601 EXAMINATIONS 7. ALCOHOL DEPENDENCE Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand your GP has asked me to see I have been asked to do a physical examination. Is that all right with you? Would you like a chaperone? P: No thank you (Use hand gel provided) C: I will be commenting as I go along, please feel free to interrupt me if you do not understand me. A. General Examination Withdrawal signs Agitation, restlessness Tremor (the shakes) Autonomic hyperactivity :diaphoresis-raised temperature(hyperthermia) and sweating Hypertension, tachycardia Tachypnoea Bruises, abrasions or scars suggestive of falls or violence Spider naevi on trunk , face and arms Evidence of self-neglect INSTRUCTIONS TO CANDIDATE The GP has referred this 35 yr old man who has a history of alcohol dependence TASK FOR THE CANDIDATE Please do a physical examination related to alcohol dependence PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) General examination observe for alcohol withdrawal signs Chest examination Cardiovascular examination Abdominal examination Neurological examination COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
602 EXAMINATIONS gynaecomastia B. Examination of hands/arms Check pulse and blood pressure Tremor Hepatic flap-ask the patient to hold arms straight with hyper extended hands Palmar erythema Dupuytren’s contracture Clubbing Koilonychia Nicotine stains C. Examination of eyes Check extra ocular muscles and rule out nystagmus Jaundice Pallor D. Mouth Fetor hepaticas E. Chest examination Spider naevi Gynaecomastia Loss of body hair Auscultate for heart sounds F. Abdominal examination Scratch marks Caput medusae Umbilicus everted/inverted Palpate liver and spleen Check for ascites Ask to check the external genitalia for testicular atrophy G. Neurological examination Check reflexes Check for peripheral neuropathy and proximal myopathy Heel shin/finger nose and dysdiadokinesia Assess gait Summarise Thank you for allowing me to examine you. Do you have any questions for me? I would like you to go and see your GP and have some blood investigations done more specifically looking at your liver function test.
603 EXAMINATIONS 8. ALCOHOL DEPENDENCE - CEREBELLAR EXAMINATION Suggested approach Introduction C: Hello, I Dr ….I have been asked to do an examination Is that all right with you? Would you perhaps like a chaperone? (Use hand gel provided) I will be commenting as I go along, please feel free to interrupt me if you do not understand me? A. Eye signs Check for nystagmus or opthalmoplegia B. Speech Can you please repeat British constitution? (Dysarthria) C. Hands Ask patient to tap the back of their own hand with their other hand repeatedly. (Dysdiadokinesia) INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 45 yr old man Bremer Davidson who has a history of alcohol dependence. TASK FOR THE CANDIDATE Please do a cerebellar examination. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Examine for eye signs- nystagmus/opthalmoplegia. Establish presence of dysarthria or staccato. Assess for impairment of motor coordination -Past pointing phenomenon-finger nose test -Dysdiodokinesia -heel shin test Truncal ataxia. Examine for gait abnormalities -limb ataxia -rhombergs test Motor examination of upper and lower limb. Tone, power, reflexes. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
604 EXAMINATIONS 1) Finger nose test Ask the patient to touch their own nose with their forefinger and then to touch your finger. Alternate back and forth between their nose and your finger whilst moving your finger. (Intention tremor and past pointing phenomenon) 2) Limb ataxia Ask patient to stretch hands out and observe for hyperpronation of one hand. 3) Heel shin test Ask the patient to place their heel on the opposite knee and slide it down to their ankle. Ask them to take it back to original position. Repeat on the other leg. 4) Truncal ataxia Ask the patient to sit up with the arms crossed. (observe for inability to sit up unsupported) D. Examine for gait abnormalities Ask the patient to stand up and walk heel to toe in a straight line. (Observe gait) Ask patient to stand with their feet together and to close their eyes, while you support with your arm behind them to stop them falling. (Positive Rhombergs signs) E. Motor examination of upper and lower limb Assess for tone, power and reflexes in upper and lower limbs Other variation Neurological examination in Alcohol dependence Neurological Examination Cerebellar Examination Peripheral neuropathy- Sensory examination Examine cranial nerves –Examine cranial nerves –for lateral gaze palsy ©Smartsesh
605 EXAMINATIONS 9. KORSAKOFF SYNDROME Suggested approach Introduction C: Hello, I’m Dr … I’m one of the psychiatrists. I have been asked to come and see you. It would be helpful if you could tell me more about how you ended up her? P: I came to see my friend in the Birmingham hospital. C: can you tell me how you came to the hospital? A. Establish orientation (elicit some components of the MMSE) 1) Orientation to time Year, season, day, date and month 2) Orientation to place Country, county, town/village, address or building, floor/ward B. Enquire about memory So how is your memory in general? Have you been more forgetful of late? Are you able to remember your appointments? INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 50 yr old man Heinricht Gustav who has been admitted into the medical ward. He has a history of alcohol dependence TASK FOR THE CANDIDATE Elicit a history with a focus on Korsakoff’s syndrome. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Establish cognitive assessment-orientation. Assess short term memory. Assess long term memory. Demonstrate Confabulation. Establish short term memory. Establish long term memory. Establish autobiographical memory. Establish procedural memory. Establish working memory. Perform cerebellar examination. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
606 EXAMINATIONS 1. Short term memory (STM) Can you tell me what you had for breakfast? 2. Long term memory (LTM) Can you tell me when you got married? 3. Autobiographical memory Can you tell me when you got married? 4. Procedural memory Are you able to ride a bicycle or drive a car? 5. Working memory Forward digit span. Read a series of numbers to the patient and ask them to repeat the numbers back. Read the numbers at one per second and start with three digits in it. Normal range 6+-1. Backwards digit span Repeat string of numbers backwards. (For example, examiner reads 793 and patient reads 397) Normal range is 5+-1 Registration and recall of seven item name and address John Brown, 42 West Street, Luton, Bedfordshire. Confabulation (patient will fill gaps in his memory. Demonstrate this by saying we would need to collateral history.) What did you do today? C. Perform relevant cerebellar physical examination Summarise Thank you for talking to me and allowing me to examine you. From what you have told is that you came to hospital to see a friend. I am concerned about your memory. If it is all right with you I would like to speak one of your relatives to gather some more information.
