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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: I’m 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.

Task
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?
- How’s 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?
- How’s 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 down’s syndrome. He had a head injury which required surgery when he was young. And then his family put him in this house as he
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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 James’s 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 didn’t come. He respond
but doesn’t 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. It’s 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 doesn’t want to talk to
anybody. They used to go to work, but last 4 weeks he doesn’t want to go to work.
- How’s his mood? Anhedonia? Sleep? Weight? Appetite? try to self harm himself or somebody else? No he doesn’t.
- 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, I’d like to see James. I’d also organize psychiatrist. I’m 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. I’d 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 I’m 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?

- 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.
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- 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, we’ll 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 father’s 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 father’s 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)
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- 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....

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 don’t 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
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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.

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?)
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- 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

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
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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

Dementia and Disclosure of patient’s condition (Book case 119 – pg. 641)

Case: Michael aged 70 years had come to see you in your GP clinic. He is concerned about his wife Jenny who had increasing
forgetfulness over the past 6-12 months. She has misplaced her bag and bank cards on numerous occasions. She is spending very little
time reading or knitting which were her favorite hobbies. You had seen Jenny last week with URTI. Michael is interested that if you can
recommend Jenny for Nursing home placement and is requesting for your approval letter.

Task
a. Focused history
b. Management advice

- Assess MMSE
- Draw clock test:
o Circle: 3 points
o Number of the clock: 2
o Right numbers: 2
o Put the time of the clock: 2
- Investigations/Screening Test:
o RFTs, LFTs, TFTs, FBE, Blood glucose, serum electrolytes, calcium and phosphage, urinalysis, serum vitamin B12
and folate, serum vitamin D, syphilis serology (HIV), CXR, CT/MRI,
o PET or SPECT scan for further information
- Multidisciplinary assessment (aged care assessment team/memory clinic): geriatrician, occupational therapist, psychologist,
etc…

Features Dementia Pseudodementia

Onset Insidious Clear-cut, often acute
Course over 24 hours Worse in evening or Worse in morning
night (“sundown
effect”)
Insight Nil Present
Orientation Poor Reasonable
Memory Loss Recent > remote Recent = remote
Responses to Agitated Gives up easily
mistakes
Response to Near-miss! Difficulty “don’t know”; slow and
cognitive testing understanding reluctant but
(question) understands words (if
cooperative)
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DRUGS, SUBSTANCES OF ABUSE AND ALCOHOL

Alcoholic Counseling

Case: You are a GP and a 47-year-old businessman comes to you to discuss his alcohol consumption because he got pulled over by the
police on his way to work. The blood alcohol level was 0.04. He was given a warning as it was near the legal limit and a sign that he had a
lot of alcohol last night. He wants to discuss the safe level of alcohol and the effect of alcohol on a person.

Case 2: Jarrod aged 30 years is a new patient to your clinic. 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.
Before this he was consuming on average 2SD drink two days per week. Last night while drunk, he met a minor accident and his girlfriend
asked him to see you as she is not happy with his drinking habit. Jarrod works in a local supermarket and is otherwise fit and healthy. He is
not on any regular medications and had no known allergies.

Task
a. Further history

b. Physical examination/investigation results (FBE 140, MCV 107, Plt 300, LFTs GGT increased, other enzymes normal including
albumin, RFTs normal, BP 150/100mmHg,
c. Management advice

