Professional Documents
Culture Documents
Brief comment: The patient is well dressed, well groomed; his appearance matches his
chronological age. His speech is not slurred, not pressured. There are no delusions or
hallucinations. There is no suicidal ideation or homicidal thoughts.
Though
Processing:
o How did you come here today?
Content:
+ Obsessions:
- Repeated intrusive thoughts that the patient knows it is wrong, and he can not
resist, if he resists ! ↑ anxiety ! take actions to try to ↓ anxiety (compulsions)
- Mostly regarding: cleanliness, contamination / order / checking / …
o Do you have any repeated thoughts or images that you find difficult to
resist? About what? What do you do?
Cognition:
- Are you becoming forgetful? Are you losing your staff?
- Assess abstract vs. concrete thinking!
Insight:
- Do you think that you are doing well? Or do you need help?
Judgement:
- If there is a fire in the building, what are you going to do?
- If you find a stamped and addressed envelop on the ground, near the mail box,
what would you do?
General screening:
- Depression:
o What is your mood? How do you feel?
o Did you lose interest in things that were interesting to you before (e.g.
certain hobby, playing something)?
- Anxiety:
o Are you the kind of person who worries too much?
o Do you have excessive fears or worries?
- Psychosis:
o Do you hear voices or see things that others do not?
o Do you think that someone else would like to hurt you?
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- What about the opposite? 5- PTSD S
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Dx: one of the mood disorders
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Past psychiatric history Past psychiatric history
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Organic:
1- SAD if IV drug use: check for liver (hepatitis) / constitutional symptoms (HIV)
2- PMH, including constitutional symptoms
3- Rule out medical conditions as DD, e.g. medications and specific diseases
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Social history:
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Differential diagnosis:
- Brief psychotic disorder Schizoid Schizophrenia
- Post-partum psychosis Drug-induced Brain tumour
Difficult situations:
- If the patient with hallucinations tells you that he sees a radiation and gives you a
photo and asks: do you see it doctor? ! For me it does not look like radiation, but
I can understand that you see this as radiation
- At any time the patient starts to agitate and worries about special hallucinations!
o You are safe here, no body will harm you
- If the patient is away:
o Do not chase him/her around the room, stand by your chair
o I would like to assure you that you are safe here, no one will harm you
- I do not like “Egyptian people”, by the way, are you Egyptian doctor?
o Why are you concerned about that?
o Whether I am Egyptian or not will make no difference in this situation
- I do not like “gays”, by the way, did you see a gay patient today doctor?
o Why are you concerned about that?
o As a physician, I deal with all kinds of patients, regardless their race,
religion, sex, sexual orientation or anything else!
- Do you think I am crazy doctor?
o There is no medical term called “crazy”. However sometimes some people
have difficulties in the way they handle their thoughts and the way they
interact with and perceive reality, we call that schizophrenia. It is a mental
illness like any other illness that can affect the body, that we can treat with
medications
Clarify the CC
OCD
Criteria : Any tactile hallucinations: cocaine until proven otherwise
Hallucinations
Delusions
1st time or did you have it
before?
Past psychiatric history
Organic Cover the following: head injury / trauma / vomiting
cocaine / amphetamine
Mood / Anxiety
Serious conditions
Social history
Family history
DD - Drug-induced psychosis
- HIV
- Schizophrenia
Investigations - CBC / urine / toxicology screen
- HIV / syphilis test
- CT / MRI brain
- Magical believes
- Limited number of friends that share the same believes
- Delusions
1
Any heart racing, ask the patient “can you tap it for me”, then comment to the examiner: “it looks regular /
irregular for me”
- Good day Mr … With what I heard from you today, the most likely diagnosis to
your symptoms is a medical condition that we call “panic attack”
o Now Mr … what do you know about “panic attacks”?
o Do you want me to explain this in details over the next few minutes?
