Short case in psychiatry

1. MSE
2. Short hx
a. OCD
b. Bipolar
c. Depression
d. Schizophrenia
e. Single substance use
f. Poly substance use
g. ASD
h. ADHD
3. Suicidal risk assessment
4. Advice on clozapine
5. Advice on lithium
6. Advise on methylphenidate

Introduction
1. Greet the patient – good morning
2. Introduce yourself – I’m a final year medical student
3. Describe the purpose of interview – I’m going to examine
you
4. Describe pre requisites – I’ll ask questions bit fast since
there is short time , but if you don’t understand any of my
questions or if you have any problem please feel free to
stop me then and there and clarify it .
5. Ask for permission – may I proceed
6. Opening statements – what is your name , age , from where
,are you married ?, how many children ? , what made you
come here ?
Concluding the interview
1. You answered me very well and helped me to carry out
interview well.
2. Thank you very much .

OCD
1. Confirm that it is OCD – repetitive , intrusive , own ,
distressing, resistance
a. Content , frequency, duration of compulsions ,
attempts to resist , triggers , avoidance behavior,
impact on life
b. Establish the Dx
i. Patient know that these are own thoughts
ii. Patients have a insight – know that these
thoughts are not true
iii. These thoughts cause distress , delusions may
or may not cause distress
iv. They try to resist the thoughts , but delusions
not
v. Obsessional thoughts can occur in depressive
disorder and schizophrenia
vi. Obsessional rituals – occur in normal people
also ( checking behavior)
2. Ask about other obsessions
3. Impact on life – missing works , relationship issues , sad
mood ,
a. Obsessional slowness ( their activities become slow
due to time spent on this )
b. Time wasting – depend on type and frequency
c. Depression – depressive cognition
d. Panic attacks
e. Avoidance behavior
4. Other anxiety disorders – generalized, social, agoraphobia,
specific , panic
5. Personality traits – anxious,
6. Cognitive errors – perfectionist , black and white thinking ,
need to be in control , thought action fusion , unable to
understand uncertainty
7. Psychotic symptoms – delusions, hallucinations
8. Depressive symptoms – sad mood , apathy , anhedonia ,
9. Substance use – alcohol , smoking, other drugs
10. Social support – spouse , children, relatives
11. Risks – suicide, DSH
12. Avoidance behavior – they tend to avoid precipitating
events
13. Reassurance seeking
14. Associations – Tics , Tourette syndrome in childhood
15. Assessment
a. Content , frequency, duration of compulsions ,
attempts to resist , triggers , avoidance behavior,
impact on life
b. Establish the Dx
i. Patient know that these are own thoughts
ii. Patients have a insight – know that these
thoughts are not true
iii. These thoughts cause distress , delusions may
or may not cause distress
iv. They try to resist the thoughts , but delusions
not
v. Obsessional thoughts can occur in depressive
disorder and schizophrenia
vi. Obsessional rituals – occur in normal people
also ( checking behavior)
16. Past psychiatric hx
a. Onset
b. Predominant themes
c. Rx given – dose , duration, CBT , ERP , thought
stopping, thought habituation
 d. Autism is a DDx
17. Family hx - OCD , depression, tics, Tourette syndrome
associated
18. Suicidal risk assessment

Substance use
1. Pattern of use – onset , duration, frequency, amount ,

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binging +/- , with whom, where "
2. Current Day description
.

3. Dependence – strong desire , craving , use despite harm ,

tolerance, withdrawal, lack of interest in other activities
4. Risk level – low risk , high risk , dependent
5. Complications –
a. physical – illness , trauma , accident , Past over dose
episodes and hospital admissions
b. psychological – depression , psychosis , OCD ,
anxiety
c. social – relationship issues , fights , selling substance,
arrests , law issues , forensic
d. financial – how much spent , Debts ,
6. Other substance use –
7. Risks – needle sharing , prostitution, drug selling
8. Previous attempts to stop and reasons for relapse – how
many times , duration
9. Have you previously gone to any rehabilitation program ?
10. Current motivational state – pre contemplation,
contemplation, determination, action, maintenance, relapse/
termination
11. Social support – family support, relationships, social
workers
12. Examine the patient for needle marks etc

