Thursday, December 25, 2014

Examination in Psychiatry Posting

So I have finished my exam yesterday. Let me tell you how we were assessed in this 7-week-posting. Apart from logbook completion, seminar presentations, department case presentation (DCP), case presentations, tutorial, oncalls, reports, case write-up - let's focus more on the exams.

First, short cases examination. It is different from every other postings where you have short case conducted right after long case exam in the end of posting. In psychiatry, two short cases are conducted during the study period. You will be assessed by your own mentor. You will be divided into 8 small groups and each group has its own mentor.

For my group (Firdaus, Aida, Me), our mentors were Dr.Hanisah from week 1-4 and Dr.Ali Sabri from week 5-7. So our first short case exam was conducted in week 4. It was held in Psychiatric Ward, HTAA. All three of us sat in the room, and Dr. Hanisah brought us patients, one at a time. First, it was Firdaus's turn. He got an Indonesian man with Schizophrenia. Aida got a female patient with Bipolar Disorder, and I got a male patient with Schizophrenia, who had restricted affect and was so preoccupied on how to get a license.

We were given 10 minutes to clerk the patient. Dr.Hanisah listened to each one of us interviewing the patients. And when the time's up, we presented the case to her. After history, she asked us to do Mental State Examination, followed by provisional and differential diagnoses, investigations and management. We finished the exam around noon.

Short case with Dr.Ali in week 7 was different. Since he did not understand Bahasa Malaysia well, we were given 10 minutes to clerk the patients, another 10 minutes to translate to Dr.Ali what did we ask the patients, 10 minutes to do Mental State Examination (eg. how to test patient's memory,  or abstract thinking), and then the discussion on investigations and management. That time we were not sitting in the room together. We were assessed one by one. That means, one student, one patient and Dr.Ali. It was more like preparing us for the end posting examination.

I went in first and got a male patient with Schizophrenia, presented with 3 days history of hearing voices and belief that he had special power aka 'ilmu firasat'. Aida got a case of Bipolar Disorder again, and Firdaus got Schizophrenia. We finished the exam at 12pm.

Two short cases done, then we had VIVA aka logbook assessment with Dr.Hajee. It was conducted in week 7, on Friday. We were called into the meeting room, Level 4 Psychiatry Department, JHC group by group. When we were inside the room, we showed our logbook to Dr.Hajee, and he asked us either to present a case from our logbook, or he asked random questions. Aida was asked on 'What is Cognitive Behavioural Therapy?' and 'How do you do Deep Breathing Technique and Progressive Muscle Relaxation?'. I was asked to present a case of Bipolar Disorder. My question was 'How do you manage this case?' Then I answered, 'I would like to manage this patient by using bio-psyhosocial-spiritual approach. Starting with investigations, bla bla bla'. Then, Firdaus was asked to present a case of Parasuicide. He was asked a bit about history of the patient, the meaning of extended suicide and the management. Dr.Hajee wrote our mark inside our logbook, and then he kept them. Most of us got 6 over 10.

Last but not least, the end posting examination. It was held on 22-24th December 2014. First day was theory examination, and the last two days were clinical examination. On first day, as usual, at 9am we started with MCQ, OBA and the newly introduced Extended Matching Questions (EMQ). While other postings had to sit for OSPE, psychiatric students were exempted. At 230pm, we had PMP. First case was on Bipolar 1 Mood Disorder and the second case was on Generalized Anxiety Disorder.

My clinical examination was on Wednesday. I got patient from clinic, and my examiner was Dr.Kartini. Here's a case summary (EDITED VERSION) of my exam yesterday.

Mr.Z, a 61-year-old Malay man, an ex-smoker, married with 5 children, from Indera Mahkota 2, works as a director of his own company, educational level up to Diploma in Oslo Norway, first presented to psychiatric clinic in March 2014, with four months history of low mood and loss of interest, associated with weight loss, appetite loss, insomnia, fatigue, psychomotor retardation, difficulty to concentrate and feelings of guilt and worthlessness. He mentioned that his depression became worse in the evening. It all started after his company had financial problems and he had to borrow money from a lot of people. He also believed that there are people who are trying to harm him because of his debts. There were no other delusion or hallucination. There was no history of persistent elevation of mood. He did not have any history of substance use or any general medical condition like hypothyroidism. 

According to his wife, patient became restless and worried when he was thinking about his company. Patient also admitted to having anxiety and worry about his problem almost every day, associated with palpitation. He found it difficult to control the worry. There were no recurrent unexpected panic attacks, no fear of being in open space, no social or specific phobia, no OCD or PTSD symptoms and no symptoms of hyperthyroidism. All of the symptoms had caused impairment in his socio-occupational functioning where he rather stayed at home than going outside. 

He also complained of loss of recent memory. He always forgot where he put the car keys, and always asked his wife where they were going. There was no history of aphasia (language disturbance), apraxia (impaired ability to carry out motor activities despite intact motor function), agnosia (failure to recognize or identify objects despite intact sensory function) or disturbance in executive functioning (planning, organizing, sequencing, abstracting). There was no history of fluctuating level of consciousness or impaired orientation. He had no history of brain trauma or cerebrovascular diseases. 