- Inform the patient:
o Explain the pathophysiology: it is called sympathetic over-activity,
imagine you are crossing the road, and a speedy car is approaching you,
normally, our body reacts to this by enhancing the sympathetic nervous
system, which leads to some changes: increase in the heart rate, …
" The same reaction might happen without any external trigger, and
this would be stressful, and this is what we call a “panic attack”,
o Consequences: this might happen again / may cause limitations
o Investigations: I will still need to do physical exam, some blood works and
an electrical tracing of your heart (ECG), and if it is all negative, that will
be consistent with our diagnosis
- Preventive measure:
o Life style modification (↓caffeine and alcohol / better sleep hygiene)
o Relaxation techniques (e.g. breathing techniques)
- Treatment:
o Like many other conditions, it could be treated: 1/3 of cases will improve,
another 1/3 will remain the same, and the last 1/3 will deteriorate
o Treatment varieties include:
" Talk therapy
" Medications: 2 types
• Anti-anxiety: Lorazepam 0.5 mg qhs x 2 weeks
• SSRIs: Paroxetine 10 mg od x 4 weeks – similar to what we
usually use with depression.
• Like any other medication, they have their side effects;
• Follow-up 2-3 weeks
- Offer more information: brochures / web sites
- Whenever you suspect social problems ! involve the social workers
Introduction
CC Tiredness
Clarify the CC - Is it weakness?
- Lack of energy?
- Decreased activity? Blocks …
- Not being refreshed after sleep?
Os Cf D Timing:
- Morning or all day: ?depression
- End of the day: organic
Ask about sleep - How many hours? And before?
- Find difficulty falling asleep?
- Do you wake up during night?
- When u wake up, do u need naps?
↑ sleep ↓ sleep
? organic ? depression
Constitutional symptoms Criteria : MI PASS ECG
All systems review (head to toe): 1st time or did you have it before?
- Cardiovascular What about the opposite?
- Lung Past psychiatric history
- GIT / liver Organic …/…/…
- Urinary Anxiety / psychosis
- MSK / skin Serious conditions
- Anemia ± LMP / periods hx Social history
- Endocrine (thyroid / DM) Family history
MI – mood / interest
PMH of cancer Counselling on depression
Social history – SAD
Family history
Diabetes Mellitus:
- Hx of DM - Blood sugar measured - Symptoms:
Fluctuations (acute) Emergencies Complications (chronic)
MICRO MACRO
- Eat more - Blurred vision DKA - Nephropathy - CAD
- Drink more - Tired Hypoglycemia - Neuropathy - CVS
- Pee more - Weight loss - Retinopathy - PAD /
impotence
Risk factors: weight / diet / family history / medications (steroids/beta blockers)
Counselling: I will need to do physical exam / laboratory to confirm diagnosis, but your
symptoms are likely due to …
Counsel on diet / weight Complications: high blood sugar
2- Depression:
" Psychomotor question: do you think things take more time to do now?
Compared to before?
" Pancreatic cancer ! depression
" Whenever you find alcoholic patient ! check for complications:
i. Cancer pancreas
ii. Liver damage (↑ liver enzymes) / hepatitis / cirrhosis / carcinoma
iii. GIT: upper GIT bleeding / peptic ulcer perforation
iv. Depression (alcohol / depression / suicide) is common combination
" Treatment for depression (or most of the psychiatric diseases):
i. Life style modification
ii. Talk therapy
iii. Medications
Usually in combination
Introduction
CC Insomnia / Tiredness
Clarify the CC - Difficulty falling sleep
- Waking up
Analysis CC: Os Cf D - More at certain time of the week?
- Did you try anything to help? Did it work?
Ask about sleep Sleep hygiene questionnaire
Anxiety - Do you have too many worries?
- What comes in your mind before falling asleep?
- Any changes / stresses in your life?
- Do you wake up with nightmares?
Depression - Screen with MI; if positive ! screen MI PASS ECG
PMH
Social - With whom do you live? Support?
! Screen for domestic violence or spouse abuse
- Children?
- Financial support?
N.B. did you ever think to hurt yourself? NO, my kids need me,
What about if they are not around? Maybe! This means: implicit yes to suicidal ideation
Verbal / emotional:
- Does he start to shout at you? Swear at you?
