car stopped before crashing into exercise)
the nearby tree. Paul says he has not thought much about the o Proper sleep hygiene
accident until 2 months ago when his son came with his new Recognize what helps patient to
drivers license. He says he felt anxious and worried about his settle best, establish a routine
son driving, despite telling himself that his son is a safe driver. before going to bed, regular
Every time his son goes out with the car, he has some difficulty daytime exercise and time of
concentrating on anything else and is generally jumpy and on arising, avoid daytime naps, avoid
the edge. Then about a month ago the nightmares started. In strenuous exercise close to
the nightmare, he sees the accident, feels time slowing down bedtime; avoid alcohol and drinks
and sees his sons head smashed into the window. He wakes containing caffeine in evening,
up sweating, his heart palpitating, breathing heavily, and in avoid heavy evening meal and
complete panic. He describes the whole experience as so real smoking; remove pets from
that often in the morning he is overcome with a strong sense of bedroom; avoid lights including
grief. He is not sure whether it is lack of sleep or the dreams but poorly screened windows and
he has been walking around the home like a zombie and not highly illuminated clocks in the
really feeling quite there. He finds it difficult to feel positive room
about any activities and feels numb towards his wife. He Sleep promoting adjuvants: warm
describes the situation as unbearable. bath, warm milk, comfortable quiet
sleep setting with right
Task temperature, sex
a. Probable diagnosis Non-pharmacologic treatment:
b. Management advise (establish SAD, mood, suicidal, meditation, relaxation therapy,
stress management; CBT and
Differential Diagnosis electromyographic feedback;
- Acute stress disorder (constellation of abnormal hypnosis
anxiety-related symptoms occurring within a 4-week- o Crisis Intervention Therapy (CBT)
period. Symptoms are grouped as hyperarousal o Refer to psychiatrist and psychologist for
phenomena, avoidance of reminders and intrusive counseling (EMDR Eye Movement
phenomena; management: debriefing and counseling) Desensitization and Reprogramming)
- Adjustment disorder (anxiety symptoms within 3 o Social support
months of response to an identifiable psychosocial o Pharmacologic: SSRIs; short-term
stressor; persists for less than 6 months following benzodiazepines (sleep)
removal of stressor; non-pharmocological: counseling,
relaxation and stress management; pharmacological: Post-traumatic Stress Disorder 2
short-term benzodiazepines)
Case: Your next patient is a 22-year-old man who presents with
Diagnosis SOB and poor sleep. SOB occurred at night and relieved by
- Type of ANXIETY disorder waking up. He had a major vehicular accident 3 months ago and
o Physiological component: autonomic broke 3 ribs. He recovered well.
hyperactivity (palpitation, increased HR, dry Task
mouth, upset stomach) a. History (SOB last night, relieved by salbutamol, went
for a walk and felt better but returned in the morning
consult; stopped socializing and had no contact
with the GF)
 19

b. Diagnosis and management Melbourne, recently divorced 3 weeks ago, not on any
contraceptives, regular with pap smear, no bleeding
History disorder; drinking alcohol 3-4 glasses of wine to help
- When did it start? Any previous episodes? Did it occur with sleep)
after the motor vehicle accident? Any triggering b. Physical examination (looks well without eye contact,
factor? Any associated features such as chest pain or VS normal, all PE normal)
sweating? How is your general medial health? Any c. Investigation
serious medical problems in the past? d. Diagnosis and Management
- I know you had a car accident, Im sorry about it. Im
not asking you to recall the event, but can you please Differential Diagnosis
tell a few words about it? Was somebody with you at - Major depression
that time? How is she? Do you have any contact with - Acute stress disorder
her? Do you experience any sudden images of the - PTSD
event? Do you try to avoid driving or the place where
the incident took place? Do you have any nightmares? Stressors:
Do you feel irritated, angry or guilty about anything - Death of a loved one
pertaining to the incident? - Divorce or problems with relationship
- How is your mood? Sleep? Appetite? Weight? - General life chages
Anhedonia? Suicidal ideation: do you think life is worth - Illness or other health issues in yourself or a loved one
living? Have you thought of harming yourself or - Moving to a different home or city
anybody else? Do you see/hear/feel things others - Unexpected catastrophes
cannot or have you had any strange experiences? - Worries about money
- Whom do you stay with? Do you have a lot of friends? - In teenagers: family problems or conflict, school
SADMA? problems, sexuality issues
- ENCOURAGE patient by nodding and showing
concern Features:
- 5 symptoms for 2 weeks daily: SAGECAPS (in
Diagnosis and Management depression)
- From the chat we had, I think you have a condition o Sleep
called post-traumatic stress disorder. Have you heard o Anhedonia
about it? It is a type of anxiety disorder where the o Guilt
patient experiences various symptoms and behaviors o Energy (lack of)
like recollection, flashbacks, avoidance, sleep o Concentration
problems following a psychologically distressing event o Appetite
which in your case is the MVA you had 3 months o Psychomotor retardation
before. o Suicidality
- The symptoms usually come immediately after the - Criteria
event but can be delayed for months or years. o Development of emotional or behavioral
- I will refer you to a psychiatrist. He will talk and listen symptoms in response to an identifiable
to you and will use some techniques to help you come stressor within 3 months of the onset of the
out of this situation cognitive behavioral therapy. stressor
As you havent slept for a few days, he may offer you o Symptoms or behaviors are clinically
sleeping pills for a short time but I would advise you to significant as evidenced by:
start with sleep hygiene. marked distress that is in excess
- At this stage, you might not need any medication, but of what would be expected from
if required, the specialist might offer SSRIs. exposure to the stressor
- I would like to do a family meeting if its okay with you. Significant impairment in social or
Family support is very important at this stage. occupational functioning
- Safe level of drinking. o Stress-related disturbance does not meet
- Review. Reading material about PTSD and sleep criteria for another specific axis I disorder
hygiene. and is not merely an exacerbation of pre-
- Differentials: anxiety disorder (GAD, adjustment existing axis I or II disorder
disorder, panic attacks, substance abuse) o Symptoms do not represent bereavement
o Once stressor has terminated, the
ADJUSTMENT DISORDERS symptoms do not persist for more than an
additional 6 months
Adjustment Disorder - Treatment
o CBT
Case: Your next patient in GP practice is 32-year-old Shirley o Relaxation technique (yoga and meditation)
Coombs complaining of SOB. She has recently moved from o Healthy diet and exercise, reduce caffeine
Sydney to Melbourne with prolonged travel time. o Stress management (dont bottle things up!)
o Sleep hygiene
Case 2: lady with chest tightness and pain and normal o Short-term course of drug treatment is
investigation husband died recently; necessary in persistent or severe case

Case 3: sad woman anniversary grief Developmental Disability with Adjustment Disorder

Task
a. Focused history (started 2 days ago, comes and go,
does not change with position, started 4 weeks ago,
present at rest, not feeling comfortable, no fever, feels
tired, and breathless, drove from Sydney to
Case: You are a GP and your next patient is a 26-year-old with
Down Syndrome living in a support home. There is change in
behavior recently and he is very tired. He is afraid to coming to
the GP and that is the reason he hasnt come today as well.
Instead, there is a legal carer who has come to see you.

Task
a. History from legal carer (he is not active, tired and
doesnt want to get out of bed recently since last week
when his close friend left the home and moved
interstate; weight loss; no medications; mood is sad;
cant express in words because is mentally changed)
b. Diagnosis and management
History
- Confidentiality
- I understand that you are concerned that you noticed
changes in your patients behavior and that he is very
tired.
- Could you please explain what you mean by change
in behavior? When did it start? Did anything happen
around that time when it started? How is Johns
mood? Does he have the capability to express
himself? What about his weight? Appetite? Sleep?
Has he ever thought of or done something to harm
himself?
- Do you think he has fever? Any chest pain or tummy
pain? Does he complain about anything? Any change
in bowel motion, color of the stool, or waterworks? Is
there any smelly urine, frequency or urgency? Any
weather preference especially cold intolerance? Any
change in color of the skin?
- Any history of getting heart problems? Has he traveled
recently overseas or anywhere else? SADMA? Does
he have family? Do they visit him? Does he have
other friends in the support home?
Management
- Most likely, he has a condition called adjustment
disorder. Because he was emotionally attached to his
friend, he might have develop these symptoms when
he left but it could be depression resulting from
hypothyroidism which is common in patients with
Down syndrome. I would like to run some basic
investigations for him including FBE, TFTs, BSL, iron
studies, urine MCS, U&E, and LFTs.
- At this stage, I want to see him. If he doesnt come,
then I would like to arrange a home visit. If he has a
family, I can arrange a family meeting because he
needs a lot of support right now. If you are really
concerned, I can refer him to the counselor to help
him deal with stress.
- I would encourage you to engage him in his favorite
activities.
- I would like to review him once the results are back.
- Reading material.
- Red flags: for severe depression
EATING DISORDERS
Bulimia Nervosa
Case: You are a GP and your next patient is a 26-year-old
female referred by a dentist because of poor dentition, dental
hygiene, dental carries and repeated vomiting.
Case 2: You are a GP and a 26-year-old computer analyst
comes in complaining of self-induced vomiting and some
changes in dorsum of hands. BMI is 24
Task
a. Relevant History (toothache, filling, self-induced
vomiting; dont want to get fat since teenage; mood:
sometimes low eat more, more depressed; normal
sleep
b. Explain Diagnosis
c. Management
20
DSM IV criteria:
- Eating amounts of food larger than most people eat in
a short period of time
- Lack of control over eating
- Eating is followed by compensatory purging by the
following mechanisms:
o Self-induced vomiting
o Laxative abuse
o Periods of fasting
o Excessive exercise
- Distorted self-evaluation of body shape and weight
Types of bulimia
- Purging
- Non-purging: fast, exercise, abuse appetite
suppressant
- Commonly seen in people with depression. They
usually have a history of neglect or sexual abuse as a
child or young adult. It is commonly seen in well
educated high achieving females (compensating
mechanism). There is a coexisting history of alcohol
abuse, social functioning impairment, along with FHx
of mental disorders. 50% of these patients are also
diagnosed with a borderline personality disorder.
History
- Confidentiality
- How is your appetite these days? Can you describe
your typical daily diet to me? What is your perception
about your weight and your body image?
- Has there been a recent change in your body weight?
Do you ever lose control over how much you eat? Do
you force yourself to vomit? How frequent? Since
when have you been doing this? Have you ever used
any meds to lose weight (laxatives, water
pill/diuretics)?
- Any change to your period? LMP? Regular cycles?
- How is your mood recently? Any changes? Do you
sleep well? Are you able to perform daily life
activities?
- Are you in a stable relationship? Any sexual
problems?
- Do you feel your life is worth living? Have you ever
thought about harming yourself or others?
- Do you see/hear/feel things that others dont? Any
strange experiences?
- Some people have a history of sexual abuse as a
child. Do you think it may be related to you?
- FHx: mental illness?
- SADMA?
Diagnosis:
- You have condition called bulimia nervosa which is a
part of eating disorders. It is uncontrolled episodic
rapid ingestion/intake of large quantities of food in a
short period of time. The patient then feels guilty and
afraid of gaining weight. They induce vomiting
themselves or might use medications/laxatives. It is
very common in young females.
- It is a risky condition. Repeated attempts to lose
weight cause a fluctuation in body weight which
affects all body systems especially the hormonal
balance. It can cause:
o Irregular periods
o Depressed mood
o Loss of fluids and minerals
o Dental decay
- What we need to do is refer you to a psychiatrist. They
will confirm the diagnosis first and then start treatment
such as CBT and sometimes medication like SSRIs.
You need to come for regular follow up. We have
support groups for patients with eating disorders.

