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Welcome to Individual Patient Management Page
General Introduction
To acquire skills there is no alternative other than to practice. You must get in to a habit of presenting to a senior psychiatrist, at least once a week. It is wise to start this well in advance of the exam. Always do your practice under strict exam conditions (as in your clinical practice you are doing this every day under uncontrolled conditions) and you can ask your examiner to be unsympathetic in marking you.
Read about history taking and examination in a good text (e.g. Oxford Textbook) until you are familiar with all the techniques of clinical assessment. Apply these during your mock practice.
It is important to have your own method of the order the headings under which you are going to present. There are several in use. We find the following useful as it forms a logical sequence to organise the information enabling you to tell a story.
Always mention the heading or the subheading of the history or the MSE to the examiners before you present the corresponding findings.
Introduction
e.g. My patient is, Mr A a 36 yr. old school teacher, from Edmonton, who was admitted to ward B on the 3rd of March 1999 informally, but is currently detained under section 3 of the Mental health act 1983.
Presenting Complaint
Presenting complaint/s and the duration.
History of the presenting complaint
This would include the sequence of events leading to the admission or presentation. Don't forget to mention the risks of self harm and suicide and of harming any body else. Associated somatic symptoms, the treatment and other help the patient has had so far and their effects would also be appropriate to be mentioned under this heading.
Family History
Doesn't quite sound appropriate to be included here but this part of the history is very important, and is therefore better to be mentioned at the outset itself. Don't forget to look for similar problems to those of the patient in the family (e.g. alcohol, criminality, or personality problems etc.)
Past Psychiatric History
Better to mention this before it is too late so that examiners will be able to put the parts of the story together. Mention about what happened from the onset of the illness, about past treatment etc. Find out what happened in between relapses (e.g. completely well / maintained on treatment or not etc.) Don't forget to mention about past attempts of suicide or harm to self or others.
Past Medical History
Ask about physical illness that may be causative or otherwise associated with the patients psychiatric problem. Ask about physical effects of self poisoning or alcohol and drug abuse and be prepared to mention important negative findings. It is important to remember the past medical history when you physically examine the patient so that you can concentrate on relevant aspects.
Personal History
This would include
Childhood and Schooling
Occupational History and Financial Circumstances
Marital and Psychosexual History
Home Circumstance
Forensic History
Alcohol and Drug History
Premorbid personality
A good question to start questioning about premorbid personality is to ask, "If I were to ask your friends about what sort of a person you were before you fell ill, how do you think they would have answered"? Mention about the intermorbid personality as well and find out what has happened to the personality over time.
Mental State Examination
There are again different methods of ordering your sequence of headings
Following order is acceptable to most psychiatrists.
General Appearance
You may want to include details about the dress, eye contact and rapport abnormal movements e.g. responding to hallucinations, other motor abnormalities such as TD, abnormal postures under this heading. If the patient is on medication you may mention about the presence or absence of EPSE, and other obvious anticholinergic side effects.(e.g. dry mouth)
Speech
It is common for you to be able to say that your patients speech is spontaneous, coherent and there is no formal thought disorder. However if there are abnormalities (e.g. reduced amount, slowness, low volume, pressure of speech etc.) you will not have this luxury and will have to explain them.
Mood
This can be explained under following sub headings
Main mood (Depression, or Mania)
Subjective(patients) and objective(your) appraisal
Other associated moods (anger,fear, suspicion, irritability etc)
Affect (labile, flat, blunt or reactive and congruent/incongruent)
Associated cognitions (e.g. depressive : guilt, life not worth living, self blame,
pessimism regarding the future, ideas of suicide or DSH / anxious : about going mad,
having a heart attack, or collapsing and other catastrophes)
Thought content
This includes
Delusions (challenge them to see how fixed they are. Don't commit yourself to the type (primary / secondary) if you are not absolutely sure.)
Overvalued ideas
Phobias
Obsessions
Perceptual abnormalities
Would include
Hallucinations
Pseudo Hallucinations
Illusions
Misperceptions
Cognition
To what extent you carry out the cognitive state examination will depend on the patient you get, and if you have no reason to suspect cognitive problems following will be adequate to mention. Otherwise you may have to do a MMSE or even extend the examination beyond that.
Orientation in time place and person
Memory, both registration (immediate), and recall (five minutes)
Concentration
Insight
Find out following points
Does the patient thinks that he is ill, if so is it mental? Can it be helped and will the patient require / accept treatment or what the patient thinks about detention? (if relevant) What does the patient thinks about the effect the illness has had on self and others?
Physical examination
Don't forget to mention this even if there are no positive findings. Try to look for relevant findings, related to the psychiatric and medical history.
Cognitive State Examination
If the patient is an elderly, or there is suspicion of cognitive impairment, a more comprehensive assessment of cognition is essential.
Mini Mental State Examination (MMSE) by Folstein and colleagues is a common one in use as a screening test for dementia and delerium. However, it does not test long-term memory.