- Does he call you names?
Physical:
- Did he ever get angry to the extent that he became physical?
- Does he try to put you down? Does he try to control you?
- Did he try to push you? Hit you? How many times?
- Any visits to the ER? When was the last time?
Financial:
- Who is controlling the spending at home?
- Do you have access to financials? Do you take permission?
- Did he ever to try to take you money against your wishes?
Sexual:
- Did he ever force you to sexual activity?
OUTCOME:
- The patient decides to end the relationship and leave ! you must provide support
and shelter
- The patient decides to continue: either with OR without police involvement
The child came to the ER with femur fracture, the skeletal survey showed multiple
healing fractures, counsel
2
Good TWO screening questions: immunization (not up-to-date) / weight (FTT or under nutrition)
You are bout to see a 55/60 years old gentleman, whose wife is recovering in the ER, she
has bruises, and he asked to speak with you. In the next 10 minutes counsel him
Introduction
Analysis
SH / Safety
Counsel " Domestic violence
" Drinking rehabilitation
" Stress management and anger control
" Family marital counselling
" Offer social support if there is a need
Introduction:
" If the patient asked to see you: I understand that you are here because you are
accompanying your wife, she has bruises and my colleagues are taking care of her
right now. How can I help you today?
" If the patient is inquiring about her status: I can assure you that she is stable and in
safe hands now.
" If the patient asks to see her: After we will finish, I will ask her, if that is ok with her,
I can take you there.
Analysis:
" Do you have any idea how did she end up having all these bruises?
" Was there any argument / disagreement / shouting? Did you lose control? Did it end
up that you physically hurt her?
" Is this the first time or happened before? Any repeated visits to the ER before?
Social history:
" How long have you been together? What is the nature of your relationship? Stable?
Was there and significant conflicts before?
" Was there any recent change or stressor in your life? How do you support yourselves
financially? Do you have enough resources?
" Do you have anybody else at home? Any family support? Do you have children?
How is the relation with them?
" SAD
Safety:
" Criminal record / access to weapons at home
" If you go home now and face the same situation, how would you react?
" Any chance that you might hurt yourself or any other one?
" I can see that you are going through stressful period of time. It must be difficult for
you and your wife. Sometimes this stress might present by changes in behaviour
and/or personality.
" If you do not have enough support at home, things might get out of control.
" What happened is what we call “domestic violence”; it is a kind of “physical abuse”.
It is not acceptable, and it is considered illegal crime. However, this is your wife
decision. If she chooses to report you, that is her right, and nobody can prevent her.
She can press charges against you, and they will take you to the court, in this case you
might need legal help, this might have serious consequences.
" On the other hand, if she decides not to take any measure, may be you should try to
improve the situation by taking steps to decrease the stress in your life, and you can
consider reducing your alcohol drinking. Drinking alcohol might leads to what we
call “disinhibition” in which one might lose control on his reactions and usually this
leads to violent and serious consequences.
" I can help you by referring you to attend:
o Alcohol rehabilitation programs
o Stress management and anger control programs
" I recommend also that you consider attending family marital counselling; they have
good experience in dealing with couples going through difficult times.
" Finally, I can help you to contact the social services. They might be able to help; you
can speak with them and see what they might be able to do! Is that ok with you?
Management:
- Suicidal patient: ! hospitalization
From what you have told me, you are meeting the criteria of what we call “…”
and I have concerns about your safety, because you have more than THREE risk
factors for suicide as per the screening test. Do you mind to stay with us in the
hospital for few days, so we can do the required investigations and start the
medications, until you feel ok, what do you think about that?
- Outpatient: ! SSRIs
o Cipralex 10 mg PO od x 3 weeks (side effects include: headache, nausea,
ejaculation disorder, somnolence, insomnia, diarrhea, fatigue, anorgasmia)
o Follow up visit after 2-3 weeks
o Contract: sometimes when the anti-depressant starts to work, the energy
level improves while the mood is still low, that is why sometimes there is
increase in suicidal ideation. Usually happens 2-3 weeks, if this happens
with you, call 911 or call me immediately and come to see me.
