Psychiatry-Plab 2 Nuggets by Ali Munawar

Disease Psychosis Depression Depression Drug Intake Over Dose Eating Disorder
Plab 2 (With or without

Revision (less
Notes By Ali severe)
Munawae (Severe Counselling (PCM/OCP)
insight) depression)
Presentation 30-40 Y 40Y Failed CBT 45y/F 16Y/F-Psych dep Case: 1
Not feeling well 1. Poor Appetite Wants to stop 16 tab OCP 18Y/F-ED
1. Poor Appetite 2. Insomnia drinking alcohol overdose-Cut Referred by GP
2. Sleep 3.low energy -tried in past but wrist-Last night BMI 17
disturbance 4.Low Mood 4/10 failed> developed due to With mother
3. Low 5.Poor conc seizure and unsupported >Not eating
energy/Tiredness agitation. boyfriend after well +Lost some
hearing of getting weight
pregnant (1W late 39>35 (BMI 17)
period)-Come
hospital on her
own.
Presenting Major: 6.Loss of interest 1.Last drink 22Y/M-ED -On specific diet
Complaint: Not going out in sex Yesterday. 16tab PCM 2H ago (no carb)
with friends + loss 7.Difficult to cope Usually 6Can of >Told my mom (Coffee for
of interest in work beer everyday about being gay breakfast, no
plying 8.Wine bottle 2.Withdrawl >she didn`t lunch, Apple fro
squash/everthing everyday symptoms> Shaky, approve dinner)
(shopping/cycling) 1.Loss of Interest Nervous, agitated Came to hospital -ADL>university
Mood(low) 4-6/10 in football/Friend (NAS) on advice of work
partner compromising.>
reading all time
how to lose
weight (used to
be good
student)
Rule out -Suicide -Suicide -Reason behind Pregnancy
-PTSD -PTSD drinking Liver Failure
-Bipolar -Bipolar -Suicide Bleeding disorder
-Psychosis -Psychosis -PTSD Shock
-Hypothyroidism -Hypothyroidism -Psychosis
-Occupation+ -Occupation+ -Occupation+
Driving Driving Driving
Risk Factor -Cause unknown 1.Break-up/ -Failed CBT -History of -Stress
Divorce 6/Cycles previous -Emotional
2Daughter`s -Caught wife admission for exhaustion
death Cheating on him withdrawal but -Psychotic
3.Unemployment -1 Bottle of after discharge> disorder
4.Post Natal wine/D felt agitated -Unsupported
5.Alcohol/ -No support at >drink again surrounding
recreational drugs home -Unemployment
6.Family Hx
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Plab 2 Revision Notes By Ali Munawae
Examination -OBS+GPE+BMI -OBS+GPE+BMI -OBs OBS

Thyroid exam Thyroid exam Head to Toe Head to Toe
-FBC, LFTs, TFTs, -FBC, LFTs, TFT, -Routine Wrist/ abdominal
ECG Urine test, RBS LFTs & RFTs examination.
Management 1.Wtachful 1.CBT+SSRI 1.Admit if 1.She regrets
waiting Reboxetine withdrawal doing it, she
2.CBT 2. Sleep hygiene symptoms thinks she has a
3.Exercise 3.Mental health 2.Advice: bright Future, No
4.Manage stress team -All about will- future suicidal
5.Sleep Hygiene power thoughts.
-Alcohol diary 1. I think no need
3.Refer to to keep you (tell
1)Alcohol and reason why
substance misuse according to hx).
clinic > guide + 2. Senior for
mediction second opinion
2)Alcohol and before
anonymous group discharge
(for counselling) 3.Refer to A
3)CBT (Stress) gynecologist
4)CAB > for job. regarding
pregnancy
(pregnancy test).
4. We will also
take a look at your
wrist. 5.Refer A
Poison
information
center in
regarding to
overdose of OCP.
(Does not regret,
Thinks no good
Future, Suicidal
thoughts)
1.Admit. 2. Senior.
3, 4, 5 same as
opposite.
Safety Net 1st F/U<30 1 W Suicidal thoughts 1.Avoid people u 1.Crisis Card
>30 2W F/U inform DVLA use to drink with. 2.Good
After that 2-4W Suicide + with Samaritans group
drawl symptoms 3.s/n: Vomiting
/Abdominal pain.
4.F/U: Community
Mental health
team
5.GP to discuss
long term
contraception
Disease Somatoform Bulimia Nervosa

