Useful series of articles on key mental health areas… great summaries for revision and study purposes – and with an Australian slant on it.

MJA Mental Health Series.

According to Jane Turner (Block Head), the following is expected:

You are expected to highlight the core features (please don’t just read out the proforma!) including key aspects of mental state, then give a diagnosis and differential. The examiners will ask you what other information you want (gaps in history), and they will also ask you to talk about management. So the first three minutes is the “guts” of the case and what is wrong in your opinion. If you can make some links between diagnosis and other information, that is good eg. if the person might be depressed, and they have a past history of depression, to say that the diagnosis is likely to be depression, and the past history of depression makes you feel that this is more likely than an adjustment disorder.

So basically:

• The Summary of Patient Presentation(3 minutes)

The patient is John Doe age 36 **insert any other relevant demographics eg father of two**
presenting with symptoms of **Insert provisional diagnosis here>. These include **Insert list of relevant symptoms** on a background of **Insert known mental history**.

This presentation appears to have been precipitated by: **Insert precipitating factors here**.

Pertinent features of his mental state exam include: **Insert pertinent MSE features**

John has **Insert relevant past history history including developmental, social, forensic, occupational etc**

Diagnoses include: **Insert list of differential diagnoses**

I believe the diagnosis to be **Insert diagnosis** because…..

• Gaps in the history(about 5 or 10 minutes maybe)

You need to identify gaps in the history. Ideally in the preparation time you shoul have written out the headings of the Psych History and also the headings of the MSE and fill in the blanks.

Thus you can identify pertinent parts of the history that are missing that you would like to be able to fill in.

• Management of the patient(the rest of the time)

See the separate document for the Management of a psych patient (Viva).

And that’s basically it. Answer any questions they have and cross your fingers and hope you have passed.

• Immediate Risk / Grounds for admission

Does the patient show signs that they may be a risk to themselves or to others around them?

Is the patient in such a state that there is grounds for admission – are they medically unwell? (consider Wernicke’s encephalopathy, acute psychosis etc).

Look at the past psychiatric history, is there something there that may assist you with your decision making?

If the patient is not to be admitted is there support surrounding the patient that will provide for the patient (ie a supportive family that understands the situation).

Is there a need to consider an Involuntary Treatment Order (ITO)?

• Investigations to perform on the patient

We want to rule out Organic causes of the illness. As such it is wise to perform various tests. These include but are not limited to:

• FBC/U&E

– There could be a delerium from an electrolyte abnormality, the FBC may show things such as alchol abuse or an infection that could be causing the symptoms presented.

• LFT

– Presence of a substance abuse (e.g. Alcoholic liver disease)

• CT/MRI

– After a recent change in behaviour always consider the possibility of a Space Occupying Lesion. There may have been a fall in the elderly or a tumour. This will also show cerebral atrohpy which may assist with diagnosis of Alzheimer’s dementia or other forms of dementia.

• Urine Drug Screen

– This may be useful in picking up illicit substances in the urine.

• TFTs

– In the instance of depression etc, always consider the possibility of hypothyroidism.

Buzz Word City!!

Three Words: Bio – Psycho – Social.

BIO

• AWS

– if the patient is a known alcohol abuser, it may be worth implementing the alcohol withdrawal scale treatment protocol. Consider also involving ATODS and initiate treatment with Thiamine (remember Wernicke’s encephalopathy).

• Antidepressants/Antipsychotics

– Consider initiating doses, side effects, when to increase, patient compliance, which one to use, contraindications etc.

• Anxiolytics

– Always consider the risk of addiction. Patient might need sleep, calming etc but particularly where there is substance abuse etc there is the risk of dependence with benzodiazepines. Consider perhaps using quetiapine (sedative effect but also atypical antipsychotic). Involve ATODS if not sure.

PSYCHO

• CBT/Psychoeducation

– Patient may benefit from sessions with a psychologist doing cognitive behavioral therapy. This will allow identify distant antecedents and allow the patient to learn coping skills and skills to resolve some issues.

Psychoeducation of the patient is very important as well. They need to understand that they have an illness, the issues surrounding their illness and what they can do to help with the treatment of their illness. This will assist with concordance and treatment.

Consider with this also ongoing management of the client. Do they have a regular GP? Should they be linked in with the community mental health service? Should ATODS be involved.

SOCIAL

• Family and Friends

– Do they have a support network of people who understand their illness and are available to help out.

• ADLs and Financial Support

– Do they have an income? Do they require someone to help them with things such as shopping, housework, managing bills etc. Should the public trustee or a financial power of attorney be considered.

• Employment

– Will they be able to work? Is their work affecting their illness? Do they need time of work? Is there an issue of workcover? Should they consider alternative forms of work?

• Followup and Ongoing Management

– Have the got a GP? Do they need to be treated at community mental health? Do they need a case-manager? Should ATODS be involved?

