MBBS FINAL EXAM / TUTH-IOM

THEORY: MEDICINE B (PSYCHIATRY, MARKS-16)

PRACTICAL EXAM

TOTAL MARKS-20; PASS MARKS-10

EXAM PATTERN
EXAM at Psychiatry WARD at 9AM
ONE LONG CASE- HISTORY TAKING AMD MENTAL
STATE EXAMINATION
After long case- History presentation and VIVA of
the case with examiner (both external & internal at
the same time)
Time of History presentation and VIVA- 13-15
minutes (time will be exactly the same for ALL
students starting Sunday Psychiatry exam first
student to Friday’s last student)
During long case and VIVA, students should answer
based upon Psychiatry Department History Taking
Format
Don’t go beyond the format
Q: How will you assess patient’s judgement?
A: Suddenly snake facing test; house on fire;
stamped envelope
History of Present Illness (HOPI)
SYMPTOM ANALYSIS- description of all main
complaints given by patient and informants in
details- duration/mode of onset/aggravating and
relieving factors/currents status
Describe whether there are any features S/O
DEPRESSION/ANXIETY/MANIA/SCHIZOPHRENIA
SUICIDAL ideas / death wish / plan / any past
attempts
Use of SUBSTANCES: ALCOHOL / NICOTINE
(CIGERATTE/TOBACCO) / CANNABIS /
BENZODIAEPINES / OTHERS
FEW SYMPTOMS THAT SUGGESTS ORGANIC
BASIS IN PSYCHIATRY
1. High grade fever
2. Incontinence of stool and urine
3. Convulsion
4. Loss of consciousness or Fluctuating
sensorium
5. Head trauma
6. Signs and symptoms of meningeal
irritation / encephalopathy
 7. Cognitive dysfunctions- SUBTLE
abnormalities in orientation / memory /
attention & concentration / judgment /
intelligence / insight
8. Unstable vital signs
DIFFERENCE FROM MEDICINE- HISTORY FROM
PATEINT & INFORMANT(S) / TWO FAMILY
TREES [FAMILY OF ORIGIN IN FAMILY
HISTORY &PATIENT’S FAMILY IN PERSONAL
HISTORY] / DETAIL ELABORATION IN
PERSONAL HISTORY / PREMORBID
PERSONALITY

ALCOHOL (or SUBSTANCE) USE DISORDERS

MANAGEMENT
Assess for motivation
Hospitalization
Detoxification
Reassess for medical and other psychiatric co-
morbidities and plan to treat them
Follow-up for a long period of time (at least
TWO years recommended)
Assess for motivation
Motivated to get rid of alcohol- patient can be
admitted easily. If NOT MOTIVATED, MOTIVATIONAL
COUNSELLING to get rid of alcohol and related
[Link] problems are severe and life
threatening, admission needed.
Hospitalization
Needs hospitalization if alcohol problem is severe-
early morning drinking / seizure / dependent level /
patient having other psychiatric disorders
(psychotic symptoms, mood symptoms, amnestic
symptoms etc…..) / hepato-biliary dysfunction /
violent behavior / self-harm / other medical issues-
hypertension, diabetes, COPD, chest infection.
Detoxification
Investigations- Hb / TLC / DLC / Platelets / Renal
function test / Liver function test / Urine-RE &ME /
USG-abdomen & pelvis / CT scan Head (if needed)
Medications= Chlordiazepoxide 80-150mg/day in
divided doses; Lorazepam 1-16mg/day in divided
doses; Diazepam 5-30mg/day in divided doses.
Doses should be gradually tapered within 10-14
days. If orally not practicable, injectable can be
[Link] rehydration and vital monitoring is
needed. Patient should have good input-output
maintenance. Adequate feeding if, orally not
possible may need naso-gastric [Link] and
other multivitamin supplements are needed.
Other supportive treatment done (for APD /
vomiting / constipation)
Reassess for medical and other psychiatric co-
morbidities and plan to treat them
Assess for psychotic disorders / mood disorders /
anxiety disorders / amnestic disorders / sleep
disorders / sexual disorder / miscellaneous
disorders
Treatment done for above psychiatric co-
morbidities along with physical complications.
Antabuse treatment [DISULFIRAM 250-500mg/day];
Anti-craving agents (receptor blockers)
[NALTREXONE 50-100mg/day; TOPIRAMATE 100-
200mg/day; ACAMPROSATE 600-1200mg/day.
These treatments are given to reduce cravings.
Psychological Treatment
Counseling / Psycho-education- diagnosis /
duration of illness / duration of treatment / possible
hypothetical etiology / prognostic factors /
importance of taking medications / importance of
NOT TAKING SUBSTANCES / possible relapse signs.
Psychotherapy – Group therapy (example- Alcoholic
anonymous; AA )Supportive therapy / Individual
therapy / Cognitive behavioral therapy / Family
therapy / Marital therapy / Occupational therapy /
Social skill training / Recreational support /
Community-outreach support / Sheltered
employment.

