PSYCH REV - Hustle Hub (@amc.withdrLav )

Thank you. All right. Let me put my chat box at the side so I can see you guys. Okay, one second. Hash. I will answer your question at the end, but you must copy and paste the same question because I will 100% forget that question.

All right. So, first of all, uh, thanks for all of you guys for joining. Okay. I think it was quite cute. Some of you guys um were just didn't even ask me anything about site revision. You just sent me and then you're like, "Love, add me to the group." I'm like, "Oh, wow." So I think I just wanted to say I'm really grateful for the trust that you guys have. Um, in fact, barely any of you asked me questions about how the psych vision was going to be. You guys just said, "I want to join." So that shows a lot of trust. So I hope I live up to that trust that you have.

And first of all, um, psychiatry in general, let me just explain what psychiatry is all about. Psychiatry is a very easy station to pass in the AMC. Reason is, we are not psychiatrists. We are not OB/GYN, and we're not pediatric. So in general, these stations have an easier threshold of passing if you are able to rule out the differentials very well. If you're able to do a good history of presenting complaint, you have a good structure. You hit your red flags. That means you don't miss out your red flags. So apart from suicide, other stations have unique red flags. If you don't miss them, more or less you would have an easy, easy, smooth pass in your psychiatry stations. So when I had my exam, I had four psychiatry stations. So it was a little bit easier to pass on that. I would say it was a lucky, lucky day as well to pass.

One thing is, every psychiatry station always has a trigger, which means you need to get down to your heads assessment or you need to find out why is my patient feeling in this particular way. In fact, 90% of the time, stations will have a trigger. And remember this, psychiatry is a diagnosis of exclusion, which means you need to 100% rule out a few of your medical causes before you move on to saying that, "Yeah, I think this is a psychiatry problem. I'm going to diagnose them with a psych issue." Even then, if you say someone has a psychiatry problem, remember this, thyroid is your genre 7 masquerades. Which means under psychiatry differentials, your psychiatry organic differentials would be thyroid and head injuries. Both of these can always cause an issue with psychiatry. Which is why in every station, I would encourage you to ask these two questions.

And apart from that, when you talk about management in a psychiatry station, investigations is always part of management. And of course, do not do everything under the sun when you talk about investigations. If you have a psych station, thyroid is usually warranted because it can again, it's a hidden thing. Even if you do a screening question for thyroid on any kind of weather preferences, there is a chance you have thyroid with non-symptoms, right? You have thyroid discrepancies with patients with no symptoms at all. Which is why a thyroid function test can and will always be warranted in your psychiatry stations. But on top of that, no reason to do all of your uh, blood tests without um, understanding why you're doing them. So please, if you have time before your exam, justify each and every time why am I doing a particular investigation.

So if you have alcohol in your picture, which means the patient's an alcohol abuse or drinks alcohol relatively often, uh, then you can think of LFT, then you can think of B12. Makes sense because you want to know there's an issue with these things. If someone has um, any kind of eating disorders, then you want to take a pause. You want to spend time doing an ECG because that can cause arrhythmias. You can have any kind of nutrient deficiencies or electrolyte imbalances. You want to do ECG. You want to do your basic electrolytes. You want to do your FBC nutrients. Again, anemia might be a problem.

Let me just admit a few more people. Okay. Give me a give me a second. Okay. Done. Right. That's when you do your uh, bloods. Now, when you move on to after investigations, you go for non-pharmacological and pharmacological. The very nice thing about psychosis is this, most of the non-pharmacological is CBT. You refer them to a cognitive behavioral therapy to a psychologist who can help them with. If it still doesn't help, then I'll refer you to a psychiatrist who might need to prescribe you medications. That's how we usually explain. In non-pharmacological, you have CBT, you can have exposure therapy, you can talk about family meetings. So in some cases where you think family support might be necessary, bring in your family meetings. Talk about support groups. Very well-liked by the AMC. If you show you know about the support groups existing in Australia. But I would say do not spend so much of time trying to go and find out or memorize the support groups. Not necessary. In my exam, I barely memorized the support group. I barely said reading materials. Reason is, you'll be talking so much of information that these things are not as critical anymore for you to mention. There are more important things to mention in a station than to tell me that you want to send me to a support group.

When it comes to management, red flag is so important, which means every time telling them that if you do have any thoughts of self-harm or harming others, or you think that your eating behaviors are starting to change, please come back to me. Please give me a call. Now, giving your red flags is way more important than telling me you have a support group. So, weigh what is important and give the key things first, then tell them if you have time, reading materials, support group. Ideally, you would have done so well in all your in beginning, you won't even have time to talk about reading materials and support group. That's how strong you should become. At the end of the day, towards the end of your stations, I will be running through with you.

Before I go on, let me show you this big mind map here. So today, I won't be touching on everything. I won't have time to do that in 3 hours. I'm only going to tap on um, mood disorders like depression and mania. Run through the questions that have been coming up for them. I'll run through anxiety disorders a little bit more deeply, giving you the key pointers for, like for example, panic attack versus panic disorder, key questions, uh, OCD, OCPD versus all those. I'll be doing for you PTSD. We will cover, we'll cover MSE, MMSC, and the alcohol smoking counseling. Essentially, that I only have time for these ones today, but I do hope to have a second session and then I will cover all the others. And hopefully, if you can join the other one, you this map will make a little bit more sense to you. But for those of you who don't have time for the next session, or maybe your exam is before the next session can conduct this thing. When you're looking at this mind map, it has majority of your differentials, majority of your pointers. Only thing I was missing here, I would say, would be more of the counseling stations like mental health act and um, maybe your lithium and all those bipolar counseling. But most of your diagnosis are here. So spend time again, look at the diagnosis, think about the key questions you'll be asking and how to differentiate them in um, with the key questions which I'll be running through today.

Okay, I essentially explained this, most of it. Now, we'll run through a little bit on the psychiatry history structure. I know some of you guys already have a fixed structure. So no worries. Now, how are you going to benefit from this is those of you who already have courses, your exam is coming nearer. You just have to find things to value-add into your history structure. So if you have your own history structure in front of you, written out or laid out in a way, it would be good if you can get that in front of you. Add on only things you find interesting or you think you want to add and is justified. For those of you who have not done history, I mean, psychiatry before, you're brand new to psychiatry or getting a refresher. Especially for those who got a new date uh, recently in the exam, then take a listen about this. See if you can absorb this history structure. If you get structures from your other friends, again, value-add that. That's how you should benefit from this particular history structure portion of it.

Number one, in psychiatry, confidentiality will be established right on top. Ideally, in OB/GYN stations, you would be doing it right before your sexual history. But in psychiatry, unfortunately, because you have a trigger, you want to identify what on earth is going on, you would do it right in front, on top. And based on your history of presenting complaint, you would be ruling out your organic causes first. So later, when we do mood disorders, I will tap a little bit on tiredness cluster leading to depression and how are the big differentials or big guys we can rule out without spending so much time on medical history in a tiredness cluster. If you have other presenting complaints, for example, in your eating disorder station, your presenting complaint would come with, "Oh, doctor, my dentist sent me here because I'm having dental problems." How would you explore that? When did it start? A little bit on that. Now, what can be causing someone to have dental problems? If you're not thinking of an eating disorder, go for sugary foods, unhealthy eating habits, not good hygiene. Are they, some of them have a lot of oral sex as well, or they put a lot of things in their mouth? Now, those questions, those can also affect their hygiene in their mouth. So, ask these questions first. You can't find your answer in medical certain organic causes. Then you go for, "Okay, I'm thinking this might be a psychiatry station. Therefore, I'm exploring mood, sleep, appetite, and my structure down below."