• Community Support Organisations

– Does the patient or their family need to be referred to a community support group (eg Alzheimers Disease Support, Schizophrenia, Beyond Blue etc)

So that about sums up management. At least in the short to medium term.

Note: the MSE should be made up of observations and answers given during the history taking exercise – not based on the history of the patient etc.

The Mental State Examination Consists of:

• Appearance

Are they dishevelled (may indicate depression, schizophrenia etc) or brightly dressed in outrageous clothes (poor taste in clothes or potentially manic).

Are they clean shaven? Clean? Dressed? Smell?

• Behaviour

What is the behaviour of the patient during the interview? Do they make eye-contact? Are the shifty? Do they look agitated or afraid? Is their behaviour appropriate for the interview?
Are there any mannerisms? Is there a problem with their gait?

• Conversation (Speech)

Is their speech at a normal pitch and speed? Is their speech comprehensible? Is it pressured? Loud? Mumbled?

• Affect (Mood)

Affect is what you describe
Is it restricted? Blunted? Labile? Euthymic?

Mood is what they describe
Are they anxious? Depressed? Irritable? Cheerful?

• Perception (Thought)
• Thought Form

That is…flight of ideas, derailment

• Thought Content

Are there delusions? Are they suicidal?

• Perception

Are there any hallucinations, illusions (eg visual, auditory, gustatory, tactile)

• Cognition

Are they orientated to time place and person?

• Insight

Are they aware that they have an illness?

• Judgement

Do they show appropriate judgement when asked?

• Rapport

Do they develop a rapport with the interviewer? Are they withdrawn?

• Memory

Is their short and long term memory in tact?

• Presenting Complaint

What is the psychiatric problem of interest in this patient.

• History of presenting complaint

Tease out the details of the presenting complaint including precipitating factors that might have caused this presentation. Ascertain whether this is a new problem or a presentation of an old problem.

• Past Psychiatric History

The presence of a previous psychiatric history will affect the management of the patient. Look for other co-morbid conditions and ascertain the details of what has happened in terms of the psychiactric past of the patient.

• Past Medical and Surgical and Obstetric history

These histories may give you clues as to what might be contributing to the problem or may show things that have been caused by potential psychiatric issues – e.g. Alcoholic liver disease, miscarriages, terminal illness, thyroid dysfunction…..

• Medications

May show a cause of mental illness or a predelection for substance abuse. If already taking psychotropic medication this may assist with management and diagnosis.

• Allergies

It never pays to miss an allergy. You might get sued – or worse….the patient might suffer.

• Alcohol and Cigarettes

Big problems. Ascertain consumption amounts and types. Where consumed. Pattern of consumption etc.

• Illicit Substances

Pot. Amphetamines etc….can contribute to the psychiatric problem. May be the cause of a psychosis etc.

• Forensic History

This can be particularly important for a number of reasons – there may be an attempt to hide behind insanity for a crime committed. Alternatively, a substance abuse problem or mental illness may predispose person to crime. There are potential legal complications if there is a forensic history. This may affect management.

• Developmental History

(may need collateral)

Details of childhood, normal birth, how the patient grew up. What their relationships were like with their siblings. Did the have many friends or were they loners. Has this changed recently.

• Education and Occupation

(may need collateral)

Level of functioning prior to mental illness they are presenting with. What occupation do they have? Is this affecting the patient’s illness. Is there a need to consider workcover or a disability pension or assistance to help the patient recover. Are they able to work in their current condition.

• Relationships

(may need collateral)

How do they relate to other people. How do they relate to family. Are they loners? Are they scared of personal interaction? How have these relationships been affected?

• Supports

Does the person live alone? Are they elderly? Is their home appropriate for their level of functioning? Are they able to support themselves financially?

• Pre-Morbid Personality

Personality before the condition may provide insight into the prognosis of the patient.

Of course collateral can be a useful tool for all of the above.

How horrible. Got the timetable for viva today. I’m on for 0900 Thursday morning. Eeeeek. Well at least it will be over and done with. I swear it will not be pretty.

Michelle is up first – then me…then Theresa. I fear that I shall be giving a somewhat lacklustre performance compared with young Ms Allizart.

At least loopy mental health will be out of the way. Except that I need to get that bloody orange book signed off. Grrr. Grrr grrr grrr.

And then there’s lovely GP to look forward to. The two things I have decided I am not going to be….Psychiatry and GP….both one after the other. Medicine will be such a relief after four months of the Doldrums. Especially since the Gatton GP I suspect I will end up with. Word is that he doesn’t let students do anything much in their rotation. So much for learning.

I REALLY need to start thinking a bit more positively.

Muffins taste gooooooooooood! .

Mother made muffins for me. It’s almost an exam tradition. It was really good to see Mum last night at today. And it’s really nice that she thought of me and made me feel better.

It’s good to have friends. And a broad range of diverse and varying friends is better.

A friend for all occasions.

And in different parts of the world.

And friends who have nothing to do with medicine.

Friends who can say to you……

“i got the impression all seasons brought you discontent”

(emma)