History:
- Establish pattern of drinking: I know you are concerned about your drinking. It is a very good decision to come and see me. I
need to ask several questions that may be personal. Is it alright? Since how many years have you been drinking (years)? How
much do you drink per week? What type of alcohol do you drink (spirit, beer, wine)?
o Safe drinking: 1 SD for female, 2SD for males per day everyday
- Where do you prefer to drink? With family, friends? Is it binge drinking or continuous? Are you aware of safe level of drinking?
Have you noticed any ill effects of alcohol on you? Do you think you can drink heavily without appearing drunk (tolerance)? Are
you able to work as efficiently? How is it affecting your relationships at work and in home? Have you ever had any accidents
related to alcohol?
- CAGE:
o Have you ever thought of cutting down?
o Do you feel annoyed when people criticize you?
o Do you feel guilty for taking alcohol?
o Do you take alcohol first thing in the morning?
- How motivated are you on a scale of 1-10 to quit/cut down on your alcohol?
- Withdrawal Effects
o How long can you go without alcohol? Not more than 1 day
o How do you feel after a period of abstinence?
o Do you think you need to drink to sleep?
- Social effects
o Have you noticed any problems at work with alcohol?
o How is your relationship with partner and children?
o How is your financial situation?
o Have you had any accidents/fights because of drinking
- Health problems
o Have you ever noticed heartburn, gastritis, heart disease, liver disease, anemia, hypertension, problem with memory,
mood changes, depression, change in sexual performance (thought it was related to age)
- SADMA
- I will need to organize some investigations to see effect of alcohol. FBE, anemia (macrocytic-vitamin b12), LFTs, Lipid profile,
serum lipase, BSL, liver USD, ECG,
- 1 SD = increase blood alcohol concentration by 0.01
- Liver takes 1 hour to metabolize 1sd

Counseling
- Feedback: History shows that you have been drinking more than normal. This is why I ordered some tests to determine the effect
of alcohol in your body. The high level of alcohol may cause HTN, cause tummy problems (heartburn), increased weight, affects
your liver, heart, brain, loss of memory, gout, sexual and social problem
- Listening: What do you think?
- 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 Don’t 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”
 9

o When you’re 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. I’m 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 child’s 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 son’s 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

- 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?
 10

- 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 you’re 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 you’re 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. Don’t share medications. If you start smoking again, may have
nausea and vomiting.

- 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?
 11

- 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 you’re 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. Didn’t see the psychologist for 3 years and cut down dose by ½ 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?

(persecution) do you think you’re special? (grandeur) do you think someone is putting thoughts on your
mind? (control) do you think you’ve 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
 12

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
 13

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 who’s 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

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 you’re 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 son’s 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.
 14

- Is there any antidote available? No.

- Is ice addictive? It is a highly purified form of amphetamine and that’s 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 wife’s 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 (doesn’t take care of the baby and husband too tired to take care; scared to leave baby with her; behavior is odd; doesn’t
sleep much; lost weight, feels like they’re 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 she’s weak and has no energy?
Does she think that life is

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 baby’s 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 don’t 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.
- Don’t 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
don’t 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, don’t 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?
 15

- 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 can’t
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!

- 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 father’s 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
 16

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 husband’s death? How’s your mood? Do you still find things pleasurable?
How’s your sleep? Appetite? Weight? Psychomotor retardation or agitation? Do you think life is worth living? Do you feel guilty
about your husband’s 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 husband’s presence is a part of anniversary reaction and it doesn’t 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.
- Can’t 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 week’s 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

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
 17

- 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 don’t? Do you have strange experiences? Do you think some people are trying to harm or spy
on you? Are there repetitive thoughts that you can’t 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 you’re 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 you’re irritable?
- Confidentiality
- Any SOB or did you have a lot of blood loss? Do you think you’re pale? Any weather preferences? How are your waterworks?
How’s your discharge? Any offensive smell? How’s your diet?
- Mood: How is your mood? Do you still find things pleasurable? How’s 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?
 18

- 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.

- You’re doing a good job as a mother. Don’t 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. She’s 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, she’s 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 you’re 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 that’s the reason why you’re 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

- psychiatrist. They will start you with lithium, anti-psychotic medications, and antidepressant medications as well. If you don’t 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.

