presenting a psychiatry long case in final professional undergraduate examination date: March 2003

1. Pro3 RevisionPro3 Revision

2. Common Long CasesCommon Long Cases
 In-patient = psychoticIn-patient = psychotic
 SchizophreniaSchizophrenia
 Major depression w psychotic featMajor depression w psychotic feat
 Mania w psychotic featuresMania w psychotic features
 Out-patient = neuroticOut-patient = neurotic
 DepressionDepression
 Anxiety disordersAnxiety disorders
 Panic with agoraphobiaPanic with agoraphobia
 Social phobiaSocial phobia

3. Less Common CasesLess Common Cases
 In-patientIn-patient
 Organic disorderOrganic disorder
 Mental disorder DTGMCMental disorder DTGMC
 Psychotic disorder due to epilepsyPsychotic disorder due to epilepsy
 Substance-related disorderSubstance-related disorder
 Addiction or dependenceAddiction or dependence
 Substance-induced psychosisSubstance-induced psychosis
 Out-patientOut-patient
 GADGAD
 OCDOCD

4. Presenting Long Case - 1Presenting Long Case - 1
 Diagnosis & managementDiagnosis & management
 SymptomsSymptoms
 Objective = observableObjective = observable
 Subjective = phenomenologySubjective = phenomenology
 SyndromesSyndromes
 Number, duration, severityNumber, duration, severity
 May be > 1May be > 1
 Cross sectional and longitudinalCross sectional and longitudinal

5. Presenting Long Case - 2Presenting Long Case - 2
 DisorderDisorder
 CharacteristicsCharacteristics
 TypicalTypical
 Illness = subjective distressIllness = subjective distress
 PatientPatient
 Side-effects, compliance, stigmaSide-effects, compliance, stigma
 FamilyFamily
 BurdenBurden
 StressorsStressors
 Precipitating & perpetuating factorsPrecipitating & perpetuating factors

6. Presenting Long Case - 3Presenting Long Case - 3
 Chief complaintChief complaint
 Be as accurate possibleBe as accurate possible
 Punched father vs. aggressivePunched father vs. aggressive
 Avoid technical termAvoid technical term
 Heard voices vs. audit. hallucinationsHeard voices vs. audit. hallucinations
 Consider patient poor insightConsider patient poor insight
 Choose easy to elaborateChoose easy to elaborate
 Typical of the illnessTypical of the illness
 Example palpitations for panicExample palpitations for panic

7. Presenting Long Case - 4Presenting Long Case - 4
 HOPIHOPI
 Most crucialMost crucial
 SymptomsSymptoms  illnessillness
 Inclusion = relevant +veInclusion = relevant +ve
 Adequate to convinced examinerAdequate to convinced examiner
 e.g. provide examples of pt behaviore.g. provide examples of pt behavior
 Exclusion = relevant -veExclusion = relevant -ve
 Need not be detail … to save timeNeed not be detail … to save time
 e.g. no history to suggest organicity suche.g. no history to suggest organicity such
as recent head trauma etcas recent head trauma etc

8. Presenting Long Case - 5Presenting Long Case - 5
 Past Psych.Past Psych.
 Number of admissionNumber of admission
 e.g. pt was 7 times between 95 to 99e.g. pt was 7 times between 95 to 99
 In between functional levelIn between functional level
 Personal & FamilyPersonal & Family
 Predisposing vs. assetsPredisposing vs. assets
 Disorder & prognosisDisorder & prognosis

9. Presenting Long Case - 6Presenting Long Case - 6
 MSEMSE
 Brief and accurateBrief and accurate
 Use specific termUse specific term
 Provide example when necessaryProvide example when necessary
 Thorough and focusedThorough and focused
 Don’t forget cognitive testDon’t forget cognitive test
 e.g. attention / concentratione.g. attention / concentration
 +ve findings merit > detail+ve findings merit > detail
assessmentassessment
 e.g. in MR, > arithmetic, knowledgee.g. in MR, > arithmetic, knowledge

10. Presenting Long Case - 7Presenting Long Case - 7
 Physical ExaminationPhysical Examination
 Vital signsVital signs
 Relevant systemRelevant system
 History of alcoholismHistory of alcoholism
 Liver, neurologicalLiver, neurological
 Chief complaint palpitationsChief complaint palpitations
 CVS, thyroidCVS, thyroid
 Older patientOlder patient
 Higher possibility of organicHigher possibility of organic

11. Characteristic Vs. TypicalCharacteristic Vs. Typical
 CharacteristicsCharacteristics
 Operational definitionOperational definition  necessary ornecessary or
minimum requiredminimum required
 Sensitivity > specificitySensitivity > specificity
 Need TRO other disordersNeed TRO other disorders
 TypicalTypical
 How much the case resembles theHow much the case resembles the
textbook casetextbook case
 Useful in doubtful casesUseful in doubtful cases
 e.g. Schneider FRSe.g. Schneider FRS

12. Atypical FeaturesAtypical Features
 Make your diagnosis lessMake your diagnosis less
certaincertain  differential dx.differential dx.
 Schizophrenic who plan to getSchizophrenic who plan to get
married, talked in malay + englishmarried, talked in malay + english
 Mania? e.g. schizoaffectiveMania? e.g. schizoaffective
 First onset of mood symptoms atFirst onset of mood symptoms at
60 years of age60 years of age
 Organic? e.g. dementiaOrganic? e.g. dementia