The reason why people fail psychiatry stations is because they don't do medical differentials. They assume it's a psychiatry station because they know the recall. So, assume that you don't know the recall whenever you see a particular question. It's good an idea like, "Okay, I know this is psychiatry, but I need to do medical search first because I'm a good doctor. I'm a good candidate. I'm going to do that first." So, your mood question ideally would be um, asking for, of course, "How is your mood?" Some people like to ask, "How are you feeling today?" "How are you feeling today?" Still works. Not very specific. But the why I'm um, giving you other questions is because when you do get your MSE video station, they might not ask mood the same way you are asking. We always go, "How is your mood?" because we are very targeted people. But in Australia, they have a lot of lingo. They discuss a lot of things. Sometimes even the question of "How is your life feeling lately?" can also be a mood question. Which is why I always think MSE video is a little bit harder to present than an MSE history-taking station.

And now, when someone tells you their mood is low, your follow-up should be or can be, "Has there been any highs?" You're very smoothly ruling out bipolar at this point in time. When you go for, if they say, "Oh, doctor, I'm feeling very worried." Your follow-up can be, "Are you generally an anxious person?" So when someone says they're worried or anxious, it just means that whatever problem they are having is falling under the anxiety cluster, not 100% a generalized anxiety disorder. But if you follow up and ask them, "Are you generally an anxious person?" They'll be like, "Oh, yeah, doctor." Ah, then you know, "Okay, maybe this one is going towards generalized anxiety disorder. Let me continue my questioning and see where this goes." So that's how you can do your mood stations. Of course, I tell doctor, "I'm full of energy, doctor. I'm so happy again." Has there been any kind of low lows? So, rule out your mania. I mean, rule out your bipolar when they tell you they have a mania condition.

Now, we move on to sleep. Many people tend to skip sleep sometimes, or you don't know why you're asking sleep. You need to understand why you are asking these questions. For sleep, "How is your sleep lately?" Very generic, open-ended questions. If they just keep quiet, take a 1-second pause, move on, and ask, "Have you have any early morning wakening?" Now, that's to rule out depression. And "Do you think any kind of thoughts are keeping you up awake or anything's keeping you up awake?" That's your anxiety cluster. Go deeper. "Do you think you're having any kind of nightmares or flashbacks that you might be keeping you awake or waking you up in the middle of the night?" That is your PTSD. So, very nicely, as you're asking sleep, you're also ruling out other differentials within it. And you must understand why you're asking the question.

Now, with this next question on appetite, if you guys are have a bigger computer right at this point in time, you can open the notes. I sent it to 11 people because I got to check their email before that. For the rest of you who don't have the notes yet, I will send it to you after the after the session. But for those of you who have it, you can open it sidelines because if you look at the history structure format in the uh, psychiatry revision, it is a bit more well-explained or whatever I'm saying will be there. All right? So you can follow me through that if you're lost. Now, for appetite, you need to understand why you are asking this appetite question. To be very honest, appetite is not a very key or crucial question. But we do ask in the psychiatric history if you are concerned about an eating disorder. But let me tell you this, if I, if you ask someone with an eating disorder, "How's your appetite?" They will tell you, "Yeah, doctor, it's good." Reason is, appetite is just the feeling of eating, right? You're like, "I can eat. I feel like eating. I can eat." It's not like I don't feel like eating. But your better questions for eating disorders would be, "Do you have any kind of binge eating episodes? Any crash dieting or any kind of compensatory mechanisms or measures you are taking after eating?" Now, those questions are more specific to your eating disorders. So that's why you want to go deep in an appetite history if it's an eating disorder station. Otherwise, the reasons for why you would like to ask appetite is if someone has depression, they can have low appetite, right? And that's because they just have no mood to eat. It's not because they're having cancer. And the other safety net of why appetite is put here is cancer can be a differential for a lot of things, and you just safety net by putting an appetite here. Otherwise, if you are doing, for example, a schizo station, um, not super necessary to ask for appetite unless he is living on the streets and maybe he's not eating well and you want to bring that back in management under nutrients or any kind of dietician concept. Uh, then you can ask for appetite, then you can explore. If not, if you're running out of time, if there's one thing you want to kick out, I can say you can kick out appetite. If it's not a depression station, if it's not an eating disorder station, you can kick out and you will still can do well in that station.

Okay, now we move on to suicide. Suicide, please get comfortable with asking just a question. Some of you guys do ask, "Are you having any thoughts of self-harm?" And then you stop exploring about harming others. While some of you guys think about, "How can I directly ask this question?" Um, I do understand that in many of our countries, especially Asian-dominated countries, uh, suicide is a very taboo thing. Psychiatry itself is a very taboo topic, right? We don't like to talk about mental health in a lot of Asian countries. It's a silent, hush-hush thing. But remember this, it's AMC, you're in Australia. They are super cool people. Um, they love talking about mental health. In fact, they love mental health more than they speak about their medical search problems. So, please be comfortable asking of, "Do you have any thoughts of self-harm or harming others?" Now, at this point in time, if you have forgotten to establish confidentiality, your next chance will be right before you ask for suicide. Establish confidentiality and then ask this question. So, question would be, "Do you have any thoughts of self-harm or harming others?" Put them together. And here, if the person says yes, please do not just run over to your next uh, task of delusion or hallucination and skip it. If someone says yes, please follow up. "Do you have any plans?" "Do you have..." If, if they say yes or no, depending on what they say. If they say yes, ask them more about the plan. Ask them if they've already bought the materials for the plan. So depending, right? If they want to um, cut themselves. So ask if they've gotten the materials like knives or how do they intend to do it? So explore it a bit more. Usually, so far, I've not seen a a proper suicide positive case in the AMC. Yes, there is suicidal ideation stations, but not a planned positive or a um, previous attempts have been positive, but not a planned positive. The reason is because to be able to explore a plan is a skill. It's a technique, and um, psychiatrists and psychologists are better trained to do that. But you need to know how to take the direction of suicide if it becomes a positive. But so far, don't have. So don't panic, but please explore if there is.

Now, even if they say they don't have there are no ideations, move on to, "Have there been any kind of previous attempts?" Previous attempts is an increased risk factor for suicide, which is why you want to ask that at the beginning. Any questions so far? No questions. If any questions, just post in the chat box. Okay? I will take a pause and I'll read it or press the raise hand marker and I'll answer your questions.

Then you can move on a little bit to delusions. Now, delusions can need to dive in a few stations. So, if you're doing schizo stations, I would say spend time diving into delusion and hallucinations. But if it's a depression station with no psychosis, not necessary to spend so much of time asking all your delusion questions. So, screening ideally, not just screening, but ideally, you just like to ask, "Anybody putting any kind of thoughts in your head, right? You want to see if anybody's spying on you, so you have paranoia, you have persecutory..." What, what do you think they're telling you, right? And if your hallucinations are positive, for example, auditory hallucinations are positive, move on and say, "Are they giving you any kind of command? Are they telling you what to do?" If it's a yes, move on further. "What are they telling you to do?" The reason why you need to explore this is because you have a postpartum psychosis case where the voice will be asking um, the mom to kill the baby. "Tell the mom you're not a good mom. You need to kill the baby because you're just not going to throw the baby down the window." You need to catch that. Now, that becomes a risk for you. And when it goes to management, you need to tackle that entire aspect. The safety of the baby's compromised. That's why those questions become key in your postpartum psychosis or generally in hallucination um, stations. And then you can, once you have done delusions and hallucinations, later I will explain a little bit more on how you put this into an MSE, which is why I'm spending time doing psychiatry structure first, then explain depression, anxiety cluster, and then move on to MSE, so things will make sense. You would have caught the keywords here before we get to the MSE part of it.