Poly substance use

 1. What are the substances using
2. When was the onset ?
3. How progressed?
4. Current usage pattern ?
5. Current Day description
6. Dependence
7. Risk level
8. Complications
9. Previous attempts to stop and features for relapse or failure
10. Current motivation to stop
11. Social support

Dementia
a. Establish Dx
i. Evidence of cognitive impairment
ii. Personality changes
iii. Psychiatric symptoms
iv. Behavioral symptoms
b. Exclude DDx
c. Level of functioning( self care , basic living skills ,
household survival skills, occupation)
d. Risk assessment (to self , to others )
e. Assessment of capacity ( testamentary , financial ,
property, legal )
f. Living circumstances and social supports

Schizophrenia
g. Establish Dx
h. Exclude DDx
i. Precipitating factors
j. Level of functioning
k. Risk assessment
l. Needs and expectations
Depressive disorder
m. Establish the Dx
n. Exclude DDx
o. Precipitating factors
p. Level of functioning and impact on life
q. Risk assessment
r. Reasons for relapse
s. Living circumstances and social supports

Bipolar disorder
t. Establish Dx
u. Exclude DDx
v. Level of functioning
w. Reasons for relapse
x. Risk assessment

Common to all anxiety disorders

1. Thyroid disease ? Adrenal disease ?
2. Depression ? OCD ?
3. Impact on life ?
4. Complications?
5. Substance abuse ?
6. Treatment taken ?
7. Tests done ?

Agoraphobia
1. At which places do you get this fear ?
2. Are you afraid to go out of home ?
3. Are afraid to go to shops / super markets ?
4. Are you afraid to be in public places where lot of people
are ?
5. Are afraid to go on trains or busses alone ?
6. Symptoms – sweating , palpitations, dizziness , dry mouth ,
 7. DDx – social phobia , depression , schizophrenia

Specific phobia
1. Do you have a special fear ?
2. For what else do you have fear ?

GAD
1. Do you have fear at all the times ?
2. Are you afraid of everything?

Social phobia
1. Are you afraid to talk before a crowd ?
2. Are you afraid to talk to strangers?
3. Are you afraid to talk in public ?
4. Are afraid that you are being observed by other ?
5. Are you afraid to do to presentations?

Panic disorder
1. Do feel like you are going to die without a reason ?
2. Do you feel like you are going mad without a reason ?
3. Symptoms – heart melting feeling , palpitations, sweating,
bursting feeling of heart , dry mouth
4. Does this occur without any special reason ?

Panic attack
1. Do feel like going mad or going to die in special situations
?
2. Is it secondary to agoraphobia , social phobia , specific
phobia ?

Sexual disorders - erectile dysfunction

1. Duration ?
2. Can you describe what happened?
3. Do you have the desire ?
 4. Is it sudden ? Or gradual ?
5. Can you describe the sexual act ? Bed scene
6. How about your fore play ? Non genital sensate ?
7. Does wife do the things to stimulate you ?
8. Do you only get this problem with your wife ?
9. Can you masturbate ?
10. Is there early morning erection ?
11. Are you afraid of sex ?
12. Are you having this problem with every one ?
13. Is there premature ejaculation ?
14. Do you engage sex with both males and females ?
15. How do you see the sexual intercourse
16. Spinal card trauma
17. Do you use any drugs ? à antihypertensives,
18. Smoking ?
19. Substance abuse
20. Depression , anxiety
21. Relationship problem
22. Do you use nitrates ? à important in prescribing PDEI
23. Morbid jealousy? ( this can come as an complication )