607 EXAMINATIONS 10. RESPIRATORY EXAMINATION Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand your GP has asked me to see. I have been asked to do a physical examination. Is that all right with you? Would you like a chaperone? P: No thank you (Use hand gel provided) C: I will be commenting as I go along, please feel free to interrupt me if you do not understand me. Ensure adequate exposure. Ideally patient will be sitting at the edge of the bed. A. General examination Finger clubbing Cyanosis – Peripheral and Central B. Chest examination 1. Inspection of chest Note the respiratory rate Check for symmetry of chest movements and use of accessory muscles Note any deformity and shape of chest (barrel shaped in COPD) INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 47 yr. old man. TASK FOR THE CANDIDATE Please do a respiratory examination. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Perform a general examination. Systematically examine using the following format. Inspection of chest Palpation Percussion Auscultation COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
608 EXAMINATIONS 2. Palpation Ask about tenderness or soreness Confirm that the trachea is central Place hands on the posterior aspect of the chest with thumbs touching each other in the midline and ask the patient to inhale deeply. This will confirm symmetry of movement during expansion. Vocal fremitus is checked by placing the ball of the hand on the back of the chest and the patient is asked to say 999. Move hand from apices to interscapular region to the pulmonary bases. Check on both sides. 3. Percussion Percussion note is also checked on both left and right sides. Compare one side to the other looking for symmetry. Start from the back again and percuss the apices, interscapular region and the lung bases. Percuss laterally in the mid axillary line. Check percussion note on the anterior aspect again comparing one side to the other. 4. Auscultation Auscultate apices, interscapular region, bases posterior and the mid axillary region chest comparing one side with the other. Anteriorly auscultate bilaterally superior lobes, right middle lobe and left lingular division of the superior lobe. Summarise Thank you for cooperating with me and allowing me to examine you.
609 EXAMINATIONS 11. CARDIOVASCULAR EXAMINATIONS Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand your GP has asked me to see I have been asked to do a physical examination. Is that all right with you? Would you like a chaperone? P: No thank you (Use hand gel provided) C: I will be commenting as I go along, please feel free to interrupt me if you do not understand me. A. General examination 1. Examination of the hands Check for peripheral cyanosis Osler’s nodes (0.5-1 cm reddish brown painful subcutaneous papules on finger tips, palmar eminences) Clubbing Splinter Haemorrhages Tremor (thyrotoxicosis) Pulse: rate, rhythm, character, radio radial delay. Character best assessed at the carotid INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 26 yr. old lady. TASK FOR THE CANDIDATE Please do a cardiovascular examination. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) General examination Chest inspection. Chest palpation. Chest auscultation. Examination of the back. Examination of the abdomen. Examination of the legs. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
610 EXAMINATIONS 2. Examination of the arms IV injection scars Take blood pressure 3. Examination of the face Malar flush Pallor (eyes) Xanthelasmas (yellow plaques deposited in the per orbital region) Corneal arcus (seen in severe hypercholesterolemia) Lips (for central cyanosis) High arched palate (seen in Marfan’s) 4. Examination of the neck Carotid: inspect for carotid pulsations Compress one carotid at a time to check for character (fingers behind neck, assess with thumb) Check for carotid bruit with bell of stethoscope JVP: inspect height with patient at 45 degrees B. Chest examination 1. Chest inspection Scars (mitral valvotomy laterally on left breast) Deformities Visible pulsations Apex beat 2. Chest palpation Check for tenderness Palpate apex beat for deviation C. Examination of the back Sacral oedema D. Examination of the abdomen Liver palpation Splenomegaly (seen in endocarditis) Abdominal aortic aneurysm E. Examination of the legs Peripheral oedema Summarise Thank you for cooperating with me and allowing me to examine you. Comment on the positive or negative findings.
