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Gurpal

Spring 2007 Part 2 Long Case Feedback

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Please post feedback on the long case clinical exam. Useful information includes the clinical problem you were presented with (please respect patient confidentiality - click here for more info), the information you were asked to illustrate in the observed interview and details of the types of management questions asked. Thanks!

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had a hell of a case today

young male (late teens)

polysubstance abuse since 8

detained under 37/41 for murder (after arson)

previous h/o aquisitive offences and subsequent prison sentences

carried gun in the past (actually shot someone)

LD

ADHD

traumatic brain injury @ age of 12

spent 3 yrs in hosp (9 months in coma)

comes from a family of 17 siblings (5 of them step bro-sis)

described home enviornment as cushty

mum died wen he was 11

poor historian

lots of frontal signs therefore difficult to believe things like 'member of gymnastic team of GB, tony blair visited him in hosp)

nurse was escorting him but no corraborative info

std excuse 'i am a bank staff'

didnt even know patients current meds or how he is on ward usually :)

every 15 minutes the patient wanted to leave room for a cigarette

I was literally begging him to continue.. made a real mess of my train of thoughts

and then icing on the cake.. refused to answer questions of second task

my tasks were : assess h/o drug use

assess forensic history

my presentation was crap coz i had no clue where to start, what to include and how to organise all the info which made no sense to me leave aside examiners

management again i struggled coz i wasnt clear what of all these was actually the problem and therefore needed managing

imagine he had no ongoing anxiety, depression, psychosis

nurse said he was well behaved

so manage what??????

i mean if its just behaviour modification and rehab. then there isnt much to say apart from FBA and even there the role of psychiatrist is limited

i guess someone needs to put some sense into the royal college coz quiet frankly i felt like a complete idiot and it wasnt really all my fault !!!!

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I got BPAD--current episode hypmanic..recieving Rx in community.

Past 2 clear manic episodes and 1 depressive episode.

H/O sexual abuse by grandfather

Hemithyroidectomy in 2005

Currently on olanzapine

tASKS

Mood symptoms and premorbid personality.

Disussion--how will you manage further.SE of olanxapine.Role for CPN.

The discussion went well.

BUT THEN MY PROBLEMS STARTED IN THE AFTERNOON BUT I GUESSS IT MIGHT BE ANOTHER THREAD.

mY pmp THE EXAMINERS KEEP INTERRUPTING FORM 2ND MINUTE AND I REALLY LOST MY FLOW AND APPEARED LIKE A BIG FOOL WITH OURT CONFIDENCE IN ANSWERING QUESTIONS.

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Hi docpurrs

Seems like you had a difficult case. Did you brief the examiners about your difficulties (No corroborative history, that you interviewed him with constant interruptions). But looks like you have managed quite a good history with a difficult patient. I had a difficult case in autmn as well (Child hood abuse+eating disorder as adolescent+Homosexual orientation +HIV+personalitydisorder+substance abuse+psychotic symptoms+self harm) the only difference from your case was that he was a reasonably good historian. I was not confident at the end of exam but I passed. Hope it happens to you as well.

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Head Injury Long Case

Did Pmp well had worked hard was feeling confident , wanted to finish the long case and chill out, BUT Destiny God whatever you say didnt want that-Patient really difficullt to control in terms of history , you can ask her something and she will give you an answere which is all over the place didnt make much sense and took me a long tme to make sense of what she was trying to say!! I did tell that to the examiners

My long case was Head Injury frontal lobe syndrome , MMSE 20,

What I did right

MMSE Frontal Lobe testing luria, abstract functioning, cognitive etimates, agnosia ,dysgraphia,Forced utilisation

trsied looking at mood symptoms had some personality change, forced utilisation, poor concentraion.History structure was fine

DD- I said Frontal Lobe Dementia or Frontal Lobe syndrome

Pushed me to say one and i said F L dementia(Disaster) asked did she have deterirating cousre and I said no and said I would consider F Syndorome and said sorry

Then comes obs iv

ask about head injury and change in personality

Disaster again patient difficult to control rambled on

Managemnt went well I said Later I should have considered PTSD as well abut the lady didnt have any symtoms

examiners asked me about Post traumatic amnesia and i ealised I had missed that but inswered all the questions in management like head injury is a risk factor for Alz dem, Shizo, depression, epilepsy, psychotropics reducing siezure threshold, PTSD ICD 10 criteria

Examiners were looking for LOC and PTA mainly which I missed and I am most likely to fail

BUT In my 42 months of training I have not seen a single case of head injury , I dont know how many of us might have seen it , and the patient who was a nightmare and kept saying i will show u pics of my grandchildren (total Moria- Child Like)) and disinhibited

Have got a really bad feelikng and thinking they will fail me for it

What do people think are there any grounds for appeal with this performance if I fail ??

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I too got a poor historian. He said he had a diagnosis of schizophrenia and was on clozapine but denied all psychotic screening Qs. I informed the exmainers of the diffculties however and they seemed to accept that.

I think so long as you present your case as good as poss and answer their Qs you should be fine!

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I got a guy with long hx of OCD. He was great. Initially referred to his diagnosis as 'my condition' for some time. But once I asked him to describe his first presentation, he had a cheeky smile and said, now you already know the diagnosis.

