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Autumn 2007 Part 2 PMPs Feedback

50 posts in this topic

Please feedback your experience of the PMPs exam. It would be very helpful if you could list the PMPs you were asked. The more detail the better. Cheers!

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I must have been the one of the cohort who took the PMP first in the country...

My experience ...

Called in at 10am and my reporting time was at 9.50

Both the examiners shook hands and made me feel comfortable....I felt relaxed ... One examiner read the PMP, rather very slowly, by the time he finished I had read it 2 times....!!

1. A 21 year old man who is experiencing hallucinations..delusions his first episode was when he was 19. He is using amphet and cannabis, isolating himself in his room. He has been tried on various Antipsychotics and he is non compliant with these. Assess and Manage

I went through the risks the main issues of managing this gentman with negative symptoms , noncompliance and substance misuse...

said I would see him as soon as possible, then I was fired a serious of questions

how would u know he is using drugs? said history and urine drug screen..

how do u know he is treatment resistant? same stuff..2 anti psychotics..adequate time and adequate period...

What would u use? ..Clozapine

What is the evidence for Clozapine?

what dosage --i said 50mg...the said sorry 12.5 and monitor for hypotention..inpatient if risk of relapse high..max dose of clozapine..? then i said i would add sulpiride due to evidence...

they were ok and went to 2nd PMP

2. A doctor has been admitted for haemetemesis in the surgical ward a day ago. He is disinhibited towards female staff now..how would u manage

I said the core issues are 1. Managenet of acute confutional state

2 Specific Management due to the fact of his profession

1. Contain the risks, I would tell the surgical team keep him safe, male staff if possible and make sure the risk to female staff is contained

then would rush to surgical ward

then DD..from organic..epilepsy, infection to psychosis to personality

narrowed down to Delerium and DT( I knew it was going towards DT)

Examiner said let us say it is DT wht would you do

I said-management is Non Pharmacological and Pharmacological

and went on the same stuff...

till it came to Long term benzos for DT, then came the same question..what else? anticonvulsants

what else? antipsychotics only if disturbed and with caution...what else? i was wondering what else?

then said Pabrinex iv...then he appeared happy...

then the next line of management was due to the fact he was a doctor

1. Doctor in the same trust- can be treated in a different hospital after he is stable

doctors job is stressful, so he needs help and he could notify-Occupational Dept.

further management will be Detoxification and Relapse prevention

I was asked let us ay he is drinking..what is the risk?

Risk to patients ..stop him seeing patients..advice, line manager...medical director...if continues..GMC

that was the end of the 2nd one..so far it was smooth, altough I felt i could do better..I still remained calm ..just like it was a MDT meeting with colleugues.

3. A 50 yr old lady whos husband died 7 months ago..in a car accident in which she was present. She is now hopeless and guilty. She relives the experience and stopped driving.she is a van driver by profession and her emplyer is pressing for her to start work.

This one looked straight forward and so I started saying management of what seems to PTSD - due to reliving and avoidance ..but at the same time I need to r/o organic...pathological grief, depression, psychosis, OCD...

then this examiner just shot a question....her employer is asking her to drive...wont u do anything about that...( i thought...wait..i am coming to that..!!!) I would write to him...at the same time i need to keep confidentiality as well.

Then he asked me ' u told me pathological grief..how would you say that...i said the RISK factors and Symptoms of Pathological grief...Ambivalent Realtionship, traumatic death, not able to see the deceased ..funeral...then he asked wht about the GUILT.... i said yes..guilt is a symptom( and I am coming that u impatient fellow)...I said the symptoms ...remembered 3 to 4...

It would be difficult to differentiate b/w grief and depression..will you prescribe her meds I said SSRI.. How will you explain PTSD ...I said i shall explain PTSD symptoms..psychoeducation...trauma focussed therapy referral or EMDR..by this time i was wondering whre is he leading me to...Pathological Grief or PTSD... asked she will go home adn read the leaflet and complain..she is not able to sleep, she may loose wt..wont you explain to her the side effects....I then thought..ok..lets go with this fellow...said...yes its very important to explain side effects also that all of them dont get the side effects...and if she has any she could let me know I could make changes to it......What abt her driving...which antidepressants impair driving...I said Tricyclics..due to drowsiness.If she continues driving what will you do?(she has PTSD man..how will she drive...i thought) I will have to tell DVLA..then I wl inform

TIME up

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Don't know if it was ok..I have not done very well in the IPA..so just counting on my luck..and gods grace....!!