Case 2: Your next patient is 24-year-old university student brought by parents who are concerned because of his change in behavior for 2
weeks. He seems to have been hyperactive, sleeps less and has slept with 3 girls in the last 2 days. He has been drinking a lot of alcohol
and are worried he might get into an accident.
 19

Task
a. History (6 minutes)
b. Explain to examiner differential diagnosis

Differential Diagnosis
- Bipolar Mood Disorder
- Schizoaffective Disorder
- Personality disorder
- Hyperthymic personality (no treatment unless they come with mania or depression)
- Alcohol/drug dependence
- Anxiety disorder
- Hyperthyroidism

Treatment
- Admit
- Lithium carbonate, sodium valproate
- Anti-psychotic
- Anti-depressant (need to used with caution with mood stabilizer)
- Psychiatrist review and long-term followup
- Mental health care plan

Mania MMSE

Case: Your next patient is a young uni student brought in by their concerned parents. She is insisting to fly to US to meet the president.

Task
a. Mental state examination
b. Present findings to examiner

MSE
- Confidentiality
- General appearance and behavior: restless and agitated
- Speech and language: rate, volume, quantity; fluency, range of vocabulary
- Mood and affect: congruent/incongruent; appropriate/inappropriate (related to situation)

- Thought:
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.

Differential Diagnosis
- Mania
- Drug-induced
- Acute psychosis
- Hypomania

Diagnosis and management

- Urine drug screen
- Admit patient
- Call psychiatric registrar: they might start him on mood stabilizers

ANXIETY DISORDERS

Generalized anxiety disorder (JM 1259/1260)

Case:
- R/O drug dependence/withdrawal, hyperthyroidism, cardiac arrhythmias, pheochromocytoma, depression, Diabetes

- Do ECG, BSL and Urine at the office during his first visit
- DSM criteria:
o “UNREALISTIC” worries
o Uncontrollable worries
 20

o Symptoms are not the direct result of any organic or psychiatric disturbances
o 3 or more symptoms:
Irritability
Restless, keyed up or “on edge”
Easily fatigued
Difficulty concentrating or “mind going blank”
Muscle tension
Sleep disturbance
- Management:
o Relaxation techniques: YOGA AND MEDITATION
o Lifestyle modification: Diet
o Physical activity: 30 minutes brisk walking most days of the week
o Refer to psychologist for CBT
o Sleep problems: sleep hygiene; may give short-term benzodiazepines (up to 2 weeks but usually 2 days to prevent
drug 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 (can’t 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

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:
 21

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?
- How’s 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. She’s 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 don’t? any strange experiences which others find hard to believe?
- Insight: do you think you need help?
 22

- 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.

- 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? How’s your mood?
How’s 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? How’s 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.

- Medical treatment from psychiatrist: SSRIs

- Would you like me to organize family meeting? Do you need any support for studying?
- Prognosis:
o 20-30% will improve significantly.
o 40-50% will have moderate improvement.
o 20-40%, they have chronic OCD or worsening symptoms.
- People who can have a good prognosis:
o Good social environment
o Clear precipitating event
o Episodic symptoms

Delayed-Onset PTSD

Case: Paul is 55-years of age and a father of four. He presents with difficulties sleeping and concentration. He says that he wakes up in a
cold sweat every night after a nightmare and he finds it difficult to sleep because of “anxiety”. The nightmare is always the same: a car
accident like the one he experienced 10 years ago. Paul was driving from the hardware shop with his then 8 year old son and suddenly hit
on the side of the car and swerved onto the side road. He remembers time “slowly down” as the car was sliding off the road, thinking “this
is it” and turning to see his son leaning towards the window. He had wanted to reach out and grab him but had to keep his hands on the
 23

wheel and regain control of the car. He said it was probably the most intense and scariest few seconds of his life. No one was injured and
at the time Paul felt relieved, thinking for some time after how lucky they were that the car stopped before crashing into the nearby tree.
Paul says he has not thought much about the accident until 2 months ago when his son came with his new driver’s license. He says he felt
anxious and worried about his son driving, despite telling himself that his son is a safe driver. Every time his son goes out with the car, he
has some difficulty concentrating on anything else and is generally “jumpy” and “on the edge”. Then about a month ago the nightmares
started. In the nightmare, he sees the accident, feels time slowing down and sees his son’s head smashed into the window. He wakes up
sweating, his heart palpitating, breathing heavily, and in complete panic. He describes the whole experience as “so real” that often in the
morning he is overcome with a strong sense of grief. He is not sure whether it is lack of sleep or the dreams but he has been walking
around the home “like a zombie” and not
really feeling “quite there”. He finds it difficult to feel positive about any activities and feels numb towards his wife. He describes the
situation as unbearable.

