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Autumn 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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Long case Autumn 2007

Asked to assess;

1. compliance

2. how the mental illness has affected function

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Holy Sh*t Batman...

What I thought:

bipolar disorder (resistant to treatment)

psychosurgery ( :o :o :o :o)

...'I take trotoxin for an overactive lymph gland' (Bl**dy hell, I'm thinking- is this guy dying of some hideous leukaemia and receiving chemo???? Luckily, was inspired a few minutes later to ask him if he was taking thyroxine for an overactive thyroid gland, and sure enough.... ::) ::) ::) (But don't worry about that, he says, that's a physical illness!!!! And I'm thinking, you try persuading a Part 2 examiner that thyroid disease has nothing to do with affective disorder resistant to treatment.....)

and PHx of alcohol dependence, currently bingeing on work nights out with his colleagues 10 pints a time.

Currently well, he tells me (ie , no PC).

What the examiners probably had written down, judging by what they were grilling me about was that he is currently drinking considerably more frequently than this... :-[ :-[ :-[

So, observed interview- can you elicit any psychotic features he may have had during his depressive episodes (15-20 years ago!) cos I said I got the impression it may have been severe/psychotic although he couldn't remember ( and sure enough, there were none when I enquired in detail, specifically, about 20 yr old symtoms...)

Can you elicit symptoms of hypomania that you said he had but was never admitted for (and he came up with these like a goodun)

And if you have time, they said ( :o :o :o) can you elicit this 7 month period of amnesia he says he's had following his 55 ECTs.....

Well, what can I say. It was quick and dirty- basics, no detail, and there were probably a million and one ways to fault me. But I did the best I could, and if I fail, fair do...It wasn't perfect- it was practical, and I certainly couldn't have done more in the time given. If it wasn't good enough, I shall know why- I'm not anankastic enough to be a psychiatrist ;)

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long case was abstinent for three years alcoholic with significant history of depression, anxiety, social phobia and panic disorder with physical complications i.e peripheral neuropathy etc...

observed tasks were not that structured..

1. elicit description of panic attack and the link to alcohol....

2. see what he does to avoid relapse...

thought they were ok, but then there is no structured list that comes to mind (and if there is I DON'T WANT TO HAVE IT NOW...too late...! Ok?)

anyway, mostly flat examiners faces, so hard to say, but gut feeling was ok...!

At least it is over now!

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again nerve wrecking expereince.

an 80years old man was very nice and co operative. lead a lonely life. hade one relationship in the past for a couple of years, no children and that is it. five years ago had depressin because new neighbours moved up stairs and were making lots of noise. treated through out-patient. moved himself to sheltered accommodation later. this episode precipitated by neighbour putting the telly volume very high because she is deff. that was for five weeks. felt very depressed, classical symptoms and took a massive overdose of paracetamol.

addmitted to general hospital for three weeks and transferred to the psychiatric hospital.

born in a farm, the only child. no history of abuse but had a lonely childhood.

employed untill the age of 65 when retired. no other significant history.

observed interveiw

1/ clarify the noises he heared?

- tell me about these noise

- how often do you hearit

-any one else heared it- next door neighbour

- how did you cope with it

- have you tried to do any thing like smashing the telly etc.

2/ illicit symptoms of depression

- went through the list from anhidonia,low mood, fatigue, no light at the end of tunnel etc

then I was grilled about the ICD symptoms of depression, I answered all that

then do you only diagnose depression by symptoms? I said also by functional impairment,grilled about his function. then what else to diagnose depression? suicide no that is a symptom. I did not know what was in his mind.

other examiner asked him to go to management. then he asked me. I started with the mdt and biopsychosocial, did the investigation, then a nock on the door and 5 minutes left. I started rushing through the medical treatment and Nice and follow up, which was interrupted by qs about the ect and cipramil. I tried to rush to social managemnet and he interrupted about CBT and grilled me on it. why you do it, how. then the bell rang. the other examinor asked me to stop. but looking at the other examinor I said the short term prognosis is good and the longterm one is favourable because few episodes and... he said you have thrown good bits at the end and I left the room.