Abdominal pain for few weeks, and was seen by a surgeon last week, comes to your
office (± to have MRI OR to renew medication).
Headache for 7 months, young man, comes to renew Tylenol 3
Introduction
Analyze the previous visits Is the pain different?
Analyze the CC Os Cf D / PQRST / ↑↓ / 1st time
AS " Constitutional symptoms
" GIT / liver
" Genito / urinary
Notes:
- Somatisation disorder: (4 pains / 2 GIT / 1 neuro / 1 sexual) complains
- If the pain is only during the day, and not nights ! mostly non-organic
If you find a man searching in the drawers of the hospital, firmly ask him to stop, tell him
this is private property and he is not allowed to go through these medical stuff
Introduction Why are you taking it? What was the diagnosis?
Analyze the CC Os Cf D / PQRST / ↑↓ / 1st time
AS - Constitutional symptoms
- Red flags for headache:
" Nausea / vomiting
" Bothered by light
" Neck pain / stiffness
" Weakness / numbness / tingling in body
Analyze Tylenol 3
Other medications In addition to Tylenol 3, do you take any other meds?
Sleeping pills?
MOAPS
PMH If teenager: HEAD SSS
SH SAD (if not done with PMH)
Analyze Tylenol 3
- So you told me you are taking it for …
- Who prescribed it to you?
- Who renewed it to you? Why?
- When was the last renewal? Can you show me your last bottle?
- How many tablets do you use now? And before? When did you start to ↑ the use?
- When you take it, aside for the headache relief, how do you feel? What if you do
not take it, how do you feel? Start shaking? Heart racing? You feel you are on the
edge?
- Do you renew it from the same doctor or different doctors? Why you did not go to
him this time? Is it ok that I contact him?
- Do you renew it from the same pharmacy or different pharmacies? Is it ok that I
contact the pharmacy?
- Did you ever obtain the medication from the street?
Counselling:
- I understand that you are here to renew your Tylenol 3, we will discuss that, but
before that let me ask you what is your understanding of Tylenol 3?
- Tylenol 3 is a good medication when it is used for particular indication.
- Do you know what does it contain? It contains 2 medications:
o One of them is the regular Tylenol as you buy it from the pharmacy
o The other one is codeine
Introduction Have been diagnosed with bipolar 3 years ago, and would
like to discontinue the lithium
Tell me more Why would you like to stop your medication?
I am glad you came here to discuss it, any other concerns
Mania History " When were you diagnosed? How?
" Any serious consequences? Were you hospitalized?
For how long?
" Were you seen by a psychiatrist? Regular f/u?
Today Do you feel: DIG FAST (distractibility, impulsiveness,
grandiosity, flight of ideas, activity, sleep, talkative)
Scan for MI PASS ECG
depression
Lithium History " Do you renew your medications on regular basis?
" How much lithium do you take? From the beginning?
" Are you taking it regularly?
" Do you measure lithium level? On regular basis? When
was the last time? What was it? What is your target?
" Are you still taking it? Did you stop?
" How do you feel about lithium?
Side " Hypothyroidism: do you have your thyroid hormone
effects measured? Do you feel cold? Dry skin? Constipation?
" Diabetes insipidus: do you feel thirsty? Drink more?
Pee more? Got your urine checked? ttt: thiazides
" Abdominal pain? Nausea / vomiting?
" Neuro – shaking/tremors: β-blockers
" Neuro – ataxia/balance/seizure: stop it
MOAPS I know that you have been asked all these questions before,
let me ask it for another time!
Introduction
Ask about the mood
Assure the patient Assure the patient: you are safe here, you are in the hospital
and no one will hurt you
Red flags Fever / headache / nausea & vomiting / head injury
HPI " OCD
" Mania (DIG FAST)
" Depression (MI PASS ECG)
" Suicide (SAD PERSONS)
" If you leave what will happen? What would you like to do?
