CBLE- Psychiatry
Examples Exercise
Example-1
A 22-year old boy is brought to emergency by his father
because of his son is found “abnormal and non communicative”. Father suspects the boy is addict. Preliminary examination shows the boy to be drowsy,
with slurred speech, pupilary constriction, lethargy and generally positive effect.
| a) Based on the initial presentation what could be possible diagnosis? | 4 |
| b) How will you proceed for diagnostic confirmation? | 2 |
| c) What is your immediate management plan for this boy? | 4 |
Extraction
- Presenting features indicative of substance intoxication
- Pupilary constriction and lethargy-signs of opiates intoxication
- Father’s suspect- strongly indicative of addiction
- No such information of other causes of confusion
- No better explained other substance intoxication
Tasks
Dx- Opiates intoxication
Assessment for Dx confirmation
- Toxicological test
Immediate Rx plan
- Hospitalization
- Maintenance of nutrition, fluid, electrolytes
- Checking and monitoring vitals
- Measures of confessional state
- Details history, clinical exams and lab investigations for diagnostic confirmation
- Detoxification
Example-2
A 26-year old male presents in psychiatry OPD who had been arrested for the charge of snatching act with gang. After getting bell he has been forcefully confined at home. Since then he develops insomnia, low mood and bad dreams. Parents report his long lasting challenging, aggressive, demanding behaviours. He had previously been treated for opiate misuse.
| a)What could be your best possible diagnostic impression? | 5 |
| b)Make a check list of your assessment plan. | 5 |
Extraction
- s/s starts after confinement
- insomnia, low mood and bad dream are the key features of amphetamine withdrawal
- Possibly not depressive due to pattern of onset, lack of evidence of other features including duration
- challenging, aggressive, demanding traits- APD
- Long standing indicative of prior CD
- H/o addiction and its Rx further support APD and addiction
- May be poly-druge misuse either co or continuum
Tasks
Dx- Amphetamine withdrawal, APD
Assessment
- Other features and Dope test for confirming Dx
- Use the line of general assessment of a case
- Details of drug misuse-prior or present SUD
- Details of personality traits, law-breaking behaviour and co-morbid or co-features of other PD types
- ODD-CD continuity or other syndromal co-morbidity-mainly depression
- Assessing general health and mental health status- general, systemic exam, MSE including risk assessment, relevant lab test
- Toxicological test for other substances
- Psychometrics
Example-3
25-year old woman was 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 |
Extraction
- Impulsive act
- Indicative of intense but short-lived attachment
- Strong indicative of non-suicidal injury
- Seems to be attention seeker
- All goes in favour of BPD
- Not Histrionic: no evidence of other features except attention seeking
- Not Depressive: The distress can be explained by the overall situation, self harm is non-suicidal and better explained by attention seeking
Tasks
Dx-BPD
Information to be gathered
- General assessment of a case
- Details of personality traits/other features
- Impairment of personality functioning areas-identity, self-direction, empathy, intimacy
- Any past/present co-morbidities
- Risk-immediate and predictive
- Family and social life situations
- Early upbringing -Parental attitude, any ACEs-S Abuse
Example-4
A 30-year old male patient in medicine OPD refuses to provide answers during initiating history taking like address, family information. When asked the reason for the refusal, he replies he does not see why the physician needs such irrelevant information and watches the physicians suspiciously. When pressed further, he asks angrily, “Are you going to treat me or my family? Should I complain to the authority?” The surprised physician discussed the matter to you.
| a) What is the most possible diagnosis? | 4 |
| b) What strategies you will adopt to advocate the physicians to assess and manage such case? | 6 |
Extraction
- Has definite suspiciousness in general as he comes for medical consultation and also evident by the pattern of behaviour
- Mistrust
- Indicative of Paranoid PD
- Possibly not paranoid schizo because of general pattern of suspicious behaviour and no indication of psychotic features
- Possibly not paranoid DD no evidence of fixed and focused delusions
Tasks
Dx- PPD
Strategies of advocacy
- Firm and assertive approach
- Give him space to understand his odds
- Enhance observational learning
- Offer consultation when he requests or agrees
- Develop trusted and empathic relationship
- Refer to psychiatry after recognizing his problems subsequently
Example-5
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 |
Extraction
- Neat and conscientious traits
- Confirm evidence of perfectionist trait
- Focusing in details, loving routine-evidence of orderliness
- Having sense that there is only one way to do thing-rigid evident in her statement
- Few close relationships
- Possibly, lacks sense of diversity and humour
- Evidence of impairment of at least 2 personality areas; loss of sense of self derived from work pattern (identity)
- Rigidity and stubbornness –vely effect relationship (intimacy)
- All these go in favour OCPD
- Not borderline, though repeated fights-can be explained by his inflexibility, rigidity, orderliness
- Not OCD because the evidence of traits
Tasks
Dx- OCPD
Assessment Plan
- Desire of seeking treatment or help and its intensity-for engagement task and subsequent long term no-directive therapy
- Follow general assessment line
- Impairment status of personality functioning areas
- Listing disgraceful, annoying and distressful objects, activities and situations for behaviour therapy extinction, rewards
- Aggravating factors-for counselling to avoid, minimize, acceptance
- Comorbities or associated features- anxiety and depression for specific Rx
- Stressors- for stress management therapy and adopting coping strategy
- Level of preparedness for group therapy
Example-6
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. But he says he snores since childhood adds “all the men in my family are snorers”. He is hypertensive, diabetic and receiving treatment for these. He complains of heart burn and erectile dysfunction and headache. On examination he weighted 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 |
Extraction
- Revaluation of depression- stable
- Presenting symptoms: fatigue and sleepiness are notable than for depression
- Loud snoring, episodes of chocking sensation and gasping strongly suggestive of OSAH
- No other features of GMCs for explaining all these symptoms
- Repeated arousal further evidence of apnoea to restore normal breathing
- Other symptoms-heartburn,nocturia,sexual dysfunction, headeachs reflecting the multisytemic effects of OSAH
- Risk factors like above age 50, obesity, and family h/o of snoring for all men go as further supporting evidence
Tasks
a)Dx: Obstructive Sleep Apnea Hypopnoea(OSAH)/Obstructive Sleep Apnoea(Pickwickian syndrome)a)
Tasks
b) Assessment
- General physical assessment-system examinations for any other associated disorder and status of present disorders
- General assessment of a psychiatric case
- Sleep history, Sleep diary,3rd party report
- Assessment of risk factors: BMI and others
- Video
- Polysomnography-to confirm the diagnosis and assess severityAHI(Apnea hypopnea index); 15 & /hour is diagnostic for OSAH AHI=15 or Mild 15-30 Moderate 30 severeOther indexes (Oxygen desaturation index, % Time with O2 saturation 90%, Arousal index, Sleep stage% N1,N2,N3,N4,REM) gives clear pictures as supporting evidence and also for indicative of Rx plan.
- Other relevant lab investigations
- Relevant information for appropriate referral note