PTSD
1. Traumatic event – bomb blast , floods, earth slips, seeing a
person dying, child birth, symptoms of a serious disease
2. Job – police , forces , doctors or health care professionals,
first aid people
3. Traumatic memories comes back and re experiencing the
situation win same emotions and feelings as the event
occurring again with the same fear that felt during the event
( flash back)
4. Night mares ? à wake up suddenly during the sleep ?
5. Intrusive memories of the event ( commoner than flash
backs )
 6. Avoidance behavior
7. Emotional numbing
8. Hyper vigilance à over concerned about the things
9. Duration of symptoms ( should persist more than one
month after incident)
10. Onset after event – usually starts within 6 months , if more
than 6 months à delayed PTSD

Morbid jealousy
1. What is the suspicion you have ?
2. Do you suspect a single person or lot of people?
3. How long ?
4. Do you have evidence to prove ? Have seen to eye ?
a. If no ; it is more likely delusional jealousy
i. Do you check phone ?
ii. Do you check underwear?
iii. Do you follow her ?
b. If yes ; is it one time just talking with some one ?
i. Overvalued idea – just curious about her
ii. Obsessional – do you get that thought again and
again?
5. Aetiology
a. Sexual problems? Like erectile dysfunction and
premature ejaculation
b. Alcohol? Or any substance?
c. Age difference?
6. DDx à schizophrenia – ask about psychotic features
7. Complications/ impact
a. Family conflicts due to this ? Fights ? Physical abuse ?
b. Have you out limits to your partner?
c. Is there any effect to children due to this ?
d. Any suicidal or homicidal ideas ?
8. What is your expectation ?
Somatoform disorder
1. Is it a concern or a symptom ?
2. Duration ? Acute or chronic ?
3. Preceding or anticipating problem/ stressor ? When do you
get these symptoms most ?
4. Worsening factors
5. How during sleep
6. What is symptom ? Pain or any other ?
7. What is the concern ? About a disease or about a part of
your body ?
8. What have you done up to now ? How many consultations?
How many investigations? Have you done Ix yourself ?
How much have you spent ?
9. Results of these ?
10. How frequent is the symptom or concern?
11. What is the impact? Financial , social , activities,
psychological, medical
12. Co morbidities psychiatric – anxiety(curiosity , fear,
palpitations ), depression
13. Aetiology- cultural , sick role , anxiety
14. What is your expectation ?
15. Family support?
16. Do you think that you have a disease ?
17. Reason why you think that it is that disease ?
18. Have searched in internet ?
19. How it affects life – work , financial , substance use , time
wasting ,
20. Personality trait
21. Primary gain
22. Secondary gain
23. Whether patients is aware of a disease called dissociative
disorder
24. Have you had this before ( regarding dissociative)
 25. DDx – depression(sad without a reason ) , OCD , organic
diseases, malingering
26. Management à stop doctor shopping , give insight ,
psychoeducation, reassurance ,

Risk assessment in psychiatric patients

• Risk to self
a. By himself
i. Intentionally
1. Self harm
2. Substance abuse
ii. Unintentionally
1. Self neglect
2. Educational failure
3. Risky behaviorà Harm , sexual promiscuity ,
accidents
b. By others
i. Being punished
ii. Being bullied
iii. Being neglected
iv. Being abused
• Risk to others
a. Intentionally
i. Violence
ii. Robbery
b. Unintentionally
i. Risky behavior- accidents ,
• Risk to property
a. Destroying
b. Stealing
c. Wasting or spending
Suicidal risk assessment
1. Current attempt
a. Before – planning , last acts ( notes , msgs , posts ,
giving property , last will , bank accounts transferring)
, anticipating barriers ,
b. While – unseen , undiscovered, locked , alone,
lethality of act , didn’t seek help ,
c. After – how he was discovered , sad about being saved
, ambivalent, regret about being saved , wish to have
died , any persisting suicidal ideation
2. Previous attempts – why ? , how ? , how lethal ?
3. Co morbidities - what is it, how severe , treatment,
compliance to treatment, insight
4. Ongoing stressors – family issues , relationship problems,
job problems, financial problems
5. Substance use
6. Family hx
7. Personality – irritable , emotional , impulsive , not open to
others
8. Coping skills – previous DSH , fights , homicides
9. Problem solving skills – law cases , arrogant
10. How do you face a problem ? à by arguing? , by shouting
? , by crying ?
11. Do you keep problems in your mind without telling others
?
12. Social support and relationships -
13. Protective factors - children , good relationships, job ,
MSE