Now, inside judgment, cognition, very easy to remember, but also very easily forgotten. In every station, why is it important? Not having insight is a risk. This affects your management. And and insight is just one question, guys. "Do you think um, you need help?" Right? "Do you think you need treatment? Are you aware of what's going on to your mental health?" You can try asking that. Now, in my exam, I, I asked a question. I asked the first, I had four psych sessions, right? So, my first psych session, I asked, "Do you know what's happening to you?" Um, that's what I usually use to use as my insight question. And I looked at my role player, and he looked at me really confused. He was like, he looked at me like I asked some alien question. And I was like, "Ah, he doesn't understand my question." So, "Are you aware of what's happening to you?" is not a very good question for insight if that's what you guys have been using. Um, a better question would be, "Do you think you need help? Do you think you need treatment?" That would be a better question.

For judgment questions, there are quite a number of judgment questions. The one that most of us are familiar with would be, "If there was a fire in this room, what would you do?" Of course, before you ask that question, you can say, "A lot of you like to use this statement. I can't remember what is it now. You guys will say, 'It's going to be a weird question, but let me ask you this weird question. If there's fire in this room, what would you do?'" Well, yeah, okay, can. But a better way to phrase would be, "I'm going to ask you a hypothetical question. If there was a fire in this room, what would you do?" In this way, you don't have to create that funny atmosphere like, "I'm going to ask something weird. Is it okay?" No need to ask. "I'm going to ask you something hypothetical." Go for it. Give it open. I'm not saying open-ended. Don't have to ask them whether it's okay to ask the weird question. What are you going to do if they say no, man? You, you're going to be stuck. So, just go with hypothetical and then this is the question. And other questions of course would be the ones that I found okay on uh, DSM, I mean, on your site would be, "If you found a stamped addressed envelope on the street, what would you do?" Now, it's a bit hard for me to remember that question, so I never remembered it, but that's one. If you guys have that, you can use that. Um, the next other question you can use is, "What would you do if you ran out of medication on a weekend?" All right. Honestly, I don't 100% know the answer to this, and I feel like there's so many ways. It depends on like your financial ability. It, it depends on where you're living. There's so many questions. So, I do think the best question would be, "If there's a fire in this room, what would you do?" Because it shows that emergency significance. It shows that ideally, you would run. And if they don't run, then obviously they need help. So, that's the best question so far compared to all of those out there in your psychiatry textbooks for a judgment. So, I think the use the fire question. I think you'll be fine.

All right. Now, sorry, back to delusion. I forgot to uh, tap on other delusions that are out there for you. So you have grandiosity. So grandiosity, usually your mania people have grandiosity, and in those patients, they will tell you, "Can you ask them, do you believe you have any kind of special powers or superpowers?" Those are the questions. If you do think about thought insertion, the one I told just now, "Any thoughts that being put into your head, or any thoughts that are broadcasted onto the TV or into the radio about you?" Usually, I, I like to ask that question because I can use my hands. And if you notice by now, I'm a very hand-like, I use my hands a lot. So when I ask that question, I'm like, "Do you think anybody's putting thoughts into your head?" You know, and then, "Do you think some of your thoughts are being broadcasted elsewhere?" So I used to do that with my patients. I still do. Okay? And it makes it feel a little bit more um, interactive, more use of space. Remember this, it is an AMC exam at the end of the day, but you have to strategize. You have to think about how to maximize your impression with the examiner and with the patient. You need to be memorable at the end of the day. So it's on top of clinical. It's about you being memorable. So you don't fall into that, "Should I pass this candidate or not pass this candidate?" You should do these extra things like, "Yeah, I like this candidate. I enjoyed myself in this uh, consult. I'm going to just u move on and um, pass this candidate without a doubt because they hit all the minimum pointers." That should be the emotion you give the examiner. 100% you'll pass the session. All right.

So Anisha, you asked me about, "Can you explain about paranoia and uh, persecutory delusions?" Well, I can do that, but I will tap it a little bit more in detail when I'm doing the MSE because I'm going to re-explain delusions in the MSE station, and it's very, very, I have an entire slide on delusion. So I'll do it then again. All right.

Then when you move on to cognition, very easy. It's just about orientation to place, person, and time. But you got to ask those specific questions. "Do you know who I am?" Or if you think your patient has been already addressing you as doctor while giving you all the previous answers, you don't really have to ask um, "Do you know who I am?" You can just move on to, "Do you know where you are? Do you know what time is it?" Now, there are some stations in Schizo where if you ask the patient, "Do you know what time is it?" The patient will tell you, "Doctor, there is no window in this room. How do you expect me to know what time is it?" Don't panic. They do these kind of things. Move on to other time questions. "Do you know the season?" And that is also a time question. So if you think it's safer to memorize that time question on, "Do you know what's oh dear, do you know what season is it?" You can try that as a question, but I prefer always, "Do you know where you are? Do you know what time is it? Do you know who I am?" Stations a little bit better for me.

Then you can move on to heads assessment. Assessment, quite important. As I said, every psychiatry station, there's always a problem going on. So that would be your home questions, asking about their home situation, who they live with, if any good support up there. Can ask about education. If it's a teenage uh, child, then you want to spend time on education. Non-teenage can skip the um, education and move on to asking about activities they like to do. If you forgot anhedonia questions in a depression station, uh, this is where you can bring back your anhedonia and your MCD caps. Uh, mnemonic for depression diagnostic questions. Then you move on to D. Usually, if you can do drugs, right here, S will be social, and the other S will be um, sexual. Why do we ask sexual history in psychiatry? When your insight and judgment is off on alcohol and drugs, people do a lot of reckless things. And in many of the uh, let's say bipolar or mania or schizo, they're not really, they don't really know what's going on. And this is when they engage in sexual behaviors. That's why you want to establish sexual history at this point in time. But if you think it's not necessary, don't have to. Okay? You don't have to. If you think it's not necessary, unless you think that station requires sexual history, for example, it's a men's sex man. This guy, when you, as you found out in the middle of somewhere that he prefers males, then you want to spend time on sexual history because when it comes to management, you have to fix that. Now, you got to figure out his MSM. You got to give your HIV discussions, see what is necessary. Even your investigations will start changing. Now you want to start doing your STI screening, which you would not have done if you never knew he was an MSM. That's why it's important to identify the sexual part of it. But it is not routinely in your psychiatry stations. Just look and gauge whether you have time, first of all, and whether it's necessary in this station. Then you can move on.

When you wrap up your stations, a way of wrapping up will be previous mental health illnesses. You can ask that. Previous medical. Oh, sorry, Alisha. Men sex men male sex male men sex. And just type it in the chat box there. Sorry. Okay. Uh, yeah, when you're wrapping up, you go for past medical history. If you have specific questions you want to ask in past medical history, something out of tapped a little bit more relevant in your medical search revision, not really in psychiatry, but here you're more keen on mental health issues. So, previous mental health conditions in the family and in themselves. So, go for personal history or family history. Put that in one sentence. A lot of times we ask, "Any personal history of this? Any family history of this?" Not super necessary. Go for personal and family history of, then spend time establishing the conditions. You need more energy to know why you're asking a particular uh, diagnosis rather than splitting up the question and wasting your time. So you need to learn how to save as much time as possible in your history taking but still being effective and asking everything that you need.

Was um, history that should be the end of psychiatry history. Any particular questions? The delusions I will tap later in super detail when we do um, MSE, but otherwise, any questions about history, it should give you a good insight on what a history should be, and then we'll move on to mood disorders. Right, let me move on. Any questions, just keep posting. Yeah.

