Nac Osce Psychiatry V7.0

Psychiatry
NAC OSCE JULY 2021
© 2021 All rights reserved Medical Training Express, Inc.
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List of Topics
1. Psychiatric History Taking
2. Psychosis
3. Bipolar
4. Depression
5. Panic Attack
6. Mini Mental State Exam
7. Dementia
8. Suicide
9. Eating Disorders
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HISTORY TAKING
Patient Identification
● Name
● Age
● Occupation
● Current marital status
● Current living situation
Reason for Being Seen

● What’s your understanding of why you are here today?
History of Presenting Illness (MOAPS)
Screening questions
Major Depressive Disorder (At least 5 of the following must be present during the same 2 period) – at
least one of the symptoms is either 1) depressed mood or 2) loss of pleasure or interest.
MSIGECAPS
● Mood: Are you feeling sad or depressed most of the time?
● Sleep: How are you sleeping? Too little or too much? Are you having trouble
falling asleep or staying asleep?
● Interest: Are you still enjoying the things that you have previously found
pleasurable?
● Guilt: Do you feel guilty or worthless?
● Energy: Do you have enough energy to get through the day or do you find that
the day drags on? Do you think your lack of energy is because of your mood?
● Concentration: Are you having problems with focus and concentration? Are
you finding yourself getting lost when you are reading or watching television?
● Appetite: Have you noticed any changes in your appetite? Have you gained or
lost weight recently?
● Psychomotor agitation: I don’t really ask about this.
● Suicide: Some people who are going through a tough time have thoughts that
life isn’t worth living or things would be better if I weren’t around. Have you
had any thoughts like that? How often? People who have had those thoughts
often have thoughts like I want to kill myself and this is how I am going to do
it. Have you had thoughts like that? Did/do you have a plan?
Mania
● Have there been times lasting at least several days when are feel high, on top
of the world, euphoric, or overly cheery?
● Have you ever had a period in your life when your need for sleep was
decreased? Did you need 1 or 2 hours a night for days and weeks on end? Was
your energy better than normal?
● Have you ever had a time in your life when you made decisions that were out
of character for you? Did you ever do things without concern about the
consequences? Some people spend money in a manner that they don’t have or
are more interested in sex with their partner or with casual acquaintances.
Others do things like use drugs or drive fast. Have you ever experienced this?
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● How was your energy during these times?
● Were you more social or talking fast during this time? Did other people mention
that you were talking more or faster than usual?
● How was your mood? Were you hyper or overconfident?
Remember, these symptoms should be happening at the same time.
Organic (Always rule out an underlying medical condition)
Endogenous
● Medical illness (Hypothyroidism, Hyperthyroidism, Post MI, CVA, Malignancy)
Exogenous - MAD
● Medication
● Alcohol
● Drugs
Generalized Anxiety (ANDICREST)
● Anxiety: Are you a worrywart? Do you spend hours a day worrying about a
lot of different things? Do you feel you tend to worry about things that other
people don’t?
● Not worry: Are you able to put your worries on the side and get on with your
day and do things that you need to do?
● Duration (6 months or more): How long has this been going on?
● Irritability: Has all this worry influenced your mood? Does it make you
more irritable?
● Concentration: Some people who worry excessively feel that it makes it
difficult for them to focus or concentrate. Does that happen with you?
● Restlessness: Does worry make you feel like you are always on edge and that
you can’t sit still?
● Energy: Does excessive worry make you feel worn out physically?
● Sleep: Does worry make it difficult for you to fall asleep?
● Tension: Does worry ever make you feel tense in your shoulders or muscles?
Social Anxiety
● Is the fear of being judged by others or embarrassed by people one of your

greatest fears?
● Has this fear ever prevented you from doing things?
● Do you avoid situations where you would be the center of attention?
● If yes to the above questions:
o Can you ask for help when you are at a restaurant?
o Are you able to do things like taking the bus?
Try to get patients to describe the situations that are difficult for them.
Panic Disorder
● Have you ever had a panic attack? How often? When was the last time you had
one? Does worrying about having another one prevent you from doing things?
● Try to get the patient to describe the symptoms that occur during an attack.
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● Anxiety: Do you have discrete episodes where you are overcome by anxiety?
● Palpitations: During these attacks, do you have chest pain or feeling like your
heart is beating fast?
● Do you feel short of breath or feel that you are choking?
● Do you feel numb or tingly?
● Are you worried that you are going to die or that you are losing your mind?
PTSD
● Have you ever experienced physical, mental, or sexual abuse?