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PMP's on 15/11/07 at St Vincent Hospital, Dublin- 1400-1430

1) Middle aqged man brought by police to casualy, long history of heavy alcohol use. Currently, clutching thin air, perplexed, frightened, visual hallucinations. also has pyrexia, crepts, assess and manage.

2) 4 year old boy, sticks to routine and gets aggressive if things/toys are moved or changed. Assess and manage

3) 55 year old lady with pain in muscles and joints of unknown origin, GP thinks she is depressed. Currently on high dose of opioids and non opiod analgesic and low dose amitryptiline. Assess and manage.

The way i saw it, it was delirium tremens, autism and somatization disorder. But dont think i did very well for some reason. Any comments or suggestions welcome.

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pmp 4pm

1-26 yrs old woman who broke up with her partner with previous ODs presented toA&E after taking an od and self harm requesting admission

also she has 2 misscarriges recently and she abuses drugs

assess and manage

2-30 yrs old man with mild ld became aggressive who live with elderly parents,and he started rubing his genitals against furnuture and also approaching school children.

Qhow did he develop this behaviour

Q what are the risks,DD,and how to contain him

assess and manage.

3- 45 yrs old man referred to u by cardiologist after he was cleared of any organic cause.he still complain of tight chest and difficulties breathing. he has been off work 9teacher) and requesting further investigations.

assess and manage.

examiners were very interupting and abrupt

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My 3 pmps at 11.20 am on the 15th

1. 63 yr old man 5th episode of depression. He was severely depressed, not taking tablets. His physical health was very poor..

I spoke a lot on this but think that this one did not go very well. My examiners did not interrupt me much until about 7 minutes after i had finished the assessment and investigations. I spoke about ECT because of his physical health (talked about consent, mental health act, second opinion etc) Long term - compliance therapy etc.

2. A 59 year old lady broke her leg.. within 12 hours. with visual hallucinations..

I thought this one went well. Talked about how i felt this looked like D.Ts.. but would have to rule out other causes such as other causes for A.C.S.. discussion went later to the management of D.Ts..

3. Finally a lady with agoraphobia not leaving her house (the one in the prev pmps on this website). I did not go into too much detail with the differentials (said that i would keep in mind depression, other diagnoses and co-morbid substance abuse.. talked about risk) Management was ok.

Hope I get a score of 10 at least!!! If I fail, i'll really kick myself cos my pmps could not have been easier than this

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I had the same PMP as MFS.

1. 30 year old lady presenting to A& E after paracetomol overdose after breaking up with her boyfriend.history of suicide attempts in the pasts by taking O.D and lacerations on her wrist.

Had been in foster care until age 15 and has history of sexual abuse and history of alcohol and substance misuse.she is sking for admission into hospital.asess and manage.

started off with risks

back ground info from all the sources

DD- substance and alcohol induced psychiatric diorder

Dep

Adjustment

Acute stress reaction

Anxiety

P.D

HOPC-current attempt-asses intent and risk

associated mood

substance misuse and dependence

past attempts and seriousness-needing medical treatment

social supports

Developmental history and problems

By then examiner interrupted-what are the prones and cons of admitting her?

Admission will reinforc e the behaviour,and helps to maintain the cycle,if not associated with serious intent I would treat on O.P basis and reguler review.

Asked about therapies-Psychodynamic therapy-big nod

DBT-explain .started talknig about DBT and said -brief admissions for crisis resolution(remembered from manchester notes!) nd examiner asked if this is a part of a package and i said yes.she moved on to the next. NOT SURE IF I BURRIED MYSELF BY SAYING BRIEF CRISIS ADMISSIONS...........

2.A 30 year old L.D who can manage to find his way around the roads presents with increased levels of irritability and behavioral problems.currently living with elderley parents.