611 EXAMINATIONS 12. EXAMINATION OF CRANIAL NERVES Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand your GP has asked me to see I have been asked to do a physical examination. Is that all right with you? Would you like a chaperone? P: No thank you (Use hand gel provided) C: I will be commenting as I go along, please feel free to interrupt me if you do not understand me. Cranial Nerves A. Olfactory nerve (1 CN) Can you smell this please (give piece of soap to smell)? B. Optic nerve (2 CN) Visual acuity Test each eye separately Tell patient that you are going to check their eyesight INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 29 yr. old man. TASK FOR THE CANDIDATE Please do an examination of the cranial nerves. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Examine each cranial nerve individually.(cranial nerve 1-12) Olfactory nerve (1 CN) Optic nerve (2 CN) Occulomotor nerve (3 CN), Trochlear (4CN), Abducent nerve (6CN) Trigeminal nerve (5 CN) Facial nerve (7 CN) Vestibulocochlear nerve (8 CN) Glossopharangeal nerve (9 CN) and Vagus nerve (10 CN Accessory nerve (11 CN) Hypoglossal nerve (12 CN) COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
612 EXAMINATIONS Ask them to close one eye and test distant vision using Snellen’s chart at a distance of 10 feet Visual fields Sit directly opposite the patient at the same level with your right eye closed approximately one metre away. Ask the patient to cover left eye with left hand, not to move their head and to say yes when they see your finger. The finger should be equidistance from you and the patient. Bring the finger into the field of vision in a curved not a straight line. Repeat with other eye. Fundoscopy Given separately. Accommodation Ask the patient to look into the distance and then at the tip of their nose C. Occulomotor nerve (3 CN), Trochlear (4CN), Abducent nerve (6CN) Pupillary light reflex Ask the patient to look into the distance and explain that you are going to shine a light into their eyes. Bring light from below and side. Observe for direct and consensual light reflex. Repeat with other eye. Extraocular movements Tell the patient that you are going to check the movements of their eye muscles. Ask them to follow your finger with their eyes without moving their head and to tell you if they see double. You should again be at a distance of one metre from the patient. Make an H, pausing at the ends of each direction of gaze to observe for nystagmus. D. Trigeminal nerve (5 CN) Consists of 3 sensory and one motor divisions a. Sensory Light touch Sensation is tested with cotton wisp, lightly touching (do not drag) both sides of forehead, cheek and chin. Avoid touching the angle of the jaw, which is innervated by upper cervical roots. b. Motor Supplies muscles of mastication. Palpate the temporalis and masseter muscles on each side. Ask the patient to clench their teeth tightly and palpate the muscles again. Ask the patient to open their mouth and then repeat against resistance from your hand under the patient’s chin. Jaw jerk Place a finger in the midline, over patient’s mandible, with patient’s mouth slightly open. Tap your finger with a hammer. Corneal reflex Normally not checked E. Facial nerve (7 CN) a. Sensory Ask the patient if they can taste their food as before
613 EXAMINATIONS b. Motor Upper MN Observe for narrowing of the palpebral fissure or loss of nasolabial fold. Ask the patient to wrinkle their forehead. Ask the patient to close their eyes tightly and not let you open them. Motor Lower MN Smile or show their teeth Ask them to blow out their cheeks. F. Vestibulocochlear nerve (8 CN) Hearing Rub fingers close to the patient’s ear and ask if they can hear the sound. Gradually move the fingers away and tell the patient to let you know when they can’t hear the sound. Rinne’s test Air conduction is better than bone conduction. Use tuning forks of 256 or 512 hertz frequency. G. Glossopharyngeal nerve (9 CN) and Vagus nerve (10 CN) Ask the patient to open their mouth and see if the uvula is central. Tell them to say “ah” and see if the fauces move. H. Accessory nerve (11 CN) Stand behind the patient and ask them to push their chin against your hand. Palpate sternocleidomastoid muscle while patient is doing this Ask patient to shrug their shoulders against resistance. Check power by pushing down. I. Hypoglossal nerve (12 CN) Ask the patient to take out their tongue and move it from side to side. Ask to press their tongue against the cheek and feel the muscle bulk. Repeat on the other side Summarise Thank you for cooperating with me and allowing me to examine you. Comment on the positive or negative findings.
614 EXAMINATIONS 13. EXAMINATION OF UPPER LIMB MOTOR AND SENSORY SYSTEM Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand your GP has asked me to see you. I have been asked to do a physical examination. Is that all right with you? Would you like a chaperone? P: No thank you (Use hand gel provided) C: I will be commenting as I go along, please feel free to interrupt me if you do not understand me. Ensure proper exposure Explain what the examination involves A. Inspection Muscle bulk (wasting/hypertrophy) Fasciculation Abnormal movements (tremor, choreoform, tics, myoclonus) B. Tone Check for cogwheel and lead pipe rigidity INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 34 yr. old man Jamie Brook. TASK FOR THE CANDIDATE Please do an examination of upper limb motor and sensory system. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Upper and lower limb examination should include: Inspection Tone Power Reflexes Sensations Vibration sense Co-ordination COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
615 EXAMINATIONS C. Power Ask the patient to raise first the right arm and then the left one Shoulder abduction: Ask the patient to hold arm outwards at their sides and keep them up. Explain that you will try to press down but they should not let you. Shoulder adduction: Ask patient to push arms inwards against resistance from you. Arm flexion: Stabilize elbow and ask patient to bend their elbow and pull you towards them. (Check both arms) Arm extension: Ask patient to straighten flexed elbow against resistance and push you away. (Both arms) Wrist extension: Stabilize the wrist. Ask patient to clench fist and bend wrist up and not let you stop them. (Both wrists) Wrist flexion: Ask patient to push the other way against resistance from you. Thumb abduction: Ask patient to hold hand with palm facing the ceiling and point thumb towards the ceiling against resistance applied by your finger. Finger adduction: Tell patient to hold a piece of paper between their fingers and not let you take the paper out. Finger abduction: Ask patient to spread fingers wide apart and not let you push them together. D. Reflexes (both sides) Supinator Biceps E. Sensations Compare sensations on both sides for symmetry Tell patient to say yes every time they feel you touch with cotton wool. Do not stroke as this tests tickle which travels in the spinothalamic tract. Touch: outer border of arm, lateral border of forearm, thumb, middle finger, little finger and medial border of forearm. Joint position sense Hold the distal interphalangeal joint of one finger. Explain to the patient that you will move the finger up and down. Show them both positions. Ask them to close their eyes and say if the finger is up or down. F. Vibration sense Make a fork vibrate silently. Place it on the patient’s sternum and ask them if they can feel it. Now check on the distal interphalangeal joint of a finger with patients eyes closed. G. C-ordination Ask patient to touch your finger with their index finger and then touch their nose. Move patient’s hand once to show how it’s done so that it is clear. Tell them to do it quickly. Summarise Thank you for cooperating with me and allowing me to examine you. Comment on the positive or negative findings.