● Have you ever experienced anything that you found horrible or terribly upsetting,
such as violence or a severe accident?
● In the past month, have you had nightmares or found yourself thinking about it
even when you didn’t want to?
● Have you tried not to think about it or avoided situations and places that might
remind you of these events?
● Have you been feeling numb or detached from other people, places, or situations?
● Have you been feeling as if you are on guard or easily startled?
OCD
● Do you have frequent thoughts that you find difficult to control?

● Do you do anything to get rid of these thoughts? What do you do?
● Do you have any repetitive behaviors or rituals that take up a lot of your day?
● Do you spend a lot of time washing or cleaning?
● Do you check things over and over?
● Do you find yourself concerned with having things a certain way?
● How much time do your daily activities take?
● Are these problems upsetting to you?
● Do they make sense?
Psychosis
● Have you ever seen things or heard things that other people cannot? What?
● Are you hearing voices? What? How many? Male or female?
o Do these voices ever tell you to do anything?
o Do they ever comment on your behavior?
o Do they ever converse with each other?
o Do they ever criticize you? If yes, what do they say?
● Can people ever read your mind?
● Can you ever know the thoughts of other people?
● When listening to the radio or television, do you ever feel that people are talking
specifically to you, not just people like you?
● Do you ever feel that people are conspiring against you?
● Do you ever taste or smell things that other people can’t?
● Do you ever feel there are people out to get you?
● Do you ever feel you are being watched by cameras either outside or inside your
home?
● Do you ever have the sensation that bugs are crawling on your body?

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Eating Disorders
● What do you think about your weight?

● What does a typical day look like for you with respect to your meals?
● Do you restrict what you eat?
● Have you ever made yourself sick?
● Do you ever work out excessively?
● What is the highest and lowest weight you have been?
● Have you ever used things like laxatives to help keep your weight down?
● Do you ever have episodes where you eat more than you wanted and felt that you
could not control your eating?
Suicide
● Have you had any thoughts that life isn’t worth living or things would be better if
you weren’t around?
o How often?
● People who have had those thoughts often have thoughts like I want to kill myself
and this is how I am going to do it. Have you had thoughts like that?
o Did you have a plan?
o Leave a note?
o Give away your belongings?
Past Medical History & Psychiatric History
● Have you ever been seen by a psychiatrist before?

● Have you ever had any therapy? What type? For what reason? For how long? Was
it helpful? Why or why not?
● Do you have any medical illnesses? Any problems such as hypertension, diabetes,
cholesterol, etc.?
● Any history of seizures, traumatic brain injury, loss of consciousness?
● Do you take any medications regularly? Any Allergies?
● Have you had any surgeries?
● Have you ever been hospitalized?
Family Psychiatric History
● Any family members who have struggled with mental illness such as depression,
schizophrenia, anxiety, or bipolar disorder?
● Any family members who have struggled with substance use?
● Any family members who have completed suicide?
Personal History
● Whom do you live with?

● What is your occupation? (if you have not already asked)
● Have you ever had trouble with the law?

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Substance Use
• Do you smoke cigarettes? If yes, how many packs per day?

• Do you drink alcohol? How much? How often?
• Do you use marijuana? How much? How often?
• What about other drugs such as cocaine, ecstasy, heroine, methamphetamine
painkillers, etc?
• Have you ever had treatment for substance use?

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Mental Status Examination
● Essentially, the physical examination of a psychiatric interview

● During the MSE, you are attempting to provide information that will allow you to
paint a picture of how this person is presenting.
Features:
● Appearance
o Dress, grooming, do they appear their stated age, do they have any
atypical features, height/build, ethnicity, do they look healthy.
Distinguishing features such as scars, birth marks, tattoos
o Clothing, hygiene, objects that patient may have
● Behavior
o Engagement and rapport, eye contact (reduced, excessive), facial
expression (relaxed, angry), body language, psychomotor activity,
abnormal movements, or postures
● Speech
o Rate of speech, quantity, tone, volume, fluency, and rhythm
● Mood and Affect
o Mood is patient’s subjective internal state
o Affect is expressed and an observed emotion
● Thought
o Thought form – organization and processing of thoughts
o Flow of thoughts – loose associations, circumstantial, tangential,
thought blocking
o Thought content – delusions, obsessions, compulsions, suicidal
ideation, homicidal ideations
o Thought possession – insertion, withdrawal, broadcasting
● Perception
o Hallucinations
o Illusions
● Cognition
o Oriented to time, place, and person
o MMSE
● Insight and Judgement

