1. General Adult Psychiatry

General Adult Psychiatry

 1. A 35-year old male comes with marked distress. He upsets, as he believes that his wife is not sexually faithful since 2 years of his married life.
a) Mention the list of information you need to reach a diagnosis.  7
b) What treatment you will adopt for this patient at this point? 3

2. A 25-year old man with schizophrenia is on haloperidol with the dose of 20 mg/day. After 2 weeks, he has complained of restlessness, inability to sit at one place and fidgetiness.
a) What are the treatment options for this case? 6
b) Make a list information you will provide to patient and caregivers.  4

3. A 22-year old university student referred to psychiatry OPD by university medical officer. He appears to be perplexed, frightened and expresses idea of persecution. He has no previous psychiatric history.
a) What could be best possible differential diagnosis? 5
b) Prepare a list of laboratory investigations that you would consider in the first step. 5

4. A 40-year old man is getting clozapine for his psychiatric problem. He is smoker, obese and has significant amotivation. Suddenly he developed chest pain, respiratory distress, fever, and hypotension.
a) Mention the areas of assessment keeping in mind the differential diagnosis for these newly developed problems 7
b) List the laboratory investigations you need to do for confirming your diagnosis. 3

5. A 44-year old male admitted patient with CRF referred to you. He was depressed during admission. Later, he developed irrelevant talks, excitement, violent behaviour, sleep disturbances and loss of appetite.
a) What areas you need to assess to reach a diagnosis? 6
b) What will be the management plan? 4

6. A 30-year old depressed patient has failed to respond to therapeutic doses of sertraline, mirtazapine and venlafaxine. For his worsening of mood, low food intake and the emergence of psychotic features, he has been admitted in the inpatient psychiatry unit
a) List the information you need to gather at this point.  5
b) Make a list of first line investigations as part of your management plan. 2
c) What management plan you need to adopt for this patient? 3

7. A 25-year old male developed acute episode of schizophrenia 5 years back. His symptoms were remitted significantly after one year of treatment with olanzapine. Subsequently he became aloof, lack of drive, odd and inappropriate his social behaviour and affective bluntness. He spends most the time at home and does almost nothing.
a) What treatment options will you consider for this case? 5
b) What advice will you give to the family members?  5

8. A 52-year old woman lost her husband, who died suddenly of stroke 3 years ago. They had been staying alone for almost a decade with infrequent visit from her son and daughter who lives in abroad. About a week after death, she heard his voice clearly talking to her as he would in a routine manner in the next room. She went back and checks but saw nothing. Subsequently, she often heard his voice conversing with her and she would discuss her daily matters with him. This, however, provoked anxiety and sadness and gradually she pre-occupied with his thought.
a) What are the possible diagnoses? 4
b) What are the areas you need to explore to reach confirm the diagnosis?  6

9. A 19-year old student presents with lack of interest in studies since last 6 months. He also has frequent quarrels with his parents and headache.
a) What could be beat possible diagnosis?  6
b) What other things you need to rule out? 4

10. A 28 year old housewife presents with attempt of self-injurious behaviour to her right lower limb since one month. She repeatedly utters for arranging to cut her leg and that will be good for her. On asking why she wants to do that, she says that this question is unnecessary and she cannot tale it. She is distressful, restless, and dishevelled.
a) What are the differential diagnoses? 5
b) How will you proceed to reach the diagnosis? 5

11. A 40-year old female has been suffering from schizophrenia since last 12 years. She treated with a series of antipsychotics and finally responded with Clozapine, 550 mg in divided dose. Her only persisting symptom is infrequent hearing of mostly unclear voice though she is not reacting as before.
a) What could be further treatment plan? 5
b) How will you counsel the patent and her caregivers?  5

12. A 30-years old man survived after jumping from the rooftop. He admitted in the Orthopaedic department of your hospital due to multiple fractures and other complains. After his stability, he has been asked why he did such act. He replied that he had no way other than such act as he was commanded to do so. He is anxious, sad and occasionally perplexed. You are requested to see this patient.
a) What is your first diagnostic impression? 5
b) What will be your treatment plan?  5