- Reading materials
- Admission
o Affecting hormone system
o Cardiac disease
o Suicide
o Hormone changes
Bulimia Nervosa
Case: An 18 year-old-female has been admitted to the hospital
in the ED for Diabetic Ketoacidosis. Now she is ready to be
discharged. She has normal weight and has a history of binge
eating and self-induced vomiting and laxative abuse.
Task
a. Relevant history
b. Explain the condition to the patient and the
management
History
- When were you diagnosed? Medication? Under
control? Last reading of your BSL? Is she on constant
follow up by her GP? Diagnosed two years ago.
Insulin injections. Missed some doses not regular. Do
you check your sugar level everyday? How many
times per day? Do you skip meals regularly? Have
you ever been admitted to the hospital with
complication of DM? When was the last time you
visited your GP (2years back. After Ive been
diagnosed I never went back)? Could you please tell
me about your daily meal for one whole day (She eats
2-3times a day and large amount of food). Do you feel
guilty about your eating habit? What do you do about
it (She induces vomiting.)? How often do you vomit?
Do you take any laxatives (Yes, 3 times per week)?
What do you think about your body weight (Very fat I
cant look at myself in the mirror)?
- Periods: Are they regular? When was your LMP?
Sexual history if she is sexually active? Do you use
any contraception? Do you think you could be
pregnant? Psycho social history. Hows your general
health? SADMA?
Counseling
- Susan, you are suffering from two conditions:
Diabetes and eating disorder most possibly you have
bulimia nervosa. Have you heard about it?
- Its a common condition in your age group. A person
with this disorder eats large amount of food in a short
time the loose control and cant stop eating. After that
they induce vomiting to compensate. Its a very risky
situation for you as you are not taking your meals and
insulin regularly. You had a complication of diabetes
called DKA for which you were admitted to the ED.
When you induce vomiting you only loose water and
salts from your body but not body fat. Its dangerous
as it can cause damage to your kidney and cause
water and mineral imbalance. In the long run, it can
affect your heart, lungs, eyes and nerves also. Eating
disorder can affect your health adversely, it can cause
dental problems, I know your main concern is your
body weight. Let me assure you we will help you to
achieve an ideal body weight without having to induce
vomiting or use laxatives. We will work as a
multidisciplinary team. I will refer you to a dietician
with whom you can discuss an appropriate diet plan
for you. I will also refer you to endocrinologist to adjust
your insulin dosage.
- Psychologist for CBT. With your consent I can arrange
a family meeting as family support will be essential. Id
also write a letter to your GP so that he can follow you
up regularly and we can prevent complications in the
future.
21
- Support group: Eating disorder foundation Australia
Eating Disorder
Case: You are a GP and the mother of a 13-year-old girl has
come to you because her daughter has lost weight recently. She
does not feel hungry at the time of meal and her periods have
not come up to now.
Task
a. History from mom (BMI 17, fear of being fat, excessive
exercise, constant checking in the mirror, switched to
vegetables)
b. Diagnosis and management
Case: Karen aged 16 years comes to your practice with her
mom Julie. Julie tells you that she is quite concerned about
Karens eating habits. On your questioning to Karen, she tells
you that her mom isf forcing her to eat all the time and she is not
happy and wants you to help her. Karen is a year 10 student in
local school and lives with her parents at home.
Task
a. Further history (wants to lose weight because she
thinks she is fat; does not socialize with friends; mood
okay, no psychotic features)
b. Physical examination (BMI 16.5, BP 100/70, postural
drop 15mmHg, HR: 56/minute; T: normal, oxygen
saturation, BSL 4.6)
c. Probable diagnosis and Treatment Advise
Common Adolescent Problems
- Asthma
- Obesity
- Eating disorder (0.3% for anorexia and 1% for bulimia)
Early Warning Signs for Eating Disorders
- Concerned about food, dieting and exercise
- Frequent weighing
- Refuse to join other family members in the table
Differential Diagnosis
- Malabsorption
- Thyroid disorders
- Diabetes
- Malignancy
Admission Criteria
- Electrolyte imbalance
- Suicidal ideations
- Severe dehydration
- Hypothermia (<35C)
- ECG showing arrhythmias
- Postural hypotension (>10)
- Bradycardia (<50/minute)
History
- When exactly did you start to realize that her weight is
less than expected? Do you know her weight at the
moment? Can you describe her typical daily diet? Is
she eating vegetables and fruits only? Is there any
intake of meat as well? Can you describe what you
mean when you say that shes not hungry? Does she
eat fast food? Did you try to invite her to eat with the
family? How is her school performance? Is she still
engaging in sports and other activities? Does she
exercise? How much? How many days a week? What
type of exercise?
- How is the situation at home? Any stress like financial
or emotional problems within the family. How is her
relationship with you and with the rest of the family?
Does she go out with friends? Does she enjoy their
company? Do you know if she is sexually active?

- Please tell me more about her period problem? Any
spotting/bleeding? Any lower tummy pain? Have you
noticed that she has become mature physically
(breast, armpit and pubic hair development)? What
was your age when you had your periods?
- Can you describe her mood to me? Have you ever
noticed that she cries or irritable at times? Sleeping
problems? Has she told you that shes able to see or
hear things that you dont.
- Can you feel how she feels about her body? Do you
think she is scared of becoming fat? Does she deny it
when you try to tell her shes becoming thin? Has she
ever talked about harming herself? Have you noticed
that she eats large quantities of food and vomits
forcefully? Does she have access to any kind of
medications especially laxatives or water pills? Has
she ever complained of dizziness or loss of
consciousness? Any other past medical or surgical
condition? Any problems with waterworks and bowel
habits? Are you aware if she smokes or drinks
alcohol? Do you think she might be using recreational
drugs? Is there a family history of eating disorder or
psychological problems?
Criteria:
- Refusal to maintain normal body weight at or above a
minimum normal weight for age and height (<85% of
expected BW)
- Intense fear of gaining weight or becoming fat despite
current underweight status
- Disturbance of body image (body size or shape)
- Amenorrhea in postmenarchal females (absence of at
least 3 consecutive cycles)
- Types: restricting type OR purging/binge eating type
Management
- From the history, most likely your daughter is suffering
from an eating disorder. It can be of many types, most
probably, her eating disorder shows some anorexic
features. It is important to diagnose any eating
disorder as early as possible because the outcome
improves. If possible, bring her to me on your next
visit. If you like, you can see a psychologist straight
away. I can write a referral letter for you.
- The treatment involves CBT (FBT more effective)
sometimes with the use of medications such as
SSRIs. I will also write a letter to a dietitian. She will
make a diet chart for her. With the help of a diet chart,
she can eat a healthy balanced diet without putting on
weight.
- Please remember that she will need family support
throughout the way because sometimes, eating
disorders may be complicated by depression,
electrolyte disturbances, nutritional deficiencies, as
well as drug and alcohol abuse.
- We will work in a MDT approach with myself as her
GP, counselor/psychologist and dietitian in order to
help her.
- Investigations; FBE, TFTs, Dexa Scan, Hormone
study, U&E (calcium, magnesium, potassium,
phosphate, sodium), ECG
SOMATIZATION DISORDERS
Conversion Aphonia
Case: A young 18/F presents with sudden loss of voice. Her
mother was diagnosed with end-stage liver cancer with
metastases. She lost her voice when she was singing prayers in
church for her mother.
22
Task:
a. Focused history
b. Investigate/examination (jug, glass, pen torch, tongue
depressor)
c. Diagnosis
d. Management
DIFFERENTIAL DIAGNOSIS for aphonia
a. Hoarseness
b. Lump (thyroid)
c. Vocal cord paralysis
d. Psychiatric
e. Tumor
f. URTI
g. Overusage of voice
Focused History
- Start with confidentiality statement (station 7, 19)
everything we talk today would remain between you
and me. I will only breach the confidentiality if you are
in danger, if somebody else is in danger because of
you, and if I have to give this statement in the court
- I understand that you are worried about your moms
condition and I am sorry to hear about her
- I understand that you lost your voice while singing
prayers for your mom
- I would like to ask you some questions. I would
appreciate it if you could nod your head or write it on
paper.
- Any problems like this before? Can you make a sound
(look for hoarseness)? Can you cough (nerve
paralysis)? Singing or shouting aloud? Runny nose or
flu-like symptoms? Feeling of lump in throat making it
difficult to talk?
- Mood questions: is your mood low? Any sleep
problems? Have you lost or gained weight? Changes
in appetite? Suicidal ideations (do you think life is
worth living? Have you thought of harming yourself or
anybody ever?)
- Psychotic symptoms: do you hear or see things which
other people do not? Unusual experiences?
- SADMA
- Take informed consent for physical examination
Physical examination:
- Sip water and swallow when you ask her to swallow
- Push out the tongue to look for tongue deviation; gag
reflex; uvula; throat
- Do other cranial nerve examination; ENT;
chest/heart/abdomen
Diagnosis/Management
- From history and examination, the sudden loss of
voice in your case is because of a condition called
conversion disorder (aphonia).
- This results from an unresolved emotional conflict
where thoughts or experiences are unacceptable to
the mind resulting into a physical symptom.
- Draw the body-mind axis body and mind are inter-
connected. The stress from concern of your moms
condition has resulted in bodily symptoms. Whatever
youre experiencing is real but we could not find an
organic cause for it. For example, students start
getting tummy pain or vomiting when exams come up.
- Dont worry. This has a good prognosis. We can treat
and cure it. I will refer you to the psychiatrist and
counselor who will help to relieve your stress and
anxiety.
- If you are happy, I can organize a family meeting to
discuss your situation with the family and if the family
agrees, I will contact the oncologist who is looking
after your mom.

