Re: Psychiatric Cases

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Posted by Alvin from IP on February 28, 2017 at 14:53:40:

In Reply to: Psychiatric Cases posted by imi on February 02, 2017 at 21:43:34:

Here are my advices to you in any psychiatric case in CSA..

First of all, you have to deal with psychiatric cases as other ordinary case..
Regarding the history taking,
You have to take the history systemically. I mean analysis of the chief complaint, past medical history, family history, social history and menstrual and obs/gyn history in case of female patients. The different thing in psychiatric cases is that you have to emphasize on the social
history..Here are some examples:
· When you ask about the job..Ask: Do you have any problems in your job? How is your performance in your job?
· Have you had any recent emotional or financial problems?
· Have you had any recent traumatic event in your family?
· Are you living alone or you are living with anybody else? Does anybody support you?
These are the very important questions that should be emphasized in the social history ..You have to try to ask them once you feel that the case you are dealing with is a psychiatric case..

In addition to that, there are specific questions that should be asked in each case if you know the diagnosis(see below)

Up to my knowledge, the psychiatric cases that has been introduced in the CSA so far are as follows;
· Generalized anxiety/panic disorder.
· Posttraumatic stress disorder(PTSD)
· Dementia
· Depression (mild and major)

There some specific questions in each case that should be asked:
Have you ever had any head trauma?, Do you complain of any heart problems?, Do you complain of high blood pressure or DM?, Do you have any problems in remembering things?, Do you have any problems in performing your daily activities like shopping or transferring ?
Do you have any problems in using instruments in your life like cooking or telephoning? Do you have any feeling of depression, hopelessness or worthlessness?
One of my friend had a case of dementia and he immediately diagnosed the case when the patient said to him, “I made a fire in my house”

"SIGN E CAPS" which stands for: Sleeping disorders(Do you have difficulty in falling asleep or in maintaining your sleep?) Loss of Interest(Do you feel that you have lost your interest in the surroundings, in your social relationships?) Guilt sensation (Do you have the feeling of
guilt or blame?) Loss of Energy (Do you feel fatigue or weak?) Lack of Concentration (Do you feel that you have lost your concentration while doing things?)
Loss of Appetite and weight(Do you have any weight or appetite changes. Don’t ask the patient closed question like Did you lose weight?) Suicidal thoughts(Have you ever tried to kill yourself ? Did you have any suicidal attempts in the past? Do you have any suicidal plans?).
Remember that if the patient said that he has any suicidal ideations or intentions, you will directly diagnose the depression as MAJOR/SEVERE Depression. Otherwise, it will be mild/moderate .
In depression cases, don’t forget to cover hypothyroidism questions..since it is one of the differential diagnosis (Do you have any changes in your bowel movements?, Do you feel that you like to be in warm places and you no longer tolerate the cold places?, Did you notice
any changes in your skin, hair?)

PTSD: Do you have any sleeping disorders? Do you have any nightmares?, Have you had any recent traumatic event?

ANXIETY/PANIC DISORDERS: Do you fright feelings? Is there anything that makes you feel afraid or frightened? Do you have episodes of shortness of breath and sweating?

You can also ask : Do you hear any strange sounds in your ears? Do you see any strange objects?(Auditory and visual hallucinations. just in case you have a case of schizophrenia ..who knows?)

Regarding the physical exam in psychiatric cases:

I will tell you here the exact scenario that you have to do in exam.:

1- I would like to ask you some questions to see your orientation(Always tell the patient what you are going to do…this is very important in your communication skills!!):
Can you tell your name and age?(person orientation)Do you know where are we now?(place orientation) Do you know what the day is it today?(time orientation)
Show him/her your pen and ask the patient” Do you know what is this?”
2- Now I would like to ask you some questions to see how your memory is..
I will name three objects to you and I want you to repeat them immediately,OK?
Bed, pen and book..(Immediate memory) After the patients mentions the names, tell him “I will ask you to repeat these names after few minutes(short memory)
Do you remember how was the weather yesterday?(recent memory)
Do you remember your birth date?(distant memory?)
Now, can you repeat for me the names that I have just mentioned to you?(short memory)
3- Ask the patient ,” Are you left handed or right handed?”… I will give you a piece of paper. I want you to take the paper from my hand, fold the paper in its half and put it on the floor (3-step command)
4- After the patient completes the 3-step command and while the paper in his hand, ask him,” Now I want to write on the paper any sentence of your own choice”. after that,tell him”I want you to draw a face of clock with its hands and make its hands on 10 and 11”
5- Ask the patient ,,I want you to spell the word (world) backwards. If you have problems in the pronunciation of these two words, ask him to substract 7 from 100 serially..(CONCENTRATION)
6- If you still have time, ask him. would you mind explaining this proverb for me (people who live in glassy houses shouldn’t throw stones) (ABSTRACT and REASONING)
What would you do if you see a fire coming out from a paper basket? (JUDGEMENT)

I think that doing the first five steps is enough and make the sixth step if you have more time..
I do believe that these steps of examination are the steps that should be done..
Don’t forget to make chest examination in case of dementia!!

Remember that when the patient does any exam step in a right way..praise the patient (Great ! you are doing well!)..This is very important in your communication skills..
When the patient complains of bad thing , show sympathy to him/her in an EXAGERATED MANNER…(Oh! I am so sorry to hear that! ….That must be very difficult to you…I konw that you are suffering but don’t worry.. I will try to help you..say these sympathetic phrases
throughtout history taking and physical examination)..All these are very important in COM. skills!!!!

Regarding the patient notes in psychiatric cases:

You have to write it down as in other ordinary cases but here are the differences:

In the division of physical examination write the following:
Comment of the speech pace and eye contact
Example:The patient speaks at a slow pace with poor eye contact. No hostile behavior toward the interviewer. Blunt affect. Lack of concentration and interest in the interviewer.
Then write down your findings in the exam steps that I have mentioned above;

· Immediate, short memories are intact- Recent and distant memories are impaired.
· Oriented to person, date and place.
· Completed 3-step command.
· Right-handed.
· Lacks concentration-cannot substract 7 from 100 correctly.
· Drawed the face of clock with its hands correctly
· Concrete abstract-explained the proverb in a concrete way
· Poor judgment

When you come to the work-up, I recommend that you write down the followings:
1-CBC (in all cases)
2- Head CT/ MRI (in cases of dementia)
3-T4/ TSH(in cases of depression)
4-Folate and B6 serum levels (in cases of dementia)
5-EKG and echocardiography (in dementia)
6-You can also add; neuro-psychatric tests..(just to fill the space!!)

I hope that these information will help you MASTER all psychiatric cases ..use my advices in com. skills in all other cases..

I wish you the best in your exam..

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