13. A 17-year old boy presents with irritable and depressed mood since last 3 months. Subsequently, he has been developed mild hand tremor and spastic gait that are gradually History reveals that parents have consanguinity. On examination, cogwheel rigidity was found.
a) What are the areas you need to explore to reach a diagnosis? 6
b) What could be the first line investigations you need to do? 4

14. A 26-years old male has been suffering from schizophrenia since last 6 years. He has been treated with a series of antipsychotics with poor outcome and finally significantly responded with Clozapine. Though most of the symptoms disappeared and decreased in intensity and frequency, still he has hearing of voices with derogatory comments that makes him resentful, fearful and occasional excitement. The drug has been increased up to 600 mg/day with divided dose no further improvement is observed.
a) What could be further treatment plan for this patient?  6
b) What are the points you have to communicate the patient and his caregivers aboutfurther treatment and its outcome? 4

15. A 26- year old woman brought to you who is violent, refuses to take food, and lacks sleep and self-care. Parents report that she is totally upset after sudden breakup of her long relationship one week back. Three days back, she blames her mother for her misfortune and repeatedly utters to her father to divorce her mother at once. Father surprises of her talks and tries to make her comfort. She became furious and started breaking household things. Subsequently, they find too difficult to control her. She has a younger brother with schizophrenia.
a) How would you proceed to assess this case?  6
b) Outline the management plan for this case.         4

16. A 24-year old women presents with amnesia, impulsive-aggressive, self-injurious behaviour, food refusal and recent overdosing. She has repeated history of self-harm, impulsivity and unstable relationship. She looks sad and irritable.
a) What will be most possible diagnosis? 5
b) Give an outline of the assessment plan. 5

17. A 23-year old university student has been arrested from prime minister’s official gate by police and is brought to you for assessment. It is alleged that he was shouting,” I want to meet prime minister and put some proposal for the development of the country”. He also mentioned that conspiracy was going on against the prime minister. On physical examination, his blood pressure found 165/100 mm Hg.
a) What are the areas you need to explore in his present history?   4
b) What additional information would be useful? 2
c) What is your differential diagnosis? 4

18. A 32-year old housewife presents with intrusive thought of contamination and severe washing rituals. She has been diagnosed as OCD and subsequently treated with fluvoxamine followed by clomipramine with adequate dose and duration. She has also received exposure with response prevention appropriately. Initially, there is significant response but after three months, her condition relapses. She does compulsive behaviour aggressively and says that it is rational.
a) What will be further treatment plan?  6
b) What information you need to give to the patient and family members at this point? 4

19. A 35-year old patient with schizophrenia is under clozapine and responded well. Recently, he develops repetitive thought of something worse will be happened, as mother will die if he does not touch specific things. To prevent this thought he does some bizarre motor movement that is somewhat stereotypic in nature.
a) What are the areas you need to assess? 5
b) How will you manage this case? 5

20. A 36-year old woman comes to you for follow-up who is under Disodium valproate and valproic acid for her manic episode that is partially remitted. You come to know that she has 4 months pregnancy.
a) List the information you need to be gathered. 4
b) List the steps of further management.  6

21. A 30-year old man attends in follow-up who is diagnosed as depressive disorder and getting sertraline 50 mg/day since last two weeks. He says that he has lack of sexual desire as well as dysfunction.
a) Mention the areas you need to evaluate further. 5
b) What measures you need to take? 5

22. A 28-year old woman is a diagnosed case of bipolar disorder, recent episode manic who attends in psychiatry OPD as part of periodic follow-up. She is getting disodium valproate & valproic acid along with quetiapine. Her symptoms significantly remitted since last five months. She has three mood episodes in the last three years and the average duration of each episode is about 7 months. Now, she wants to conceive a child.
a) What information is necessary to address her desire? 5
b) How will you counsel this patient? 5

