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Welcome to trainee's forum,
where your views and ideas are published with no red tape!
'I was pleasantly surprised to hear that college has changed the examination format. Abolishing minus marks and calling only those who pass the theory papers for the clinicals is a significant advance, and should be welcomed by all. One point, I was not impressed about was that, the money refunded to those who fail theory part is significantly less than the proportion paid by the other Royal Colleges. If the College refunds a reasonable proportion of fees to those who have already lost a lot by failing it will certainly be a gesture of good will.'
Dr F. G.
'The critical review paper has been introduced from last Part II examination, and as we anticipated this paper was not very difficult. If my understanding is right, college is not going to set questions about qualitative research papers and therefore, I think that the college will soon run out of ideas for setting questions, as the different types of research papers that can be questioned about, are limited. This will obviously be to the advantage of the candidate as very soon it will be possible to predict what to expect if one looks at the past questions. My fear is that in the attempt to set different questions the college may set quite difficult questions perhaps involving calculations too. (I fear calculations as many other psychiatrists!)'
Dr C I
'My consultant is of the view that the standard of the trainees have improved over time and therefore the percentage passing the exam also must increase to keep up with this. I suspect that, due to this reason, and because the percentage passing is constant, the exam is becoming more and more difficult with time. (due to removal of consistently answered questions, especially MCQs.) If one examines questions set several years ago with the questions today, this is quite clear.'
Dr T B
'College organises workshops for examiners, why can't the college organise workshops for examinees at least on critical appraisal of research papers.'
Dr D P
'Model answers are available to the examiners. I think it will be a good idea to publish model answers, after the exam (at least for essay paper and preferably for both essay and critical appraisal paper) for the benefit of the candidates as well. This will be interesting reading for all the psychiatrists and will also help raise academic standards, and obviously the college will not be loosing anything by doing this.'
Dr KD
Dear sir/Madam,
I would like to submit this case presentation. This has been prepared following the suggestions of my consultant after I presented a case.
Please contact me on 01962 843288 for further information. E mail- gshyamkishore@hotmail.com Address- SHO Psychiatry, Melbury Lodge, Royal Hampshire County Hospital, Winchester, Hampshire, SO22 5DG.
Case Presentation.
Dr Shyama Kishore Gopalkaje
It is common experience that we cannot follow one standard method in interviewing patients. One has to be versatile at the same time making sure that important details are not missed. One cannot write them down in this disorganized way, hence the information would be organized into a standard method while recording. It is also a common experience that this standard method cannot be presented exactly like it was written. One will have to resort to a different way of organizing the information while presenting. For example, the personal details which would be recorded initially, can not be presented as they are recorded. We will have to arrange it into a nice introduction.
A case presentation should start with an introduction. Then the presentation should flow easily like a story but it is important to mention the main headings such as presenting complaint, past psychiatric history, past medical history, social history, pre morbid personality, family history, personal back ground, physical examination, mental state examination.
A good introduction should aim at giving a clear image of the patient being presented. It should include patient’s age, sex especially if this is not clear from the name, name, area he/she is from, occupation/employment, marital status and if has children, their number and whether they are living with him or her.
It could be something like this.
I would like to present a ---year old lady/gentleman, from ----(place) at -----(town) by name -------. Mr./Mrs. -------is employed as-----/ unemployed and he/she is married and has ----(number) children living with him/living separately. One should be careful not to go into too much detail at this stage.
Next part is most important.
Presenting Complaints- One should aim at listing most of the patient’s complaints either in an order of importance/severity or chronologically. The important complaints should be accompanied by the time of occurrence or duration.
History of Presenting Complaints--
Now it should take a form of story and one can have the freedom of going into the details of the events. If there is any precipitating factor, one should start by describing this. Then move on to describe the progression of the condition. One should also explain the nature of the important/severe complaints. This is the main body of the case presentation.
Next we can go to Past psychiatric history. It is best to comment like this. Mr. X does not have past psychiatric contact/ has contact with the services for ------years/months. One should also remember to comment about treatment of psychiatric complaints by the GP. In a depressed patient one should comment if there was a history of mania.
In a chronic psychiatric patient one should include the past diagnoses, number of hospital admissions, duration of stay, treatment history including ECT. If it is possible to be precise in the number of past admissions and duration of stay it is fine otherwise one can use words such as, several past admissions, long/short periods of stay in the hospital, various types of antidepressants or antipsychotics. It is also useful to compare the current presentation with the past ones and compare the severity.
Past medical history--- Significant past medical illnesses should be included here. It should also include past surgical history.
Next it is convenient to talk about the Social history- This would include the patient’s living circumstances. One should comment on the current occupation, financial situation, marriage/relationship, friends, support networks.
After this we can go on to pre morbid personality. One should comment on the 1. Sociability, 2. Enduring mood, 3.Depending upon the final diagnosis one should mention the presence of or absence of specific personality traits. As there is research evidence that people with Cluster A traits have higher chances to develop schizophrenia and Cluster C traits have higher chance of developing depression, commenting on this is very important. 4. It is easier to include Addictions here- drink, drug, smoke. commenting on the quantity and duration of use. 5. Moral and religious attitudes should be mentioned and trouble with law could be included here. Involvement with special religious beliefs could be mentioned if present. 6. One should comment on patient’s hobbies especially when they are strange. One should also include how the patient generally spends his leisure time.
Now it is very important to know as much as possible about a patient’s background. This should also cover the Family history. One can start by talking about patient’s parents then other family members focusing on most important things. One must comment if there is family history of any mental illness. Then one can go on to the details of patient’s life, starting from birth, childhood( it is convenient to describe it in five yearly periods), School, Work, Relationships.
One should mention physical examination findings in every case. If the examination is normal, then it should be stated that Physical examination was normal.
Next, the patient’s mental state examination findings must be presented. Start with the appearance and behaviour. It is useful to say if the patient was able to give a coherent account of himself. Comment on speech, mood, suicidal ideation, thought form, thought content, perception, cognition, insight, rapport.
Next it is very important to summarize the case or make a formulation. For e.g., 23 yr. old single unemployed woman with 2 yr. history of depressive symptoms, presenting with symptoms of moderate depression without psychosis(-ICD 10 diagnosis), namely---------------- On Mental State Examination, ------(list positive findings and important negative findings.) The current presentation has been precipitated by ----------- The predisposing factors are-------------- Perpetuating factors include--------------------.( Think in terms of Social, Psychological, Pre morbid personality, Physical causes as aetiological factors). In all case you would like to exclude organic causes and it is very important that this is mentioned.
One must note that this presentation deviates from the standard format in which cases are written down. From past medical history we go on to social history and then to pre morbid personality and then family history and personal history. In the standard format, we write past history which includes past medical history, past psychiatric history, then family history, personal history which includes pre morbid personality and social history. One will definitely notice that the method described here is more easily understood as all the pieces join together in the form of a story. It has an easy flow with one information leading to the next. We all know that most important thing while presenting a case is to maintain the flow. The above format not only helps with the flow but also focuses on important aspects such as good introduction, pre morbid personality, social circumstances, precipitating, predisposing and perpetuating factors.