Started rubbing hid genitalias and exhibiting sexually disinhibited behaviour in the day centre he goes to.staff are concerned that he is exposing himself to the school girls.

Went fine.followed the structure.

Again examiner asked how will i asses the risk?spoke about previous sexual assaults,lack of remorse,current fantasies,matrubation,sexual pleasure,aimed at a perticular victim,substance misuse.

Asked reasons for his deterioration-spoke about physical(pain,constipation,infection epilepsy),psychological(hypomania.mania,psychosis)social(changes in staff,parental illness).

They were fine.said invlv e social work to arrange respite care for elderly parents.

EXAMINER ASKED IF I WOULD INVOLVE ANY VOLUNTARY ORGANISATION.......Blanked out.......

said LD team .I should have said ?POLICE if risks are high.....

3.A 42 year man has been referred by the cardologist.has chest pain ,palpitations,and sweating for which no physical causes have been found.He is a school teacher being head in english.how will you asses and manage?

Spoke about DD-Depression

anxiety disorder

agoraphobia with or without panic

somatisation

hypochondriasis

substence induced psychiatric disorder.

Asked about etiology-dysfunctional beliefs during childhood(forgot parental illness,attention seeking in parents)

how will you manage?

Spoke about general approach to somatisation management-avoid unnessesary investigations,same memner of staff,discourag e emergrncy appointments,

CBT-asked to describe-did as well as i could but could have done it better.

NOW COULD ANY ONE TELL ME IF

mentioning acute admissions for crisis managment as part of ?DBt/TC in 1 pmp

Not involving police in second PMP(do we need to not sure at this stage and he asked me for voluntary organisatins)

will make me do this exam again..?

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I had college observers for both the parts.

Does any one think that will make any difference to the result?

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well.. it depends.. i've heard people say that sometimes the observer will encourage the examiners to pass a candidate and sometimes they will to fail.. so the answer to your question actually is not sure.. just have to wait for the result next month.. just keep praying and hope that you have done well to pass.

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1. 63 year old man with Recurrent Depressive Disorder currently on the ward under your care. He has been admitted 5 times and his current admission was as a result of not taking his medication because he felt it was not working. Whilst on the ward staff discover that he has been collecting his medication in a tissue paper for the last 2-5 days. he has also reported to staff that he feels as though his bowels are rotting and internal organs are missing. He has not been eating and drinking for 2 days.

Outline your assessment and management.

My approach was to identify were the risk of suicide, the Dx of severe depresssion with psychotic features, role of ect in this case

2. 53 year old lady in A & E with a fracture of the wrist. Suddenly becomes confused and agitated, tremulous, wanting to run away from little creatures on the floor.

Assess and Manage

I was quick to say that I was probably dealing with DT's here, said the usual stuff about ruling out other organic and psychiatric illness in my assessment. included psychosis, agitated depression, mania, other metabolic disorders in my differentials - spoke about admission to MAU, chlordiazepoxide, pabrinex, management of dehydration, involvement of the DAT, CBT, disulfiram, acamprosate, social care in community etc.

3. 40 year old lady who dropped her shopping in the supermarket, became very embarrassed, anxious, self-conscious. She vowed never to return to the same supermarket again. Husband concerned about her.

Assess and Manage

I mentioned Agoraphobia with panic attacks as my primary differential, to rule out depression, social phobia psychosis. Offered to do a DV instead of outpatient appointment is she was still too scared to go out. They asked me how to specifically carry out the CBT so I stattered about graded exposure etc  - I mentioned role of medication and they wanted to know what the problems with medication would be. Wasn't so sure about this but I talked about how, CBT would at times be ineffective if patient was on benzos, It felt like they wanted more. I feel my downfall was that I did not state the risk of suicide in this case, if i fail I know that will be the reason.

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PMPs - November 15th 12.00 -

1. 58 year old woman with a long history of chronic insomnia. She has osteoathritis and a previous history of depression. She does not think either of these things are her main problem. How would you assess and manage?

probe -

would you use benzodiazepines?