616 EXAMINATIONS 14. PHYSICAL EXAMINATION IN ANOREXIA NERVOSA Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand your GP has asked me to see I have been asked to do a physical examination. Is that all right with you? Would you like a chaperone? P: No thank you (Use hand gel provided) C: I will be commenting as I go along, please feel free to interrupt me if you do not understand me. A. General examination Thin/emaciated Dry skin/yellow discolouration Weigh patient and check height. Calculate BMI Ask when was your last normal period? B. Examination of hands/arm Brittle nails Calluses/laceration on knuckles (Russell’s sign) Pallor Bradycardia/Low blood pressure Swollen joints/healed fractures INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 16yr old young lady Eva Smith who has been admitted with Anorexia Nervosa. TASK FOR THE CANDIDATE Please do a physical examination in anorexia nervosa. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) General examination Examination of the hands/arm Examination of the face Cardiovascular examination Abdominal examination Neurological examination Medical complications COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
617 EXAMINATIONS Lanugo hair (arms and chest) Look for signs of self-harm C. Examination of the face Swollen parotid glands Dental caries Conjunctival haemorrhages from vomiting D. Cardiovascular examination Apex beat Auscultation Sacral and pedal oedema E. Abdominal examination Scratch marks (hyperbilirubinaemia) Liver palpation Ascites F. Neurological examination Proximal myopathy (ask the patient to rise from squatting position) Rule out peripheral neuropathy. Associated medical complications G. Medical complications –electrolyte imbalances to consider Elevated growth hormone Low T3/high T4/suppressed TSH Decreased gonadotrophin hormones Bradycardia, hypotension and dehydration Normochromic normocytic anaemia, leucopoenia and thrombocytopenia Hypokalaemia and hypernatremia Low calcium, phosphate and magnesium Deranged LFT(Liver function tests)s Low foliate and vitamin B levels Summarise Thank you for cooperating with me and allowing me to examine you. I am concerned about your recent weight loss and would like to arrange with your GP to have these tests done. I will arrange to see you with these results.
618 EXAMINATIONS 15. OPIATE WITHDRAWAL HISTORY AND PHYSICAL EXAMINATION Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand your GP has asked me to see I have been asked to do a physical examination. Is that all right with you? Would you like a chaperone? P: No thank you (Use hand gel provided) C: I will be commenting as I go along, please feel free to interrupt me if you do not understand me. A. Brief history of withdrawal symptoms 1. Can you tell me what substances you are using? 2. When was it last taken? 3. Do you have any cravings? 4. Have you had any joint pains, muscle aches, twitching or headaches? (Withdrawal symptoms) 5. Have you had any abdominal cramps, nausea, vomiting and diarrhoea? 6. Have you had any hot and cold flushes? 7. Have you been sneezing? 8. How have you been sleeping? (Restless sleep) 9. Have you been feeling anxious? (Agitation or Anxiety) INSTRUCTIONS TO THE CANDIDATE You have been asked to see this man 34 yr. old man, Colin Balliram, with a history of heroin dependence. TASK FOR THE CANDIDATE Do a physical examination in a heroin dependant person. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Perform a general examination. Check for withdrawal signs and symptoms. Check for intravenous drug use –paranerphalia sites. Suggest further investigations and treatment. Discuss harm reduction techniques if using intravenous. substances COMMUNICATION SKIILLS Obtain consent. Ask if a chaperone is required.
619 EXAMINATIONS (Opiate withdrawal symptoms peak between 36-72 hours. Symptoms run their course in 5-7 days though craving continues for some time. ) B. Physical examination 1. Check B.P., pulse, temperature and respiratory rate (all raised in withdrawal) 2. Check patient’s palms and hands. (Wet sweaty palms and piloerection commonly seen.) 3. Check for intravenous drug use –paranerphalia sites 4. Comment if the patient is shaking or yawning 5. Check for lacrimation, rhinorrhoea and dilated pupils 6. CVS examination concentrating on the presence or absence of murmurs. 7. Examine for signs of liver failure C. Tests 1. Full blood count, LFT (Liver function tests)s, U&Es 2. Hepatitis screen and HIV test after counselling the patients 3. Urine drug screen for opioids. 4. ECG and chest X-Ray. Echo if any cardiac murmurs. 5. Tests for sexually transmitted disease if patient has been promiscuous and has not been taking precautions. D. Treatment 1. Supportive treatment 2. Clonidine to help with physical symptoms 3. Buprenorphine 4. Methadone detoxification Summarise Thank you Colin for allowing me to examine you. If you wish I would like to make an appointment with you to discuss the treatment options available.