Task
a. Probable diagnosis
b. Management advise (establish SAD, mood, suicidal,

Differential Diagnosis
- Acute stress disorder (constellation of abnormal anxiety-related symptoms occurring within a 4-week-period. Symptoms are
grouped as hyperarousal phenomena, avoidance of reminders and intrusive phenomena; management: debriefing and
counseling)
- Adjustment disorder (anxiety symptoms within 3 months of response to an identifiable psychosocial stressor; persists for less
than 6 months following removal of stressor; non-pharmocological: counseling, relaxation and stress management;
pharmacological: short-term benzodiazepines)

Diagnosis
- Type of ANXIETY disorder
o Physiological component: autonomic hyperactivity (palpitation, increased HR, dry mouth, upset stomach)

o Psychological component: constantly worried, sleeplessness, restless, lack of concentration

- Constellation of symptoms that persist for 1 month after exposure:
o Acute PTSD: duration of symptoms <3 months
o Chronic PTSD: duration of symptoms > 3months
o Delayed onset PTSD: onset at least 6 months after stressor
- Experienced or witness a traumatic event (death, near-death experience, rape, earthquake, natural calamities) with situation with
feeling of helplessness and extreme fear
- Typical distressing recurrent symptoms
o Recurrent intrusive features – recollection, nightmares, flashbacks
o Avoidance of events that symbolize or resemble the trauma, detachment, feelings of numbness or withdrawal, guilt
o Hyperarousal phenomena: exaggerated startle response, irritability, anger, difficulty with sleeping and concentrating,
hypervigilance
- Management
o Meditation and yoga
o Lifestyle modification (smoking cessation, decrease alcohol intake, healthier food, and exercise)
o Proper sleep hygiene
Recognize what helps patient to settle best, establish a routine before going to bed, regular daytime exercise
and time of arising, avoid daytime naps, avoid strenuous exercise close to bedtime; avoid alcohol and drinks
containing caffeine in evening, avoid heavy evening meal and smoking; remove pets from bedroom; avoid
lights including poorly screened windows and highly illuminated clocks in the room
Sleep promoting adjuvants: warm bath, warm milk, comfortable quiet sleep setting with right temperature,
sex
Non-pharmacologic treatment: meditation, relaxation therapy, stress management; CBT and
electromyographic feedback; hypnosis
o Crisis Intervention Therapy (CBT)
o Refer to psychiatrist and psychologist for counseling (EMDR – Eye Movement Desensitization and Reprogramming)
o Social support
o Pharmacologic: SSRIs; short-term benzodiazepines (sleep)

Post-traumatic Stress Disorder 2

Case: Your next patient is a 22-year-old man who presents with SOB and poor sleep. SOB occurred at night and relieved by waking up.
He had a major vehicular accident 3 months ago and broke 3 ribs. He recovered well.
Task
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)

b. Diagnosis and management

History
- When did it start? Any previous episodes? Did it occur after the motor vehicle accident? Any triggering factor? Any associated
features such as chest pain or sweating? How is your general medial health? Any serious medical problems in the past?
 24