23. A 30-year old male is under treatment for his schizophrenia since last one and half year. He is under olanzapine 20mg/day. Now he wants to marry and asks whether it could help in his treatment.
a) List necessary information those are required to counsel this patient. 6
b) Mention the issues you need to communicate during counselling this patient. 4

24. A 35-year old man is admitted in psychiatry ward suddenly becomes violent at his office and assaults his boss. He talks incoherently and poorly responsive. Your consultant asks you to evaluate the patient.
a) What are the differential diagnoses you will keep in your mind?  4
b) What are the areas you need to explore to reach a diagnosis?  3
c) What investigations you need to do in first step? 3

25. A 26-year old woman who is a diagnosed case of borderline personality disorder admitted in the psychiatry department after serious overdosing.
a) List the measures you will take immediately for preventing farther self-harm. 5
b) What information you will gather to assess suicidal risk? 5

26. A 22-year old woman attends in psychiatry OPD who says that she has been watched whenever she stays in and uses toilet. She is upset and irritable.
a) List the related information necessary to find out the reasons of her problem. 6
b) What is your differential diagnoses? 4

27. A 32-year old petty officer brought by his parents who starts saying that he  is the son of the president of USA and the  owner of Microsoft. He hears and   does daily task from Dhaka through a special device that is superior to internet. His parents say that he shouts and violent without apparent reason, not going his office and now takes very little care of himself. He has long history of cannabis intake.
a) What else are required to reach a diagnosis? 5
b) What investigations you need to do at this point? 5

28. A 24-year old patient attended in psychiatry OPD got a diagnosis of anxious personality disorder and is getting psychotherapy. Since last 3 months, he appears to be marked anxious, keeps himself isolated and talks very little. Subsequently, he did not turn up for his previous two appointments. You are asked to assess the patient.
a) Gather relevant information related to his recent changes in behaviour considering differential diagnoses. 6
b) What could be the revised management plan for this case? 4

29. A 28-year old woman admitted in stuporus condition in psychiatry word. After five days of conservative treatment, she starts talking and only says, “My everything has finished”. On repeated inquires she says nothing. She is retarded, very much clingy to her attendant, and dependent in all the ways in her daily functioning. She walks with support and inconstant swinging gait observed.
a) What will be the differential diagnoses? 5
b) How will you proceed further to assess her? 5

30. A 41-year old male works as a banker. In late 20’s he diagnosed with schizophrenia. Because of his unremitting auditory hallucinations, eventually prescribed clozapine and that responds well. Five-year letter, obsessive thoughts and compulsive urges to make antireligious and sexual comments. He is worried that he would act, and scared of living home. He becomes increasingly withdrawn and isolated. More recently, compulsive checking of door and taps are developed. No paranoia, apathy, blunting of affect and poverty of thought observed. The declines in social and occupational functioning are developed.
a) How can you explain the patient’s present situation? 5
b) Outline the possible further management plan. 5

31. A 32-year old woman presented in psychiatry OPD who leaves from her house in Dhaka 7 days back at morning without informing family members and found in Kumilla at night after extensive search. She cannot recall the events during that period. Similar episode happened two years back.
a) What are the areas you need to assess? 6
b) What investigations you need to do considering differential diagnoses? 4

32. A 30-years old housewife is assigned the diagnosis of Major Depressive Disorder during her first visit in psychiatry OPD. Subsequent assessment revels that she has obsessive thoughts of contamination and compulsive cleaning since last 10 years that run in a waxing and waning course. Since last one year, the obsessive-compulsive symptoms turn into severe in nature. Further, blasphemous obsession and compulsive begging pardon appear. More recently, she mutters frequently and becomes confined herself in house. Significant decline of personal, familial and social functioning observed.
a) Make an effective treatment plan for this woman.  6
b) Outline the prognosis of this case.  4

