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 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 DSM Criteria MDD 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, postpartum, 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 Alcohol withdrawal (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 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 Wernickes encephalopathy (WACO) acute/reversible, ocular nystagmus (horizontal), CN VI palsy, ataxia

Korsakoffs 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 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 Etiology Intracranial 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