Therefore you may have to extend it (e.g. ask, dates of 2nd World War, name of Prime Minister or Monarch, any recent items of news or current affairs)
MMSE is not useful for detecting focal cognitive lesions and is insensitive to frontal lobe pathology, therefore you may also concentrate on these aspects in your assessment (e.g. history of partial epilepsy, or strokes involving a side, Luria's motor test, or other focal neurological signs on physical examination, cognitive estimates or verbal fluency in mental state)
The Mini Mental State Examination
Conventionally cut-off point is 24 out of 30 (for elderly, and it has to be adjusted upwards for the young and educated)
Orientation to time (5 points)
Ask the : day, date, month, year,and the season
Orientation to Place (5 points)
Ask the : country, county, town / city, place, and floor (what floor are we on?)
Memory (registration) (3 points)
apple, penny, table (say, "I am going to name three objects. After I have finished saying their names I want you to repeat them after me")
Attention and concentration (5 points)
Serial sevens or threes / or spell 'world' backwards
Memory (recall) (3 points)
Ask the three objects you asked to repeat a few minutes ago?
Expressive Language (naming) (2 points)
Ask what they are (show pen or pencil and a wristwatch)
Expressive Language (repetition) (1 point)
No ifs, ands, or buts (say, listen carefully as I am about to say something which I would like you to repeat after me)
Language (reading and comprehension) (1 point if obeyed)
(Show sheet with 'Close your eyes' printed on it)
Can you do what it says?
Praxis (ideational) (3 points)
Paper folding (say, "I am going to give you a piece of paper. When I give it to you, take the paper in your right hand. Fold the paper in half with both hands and put the paper down on your lap")
Praxis (copying and drawing) (1 point)
Double pentagons
The patient should be shown the design on the MMSE sheet and asked to copy it.
Praxis (spontaneous writing) (1 point for a sentence with a noun and a verb)
Ask the patient to write a complete sentence
TOTAL (maximum score 30)
It is important to orientate the patient about what is going on at the beginning itself. Mention that you may have to interrupt due to time restraints. Telling the patient that you will have to probably ask some questions, you have already asked, when you go in front of the examiners, and as it is generally not a reclarification of what is already asked (and is mainly a matter of showing examiners how you interact with the patient) the patient can give the same answers that has already been given, is good practice. (helps some patients to overcome confusion).
It is important to have enough time for thinking about the case as this is a very important. Have the patient by your side while you do this and clarify if something is not clear.
Practice formulating cases over and over again so that you don't have to struggle with it on the day when you are under pressure. If you try to remember the salient points during the assessment, this will be easier but don't forget that formulation is not a summary, and therefore not a repetition of your assessment.
Examiners will not ask you for a formulation, but will ask you questions which you can easily answer if you have done this exercise. (an examiner once asked the candidate to present the history, MSE, Diagnosis and the DD, reasons for and against the diagnoses, and aetiology during the candidates presentation itself. During the discussion that followed the candidate was questioned about the investigations, management and the prognosis. [practically the whole of formulation])
Following is a suggested method for formulation.
Introduction
(e.g. Mrs Mary Smith is presenting with a H/O .............................. .
Diagnosis / Differential Diagnosis (work out the DD by applying the diagnostic hierarchy, and process of exclusion)
(Diagnostic Hierarchy [top diagnoses trumps lower ones]
Organic illness, Epilepsy, Drug and Alcohol induced illness
Schizophrenia and other psychotic disorders
Affective disorders
Neurotic illness, Eating disorders, PTSD, Somatisation
Personality disorders
Personality traits)
Reasons for and against each diagnosis.
Aetiology
Consider Physical, Psychological, and Social causes, and cross tabulate these with predisposition, precipitation and maintenance. (try to throw some theoretical knowledge here, e.g. vulnerability factors for depression, high EE family, treatment with anti depressants leading to mania etc.)
Investigations
Consider again under Physical, Psychological, and Social headings.
Management
Once again consider Physical, Psychological, and Social management in the context of short, medium and long term. (remember, Multi disciplinary assessment, followed by Multi disciplinary management)
Prognosis
In the short term and in the long term. Always be ready with the answer to the question, why you say that?
Other important points
Have your own management plan for each main diagnoses that you can get in the exam.
Have a plan for asking questions in front of the examiners under each subheading of the mental state examination (This is different to what you would do with the patient when you take your history and do the MSE, e.g. you will have to ask about associated somatic symptoms, and psychotic symptoms etc, if you were asked to elicit the mood)
Know the common theory questions that can be asked and the answers . (e.g. Pharmacology of common medication, Few key papers of evidence, that you can throw such as Brown and Harris's vulnerability factors, and Vaughn and Leff's EE.)
Know the ICD 10 well as most examiners won't know it that well. You may have to tell the examiners that your diagnosis according to ICD 10 is for e.g. depressive disorder severe in intensity with psychotic symptoms so that he knows why you are talking in a different language.
Knowing the PSE definition of common symptoms can help. (e.g. If you say that according to the PSE, pseudo hallucinations mean hallucinations occurring in the head , examiners won't argue with you)
Know your phenomenology well for part I, and management for part II. Don't mention anything you don't know as you may be asked to explain that. (e.g. a candidate was asked what he meant by overvalued ideas, because he mentioned it and unfortunately he didn't have a clear idea about it. The discussion that followed didn't go well as the candidate was now anxious and defensive thinking that he is not doing well)
Lets learn from an example IPM case
By Athula Sumathipala, MBBS, MD, MRCPsych,
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