33. A 28-year old man is treating form his manic episode in psychiatry OPD. On subsequent follow up it explored that he misuses amphetamine and cannabis.
a) Mention the assessment areas that you need to explore. 5
b) How would you manage this case? 5

34. A 25-year old male patient with refractory schizophrenia is under clozapine 400 mg/day in bid dose since 4 weeks with good response though the derogatory and distressful voices still present. Due to his associated obsessional doubt, fluoxetine 40mg/day is given. After developing sudden seizure attack, he has been prescribed sodium valproate 600 mg /day. Now the patent comes with further seizure attack.
a) Prepare a checklist for the assessment of this case. 5
b) Outline treatment plan. 5

35. A 20-year old married girl admitted in the neurosurgery department who becomes unconscious and has small intra cranial haemorrhage in the right frontal region after falling from Rickshaw. After conservative treatment, she becomes stable. However, suddenly she develops difficulty in speech, frequent fit, weakness of limbs, tempered behaviour, sleep disturbances, and for that referred to psychiatry. The girl did excellent result in her HSC exam and currently is preparing for university admission test. She has six-week pregnancy. Her family members are markedly worried about her situation.
a) What will be best possible diagnosis? 4
b) Outline the management plan.  6

36. A 28-year old woman presents in psychiatry OPD who suddenly starts hitting her new-born baby 7 days after child’s birth. This repetitively happens that threatens baby’s’ life. The woman looks very indifferent.
a) Prepare a checklist of assessment mentioning the areas and reasons. 5
b) What could be possible diagnoses? 2
c) Outline the management plan for this case. 3

37. A 30-year old woman binge eats and vomits since last 7 years. Recently she appears to be depressed and seeks help for her problem. Her persistent underweight gradually changes to overweight.
a) Outline the assessment plan considering possible diagnoses. 6
b) What investigations you will do at this point? 4

38. A 39-year old man attends in psychiatry OPD forcefully by his wife and family members who is suspicious and increasingly asultative since 5 years. He says that wife has intense sexual relationship with his 14-year old son that he knows from hearing the repetitive erotic conversations spreading through the sound of moving ceiling fan. As he is vocal about the matter wife tries to damage him in all the ways and cleverly convinces his family members. Ultimately, all are involved in plotting against him for their gains and now want to proof him “mad”. Family members says that he drives his elder son from the house, does not sleep , beats wife, shouts and now threats that everything must be end. He looked very irritable and resentful.
a) What is the most likely diagnosis? 4
b) What is the information you need to gather for the management of this case. 6

39. A 28-year old woman presents in psychiatry OPD with her husband who has intrusive though and image of husband’s love relationship with a woman who is their distant relatives since last four months. Husband disapproves the fact saying that he has had some casual meeting and telephone conversation with his sister like relative. The woman is worried with fearful anticipation, depressive and has repetitive suicidal thought.
a) What could be best possible diagnosis? 6
b) Make a treatment plan for this case. 4

40. A 40-year old man attends in psychiatry OPD who is persistently querulous, impulsive and has unstable interpersonal relationship. After completing his masters, he starts doing job. Up to this point, he does about 23 jobs consequently and most of the times fired. He is unemployed now. His first wife left him and has persistent discord with present wife. Throughout the conversation, he appears indifferent.
a) What will be most likely diagnosis? 6
b) Make an assessment plan for the case. 4

41. A 27-year old male presents at gastroenterology ward with the complaints of severe abdominal pain and hematemesis. He reports tenderness during palpation and distress. Subsequent investigations revealed no abnormality. Review of the medical record shows that this is the third time in the past year that the patient has appeared for medical attention. On each previous occasion, no identifiable medical problem could be uncovered. Despite of his hematemesis in the ward as he said, neither he is able to show nor is observed. He referred for psychiatric evaluation. When he is confronted with the history, the patient confesses that he manufactures his symptoms before coming to the hospital. He says that he knows this is wrong, but he cannot stop himself for doing this.
a) What is the most likely diagnosis for this case? 3
b) Mention your assessment and treatment plan. 7

