Вы находитесь на странице: 1из 4

Psychiatry OSCE Pack

Nicole Todd

Table of Contents Standard History and Physical Depression Anxiety Psychosis Alcohol Dependence Delirium

Standard Psychiatry History and Physical ID: age, sex, ethnicity, marital status, occupation, education, living situation Mode of Admission:

CC:

HPI: Situation Stressors Symptoms

MSIGECAPS

GST PAID

BE SKIM, STUDENTS Fear CCC

Substances

Suicide

SAD PERSONS

Safety

ROS:

Past Psych Hx: previous dx, prev hospital admissions, past suicide attemps, past substance abuse PMHx: including head trauma, seizures Medications:

Allergies:

FHx: psych dx, hospital admissions, suicide, depression, substance abuse Past Personal Hx: childhood, adolescence, adulthood, occupation, legal problems Mental Status Exam:

Appearance – hygiene, agreeable, eye contact

Speech – rate, rhythm/fluency, volume, quantity

Emotion, Affect (appropriate, labile, restricted)

Perception – hallucinations

Thought – form (coherent), content (delusions)

Insight, Judgement

Cognition – GCS, orientation, attention Mini-Mental State Exam

Orientation – time (5), place (5)

Memory – ST (3)

Attention – serial 7, WORLD (5)

Memory – LT (3)

Reading (1), Writing (1), Repetition (1), Copying (1)

Naming (2)

Command (3) Multiaxial Assessment Axis I – DSM-IV clinical disorders Axis II – personality disorders Axis III – GMC Axis IV – psychosocial and environmental stressors Axis V – GAF

Depression DSM Criteria MDE

DSM Criteria MDD

A. 5 or more MSIGECAPS for at least 2 weeks

B. Not a mixed episode

C. Cause distress or impairment in social, occupational functioning

D. No GMC, substance

E. No bereavement

A. MDE

B. No schizophrenia, delusion, psychotic disorder NOS

C. No manic, hypomanic episode

Epidemiology – Male 5-12%, Female 10-25%, genetic 65-75% MZ, 14-19% DZ

Risk Factors

female, 25-50years, FHx, childhood experience, stressors, post- partum, lack of social supports

Prognosis – at one year 40% still have sx, 40% no sx DDx - VITAMINC Investigations – CBC, Electrolytes, TSH, U/A Treatment

SSRI – Fluoxetine, Paroxetine, Sertraline, Citalopram

o

SE – GI, restlessness, sexual problems, 5HT syndrome

o

Energy returns before mood improves - suicide

TCA – toxic in overdose

MAOI – diet, 5HT syndrome when combined with SSRI

Start Low Go Slow, re-evaluate after 6 weeks

o

Optimize dosing

o

Switch classes

o

Combine

o

Augment – Li, T3

o

Re-evaluate diagnosis

Anxiety HPI

Anxiety experienced as panic?

o

Specific Phobia – animal/insect, enviro, blood, situational, other (clowns)

o

Social Phobia – fear of being judged/humiliated

o

Panic Disorder – w/w/o Agoraphobia

Anxiety secondary to specific trauma?

o Acute Stress Rxn (<1month), PTSD (>1month; re-experience, avoid, arousal)

Anxiety experienced as excessive worry?

o

Adjustment disorder (<6 mos + stressor)

o

GAD – BE SKIM

o

OCD (intrusive thoughts with repetitive behavior)

DDx – VITAMINC Investigations – CBC, electrolytes, TSH, U/A, ECG, CXR, CT Treatment

CBT

Short acting benzodiazepines (Lorazepam)

o WD Sx: anxiety, insomnia, autonomic hyperactivity, tachycardia, hypertension, perceptual disturbances

SNRI (Venlafaxine), SSRI (Paroxetine)

Psychosis Mental Health Act:

A. Suffering from a mental disorder

B. Danger to self or others

C. Patient is unsuitable for admission any other way than as a

formal pt Management of Agitated Patient

Physical restraints

Chemical restraints

o

Haloperidol 5-10mg IM q1h until sleep or calmness ensues

o

Lorazepam 2-4 mg IM/IV/SL q2h prn

Alcohol Dependence HPI

Ask if patient drinks (CAGE +1 M, +2F)

Advise patient to quit

Assess willingness to quit (Pre-contemplation, contemplation, preparation, action, maintenance, relapse)

Assist in quit attempt

Arrange follow-up (CIWA Scale)

Stage I (6-12h): tremor, sweatiness, jumpiness, anorexia, cramps, diarrhea, sleep disturbance

Stage II (1-7d): visual, auditory, olfactory, tactile hallucinations

Stage III (12-72h to 7d): grand mal seizures

Alcohol withdrawal

Sage IV (day 3-5): delirium tremens, confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (tachycardia, HTN) Management – diazepam 20 po/IV q1-2h prn, thiamine 100 mg IM then 100mg po X3d, Lorazepam 2-4 mg IV/po q30min, Librium

Sequlae

Wernicke’s encephalopathy (WACO) – acute/reversible, ocular nystagmus (horizontal), CN VI palsy, ataxia

Korsakoff’s syndrome – chronic, ST memory loss, difficulty learning new information, confabulations

Delirium

DSM Criteria (AIDS): A. Disturbance of consciousness

B. Change in cognition

C. Acute onset

D. GMC

Etiology: DIMS Investigations: CBC, Electrolytes, Ca, Phosphate, MG, glucose, ESR, LFT, RFT, TSH, Vit B12, folate, albumin, U/A, ECG, CXR, CT head, tox screen Management

Intrinsic – identify and treat underlying cause

Extrinsic – quiet, light environment, optimize sight/hearing, reorientation Prognosis – 50% one year mortality rate

Dementia

DSM Criteria for Alzheimers type: A. Memory impairment and >1 of aphasia, agnosia, apraxia, executive function

Etiology

Intracranial

B. Significant impairment

C. Gradual onset with continual decline

D. Deficits not due to GMC,

E. Deficits not present during delirium

F. No other alternative dx

o

Alzheimers

o

Lewy Body – hallucinations, parkinsonism, memory

o

Frontotemporal – disinhibition

o

Huntingtons – chorea

o

Vascular – stepwise decline

o

Infections

o

Trauma

o

Anatomic – NPH

o

Tumor – benign, primary, metastatic

Extracranial

o

Drugs

o

Metabolic

o

Endocrine