Disorder
Presentation 28Y/M-GP 16Y/F-GP

Lump in chest and Mother made
mole on hand for appointment>
6M. Vomiting for 18M.
-BMI 20
-Friend is Role
Model
Presenting -He thinks lumps -She Doesn`t think
Complaint: and mole she has any
increasing in problem.
size>Thinks -she claims she
Cancer. induce vomiting
-All routine blood by herself by
test normal putting her fingers
-Little bit anxious inside her throat,
and worried about because she
cancer. thinks she is fat
O/E> no mole and -Vomiting 1/W
Lump on chest. >After eating a
lot.
-Doesn`t like
Gym> people are
thin there
Rule out -Use of Drugs Anorexia Nervosa
-Suicide
-Psychosocial
Risk Factor 1.Unknown cause 1.Ask about

BMW-CLEVER.
Examination Obs+ GPE -OBs +GPE

Lump and Mole -Mouth and
(No mole or lump teeth+ Hands
present) -BMI
Management Somatic symptom -Someone thinks
disorders, in their weight is
which a person high but actually
has a significant they are in
focus on physical normal weight
symptoms, such range.
as pain, weakness 1.Clear
or shortness of misconception
breath, to a level >BMI is normal>
that results in you r not obese.
major distress or 2.Refer to Child
problems and adolescent
functioning. The mental health
individual has team>CBT.
excessive 3.Refer to eating
thoughts, feelings disorder
and behaviors specialist/pedriati
relating to the an.
physical 4.Dietian
symptoms.
1.Not Absolutely
curable
2.Counselling
sessions >to cope
symptoms
3.Exercise, Going
Out, Break from
work, Time to
yourself and
family.
Safety Net 1.Reassure the F/U in 2W
patient he will be
followed up
2. Safety netting
3.He doesn’t have

any life
threatening illness
or cancer, he can
relax (he seems
worried still)
NB/ Suicide Risk factors: SAD PERSONS
Sex (male). Age (young adult or elderly), Depression,
Previous attempt, Ethanol or drug use, Sickness, organized plan, no spouse or other social support, future intent
NB/ Suicide Risk assessment:
1.Do you ever wished to end your it all? (Past)
2.Have you ever thought about ending it? (Past)
3. Have you ever attempted to end your life before? (Past)
4. Have you ever thought of how you would do it? Plan(Past)
1.How do you feel about life at the moment? (present)
2.Have you felt life is not worth living? (Present)
1.How do you feel about the future? (Future)
BMW CLEVER ANOREXIA NERVOSA & BULIMIA
B - Body image: How do you see yourself?  How do people see you?
M - Mirror: When you look in the mirror what do you see?
W - Weight loss: How much weight have you lost in the last 3-months?
C - Clothes: What is your clothing preference?
L - Laxatives: Do you use laxatives / weight losing drugs?
E - Eating: What is your regular daily diet?
V - Vomiting: Do you make yourself vomit?
E - Exercise: Do you exercise excessively?
R - Role model: Who is your role model in terms of appearance?
Depression: (Consultation flow)

GRIPS (Smile, greet (hello, hi) Rapport:( Nice meeting you, I can
see from my that you are here to discuss about your concern/
concern regarding…. I am really sorry to hear that you are very upset/having a difficult time of your life, I
am here to help you may u know the reason behind it? Then
A) ODIPARA (How did it started? When did it started? Getting better or worse?)
B) Background- Support system: (do you have anyone like friend relative or family around to
support you?)
C) Core criteria: (2major / 10 minor)
Major:
1. During the last month, have you often been bothered by the feeling of sad, low and hopeless?
2. During the last month, have you felt like you are losing interest in activities you use to enjoy?
Minor: (bio-psycho-social)(ALS-CAGE-IS)
A- How is your appetite?
S- How is your sleep?
L- Loss of libido?
C-How is your concentration/ any problem with concentration of daily acytivities?
A- Have you felt angry/ irritable more than usual?
G-Do you feel inappropriate/excessive guilt?
E - Have you felt empty/ worthless?
I-Impact on life, work, people around you?
S-how is your sexual relationship?
D) Ask about DDs
PTSD (Anything specific happened before the beginning of these symptoms?
Bipolar Psychosis (have you ever heard voices when no one around?)
Hypothyroidism (BMW-Bowel/mood/weight)
E) Effect - Ask about Mood, suicide
P2: (Past medical History)
P3: (MMMA) Medical mental family history
Medication, Allergy history.
4F:
1. Who do you live with? Any friend or family around? Anyone with whom you share your feeling?)
2. What do you do for living?
3. How do you manage your finances?
4. Hobbies: how do you spend your day?
DESA: (smoking, alcohol and recreational drugs)