42. A 32-year old woman appears in psychiatry OPD with incoherent talks, excessive religiosity, marked lack of concentration, agitation, excessive talkativeness and marked distressful for 3 days. She is relocated with new house 2 months back and cannot adapt herself with new situation. Further, she watches a video that content is horrific after life fiction.
a) What information you need to gather to reach a diagnosis? 6
b) What could be your treatment plan?  4

43. A 21-year old female appears with fear of increasing weight despite of significantly low body weight. She takes low quantity of food, does vigorous exercise, long times cycling with the aim of burning calories. She repeatedly confronts with parents about their concerns of her low body weight. Occasionally, she takes excessive amount of food and vomits thereafter.
a) What could be most likely diagnoses? 5
b) Outline the assessment plan. 5

44. A 27-year old woman with third trimester pregnancy comes with self-muttering, aggressiveness and suicidal attempt. She believes that her family members will kill her baby.
a) How will you asses this case keeping in mind the diagnosis? 4
b) Outline the management plan. 4
c) What information you need to provide the caregivers based on your prediction? 2

45. A 58-year old man has been admitted in medicine unite for hepatomegaly and jaundice. Subsequently he develops excessive sweating, agitation, tremor and insomnia and thereby psychiatric referral is given for him. It revealed that he intakes alcohol since last 15 years.
a) What are the areas of your assessment?  5
b) How will you manage this case?  5

46. A 41-year old woman brought to psychiatry OPD by her family. The family reports that since last three years she has had trouble controlling her movements. She has frequent and brisk jerks of the pelvis and limbs as well as grimacing and smirking movements of the face. Recently, she forgets easily and cannot able to do her usual activates.
a) What is the most likely diagnosis? 5
b) Outline the required information and investigations. 5

47. A 44-year old male referred from emergency suffering from head trauma following an automobile accident. Over the next week, he develops hallucinations, delusions, incoherence and poor verbal comprehension.
a) What is your diagnosis?  4
b) What is your management plan? 6

48. A 28-year old woman appeared in psychiatry OPD with her family members who recently gives birth a male child. She is nearly mute, takes little food, and does not sleep. She always holding her baby in her womb and does not allow anyone to take her child from her but cares the child very little. She appears dishevelled.
a) How would you proceed considering differential diagnoses? 6
b) Outline the management plan. 4

49. A 32-year old man appears in psychiatry OPD with family member who suddenly becomes suspicious, hears threatening voices of aliens, controlling experience of preventing him to do his desired act since 2 weeks. He has had manic episode one year back that responded well in treatment. He looks fearful, agitated and excited.
a) What is the best possible diagnosis? 5
b) Outline the management plan. 5

50. A 32-year old man is a known case of schizophrenia since last five years. He responds well with antipsychotics but relapses since last one month after noncompliance. He also has similar prior history of response and relapse.
a) Make a checklist of the assessment areas. 5
b) How will you treat this case? 5

51. A 72-year old man brought by his family members in psychiatry OPD. The family says that for the last 6 months he does disinherited sexual behaviour at home that is increasingly odd, pervasive and embarrassing. The female members of the family are scared after a recent incidence when he tried to do sexual act with his wife in front of others. He has long history of hypertension and a stroke. The family informs that as a person he is well balanced, polished and successful in his profession, now spending retired life. He is euphoric, over familiar and talks spontaneously.
a) Make a checklist of information keeping the diagnoses in your mind.  6
b) What investigation will you do at this point?    4

52. A 25-year old woman has rushed to emergency department asking for help. She describes recurrent episodes of fearfulness, palpitation, faintness, hyperventilation, dryness of the mouth with perioral paraesthesia and curpopedal spasm. Her symptoms last 5-10 minutes and have increased since their onset 3 months ago. She is worried she may be having heart attack. An ECG shows sinus tachycardia.
a) What is the single most likely diagnosis? 4
b) What is the immediate and ultimate intervention? 6