- Consider ENT referral to rule out organic pathology
- Review after couple of weeks
Critical Errors
- Not sympathetic
- Did not rule out organic causes
- Does not know the diagnosis
Body Dysmorphic Disorder
Case: You are an HMO and your next patient is a 29-year-old
male who came to see you. He brought an envelope containing
hair and he asked you to examine it under the microscope. He is
worried that he is getting bald and he believes that this hair loss
will affect his promotion.
Task
a. Focused history
b. Diagnosis
c. Management
Case 2: Female wants to have a breast reduction surgery
Case 3: Man concerned about penis size
Case 4: You have a 24-year-old male student coming to your
GP clinic asking for referral to plastic surgeon because he thinks
his nose is too big. On examination, you find that his nose is
completely normal.
Task
a. Further focused history
b. Examination not necessary
c. Advise patient
Features
- Preoccupied
- Try to HIDE it
- Frequent mirror checking
History
- I can see from the notes that you have hair in this
envelope and you want me to take a look at it under
the microscope? Why? Is it the first time? How is it
affecting your life? Apart from hair loss, are you
concerned about any other part of your body? Does
this concern preoccupy you? Do you try to hide it?
- How is your sleep? Restless? How is your mood?
Appetite? Weight? Anhedonia? Guilt? Do you think life
is worth living? Have you thought of harming yourself
or others? Do you have any strange experiences?
- Social history: how are things at home and at work?
Do you have a lot of friends? Do you socialize?
- SADMA?
Examination: HAIR
Diagnosis and Management:
Case 1:
- Your hair looks normal and let me reassure that I do
not see any hair loss. It is normal to lose up to 100
strands of hair a day which is the natural process of
hair regrowth. I also understand that it is normal to be
concerned about ones appearance, but in your case,
you are over-concerned which is making you anxious
and affecting your function. This is known as body
dysmorphic disorder which is a type of somatoform
disorder. In your case, it is accompanied by anxiety as
well. Unfortunately, such an irrational belief can lead
to severe self-doubt and low self-esteem. Your
problem has been worsened by your work stress.
23
- Dont worry. You made a decision to come up and talk
about it. At this stage, I would like to refer you to a
psychiatrist who will do talk-therapy. He may also put
you on some medications (SSRI and antipsychotics)
for your anxiety and concern.
- I would advise you to remove the mirrors in your
home.
- Offer family meeting/support/social workers
- Review, reading material, referral.
Case 2:
History
- Confidentiality
- History: patient information HPI
- Family history
- Personal and social history
- MSE
o Appearance: eye contact; psychomotor
agitation, how patient dresses,
o Speech: pressured, normal, soft, loud,
monotonous
o Affect
o Thought: Form and Content
o Cognition
o Suicidal Risk
o Insight/Judgment
Management
- I think you have what we call BDD. This means that
you have a preoccupation with a certain part of your
body even though it is normal and this is causing you
distress and anxiety.
- I can give you a referral to a plastic surgeon if you
want, for a second opinion, but honestly at this point, I
dont find it necessary.
- I would, however, like to refer you to a psychologist for
cognitive behavioral therapy so that he can talk things
through and identify any stressors and help you cope
with them.
Somatization Disorder with Agoraphobia
Case: You are seeing a 26 year old female, Nardia, who comes
to you for review of the result of MRI brain which was requested
by the neurologist specialist. Nardia did the MRI as she has
headache associated with severe neck spasm. Nardia has past
history of abdominal pain and nausea. Investigation with blood
tests, CT and U/S were all normal. Colonoscopy and upper GI
endoscopy were normal too. Past history revealed she had a
feeling that she had a breast lump on investigation that was
normal as well, history of chest pain investigation ECG stress
test echo and Holter were all normal. Nardias MRI results are
all normal
Task
a. Talk to patient regarding her complaint (Mood is flat.
Dad and mom left job and looking after her. She is
eating well and putting on weight. Wont hurt herself.
Stays at home all day not interested to go out, no
friends or siblings. No hallucination or thought
insertion. Anxious and worried. Married before and
now divorced. Period regular, not sexually active (not
interested) Been like this for 6-7 years. No smoking
alcohol and drug.)
b. Diagnosis and counsel accordingly
Features:
- History of symptoms for which significant medical
treatments have been sought
- History of doctor shopping

- Appear before the age of 30
- Criteria: 4 pain symptoms, 2 GIT, 1 sexual, 1
pseudoneurologic symptom
History
- May I ask more about the pain? How bad is it? Does it
go anywhere? Has it changed over the past few
hours? Is it the first time for you to have neck pain?
- I understand from the notes that you have had
previous treatments for different symptoms like
headache, tummy pain, etc. any complaints now?
What treatments were given? Did it help? At the
moment, how is your mood? Are you enjoying daily
life activities? Are you socializing with family or
friends? Do you work? Are you able to concentrate
well on your work? Any difficulties in making
decisions? How is your appetite these days? Sleep?
Weight? Are you in a stable relationship at the
moment? Sexually active? Are you still interested in
sex?
- I need to ask you some strange questions. Do you
see/hear things that others dont? Do you think that
someone is trying to harm you at any way? Have you
ever thought about harming yourself or ending your
life? Have you thought of a plan? Have you bought
something to carry out that plan? Do you feel
excessively anxious about things? Do you feel SOB,
dizzy, or fainting at any time? Are you happy with your
life? Do you feel guilty about anything? Any bad
memories for you? Any childhood incidents that you
cant forget? Any repetitive thoughts? Any other
medical or surgical conditions that I should be aware
of? Have you ever been diagnosed with depression or
other psychological illnesses? FHx of psychiatric
illnesses? SADMA? How do you support yourself?
Financial issues for you?
Diagnosis and Management
- I understand that you have pain in the neck along with
stiffness. On the other hand, it seems like you are
unhappy and depressed. Im wondering if we can link
the two conditions. In my opinion, the mind and body
are connected deeply. Whenever there is stress upon
the mind, the body reacts by producing symptoms like
nausea, vomiting diarrhea before exams. Just like
that, you are having pain in your neck. This pain is
quite real; however, the CT scan shows that there is
nothing physically wrong with the structures in the
neck.
- We have a management plan which involves a
multidisciplinary approach. First, lets deal with your
pain. We can refer you to a pain management clinic
and give you a stronger medication.
- Sometimes, talking about the stress and emotional
conflicts within the mind can help to relieve these
symptoms. So I would recommend for you to see a
psychologist for a type of treatment we call as
cognitive behavioral therapy/talk therapy. They might
give you some medications like SSRIs or certain
anxiolytics.
- This problem in your neck can go away. I will see you
in two weeks to see how you are going. There are a
few things you can do to reduce your anxiety:
breathing slowly, hyperventilation will make symptoms
of panic attack worse, use relaxation technique,
exercise and swimming. Make a change in your life
style. Reduce caffeine intake and alcohol. Exercise
regularly.
- Refer to Anxiety recovery center Victoria or Metal
health organization of Australia
24
- I will give you some reading material about this
disorder medically named somatization disorder with
agoraphobia.
- Please understand that this treatment will take some
time to work. Meanwhile, you can take some OTC
painkillers to relieve the pain.
Hypochondriasis
Case: Suzanne aged 45 years presents to your surgery in a
busy afternoon. She tells you that she had right sided abdominal
pain for a few years and she bad been investigated in detail with
negative results. She describes pain is not present all the time
and she thinks she has colon cancer and maybe doctors are
unable to diagnose. On further questioning she denies weight
loss, change in bowel habits or any history of melena or
hematemesis. Her appetite is good and is well otherwise. She
requests you to do another ultrasound and colonoscopy.
Suzanne lives independently in a flat and had no known medical
or any surgical problems.
Task
a. How will you manage Suzannes request
Features
Somatoform disorder
- DSM IV Criteria
o Preoccupation with fears of having or the
idea that one has a serious disease based
on the persons misinterpretation of bodily
symptoms
o Preoccupation persists despite appropriate
medical evaluation and reassurance
o Belief (A) is not of delusional intensity and is
not restricted to a circumscribed concern
about appearance
o Preoccupation causes clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning
o Duration of disturbance is at least 6 months
o Not better accounted for by GAD, OCD,
Panic disorder, major depressive episode,
separation anxiety or another somatoform
disorder
History
- r/o organic disease
- risk assessment: mood, and suicidal ideation
Counseling and Management:
o Group psychotherapy and CBT
o Lifestyle modification
o Relaxation techniques
o SSRIs
PERSONALITY DISORDERS
Antisocial Personality Disorder
Case: You are an HMO in ED when a police brings a 27-year-
old Michael from a boarding house where he had been in a fight
with another resident which he seems to have started and he
dislocated her middle finger. The police want him to be
medically checked before they take him to the police station to
charge. Michael is well known to your hospital.

Task
a. Focused history (bored by what the resident was
watching on TV, he deserved to get punched
switched the channel and punched him, mood is okay,
frustrated, recently got out of prison)
b. Review the hospital record (involved in a lot of fights
at the age of 13, shoplifting, no medical illnesses,
substance abuse,
c. Diagnosis and Management to examiner
Features
- Behavioral problem associated with a lot of arrest,
physical assaults, inability to keep a job, impulsive
behaviors (gambling, promiscuity, alcohol, drugs)
- Impulsive, insensitive, selfish, callous, superficial
charm, lack of guilt, low frustration level, doesnt learn
from experience, relationship problems, reckless,
disregard for safety of self and other
History
- Confidentiality
- What actually happened? How did you break your
finger? Did you feel bad about punching him? Do you
pick up fights easily? Have you been imprisoned many
times? Do you have problems with the law? SADMA?
Have you ever been cruel to animals before?
- How is your mood? Suicide intentions? Psychotic
symptoms?
- Whom do you live with at home? Are there any
problems? Do you work? Any financial problems?
Hospital record from examiner
- Reason for admission
- Has he been referred to any psychiatrist (he doesnt
followup because he think hes not crazy)
- Was he given any treatment?
Differential Diagnosis and Management
- Substance abuse
- Antisocial personality disorder
- Intermittent explosive disorder
Management
- It can be very difficult to manage. Aim is to manage
impulsive behavior
- Group therapy is important
- Drugs: SSRIs, mood stabilizers, and beta-blockers
- As they grow older (>40), the condition gets better.
Histrionic Personality
Case: Your next patient in GP practice is a 25-year-old male
who tells you that his life is falling apart because his GF has let
him. He cant sleep and hes thinking of her all the time. Hes
missing her and requests for help. Patient is wearing fluorescent
green shirt, well-dressed.
Task
a. MSE
b. Present to examiner
c. Management
Features:
- Seductive and flirtatious
- Attention-seekers
MSE
- Appearance: dress and grooming (makeup), flirtatious,
anxious, restless, psychomotor retardation
- Speech: quality, volume, rate
- Mood: use patients words
25
- Affect: congruent/incongruent;
appropriate/inappropriate
- Thought form: flight of ideas, loose association,
derailment, tangentiality, circumtiality
- Thought content: delusion, suicidal/homicidal
ideations
- Perception: hallucination and illusions
- Cognition, insight and judgment
Present to Examiner
- We have a 25-year old male who is well-dressed and
wears a fluorescent green shirt. His behavior is
flirtatious. On examination, his speech is quality, rate
and volume of speech is within normal. He describes
his mood as sad and it is congruent with his mood. He
does not exhibit any abnormalities in thought form or
content. He denies any suicidal or homicidal ideations.
His insight is intact with regard to his problem but not
his personality. My provisional diagnosis is histrionic
personality disorder. I would like to refer him to
psychologist for CBT, counseling and support.
Differential diagnoses
- Histrionic
- Mania: extravagant, judgment impaired, insomnia;
- Drug-induced
MEDICATION, SIDE EFFECTS AND PROCEDURES
Side Effects of Antipsychotics
- Dopamine receptors - Amenorrhea Galactorrhea
Decreased libido, gynecomastia (Increased prolactin
- Histamine - sedation and weight gain
- Alpha Blockers - orthostatic hypotension
- Muscarinic Blockers - Atropine effect
- Diabetogenic - Olanzapine and clozapine
- EPSE - Dopamine goes down Ach goes up
o Acute dystonia- within days Tx: Benztropine
(anticholinergic)
o Parkinsonism
o Akathisia - generalized restlessness
(differentiate anxiety)
treatment: BZDs or Beta Blockers
and lower dose of antipsychotic
o Tardive Dyskinesia : chronic irreversible
involuntary movements; disappear when
patient sleeps
- 1st Generation have more EPS because they act
exclusively on Dopamine receptors but can also
happen for 2nd generation drugs.
- Clozapine : only antipsychotic drug that does not have
EPS and Endocrine SE's because it is not using
substantia nigra
o kept as last resort because of
Agranulocytosis
o Indications for use: 2 drug failure; if patient
develops TD
- Crossover for Antipsychotic drugs
- Washout period for Antidepressants to prevent
serotonin syndrome
Serotonin Syndrome
Case: Your next patient in GP practice is a 27-year-old male
who is being treated for depression. He has been given a trial of
medication without much improvement. He was started with
Sertraline (Zoloft) 100mg OD. He is undergoing CBT with
psychologist. His mood is the same with no improvement. He
comes complaining of inability to sleep, nausea, and diarrhea.