1. I examined Mrs. X who is a 55 year old female patient

2. General appearance
a. age appropriate to chronological age
b. Dress appropriate and clean / not
c. Hair combed and shaved / not
d. Well nourished/ emaciated / wasted
e. Features of self harm
3. Facial appearance
a. Anxious / depressed/ elated / masked face
b. Smiling / lip moving like talking – responding to
hallucinations
4. Social behavior
a. Eye contact
b. Overfamiliar
c. Disinhibition / derogatory words
d. Irritable
5. Movements
a. Abnormal movements / postures
b. Tremors
c. Akathisia / dystonia / dyskinesia
6. Speech
a. Spontaneous
b. Coherent
c. Rational
d. Volume
e. Rate – normal / pressure / poverty
f. Congruent
 g. Abnormalities –
stammering/dysarthria/dysphasia/neologism/word
finding difficulty/perseveration
7. Mood
a. Subjective – happy / sad / ambivalent
b. Objective – mood , severity, variation, liability , range
, congruity , reactivity
8. Thoughts
a. Content
i. Delusions ( bizarre, persecutory, nihilistic,
grandiose, broadcasting, passivity/control,
jealousy , reference, guilt , insertion, withdrawal,
hypochondriacal, love , misidentification,
primary ( sudden delusional ideas , delusional
mood , delusional perception)
ii. Overvalued ideas ( ex: self expansive ideas )
iii. Obsessions
iv. Other – pre occupations, phobias, depressive
cognition, self expansive ideas
v. Suicidal or homicidal ideas
b. Speed and amount – pressure , poverty , block
c. Form/link – flight of ideas , loosening of associations,
perseveration, formal though disorder
9. Perception
a. Illusions
b. Hallucinations – AH ( noises , voices- 2 P, 3 P,
nd rd

running commentary, echo), VH , SH , GH , OH

c. Derealization
d. Depersonalization
10. Cognition
a. Orientation – time , person , place
b. Attention and concentration – serial seven , week days
c. Registration – address , 5 words or 3 words
d. Short term memory - address , 5 words or 3 words
 e. Long term memory – general knowledge
f. Intelligence – how answers are
11. Insight – about disease , about using drugs

✓Advice on clozapine
• What is clozapine ?
a. Second generation antipsychotic medication
• Why it is given ?
a. Dx as schizophrenia resistant to other medication
b. superior - 30% of resistant ones respond to clozapine
c. Resistant mania also be given

• How to use it ?
a. Started at ward - risk of First dose Hypotension
b. Prior to start – FBC , ECG, echo , weight, lipid profile
, FBS , LFT ,
c. Tail of other antipsychotics unless he is very disturbed
d. Start with – 12.5 mg Nocte and increased gradually
e. Monitor blood pressure, Pulse and temperature in first
6 hours and 6 hourly after first dose
f. Patient can be discharged after stabilizing on 200mg/
day dose
g. Maximum recommended dose 900 mg per day
h. If treatment is stopped for more than 48 hours à restart
at 12.5 mg
• What are the effects ?
a. Reduced positive symptoms of schizophrenia
b. Less EPSE
• What are the SE s ?
a. Metabolic SE – weight gain , DM, hyperlipidemia ,
metabolic syndrome
b. Blood dycrasias – neutropenia , Agranulocytosis,
leucopenia , leucocytosis , eosinophilia
 c. CVS – hypotension, tachycardia, ECG changes ,
myocarditis , cardiomyopathy, thromboembolism
d. Others – seizures, sedation , dizziness, hyper
salivation , constipation , intestinal obstruction