So, move on to mood disorders. For mood disorders, I'm going to tap on depression, mania, serotonin, and syndrome comes once in a while in the AMC. It's a handbook case, so I will tap on that. Then I'll also tap to you about uh, what if an antidepressant or a medication is not working? How would you further explore the history? Reason is, in psychiatry, there are many stations where there's non-compliance going on, and sometimes we fail to first ask about non-compliance and we forget the reasons to why someone can be non-compliant. We just move on to, "Okay, you're non-compliant," and we move on to fulfilling the history structure because we are in panic to finish a particular station. Please have a read on this station, and then I'll explain a little bit more in detail.

So this station comes with a presenting complaint of tiredness. She's been feeling extremely tired, and she lives alone. So you know her support system by reading the "lives alone." You know that she's feeling tired. You know, she also works as a secretary to her lawyer, which means you need to establish, you need to identify a little bit more about it in your history taking. Some positives around it. First things first, yeah, let's just talk generically AMC history taking. When you have a stem provided to you, do understand this is a stem. This is not a note. This is not um, your what do you guys always say? You guys always say, "From the notes, I noticed that you have been feeling tired." This is just a stem for you as a candidate to understand how your patient is going to be when they come in and to under formulate your diagnosis so you can pass the exam. But this is not a note because a note would start with the name. It would give you every information, the ID. It would give you the where the address of where the patient is living. We give you past medical history, every single procedure, every single medication that patient has been on. That is a note. I think most of us have seen this in our hospitals or in our clinics. So what you see in a stem is not a note. Try your best to not refer back to say that, "From the notes, from the stem, I saw this." Avoid that as much as possible. Everything there, you should be able to elicit from the patient, or in the opening statement, the patient would tell you these conditions.

The reason why many candidates fail under approach to patient is because they run into, "Oh yes, you've been feeling tired. Tell me, when did you feel tired? When did it start? I know it's been for six months. I know you're living alone." That's not going to work. You're going to mess up your approach to patient. Why is approach to patient important? I believe most of you will still do well in approach to patient. But um, there is a candidate, I only saw the results slip of this person. I don't 100% know who this person is, but this candidate passed nine stations. Okay, they passed clinically, they passed nine stations, but overall AMC failed them because approach to patient was zero or one in every single station. I never knew this was possible until I saw the results slip. I, I never, I thought if you get nine means clear-cut pass, but I didn't know that if you get nine and you still fail approach to patient in everything, overall is still a fail. Yes, it feels very unfair. Um, I was, I felt really bad for that for that candidate because I was like, "Oh man, like they're really good. Why, you know, it's so mean." But then when I take a step back and I think about it, if I have a doctor who's clinically very good but not able to talk to patients, would I want to hire that person? Now, if you take a step back and think about it, like life is unfair, but still makes sense. Life still makes sense, and there's a little bit of fairness. So you, I think even you might be nodding your head behind the screen, like maybe you wouldn't hire that person too, if they're going to just shut off your patient. So yes, you're going to be a very good doctor um, getting your history, nailing your history and diagnosis, but you're going to upset all of your patients. You're not going to get business. I mean, if you think about it economically, right?

So for this particular station, when you have tiredness here, spend time asking the patients, "How can I address you?" And the reason why you ask, "How can I address you?" is some, yes, the names are usually given by the examiner. Examiner will tell you, "This is your patient Lily." Any questions? And then you go to your patient. Why do I suggest you to ask, "How can I address you?" That's when you are writing all your tricks on your paper, right? You need to, you need a time. You've not, you will never have time to write your mnemonic. You will never have time to write anything. So only when you ask, "How can I address?" That's when you're scribbling. Okay, I'm going to ask this question. I cannot forget this. I cannot forget. I'm going to write the mnemonic. That's why you ask, and then you go, "How can I address you? How can I help you? What can I do for you today?" Open-ended questions. Let them pour the opening statement to you. You have so much of positives in the opening statement.

When someone comes to you telling you that you're tired, take your medical search explanation or HOPC history of presenting complaint that you would do for tiredness. Describe what do you mean by tired? How long have you been feeling like that? Is it on and off? Is it only in the morning, or is it only towards the night? As you asking these questions, you are ruling out technically. They say they're tired only in the morning. Might be a possible OSA or they didn't sleep properly. It might be an insomnia problem, right? Or if they think that, "Oh, doctor, I'm only feeling towards uh, feeling tired towards the night." It might be a myasthenia gravis autoimmune condition where they're feeling tired a bit more later towards the day, and you want to know if it's on and off or if it's constant. On and off, you're thinking, is it something like it's cancer, it's only coming on, and they're doing something that's causing this? It's something inducing the tiredness because you have your statins that can cause muscle pain and can cause you to be tired. So you want to explore the tiredness very well.

In this station, when you look, you have to present MSE. So you're going to panic because of your panic, you won't do a good medical search exploration. Which is why I'm going to go tell you five questions to ask under your hemifod. So you don't have to run through hemifod. Just ask about skin discoloration. Reason is, skin discoloration, uh, rules out for you hemochromatosis, hepatitis, and Addison's disease. Okay. So you ask about skin discoloration. One question, three diagnoses, kick out. Then you're going to ask about thyroid. Why thyroid? Your screening question would be um, "Any weather, weather change preferences, right?" Why thyroid? Because it's your seven masquerades. It falls under both the medical search differential for tiredness, it also falls under psychiatry depression. So you want to overlap them and ask your thyroid question. You want to ask about malignancy. So do your screening questions for malignancy. There's a difference between screening questions and diagnostic questions. So I think just now for those of you who came early, we spoke a little bit about tumor and I mean, brain tumor, and the key questions to ask for a brain tumor versus just asking me, "Any loss of weight, lumps and bumps, and loss of appetite?" Now, that is a screening question for cancer. It is not a diagnostic question for cancer because if you want to diagnose someone with cancer, you need to know what cancer they're having and go for the symptoms that they'll be having for that particular cancer. Right? So, we as we'll, if I have time, I'll talk a little bit more about that later during the break.