- I know you had a car accident, I’m sorry about it. I’m not asking you to recall the event, but can you please tell a few words about
it? Was somebody with you at that time? How is she? Do you have any contact with her? Do you experience any sudden images
of the event? Do you try to avoid driving or the place where the incident took place? Do you have any nightmares? Do you feel
irritated, angry or guilty about anything pertaining to the incident?
- How is your mood? Sleep? Appetite? Weight? Anhedonia? Suicidal ideation: do you think life is worth living? Have you thought
of harming yourself or anybody else? Do you see/hear/feel things others cannot or have you had any strange experiences?
- Whom do you stay with? Do you have a lot of friends? SADMA?
- ENCOURAGE patient by nodding and showing concern

Diagnosis and Management

- From the chat we had, I think you have a condition called post-traumatic stress disorder. Have you heard about it? It is a type of
anxiety disorder where the patient experiences various symptoms and behaviors like recollection, flashbacks, avoidance, sleep
problems following a psychologically distressing event which in your case is the MVA you had 3 months before.
- The symptoms usually come immediately after the event but can be delayed for months or years.
- I will refer you to a psychiatrist. He will talk and listen to you and will use some techniques to help you come out of this situation
cognitive behavioral therapy. As you haven’t slept for a few days, he may offer you sleeping pills for a short time but I would
advise you to start with sleep hygiene.
- At this stage, you might not need any medication, but if required, the specialist might offer SSRIs.
- I would like to do a family meeting if it’s okay with you. Family support is very important at this stage.
- Safe level of drinking.
- Review. Reading material about PTSD and sleep hygiene.
- Differentials: anxiety disorder (GAD, adjustment disorder, panic attacks, substance abuse)

ADJUSTMENT DISORDERS

Adjustment Disorder

Case: Your next patient in GP practice is 32-year-old Shirley Coombs complaining of SOB. She has recently moved from Sydney to
Melbourne with prolonged travel time.

Case 2: lady with chest tightness and pain and normal investigation husband died recently;

Case 3: sad woman anniversary grief

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

Melbourne, recently divorced 3 weeks ago, not on any contraceptives, regular with pap smear, no bleeding disorder; drinking
alcohol 3-4 glasses of wine to help with sleep)
b. Physical examination (looks well without eye contact, VS normal, all PE normal)
c. Investigation
d. Diagnosis and Management

Differential Diagnosis
- Major depression
- Acute stress disorder
- PTSD

Stressors:
- Death of a loved one
- Divorce or problems with relationship
- General life chages
- Illness or other health issues in yourself or a loved one
- Moving to a different home or city
- Unexpected catastrophes
- Worries about money
- In teenagers: family problems or conflict, school problems, sexuality issues

Features:
- 5 symptoms for 2 weeks daily: SAGECAPS (in depression)
o Sleep
o Anhedonia
o Guilt
o Energy (lack of)
o Concentration
o Appetite
o Psychomotor retardation
o Suicidality
- Criteria
o Development of emotional or behavioral symptoms in response to an identifiable stressor within 3 months of the onset
of the stressor
o Symptoms or behaviors are clinically significant as evidenced by:
marked distress that is in excess of what would be expected from exposure to the stressor
 25

Significant impairment in social or occupational functioning

o Stress-related disturbance does not meet criteria for another specific axis I disorder and is not merely an exacerbation
of pre-existing axis I or II disorder
o Symptoms do not represent bereavement
o Once stressor has terminated, the symptoms do not persist for more than an additional 6 months
- Treatment
o CBT
o Relaxation technique (yoga and meditation)
o Healthy diet and exercise, reduce caffeine
o Stress management (don’t bottle things up!)
o Sleep hygiene
o Short-term course of drug treatment is necessary in persistent or severe case

Developmental Disability with Adjustment Disorder

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 hasn’t 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 doesn’t 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; can’t 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 patient’s 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 John’s 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 patient’s 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 doesn’t 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; don’t want to get fat since teenage; mood: sometimes low eat
more, more depressed; normal sleep
b. Explain Diagnosis
c. Management

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:
 26

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 don’t? 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 I’ve 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 can’t 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. How’s your general health? SADMA?