2. 50 year old woman with history of increased alcohol use. Recently detoxified on the ward and discharged. You are contacted as husband is more concerned. She is absent minded and leaving the gas on and cigarettes burning. She is still drinking. How would assess and manage.

probes -

the team decide to admit her to residential placement, she refuses, how will you deal with this?

3. 25 year old woman referred to you by her GP as she keeps requesting plastic surgery for what she says is a 'grossly deformed nose'. She has recently left her job and is reluctant to leave the house. Her father recently committed suicide.

How would you assess and manage?

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I must have been the one of the cohort who took the PMP first in the country...

My experience ...

Called in at 10am and my reporting time was at 9.50

Both the examiners shook hands and made me feel comfortable....I felt relaxed ... One examiner read the PMP, rather very slowly, by the time he finished I had read it 2 times....!!

[highlight]1. A 21 year old man who is experiencing hallucinations..delusions his first episode was when he was 19. He is using amphet and cannabis, isolating himself in his room. He has been tried on various Antipsychotics and he is non compliant with these. Assess and Manage[/highlight]

I went through the risks the main issues of managing this gentman with negative symptoms , noncompliance and substance misuse...

said I would see him as soon as possible, then I was fired a serious of questions

how would u know he is using drugs? said history and urine drug screen..

how do u know he is treatment resistant?   same stuff..2 anti psychotics..adequate time and adequate period...

What would u use? ..Clozapine

What is the evidence for Clozapine?

what  dosage --i said 50mg...the said sorry 12.5 and monitor for hypotention..inpatient if risk of relapse high..max dose of clozapine..? then i said i would add sulpiride due to evidence...

I think he had sexual side effects as well.

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I was lucky- think they were keeping the easy ones for 5pm!

1) 40 yr old lawyer, fitted and admitted under medics, alcohol. He asks to be transferred to you (psychs) for detox the next day. PHx of detox in private services- he beggared off after 48hrs...

Assess and manage.

2) Post-natal doctor- 3 weeks, baby prem, but home for a week. Husband a doctor, wife irritable, crying, etc etc

One probe was definitely 'Would it alter your treatment that they were doctors?'

3) Anorexia age 18, BMI 11.something, BM 2.1, two previous admissions for anorexia, started age 13. Took a load of paracetamol when her therapist told her she had to come in again...

How would you go about refeeding, what would you have to be aware of (they wanted refeeding syndrome, that's all), prognosis in this case.

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5pm today

1. 19yr old o/d of paracetamol and amitriptyline brought to A&E by friend-refusing treatment. Assess and manage.

2.37yr old Down's Syndrome-admitted to a residential home 4weeks ago following the death of her terminally ill mother now presenting with challenging behaviour.Assess and manage.

3. 22yr old man referred by gp-not coping with college work.Spending long periods in the bathroom. History of being very orderly and organised.Assess and manage.

Paraphrased big time-PTSD effects!!!!!

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I was lucky- think they were keeping the easy ones for 5pm!

1) 40 yr old lawyer, fitted and admitted under medics, alcohol. He asks to be transferred to you (psychs) for detox the next day. PHx of detox in private services- he beggared off after 48hrs...

Assess and manage.

2) Post-natal doctor- 3 weeks, baby prem, but home for a week. Husband a doctor, wife irritable, crying, etc etc

One probe was definitely 'Would it alter your treatment that they were doctors?'

3) Anorexia age 18, BMI 11.something, BM 2.1, two previous admissions for anorexia, started age 13. Took a load of paracetamol when her therapist told her she had to come in again...

How would you go about refeeding, what would you have to be aware of (they wanted refeeding syndrome, that's all), prognosis in this case.

Ros we had exactly the same pmps in this order and same questions...

I thought they were ok really...

Let's wait and see what they thought as well...!

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1. 63 year old man with Recurrent Depressive Disorder currently on the ward under your care. He has been admitted 5 times and his current admission was as a result of not taking his medication because he felt it was not working. Whilst on the ward staff discover that he has been collecting his medication in a tissue paper for the last 2-5 days. he has also reported to staff that he feels as though his bowels are rotting and internal organs are missing. He has not been eating and drinking for 2 days.

Outline your assessment and management.