Task
a. History (changed medication to Zoloft from fluoxetine
because patient is not responding)
b. Examination (temperature 37.8, and pulse 90, BP
120/80, RR normal, BMI normal, sweaty and tremors)
c. Diagnosis and management
Features:
- Increased serotonin due to overstimulation of
serotonin receptors
- Most common cause is interaction between SSRIs
and MAO or inadequate washout period
- Related to combining antidepressants and other drugs
such as tramadol, ecstasy, tryptophan
- Others: carbamazepine, lithium, tramadol, St. Johns
wort, SSRIs, TCAs, venlafaxine, mirtazapine,
amantadine, bromocriptine, cabergoline, levodopa,
pergolide, selegiline, cocaine, MDMA, LSD,
dihydroergotamine, sumatriptan, bupoprion, pethidine,
reserpine
- Clinical features:
o Rapid onset of tachycardia, dilated pupil,
increased reflexes, tremors, fever, sweating,
shivering, diarrhea, hypervigilance,
agitation, irritability, hypertension, confusion,
and convulsion, coma
o Diagnosis is usually clinical
- Treatment: urgent referral
o Meds: methysergide and cyproheptadine
o Mirtazapine TCA quicker result
o Trazodone causes sedation insomnia
Do not change frequently due to
increased risk of resistant
depression
History
- I understand from the notes that you were diagnosed
with depression and given medications.
- Confidentiality statement.
- How long have you been having these recent
symptoms? Did it start suddenly or gradually? When
were you diagnosed with depression? Were you on
any medication before this? Do you know the reason
why it was changed? How many weeks did you wait
before starting the medication? Are you regularly
taking the medications? Have you tried to self manage
or double the medication or change doses than what
was prescribed. Are you taking any other medications,
herbal teas or other OTC drugs? Have you ever tried
using illicit drugs recently? Other symptoms?
Waterworks? Bowel?
- How is your mood now? Do you think that life is still
worth living? Have you thought of harming yourself or
anyone else? Are there any times when your mood
is very high? Any strange experiences?
- Whom do you live with? Are you living alone?
Physical examination
- General appearance; agitated and may appear sick
- Vital signs
- Eye: pupil eye and shape (mydriasis), PEARL
- CNS: gait, tremors, hyper-reflexia
Investigations: FBE, UEC, LFTs, TFTs, urine and drug screen
(with consent)
Management
- This is most likely serotonin syndrome which is due to
inadequate washout of the drugs leading to excessive
effect of the serotonin in your brain.
- Mild: stop medication and review in 24 hours and
reintroduce sertraline at a lower dose
26
- Moderate to severe: stop the drug, refer for admission;
cold IV infusion and blanket for fever. For agitation,
benzodiazepines; for rigidity (dantrolene);
methysergide or cyproheptadine. Once stabilized, we
can start the anti-depressants again.
Tremor (Side effect of risperidone Parkinsonism)
Case: A 32-year-old woman comes to your GP practice. She
has history of depression with psychotic features. She is on
risperidone and mirtazapine. She developed tremor three weeks
ago and she comes today for prescription renewal.
Task
a. History
b. Physical examination
c. Explain condition and Management
History
- I understand you have come to see me for
prescription renewal. Can you please tell me about
your tremor? Which parts of your body does it affect?
Does anything make it better or worse? How does it
affect your life? Does it interfere with your writing?
Have you noticed any changes in the way you walk?
Do you have muscle stiffness? Do you have trouble
initiating movements? How long have you been on
these medications? Any recent changes in the dose?
- Hows your appetite? Did you put on weight recently?
Do you have dry mouth, constipation, or trouble with
urination? Have you noticed milky discharge on your
breast and menstrual irregularities? Do you feel
sleepy? How is your mood? Sleep? How is your social
life? Do you think life is worth living? Suicidal
ideation? SAD?
- Who do you live with at home? Do you have enough
support?
Physical examination
- General appearance: lack of facial expression,
absence of blinking, flexed/stooped posture, drooling
of saliva
- Vital signs: especially BP (Postural drop)
- Assess gait: look at the way they stand (might have
trouble rising from the chair), shuffling/festinating gait,
lack of arm swing, ask patient to stop, turn, and walk
back
- Resting tremor (asymmetric; comment where
dominant); ask for some mental test to check for the
tremor; finger-nose test (intention tremor; resting
tremor improved); fine tremor (stretch arm in front);
- Tone
- Bradykinesia test: finger tapping test (playing piano);
twiddling test; ask patient to write name (check
micrographia); glabellar tap (normal blink <3; people
with Parkinson will blink always)
- Speech: tone and volume (monotonous and volume is
low)
- Check for weakness of upward gaze; eyebrows for
sweatiness and seborrhea
Diagnosis and Management
- According to history and PE, you have a condition
called parkinsonism. It is an adverse effect of
risperidone. It is more common in older generation
antipsychotic. Typically, it develops during the early
weeks of treatment. However, it could be seen in
newer generation antipsychotics as well. I will liaise
with your psychiatrist. Ideally, risperidone drug should
be reduced and switched to a different antipsychotic.
 27

To relieve your symptoms, I can prescribe anti- akithesia (restless: motor

cholinergic medications, benztropine. However, side
effects include blurred vision, dry mouth, constipation,
and urinary retention.
- It takes one to two weeks. Your current medication
dose will be reduced while a new medication is
introduced and gradually increased until dose is
therapeutic.
- Can it be done as outpatient? It could be done if you
have a good plan from psychiatrist, family meeting
and involvement. The family should know the
symptoms of relapse and we would organize
community psychiatric nurses.
Side Effects of Antipsychotics (Olanzapine/Fluphenazine)
Case: You are a GP and a 23-year-old female came to you for
consultation. She has been diagnosed with chronic
schizophrenia for some time. She has been on some meds that
has been changed recently. She complains of weight gain.
Current BMI is 30.
Task
a. History
b. Diagnosis
c. Management
Case 2: Kelly aged 25 years presents to your surgery with
concerns about her recent weight gain. She had chronic
schizophrenia which is managed by her psychiatrist. She had
been on fluphenazine for few years but recently was changed to
olanzapine due to some tremors in her arms. Since the change
in medication she had no relapse of schizophrenia and even
tremor had settled. She is compliant with her meds. Kelly lives
with her mom who has been very helpful to her during her
period of illness. She lost her job a few months ago due to mild
relapse of schizophrenia and has been unable to find a new job.
She receives disability support pension. She is a smoker since
age 17 but drinks alcohol on social occasions. Kelly had begun
a new relationship but is concerned about her weight gain as
her boyfriend seems unhappy and she fears losing her
boyfriend.
Task
a. Further focused history (shifted to fluphenazine due to
previous history of tremors with other drug)
b. Physical examination (BMI 37, no thyroid
enlargement)
c. Diagnosis and management advise
Differential Diagnosis
- Drug-induced
- DM
- Thyroid problems (hypothyroidism)
- r/o PCOS in females
Side effects of anti-psychotics
- Atypical: olanzapine (zyprexa), clozapine (clopine),
risperidone (risperdal), quetiapine (seroquel)
- Typical:
o Phenothiazides: chlorpromazine (largactil)
o Butyrophenones: haloperidol (serenace)
o Diphenylpiperidines (pimozide)
o Thioxanthines: flupenthixol (fluanzol)
o Trifluperazine (stelazine)
- MOA: block dopaminergic neurons with additional
effects of histamine, serotonin and acetylcholine
- Side effects:
o Extrapyramidal
dystonia (spasms: trismus,
torticollis, oculogyric crisis
within1st 24-48 hours of starting
medication), tx: benztropine
restlessness that occurs within
hours of starting treatment; may
subside spontaneously; tx: dose
reduction)
parksinsonism (tremors, rigidity,
bradykniesia); develops within
weeks to months; reversible; tx:
short-term use of benztropine;
tardive dyskinesia: sudden
involuntary movements of the
face, mouth and tongue;
irreversible; seen in chronic
schizophrenia who are on long-
term tx; can come even after
stopping the medication; tx: switch
to clozapine
neuroleptic malignant syndrome:
fever, muscle rigidity, autonomic
instability, more commonly seen in
young males; tx: stop medications;
supportive treatment; ICU;
respiratory support; volume
replacement; dantrolene
Fever >40
Encephalopathy
Vitals unstable
Elevated enzymes
Rigidity
o Sedation: both typical and atypical; usually
improves with time; take medications close
to bedtime; avoid driving and operating
heavy machineries
o Postural hypotension: more common with
risperidone and chlorpromazine; more
commonly seen in elderly people; tx: adjust
dosage
o Weight gain: olanzapine/clozapine; monitor
food intake; lifestyle changes; change
medication if still not managed
o Anti-cholinergic side effects: dry mouth,
blurred vision, headache, constipation,
urinary retention (improves with time);
o Endocrine side effects: hyperprolactinemia,
galactorrhea, diabetogenic
o Hematological: agranulocytosis (clozapine);
stop and change medication
o Sexual: retrograde ejaculation and
decreased libido; tx: does not improve with
time; change medication
History:
- Schizophrenia: past and current history
- Medications: previous and current medications
(olanzapine)
- Other side effects: EPS, sedation, etc
- General medical history
- PMHx, sexual history, SADMA
- HPI: can you tell me more about your problem? How
many kg have you gained over how many weeks?
Can you describe your typical daily diet? Do you do
any exercise at all? How much? How many days a
week? What is your occupation? I understand from
the notes that you have been diagnosed with
schizophrenia. Since how many years? Who
diagnosed it for you? What symptoms do you have?
What medications were you started on? Dose? How
long did you take those medications for? Any side
effects? Why was it changed? I understand you were
recently changed to olanzapine. What dose were you