It was a horrible expereince and I had mixed feelings

but it is over

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68 year old lady with recurrent depressive disorder. Observed interview was just to evidence mood symptoms.

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50 year old lady with bipolar disorder- stable for last 4 years with no other co morbidity. Asked to assess mood and premorbid personality.

I was the last candidate for the day and the examiners didnt seem interested. After observed interview, one of them commented that i didnt ask about suicidal thought, although i had asked two straight questions on it.

They also didnt have many questions- the last question was where would i treat this lady- home or hospital, irrelevant question as this lady was absolutely fine and had been stable for past 4 years.

I think i did ok. Dont know what to make of examiners though.

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Got a case of learning disability with sex offending, that was the last case i was expecting that day. ::)

observe interview: was educational hx +insight 8-)

management: discusion around treatment of sex offenders

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My Long case was 29 Yrs old man with Schizophrenia and obsessive symptoms. Also had severe anxiety symptoms and was stammering.

Observed interview-

Take forensic history

Elicit Psychotic symptoms

and Do a Cognitive assessment.

I felt examiners were friendly, smiling not difficult.

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My examiners seemed disinterested in what I was saying and did nothing to put me at ease. It felt as though they wanted me to fail. When I read reports of smiley examiners it makes me feel annoyed!

In the PMP's one of the examiners stared at me with a perpetual frown despite the fact that I was calmly telling her the correct management of PTSD!

I can see why they are scrapping this subjective exam next time!

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schizoaffective with poly drug use, some residual symptoms

Not a good historian. was admitted because 'let down by the system, housing problems, and being on drugs....' didn't remember any of her symptoms

I tried to touch on every heading on history MSE, phy exam risks though there was very little relevant info- all the while tryoing to elicit some symptoms to aid in diagnosis

obs int on eliciting alcohol dependence though she did not drink alcohol at all!! I felt she woulf get annoyed if I keep asking ICD criteria on dependance if she is not alcoholic in first place!!

elicit insight

Ran out of time for most part of IPA. Covered most headings.

At last it is over

Cant go through these exams any more

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OCD-Perfect expert patient-gave history as psychiatrically as possible with words like 'pathological doubt' and stuff like that. Went throu entire Y-BOCS way. So my HOPC was sounding like MSE. was not aware at the time of history taking but when i started presenting was feeling odd. As much pleasure seeing a cooperative friendly patient who apparently came out and was saying ' she was extremely thorough!!!!' which my lovely husband overheard, my discussions were struggling as he had CBT for 15 yrs and what next?????

I donno in the heat of it I did say dynamic therapy??!!! which of course is not mentioned anywhere. I have said right things like couples therapy with wife as co therepist blah blah----------Hope I dont get penalised for that. U never know do u?

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can someone give an answer for the experience in my longcase. I got a lady with substance misuse (cannabis and alcohol) and psychosis. The examiners asked me about personality traits or disorders and asked me to elicit PMP (only one task given). After 2 minutes when I was halfway through they stopped me and said 'OK WE CAN MOVE ON TO THE NEXT PART OF THE EXAM' then they asked about the management and other usual stuff.

I am puzzled and worried why they gave only one task and stopped me quickly (have they decided to fail me anyway)

Any one had this experience in the past

Jey

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If it's any help the examiners also gave me only one task (mood symptoms) and also stopped me before I had finished. They just asked me what else I would look for and then moved on. There is no restriction on them asking you to ellicit things in that part of the exam most get two, some get three and we got one.

I wouldn't worry about what it means because examiners as a general rule are a law unto themselves. A SpR friend told me he came out of an exam convinced he had failed (he passed), his friend was convinced he had passed (he failed). Don't worry about it or read too much into it it, what will be will be, you'll find out when the results are out.