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GENERAL NOTES:
Always pay attention to patient cues:

● Poor hygiene
● Looking at wall or ceiling
● Paranoid
● Talking to somebody who isn’t there.
HINTS:
● Whenever you suspect substance abuse: after you ask “have you ever tried
recreational drugs?” ask “what about crack cocaine? Do you sniff? Do you inject?
Did you share needles”
● If shared needles → Scan for hepatitis (liver symptoms), HIV (repeated infections
/ repeated diarrhea)
● If the patient came because his parents or roommate have concerns, you can ask
the patient: what kind of concerns do they have?
Difficult Situations:
● If the patient with hallucinations tells you that he sees radiation and gives you a
photo and asks: do you see it doctor?
o For me it does not look like radiation, but I can understand that you see
this as radiation.
● If the patient becomes agitated and worries about special hallucinations!

o You are safe here, nobody will harm/hurt you
● If the patient runs away:

o Do not chase him/her around the room, stand by your chair
o I would like to assure you that you are safe here, no one will harm you.
● I do not like “Mexican people”, by the way, are you Mexican doctor?
o Why are you concerned about that?
o Whether I am Mexican or not will make no difference in this situation.
● I do not like “gays”, by the way, did you see a gay patient today doctor?
o Why are you concerned about that?
o As a physician, I deal with all patients, regardless of their race, religion,
sex, sexual orientation or anything else!
● Do you think I am crazy doctor?

o There is no medical term called “crazy”. However sometimes some people
have difficulties in the way they handle their thoughts and the way they
interact with and perceive reality, we call that schizophrenia. It is a mental
illness, like any other illness that can affect the body, that we can treat
with medications

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PSYCHOSIS (Schizophrenia, Schizophreniform, Brief Psychotic Disorder, Substance
induced psychosis)
Pre Door Prep: (Name, age, setting, dx, task)

Introduction: (Shake hands?)
Analyze CC: OCD
MOAPS:
Psychosis
● Have you ever seen things or heard things that other people can’t see? What?
● Are you hearing voices? What do they say? How many voices are there? Is it a male or female
voice?
o Do these voices ever tell you to do anything?
o Do they ever comment on your behavior?
o Do they ever converse with each other?
● Can people ever read your mind?
● Can you ever know the thoughts of other people?
● When listening to the radio or television, do you ever feel that people are talking specifically to
you, not just people like you?
● Do you ever feel that people are conspiring against you?
● Do you ever taste or smell things that other people can’t?
● Do you ever have the sensation that bugs are crawling on your body?
Screening
Mood: How is your mood? How do you feel? Have you lost interest in doing things that you used to enjoy
doing before?
Anxiety: Are you a worrywart? Do you spend hours a day worrying about a lot of different things?
Endogenous
● Medical illness (Hypothyroidism, Post MI, CVA, Malignancy)
Exogenous - MAD
● Medication
● Alcohol
● Drugs
Suicide:
● Do you ever have thoughts that life is not worth living or that things would be better if you
were not around?
Substance Use
● Do you smoke cigarettes? Drink Alcohol? Use marijuana? What about other drugs such as
cocaine, ecstasy, heroine, painkillers, etc?

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Have you ever had treatment for substance use?

● Have you ever had any therapy? What type? For what reason? For how long?
Was it helpful? Why or why not?
● Do you have medical illnesses? Any problems such as hypertension, diabetes,
cholesterol, etc.?
● Any history of seizures or traumatic brain injury?
● Are you taking any medications regularly? Any Allergies?
● Have you ever had any surgeries?