taking? Was it regular? Did you have any other side
effects from this medication (abnormal movement
around the mouth or the body?noticed any shaking of
your hands? Restless? Sleepy more? Dizziness
especially on getting up in the morning? Any
complaints of dry mouth, headache, blurred vision?
How are your periods? Are they regular? LMP?
- May I ask how is your mood? Sleep? Appetite?
Energy level? Do you feel interested in daily life
activities? Have you ever thought of harming yourself
or others? I need to ask you some questions that
might sound strange or funny. Do you ever
see/hear/feel things or voices that other cant? Do you
think the TV/radio are talking to you or about you? Do
you think someone is spying on you? Do you think you
have special powers? Any past medical or surgical
history that I should be aware of? SADMA? Have you
ever had your blood sugar checked? Any family
history of psychiatric illness. Are you on a
relationship? What methods of contraceptive do you
use? What contraception do you use? Any chance
you might be pregnant at the moment?
Management
- I would like to organize some blood tests on the
patient. FBE with PBS, BSL, TFTs, LFTs, lipid profile,
serum prolactin, U/E/C, ECG, CXR
- Most probably what you have is a side effect of
olanzapine (zyprexa). All medicines have some side
effects but they are important to control your
symptoms of schizophrenia. At the moment, I need to
talk and liaise with the psychiatrist. They might decide
to change this medication but before that, I want you
to try some dietary and lifestyle changes. Please try
regular exercise 30 minutes a day for most of the
week, check your weight regularly, and choose a
healthy diet. The dietitian can help by making an
appropriate diet chart for you. This weight gain puts
you at a high risk to develop DM, HPN, and heart
disease, depression (obesity can cause non-
compliance of medications)
- You need to have regular followup with me and the
psychiatrist. If they decide to change the medication,
you will need to be admitted to the hospital during the
crossover period which usually takes around 2 weeks
(tapering previous medication slowly and introduce the
new one while observing for side effects).
- Diet and lifestyle should be done until she has seen
psychiatrist.
Postural Hypotension (Side Effect of Risperidone)
Case: You are an HMO and a 25-year-old male came in to the
ED due to dizziness since this morning. He has been diagnosed
with schizophrenia for the last 10 years and his symptoms are
usually controlled with medications. Recently, his wife noticed
that he had typical symptoms again, so she sent him to the GP
who changed his medications to risperidone.
Task
a. History (haloperidol x 10 years risperidone; can
talk to his dead brother recently; dizziness on standing
and sitting;
b. Physical examination (oriented to person, place and
time; no pallor, dehydration, jaundice, BP sitting
120/80 100/60, BMI N)
c. Diagnosis and Management
History
- Is my patient hemodynamically stable?
28
- Can you describe to me what exactly do you mean by
dizziness? In what position do you feel dizzy? Did you
lose consciousness at any time? Did you fall down
and hurt yourself?
- I understand you went to your GP recently. What
symptoms did you have at the time? Do you think you
can see or hear things that others dont? Do you think
the TV or radio is talking to you or about you? How is
your mood these days? Any ideas about harming
yourself?
- What medication was prescribed to you and in what
dose? Were you able to follow the instructions
properly? Who looks after your medications for you
(wife)? What dose did you take? Do you have the
prescription with you? Or do you have the bottle?
Which medication were you on previously? What was
the name? dose? Any side effects? At the moment do
you have any complaints of N/V/blurred vision/dry
mouth? Any abnormal movements around the mouth?
Do you feel restless all the time? Have you noticed
any tremors or shakes of your hands? When was your
last visit to the specialist psychiatrist? Any past
medical or surgical history? Any hospital admissions
previously? Have you ever suffered from high or low
BP before? SADMA (medication interaction: antifungal
and SSRIs inhibit liver breakdown of risperidone
increase blood levels)?
- Am I able to talk to the carer or the wife?
Physical examination
- General appearance: LOC (alert, confused, drowsy),
pallor, jaundice, dehydration; any visible abnormal
movement of the face or the body? Tremors?
- Vital signs
- Neck for LAD
- Chest/heart/abdomen
- BSL and Dipstick
Management
- You have a condition called postural hypotension.
This condition is characterized by a change of your
blood pressure while standing up from a sitting
position that gives you dizziness. There are two
possibilities: either you are having a side effect of
risperidone or a higher than normal dose has been
taken. The side effect is quite commonly seen within
the first week of treatment even at a normal dose
(usual starting dose: 1mg BD gradually increasing to
3mg BD).
- Is it the doctor who has done some mistake? Your
doctor has prescribed what is best for you. I would
prefer to take a look at the prescription and if possible,
I will talk with your wife who takes care of your
medication.
- What we need to do now is to keep you in the ED to
observe your BP and to do some blood tests (FBE,
Risperidone blood level). I will call in the psychiatric
team to review your condition. They might adjust the
dose of your current medication or they might decide
to switch to another one. If they decide to change,
then you will need to stay in the hospital for the
crossover period which takes around 2 weeks.
- Meanwhile, I would like you to be aware of general
rules to be followed when taking an antipsychotic
medications:
o Take medication exactly as prescribed
o Have a routine to take at the same time
everyday
o If you forget to take a dose, take it within the
next few hours. Otherwise, skip the dose.
Please do not double the dose.

o You need to continue taking the medications
even if you feel well
o Never stop the drug abruptly
o Inform your doctor if you develop any side
effects, other symptoms, and before taking
any other medications
o Half-minute rule (30sec): when you get up in
the morning, sit up slowly and stay for 30
seconds, put the legs over the side of the
bed for 30 seconds and slowly get up and
walk prevent any dizziness in the future
Counseling on ECT
Case: A 55-year-old lady has been admitted to the hospital for
severe depression with suicidal ideation. Her son has come to
your GP clinic to discuss about ECT as the psychiatrist has
recommended it as the best choice of therapy for his mom at
this stage.
Task
a. Discuss about ECT
b. Answer questions
- Painless
- Under GA and with muscle relaxants
- Indications
- Contraindication:
o Increased ICP
- Side effects:
o Anesthesia SE
o Muscle relaxant SE
o Memory loss and transient confusion
- Drug Interactions
o Non benzodiazepines for anxiety
zolpidem, zolpidone, zolfresh
o No antidepressants and antiepileptics
o Mood stabilizers may result to postictal
confusion but does not interfere with efficacy
- Consent:
o Normal MMSE
o Not under effect of drugs/alcohol
o Age
- Is the son permitted to discuss the condition of his
mother? I understand that you are here to discuss
about ECT: its indications, contraindications,
procedure, side-effects and post ECT management
- Any particular concern? Please dont hesitate to stop
me if you have questions.
- It is a medical procedure in which a series of low-
frequency electrical pulses are passed through the
brain to produce brief-controlled fits. It can provide
rapid and significant improvements in severe
symptoms of a number of mental health conditions
and doesnt cause any structural brain damage.
- Indications
o Psychogenic depression
o Melancholic depression unresponsive to
meds
o Psychosomatic depression (Life-threating
refusal to food or severe psychomotor
disturbance)
o Severe postpartum depression and
psychosis
o Catatonic schizophrenia
o Severe mania
o Pregnancy when medications cannot be
given as they can cause harm to fetus
o Elderly people who cannot tolerate drug side
effects
29
o When ECT has been successful in the past
o Last resort to treatment-resistant OCD,
Parkinson disease, tourette syndrome
- Contraindications: raised ICP is the absolute
contraindications.
- Some specialists believe that it is more effective than
drug therapy. It is amongst the least risky medical
procedure carried under GA.
- Extra caution is required in a number of clinical
situations according to the medical history of your
mother (recent MI, cardiac arrhythmia, pace makers,
hypertension, intracranial pathology, epilepsy,
osteoporosis, aneurysm, skull defect, retinal
detachment
- Pre-ECT evaluation:
o Full medical history, physical examination,
routine investigations including fundoscopy
will be done to make sure ECT is safe for
your mother.
o Anesthetic consultation for risk of
anesthesia
o Explain of procedure and informed consent
o Patient should be fasted for 6-8 hours
before the procedure
- The procedure is carried out under the supervision of
a consultant psychiatrist and anesthetist. Patient is
given general anesthesia and muscle relaxant to keep
her relaxed and unaware of seizures. Small devices
called electrodes will be placed on specific locations of
her head to give a series of brief electrical pulses.
Patients vital signs are continuously monitored and it
takes about 10-15 minutes for the procedure to
complete and patient is taken to recovery area for
post-anesthetic care.
- Duration of treatment: typically3x/week for 6-9
treatments depending on the patients condition and
response to treatment. It can be performed as an OP
procedure or when the patient is hospitalized. The
symptoms start improving after 2-3 treatments.
- Side effects:
o Immediate: Headache, muscle pain, nausea
and drowsiness are benign and should
respond to symptomatic treatment
o Post-ECT delirium needs close supervision
and supportive treatment and IV
psychotropics if required.
o Memory impairment that usually resolves by
4-6 weeks following treatment
- Maintenance treatment: ongoing treatment will be
required to prevent a recurrence in the form of ECT,
antidepressants, psychotropics, CBT or
psychotherapy.
CHILD AND ADOLESCENT BEHAVIORAL DISORDERS
Autism
Case 1: You are GP and your next patient is a 3-1/2 year old girl
with her mother who comes to you because she is concerned
about her destructive behavior. She has been contacted by
childcare who says she is different from other kids. A hearing
test has already been done.
Task
a. History play for hours, specific game, likes TV
cartoon, energetic; doesnt want to sleep; looks fine;
talked late; lack interaction to other kids; not hearing
mom; lacks social input
b. Explain diagnosis
c. Counsel accordingly

Case 2: You are a GP, a 5-years-old girl was brought to you by
mom because childcare complained that she has destructive
behavior and claims she is different from other kids. She has a
6-year-old brother with whom she does not interact well. Her
speech was delayed by 1 year. Her hearing and vision tests are
normal. She has been to the specialist who diagnosed her with
autism. The mom is not clear about the diagnosis.
Task
a. Explain the diagnosis to the mom
b. Counsel accordingly
History
- Please explain what you mean when you say that
shes different from other kids. Is she aggressive?
How is her interaction with the other kids and with the
childcare workers? Does she exhibit any repetitive
behavior? Does she become upset when her routine
is changed? Do you think she is particularly attached
to a certain toy/object? Does she prefer to play alone?
Is she able to initiate play with other kids? How does
she respond when you or someone else call her? Any
repetitive use of a word or sentence? Is she able to
maintain eye contact? How many friends does she
have? Does she respond appropriately to changes in
your mood?
- BINDS: Please tell me more about your pregnancy?
Any complications? Mode of delivery? Any problems
like breathing? Did she require resuscitation? Can you
tell me when she started to speak? When did she start
babbling (6-8 mos)? Proper words (10-12mos)? Can
you tell me how much she can speak now
(words/sentences)? Developmental milestones: walk,
eat, drink independently? Does she smile socially?
Immunization? Any other medical or surgical
conditions?
- Any family history of mental retardation? Autism? Or
other developmental disorders?
Differential Diagnosis:
- ADHD
Diagnosis
- Most likely, your child has some kind of a behavioral
disorder. The most common one to present this way is
called autistic spectrum disorder.
- It is characterized by:
o impaired social interaction
o speech and language problems
o abnormal repetitive behavior
- It is important to confirm this diagnosis preferably by a
specialist. Unfortunately, it is a lifelong condition that
cannot be cured, but it can be very well controlled with
appropriate interventions. I will refer you to the speech
pathologist once the diagnosis is confirmed. Autism is
associated with a high risk of epilepsy and OCD so
there is a possibility she might develop fits or seizures
later on. There is no medical treatment but regular
checkups are important because these kids never
complain. You will have all the support from me as
your GP, pediatrician, child psychologist, speech
pathologist, centrelink, and Autism Association of
Australia. Please come back once the diagnosis is
confirmed and we can talk about it in more detail.
- Case 2: I can see from the notes that your child has
been diagnosed with a developmental disorder called
autism. It is a lifelong condition where the childs skills
of social interaction and communication are affected.
She will show repetitive behavior. She might have
speech problems. I understand that it might be
shocking and distressing for you to hear all this, but
30
please understand that there is a lot we can do to help
her. The actual cause of autism is not known, but
there is a genetic tendency. It is associated later on in
life with epilepsy, OCD, sometimes intellectual
disability and Tourette syndrome. This condition is
more common in males. Around 1:1000 australians
suffer from autistic spectrum disorder (autistic
disorder, high-functioning autism, asperger syndrome,
pervasive developmental disorder). Autism is very
difficult to diagnose under the age of 3. If any
suspicion is raised, it is important to establish the
diagnosis to help with treatment. The earlier the
treatment is started, the better is the outcome. I want
you to be aware that your daughter might exhibit
temper tantrums or obsessions. She will be resistant
to a change of daily rituals. She might be sensitive to
some colors, textures or smell. Otherwise, physically,
she will be a healthy and well-developed child. We do
not expect for her to have the same emotions and
moods as everyone else. In a multidisciplinary team
approach, we will start an interventional program
which includes a. behavior modification therapy, b.
speech therapy, c. education, sensory and motor
program, d. regular medical checkups e. regular
hearing and vision checks. You and your family need
to be involved throughout the program. Most of her
behavioral problems can be improved with this
program and 5% of these kids go on to live an
independent life. However, the majority will require
life-long support.
- No special school except for asperger (do not want to
stigmatize patient)
Behavioral Problem (ADHD)
Case: You are a GP and a 6-year-old boy was brought to you
by his mom because she says the child is very active and the
teacher has complained that the child is loud and disruptive in
class. He is in grade 2.
Task
a. Focused history
b. Diagnosis and management
Differential Diagnosis for Hyperactivity
- ADHD
- Asperger Syndrome
- Oppositional defiant disorder
- Visual and hearing problems
- Trauma (head injury)
- Developmental problems
- Previous infections (meningitis,
- Home/school problems
- Physical or congenital lesions
History
- Can you tell me more about the problem? What do
you mean when you say that he is disruptive and loud
at school? Is he aggressive towards his classmate? Is
it difficult for him to wait in lines? Is he pushing around
other kids? How is his academic performance?
- Please tell me more about his behavior at home. Do
you think that he is able to concentrate on a given task
for at least a few minutes? Does he pay attention to
what goes around? Does he pay attention to
commands? Does he talk rapidly without finishing
sentences? Do you think he is able to finish a task
given to him? How long can he play with a particular
new toy? Do you think hes impulsive? How many
hours does he sleep at night?