Then you move on. So you rule out malignancy, you've ruled out thyroid, you rule out head injury, you've asked skin discoloration for the three diagnoses I told you. What is the other one? Ah, fever. So ask a fever for infections. So screening question is fever. You've ruled out all your infections per se. If it's positive, then please, of course, go as explore your fever and go explore all your different systemic review on what infection it can be. But usually in this station, it would be negative. So you have done all your infections ruled out. Then you can quickly move on. So in your, in your history taking, you ruled out myasthenia gravis autoimmune, you ruled out OSA. You got three differentials for your um, question color discoloration, and another another three or four more. So you have done at least eight to nine medical differentials here. Then you move on to doing your history. In this history, there are multiple layers. First of all, you need to complete your psychiatry history because you have MSE presentation, which we will tap on it later. But you need to also confirm this person has depression, and these are your key depression diagnostic questions. So you use MCDAP. You would use um, mood. I mean, mood would be low, ideally in this person, someone with depression. You would go for sleep, and then we talked a little bit about sleeping a lot, and we talked about early morning wakening. In this patient, you would ask them about anhedonia. "Are you still interested in things that you used to do?" Ask them if they're feeling guilty. Um, you want to talk about the lack of energy here, not really the gain of energy. So now, in many of your history taking um, structure, especially those who take either First Aid or from Armor, if I'm not wrong. Correct me if I'm wrong, please, because this is just based on experience from hearing different people and working with candidates. I've not taken them, so I don't know. These candidates tend to ask the guilt question, concentration in almost every um, psychiatry structure. But well, I believe they've put it there so that you don't make a mistake and you don't miss it out if it's a depression station. But think about it. If it's a schizo station, or if it's a um, eating disorder station, or if it's something else, these questions become a non-depression station, especially. Then these questions become unnecessary. They become a waste of time question. So please note when to ask a particular question and when you can kick it out very nicely. That will help you save time. So those of you who have time, who have time before your exam, plan it a little bit more before you move on. Appetite. A lot of us, you apply the appetite under the mood, sleep, appetite structure. So it doesn't come back here. But the reason why it's here in depression is because these people usually tend not to eat. They lose a little bit of weight, or they either sleep too much and they gain weight. So it can go both ways on the appetite and changes in weight. Which is why there's always an overlap between a loss of weight. Not a very good question to ask in a depression patient. If you want to think of cancer, you don't know what's going on in this patient. Then you want to go for psychotic symptoms. So ask about any kind of, "Do you think you're speaking a little bit more slowly, moving a little bit more slowly?" And move on to suicide. Suicide is a very key red flag in every single psychiatry station. So these will be your key pointers for depression. And there's no questions. I'm going to show you another question. I mean, another slide. Sorry. Have a read on this station here. When you read the stem, you already know this person has anhedonia, has low energy levels, symptoms of major um, depression first, and then you realize that this patient has already been diagnosed with major depressive disorder. However, she's now coming to you, right? Oh, sorry, I didn't complete the station. Sorry. However, she's now coming to you because she does not feel she does not feel like she's getting better. Here, when you take the history, you would first start with, you don't have to spend so much time confirming that she has major depressive disorder, but you want to just do a very quick check on her mood. You want to check, was there any kind of highs? You want to rule out that bipolar mania condition going on. And then you want to talk about the medication she's been on and her compliance with the medications here. And at this point, you start realizing, why is my medications not working anymore? So now, in the chat box, give me a couple of reasons why sertraline might not be working in this patient. Yes, Hashtag, correct. Despite everything they've given all. Okay, unless, yes, let me just answer Hashtag question while you guys are typing why medications are not going to work. Um, unless the stem tells you, unless the the task tells you to not take any more history, then you have to depend on everything written there for you. But it will be way longer. It will occupy the entire screen. Okay. Yes. Side effects. Fantastic. That's number one why we don't want to take medications or why the meds are not working. Uh, let me see. But she doesn't feel okay. Let me add the question. Okay. But she's not, but she doesn't. All righty. Let me just go back. Okay. Yes. Side effects, non-compliance. Yes. And compliance issue, go further. Yes, you have memory. Yes, you have financial price. Definitely finances. Uh, it's a very big issue actually in Australia. Uh, there are actually more people that who are not very financially strong. We doctors don't see it because, you know, we earn quite a little bit, but for those who don't, it's so difficult to get basic drugs. The disease itself. Yes, very true.

So now, let me explain to you when you talk about, let me just run through your answers. So when someone talks about non-compliance, yes, it can be a financial problem, it can be a memory problem, or it can just that they just don't remember, they don't want. So, but why is it important to establish why? In the management, you got to fix this problem. Now, so if it's a memory problem, you want to talk a little bit about those charts you can put in your fridge. You want to talk about a phone app reminder. You want to talk about a diary. You want to talk about having a family meeting where these people around you can remember, remind you about it. If it's a financial problem, why they're

non-compliant, then you're going to think about how can I use sentink? How can I use social work? How can I help their life and make them not really be financially a bit more better or provide those medications for them? Is that alternative brand just cheaper? Right? That's how your management will come. Finances is a problem, but there's still a couple more of yes. So they have said yes. So it might not even be depression. So if something is not, if you're not even solving the problem, then it is not working. And Josephine also said that it might be taking medications, but there are other kinds of inducers. So yes, so these are so far the reasons I found. If there are any that I'm missing, please let me know. But so far from reading, um, from health pathways and guidelines, I think this is the ideal ones that I found.

First of all, the dose might not even be enough for this patient. All right, think about it. Even for a diabetic patient, if they're not well controlled, it might be because your insulin or your glucoside or your metformin might not just not be enough. That's why it's not working. And she has come to you after two weeks in the station. It might just have not been enough time. Usually takes six weeks for you to see a good difference, which is why we take patients up to six weeks before we think of any kind of tapering or we think of changing the brand of the medication. So compliance is the other one, which we discussed about the price and the memory, and I told you about the management with regards to it.

Um, yes, any interacting medications lowering the efficacy. Usually, these ones are your lithium and your bipolar, your bipolar meds, um, with serotonin SSRIs. So not really any, but if it's OCP, your liver inducing um enzymes, so OCPS, you want to ponder a little bit about it and all your uh St. John's Wort, all these herbs that sometimes patients can be taking because somebody said that it was good or not good. Then, yeah, and if someone is um drinking alcohol, then that can affect as well. Um, other kinds of drugs, uh, recreational drugs can cause memory issues to forget, or it can also cause reactions with the current medication that you're taking. And if the trigger is not addressed. So sometimes with depression medication, so yes, the medicine should be working, but after you prescribe the medication, just nice, something else happens. You probably a breakup or someone passed on, and then so it's not really the medicine is not working. The problem got a little bit bigger. So now you need a, it can go under inadequate dose, or it can be a trigger not addressed, or the problem becoming bigger. Therefore, you need a revamp of your management. So these are different reasons. If you guys can think of more, let me know. I'll definitely add it on. Um, but I think these ones do encompass um, most of it. So far, this is your AMC case as well, the one that I showed you guys just now. Explore a little bit. You also want to talk. When the minute you see SSRIs, your red flag for any kind of depression or SSRI station would be, are they having any suicide ideations? Now, because two weeks into taking medications, they can feel suicidal. It's a side effect of that drug. Uh, it takes six weeks before you see a very good uh change in them. You also want to look at serotonin syndrome, which takes me to the next uh slide.

So have a read. This is your AMC. This is your handbook station. Take a while to read it. I would say uh know a little bit about brand names, but Prozac and uh Zoloft are the most common ones. They do try to bracket and they do try to write the drug name. So far, I've not really seen a struggle with it. Um, but there are times it'd be easier for you so you won't panic if you already know this names exist in the planet. So have a little read. In this station, you need to identify the other drug that was taken and you need to stop the second drug. That is the management biggest and red flag management for your serotonin syndrome. Stop the second drug ASAP. If you have any kind of uh temperature, fix the temperature as well. Keep this patient under observation. That is what you need to do for these patients. Know all the medications which cross-interact. And then um for SSRI, usually you do the tapering down method if you need. But in this case, no reason for tapering down, just stop the second drug. Patient should be fine. There'll be no issues. If you have time, you can spend time looking at this case in the AMC handbook. I really can't remember which case it is. I'll try to find out and let you guys know. Look at the critical errors and red flags. But the critical errors here is not being able to identify serotonin syndrome. So not a very difficult station. I think when we did psychiatry for AMC 1, these things would have been, you know, pushed into our heads quite quite deeply. Now, these have been the recalls that have been coming up. So, have a little read and then we'll break it down for depression. Yeah. And then I'll be tapping on mania in a bit. Um, so ideally they come in as M MC MSSE stations or they come in as a counseling station where in general for counseling stations, if you are lost, you don't know what to talk about, take a pause, go back, ask the patients for their ideas, concerns, expectations. So use the ICE protocol, ICE strategy, rather. Let me type it out for you guys. Ideas, um, concerns, and expectations. A brain. Okay.