● Any family members who have struggled with mental illness such as
depression, schizophrenia, anxiety, or bipolar disorder?
Personal History
● Are you currently in a relationship?
● How long have you been in this current relationship? Are you sexually active?
Males, females or both?
● Are you practicing safe sex?
● Do you use protection? What? All the time?
● What is your occupation? (If you have not already asked)
Sample Counseling (only if required)
Mr. , thank you for answering my questions and providing me with this very useful
information. From what you have told me, it seems that you are suffering from psychosis.
The most common cause of psychosis is schizophrenia. It is a condition of the brain in
which there is a disturbance in the way you think, act or behave. This condition is caused
by a combination of biological factors including genetics factors and imbalance in brain
chemicals. Any stressful event may trigger your symptoms.
Mr. , in psychosis, one loses contact with reality and may see or hear things that
other people don’t. The course of the disease is chronic but treatable and many people
make excellent recovery. Treatment options include drugs known as antipsychotics,
which do have some side effects. Other therapy includes supportive psychotherapy,
family therapy and vocational counseling. Adherence to medication and psychotherapy
yields a very good result.
People with psychosis sometimes feel very low and depressed and think life is not worth
living. If you feel like hurting yourself, or anybody else, please immediately contact me,
any family clinic/ER as soon as possible. We will start treatment with medications and

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arrange a follow up meeting in a week. If you have any questions or concerns, I will be
happy to address them
Cases:
● Amanda Keller, a 34 years old female has a strange feeling in her hands. In
the next 8 minutes please take a history. After that the examiner will ask you
some questions.
o (Think of late onset of schizophrenia or patient diagnosed with
Schizophrenia and now not compliant with the medication)
● John Burns, a 35 year old male, believes that the RCMP are chasing him. In
the next 8 minutes please take a history.
o (Substance induced psychosis)
● Emilie Davidson, 24 years old female brought by her roommate because she
has not been herself in the last 10 days. In the next 8 minutes please take a
history.
o (Think acute psychosis, substance abuse, HIV, mania)
● Andrew Smith, 30 years old male wants to arrange a DNA test for his
children.
● Rebecca Chaw, 17 years old is worried about contamination. She wants to be

admitted. In the next 8 minutes please take a history.
o (Acute psychosis)
● Robin Chang, 22 years old recently diagnosed with schizophrenia 6wk ago.
He is concerned about his condition. In the next 11 minutes please take a
history and address the patient’s concerns.
o (Suicide)
● George Down, a 33 years old male complains of pain in his neck. In the next
8 minutes please take a history.
o (Medication side effect)
● Robert Mason, 29 years old male was brought to the ER because he wanted
to slaughter his son. He thinks he is on a special mission. . In the next 8
minutes please take a history.

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BIPOLAR
Sandra Walker, 23-year-old female was brought to your office by her parents because
they think she is not herself. In the next 8 minutes please take history.

Introduction: (Shake hands? → NO)
Analyze CC: OCD
● When did your parents start thinking like that?
● Becoming better or same?
● How long has it been present?
● Has this ever happened before? → if yes, what was done
● Pick up patient’s body cues and reflect:

o “You look very energetic, restless, and elated; you seem to be moving
around. Can you have a seat so we can talk.”
MOAPS
MANIA (DIG FAST)
● Distractibility: Do you have a lot of projects? Were you able to finish it to the
end? Can you focus on multiple projects?
● Impulsive, risky behavior: Are you spending more money than before? Are you
borrowing money that you cannot pay back? Are you over-using your credit
cards?
● Grandiosity: Do you feel very special? Have special mission?
● Flight of ideas / pressured speech: Do you feel a lot of thoughts? Ideas?
● Activity: How much time do you spend on your projects?
● Sleep (insomnia): How many hours do you sleep? Any changes?
● Talkativeness: Did anybody mention that you are talking fast?
Note: Always make sure to ask if they ever felt the opposite?
Screening
● Psychosis: Have you ever seen things or heard things that other people can’t see?
What?
● Mood: What is your mood? How do you feel? Have you lost interest in doing
things that you used to enjoy doing before?
● Anxiety: Are you a worrywart? Do you spend hours a day worrying about a lot of
different things?
Endogenous

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Exogenous - MAD
● Medication
● Alcohol
● Drugs
Suicide:
● Do you ever have thoughts that life is not worth living or that things would be
better if you were not around?
Substance Use
● Do you smoke cigarettes? Drink Alcohol? Use marijuana? What about other
drugs such as cocaine, ecstasy, heroine, painkillers, etc?
● Have you ever had treatment for substance use?

cholesterol, etc.?