620 EXAMINATIONS 16. RECORD A 12 LEAD ECG Suggested approach Introduction Hello I’m Dr…. I’m one of the psychiatrists. I have been asked to do a tracing of the heart. I will explain the procedure more in detail with you. Is it all right with you? Would you like a chaperone? P: Yes that is all right. C: Explain the procedure to the patient. Patient will have to remove the shirt to expose the chest. Reassure that it will be painless and will only take a few minutes. Patient should then be helped on the couch and asked to lie with legs and arms uncrossed. A. Clean areas of electrode placement with alcohol wipes. B. Place pads for limb and chest electrodes. Limb leads are colour coded. Start with the red lead and attach it to the right wrist. Yellow is attached to the left wrist, green to the left leg and black to the right leg. C. Position of chest leads V1: Fourth intercostal space at the right sternal border. (First palpable intercostal space, below the clavicle is the 2nd intercostal space. V2: Fourth intercostal space at the left sternal border V3: Midway between V2 and V4 V4: Fifth intercostal space in the midclavicular line V5: Anterior axillary line at the same horizontal level as V4 V6: Mid-axillary line at the same horizontal plane as V4 and V5. INSTRUCTIONS TO THE CANDIDATE You have been asked to see this 40 yr. old man. TASK FOR THE CANDIDATE Please record an ECG. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Explain procedure. Clean the area aseptically. Please position the leads according to the anatomic diagram V1- V6. Get electronic printed copy of ECG. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
621 EXAMINATIONS Switch on the machine, if it has a filter button press it to erase previously recorded ECG. Record ECG. Summarise Thank you for cooperating with me and allowing me to examine you. Interpret the ECG.
622 EXAMINATIONS 17. EXAMINATION OF HOW TO INTERPRET ECG Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists on call. A. Background to ECG ECG machines pick up electrical activity through 4 limb electrodes and 6 chest electrodes and convert it into 6 limb leads (I, II, III, aVR, aVL and aVF) and 6 chest leads (V1-V6) Leads I and aVL look at the left side of the heart. Leads II, III and aVF look at the inferior surface of the heart. A VR is always negative as it looks at the heart from the position of the right shoulder and electrical current moves away from it. The negative waves confirm that the electrodes have been connected correctly. The 6 chest leads look at the heart in the horizontal plane, from the front and around. V1 and V2 give information about the right heart. V3 and V4 about the interventricular septum. V5 and V6 give information about the left side of the heart. B. Interpretation of the waves P wave: represent atrial systole. QRS complex: ventricular systole. T wave: ventricular relaxation or diastole. Atrial systole gets buried in the ventricular systole and therefore does not produce a wave form. INSTRUCTIONS TO THE CANDIDATE You have been asked to see the psychiatric consultant. TASK FOR THE CANDIDATE Please explain your interpretation of the ECG. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Interpret the axis of the leads. Interpret whether normal sinus rhythm. Interpret the values of the ECG. Calculate the rate. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
623 EXAMINATIONS Q waves: When heart muscles are damaged the electrical current does not pass through them and instead of upright R waves, downwards Q waves are produced. C. Intervals When ECG is recorded the paper speed is 25 millimetres/second so in 1 second ECG tracing covers 5 large squares or 1 large square is equal to 0.2 seconds and one small square is equal to 0.04 seconds. PR interval is measured from the start of the P wave to the beginning of the QRS complex. The normal PR interval is 0.12 to 0.2 seconds or 3-5 small squares. Duration of QRS complex is normally 0.12 seconds or 3 small squares. QT interval is the time between the onset of depolarization to repolarization. It is affected by diet, gender, alcohol, time of the day, menstrual cycle and heart rate. QTc is the QT interval which has been corrected for the heart rate. QTc = QT msec/square root of RR. It can be challenging to calculate QTc with the above formula. An easier way is to calculate the RR interval (number of large squares) and if QT interval is longer than 50% of the RR interval (again check the number of large squares between beginning of Q and end of T) it is an indication that it is prolonged. You can then take out your calculator and do it properly. Potential consequences of QT prolongation include torsade de pointes (syncope), ventricular fibrillation and sudden death. If QTc prolongation is associated with T wave changes refer to the cardiologist. D. Calculation of heart rate Hear rate can be easily determined by counting the number of large squares between 2 consecutive QRS complexes (R-R interval). Normally the heart rate is between 60 and 100/min. 1 large square: rate is 300/m 2 large squares: rate is 150 3 large squares: rate is 100 4 large squares: rate is 75 5 large squares: rate is 60 (1 QRS per second) 6 large squares: rate is 50 Patient is said to be bradycardic if under 60 and tachycardic if heart rate is more than 100. E. How to determine axis Axis can be checked by looking at the direction of wave forms in leads I, II and III. A normal (11’o clock to 5 o’ clock axis means that current is flowing towards leads I, II and III and results in upward deflections in all 3.
624 EXAMINATIONS In right axis deviation the deflections in I will become negative with positive waves in II and III. In left axis deviation waves are negative in II and III. If deflections are negative in all 3 it is extreme left axis deviation. Summarise Thank you
625 EXAMINATIONS 18. EXAMINATION OF HOW TO INTERPRET ECG Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists on call. I would like to discuss this ECG with you. Explain findings from the rhythm strip 1. Is electrical activity present? (Does the tracing have any wave forms?) 2. What is the heart rate? 3. Is atrial activity present? (Are p waves present?) 4. Is the ventricular rhythm regular or irregular? (QRS complexes equally spaced or not) 5. Is QRS complex width normal or prolonged? (3 small squares or more) 6. How is atrial activity related to ventricular activity? (Every p wave should be followed by a QRS complex) A. Important rhythm abnormalities Atrial flutter (I.H.D/Digitalis toxicity): Saw tooth appearance of p waves. It is due to re-entry within the atria. As compared to atrial fibrillation is relatively regular. Often presents with 2:1 or 4:1 AV blocks. Atrial fibrillation: A chaotic rhythm, which originates from multiple sites in atria. Only some impulses get through to the ventricles. Atria contract rapidly and ventricular response is generally variable so every p wave will not be followed by QRS complex. Ventricular tachycardia: H.R > 100, QRS complexes wide (> 3 small squares). P waves may or may not be present. INSTRUCTIONS TO THE CANDIDATE You have been asked to see this on call consultant to discuss the findings of the abnormal ECG TASK FOR THE CANDIDATE Explain your findings of ECG to the consultant PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Explain the findings of the ECG rhythm strip. Explain rhythm abnormalities. Comment on myocardial infarction and Acute coronary syndrome. Explain hyperkalemia. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
626 EXAMINATIONS Ventricular fibrillation: Irregularly irregular heart rate. No p waves. Wide QRS complexes. Medical emergency treated with cardioversion. B. Myocardial infarction and Acute coronary syndrome Acute MI is characterised by ST elevation of 2 mm (2 small squares) in the chest leads or 1 small square in the limb leads. T wave inversion denotes ischaemic changes (acute and chronic). ST Depression signifies acute coronary syndrome or unstable angina. Elevation/Depression in a single lead is insignificant. C. Hyperkalaemia Tall T waves or tenting of T waves. If associated with QRS prolongation it can lead to life threatening ventricular arrhythmias. Summarise Thank you.