Counseling
 27

- Susan, you are suffering from two conditions: Diabetes and eating disorder most possibly you have bulimia nervosa. Have you
heard about it?
- It’s 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 can’t stop eating. After that they induce vomiting to compensate. It’s 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. It’s 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. I’d also write a letter
to your GP so that he can follow you up regularly and we can prevent complications in the future.

- 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 Karen’s 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 she’s 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?
 28

- 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 she’s able to see or hear things that you don’t.
- 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 she’s 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.

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 mom’s 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
 29

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 mom’s condition has resulted
in bodily symptoms. Whatever you’re 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.
- Don’t 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 one’s 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.

- Don’t 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.
 30

- 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 don’t 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. Nardia’s 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. Won’t 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 don’t? 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 can’t 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. I’m 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.
 31

- We have a management plan which involves a multidisciplinary approach. First, let’s 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

- 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 Suzanne’s 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 person’s 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
 32

- 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, doesn’t 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 doesn’t followup because he think he’s 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 can’t
sleep and he’s thinking of her all the time. He’s 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 patient’s words

- 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
 33

- 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. John’s 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
 34

- 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?
- How’s 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.

To relieve your symptoms, I can prescribe anti-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
 35

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

akithesia (restless: motor 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 can’t? 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
 36

- 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?

- 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 don’t? 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
 37

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: it’s indications,
contraindications, procedure, side-effects and post ECT management
- Any particular concern? Please don’t 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 doesn’t 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

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. Patient’s 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 patient’s 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

 38

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; doesn’t 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 she’s 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 child’s 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

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.
 39

- 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 he’s 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? How’s 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 teacher’s complaint, I do suspect that your child’s 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 child’s 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.
 40

- 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

 41

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
you’re 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)

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 child’s performance.
- Confidentiality statement. I am here to help you.
- The reason why your son’s 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 son’s 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 Johnny’s 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 don’t 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 you’re trying to work out your social identity. It doesn’t 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. How’s 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 week’s time.
 42

- Doctor what’s 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 patient’s 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 she’s 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.

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?
- I’ll ask some questions which might seem funny but do you feel/see/hear things that others do not? Do you have any strange
experiences?
 43

- Do you think I’m crazy? Sorry, I didn’t 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 mother’s 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 don’t need help, why would I need help”. Doesn’t 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 mom’s 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? How’s 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 you’re 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, I’m glad you don’t have intentions to harm yourself, but you are upset because of your parent’s divorce. If you like, I
am happy to arrange a family meeting and talk about things. I would like to

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 Don’t have coffee, tea, or heavy meals
o Hot shower or milk
o Don’t 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
 44

- 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 it’s
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 child’s 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 don’t 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. GP’s 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 baby’s body which she claims occurred when Johnny rolled off the change
table while getting his nappy changed while under her boyfriend’s care.

Task:
a. Further detailed history

b. Examination findings
c. Further management
 45

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

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 he’s 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.
 46

- 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 child’s 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 you’re getting injured quite often and now you have an injury on your forehead. How did it happen?

- Confidentiality. I understand that it’s 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? Don’t worry we’re 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?
- How’s your general health?

Physical Examination
- General appearance
- Vital signs
- Are there any other scars or bruises. With the patient’s 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 what’s 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 don’t hesitate to call police if at any time you feel it’s 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
 47

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 Sally’s questions

Features of Palliative Care Act:

- Reasonable provision of relieve of pain, suffering and discomfort.
- Reasonable provision for food and water. It doesn’t include artificial nutrition and hydration. We will provide food and drink if you
are comfortable with it.

Counseling
- Hello Sally, how are you today? “I’m very bad doctor we all know I’m 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 I’m
going through?
- It’s 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 I’m not getting to get better I’m
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 you’re getting for pain relieve at the moment? “No, I don’t 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.

- 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 it’s 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 don’t
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 it’s 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. That’s 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
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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 Sally’s question
b. Answer examiner’s 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 you’re 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.

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
patient’s 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)