MOAPS Screen
" SAD: substance abuse
" Medical conditions; hyperthyroidism: history of thyroid
problems, symptoms (heart racing, sweating, heat
intolerance, neck swelling, visual field changes)
PMH / FH Psychiatric disease
SH
N.B. if any patient has mood disorder; go through DIG FAST and MI PASS ECG
Management:
From what you have told me, you are meeting the criteria of what we call “manic
episode” and I have concerns about your safety, because you have more than THREE
risk factors for suicide as per the screening test. Do you mind to stay with us in the
hospital for few days, so we can do the required investigations and start the medications,
until you feel ok, what do you think about that?
LOTS OF EMPATHY
SAD PERSONS
S A D P E R S O N S
Sex Age Depression Previous Ethanol Rational Suicide Organized NO Serious
Male > 65 attempts thinking in the plan support illness
lost family
SAD HEAD PMH
SSS
3-4 Release if enough support
>5 Hospitalize
Conclusion / Counselling:
HOSPITALIZE
- Based on our interview, I have concerns about your safety, because you have
more than THREE risk factors for suicide as per the screening test. Do you mind
to stay with us in the hospital for few days, so we can do the required
investigations and start the medications, until you feel ok, what do you think
about that?
RELEASE
- Based on our interview, it is ok if you would like to leave, but you have to arrange
a follow up meeting with your family doctor within 3 days.
- However, I would like you to know that life sometimes could be challenging, and
you may face challenges in the future. It is important that you learn how to deal
with challenges.
- I would also like you to promise me that if at any time you want to harm yourself
or end your life, you will seek medical help immediately; you can come to my
office or call 911.
Notes:
- If no eye contact, wasting time, no pt interaction ! assure confidentiality
- Whenever you hear “car accident” ! show empathy / did you hurt yourself / ask
about who was in the car / was any one injured?
- If the person driving was < 18 and was driving alone ! be curious ! this must
be an important meeting / person that you really did not want to miss!
- The girl asks you to tell her mother that she crashed mother’s new car! She does
not want to directly (herself) inform the mother!
o I can not do this.
o Why do you think this would help? “She will not be angry”
I see, however, life is full of challenges, it is better that you try to learn
how to deal with challenges yourself.
o We can help you to tell your mother by yourself, we can arrange a meeting
with your mother, I can be present, or we can ask a nurse or a social
worker to be there.
- The girl does not want to inform her parents that she did attempt suicide!
o You assess her and if she is to be released, e.g. she regrets what happened,
she is happy to be saved, no SAD PERSONS risk factors ! she is
competent ! respect her wishes.
Young female, her parents brought her because they have concerns about her weight
Introduction Your parents brought you …. How do you feel about that?
I am glad that you came:
- To figure it out (if she is ok)
- To assure your parents (if she is not ok)
Analyze her weight
Diet
Exercise
Extra measures
Impact / consequences
MOAPS S: HEAD SSS
FH Eating disorder / psychiatric illness / suicide
Conclusion
Weight analysis:
- What is your weight today?
- When did you start to lose weight? What was your weight at that time? How
much did you lose? What was your highest weight? What is your target weight?
- Why are you losing weight?
- Are you losing weight alone? Or someone else is encouraging you?
- When do you look at yourself in the mirror, how do you perceive yourself? How
do you perceive your weight?
- Do you like to dress in baggie?
- It looks like you lost a lot of weight in short period of time; I would like to know
how did you achieve that?
Diet:
Let us talk about your diet;
- How many meals do you eat per day? How about snacks?
o What do you eat in breakfast? How about the amount?
- Do you calculate calories? How much calories do you eat per day?
- Do you eat alone or with other people?
- Do you like to collect recipes? To cook?
Extra measures:
- Do you take anything else to help you to lose weight?
- Do you take stool softeners? Do you take water pills?
- Did you try before to induce vomiting?
- Do you sometimes exceed the amount of food you intended to eat? How many
times a week?
- How do you feel after that? How do you compensate?
Impact / consequences:
Because you have lost a lot of weight, I would like to know the impact of this on you!