Follow-up for a long period of time (at least

TWO years recommended)
Follow-up for the prolonged period of time (at least
TWO years), along with treatment of other
psychiatric / medical co-morbidities is essential to
prevent relapse, though there may be minor slips.
NEUROTIC SPECTRUM DISORDERS
[Depression (unipolar) / Anxiety and related
disorders / Conversion disorders / Acute stress
disorders / PTSD / OCD / Somatoform disorders /
Hypochondriacal disorders / Eating disorders /
Biological-psychosocial treatment
[Link]
Tricyclic antidepressants (TCA)
Amitriptyline (75-150mg/day) / Imipramine /
Clomipramine / Dosulpine / Nortriptyline
Serotonin Selective Reuptake Inhibitors (SSRIs)
Fluoxetine (10-20mg/day) / Escitalopram (10-
20mg/day) / Sertraline (50-100mg/day) /
Paroxetine (20-40mg/day) / Fluvoxamine (50-
100mg/day)
OthersMIRTAZAPINE / TRAZODONE /
VENLAFAXINE/DULOXETINE
[Link] / Diazepam /
Lorazepam / Midazolam / Clonazepam /
Alprazolam
Benzodiazepines (anxiolytics) – not used for
more than one month due to chance of
dependence
[Link]- beta blockers / supportive treatment
Psychosocial
Psycho-education- diagnosis / duration of
illness / duration of treatment / possible
hypothetical etiology / prognostic factors /
importance of taking medications / importance
of NOT TAKING SUBSTANCES / possible relapse
signs
Cognitive Behavior Therapy (CBT) - Cognitive
restructuring
Situational exposure (imagine and or vivo) / Social
skill training (modeling / role play / rehearsal) /
Breathing exercise / relaxation training / Individual
therapy / Family therapy / Marital therapy /
Occupational therapy / Recreational support
PSYCHOTIC SPECTRUM DISORDERS
[Schizophrenia / schizo-affective disorder / Bipolar
affective
disorders-mania/hypomania/depression=severe
with psychotic symptoms / postpartum psychosis /
substance induced psychosis / acute psychosis /
psychosis due to GMC]
Biological-psychosocial treatment
[Link]
Typical [First generation (FGA)/Conventional]
Haloperidol (5-30mg) / Chlorpromazine (300-
1000mg) / Trifluoperazine (5-30mg) / Thioridazine
(300-600mg)
Long acting (depot injection) Fluphenazine 50mg
Atypical [second generation (SGA)/SDA=serotonin-
dopamine antagonism]
Olanzapine (5-20mg) / Risperidone (1-16mg) /
Quetiapine (150-800mg) / Clozapine (300-900mg) /
Aripiprazole (10-30mg / Amisulpride (400-1200mg)
[Link]- Diazepam / lorazepam /
clonazepam
[Link] –
Mood stabilizers (in bipolar disorders)
Lithium (300-1200mg/day)Therapeutic Levels:
0.6-1.2 mEq/L
Sodium valproate (500-1000mg/day)
Carbamazepine (400-1200mg/day)
Other mood stabilizers: Oxcarbazepine /
Lamotrigine
Antidepressants (in severe depression with
psychotic symptoms)
[Link]
Psychosocial
Psycho-education- diagnosis / duration of
illness / duration of treatment / possible
hypothetical etiology / prognostic factors /
importance of taking medications / importance
 of NOT TAKING SUBSTANCES / possible relapse
signs
Supportive therapy / Individual therapy / Cognitive
behavioral therapy / Family therapy / Marital
therapy / Occupational therapy / Social skill
training / Recreational support / Community-
outreach support / Sheltered employment

VIVA-1
 What do you understand by Psychosis?
How it is different from Neurosis?
 What is DELUSION? Name THREE types of
delusion.
 What is HALLUCINATION?
 Can you name FOUR criteria of ALCOHOL
DEPENDENCE?
 Can you tell FOUR ATYPICAL
ANTIPSYCHOTIC DRUGS?
 Can you tell THREE main side effects of
AMITRYPTYLINE?
 Can you name THREE subtypes of
Schizophrenia?
 What is DEMENTIA? Name THREE causes
of dementia?
  What is obsession? What is compulsion?
 What do you understand by intellectual
disability?

VIVA-13
 What do you understand by Psychosis?
How it is different from Neurosis?
 What is DELUSION? Can you name TWO
types of DELUSION?
 Can you name FOUR ANTIDEPRESSANTS?
 Please name THREE MOOD STABILIZERS.
 Tell THREE criteria of ALCOHOL
DEPENDENCE.
 What are THREE clinical features of
DEPRESSION?
 Please name FOUR ANTIPSYCHOTICS.
 Can you name FIVE differences between
true seizures and pseudo-seizures?
 What is bipolar 1 and bipolar 2 disorder?
 What is the difference between
SOMATOFORM DISORDER and
HYPOCHODRIACAL DISORDER?