- How is his relationship with you or with his family?
How is your home situation? Any recent changes at
home? Who takes care of him most of the time? Does
he go to child care? How is your relationship with your
partner and other kids? Any new relationship for you?
How many kids do you have apart from this one?
Hows the behavior of the other kids? How is the
relationship between them? Any family history of
similar problems? Do you think he was diagnosed with
a medical condition? How is he doing now?
- How was your pregnancy with this child? Any
problems with delivery? Any history of head trauma or
brain infections or any other illnesses? Has he ever
had a formal hearing or visual test done? How is his
immunization? Are you happy with his growth and
development at this time? Are you happy with his diet
or nutrition?
Management
- Most likely, because of your concern and because of
the teachers complaint, I do suspect that your childs
behavior is different from others. I still need to have
his vision and hearing checked by a specialist. Before
labeling a child as having a behavioral problem, it is
important to obtain assessment reports from school as
well as from the family. This is called psychosomatic
testing best done by the specialist child psychologist.
- The most common behavioral problem in this age
group is called ADHD (attention deficit hyperactivity
disorder). It is a developmental disorder that results in
poor concentration and lack of impulse control. Please
understand it is not a physical illness, but it can affect
the childs learning and social skills. Usually, there are
associated problems with family function.
- Once the diagnosis is confirmed, we will start
treatment that includes behavioral modification that is
done by the psychologist. There are classroom
strategies to help with his learning and concentration
span. There are special teachers who are qualified to
run these programs. Family counseling is also
required. The fourth aspect is medications. These
medications are usually prescribed by the pediatrician
only and are basically stimulants (methylphenidate
ritalin, dexamphetamine or atomexetine). The
single most effective treatment for ADHD is
methylphenidate. They stimulate areas of the brain for
impulse and concentration. Side effects are reduced
appetite and growth problems.
Oppositional Defiant Disorder
Case: A mother brought his 8-year-old son with problems in
behavior.
Task
a. History for 8 minutes (problem with School
performance, argumentative, disobedient, picks up
fight with other kids and has problems getting along
with them, doesn't listen to teacher's commands and
does what he wants to do; has a sister who is fine;
fights with sister; no bullying in school noted; full-term
planned pregnancy; no complications; immunization
up to date; separated from husband 4 years ago but
dad visits regularly and has good relationship with
dad)
b. Most likely diagnosis
DSM IV Criteria
- Repetitive persistent pattern of opposition,
disobedience, and disruptive behavior towards
authority figures persisting for at least 6 months.
31
- These kids might later on develop conduct disorder.
The usual age is preschool.
- Criteria
o Persistence of stubbornness
o Refusing to comply with instructions
o Unwilling to compromise
o Deliberately testing the limits
o Failure to accept responsibility
o Blaming others for their own wrongdoings
o Deliberately annoys mothers
o Frequently losing temper
- Management:
o Improved parenting skills (conflict resolution,
communication and problem solving with the
child)
o Anger management skills for the child
o Family counseling
o Classroom strategies (social skills
development sessions)
- Appear well in front of other people such as doctors
except people they know well and whom they consider
as authorities
Differential diagnosis
- Oppositional defiant disorder - argumentative,
stubborn, picks up a fight
- ADHD
- Conduct disorder - extreme; gets into physical fights,
theft/fire, cruel to animals and people, no remorse; no
relationship
Features:
- Easily lose temper
- Refuse to follow rules
- Deliberately annoy others
- Blame others for their own mistakes
- Can be verbally hostile but not physically
- Acts are usually directed to those who are well known
to them
- Parents are facing numerous arguments
VS Conduct disorder
- Aggressive
- Involve in bullying, fighting, theft, fire-setting,
- Do not follow rules
- Property destruction
- Antisocial
- Can be cruel to animals
- Don't have any remorse
- Refer to adolescent mental health service
Management: Behavior modification and family assistance
History
- Can you tell me a bit more about it? (I'm concerned
about his behavior. He is argumentative and stubborn
and is getting more difficult for me to handle him). For
how long has he been having this problem? it's been
an ongoing problem since he's very young but
increasing with age). Does he lose temper very
quickly? Yes he gets annoyed with his siblings while
playing with them. Does he listen to what you say to
him? No. He is disobedient and when I ask him to do
something he gets angry and does not do his work.
Does he have any other siblings? Any problem with
them? No. He has 2 other siblings without problems.
Des he go to school? Did you talk to his teacher about
it? Teacher has similar complaints. He doesn't listen
to teachers and difficult to settle him down. Does he
have friends in school? He has but he doesn't
have good relations with them. How is his

performance at school? His p is affected though he
enjoys going to school. Is he a hyperactive and
restless child? No. Is he able to concentrate on what
he is doing? Yes. Is he Impulsive and often acts
without thinking? No. Has he ever been very
aggressive and destructive in behavior? No. How is all
this affecting your life? I am very tired and concerned
about this situation and need your help.
- How is his general health? Any problem with his vision
and hearing? Any learning difficulties or mental
slowness? Any other developmental problems or
disabilities?
How is the situation at home? Any financial issues?
Are you able to take care of your children? Yes.
BINDS? Did you have any problems with his delivery?
Did you notice active movements when he was in your
womb? is his immunization up to date? Any previous
hospitalization for a serious condition? Medication?
Allergies? FHx of behavioral problems? Do you have
any idea of his father's childhood behavior.
Diagnosis and management
- From history he has a condition called ODB. I need to
assess the child's behavior and will arrange referral
for full assessment by a pediatrician and psychologist
to confirm the diagnosis and rule out other behavioral
disorders.
- Advice: Notice and reward the acceptable behavior by
praising him. Ignore minor irritating behaviors. You
can withdraw privileges like watching TV or playing
video games after the behavior occurs for about 1-2
days without compromise. Smacking should be
discouraged.
Slow School Progress
Case: You are a GP and an 8-year-old boy was brought by
mother because of slow progress at school recently.
Task
a. History
b. Manage the case
Differential Diagnosis
- School Bullying
- ADHD
- Absence seizure
- Hearing and Vision problems
- Child abuse
- Psychosocial factors
History
- When did it start? Any change in his behavior at
home? Is he very noisy or disruptive? Does he disturb
you quite a lot while youre talking on the phone or
doing something else? Is it very hard to keep him
attentive? Does he sit and watch movies or play
games at home? Did you talk to the teacher about
similar behavior in school? Any rigid routines or
repetitive behavior? Any funny faces or hand
movement or jerking? Are there times when you
realize that he is not responding to you? Is he happy
to go to school? Does he have a lot of friends? Did he
ever talk about being bullied in school? Any concerns
about hearing and vision? Did you get his hearing and
vision checked? Any concerns about his growth and
development? Immunization? Any problems at home?
Financial? Are you a happy family? How is his
relationship with you or his father? Are there any
stresses in the family? SADMA (parents)
32
Diagnosis and Management
- You have made a very good decision to come here
and discuss about your son. It is important to find out
the cause that is affecting your childs performance.
- Confidentiality statement. I am here to help you.
- The reason why your sons school performance has
deteriorated could be due to stress at home, school
bullying, organic reasons, hearing or vision problems
or developmental problems. In your case, most likely it
is because of the family situation. I would like to
organize a family meeting. If there are any marriage
problems, I can refer you to the marriage counselor. If
there are any financial problems I can arrange with
centerlink or if you need any other support, I can
organize a social worker.
- I would like to arrange a meeting with the child if it is
possible.
- I would refer you to the specialist pediatrician for
formal hearing and vision assessment.
Slow School Performance/Homosexuality/Adolescent
Counseling
Case: You are a GP and a mother brings her 15-year-old son
claiming that her sons school performance from bad to worse
for the past 6 months.
Task
a. Counsel the mom
- I understand you have come to see me because you
are concerned about Johnnys school performance.
How is everything at home? Any recent financial or
emotional problem? Is Johnny your only child? How is
the relationship between siblings? Has he changed
school recently? When did you talk with his teacher
last time?
- If you dont mind, I would like to talk to Johnny
separately. He is nearly an adult and it will be a good
opportunity for him to learn how to explain his
problem.
- First of all Johnny, our discussion is private and
confidential unless yours or other lives are at risk. In
case I need to report to the authority I will only divulge
relevant information but not all consultation details.
- Johnny why do you think your school performance
getting worse? Have you been subjected to any
bullying? Is there something on your mind that worries
you (I like another boy in my class)? Do you feel
sexually attracted to him (Yes)? Does he know about
it (No)? How does this situation make you feel (I am
lost. Am I gay, etc)? Johnny, lots of young people
like people of the same sex. Studies have shown that
between 8 and 11% of young people in Australia
experience same sex attraction. Sexual and romantic
relationships between people of same sex have been
found in every known culture and society. You are
going through a phase where youre trying to work out
your social identity. It doesnt necessarily mean that
you are gay because people often experiment with
their sexuality; but remember, being gay is a natural
and normal sexual identity. There is nothing wrong or
abnormal about it.
- I just need to ask you a few questions. Hows your
mood? Sleep? Appetite? Do you enjoy things which
you used to like? Do you socialize? Do you have
hobbies/interest? Do you have a good friend? Did you
talk to anyone else about it? SADMA? Are you close
to your parents? Have you ever discussed sexuality
problems with them? Are you going to tell my mom?