Now, the reason why this will help is in most of your counseling stations, they do always have a lot of questions to ask you. So, spend time identifying, getting back to the, if you are lost. Okay? If you're not lost, you know what to talk about. Proceed, man. Don't even bother. I mean, not to say don't even bother, but have pit stops in the middle to ask them if they understand what you're talking about and if they understand, uh, if there are any concerns that you want you, they want you to address. So tap on that if you have time. Now, if you look at this station, the 15th May one. Let me tap a little bit on that. So on 15th May, you have a lady who's already been diagnosed with dysthymia. Now, dysthymia, dysthymia, depression, right? You need two weeks with symptoms and low mood to diagnose someone with depression. If you want to diagnose someone with dysthymia, two years, and ideally, you would have done every investigation possible on the planet, and you still can't find an answer, and then you're like, ah, dysthymia. All right. So this lady has been diagnosed with dysthymia and she's visited for multiple visits in the hospital. She's not feeling happy. Husband is busy with work, children have left home for further studies, feels lonely, body aches and pains, no organic cause. If you see task number two, I'm very glad this candidate wrote the proper task here. Explain reasons with an S, guys, which means more than one reason for her condition. And they've already directed you towards a psychiatry history in this case. Do you, uh, would you still do med search a little bit when they ask you to explore why she's feeling tired? When you do your HPI, tiredness, you would have already ruled out a few of your med search differentials. And in your psychiatry, towards the end, you can still couple on um tiredness. But here, why they tell you psychiatric history is because they know that people will start panicking and running all over the place. This station is an empty nest syndrome station. Now, empty nest syndrome, ideally, just means that their family members are no longer at home. The mom feels a little bit lonely. That's why it's called empty nest. The task says explain reasons. She has a lot going on because her body aches and pains. This lady is on long-term steroids. She's also on statins and she was on long-term steroids and then she stopped the steroids. So now that can cause tiredness and that can cause or why she's having the pains and aches. She's also on statins recently. So that's also causing her pains and aches. She's also having the emptiness. So the people, family leaving from her home, her not having anyone to talk to. Now, all these are reasons for her condition. So please read the task. Always look if it's a singular or plural. What are they asking me for? Are they asking me for more than one thing or just one specific thing? Cuz again, if you don't address the task, most likely you might not make it through that station. That is how this station goes. If you look in that station, the task is actually the stem is actually way more longer. I had a candidate who said it took up the entire page, but they knew the recalls. They knew it was empty nest syndrome, but they did spend time asking um other kind of questions as well. So, they passed the station. It's a very easy pass station. Have to rule out suicide in this case. All your red flags. Rule out. Any questions for depression in general? Because we're going to move on to mania.

Now for mania, I haven't really seen too many um stations in the AMC with mania. The key point is I would just like to leave you with in mania would be your D-FAST mnemonic. You need to get the distractibility in this patient. So even when they're talking to you, they might be having the flight. The flight of ideas is what we would explain. Yes, it is an empty nest syndrome. Um, it's a syndrome, but yes, you can use as a diagnosis. Now, distractibility, that's something that you get from them. They're very irritable. So if indiscretion is a very hard word for you to remember, irritable is a bit of, I used to remember as irritable. I didn't really like other words. G is the grandiosity. So which means asking questions like um, do you have any, do you think of any superpowers? Do you think you're big? Do you think everybody owes you something? Those are your grandiosity big questions, which I'll be diving into the MSE part when we do delusions. Okay. Flight of ideas just means that you are having, you can't talk just about one thing. You are flying from one thing to another thing and you're all over the place, right? And then these people have very high activity. They like to do so. They think they can do so many things at one point in time. They'll suddenly feel like cleaning the house, you know? I, I've had a patient once who was cleaning the house, cleaning all the cupboards, taking all the clothes, and I was like, "Wow." I mean, I would love that sometimes, but not as a mania of conditions. That's something to think about. And they will tell you, "Doctor, I don't need sleep, doctor." And you are so surprised when you hear such patients, but yes, they don't need sleep. They don't think it's important. They think they have superpowers and they talk a lot. They talk all the time. They talk a lot, right? So these are your mnemonic for mania.

Now let me ask the question in the chat box. Now for adjustment disorder, you need to remember this. I'll bring you back to the previous question. Yeah. Oh dear, dear, dear. Here. All right. So 15th May question here. It's very hard to establish adjustment disorder reason because then the uh DSM criteria of duration for adjustment disorder is within three months of the change. Here, there is no particular change that is happening. So the change what we mean is that maybe they're going a change of environment entirely. You're traveling from one country to another within three months, you feel this um little bit of low mood, then that would be adjustment disorder. But here, her kids would have been working all their lives. I mean, husband is working all their lives. The kids have been going studying for the duration, if I'm wrong, is six months here, which makes adjustment disorder doesn't fulfill the criteria to diagnose adjustment disorder. So be very careful with durations. So again, let me just run you through. Yeah, depression, two weeks. This time, year, two years of symptoms and have you done everything? No, nothing has been done. Adjustment disorder, the change must have happened within three months of having the emotions or the sadness that you're feeling, the low mood that you're feeling. Postpartum blues, I'll tap on it here. Postpartum blues, seven days of. So it's a normal condition. It's not a bad condition, right? It's just a, you wouldn't say it's a um psychiatric or risk in a way. It's a normal feeling they might feel in when they're new to motherhood, okay? Postpartum blues, seven days. Postpartum depression, same, two weeks. But this thing, postpartum psychosis can happen any time after postpartum, as long as they have the psychotic features. Get the durations a little bit right. I know it gets confusing, but this will help you nail your diagnosis a little bit more. And here, if you look at the 15th May station, um, someone asked, Anisha asked, is it a diagnosis? They're asking reasons for a condition. They're not really asking you for a provisional diagnosis or a diagnosis per se. So she's having a condition called empty nest syndrome. It's like how I tell you, you have serotonin syndrome, right? That is a syndrome. It's a, it's a, it's a collective of symptoms that's causing it. It is not a diagnosis. Think about it. So it's, it's very clinical, very, very clinical. So just take note of these things. They're very technical. So not clinical, but technical. If you want to dive deep into them, I tell you, three months prep might not be enough for AMC. So just know enough for you to clear the exam, cross the bridge and go, man. Enter Australia, you're done. Okay.

Now, that's uh done with mania. Um, any questions for depression and mania? If not, I'm going to go into anxiety disorders. We'll take a little while for anxiety disorders. Then we can take a break after anxiety disorders. Then we'll do MSE, MMSSE, and alcohol smoking. So far, all so good. You know, sometimes I panic. You know, guys, if you guys have no questions, it means maybe you don't understand what I'm saying. Or the good thing is you understand what I'm saying really well, but I need to know which direction it's going. Okay? So please stop me if you don't understand anything.

Now, anxiety disorder. Now, generalized anxiety disorder, not a very difficult uh pointer. If you guys can open the notes at this point in time. Okay. If you go to the anxiety uh box there. Okay. So let me just answer the question Leah has asked and then I'll talk a little bit more about anxiety disorder. So, when we talk about adjustment disorder, the change, okay, of either a death of someone or something big, them moving from one location to another, or um, breakup, right? Has happened within three months. That's why in all of your psych stations, you need to ask when it happened. Okay? If it's within three months, they've been feeling low. No. And they don't fulfill your depression criteria, they don't fulfill your MDD, MCD CAPS criteria, only thing there is low mood, doctor, that's all. Everything else negative, then go for adjustment disorder. But if this patient starts filling up your MC CAPS, okay, you get your five symptoms or your nine symptoms, then you know that is major depressive disorder. I hope. Yeah. Okay, got it. Cool.