Despite taking medications and compliant to them, he still had depressive symptoms, persecutory delusion and anxiety. His wife said patient was slightly better in terms of mood and social functioning. He can watch TV at home, talk to his children and discuss about company problems with his friends and children. Patient was on Mirtazapine (Remeron), Alprazolam (Xanax) and Quetiapine (Seroquel). Currently, he complained of numbness over left-sided of his body, numbness of both hands and constipation.

Other important history : Patient had history of similar depressive symptoms for 6 months duration in 1987 due to stress at workplace and he was well-treated. His parents died when he was a teenager, then taken care by his grandmother. Poor relationship with his 10 siblings. He had bedwetting episodes at age 6 until 7 and history of truancy in high school. His first wife died of renal problem in 2005 and he got married in 2007, had one son. Good relationship with his wife and children. Premorbid personality cheerful and liked to go karaoke with friends. He did not share his problems with other people. 

Mental state examination revealed a medium built man, looked his age, wearing a pair of spectacles, black jacket and shirt, a pair of black trousers and sandals. He was sitting comfortably on a chair and not restless. He looked sad. He had good rapport, good eye contact and comfortable. He spoke in Bahasa Malaysia, coherent and relevant. His speech was of low tone, reduced rate and amount. He said that he was feeling sad because he felt that everyone was angry at him. He had appropriate affect. There was no mood lability. He had no perceptual disturbances. He had no formal thought disorder. He had normal flow of thought. He still had persecutory delusion. He was preoccupied with his debts. There was no thought possessions, no suicidal or homicidal ideation. His orientation, attention and concentration, memory, knowledge, abstract thinking were intact. He had good judgment but poor insight. He attributed all his symptoms to a problem in his body, not his mind. He felt the need to take medications. 

Physical examination revealed normal vital signs, no thyroid enlargement and normal respiratory examination. Neurological examination was not done (I forgot! Grr)

Differential diagnosis:
Major Depressive Disorder with psychotic symptom

Provisional Diagnosis:
1. Pseudodementia
2. Generalized Anxiety Disorder
3. Bipolar 2 Mood Disorder

Based on bio-psychosocial spiritual model 
Treat as outpatient, does not require hospitalisation

1. FBC (to check blood parameters before start medication)
2. RP/LFT (to check renal and liver function before start medication)
3. RBS (to rule out hyper or hypoglycemia)
4. BUSE (to rule out electrolyte imbalance)
5. TFT (to rule out hyper or hypothyroidism) 
6. ECG (to rule out cardiac problem in elderly)
7. MMSE (to rule out dementia)
8. Other tests to rule out dementia : Clock-drawing test, Trail-making test, Modified Mini Mental State Examination, Montreal Cognitive Assessment (MoCA).

To get collateral history from wife and family members 

To assess patient's obligation and responsibility towards God for further management later

1. Review old medications. If patient's condition improves and no side effects reported, continue. If not, reduce dose or change medications.
2. Start antidepressant preferably SSRI such as T.Fluoxetine 20mg OD. Side effects are headache, nausea, insomnia and sexual dysfunction.
3. Start anxiolytic preferably short-acting benzodiazepine such as T.Alprazolam 0.5mg TDS. Can use up until 6 weeks. Educate patient on tolerance and dependence.
4. Start antipsychotic preferably atypical such as T.Risperidone 0.5mg BD. Side effects are anxiety, insomnia, dizziness, constipation, nausea and rash.

1. Psychoeducate patient and family members on nature of illness and the need for treatment, side effects of medications, importance of compliance, course and prognosis, early warning signs
2. Cognitive Behavioural Therapy to correct patient's negative thinking such as feelings of guilt and worthlessness, advice patient on deep breathing techniques
3. Family Therapy to involve family together in taking care of patient

Advice patient to pray, recite Quran, zikr and take wudhu' as a form of relaxation therapy

All of us were given one hour to clerk patients and do examination. For this patient, I had difficulty in managing my time well. My first impression when I took history from patient was, this is definitely a case of MDD. And then, towards the end of 30 minutes of clerking, he mentioned that he had palpitation and anxiety. I was panicking for a while, thinking that this patient might have anxiety disorder and my history was pointing towards MDD! Luckily he did not have any episodes of panic attacks, if not I would be dead! It was more like GAD, thats what I was thinking. I completed MSE and PE in a rush, checked his BP and HR, when suddenly the patient's wife and son came into the room. I chatted to his wife and did examination at the same time. A few minutes later, I was asked by staff nurse if I have finished examining the patient or not, because Dr.Kartini was waiting.

I quickly examined his lungs and forgot to do neurological examination. There wasnt enough time left anyway. So I thanked the patients and waited outside Dr.Kartini's room. Dr.Kartini called the patient inside first, and about 15 minutes later, I was called inside.

I missed a few points in history. I forgot to rule out Bipolar 2 mood disorder. I didnt manage to answer some of the questions given. I was a bit nervous. Anyway, hopefully I will pass the exam. Hopefully all of us will pass.

So...that's about all. Enjoy your holidays!


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