Examination:
Observations Head to toe Thyroid BMI
ICE+ Insight: (Why do you think all this happening to you?)

Diagnosis:
Depression
1. Less severe (mild) 2. More Severe (moderate/ severe)
Management:
Mild Depression: Moderate to severe Depression:

(less severe) (more severe)
1. Wait and see: (Watchful waiting) Self resolve. 1. In Moderate depression we usually advice
After diagnosed with mild depression we usually combination of therapy that involves anti-
wait and see your progress for 2-4 weeks to depressants and CBT. A combination of these
resolve own its own. usually works better than having just one of
them.
2. Guided self-help: (CBT-Talking therapy) 2. Anti-depressants-
We might suggest you to try guided self- Start working in 2-3 weeks, effect in 4W, Take
help/talking therapy with one of our specialist 6Months after recovery (Relapse)
to see if it can help with your depression. It 1st line SSRI-All People Citalopram
usually involves 6-8 sessions which can be in a Breast Feeding-Sertraline
group or alone as well as you can attend these Sexual problem-Reboxetine
sessions by phone or online. S/E: Erectile dysfunction, Palpitation, dry
Def CBT: Manage your problems by changing mouth, Headache, BP, Increase suicidal
the way you think(Cognition) and thoughts
behave(behavior).
3. Exercise: 3. Mental Health Team: (Psychiatrist,

There is strong evidence that exercise can help psychologist, Specialist nurse and Occupational
depression and it is the one of the main therapist)
treatment for mild depression.
-We usually liaise with MHT to help us guide in
managing your condition in a better way
4. Advice of Sleep hygiene>sleep clinic
Safety Net: Safety Net:
Suicidal Thought >give crisis card (Contact Crisis Suicidal thoughts
resolution Home resolution team/Community Crisis card
mental health team) Inform DVLA
Refer to Specialist only if:
1. Post-natal dep
2. Suicidal ideation
3. Psychotic Idea (same day referral)
4. Not getting better after a long time
5. Difficult diagnosis
Disorder Psychosis Depression Drugs With drawl Overdose Eating Disorder

Structures 1)Introduction 1)Introduction 1)Introduction 1)Introduction
2)Use notes to 2)Use notes to build 2)Use notes to 2)Use notes to build
build rapport rapport build rapport rapport
When people come to
us with such concern 3)ODIPARA When people come to 3.Incident History
us with such concern we Before, during
we use to ask a couple 4)Support system
of Q which might seem use to ask a couple of Qs
Silly but they are 5)Core Criteria regarding substance you after (tab +
important to find out 6)DDs are using. cutting wrist)
what`s going on. 7) Comping mechanisms, 3.Itself
1.Cognition Q 4.Explore
Impact people around, 4.CAGETWD
2.Hallucination Q mood and suicide 5.DD>Hallucination complications +
3.Thought Q
8)MMMA
6.Comping mechanisms, menstrual hx
(Insertion, Impact, mood and 6.Coping mechanisms,
9) family History suicide Impact, mood
Withdrawal and
Broadcasting) Detailed 7.MMMA 7.MMMA
4. Impact, Coping 10.Insight 8.Family History 8.Family History
mechanism for 11)Examination Detailed Detailed +BF
stress > linked to 12)Diagnosis 10.Insight history
smoking, alcohol,
13)Management 11)Examination 10.Insight
drugs, suicide)
Mood and Suicidal/ 14)S/N 12)Diagnosis 11)Examination
Weapon Q (Plotting 13)Management 12)Diagnosis
against U and Carry 14)S/N 13)Management