53. A 25-year old girl refereed from ophthalmology OPD to your OPD who saw a horrific RTA in which a young boy died. The night of the event, she could not sleep and the day after she suddenly lost her vision.
a) What is the most likely diagnosis? 5
b) Outline the treatment plan. 5

54. A 45-year old woman brought to psychiatry OPD by her sister who is sad and fatigue. She is eating more, has sleep disturbance, and hears the voice of her husband who died 2 years ago.
a) What is the most appropriate diagnosis? 5
b) Make a checklist of the areas of your assessment for treatment plan. 5

55. A 20-year old man appears in Psychiatry OPD who has palpitation, dyspnoea, chest compression, and sweating and sleep disturbance. He trembles during his class presentations, worries to keep and make friends and finds heard to be easy in social situations. Since one year, he repetitively things about his past acts and upsets to find his possible faults. He worries about future events, cannot concentrate in his work and performs badly during exam.
a) What is the best possible diagnosis? 6
b) Make a treatment plan for this case. 4

56. A 34-year old man presents with low mood, low food intake and most of the time lies in bed since two month. He says that his abdominal structures are rotten as he has already died and surprises that no one is burring him.
a) What is the most likely diagnosis? 4
b) Outline the management plan. 6

57. A 62-year old man presents with low mood, does not find worth in living and lack of self-care. His son says that he frequently converses with his deceased wife who died 6 months back.
a) What is the best possible diagnosis? 4
b) Make a checklist of the information for treatment plan. 6

58. A 31-year old woman presents with two weeks following child birth who losses of feelings for the child, losses appetite, sleep disturbances and intrusive thought of harming the baby.
a) What is the best possible diagnosis?  5
b) What treatment plan you want to adopt for this case? 5

59. A 28-year old female who delivered 6 weeks ago feels sad and has no interest to feeding the baby. She has been eating poorly and having difficulty sleeping. She feels weak throughout the day and has stopped going out of the house. She also says that baby has evil eyes.
a) What is most likely diagnosis? 5
b) Outline the management plan.  5

60. A 36-year old female attends in the psychiatry OPD who attempted suicide 10 times. There is no history of psychiatric problems and neurological examinations are normal.
a) Mention the areas of your assessment plan. 5
b) Outline the best possible treatment plan for her. 5

61. A 71-year old man admitted in internal medicine who presents with fever for 3 days and confusion. There is no significant past medical history. He has a psychiatric referral.
a) What is the possible diagnosis? 4
b) List the information you need to require for managing this case. 3
c) How will you manage this case? 3

62. A 36-year old man with history of schizophrenia brought to the emergency department by his friends due to drowsiness. On examination, he is generally rigid.
a) What could be best possible diagnosis? 4
b) Outline the assessment and management plan.  6

63. A 30-year old woman in tears describing constant irritability with her 2 small children and inability to relax. She describes herself as easily startled with poor sleep and disturbed nightmares following a house fire a year ago, while the family slept.
a) What is the most likely diagnosis? 4
b) What treatment you will offer this woman?  6

64. A 25-year old woman has schizophrenia responded well with risperidone 8 mg /day. Subsequently she has been developed hyperprolactinemia and switched to aripiprazole. Her hyperprolactinemia was managed well but symptoms recur.
a) What information you need to gather as part of your assessment? 6
b) How will you manage this case? 4

65. A 32-year old man presented with mutism. Three weeks back he was markedly agitated. During interview, he showed marked negativism.
a) What is your differential diagnoses? 4
a) Outline your steps of assessment  6

66. A 48-year old man admitted in emergency after road traffic accident. Three days after he develops tremor, agitation and generalized seizure.
a) What could be best possible diagnosis? 5
b) Outline the management plan. 5