● Any family members who have struggled with mental illness such as bipolar
disorder, schizophrenia, anxiety, or depression?
Personal History

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DEPRESSION
Nancy Park, a 38-year old female, comes to your office because she is feeling down. In
the next 11 minutes please take history and counsel the patient.

Analyze CC: OCD
Pre Door Prep (Name, age, setting, dx, task)

Introduction (Shake hands?)
Analyze CC OCD
MOAPS
Major Depressive Disorder (At least 5 of the following must be present for at least 2 weeks)
MSIGECAPS
● Mood: Are you feeling sad or depressed most of the time?
● Sleep: How are you sleeping? Too little or too much? Are you having trouble
falling asleep or staying asleep?
● Interest: Are you still enjoying the things that you have previously found
pleasurable?
● Guilt: Do you feel guilty or worthless?
● Energy: Do you have enough energy to get through the day or do you find that
the day drags on? Do you think your lack of energy is because of your mood?
● Concentration: Are you having problems with focus and concentration? Are
you finding yourself getting lost when you are reading or watching television?
● Appetite: Have you noticed any changes in your appetite? Have you gained or
lost weight recently?
● Psychomotor agitation: I don’t really ask about this.
● Suicide: Some people who are going through a tough time have thoughts that
life isn’t worth living or things would be better if I weren’t around. Have you
had any thoughts like that? How often? People who have had those thoughts
often have thoughts like I want to kill myself and this is how I am going to do
it. Have you had thoughts like that? Did/do you have a plan?
Suicide: Some people who are going through a tough time have thoughts that life isn’t
worth living or things would be better if I weren’t around. Have you had any thoughts
like that? How often?
Screening
Endogenous
Exogenous - MAD
● Medication

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● Alcohol
● Drugs
Substance Use

cholesterol, etc.?

● Any family members who have struggled with mental illness such as bipolar
disorder, schizophrenia, anxiety, or depression?
Personal History
Note: Please know the difference between Depression and Persistent depressive disorder
(dysthymia)

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PANIC ATTACK
Rose Brown, a 37-year old female, comes to your office because she feels her heart is
pounding too fast. In the next 8 minutes please take history.

Analyze CC: OCD
Panic Disorder
Try to get the patient to describe the symptoms that occur during an attack.
● Have you ever had a panic attack? How often? When was the last time you had
one? Does worrying about having another one prevents you from doing things?
● Is there a particular time it comes on?
Anxiety
● Do you have discrete episodes where you are overcome by anxiety?
Palpitations
● During these attacks, do you have chest pain or feeling like your heart is beating
really fast?
● Do you feel short of breath or feel that you are choking?
● Do you feel numb or tingly?
● Are you worried that you are going to die or that you are losing your mind?
● Do you have anxiety about being in places from where escape might be difficult?
● If yes, what?
● How do you deal with a situation? Do you get worried easily? (GAD)
● Do you have repetitive impulses, images and thoughts? (OCD)
● Did you ever suffer from a life-threatening trauma? (PTSD)
● Are you afraid of heights, spiders and public? (Phobias)
● Impact: How is this affecting your life? (Show empathy)
Endogenous
● Medical illness (Hyperthyroidism, Post MI, CVA, Malignancy)
Exogenous - MAD
● Medication
● Alcohol
● Drugs
Substance Use
● Do you have medical illnesses? Any problems such as hyperthyroidism
hypertension, diabetes, cholesterol, etc.?

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● Any family members who have struggled with mental illness such as anxiety,
panic attacks or depression?
Personal History
POST ENCOUNTER PROBES
Diagnosis
Management
● Psychological
● Biological
o SSRIs, SNRIs
Medical workup for anxiety

● CBC, Electrolytes
● Thyroid function test
● Urinalysis
● Urine drug screening
Additional:
● CXR
● EKG
● Neurological consult
● Psychiatric consult?

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DEMENTIA
John Atkinson, a 64-year old male, was brought by his wife to your office because she
has concerns about him. In the next 8 minutes please take history.