No, but remember, your parents love you and worry
about you. Eventually, you should tell them or at least
explain that you are going through a difficult stage.
They are here to support you.
- I want to refer you to Family Planning Victoria. They
are specialized in sexuality and reproductive health.
There is a lot of help and support for you.
- I would also like to see you in a weeks time.
- Doctor whats wrong with Johnny? Johnny is going
through a difficult stage. There are physical and
mental changes in adolescence which often create
inner conflict which we will try to help Johnny to solve.
I will see him in a week time.
RISK ASSESSMENT
Suicidal Attempt
Case: Your next patient in ED is a 45-year-old man who was
involved in a high speed single car crash earlier today. Other
drivers reported that he was speeding along the highway and hit
a tree. Air ambulance was deployed and he sustained minor
injuries with Colles fracture. He was brought by ambulance and
was assessed by the trauma team. His injuries have been taken
cared of and they have put a plaster for the fracture. Now the
resident is handing this patient over to you for final checkup
before discharge.
Task
a. History (intended to kill herself; divorced 6 months
back and lost her job; worked as an accountant
before; had repeated attempts; overdosed before;
generally a sad person)
b. Talk to patient and management
Highlights:
- CONFIDENTIALITY
- What was the patients INTENTION? Did you intend to
kill yourself or was it to do self-harm?
- Have you had any previous attempts at self-harm?
- Have you ever been diagnosed with any mental
illness?
- Have you seen any psychiatric services before?
- Did you regret doing it? (If intention was suicidal)
- Past, present and future!
Risk Assessment (Borderline Personality Disorder)
Case: You are an HMO in the ED and your next patient is a24-
year-old lady who has a history of repeated self-harm. She has
been diagnosed with borderline personality disorder. She cut
her thigh this time. She was found intoxicated and was brought
to the hospital. Now she is okay. The wound has been taken
cared of and she wants to go home.
Task
a. Risk assessment
b. See if shes ready to go home
Case 2: A 16-year-old girl was at a party and had
benzodiazepine overdose yesterday after having a fight with her
boyfriend. She lost consciousness and was brought to you by
her friends. Now, she is ready to be discharged and your task is
to do the risk assessment.
(on history she takes tablets from mom to be able to sleep in
this case advise on sleep hygiene!!!!).
Case 3: You are an HMO in the ED and a 22-year-old female
has been admitted with a number of wounds in her arms and
legs. Most of them were superficial cuts. She has been treated
by the registrar. The wounds have been sutured and she wants
to go home.
33
Risk Assessment
- Static Factors
o Age (elderly or very young age groups)
o Past history of suicide
o Past history of any medical illness including
depression and psychosis
o Child abuse
- Changing Factors/Circumstances
o Patient living alone
o Stressor (uni, work, family)
o Relationship
o Access to means
o Drugs/intoxication disinhibited and leads
to patient being impulsive
- Ask about the INTENTION while patient was cutting
herself. Was it to commit suicide or to get physical
pain?
- When to admit
o Suicidal ideation
o Psychiatric diagnosis (depression or
psychotic)
Management
- Ensure confidentiality
- Appreciate that the patient is in stress
- I understand that you are going through a tough
phase, can you please talk more about it. I know I am
sorry to hear that. Sometimes, we are very frustrated
and some people do make us sad, but did you have
any intention to kill yourself by cutting your thigh (no
doctor, it just makes me feel better)? Have you done
this before? Have you ever thought of harming your
boyfriend or any body else?
- How is your mood? Do you feel sad? Do you think you
have lost interest in things that you used to enjoy
before? Any sleep problems? Change in appetite or
weight? Do you think life is worth living? Have you had
problems with your relationship in the past as well?
Are there any times when your mood is really high?
- Ill ask some questions which might seem funny but do
you feel/see/hear things that others do not? Do you
have any strange experiences?
- Do you think Im crazy? Sorry, I didnt mean that, but
these are routine questions for all patients who are in
your situation.
- Whom do you live with? Do you get along with them?
No issues? How about your parents? Do you have
friends? Do you socialize with them? Do you work or
are you a student? Any problems at work or at the
uni? Is there anything else that is bothering you
(financial, relationship, etc)?
- SADMA?
- Ask about insight, cognition and judgment.
o Do you think there is something wrong? Do
you think you need professional help?
o Fire/envelope question
o Do you know where you are, date, and time.
- PMHx: thyroid diseases?
- Just let me go home! I know that you are really
stressed. I am here to help you, so please just bear
with me and help me so I can help you.
- You can go home Mary. How would you go home?
When you go home, what will you do? What are your
plans tomorrow? I would recommend you to call your
family or friend to come and pick you up. I would not
recommend that you drive now. I am really concerned
with the way you are coping up with stress, so I will
refer you to the psychiatrist and psychologist. They
will do talk therapy and will teach you techniques on
how to handle stress without harming yourself.
- About alcohol we need to discuss about the safe
level of drinking.

- If you agree to it, I would be happy to arrange a talk
with your friends or family. There is also a 24/7 hotline
number 1800187263 (1-800-18-SANE). Anytime you
feel stressed, you can give them a call and you can
talk to them.
- If you have financial problems centerlink
- Organize social worker if you need support
Benzodiazepine Overdose
Case: You are an HMO in ED and a 16-year-old girl comes who
overdosed with mothers benzodiazepine tablets. Her mother
found her and brought her to you. She has been resuscitated
and now is stable. Her mother is waiting outside.
Task
a. Talk to the patient (started when parents got divorced;
had difficulty sleeping for a few months, did not have
intention to kill herself; school performance or grade;
mood is okay, I dont need help, why would I need
help. Doesnt think the TV is talking about her;
b. Decide on further management
Risk Assessment
- Dynamic:
o Patient: mental state, diagnosed mental
illness (depression, psychosis, mania),
intention/remorse,
o Context/circumstance: access to
means/weapons, accommodation, family
support and friends, stressors (financial,
personal)
- Static:
o Time: history (have you done it before), Hx
of mental illness, developmetal history (child
abuse, conduct disorder, personality
disorder)
o Place: culture
Counseling
- I understand you took some of your moms tablets,
how are you feeling now? Are you feeling better?
- I am sorry to hear that.
- Confidentiality
- Was it accidental or did you take it with intention? Did
you have any intention to harm or kill yourself? How is
your mood? Do you still find things pleasurable? Do
you go out with your friends? How are things with
school or uni? How is your school performance? I
understand you have sleep problems. Is it difficulty
getting to sleep or waking up in the morning? Hows
your appetite? Any changes in your weight? Do you
think? What do you think about life? Do you think it is
worth living? Have you ever thought of harming or
killing yourself? Are there any times when your mood
is very high? Whom do you live with at home? Do you
have enough family support? Are you a happy family?
Have you tried reaching out to your mom? If youre
happy I can arrange for a family meeting. Any other
stressors like financial or school/work?
- How is your general health? Do you have any weather
preference?
- Do you hear/see things that others do not? Do you
have any strange experiences? SADMA?
Management
- At this stage, Im glad you dont have intentions to
harm yourself, but you are upset because of your
parents divorce. If you like, I am happy to arrange a
family meeting and talk about things. I would like to
34
refer you to a counselor or psychologist with whom
you can talk about things and teach you how to handle
stresses of your life. I would also like to refer you to a
psychiatrist for formal assessment.
- At this stage, you can go home but I would like to give
you advice on sleep hygiene:
o Have a regular pattern of sleep
o Dont have coffee, tea, or heavy meals
o Hot shower or milk
o Dont watch TV before going to bed
o Bed should be used for 2 purposes: sleep
and sex
- If you are stressed or upset, then talking with a
counselor might help
- Regarding your alcohol, please book an appointment
with your GP so he can advise you on the safe level of
drinking
- Social support.
ABUSE AND VIOLENCE
Child (Sexual) abuse
You are a GP and a 4-year-old girl was brought in by mom who
says she has a rash in the genital area. Her mom is divorced
and mom lives with a new boyfriend for the last 5 months. The
girl usually spends weekends with her dad. This weekend, she
has refused to go to dad.
Task
a. Counsel the mom
History
- I have been told you are worried that your daughter
has a rash in the genital area. I need to ask you a few
more questions if its alright with you.
- Mention confidentiality
- Can you please tell me more about what happened?
When did you notice the rash? Is it getting worse? Did
your child tell you what happened? Why do you think
she refuses to go to her dad? Have you noticed any
behavior that is different than usual in your child (e.g.
nightmares, irritability, refusing to eat or drink, refusing
to talk to you)? Have you noticed her in an abnormal
position (like knee chest position)? Do you think she is
enjoying the usual activities or is she withdrawn?
- Waterworks? Does she cry when she passes urine?
Bowel habits? Allergies? Itching down below?
Bleeding? Discharge? Any possibility of trauma or
foreign body? Is this the first time to have this rash?
- I need to ask you some questions regarding your
home situation that will help me to better understand
your childs condition. How is your relationship with
your ex-husband and with your new partner? Any
stress? Any violence at home? How often does she
spend time with your boyfriend? Did you call your ex-
husband to ask him what happened? Do you know
about his family situation now? Are you aware if he
smokes, drinks, or uses recreational drugs? Do you or
your partner smoke, drink or recreational drugs?
Differential diagnosis
- Child abuse
- Foreign body
- Allergy
- Trauma
- Vulvovaginitis

Management
- At the moment, I do have a few differentials in mind
like vulvovaginitis which is an infection of the genital
area, or skin allergies, but because you are worried
about possible abuse, it makes me concerned as well.
I will notify the child protection authority as well as
VFPMS (Victorian Forensic Pediatric Medical
Services) or pediatric department of the local hospital.
- It is better for them to come and talk to your child as
they have a special way of doing it. If required, they
will do a genital examination preferable by an
experienced pediatrician. They might take necessary
swabs and samples. Please dont talk to your child
about any of this (mental trauma/might influence the
child). It is a long process to find out what happened.
You and your daughter will have all the help and
support throughout the way.
- They might admit the child to the hospital for
investigations as well as possible treatment of the
rash. She will be seen by a child psychologist as well
as the social worker. We will involve the police if
required, but the Child Protection Authorities will be
the first one to be notified.
Guidelines (VFPMS AKA Gatehouse Centre):
- All suspected cases of child sexual abuse must be
referred in the first instance.
- The genital examination must be limited to
INSPECTION only to check the amount of bleeding,
the extent of the rash or any discharge only with the
cooperation of the child. Complete examination will
only be done by a trained consultant. GPs task is to:
a. control bleeding, b. collect any evidence on the
child including clothing, hairs, c. make the child as
comfortable as possible, d. provide emotional support
for the family, e. photographs if required
- Call anytime: 24 hours a day
Child Abuse
Case: You are the HMO in the ED. Your next patient is a 24-
year-old mother with her 4 month old baby boy John. She
complains that her child is crying non-stop. You notice some
bruise marks on the babys body which she claims occurred
when Johnny rolled off the change table while getting his nappy
changed while under her boyfriends care.
Task:
a. Further detailed history
b. Examination findings
c. Further management
Case 2: A 23-year-old female presents to the ED with her 6
months old baby boy. The child has a bruise on the left cheek
and has been crying for a very long time. The mom thinks he
may be suffering from a bleeding disorder. She is worried.
Task
a. Further history (child fell from changing table,
unemployed, unplanned pregnancy, recently worked
part-time, smoker, lost all family support financial
crisis)
b. Physical examination findings (femoral fracture)
c. Management
Case 3: A 19-year-old mother brings her 6 months old daughter
to your GP. She is complaining that her daughter cries a lot. She
was born at 26 weeks of gestation. Her BW was 970 grams.
She stayed in the hospital for about 3 months. It was an
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unplanned pregnancy. The father left before she was born. Now,
they live with her new boyfriend who is unemployed. The mom
works part time and the boyfriend looks after the child. You
examined the child and found a bruise on her left cheek, a
painful swelling of her right upper arm. An xray was done that
shows a spiral fracture of the right humerus.
Task
a. Explain diagnosis to mom
b. Discuss appropriate management
Problem list:
a. Identify child abuse. Exclude organic causes.
b. Assure confidentiality
c. Assessing the psychosocial status
d. Delicate, empathetic explanation of the situation.
Convince her for hospital admission
Differential diagnosis:
- ITP
- Pancytopenia
- Leukemia
- Bleeding disorders
History
- Please tell me more about the bruise? When did you
notice it? Is it the first time you noticed the bruise?
Any other marks anywhere in the body? How do you
think this happened? Do you think the baby has been
crying since then? Does he have any fever, cough, or
noisy bruising? Do you think hes feeding well? Is he
breastfed or bottlefed? Any bleeding from anywhere in
the body? Any change in his bowel habits? Any
change in the number of wet nappies? Has he been
putting on weight since birth? Is there a family history
of bleeding problems? Is this your first child? Any
pregnancies or miscarriages before? Was this a
planned pregnancy? How was the delivery? Normal or
cesarean? Was it a full term or premature delivery?
Any problems or complications after birth? Are you
satisfied with his growth and development? At the
moment, is your child able to sit with support? Does
he smile when he sees you? How is his
immunization? May I ask how, is the home situation?
Are you in a stable relationship? Any conflicts at
home? Do you work? Does your partner work? Any
financial problems? When you go for work, who takes
care of the child? Does he go to childcare? Do you or
your partner smoke, drink alcohol, or use any
recreational drugs? Do you have any support from
your family, parents or friends?
Physical Examination
- General appearance: conscious, active, alert, or
irritable, crying, drowsy?
- Growth chart for height, weight, and head
circumference
- Vital signs
- Skin of the whole body for any bruises, fingermarks,
areas of burns or scalds, cigarette burns
- Anterior and posterior fontanelle for any bulging
(shaken baby syndrome rupture of cranial arteries)
- Eyes: conjunctival hemorrhages
- Mouth: rupture of frenulum (forceful feeding)
- Lymph nodes
- Chest and heart
- Palpate all ribs for possible fracture
- Palpate all bones of upper and lower for swelling,
tenderness, deformity