67. A 36-year old male depressed patient who is under medication and in partial remission. He fears to marry due to possible worse consequences of his sexual problem.
a) Prepare a checklist of necessary information as part of your assessment of this case. 6
b) What information you need to communicate to the patient? 4

68. A 30-year old male brought to psychiatric emergency who is severely excited, abusive and shouted continuously.
a) Outline your assessment and management plan in the first step. 7
b) What steps you will take to tranquilize this patient? 3

60. A 33-year old man referred by an internist presents himself bearing with huge medical documents. He says that he is sufficiently convinced that he has some sorts of illness that cause multiple physical symptoms mainly palpitation, difficulty breathing and feeling of fainting but  doctors  could not find any disease. Now he avoids moving alone due to his extreme fear of death that caused serious disruption of his regular life. He expresses disappointed with his problems and is planning to go abroad for better treatment.
a) What is your diagnosis?  4
b) Make a checklist to assess this case.  6

70. A 22-year old girl attends in psychiatry OPD with her parents. She believes that her face is gradually going deformed since last three years. She does not go school and avoid social situation as she thinks that she looks ugly and others talk about the matter. Gradually, she keeps herself confined in her room, avoids looking on mirrors. She shows two photos of her from her mobile captured in different time intervals in favour of her statement but no significant difference and deformity observed. She looks anxious and marked distressful.
a) Outline the assessment process to reach diagnosis. 5
b) What will be your treatment plan? 5

71. A 25-year old woman has intrusive thought that God is her husband. That causes her severe distress and she frequently begs pardon to God. Subsequently she started irresistible hair pulling that causes her relieved tension.
a) Prepare a checklist of the assessment areas.  5
b) Outline the management plan.  5

72. A 25-year old woman brought to the emergency by her boyfriend. She has many superficial lacerations on her forearm. She is so distresses and constantly says her boyfriend is going to end the relationship. On questioning, she denies trying to end her life.
a) What is most likely diagnosis? 4
b) What relevant information you need to gather for making a treatment plan? 6

73. A 38-year old woman has always been extremely neat and conscientious, good performer in her executive post of a corporate company. She stays long after normal working hours to check on the punctuation and spelling of letters that she prepared during the day. Although her work is impeccable, she has few close relationships with others. Her boss referred her for counselling after she repeatedly got into fights with her co-workers. “They just don’t take the job seriously,’’ she said disapprovingly about them. ‘’All they seem to want to do is joke around all day.’’
a) What is the most likely preliminary diagnosis for this patient?  4
b) Outline the main areas of assessment to make the treatment plan.  6

74. A 55-year old man who is a diagnosed case of MDD and under SSRI since 2 years with good response attends psychiatry OPD for review. He describes last few months of worsening fatigue, daytime sleepiness and generally “not feeling good”. He is adherent to medication and denies stressors. He sleeps well but has frequent awakenings with chocking sensation and has nocturia. His wife says he snores very loudly and intermittently stop breathing and gasping for air. Nevertheless, he says he snores since childhood and adds “all the men in my family are snorers”. He is hypertensive, diabetic and receiving treatment for these. He complains of heartburn and erectile dysfunction and headache. On examination, he weighed 89 kg, respiratory rate 90, BP 145/90. He appeared tired but without depressed mood or cognitive decline.
a) What could be best possible diagnosis for his additional presenting complaints? 5
b) Make a list of the assessment areas to confirm diagnosis and making treatment plan. 5

75. A 30 year-old man appears in psychiatry OPD with anxious-distressed condition. He says that he has intrusive thought of having diabetes after curiously assessing her blood sugar at home, which was 3.8 mg/ml. Subsequently, he has been consulted a series of physicians with repeated relevant investigations despite of clear exclusion of diabetes. He agrees with the physicians’ opinion. However, repeated thought of past ‘3.8 gm/ml’ finding upsets him that causes disruption of his daily activities.
a) What are the possible diagnoses?  5
b) How will you manage this case? 5

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