627 EXAMINATIONS 19. MANAGEMENT OF NEUROLEPTIC MALIGNANT SYNDROME Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand that your son suffered this reaction NMS. I have come to tell you more about this. WM: What is NMS-Neuroleptic Malignant syndrome? C: It is a rare, but potentially life threatening condition. It is known as an idiosyncratic reaction and occurs in a minority of the cases treated with antipsychotics. WM: What are the causes of NMS? C: It can develop at any time but usually occurs on initiation or increase in the dose of antipsychotics. The causes are thought to be the inhibition of central dopamine receptors in hypothalamus (part of the brain which regulates temperature) which results in increase heat generation and decreased loss. We do know that there are certain people who are more susceptible to get NMS. It is more common in patients with dehydration, organic brain pathology and in young males. WM: How common is it? C: as I have mentioned before it is a very rare condition and it occurs in 2in100 of the population. WM: What is the mortality rate? INSTRUCTIONS TO THE CANDIDATE A 25 yr. old male, David Williams, have suffered a NMS reaction. TASK FOR THE CANDIDATE Speak to the ward manager and explain NMS-Neuroleptic Malignant Syndrome. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECK LIST) Explain Diagnosis. Explain investigations. Explain emergency management. Explain management in terms of medical management. Explain future risks. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
628 EXAMINATIONS C: The mortality rate varies between 5-20% but if picked up early and managed appropriately it has a good prognosis. WM: what are the signs and symptoms of NMS? C: Muscle rigidity, increased salivation, dyskinesia (difficulty in performing vol. movements), orbiculogyric crisis (uncontrollable upward movement of eyes) and dysphagia. Hyperthermia (can be as high as 108 degree F but rarely goes this high), fluctuating blood pressure, increased heart rate, rapid breathing and confusion. Explain management of NMS 1. Medical investigations-Blood/urine tests Metabolic acidosis Increased CPK Increased transaminases Increased WBC count Hyponatremia, hyperkalaemia and hypocalcaemia Myoglobinuria 2. Treatment and management Stop the offending drug Monitors vitals Serial CPK to note the trend Cooling blankets Medical opinion and transfer to ICU Oral bromocriptine/sub cutaneous apomorphine or dantrolene for muscular rigidity I/V hydration and correction of electrolyte abnormalities DIC prophylaxis/intubation and artificial ventilation if required Sedation with benzodiazepines To note 3. Restarting antipsychotics Do not give antipsychotics for 2 weeks • Use different antipsychotic, preferably atypical. Best not to use depots. Start with a low dose and gradually increase Benzodiazepines for agitation and ECT can be used to treat Psychosis 4. Complications Rhabdomyolysis Renal failure Respiratory failure/PE
629 EXAMINATIONS 20. MANAGEMENT OF SEROTONERGIC SYNDROME Suggested approach Introduction C: Hello, I Dr ….I’m one of the psychiatrists. I understand this lady has now had an addition of lithium to her antidepressant medication. From the history you have given me, it appears that she has suffered a reaction to the lithium. A. Sign and symptoms of serotonergic syndrome Restlessness, confusion, agitation and lethargy. Hyperthermia, tachycardia, sweating, abdominal pain, nausea, vomiting, diarrhoea and dilated pupils. Myoclonus and hyperreflexia (symmetrical and commonly in lower limbs), hypertonia, tremor and ataxia. B. Diagnosis It is caused by excess of serotonin in the central nervous system. It occurs soon after starting or changing the dose of certain drugs. Most cases are self-limiting. It can be serious if two or more serotonergic drugs are used. B. Treatment and management of serotonergic syndrome Stop the medicine. Monitoring of vital signs. Benzodiazepines for rigidity and seizures. Rapid cooling. Involve medics. Transfer to ICU. INSTRUCTIONS TO THE CANDIDATE You have been asked to review the medication for a 29 yr. old lady who has been on an SSRI and started on Lithium. She is now experiencing tachycardia and sweating. TASK FOR THE CANDIDATE Please explain the management of serotonergic syndrome to the nurse on the ward. PAY PARTICULAR ATTENTION TO THE FOLLOWING (MENTAL CHECKLIST) Explain symptoms and signs of Serotonergic syndrome. Explain how the diagnosis is made. Explain the immediate management. COMMUNICATION SKILLS Obtain consent. Ask if a chaperone is required.