CC: “Forgetting a lot”
Analyze CC: OCD
Memory assessment
● Any fluctuations in memory level?
● Is this deterioration gradual, slowly progressive, or do you feel ok for a while then
you have an attack then you are fine then you have another attack? (Stepladder)
● Are you having difficulty in memorizing numbers?
● Do you have difficulty finding words?
● Do you have difficulty reading? Writing? Calculating?
● Do you lose your stuff?
● Do you make lists to remind you to do things you used to do on a regular basis?
Do you have difficulty organizing your schedule?
● Do you have difficulty doing tasks you used to do before; like tying a tie?
● Do you feel have difficulty recalling new events, or old events?
o Recent: What did you have for breakfast? Confirm from partner!
o Remote: Who was the president of the USA during WWII? (Roosevelt)
Behavioral changes
● Did anybody tell you that you have changes in your personality? Being short
temper? More argumentative?
● If there is a fire in this building; what are you going to do?
● How is your sleep? (Dementia: fragmented sleep /+/ delirium: reversed sleep
cycle; sleep at day, awake at night)
DEATH
● Dressing: Difficulty dressing and undressing yourself?

● Eating: Do you remember to eat all your meals? Or do you skip meals?
● Ambulatory: Do you have difficulty moving around?
● Toileting: How about urination? Have you ever lost control or wet yourself?
● Hygiene: Any difficulty taking showers?
SHAFT:
● Shopping: Who is responsible for shopping? You or your wife?

● Housekeeping: How about housekeeping, are you able to help your wife?
● Accounting: Who is responsible for banking at home? Did you ever give cheques
without an amount?
● Food: Do you cook? Have you ever forgotten to turn off the stove?
● Traffic: Do you drive? Difficulty driving? Have you ever lost your way?

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Screening (MOAPS)
Endogenous
Exogenous - MAD
● Medication
● Alcohol
● Drugs
● Psychosis: Have you ever seen things or heard things that other people can’t see?
What?
● Mood: What is your mood? How do you feel? Have you lost interest in doing
things that you used to enjoy doing before?
● Anxiety: Are you a worrywart? Do you spend hours a day worrying about a lot of
different things?
Suicide:
● Do you ever have thoughts that life is not worth living or that things would be
better if you were not around?
Substance Use

high cholesterol, etc.?
● If yes, when were you diagnosed? Do you measure your blood pressure at
home? How is it controlled? What numbers do you get?

● Any family members who have struggled with any medical illness? What
about Alzheimer’s?
● Any family members who have struggled with any mental illness? What about
substance use?

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Personal History

● Self-care?
● How are things at home? (Elderly Abuse?)
Differential Diagnosis
● Vascular Dementia
● Alzheimer Disease
● Thyroid disease (especially if patient is younger than 60 years)
● Depression – pseudo-dementia
● HIV
● Pernicious Anemia
● NPH (normal pressure hydrocephalus): if the patient has difficulty in AT of the
“DEATH”; i.e. falls due to ataxia and urinary incontinence
CASES
A 70 years old man comes to your clinic because he keeps forgetting for the last
few months. In the next 8 minutes take history and perform MMS.
(Alzheimer)
(Hypothyroidism)
● A 68 year-old man comes to your clinic complaining of difficulty with

memory. In the next 8 minutes take history and perform MMS.
o (Dementia – Vascular, history of HTN, CVA etc.)

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MINI MENTAL STATE EXAM
Orientation to time (score – 5)

● Season Year
● Month
Orientation to place (score – 5)

● Country
● Province
● City
● Hospital/clinic
● Floor
Registration (score – 3)
● Name three unrelated objects, slowly & clearly to the patient.
● Ask the patient to repeat the same
Attention (score – 5)
● Ask the patient to spell the word “world” backwards
Recall (score – 3)
● Ask the patient to repeat the three objects talked about earlier
Language (score – 5)
● Examiner shows two simple objects such as a watch and pencil (2)
● Repeat the phrase “No ifs and buts” (1)
● On a blank paper write a command “Close your eyes” and ask the patient to read
and follow the command (1)
● Ask the patient to write a sentence containing a noun and a verb (1).