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No problem. Look on the positive side, they probably stopped you cause it was apparent early on that you knew what you were doing so why subject the patient to more questions when you've already shown that you are competent?

;)

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Its all blind luck with the results, I figure... I am now wishing I'd taken a lovely holiday (somewhere warm!) after my clinicals. Instead I have a week of 9-5's then nights on Friday... :o Life is fun !!!

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Holy Sh*t Batman...

What I thought:

bipolar disorder (resistant to treatment)

psychosurgery ( :o :o :o :o)

...'I take trotoxin for an overactive lymph gland' (Bl**dy hell, I'm thinking- is this guy dying of some hideous leukaemia and receiving chemo???? Luckily, was inspired a few minutes later to ask him if he was taking thyroxine for an overactive thyroid gland, and sure enough.... ::) ::) ::) (But don't worry about that, he says, that's a physical illness!!!! And I'm thinking, you try persuading a Part 2 examiner that thyroid disease has nothing to do with affective disorder resistant to treatment.....)

and PHx of alcohol dependence, currently bingeing on work nights out with his colleagues 10 pints a time.

Currently well, he tells me (ie , no PC).

What the examiners probably had written down, judging by what they were grilling me about was that he is currently drinking considerably more frequently than this... :-[ :-[ :-[

So, observed interview- can you elicit any psychotic features he may have had during his depressive episodes (15-20 years ago!) cos I said I got the impression it may have been severe/psychotic although he couldn't remember ( and sure enough, there were none when I enquired in detail, specifically, about 20 yr old symtoms...)

Can you elicit symptoms of hypomania that you said he had but was never admitted for (and he came up with these like a goodun)

And if you have time, they said ( :o :o :o) can you elicit this 7 month period of amnesia he says he's had following his 55 ECTs.....

Well, what can I say. It was quick and dirty- basics, no detail, and there were probably a million and one ways to fault me. But I did the best I could, and if I fail, fair do...It wasn't perfect- it was practical, and I certainly couldn't have done more in the time given. If it wasn't good enough, I shall know why- I'm not anankastic enough to be a psychiatrist ;)

My experience is I had the same patient Ros had (surely there can't be two psycho-surgery patients in that particular centre!) and it seems to me he played different roles. In my own case, there were no current problems, difficulties or worries in terms of PC so narrated the history of the last admission some 13 yrs ago and since the surgery about 10 yrs ago, has remained symptom-free. Family h/o BAD. Past h/o heavy alchohol/illicits misuse, currently using cannabis with no overt sequelae (my impression). Not on any mood sbabilizers, antidepressants, antipsychotics,etc except zopiclone, thyroxine and lipitor (for hyperlipidaemia). Mental state & physical exam generalyy normal, except some odd flashes of distractibility and irritability (nothing significant, I would say).

Gave dd as : 1 BAD, currently in remission (preffered dx) 2 Frontal lobe syndrome 3 Hyperthyroidism. Was given the task of assessing his mood and current/past h/o alcohol/substance use. Thought that went very well, as was stopped before time. Was then passed over to the other examiner who grilled me about why the operation was performed, the specific type of op performed (pt had told me) and complications of op (managed to only remember personality change akin to the frontal lobe syndrome and trauma to/haemorrhages in the brains-forgot about epilepsy). The the examiner switched to pmp style questions which surprised me e.g. 'imagine someone is low and suicidal-how woulde u manage/treat'. Did say management would depend on assessment and options include admission and close nursing observation and use of CPA in the UK (exam was in Ireland). Later added that will be along the biopsychosocial model and was asked to outline biological treament. At this stage wasn't sure if I was treating unipolar or bipolar depression and forgot to clarify. However did mention use of shorterm benzos (eg. lorazepam to control agitation/anxiety), mood stabilizers (was grilled very hard-concentrated much on the traditional ones and forgot to mention atypical antipsychotics are also mood stabilizers), antipsychotics. Was asked to mention other biological treatment options-then remembered antidepressants (but managed to say would use with caution as can precipitate manic episode) and ECT (was asked indications).