Investigations
- FBE, coagulation profile, complete skeletal xray or
bone scan (provide information regarding new and old
fractures); CT scan of the head and USD of abdomen
and pelvis
Management
- After doing thorough examination on your child, it
seems like the nature of his injuries does not correlate
with the mechanism of injury. We call this non-
accidental injury. It is better if we admit your child to
the hospital where he will be seen by a specialist
pediatrician. We need to do some tests to rule out a
bleeding disorder and any other injuries to the rest of
his body. I want you to understand that this might be a
grave situation for your child. He needs urgent
medical treatment.
- I understand that it might be hard for you to take care
of this child especially because you are young,
working and studying. Our job is to help you out as
much as possible by providing you with appropriate
referrals and resources. I need to inform the Child
Protection Authorities (or VFPMS), but I want your
cooperation to ensure your childs safety and
wellbeing. We will not take away the child from you.
The CPS will interview you and your partner and
provide the necessary support system for you and
your child.
Dr. Wenzel
- ADMIT
- Report to Child protection authority
- Maintain empathetic approach to parent
- Explain further investigation will be conduct
- Explain support
- Possible photography for evidence
Domestic Violence
Case: Your next patient in GP practice is a 24-year-old Fiona.
She has visited you 4x for the last 6 months. The first she came
to you with 5% burns on left hands. The second time she had
some injury on the right hand and the other 2 consultations, she
complained of tiredness for which she was thoroughly
investigated and everything was normal. Today, she is visiting
you with a complaint of injury on her forehead.
Task
a. History (I was running after the kid and hit my head
on the door, he is very short-tempered and has lost
his job because of it; and when he comes home he
starts throwing things and pan hit me especially when
he drinks; at least 2x a week, beating started after
birth of the 3rd child when they had experienced
financial problems; no support; have trouble with
sleep)
b. Physical examination(distressed lady; 2x2 cm
laceration on the forehead with erythema and
swelling; tender)
c. Diagnosis and management
HELP Mnemonic
- Hear establish pattern and onset; how bad
violence is
- Esteem
- Life situation
- Praise
History
- I understand that youre getting injured quite often and
now you have an injury on your forehead. How did it
happen?
36
- Confidentiality. I understand that its your personal
matter but let me reassure you that
- Are you in a stable relationship? Do you have a
partner? How is your relationship with your partner?
Sometimes, partners react strongly in arguments or
may use physical force. Is this happening to you by
any chance? Have you ever been scared about your
partner? Dont worry were here to help you. You need
not be afraid.
- How often does this happen? When did it all start? do
you have enough support from family or friends? Do
you have other injuries apart from the one in your
head? How is your mood? Do you still find things
pleasurable? Sleep? Appetite? Weight? Do you think
life is still worth living? What is your perspective
towards life and towards what is happening to you?
Have you ever thought of harming or killing yourself?
SADMA? Do you have any strange experiences?
- Hows your general health?
Physical Examination
- General appearance
- Vital signs
- Are there any other scars or bruises. With the patients
consent I would like to take some pictures for record
purposes
- Chest, heart, and CNS
Management
- From the history, I am really sorry to hear whats
happening between you and your husband but I really
praise your efforts. You are a very brave woman. This
is known as domestic violence and it is not
acceptable. In my opinion, I believe you are not safe
with the situation and in your house. There are a lot of
organizations and support groups to get a safe place.
They will help you financially as well and offer you
shelter and a place to live.
- I will also organize a social worker. I would like you to
see a counselor to talk about what happened.
- I would recommend for you to stay in a separate room
and dont hesitate to call police if at any time you feel
its getting very serious.
- I would also like to see and examine your babies as
contact the Child Protection Services to assess your
situation. I would give you the numbers of the
domestic violence support groups.
- If you think your partner agrees, I am happy to
arrange a family meeting. If you want, I can contact
the social workers or police on your behalf. But I
would like to recommend you to do that because in my
opinion you are not safe in your own home.
- Before you leave, I would like to dress your wound
and give you painkillers.
LEGAL AND ETHICAL ISSUES
Confidentiality
Case: Mr. Smith comes to your GP clinic because he wants
some advice regarding his wife Joana (72-years-old who's
becoming very forgetful for the last few weeks. Mr. Smith is
concerned because last week Joana went to the shopping
center and forgot to turn off the oven, and before that she lost
the house keys. You have seen Joana 4 days ago for simple
cold. Mr. Smith wants to know if you can recommend a nursing
home placement for her.
Task
a. Counsel accordingly

Counseling
- Confidentiality
- Come again with wife
- Cannot divulge information about the wife
- What about you Mr. Smith?
- I am happy to see her tomorrow about her condition
and if she agrees to have you during the consultation
then I would be more than happy to assess her.
- Nursing home: done by ACAT (aged care assessment
team) assessment by GP, physiotherapist,
occupational therapist, geriatrician, social worker
Euthanasia/ End of life request from a terminally ill patient
Book case 124 page 655
Case: You are working in a palliative care hospital. Your patient
is Sally aged 65. Who was diagnosed with pancreatic cancer
despite active medical interventions Sally is now at the end of
her disease. Sally would like to stop her treatment and return
home to die. Sally has intravenous therapy, indwelling catheter
and nasal gastric tube in situ. Sally asks if you would assist her
to bring an end to her life.
Task
a. Respond to Sallys questions
Features of Palliative Care Act:
- Reasonable provision of relieve of pain, suffering and
discomfort.
- Reasonable provision for food and water. It doesnt
include artificial nutrition and hydration. We will
provide food and drink if you are comfortable with it.
Counseling
- Hello Sally, how are you today? Im very bad doctor
we all know Im dying, I have thought about it seriously
for months. I know you have giving me something for
me for pain. I want you to give me something I can
use to end my life.
- Sally I can see you are going through a very difficult
time. If the doctor says :I know how you feel. How do
you know what Im going through?
- Its extremely hard to stay in the hospital far from
home family and friends. I can see it takes a lot of
courage to bring up this conversation. But Sally I
cannot assist you in ending your life. Why not? You
are asking me about active voluntary euthanasia
which is illegal in Australia. As a doctor my duty of
care is to provide treatment that will be overall benefit
to the patient. And to avoid giving treatment which
may cause harm or suffering. You are supposed to be
my doctor Im not getting to get better Im scared of
pain you have to be able to do something for me.
- Sally I definitely will try to help you with the pain and
make you as comfortable as possible. How bad is
your pain? My abdominal pain is progressively
worsened, pain med made me nauseated.
- Do you know what youre getting for pain relieve at the
moment? No, I dont know. Sally I will find out and I
will involve pain team, or palliative specialist to adjust
your medication. Effective analgesia is possible in up
to 90% of cases. In general we use analgesic ladder
approach start from simple pain killer and move to
weak opioids to strong opioids
o Simple pain killer: Paracetamol, aspirin,
NSAIDs.
o Weak Opioids: Tramadol, codine.
o Strong Opioids: Morphine, Hydromorphine
(5times stronger than morphine), Fentanyl,
Oxycodone.
37
- We continue paracetamol even when we reach to
stage 2 or 3. Often when we move to strong opioid
use, we consider to give you slow release medication
once twice a day to give you a good background
relieve plus top ups with short acting medications or
break through pains (endone). Often with opioids we
will start antiemetic and laxatives to prevent side
effects such as nausea, vomiting and constipation:
Metachlorpromide or Ondansatron up to 8mg TDS.
Sometimes adding medications: NSAIDs, steroids,
anxiolytics, antidepressant can improve the effect of
using pain killer
- Also interventional techniques for pain control.
Palliative care specialist might discuss Neurolytic
Celiac Plexus Block
- My throat is very sore and I have problem swallowing!
I will examine you. I suspect its a side effect of
medication treatment which usually cause dryness
and soreness of the mouth. You can use mouth wash,
spray plus local analgesics (lidocaine).
- Ok doctor I see you want to help me but can I refuse
treatment? Sally a competent adult has the right to
refuse unwanted medical treatment.
- Can I refuse IV therapy, indwelling catheter and NG
tube? Yes you can, as long as you are competent and
fully understand the consequences for you decisions.
For example IVC makes it easy to deliver necessary
medication and hydration but if you dont want it we
can remove and look for alternative route to give you.
You can refuse artificial nutrition and hydration but if
you are in pain you cannot refuse pain relieve as its a
part of palliative care.
- I want to go home. Most of the time we can organize
it. Let me know more about your family. I have very
supportive family with a husband and two kids. Thats
great! I just want to involve Occupational Therapist
and Social Worker.
- I will organise community based palliative care to
provide you with all available services and to make
you as comfortable as comfortable. Sally you are not
alone our aim is to provide the best quality of life you
can have with your illness
End-of-life request from a terminally ill patient
Case (Condition 124): Your next patient in GP practice is a 65-
year-old Sally who has been your patient for the last 10 years.
Few years ago, she has been diagnosed with pancreatic cancer.
Despite all management, she is now at the end stage of disease
and has chosen to withdraw from further treatment and remain
at home to die. Sally has IV therapy, indwelling catheter, and
NGT. She approached and asked you to assist her to bring an
end to her life. You are doing a house visit today.
Task
a. Respond to Sallys question
b. Answer examiners questions
- What is it that you want me to do for you? I
understand that you are in a lot of pain and I can only
imagine what you are going through right now, but
there is still a lot we can do for you. I am sorry but I
am legally not allowed by Australian laws to help you
end of life.
- Patient does not have the right to stop basic life
support such as pain management, oxygen, and
parenteral feeding.
- Are there any other concerns you have? I can
organize a counselor for you. If youre a spiritual
person, I can arrange someone to come and talk to
you. The motive of palliative care is to make your end-
of-life as comfortable for you as possible.
 38

What are the ethical dilemmas and legal consequences of

assisting a patient to bring about her own death?
- Physician assisted suicide and active voluntary
euthanasia is against the law and a criminal offense
- Autonomous wishes of a competent patient
- Relief of suffering (adequate analgesia and possible
use of antidepressants)

What alternatives can you offer her?

- Palliative Care

Example Legal Status

Suicide Self-killing (hanging, Illegal:
drug OD) criminal law
Physician- Provision of means to Illegal:
Assisted Suicide kill themselves criminal law
(involvement of MD)
Passive Refusal of antibiotics or Legal:
Euthanasia I: advance directive consent and
Refusal of refusing resuscitation refusal of
treatment by treatment
competent person
Passive Turning off ventilator or Legal:
Euthanasia II: withholding nutrition consent and
Withdrawal or refusal of
withholding life- treatment
sustaining
treatment from
incompetent
patient
Active Voluntary MD administer lethal Illegal:
Euthanasia drug to cause death at Criminal law
patients request
Active non- MD administer lethal Illegal:
voluntary drug in absence of any Criminal law
euthanasia (person request
incompetent)
Doctrine of double MD administer drug Legal:
effect with aim of relieving Criminal law
suffering knowing that (may vary
SE may be hasten between
death states)