It was a really relaxed affair and he was quite easy to get along with. In fact he gave me all the required details in around twenty minutes and once I finished what I needed to ask, we were chatting about football, about the local facilities and whatever else.

My observed task was to elicit rituals. It was ok. But What else can you say about treating intractable OCD after SSRI/Clomip/CBT/?CAT/Other psycho social interventions!

The examiners were quite relaxed aswell and didn't really go to obscene lengths about differentials. It was a patently obvious OCD. However I used a head injury he had and added enduring personality change following HI in DD. They went straight for OCD and were quite pleasant with reasonable questions.

Nothing to complain. Even if I don't pass, I feel I did the best I can in the circumstances. So , no regrets.

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I got the case I was hoping for, little old lady with recurrent depressive disorder, currently euthymic, even had a history of childhood neuroticism, separation from parents to help me with my aetiology. Unfortunately, still reckon I might have messed it up. She was so clearly euthymic I never thought about asking for psychotic symptoms in detail and didn't really give them a 2nd thought when presenting. Sure enought, they zoned in on it straight away after the observed interview, asking what other symptoms somebody with recurrent depression might suffer... they had to spell out psychosis before I copped on to what they were getting at. They gave me 5 minutes to do my 2 interview tasks- assess mood and insight. Again didn't go near psychosis. This lady denied having a history of psychotic depression, but has had ECT. It was probably the one symptom they were waiting to hear about. If she had been depressed at all I'd have asked, but when she was so well was too busy rushing on with the rest of history. anyway, have only myself to blame if I fail it. The other questions they asked were about the management of severe depression and its evidence base regarding augmentation with lithium, augmentation with lamotrigine, augmentation with antipsychotics etc, abnormal grief, how to explain about lithium augmentation,

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had an elderly lady..

long history of mixed anxiety and depression..

lost hus 9/12 ago..

recent depressive episode..

currently euthymic..

o/p f/up.. doing well on A.D...

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Complex case with Depression, Anxiety and memory problems.

61 year old male, early retirement due to ill health for the past 3 1/2 years. Being managed in outpatients.

His current problems started with a panic attack 3 1/2 years back, which developed into depression, with a somewhat generalised anxiety picture. Had not gone to work since then and applied for early reitrement. During these 3 years had been admitted to private hospital twice and NHS hospital once. Has had previous depressive episodes in 1990 and 1999 and was admitted to hospital then. Has been c/o of some forgetfullness recently for remote events.

He had received all the freakin antidepressants in the world, SSRI, MAOI, Lithium, Mirtazepine, ECT (Twice).... currently going to some specialist mood disorder clinic. His current meds were Venlafaxine 225mgs, Olanzapine 5 mgs (i didn't know why, never been psychotic) and buprpion (Zyban, this is recommended in Maudsley for refracrtory depression). He put down his memory problems to ECT.

No medical co-morbids....... father had died 2 years back and was diagnosed with Alzhiemer's disease.

Feeling settled now, slight low in mood and somehwat flat affect but reactive. No other positive findinf in MSE. No positive finding in physical examination

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Feeling settled now, slight low in mood and somehwat flat affect but reactive. No other positive findinf in MSE. No positive finding in physical examination

Is that him or is it you?? ;)

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Complex case with Depression, Anxiety and memory problems.

Feeling settled now, slight low in mood and somehwat flat affect but reactive. No other positive findinf in MSE. No positive finding in physical examination

Is that him or is that you now!! ;)

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One of my senior asked me to ask the patient their diagnosis and what medication they are on and then home on the signs and symptoms relevant to those diagnosis and medication.

My patient was (very) cooperative and gave me a clear history.

The case was straight forward long standing schizophrenia with last admission about 10 years back and had been on depot for last 8 years or so. He continues to suffer sub-clinical symptoms of depression and negative symptoms but no major psychotic relapse. Halfway through the interview he mentioned alcohol and I realized that he probably satisfied the harmful use criteria. I had enough time to ask him alcohol related questions. I also had time to do a full physical including alcohol exam – no +ve findings (ref: OSCE Part 1).

I have to say, I was very lucky and the presentation wasn’t too difficult. The questions for the observed interview were: demonstrate how his mood had been recently and how his mood ties in with his relapse (which was 10 years ago – or according to the history at least). The patient and I waffled a bit on observed interview but generally stuck to the main theme. I couldn’t finish everything but was generally ok. The additional questions were: what’s his management from now on, if you had to take over her care today, given his history, do you think there might be any reason to change his diagnosis as alcohol induced psychosis?

Later on I found out (from the tutor who organized the exam), that I missed out few things – like major depressive illness about 5 weeks back etc. but the patient didn’t tell me and I didn’t waffle on depression at all.

however, i still passed the exam -- so i am guessing it wasnt too bad.

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Hi docpurrs

Seems like you had a difficult case. Did you brief the examiners about your difficulties (No corroborative history, that you interviewed him with constant interruptions). But looks like you have managed quite a good history with a difficult patient. I had a difficult case in autmn as well (Child hood abuse+eating disorder as adolescent+Homosexual orientation +HIV+personalitydisorder+substance abuse+psychotic symptoms+self harm) the only difference from your case was that he was a reasonably good historian. I was not confident at the end of exam but I passed. Hope it happens to you as well.

Thanks Balmu....I passed ... what a relief  :o  :o

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