Examiner later asked in which order I would use them if I were treating the pt on the ward. Did waffle a bit. Talked would use NICE guideline and was asked to explain it-was struggling now. Later examiner wanted me to mention side-effects of sodium valproate (I mentioned sedation, weight gain, lethargy, etc). Now wanted sideeffects in women-I mentioned teratogenicity (esp. neural tube defects), interaction with ocps (enzyme inducer), agranulocytosis, etc-examiner was not satisfied. Now switched over lithium-baseline investigations before initiation-mentioned the usual ones-was not satisfied-wanted to hear cleatinine clearance. The whole thing now was getting more & more pedantic!

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;) :-/ :'( :-X ::):P:o:( >:( The whole thing was fast paced and I must've been asked lots of questions! (probably more than 10).

Still reliving the exam and the grilling. Want to avoid the questions, but they're intrusive, persistent, recurrent with co-morbid flashbacks!

What you people think of this experience, especially the style of the questioning? In the end, the questions asked did not have much to do with the patient I clerked and presented (except the questions regarding psycho-surgery), but a lot to do with hypothetical scenerios. Is this acceptable in the IPA?

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That's weird, Justice! Were your examiners the same as mine? Khan and something that sounded arabic-Kmein or something?

It must be the same guy. Glad you didn't find he was slaughtered every night.....

I can't remember what they asked me in nearly as much detail as you- very different questions, but the style was similar- lots of questions, not necessarily related to the patient (eg. they asked me what disulfiram was)

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;) Well Ros, I had a male and a female examiners plus the college observer. I remember introducing the female examiner ( one Dr Sabat something) to my patient (or actor) by name because was closest to me and made the others mention their names.

The whole thing was weird as u say because as soon as I started presenting, the male examiner started coughing very profusely and seemed in distress. I did not know what to do: to say'are u alright, do u want a cup of water?' (showing empathy) or to continue. My sixth sense told me to stop presenting when the coughing got worse and that was what I did (again showing empathy without speaking). I don't know which response , in retrospect would've been better. Do u?

However, as soon as I had stopped, the man made a quick recovery and told to continue-he was now alright and the coughing had stopped! The whole saga did put me off a bit, but did continue. In the middle of the presentation, he asked me to present the positive findings. I stuck with my format because did not what he meant by positive findings-both important -ve (e.g no childhood abuse, bullying, truanting, no family h/o mental illness, etc) and +ve findings (e.g cannabis usage, family h/o mental illness, etc) are equally important.

When I came to the heading 'physical examination', he stopped me and asked for the differentials. Was he annoyed with me? Did I exceed the time? Did he want to make things difficult for me?Still tormented by these questions. The situation was not helped when the female examiner took over and appeared to be too pedantic and rigid with the line/style of questioning and answers she expected. Do u routine do a creatinine clearance prior to lithium initiation (BAP book says no-unless there's prior renal impairment/failure). What are the specific side effects of litihum on women? There's a debate over polycystic ovaries.

Can anyone comment on these experiences of mine? Where the examiners fair with me? What would've been the right response when the coughing started?

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did u mention hypothyroidism as one of the side effects as this is more common in women.I think u did well when the examiner coughed upi dont trhink u could do anything else.

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did u mention hypothyroidism as one of the side effects as this is more common in women.I think u did well when the examiner coughed upi dont trhink u could do anything else.

Well, didn't mention hypothyroidism. I'll be interested if you could shed more light on this as I'm not aware of this particular problem wih sodium valproate. Some people did think she was looking for polycystic ovaries, but there again, there are question marks over this (Fundamentals of Clinical Psychopharmacology, 2nd ed, Anderson & Reid).

More comments/opinions/views welcome.

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sorry i was thinking of lithium not valproate,hair loss with curly regrowth.In BNF it says menstrual disturbances(rarely),hirsutism(very rarely)

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