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SUICIDE
Catherine Manuela, a 17 year-old female, who attempted suicide by taking 24 pills of

Tylenol was brought to the hospital. She is now medically stable. Please talk to her in
the next 11 minutes.
Introduction ● To see what the next step would be, first, I would
like to ask you some questions:
● How you feel about being
saved.
o If happy, I am glad for that.
o No!
Analyze the event Assure confidentiality

● Can you tell me more about what happened?
● What is the name of the medication? How
many tablets? Any alcohol with it?
● Why did you do that?
● Is this the first time?
● Who saw you and brought you to the hospital?
Before Assess the plan here, was it organized? Or it was an

impulse?
● Did you leave a note? Recently, have you been
giving your belongings away?
After ● What is going in your mind now?
● If you leave the hospital, what are your plans?
Where do you want to go? What do you want to
do?
● If another crisis may happen, are you going to
hurt yourself?
Psychiatric assessment ● Were you ever seen by a psychiatrist? Were
you given a diagnosis?
● Do you see your psychiatrist regularly? Take meds?
Risk ● Assess the risk factors: Analyze SAD PERSONS
MOAPS ● Screen for anxiety

● Screen for psychosis
● Screen for suicidal / homicidal ideation / self -care
● Past medical history / allergy / medications / …
Decision
Conclusion / Counseling
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SAD PERSONS
S Sex: Male Person
A Age > 65
D Depression
P Previous attempts
E Ethanol (ask SAD)
R Rational thinking lost

(What did you think would be achieved by ending your life?
Sometimes people hear voices asking them to end their life, did you hear this?)
S Suicide in the family
O Organized plan
N No support (ask HEADSSS)
S Serious illness (ask PMH)
The score is 1 point for each positive.
● If the score is 3-4, you release if there is enough support

● If the score is > 5 you hospitalize.
CONCLUSION & COUNSELING:
● HOSPITALIZE
o Based on our interview, I have concerns about your safety because you
have more than THREE risk factors for suicide as per the screening test.
Do you mind staying with us in the hospital for few days, so we can do the
required investigations and start medications, until you feel ok? What do
you think about that?
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● RELEASE
o Based on our interview, it is ok if you would like to leave, but you must
arrange a follow up appointment with your family doctor within 3 days.
o However, I would like you to know that life sometimes could be
challenging, and you may face challenges in the future. It is important that
you learn how to deal with challenges. If you feel overwhelmed, talk to
somebody, and ask for help
o I can arrange a meeting with a social worker, or/and a psychiatrist!
o I would also like you to promise me that if at any time you want to harm
yourself or end your life, you will seek medical help immediately; you can
come to my office or call 911.
Notes:
● If no eye contact, wasting time, no patient interaction → assure confidentiality!
● Whenever you hear “car accident” → show empathy / did you hurt yourself / ask
about who was in the car / was any one injured?
● If the person driving was < 18 and was driving alone → be curious (this must be
an important meeting / person that you really did not want to miss)
● The girl asks you to tell her mother that she crashed her mother’s new car! She
does not want to directly (herself) inform the mother!
o I cannot do this.
o Why do you think this would help? “She will not be angry”
o I see; however, life is full of challenges, it is better that you try to learn
how to deal with challenges yourself.
o We can help you to tell your mother by yourself. We can arrange a
meeting with your mother, I can be present, or we can ask a nurse or a
social worker to be there.
● The girl does not want to inform her parents that she did attempt suicide!
o You assess her and if she is to be released, e.g., she regrets what
happened, she is happy to be saved, no SAD PERSONS risk factors she is
competent
→ respect her wishes.

27
EATING DISORDERS

Introduction:
CC:
Analyze CC: OCD
Weight analysis
• What is your weight today?
• When did you start to lose weight? What was your weight at that
time? How much did you lose? What was your highest weight? What
is your target weight?
• Why are you losing weight?
• Are you losing weight alone? Or is someone else is encouraging you?
• When you look at yourself in the mirror, how do you perceive yourself?
How do you perceive your weight?
• Do you like to dress in baggie clothes?
• It looks like you lost a lot of weight in a short period of time; I would like
to know how you achieved that?
Diet
Let us talk about your diet.
• How many meals do you eat per day? How about snacks?
• What do you eat for breakfast? How about the amount?
• Do you calculate calories? How many calories do you eat per day?
• Do you eat alone or with other people?
• Do you like to collect recipes?
• To cook?
Exercise
• How about exercise? Do you exercise?
• How many times a week?
• Do you dance? Practice any sports?
Extra Measures:
• Do you take anything else to help you to lose weight?
• Do you take stool softeners? Do you take water pills?
• Did you ever try to induce vomiting?
• Do you sometimes exceed the amount of food you intended to eat? How many
times a week?
• How do you feel after that? How do you compensate?