• How to monitor?
a. ECG , ECHO
b. FBC - weekly in first 18 weeks and monthly
thereafter
c. If sore throat , fever à do FBC
d. Weight monthly
e. FBS three monthly
f. Serum lipids 6 monthly
• How to reduce SE s / prevent SE s ?
a. Hyper salivation – use minimal effective dose / add
anticholinergic – benzhexol , hyoscine lozenges
b. Fever – check a FBC immediately and check for
myocarditis
c. Seizures – dose related , add sodium valproate
d. Neutropenia / agranulocytosis - stopped immediately,
FBC done daily , mx infection
e. Weight gain – diet , exercise, quit smoking, switch to
amisupride/aripiprazole/ziprasidone
f. DM / HL/ MS à early detection , regular monitoring,
lifestyle changes , appropriate Tx , switch to
aripiprazole/quetiapine/ziprasidone
g. Sedation à minimal dose usage , single night dose ,
switching to aripirazole
h. Sexual dysfunction à this is very less With clozapine
J

• When to seek medical advice?

a. If total < 3 * 10 9 /L or N < 1.5 * 10^9 /L à
 discontinueà refer to psychiatrist
b. Ask patients to seek advice if develops fever or sore
throat
• Other advise à take adequate water , use lactulose/ dulcolax
if constipation
• What are the alternatives ?
• How the follow up works ?
a. Monthly

Morbid jealousy

• Why do you suspect – did anyone tell you?

• What is reason
• What are the evidences
• With whom
• With how many
• Checking behavior – phone , follow up , dresses
• Restrictions to partner – stopping job , not allowing to go
out of home , not letting to have contact with others
• Violence against partner – physical , mental
• Do you think that children are not yours ?
• Affects on life
o Own life – losing job , substance use , police cases ,
sexual dysfunction,
o On partners life – losing job , depression , trauma ,
isolation
o On children – mental trauma , wrong example ,
mental and physical abuse
o On others – risk to life due to homicidal ideas ,
• Aetiology- sexual problems , substance use , psychotic
illness , depression , OCD
 • How does is affect Activities of daily living ?
• What is your expectation?
• Co morbidities – depression , schizophrenia
• Suicidal or homicidal ideas ( towards partner , the third
person , children )
• At the end decide whether Morbid jealous is due obsession,
overvalued idea or a delusion.
• What is the insight of the patient ?

PTSD
• What is the catastrophic event ?
• It should be a huge stressor for any normal person like a
bomb blast , severe RTA , earth slip, tsunami
• When did the symptoms started ?
• The onset should be within 6 months of the event .
• What are the symptoms
o Re experiencing- dreams , night mares , flash backs ,
remembering
o Hyper vigilance
o Avoidance behavior
o Emotional numbness ( not essential)
• What is the effect on life ?
• Co morbidities- depression , psychosis , anxiety, OCD
• Substance use
• Suicidal ideation
• Homicidal ideation
• What is your expectation?
• Have you taken treatment?
• How was the response?

Suicidal risk assessment

• What is the reason this time for your act ?
• Current act
o Before the act – planning, anticipating barriers ,
taking precautions to avoid obstacles, any last acts like
notes, msgs, posts , last will writing , transferring
money to someone , telling about suicidal ideation ,
o While act – intention , lethality of the act , isolation,
prevent discovery, place , time ,
o After the act – seeking help , how was discovered,
who discovered, what you feel about being saved ,
what you feel about not dying, do you still have
suicidal ideation
• Aetiology/ risk factors
o Past attempts
o Family hx
o Substance use
o Ongoing stressors – financial, social , relationships,
occupational, medical illness
o Co morbidities- depression , psychotic illness , other
cognitive psychiatric illness
o Personality – impulsive personality( do you face a
problem by taking very quick decisions without
thinking too much ) , borderline personality( do you
take decisions by harming your self , do feel empty
always , are you unable to control emotions )
o Coping skills – do you need others help to solve
problems, do you solve problems by crying , by being
aggressive, by physical fights
o Cognitive errors – depressive cognition, perfectionist,
black and white thinking , need to be in control )
• Protective factors – family support, married, children , job ,
healthy relationships, money
 • Insight

Nuwan Tharaka rajaguru 2011 AL

 • Insight

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