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Welcome
Example PMPs with model answers
You area child psychiatrist. A boy of 8 yr. is brought to you. The mother says that the child is overactive and has been academically poor. How would you manage the situation?
See the mother and the child.
Specific points in the history to consider are
development of the disorder,
is it pervasive, or only situational?
ask about home work,
ask about completion of tasks,
ask about the level of supervision needed
ask about the ability to obey instructions,
ask about the risk awareness,
ask about restlessness,
Also find out about
child's development
family history of genetic contribution,
family interactions, harshness and inconsistency,
past psychiatric history
past medical history
history of substance abuse
Examination of the child
mental state
behaviour / eye contact
speech
mood
intelligence, drawing a picture, writing, reading etc
Physical examination
motor co-ordination
Interaction between the mother and the child
Differential Diagnoses
ADHD
Co morbid disorders, anti social behaviour, (conduct disorder), specific learning
disorder, or general learning difficulties
no illness and parental over anxiety
Investigations
information from GP
school
Conner's rating scale (helpful for monitoring purposes)
psychological / educational assessment
physical investigations
Management
advice to parents, and teachers, regarding nature of handicap
encourage solitary settled activities, requiring cognitive skills
behavioural therapy on operant lines
attend to education, advice to LEA,
medication, Methylpenidate, Dexamphetamine, Pemoline
diet, exclusion of preservatives and colourants
Prognosis
main problems are, poor self esteem, peer rejection, and aggressive behaviour.
can develop anti social behaviour in later childhood, and in adolescent
one third abates in early teens, but impulsivity remains.
You are called to A&E to see a drunk, suicidal male patient. How would you respond?
Try to ascertain the urgency of the situation,
is the patient disturbed?
has he tried to commit suicide?
is there verbal/physical aggression?
Go and see the patient.
read the A&E medical officer's notes
speak to the A&E medical officer
speak to the A&E nurse
is he a frequent A&E attender with similar complaints? (see
his old notes)
Anybody accompanying the patient? speak to them.
See the patient
(though a psychiatric assessment is best left to be done later)
try to find out
the presenting complaint
threatening suicide? / already attempted?
any H/O acts of DSH?
History of the P/C
haw was he referred?
why?
when did he decide to commit suicide? before or after taking alcohol?
what are his plans?
what has he done so far to kill himself?
any H/O psychiatric illness?
any evidence of manipulation?
Past Psychiatric History
past DSH/suicide acts?
H/O alcohol? drugs?
H/O past psychiatric illness, and treatment?
Personal History
Available social support, family, friends etc.
problems with law, are there any officials (e.g. probation officers) involved?
Past medical history
any treatments from the GP?
MSE
any evidence of delusions?
any evidence of hallucinations?
any evidence of thought disorder?
Physical examination
stigmata of alcoholism
malnutrition
breathalyse for alcohol level
Options are
keep in the community with increased support until reassessment
keep him in A&E, assessment ward, until he is sober
He becomes angry and threatens physical violence. What would you do?
always consider that your safety as of paramount importance
talk him down
explain that we will be willing to help him and that we need his co-operation
involve the police if necessary
Few more example questions
You are providing a liaison service to a GP practice. A mother comes and complains
about being feeling low for 4 months. Her husband drinks heavily. Her only 11 year
daughter has complained that he comes to her room in the night and plays with her body.
Tell us how you would respond and what you would tell the mother?
Points to consider in this question are mothers depression, husbands alcohol problem and
most importantly probable sexual abuse of the daughter. Examiner likes to hear what you
would tell the mother, and this suggests that he is interested in something
important that you are going to tell the mother. Obviously the fact that, it is beyond
your realm to do an assessment of the risks to the daughter and that you will be informing
the social services, to carry out an investigation.
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A 55 year old man is brought to you. He has been saying that his wife has been
unfaithful to him and has been constantly arguing with her. Wife is at the end of her
tether and has in fact considered leaving. Can you take us from there as to what you would
do?
This question needs you to be able to identify the important issues, namely, assessment
and the management of the man.(consider organic disorders, [dementia, delirium, alcohol]
psychotic disorders, [schizophrenia, paraphrenia{delusional disorder} affective disorders
[depression, bi-polar illness] jealous traits, or genuine family problems, and the
possibility of impotence.
Wife may also be mentally unwell, and may require help.
History of this man's past relationships may shed light on chronicity of the
illness.
It is important to talk about risks to the wife, and consideration of compulsory admission
under the mental health act.
Long term care, is important as morbid jealousy runs a chronic course and these
patients are difficult to help due to poor insight and poor co-operation with the
treatment.
In management you may have to mention geographical separation as an option if all else
fails. Same psychopathology will manifest in future relationships as well and the risks to
the spouse will be an important long term concern.
Examiner concluded this PMP by asking, what psychological defence mechanisms
(projection) has been operating in this man, a clear sign that the candidate has been
doing well.
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A 73 year old man is reported to have been, confused and wondering. He has now barricaded himself in the house and would not let anybody in. A concerned neighbour has informed the GP and GP asks for a DV. How would you respond?
This needs urgent attention and you will want to arrange a DV as soon as possible due to
the risks involved. (self neglect, hypothermia, dehydration, etc.) However you will have
to get a social worker involved who will apply to the courts for entry into the house.
(section 135 of the MHA) You will go with the police who will break the lock to gain
entry, and the social worker.
You will also talk about the differential diagnosis which includes dementia, delirium,
psychotic disorder and depression. Admission under a compulsory order will be necessary.
Long term care including appropriate placement are important points.
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When you are in the out patient's department you see a patient waiting outside. He is having involuntary movement involving his body, and hands. He is 40 years old and when you see him, he tells you that he is adopted and that he doesn't know his real parents. What are is your differential diagnosis?
Whatever you want to mention in your differential diagnosis the examiner here has given you a hint that he wants you to speak about a genetic condition by mentioning that the patient doesn't know his parents. (it is important to put yourself in the examiners shoes and think why he has mentioned about patient's parents, [what we call reading between the lines])
The candidate who was asked this question, was able to rightly mention Huntington's disease as the one he would consider most likely, which was followed by a discussion of predictive testing and genetic counselling.
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