13. SchizophreniaSchizophrenia
 ComplianceCompliance
 Reasons for poor complianceReasons for poor compliance
 Atypical vs. typical antipsychoticsAtypical vs. typical antipsychotics
 Oral vs. depotOral vs. depot
 PsychoeducationPsychoeducation
 BehaviourBehaviour
 Leading to admissionLeading to admission
 Burden to familyBurden to family
 Aggressive, apathy, asocial etcAggressive, apathy, asocial etc

14. ManiaMania
 ComplianceCompliance
 Need for maintenance?Need for maintenance?
 Irritability, aggressiveIrritability, aggressive
 Pleasurable activity wPleasurable activity withith badbad
consequenceconsequence
 Spending spreeSpending spree
 PromiscuityPromiscuity

15. Major DepressionMajor Depression
 Major or not?Major or not?
 Severity, psychotic, durationSeverity, psychotic, duration
 Biological, suicidalBiological, suicidal
 Risk of suicideRisk of suicide
 Suicidal intent?Suicidal intent?
 Psychosocial problemsPsychosocial problems
 Interpersonal conflictsInterpersonal conflicts

16. Panic With AgoraphobiaPanic With Agoraphobia
 RUPARUPA
 RecurrentRecurrent UUnexpected PAnexpected PA
 For stable out-patientFor stable out-patient
 Agoraphobia > panicAgoraphobia > panic
 ImpairmentsImpairments
 May confuse with social phobiaMay confuse with social phobia
 Behavior therapy > anxiolyticsBehavior therapy > anxiolytics

17. Reasoning A Diagnosis – 1Reasoning A Diagnosis – 1
 Provisional diagnosis of pt is …Provisional diagnosis of pt is …
because he has characteristicbecause he has characteristic
features such as …(symptoms)features such as …(symptoms)
…(duration) … (severity)…(duration) … (severity)
 There is no prominent …There is no prominent …
(organic, substance, other axis(organic, substance, other axis
I) to suggest otherwiseI) to suggest otherwise

18. Reasoning A Diagnosis – 2Reasoning A Diagnosis – 2
 DDx is … because bothDDx is … because both
conditions have … (shareconditions have … (share
similar features, thus can besimilar features, thus can be
confused)confused)
 However, … is unlikely becauseHowever, … is unlikely because
… (what make provisional >… (what make provisional >
characteristics or typical)characteristics or typical)

19. ManagementManagement
 Bio and psychosocial approachBio and psychosocial approach
 In two stagesIn two stages
 AcuteAcute = in-patient= in-patient
 Fastest symptoms reductionFastest symptoms reduction
 Primary medication + othersPrimary medication + others
 MaintenanceMaintenance = out-patient= out-patient
 Prevent future recurrence or relapsePrevent future recurrence or relapse
 Primary medication +/- othersPrimary medication +/- others
 Adjunct, augmentationAdjunct, augmentation

20. MEQ - 1MEQ - 1
 A man developed abnormalA man developed abnormal
behavior on the 4th day ofbehavior on the 4th day of
admission to a medical ward.admission to a medical ward.
He was restless, shouting away,He was restless, shouting away,
and hallucinating. Theand hallucinating. The
disturbance was worse at night.disturbance was worse at night.
He was disorientated when youHe was disorientated when you
saw him.saw him.

21.  List two (2) differential diagnosesList two (2) differential diagnoses
 State the phenomenon referred to asState the phenomenon referred to as
“the disturbance was worse at night”“the disturbance was worse at night”
 List two (2) measures with regard toList two (2) measures with regard to
patient’s environment in order topatient’s environment in order to
reduce the severity of phenomenonreduce the severity of phenomenon
mentionedmentioned aboveabove
 Name a suitable antipsychotic forName a suitable antipsychotic for
this patient and give two (2) reasonsthis patient and give two (2) reasons
for your selectionfor your selection

22. MEQ - 2MEQ - 2
 A 25-year-old male schizophrenicA 25-year-old male schizophrenic
was admitted to medical ward duewas admitted to medical ward due
to an overdose of medication. Theto an overdose of medication. The
patient did not recognize you as apatient did not recognize you as a
doctor and was unaware he was indoctor and was unaware he was in
the hospital. According to his fatherthe hospital. According to his father
he was depressed after recoveringhe was depressed after recovering
from the last relapse of his illness.from the last relapse of his illness.
He took a handful of medicationHe took a handful of medication
that was prescribed to him before.that was prescribed to him before.

23.  StateState the most likely conditionthe most likely condition
patient is havingpatient is having
 Describe the mechanism involvedDescribe the mechanism involved
 If the patient fulfilled the diagnosis ofIf the patient fulfilled the diagnosis of
major depression, state yourmajor depression, state your
provisional diagnosis at this stageprovisional diagnosis at this stage
 List 4 other points in history toList 4 other points in history to
suggest a high suicidal intentsuggest a high suicidal intent

24. The EndThe End