Now, for generalized anxiety disorder, that's the biggest one we usually have. In this state, in this key questions would be, are you generally an anxious person? That's the best and easy way. Or do you think you worry about things all the time? Are you a nervous person all the time? Or do you worry about things people tell you not to worry about? These are typically your GAD um questions. I'm not going to spend too much time on GAD because it's so generic. In fact, AMC is testing more on the clusters within the anxiety, not really your GAD. Okay.

Now, bring you back to this map again. Reason why is under anxiety disorders, I've tried a goalpost mnemonic, G-POST. So, those are all your possible anxiety uh differentials if you have an anxiety cluster, which means they can be ruled out. If you panic and you don't know what to do, think about this GO mnemonic. Think about what are the differentials are possible in this stage and start ruling them out. Or if you can't think, you know someone is anxious because you got worried in your mood, but now you don't really know what's the diagnosis. Think about all this evident in front of you. Remember this. If you don't know what the diagnosis is, you can just say it's an anxiety disorder. So you're not saying generalized anxiety or it's an anxiety disorder. You will still pass the station compared to someone who gives you a totally wrong diagnosis. Even everything after everything being negative, you are still giving something accurate. Maybe you wouldn't score a six or seven in that station, but you can score a four and five and you will pass. That is good enough for us for that station if you think you are messing up. So go for the bigger word if you can't identify what exactly is it or the word is not coming to your head. So you know it might be obsessive-compulsive personality disorder, for example, but the word is just not coming into. It's going to happen in the exam, guys. Even for me myself, I failed my first station in my exam. Reason is because I couldn't think of the word and I gave a wrong diagnosis. Even though I knew it was wrong, just because I couldn't remember the correct diagnosis. And before it was time's up, I remembered the word. It was just atypical pneumonia, not very complicated. I couldn't remember it. It just didn't come into my brains. I failed the station. I knew I was going to fail because I said the wrong thing, even though I knew that was not the answer. So I would say if you don't know what something is, ex, tell them, I don't really know the exact name of this condition first, but let me tell you more about the condition. Maybe the name will come to me because this happened to me again in station number. I can't remember the number. It repeated again. I did know the diagnosis name. I panicked. I didn't know the diagnosis name. But I used the strategy. I was like, well, I can't remember the name right now, but let me explain to you. It will probably come to me. And actually, it did. Like I think 30 seconds later, I got it was Perth, by the way. I got Perth. I said, "Oh, wow, love. You remember Perth?" So it will come to you because you have studied so much. It's just that anxiety is just the brain block. So I know the strategy works and I know you will fail if you tell the wrong thing, even though you give the correct answer as your second or third differential. So go for cluster-wise. Go for, tell them I don't know. Now, I'll get back to you. All right.

So let's move down into OCD versus OCPD. Have a little read and then I'll explain to you the different cases that have been coming up in this station. Now, OCD, OCPD uh are under your anxiety cluster, as we both know. However, OCPD is a personality disorder. The big difference between OCD, OCPD is that your personality disorder patients do not have any kind of insight. So if you ask the question of, do you think you need help? They will tell you, no doctor, I don't need any kind of help. I'm just here to see you because my hand is injured or someone asked me to come and see you, doctor. I don't need any help. That is how you differentiate OCD versus OCPD. But most of your questions for the obsessive compulsion will remain the same. Now, you will ask me, let's say you didn't ask in OCPD station, which is what happened in my exam. The diagnosis was OCPD. Okay. But there are candidates who answered OCD and they passed the station, but they passed a four. People who ask the insight question and diagnose OCPD pass the six or seven. So it is not that you would fail the station, it is just that it is a um layers. So AMC has layers, right? The more layers you discover in the station or the more closer you get to the main diagnosis, the higher your global rating score in that station would be. That's all. Doesn't mean you would fail that station if you got the diagnosis wrong. Which is why in exams, if you go speak to many candidates, they all come with different diagnoses sometimes, but they also make it. It's not really about that they're not able to make it. So be very careful about that, but just don't give something you know that is 100% wrong.

Now for OCD, OCPD stations, questions you need to ask are there any kind of rituals that you have to carry out every day? And the key question here would be, what happens if you do not carry out this ritual? You need to get the, "I feel anxious, doctor" answer when they don't carry out that act. So I will show you a couple of questions later and we'll pick up that difference in those questions. The next question is, what happens? Oh, do you think they are rational? Sorry. Do you think they are rational? That's the other one. Do you think they are rational? And do you have any other thoughts or any other rituals that you need to do? So, let me just repeat the key questions. Oh, yeah. Any other rituals or habits? What happens if you don't do them? Do you think they are rational? Have you tried to resist them? That would be your key questions when it comes to the OCD, OCPD stations.

Now let me explain to you the different types of OCD, OCPD stations. So you have the station where um contamination and cleanliness station. I think it's the next slide. Is it? Oh, no, it doesn't. Okay. Anyway, the station where this lady wants to wash her hands all the time because it's dirty. Same. Likewise, in that station, you would explore what happens if she doesn't wash her hands. You need to get the idea that it's an obsessive thought causing a compulsive action. You need to get both of it in your history to diagnose someone with OCD. I want you to remember this concept of obsessive and compulsive act when we are doing the body dysmorphic disorder station later on. Okay.

Now, the other stations that come up for other types of OCD, OCPD stations would be the hoarding obsession, which means they like to keep a lot of things in their house. Okay, that's one. The other one is the very perfectionist people, right? They have symmetry or color coordination in their life. That's the other one. The other one that, yes, as H said, the other one is the one that listens to the king word and every time they hear the word king, they need to start clapping their hands and they need to start walking around the room. So, concept is the same. What happens if you don't do the action? Doctor, I feel anxious. Have you tried to resist this thoughts? Now, that's what you want to do in those stations. Okay. The other one is your safety checking as well. They're always checking if they are safe. Now, in my exam, the station that I got for OCPD was um this boy, every time he thought about his parents, he had to punch the wall. And I got it was OCPD, and he had other rituals as well. Can't remember the other rituals. He had other things that he needed to do, like I think every time he woke up, he needed to take his table or wash or something like that. Can't remember, but that one. But the key point here was the insight. He didn't have any kind of insight. So the minute you have someone giving you OCD symptoms, immediately go check for insight. Rule out your OCPD. Your examiner will know what you're trying to do. Okay.

Now, these are, I think I, I do have a, you, these are your OCPD features. So in someone with obsessive-compulsive personality disorder, they're a little bit more, they don't like group work. They like to do things only on their own, and they're very perfectionist, perfectionist people. So those are extra questions you can ask in your OCPD station. So the other one with OCPD is also the one where again comes with grades declining. Um, the king, I can't, I can't remember if there's OCPD or OCD station. So you need to get the insight out of the patient before you identify what type of a, uh, OCD it is. Any questions about OCD, OCPD? I'll show you the question now.