Weapon to (If +ve insight → may be
protect?) no admission) (If no
5.DD insight → You must
6.MMMA admit)
7.family History 14)S/N
Detailed
8.Insight
9.Examination
10.Diagnosis
11.Management
12.S/N
Disorder Psychosis Depression Drugs Overdose of Drug Eating Disorder
(Alcohol/Heroine) (Anorexia and
Bulemia)
PC 1.Cognition Q 1.ODIPARA (How did it Itself: What do you Explore cut wrist: what
started? When did it happened to your wrist?
2.Hallucination Q drink? How much? Since when? Did it bleed
started? Getting better
or worse?) Where do you much? Do you feel
dizzy? Has anyone
2.Background- usually drink? With
looked at it? What did
Support system: (do who? Since when? you use to cut yourself?
you have anyone like For how long have Explore BF: Age? Stable
friend relative or relationship? How long
family around to
you been drinking? have you been
support you?) together? Explore
3.Core criteria: Menstrual History: LMP?
Have you had a
(2major / 10 minor)
pregnancy test at home?
Did A&E Drs offer you a
one?
Associated S 3.Thought Q (Insertion,
Withdrawal and
Broadcasting)
4.Suicidal/Weapon Q CAGE: Cutting off (have you ever Questions on the incident
Red Flags Suicide tried to cut off alcohol? Why did Before incident During
(Plotting against U and Carry Mood you try? What did you try? What incident After incident 1.
Weapon to protect?) were the challenges? Did you tell Did you plan it? 2. Did you
Coping mechanism for stress anyone about this? were people tell anyone? 3. Did you
> linked to smoking, alcohol, around you supportive? How did write note? 4. were you
they take it?) Annoyed: do under influence of alcohol
drugs, suicide) people comment on your habit? or drugs? 5. Were you
Mood How do you feel about it? Guilt: forced in to doing this? 1.
do you feel guilty about it? Eye Where were you? 2. Were
opener: do you drink 1st thing in you by yourself? 3. How
the morning? TWD: Tolerance: many pills? 4. Any other
do you feel you need to increase tab? 5. With what water or
the amount to get the same feel? alcohol? 6. Did you vomit
Withdrawal: when you reduce after that? 7. how did you
the amount, do you get any get them? 1. Who brought
symptoms? Dependence: are you you? 2. How do you see
able to perform your daily life? 3. How do you see
activities if you don’t drink? future? 4. Would you do
this again?
DD PTSD PTSD Hallucination Explore Complications:
any abdominal pain?
Bipolar Bipolar Psychosis change in color of eyes?
Drugs Psychosis Vomiting? Abnormal
bleeding?
Brain Lesion Hypothyroidism
Infections
Back Ground MMMA+DESA MMMA+DESA MMMA+DESA MMMA+DESA
Support System Family HX Family HX Family HX Family HX
Examination OBS+GPE OBS+GPE+BMI+ Obs Obs+ Head to Toe

Thyroid Head to Toe Wrist/Abdomen
INV Blood + Serology for STI, Routine +RBS Routine + LFTS Routine
HIV, Urine for drug TFTs Drug level
abuse, CXR CT brain ECG
DX
1. Admit for rehabilitation She regrets doing it, she
Management 1.Admit 1.Admit (If thinks she has a bright
2.Senior+INV indicated) (only if she has Future, No future suicidal
withdrawal symptoms) thoughts. Or (Does not
3.Therapist 2.Senior+INV 2.We can cooperate to regret, Thinks no good
(Psychologist)>CBT 3.Therapist help you on cutting Future, Suicidal thoughts) 1.
I think no need to keep you
Social Support. (Psychologist)>CBT down: It’s all about your (tell reason why according
4.Medication Social Support. well power at the end of to hx). 2. Senior for second
the day so, would you opinion and before
(Risperidone, 4.Medication for consider that? there are discharge Refer A
gynecologist regarding
Olanzapine) severe depression. helps available on NHS pregnancy (pregnancy test).
5.Treat the cause. (Citalopram) (alcohol and substance 4. We will also take a look at
misuse clinic) which can your wrist. Refer A Poison
5.Treat the cause information center in
(Avoid Stress)+ offer you medications: regarding to overdose of
Anti-craving OCP. 1. Admit. 2. Senior. 3,
Sleep Hygiene (Acamprosate), Deterrent 4, 5 same as opposite. 6.
Safety netting (in both
(Disulfiram), Withdrawal stations): We will give you
(Chlordiazepoxide) + crisis card Which contains
Counselling: Alcohol an emergency number that
anonymous group (closed you ring if you feel the need
to speak to someone. We
one to one session or can refer you to good
open with a group of Samaritans groups. +
people) + CBT (talking vomiting and tummy pain 7.
Contraception can prevent
therapy) 4. Keep an pregnancy but they would
alcohol diary: type of not get rid of it. 8. Follow up
alcohol, quantity taken with (2): community
and who they took it with psychiatry services + GP to
discuss long term
5. address risk factors: contraception in order to
like job and offer her avoid similar situation in the
working something else, future.
anagement in PCM
Citizen advice bureau + Scenario: 1.Admission to
avoid people you use to close monitoring for 24h or
drink with more. 2.Investigations:
Routine bloods (CBC, LFTs,
RBS, ABG, clotting profile)
3.check PCM level after 2h:
(if below treatment level,
then refer to the
psychiatrist for assessment)
(If above treatment level,
then start acetylcysteine
and refer to psychiatrist
after treatment) 4.possible
complications: Liver failure,
kidney failure, bleeding and
low blood sugar 5. Safety
netting: We will give you
crisis card Which contains
an emergency number that
you ring if you feel the need