630 EXAMINATIONS Serotonin agonist: Cypraheptadine. Other drugs like propranolol and methysergide can also be used. Summarise Thank you for cooperating with me and allowing me to examine you. Comment on the positive or negative findings. Drugs that causes serotonergic syndrome Drugs that have been implicated include SSRIs (fluoxetine has the longest half-life), MAOIs, TCAs, Lithium, Buspirone, St. John’s wort, Tramadol, Selegiline, Pethidine and OD of amphetamines, cocaine, ecstasy, LSD. Differential diagnosis: NMS, dystonia, encephalitis and thyroid storm. Diagnosis is made on clinical grounds. On investigations WBC count can be mildly increased and a rise in CPK may occur because of rhabdomyolisis. Complications include Rhabdomyolysis, DIC, adult respiratory distress syndrome, coma and death.
631 EXAMINATIONS 21 PARIETAL LOBE TESTS Parietal Lobe Tests to include the following Test for dominant lesion Finger Agnosia Astereoagnosia-inability to recognise objects by palpation-e.g. coins in hand Dysgraphaethesia –inability to recognise letters or numbers written on the hand Test for non-dominant lesion Constructional dyspraxia- inability or draw shapes or construct patterns Asomatognosia- inability to recognise parts of the body Test for visual fields Speech Alexia Receptive Dysphasia Conduction Asphasia-person can’t repeat what is said to them Other tests of reading and writing Also ask if how they would brush teeth, comb hair etc ©smartsesh
632 EXAMINATIONS 22 TEMPORAL LOBE TESTS Temporal Lobe Tests to include the following : Language function Repetition-word and sentence repetition Memory Semantic memory Aspects of objects Recall and knowledge of famous people e.g. Marilyn Monroe Recall and knowledge of famous landmarks e.g. Eiffel Tower Temporal lobe personality Pedantic-teacher like speech Egocentric Perseveration –Stickiness Pay attention to trivial detail Auditory functions Ability to recognise melodies Visual function Name 10 objects Prosopagnosia- inability to recognise familiar faces Visual fields Colour recognition Test of visual fields ©smartsesh
633 INDEX A acamprosate 455 acute confusional state 157 addictions psychiatry 439 advanced directive 271 agoraphobia 164 agranuloscytosis 138 akathisia 589 alcohol and depression alcohol dependence 451 alcohol dependence examination 604 alopecia 107 alzheimer’s dementia 271 amantadine 157 amenorrhoea 526 amisulpiride 131 amnesia anorexia nervosa 524 anorexia nervosa examination 619 anticonvulsants 107 antidementia drugs 270 antipsychotics 128 aripiprazole 312 arson 382, 407 aspergers syndrome 371 assault 429 assault on the ward 429 assertive outreach team 158 atomoxetine 342 attention deficit hyperactivity disorder 333 atypical grief 92 auditory hallucinations 118 -complex -second person -third person -running commentary -derogatory command -thought echo aura 220 autism 343 autism diagnostic tools 343 -ADI -ADOS -DISCO -AAA 376 antipsychotic 128 -first generation -second generation
634 INDEX B becks negative cognitive triad 490 becks suicide inventory 48 bereavement 92 bereavement counselling 93 bilateral ect 87, 259 bipolar 1 102 bipolar 2 102 bipolar affective disorder 102 blood dyscrasia 107 body dysmorphic disorder 186 body mass index 525 borderline personality disorder 223, 507 borderline personality disorder features 223 borderline personality traits 57 breaking bad news 98 bromocriptine 157 bulimia nervosa- assess for prognostic factors 552 bullying 331 buprenorphine 463 buspirone 82 C cannabis and schizophrenia 472 capacity 215 carbamazepine 107 cardiac rehabilitation 59 cardiovascular examination 612 care programme approach 135 cerebellar examination 606 challenging behaviour 353 child act 1989 child and adolescent psychiatry 302 chlordiazepoxide 448 citalopram 73, 166 clomipramine 166 clozapine 132, 136 cocaine 461 cognitive analytical therapy 510 cognitive behavioural therapy (cbt) 489 cognitive distortions 476, 490 cognitive examination 597 community treatment order 144 computerised cbt 493 complete delusion 108 conversion disorder 168 cotard syndrome 283 counter transference 486 couple therapy 69
635 INDEX cranial nerves 614 creatinine phosphokinase (cpk) 156 cyclothymia 102 cyp2dt enzyme 63 D dat scan 269 dejavu 226 deliberate self-harm 53 delusion of guilt 108 delusion of infestation 108 delusion of infidelity 108 delusion of jealousy 108 delusion of love 108 delusion of poverty 108 delusion of reference 108 delusional mood 108 delusions 108 dementia 271 depot 148, 151 depression 36 -non pharmacological management 235 aromatherapy reminiscence therapy music therapy art therapy reality orientation. others to mention are bright light,dementia care mapping, and validation therapy. -bpsd 235 delirium 291 delirium tremens 444 dementia vs. depression 359 developmental history 343 dexamphetamine 342 dialectical behaviour therapy 515 diclemente and prochaska stage of change 454 displacement 396 dissociative motor disorder 203 disulfiram 455 de clerambaults syndrome 427 donepezil 270 downs syndrome 357 E early onset psychosis 303 eating disorder 524 electrocardiogram (ecg) interpretation 623, 625 electroconvulsive therapy (ect) 87, 259