2. 53 year old lady in A & E with a fracture of the wrist. Suddenly becomes confused and agitated, tremulous, wanting to run away from little creatures on the floor.

Assess and Manage

3. 40 year old lady who dropped her shopping in the supermarket, became very embarrassed, anxious, self-conscious. She vowed never to return to the same supermarket again. Husband concerned about her.

Assess and Manage

Sorry to be so picky Jingles

Just want to add missing bits in history for sake of future record in SEC...

1. The man said he could not swallow the medications as he felt his internal organs were rotting...

I said the possibility of secreting medn 2ndary to nihilistic delusions/ collecting tablets to commit suicide...

I tried to jump into ECT... they stopped me... asked me how else cud I give him medications... said liquid form and covert medications....

Asked me about how I will ascertain compliance when he is discharged: Relatives; dosette box; electronic alarm; carer prompts; once a day dosing.

2. Confused in 12 hours after admission, ataxic gait...

Mentioned Wernicke's... they asked me about signs and treatment of Wernicke's

General principles of dealing with delirium.

3. Felt giddy and light headed at the supermarket; Now literally housebound

I said I would ask her husband to be with her at the time of assessment at home... They asked why

I said... 1. The husband is concerned; 2. Collateral h/o and psychoeducation; 3. Possibility of involving him in graded exposure treatments

Asked me the advantage and disadvantage of starting her on an SSRI... I said initial exacerbation and non compliance

Asked me what else I will do... said agoraphobia group.. and they asked me to get out..

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First one was about a driving instructor with a history of depression who had been in an accident and broke his leg. Now referred back by his GP, they asked about PTSD and related management fairly straighforward.

Second was a 20 year old with learning disability who was isolating herself and now complained about the old man in her room at night. Seemed more interested in the possibility of it being real than psychotic.

Third was a 68 year old in a ward post chemo from a thyroid cancer. Now sexually disinhibited. Cocked this one up slightly, they focussed on the possibility of it being alcohol withdrawal and I was a bit slow picking that up.

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Lady afraid of spiders, not leaving house, asking husband to sit with her in bath cos afraid spider will come

prompts : how does psychotherapy work, whats role of husband as cotherapist,

62 yr lady reporting people doing black magig and moving her jaw and face

prompts what are ethnic issues (though nothing was mentioned on PMP), what is role of ECT (though nothing mentioned about severity or other indication of EC%T on PMP), how would you go about ECT.

I am wondering did read the PMP wrong?

Severe dementia lady with bruises on hands- CPN concerned husband abusing her

prompts- can husband refuse her admission to hospital.

its over.

getting S/s of PTSD myself

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last day 11 20 am

1. 2 antidepressants tried. one of them ssri. Symptoms of depression not wel controlled. How do u assess and manage the situation?-

main discussions about -best combinations, evidence for those combinations and I stupidly forgot until asked about the the great CBT.

2. 75 yr old man, self neglect. complaints from neigh bours that he is hoarding and garden in bad condition. assess and manage.

Main discussions- de Squalor syn, how to gain access to the house. Prognosis. Repeatedly asking -GOOD or BAD. No amount of explaining helped on what are the good factors and what are the bad ones.

3. On the medical ward. 35yr old c/o several non specific symptoms. Now abdominal pain and weight loss. Assess and manage.

Main discussions on where to see the patient. What are the problems that might hinder the treatment. DDs?? how do u differentiate them?

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Did anybody have their PMP's on 15th at 2 pm, perhaps we can discuss, where did it lead upto.

Did people notice lot of PMP's on somatoform disorders/

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[b

5pm today

1. 19yr old o/d of paracetamol and amitriptyline brought to A&E by friend-refusing treatment. Assess and manage.

2.37yr old Down's Syndrome-admitted to a residential home 4weeks ago following the death of her terminally ill mother now presenting with challenging behaviour.Assess and manage.

3. 22yr old man referred by gp-not coping with college work.Spending long periods in the bathroom. History of being very orderly and organised.Assess and manage.

Paraphrased big time-PTSD effects!!!!!

[/

I had the same questions as Twinkle. I'm going to add some additional information I remember about their wordings and then discuss my answers and encounters with the examiners.