to speak to someone. We
can refer you to good
Samaritans groups. +
vomiting and tummy pain 6.
Follow-up 7. Would you like
me to call anybody to be
with you?
S/N Suicide Suicide Safety netting for

DVLA DVLA(more suicide +
severe) detoxification
F/U

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Psychiatry-Plab 2 Nuggets by Ali Munawar

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Disease Psychosis Depression Depression Drug Intake Over Dose Eating Disorder

Plab 2 (With or without

Examination -OBS+GPE+BMI -OBS+GPE+BMI -OBs OBS

Disease Somatoform Bulimia Nervosa

Presentation 28Y/M-GP 16Y/F-GP

Risk Factor 1.Unknown cause 1.Ask about

Examination Obs+ GPE -OBs +GPE

3.He doesn’t have

Sex (male). Age (young adult or elderly), Depression,

NB/ Suicide Risk assessment:

1.Do you ever wished to end your it all? (Past)

2.Have you ever thought about ending it? (Past)

3. Have you ever attempted to end your life before? (Past)

4. Have you ever thought of how you would do it? Plan(Past)

1.How do you feel about life at the moment? (present)

2.Have you felt life is not worth living? (Present)

1.How do you feel about the future? (Future)

BMW CLEVER ANOREXIA NERVOSA & BULIMIA

M - Mirror: When you look in the mirror what do you see?

C - Clothes: What is your clothing preference?

L - Laxatives: Do you use laxatives / weight losing drugs?

E - Eating: What is your regular daily diet?

V - Vomiting: Do you make yourself vomit?

E - Exercise: Do you exercise excessively?

R - Role model: Who is your role model in terms of appearance?

Depression: (Consultation flow)

A- How is your appetite?

S- How is your sleep?

C-How is your concentration/ any problem with concentration of daily acytivities?

A- Have you felt angry/ irritable more than usual?

G-Do you feel inappropriate/excessive guilt?

E - Have you felt empty/ worthless?

I-Impact on life, work, people around you?

S-how is your sexual relationship?

D) Ask about DDs

PTSD (Anything specific happened before the beginning of these symptoms?

E) Effect - Ask about Mood, suicide

P2: (Past medical History)

P3: (MMMA) Medical mental family history

Medication, Allergy history.

2. What do you do for living?

3. How do you manage your finances?

4. Hobbies: how do you spend your day?

DESA: (smoking, alcohol and recreational drugs)

Observations Head to toe Thyroid BMI

ICE+ Insight: (Why do you think all this happening to you?)

1. Less severe (mild) 2. More Severe (moderate/ severe)

Mild Depression: Moderate to severe Depression:

3. Exercise: 3. Mental Health Team: (Psychiatrist,

Refer to Specialist only if:

Disorder Psychosis Depression Drugs With drawl Overdose Eating Disorder

against U and Carry 14)S/N 13)Management

Examination OBS+GPE OBS+GPE+BMI+ Obs Obs+ Head to Toe

you ring if you feel the need

S/N Suicide Suicide Safety netting for

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