636 INDEX electrode 90 elementary type hallucinations 118 emotionally unstable personality disorder 507 enmeshment 541 enuresis 349 epilepsy 378 epses- extra pyramidal side effects 310 epses- examination 584 epstein anomaly 78 erotomania 411 erotomanic delusion 412 examinations 583 exposure and response prevention 501 extracampine hallucination 118 F family therapy 536 fight and flight 165, 497 first rank symptoms 108 fitness to be interviewed 436 focal dynamic therapy 528 folic acid 107 forensic psychiatry 387 flupenthixol decoanate depixol 152 fluphenazine decoanate modecate 152 frontal lobe tests 266, 594 fronto temporal dementia 262 functional hallucination 108 fundoscopy 600 G galantamine 270 generalised anxiety disorder 158 genogram 452 grandiose delusion 108 grief 92 gustatory hallucination 108 H hachinski score 247 haloperidol 127 hallucinations 118 ham-d 62 head injury 209 hellmans triangle 382 heroin 461 haematemesis 215 high expressed emotion 123 hot cross bun diagram 487
637 INDEX hyperventilation syndrome 497 hypnogogic 118 hallucinations 118 hypnopompic hallucinations 118 hypokalaemia 526 hypochondriacal 118 hypochondriasis 197 hypomania 102 hypothyroidism 382 I iapt 520 ictal 220 illusion 118 indecent exposure 284, 366, 387 infanticide 571 informed consent 88, 90, 259 interpersonal psychotherapy 494, 546 J jamevu 226 K korsakovs syndrome 608 kubler ross model 93 L labelle indifference 168 lasting power of attorney 250, 298 lilliputian hallucinations 118 learning disability psychiatry 353 lewy body dementia 267 liaison psychiatry service 63 lithium 77, 255 lithium alert card 80 lithium augmentation 77 lithium toxicity 81, 258 lithium treatment pack 80 lofexidine 463 lower limbs 617 M mania 102 manic depressive 102 maoi’s(monoamine oxidase inhibitors) 76 mappa 405 master and johnsons sensate focus 69 meclobemide 76 memantine 270
638 INDEX mental capacity act 215 mental health act 145 section 2 section 3 section 4 section 5 metabolic syndrome 238 methadone 456, 463 methadone in pregnancy 456, 463 methylphenidate 341 mindfulness 518 mini mental state examination 597 mirtazepine 86 mood stabiliser 102 morbid jealousy 392 mummification 92 musical hallucination 118 myocardial infarct 59 myocarditis 132 N naltrexone 463 neural tube defects 107 neuroleptic malignant syndrome 154 neuroleptic malignant syndrome examination 630 neurological examination 600 nihilistic delusion 108 normal bereavement 92 norclozapine 136 negative automatic thoughts 490 O obsessive compulsive disorder 177 olanzapine 128, 131, 152, 238, 312 old age psychiatry 227 olfactory hallucination 118 opiate detoxification 439 opiate examination 621 opiate dependence 439 overdose 48, 316 othello syndrome 405 ovarian scan 536 over protectiveness 541 P Pabrinex 448 paedophile 425 panic attacks 162 pans 121
639 INDEX paranerphalia 439 paranoid delusion 102 paraphrenia 228 parenting capacity 367 parietal lobe test 631 parkinson’s 267 partial delusion 102 pathological bereavement 92 perinatal psychiatry 559 persecutory delusion 102 personality disorder 514 phenelzine 76 phosphodiesterase inhibitor 70 physical examinations 583 polycystic ovarian syndrome 107 post myocardial infarct depression 59 post partum blues 570 postnatal depression 560 primary delusion 102 pseudo seizures 378 pseudo-hallucinations 118 psychoanalytical psychotherapy 486 psychodynamic psychotherapy 483 psychosexual history 65 psychosis 303 psychotherapy 475 psychotic depression 280 ptsd 189 puerperal psychosis 571 pipothiazine palmitate sanofi 153 palperidone invega xeplion 153 paroxetine 166 post ictal 220 Q qtc interval 626 Quetiapine 83, 131 R rapid cycling 103 rapid tranquilisation 434 recurrent depressive disorder 44, 254 refeeding syndrome 538, 547 reflex hallucination 116 religious delusion 116 respiratory examination 610 risk assessment 421 risperidone 131, 153, 309, 312 rivastigmine 270
640 INDEX S Secondary gain 166 sadhart trial 63 sans 125, 219 schizophrenia 121,306 schneiderian first rank symptoms 304 secondary delusion 108, 280 seizures 131, 377 self-harm 50 sertraline 63, 166, 569 sex offender treatment programme sotp 289 sex therapy 67 sexual assault 191, 391, 426 sexual dysfunction 67, 641 sexual side effects 65 sildafenil 69 soad 90, 261 social phobia 174 sodium valproate 107 somatisation 195 somatoform pain disorder 194 ssri’s selective serotonin reuptake inhibitors 73, 166 steven johnsons syndrome 105, 107, 131 strokes 58,231, 248 suicide risk assessment 55, 315, 323 systematic desensitization 497 systematized delusion 102 schema focused therapy 510 T tachycardia 131,137,312,604 tactile hallucination 118 haptic, fornication, hyric, kinaesthetic, vestibular, autoscopy tardive dyskinesia 127 temporal lobe epilepsy 220 temporal lobe tests 632 therapeutic alliance 63,219 therapeutic relationship 486 thiamine 448,450,550 thought block 111 thought broadcast 111 thought disorder 111 thought insertion 111 thought withdrawal 111 thrombocytopenia 105,107,620 thyroxine 83 thyroid examination 591
641 INDEX tourettes syndrome 180,197 toxic serotonin syndrome transference 505 treatment resistant depression(trd) 82,253 treatment resistant schizophrenia 131 tricyclic antidepressants 46,76 U unilateral ect 91,261 upper limb examination 617 V Valproate 107 vascular dementia 244,248,251 venlafaxine 86 violence risk assessment 421 visual hallucinations 116 W wandering 249 Wernike-Korsakoffs syndrome 608 Z zuclopenthixol decoanate clopixol 154