- Do you have amenorrhea? When was the LMP? Regular?
- Do you feel cold / tired / swelling in your legs?
- Pigmentation on your skin? Fine hair growth? Skin changes?
- Any bony pains? Fractures?
- Muscle cramps?
- Heart racing? Light headedness, dizziness, fainting?
MOAPS:
- Mood: scan for depression
- Organic: hyperthyroidism / constitutional symptoms (for cancer)
- HEAD SSS
- Screen for anxiety / psychosis
Family history:
- Eating disorder / psychiatric illness / suicide
Conclusion:
- Anorexia patient is to be admitted if BMI < 18 or body weight is < 85% of ideal
body weight
Notes:
- So doctor do you agree with me that I am overweight? Or do you see me like my
parents I am not good?
o I will share your parents concern, it looks like you lost significant weight
in short period of time, and this is concerning.
- If the patient lost interest ! slow down ! summarize and start again slowly
22 23 24 3 3 steps command
25 26 2 Aphasia (pen / watch)
27 Close your eyes! 1 Read / execute
28 1 Write
29 1 Copy
30 No ifs, ands or buts 1 Repeat
1-5 / Orientation to place: do you know which country we are in? Province? City?
Hospital (or street) name? Which floor (or suit number)?
6-10 / Orientation to time: do you know which year we are in? Season? Month? Day of
the month? Day of the week?
11-13 / 3 words recall – immediate: I am going to tell you 3 objects, and I would like
you to repeat after me and memorize it, and I will ask you about it later! (penny/ tree/ car)
14-18 / Concentration: can you spell the word “world” backwards? He gets -1 for each
non-matching letter
19-21 / 3 words recall – delayed: can you tell me the 3 words that I told you before
22-24 / 3 steps command: give all the instructions at once; are you left or right handed?
Can you please take this paper by the … hand / fold it into halves / give it back to me?
25-26 / Aphasia (pen / watch): what is the name of this? What is this?
27 / Read and execute: can you read this sentence and do what is written in it!
28 / Write: can you write a sentence for me!
29 / Copy: can you copy these two shapes!
30 / Repeat: can you repeat after me; “no ifs, ands, or buts”!
MMS score < 24 ! incompetent
Introduction I would like to ask some questions; then we will do a mental exercise
Analysis of CC Memory assessment
Behavioural " Did anybody tell you that you have changes in your personality? Being
changes short temper? More arguments?
" If there is a fire in this building; what are you going to do?
" How about your sleep? (dementia: fragmented sleep /+/ delirium:
reversed sleep cycle; sleep at day, awake at night)
MMS
Let us take a day of your life; I would like to see how did it affect your life?
DEATH
SHAFT
MOAPS Organic in details and screen the rest (especially mood for pseudo-dementia)
Memory assessment: Can you tell me more about this difficulty! OCD +
- Any fluctuations in memory level?
- This deterioration is gradual slowly progressive, or is it you feel ok for a while
then you have attack then you are fine then you have another attack? (step ladder)
- Are you having difficulty memorizing numbers?
- Do you have difficulty finding words?
- Do you have difficulty reading? Writing? Calculating?
- Do you lose your stuff?
- Do you make lists to remind you to do things you used to do on regular basis? Do
you have difficulty organizing your schedule?
- Do you have difficulty doing tasks you used to do before; like tying a tie?
- Do you feel difficulty for new events, or old events?
o Recent: What did you have for breakfast? Confirm from partner!
o Remote: Who was the USA president during WWII?
DEATH:
- Dressing: difficulty dressing and undressing yourself?
- Eating: do you remember to get all your meals? Or do you skip meals?
- Ambulatory: do you have difficulty moving around?
- Toileting: how about urination? Have you ever lost control or wet yourself?
- Hygiene: any difficulty having showers?
SHAFT:
- Shopping: who is responsible for shopping? You or your wife?
- House keeping: how about house keeping, are you able to help your wife?
- Accounting: who is responsible for banking at home?
Did you ever give cheque without balance?