28
Impact / Consequences:
Because you have lost a lot of weight, I would like to know the impact of this on you:
• Do you have amenorrhea? When was you LMP? Regular?
• Do you feel cold / tired / swelling in your legs?
• Pigmentation on your skin? Fine hair growth? Skin changes?
• Any bony pains? Fractures?
• Muscle cramps? Calf pain?
• Heart racing? Light headedness, dizziness, fainting?
Conclusion:
• I am concerned that you have a condition called “Anorexia Nervosa” (explain)
• It is affecting your body, and without treatment it could be fatal
• The treatment is to start eating and to gain weight. It is a tough task but I will
refer you to a multi-disciplinary team to start treatment
• Would you like to discuss this with your parents?
Management of Anorexia Nervosa:
• Anorexic patient is to be admitted to hospital if:

o <65% of standard body weight (<85% of standard body weight for
adolescents),
o Hypovolemia requiring intravenous fluid,
o Heart rate <40 bpm
o Abnormal serum chemistry or if
o Actively suicidal
• Agree on target weight on admission and reassure this weight will not be surpassed
• Psychotherapy (individual/group/family): addressing food and body perception,
coping mechanisms, health effects
• Monitor for complications of AN
• Monitor for re-feeding syndrome: a potentially life-threatening metabolic response to
re- feeding in severely malnourished patients resulting in severe shifts in fluid and
electrolyte
Bulimia Nervosa:
• Criteria for admission: significant electrolyte abnormalities
• Treatment: biological (treatment of starvation effects, SSRIs), psychological
(cognitive behavioral therapy, family therapy, recognition of health risks)

29

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Psychiatry

NAC OSCE JULY 2021

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1. Psychiatric History Taking

6. Mini Mental State Exam

© 2021 All rights reserved Medical Training Express, Inc.

Reason for Being Seen

Organic (Always rule out an underlying medical condition)

Generalized Anxiety (ANDICREST)

● Is the fear of being judged by others or embarrassed by people one of your

● Have you ever experienced physical, mental, or sexual abuse?

● Do you have frequent thoughts that you find difficult to control?

© 2021 All rights reserved Medical Training Express, Inc.

● What do you think about your weight?

Past Medical History & Psychiatric History

● Have you ever been seen by a psychiatrist before?

Family Psychiatric History

● Whom do you live with?

© 2021 All rights reserved Medical Training Express, Inc.

• Do you smoke cigarettes? If yes, how many packs per day?

© 2021 All rights reserved Medical Training Express, Inc.

● Essentially, the physical examination of a psychiatric interview

© 2021 All rights reserved Medical Training Express, Inc.

Always pay attention to patient cues:

● If the patient becomes agitated and worries about special hallucinations!

● If the patient runs away:

● Do you think I am crazy doctor?

© 2021 All rights reserved Medical Training Express, Inc.

Pre Door Prep: (Name, age, setting, dx, task)

Organic (Always rule out an underlying medical condition)

© 2021 All rights reserved Medical Training Express, Inc.

Past Medical History & Psychiatric History

Family Psychiatric History

Sample Counseling (only if required)

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● Rebecca Chaw, 17 years old is worried about contamination. She wants to be

© 2021 All rights reserved Medical Training Express, Inc.

Pre Door Prep: (Name, age, setting, dx, task)

● Pick up patient’s body cues and reflect:

MANIA (DIG FAST)

Organic (Always rule out an underlying medical condition)

© 2021 All rights reserved Medical Training Express, Inc.

Past Medical History & Psychiatric History

Family Psychiatric History

© 2021 All rights reserved Medical Training Express, Inc.

Pre Door Prep: (Name, age, setting, dx, task)

Pre Door Prep (Name, age, setting, dx, task)

Organic (Always rule out an underlying medical condition)

© 2021 All rights reserved Medical Training Express, Inc.

Past Medical History & Psychiatric History

Family Psychiatric History

© 2021 All rights reserved Medical Training Express, Inc.

Pre Door Prep: (Name, age, setting, dx, task)

Organic (Always rule out an underlying medical condition)

© 2021 All rights reserved Medical Training Express, Inc.

Family Psychiatric History

POST ENCOUNTER PROBES

Medical workup for anxiety

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Pre Door Prep: (Name, age, setting, dx, task)

● Dressing: Difficulty dressing and undressing yourself?

● Shopping: Who is responsible for shopping? You or your wife?