1st pmp-the female had taken 20 tabs of paracetamol and 30 tabs of amitrityline. Has no past psychiartic history or h/o dsh or suicidal attempt. The Poison Unit had advised the medics to commence gastric lavage and charcoal treatment but girl had refused. ?She had come with/told a friend about the od. Assess and manage. I started by identifying the main issues-safety & risk issues (suicide, dsh, harm to others); issues of diagnosis & management and assessment of capacity. Then gave a differential diagnosis-depressive disorder, substance misuse disorder, psychosocial difficulties/problems, psychosis. Then talked about components of my assessment-full history from as many sources as possible, conducting a full mental state examination, including risk assesment and full physical exam including neurological exam. Examiner briefly me sources of history/info, later asked how to assess suicide risk and capacity. Inbetween had asked whether the od was a serious one and whether I would admit (I was not sure if he meant to medical or psychiatric ward, but had said yes). Later had asked what I would tell the a&e staff after the capacity assessment and was found not to have capacity and staff had wanted her detained under the mha (had said that the mha applies to mental/psychiatric conditions/disorders).

2nd pmp-the 30 yr old had been exhiting severe challenging behaviours and had been referred to the outpatient. The mother was the sole carer before her death. I identified main issues as safety and risk assesment; determining what could be responsible for the presentation (i.e. diagnostics); management. My d/d included depressive disorder, bereavement reaction, early onset dementia, epilepsy, substance misuse, infections e.g encephalitis and psychsocial factors (e.g change of environment). Was asked which investigations to do (I mentioned the routine ones-examiner wanted more and I added ct scan and mri of the brain. He was not still satisfied and gave a clue saying I had mentioned substance misuse-then I said urinary drug screen). Was later asked to explain the impact the loss had on her. When it came to treatment, had stated this would depend on the assesment and conditions/disorders identified, e.g. if depression treat with antidepressants, etc. At this point was asked whether I would give antidepressants for grief reaction-was a bit surprised by the question, but had said no and that counselling would by choice. I later talked about other forms of treatment like low dose atypicals and naltrexone. Examiner seemed surprised when naltrexone was mentioned-did not say anything and passed me on the other examiner. Instead of giving the 3rd pmp straight away, he continued with naltrexone-asked if it has an evidence base (I had said yes and went on explain its mechanism of action-antogises endogenous endorphins which are said to mediate the rewarding behaviours, including challenging behaviours in some LD conditions/disorders. He seemed satisfied.

3rd pmp-The man is also not going out of the house and is being supported/looked after my ?partner/wife/relative. Washes hand excessively. Straightforward, I think. I identified main issues-risk and safety issues (suicide, dsh, self-neglect, harm to others; diagnostics & treatment) and gave d/d as ocd, psychotic disorder (e.g. schizophrenia), schizo-affective disorder, substance misuse. Totally forgot agoraphonia, GAD, depression,panic disorder, etc. I was asked to state the main features of ocd (recurrent, persistent ideas/thoughts/images/impulses which patient acknowledges are his own and not being imposed on him (good insight); patient tries to resist these but cannot, resulting in distress and compulsions). I was asked about treatment-I mentioned anti-obsessional medication (did not mention their names specifically and was not asked to by examiner), psycho-surgery as a last resort ( remembered this as my ipa patient had it for intractible bipolar disorder). There was the last knock on the door and I had to squeeze in cbt (exposure and response prevention). And that was the end!

What do u think of the above? Is it good enough? The performance could have been better, but tha was my best under the circumstance

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Seems pretty good to me, from what you say the examiners seemed happy too.

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Seems pretty good to me, from what you say the examiners seemed happy too.

Thanks cmo. Hope yours went well. I had the college rep in both sections of the exam-ipa and pmps. Is that usual?

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well.. it depends.. i've heard people say that sometimes the observer will encourage the examiners to pass a candidate and sometimes they will to fail.. so the answer to your question actually is not sure.. just have to wait for the result next month.. just keep praying and hope that you have done well to pass.

:lol:

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Hi is there anyone who had there pmp's on 14/11/07 at 11:20.(Alcohol/ocd/ssri discontinuation syndrome)

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