- Food: do you cook? Did you ever forget the stove on?
- Traffic: do you drive? Difficulty driving? Have you ever lost your way?
Dementia cases:
- 69 years old man comes to your clinic because he is keeping forgetting for the last
few months. In the next 5 minutes; take history and assess (this is too long for 5
minutes, but during taking history, and if you mention: I would like to do the
MMS exam, the examiner will give you the score).
- 55 years old patient comes to your clinic because he has difficulty in memory. His
MMS score is 21. In the next 5 minutes, take history.
- 67 years old man, comes to your clinic complaining of difficulty with memory. In
the next 10 minutes take history and assess (make MMS exam).
N.B. If the patient has difficulty in AT of the “DEATH”; i.e. falls due to ataxia and
urinary incontinence; consider normal pressure hydrocephalus.
Introduction I can assure you that are safe here, you are in the hospital and no
one will hurt you, we would like to help you
" I can see that you are looking to the wall, do you see anything?
Do you see anything else?
" Doctor, do you see the spiders I see? For me, it does not look
like spiders, however, I understand that you can see them at the
moment, but I can assure you that nothing will hurt you!
Analysis of CC " I can see you are scratching; do you feel anything? Do you hear
/ see anything?
" Do you think any one would like to hurt you? Assure safety!
" When did that start? OCD?
Full MMS exam
Causes " Constitutional symptoms
DD " Any headache / vomiting / neck pain / skin rash / red eyes / any
ear discharge / runny nose / teeth pain / diff swallowing / SOB /
Infection cough / urine changes / abd pain / calf pain / swelling
Trauma " Head trauma? Injury?
Surgery " Recent surgeries? Pain at site of injection? Dressing change?
SAD " SAD: any shaking / sweating
Medications " What about medications, do you have a list with medications?
Any sleeping pills?
" Do you have nay long term disease? Kidney? Lung? Heart?
Conclusion
Notes:
- It the patient is not cooperative, keeps repeating “I do not know”; start to ask the
questions of the MMS exam, they will go with you. After you finish, you can
continue the rest of your exam
- If the patient is starring at the wall; ask him: I can see that you are looking to the
wall, do you see anything there?
- Mental status exam = psychiatric interview
- For delirium; we do the MMS exam daily until he improves
- For dementia; we do the MMS exam every 3-6 months; for follow-up
Mrs … 56 yrs old, was recently diagnosed with lung cancer, counsel her.
Introduction I understand you were diagnosed recently with lung cancer
How do you feel? How are you coping?
Support - With whom do you live?
- Any family support?
- How do you support yourself financially?
Brief history - SAD
- Fm Hx of lung cancers
Lung cancer - What do you know about lung cancer?
- Do you know which type you have?
- Available treatment
- Now, I would like to explain the treatment options we have,
- Once diagnosed, usually surgery is late to be done, so we have
radio and chemo therapies
- Based on your condition and stage of cancer, the surgeon thinks
that “chemo” and/or “radio” therapy are the best line of treatment
for you, this is based on the many clinical trials and evidence-
based medicine.
Treatment refusal No doctor, I do not want to contaminate my body with chemicals, I
am going for spiritual therapy!
Why you do not want to be treated?
Assess Rule out depression:
competency - I want to ask you some questions to know more about your
health! MI PASS ECG
- How is your mood? Do you find yourself cry easily? …
If depressed ! assess suicide and psychiatric consult
Counsel In not depressed ! she is competent, she can refuse treatment
- After all this is your decision; I just want to make sure you know
the available treatments that were proved to be beneficial in
treating lung cancer.
- Why not to try both? We start the medical therapy that we are
sure it works, and you go for spiritual therapy!
- Explain the condition, the available treatments
- The side effects of treatments and the complications of not
getting treatment
- What about arranging a meeting with some one who has had the
same medical condition, and speak with him/her. You will get
better insight into the disease and you will see the results of
treatment.
- How about arranging a meeting for your and your family
members (if you wish) with the surgeon, so that he can explain
the process in more details?