Please have a read on this question. The 35-year-old female, okay, she's a nurse. Repeated hand washing is the one that I discussed with you guys just a while ago. In this station, why do I like to show this station? Every time I, I have, I discuss this station with many candidates, they run straight into doing your psychiatry history. Yes, I know you know it's a psychiatry station, but you're a doctor, right? We, we're really good clinicians, and I believe all of you guys are really good clinicians. So, spend your time asking about the history of presenting complaints. So, how long has this been going on for? Right? And it's not about how long, it's about how frequent and how often you need to wash your hands. Is this the first time it is happening? Now, this first time is a very big and important question. Whether it's psychiatry, whether it's med search, obvious pediatrics, whichever, whichever, asking the first time is a very good question that's always usually justified in any of your stations. In this station, if it's not the first time, it's good because now you have back, not say backup, but you can go and check on something else that might have happened in the past. What was that habit? Was it another habit that this patient had? Because OCD, OCPD people can have different kind of habits going on. And then you realize that this person has been washing their hands 20 times a day for the past one month, whether they're using sanitizer or soap, whichever you identify. Your thought should be as a doctor, "Oh my, how are hands doing?" Right? Is she having any kind of skin problems? So go only one liner, any skin problems you might be having because you want to rule out your med search. So likewise in the previous station where I told or discussion, I told in my exam that I got the boy who punched the wall every time he thinks of his parents, very quick follow-up on, "Oh, how's your hand doing? Is there any kind of cuts? Any kind of fractures that might be there?" So take a pause, spend time exploring that. So even the question that H asked posted on the chat box about the candidate with the, I mean, not the candidate, the patient with the low school grades and that cause and him walking every time he has the word king, spend time on how he is doing because of his low grades or how he's feeling because of that, and then move on to your mood, sleep, appetite, your psychiatry history. Many times we run to do psych, we for yes, because it's an AMC exam, but we forget that this is just another consult. Treat it as how you would have a normal consult on a normal day. I am so sure you guys would be like, "How is your hand? Is there any cuts? Is there any dry skin going on? Is your skin peeling?" I'm so sure you guys would have asked that just because an exam, you forgot about it. Then you move on to do all your OCD key questions. Rule out your OCPD by asking your insight question and spend time exploring why um she might be, what triggered her. Again, every psychiatry station has a triggering, triggering condition, right? So why did she suddenly now go and wash hands all the time? So in this station, so far the story we have heard about is that she, uh, was in the oncology ward, or she's changed the oncology ward, or she was a surgical nurse at first, and while she was there, a child died, and now she's referred to the oncology ward. She thinks the child died because of an infection that was transmitted during surgery, and now she's in the oncology ward. She's very scared of transmitting infections to all her other patients, which is why she keeps on washing her hands all the time.

Let me show you a couple of recalls that has been coming up for OCD, OCPD. I mean, the 12th March were not very clear. This is a video. Oh, but I had a candidate on 12th March. Yeah, it was OCD on that day. But again, it was a differential station, and I remember the candidate told me, it was my friend. She told me that she loved. I didn't understand um the questions. I think we, we practiced so hard on at that point in time. March was brand new. Was when video started becoming, video was still not very popular. It's a very new thing in March. So, uh, when we were all practicing, it's all very psychis driven, not, um, video driven. But when the video came, she panicked and she was like, I don't know what the question means. I know they're asking something, but I don't know if it's a judgment or cognition or insight question. I just know that it's something to do with psychiatry. That's why be, be exposed yourself. Please go to YouTube, um, watch those videos that they have for psychiatry, MSE presentations. Get used to the accent. First of all, a lot of us struggle with English. So used to the accent, use the vocabulary, then that will give you a bit exposure about it. Uh, 14th March again, um, I think it was OCD as well. The king word and same, very similar. 8th April. Um, there has been more recalls definitely. I just hadn't had time to paste all of July, May, and all of that.

Now I want to tap on the body dysmorphic disorder station. So please have a read first and then I will explain to you the station. Again, for body dysmorphic disorder, I want you to remember this. It is part of anxiety cluster. Then it subdivides further. It's part of your obsessive-compulsive disorder, and then it is body dysmorphic disorder, which means in order to diagnose someone with body dysmorphic disorder, apart from asking them about whether they're happy with their body, whether they like, or any other kind of other thoughts they might have or want to do, you need to also identify the obsession and compulsive act. There's more than two things you need to do. You need to establish the anxiety. So in this station, how would you do this station? First of all, someone is coming to you with breast reduction, which means their breast is a little bit more bigger than us, or they believe, okay, their breast is bigger than usual. And you also read from the stem. This patient has been going to the toilet six times. So when she comes to you, first ask her, "How can I, how can I address you? How can I help you?" Tell, "Oh, doctor, I need a referral letter to go, go do a surgery for my breast because it's really big." Your first thought should not be body dysmorphic disorder. Okay? If that was your first thought, unfortunately, the recalls have been subbed into your brain. You know it's diffused into your brain deeply. Your first thought should be, is it unilateral? Is it bilateral? Is it cancer or is it pregnancy that's why her breast is getting a little bit big, or is it a mass inside that? So you should go for med search first. So people, it's a very easy decision to pass, but candidates forget the med search aspect of things. So please spend time identifying the first, is it unilateral, bilateral? Why she wants the surgery? When did this start? And then move on to talking about, now, is it, is there any kind of mass going on? Any lumps and bumps? Okay? Any weight loss? Any discharge coming out from your breast? Ex, ask all of this. Um, by any chance, do you think you might be pregnant? If you don't want to ask that question, can I just know when was your last menstrual period? Um, do you happen to be sexually active? So if her last menstrual period was more than three, four, five weeks, like really long, then you want to think of pregnancy. If not, LMP, 10 days, five days, skip it, man. Don't have to do sexual history. But if LMP, six, seven weeks, you need to panic. Now, you need to go on to do sexual history. You need to confirm that she was sexually active. Okay? Just because someone's LMP was six to seven weeks ago, it does not make them pregnant. It just makes it into a secondary amenorrhea case. Please remember that. And under secondary amenorrhea, your number one differential is pregnancy. Then you rule out PE cause, thyroid, post-pill amenorrhea, and all the eating disorders and all the other stuff. So after you do LMP, if it's more, if it's very, very long, go for sexual history because if she's LMP is seven weeks, but she's not having sexually active, highly unlikely she's pregnant, right? So go for sexual history. Then move on. If she's still sexually active, then you panic a little bit more. Then you go for pregnancy symptoms to confirm she's pregnant. Okay? You don't need a urine dipstick all the time. His history should be so good. Okay? I've always said PFE, physical examination is all ego. Go boost at the end of history. You must know your diagnosis. That is when you know you have nailed your history. And you also need to have ruled out red flags also. Okay? Ruled out red flags, ruled out differentials in your history taking. Uh, then you know you would nail the station. So otherwise, in this station, once you've done all the med search differentials, I'm not saying med search, but not the big why the breast might be big causes, then you go further. Okay, she'll tell you, "Oh, doctor, you know, I need to go and check the mirror every time." That's where you get your OCD concept out of it. So what happens if you don't go to the mirror or do I? What do you look for when you're looking at the mirror? How often do these thoughts appear into your head? Now, is there any other body parts you're not satisfied with? So, usually BDD patients, they might have other, uh, other episodes or other times where they're not happy with their body. Otherwise, it might just only be one thing at your hand that you are solving. And then you start your, then only you start your mood cycle. So, mood, sleep, appetite, history. All right.

Now, uh, what a question you asked if OCD G. Yeah, you can definitely give that as a because she would have told you she feels anxious, right? In this station, she tells you she's feeling anxious. So GAD is a differential for OCD as well. Can be done. All right.

Now, as you're continuing the history, now let's go to management a little bit more in this station. A lot of people get very confused with management. In management for people who are looking at the mirror, so first of all, go for um investigations first. So thyroid always up there for you. In this case, if she's doing anything else, so let's say you go for appetite and then you start identifying that she's, oh, has a lot of issues with appetite, she's not eating properly because she wants to lose weight, then that is your eating disorder plus your body dysmorphic disorder, right? There's two diagnoses going on there. Then you need to do more investigations like ECGs, look up for your arrhythmias, you need to go for electrolyte imbalances, you need to do electrolyte test. Otherwise, in a simple BDD station, thyroid is the only thing warranted. If she's drinking alcohol, definitely you can think about going for LFT or vitamin B12. Up to you. All right, but that depends if your sad history is positive or negative. Here, very unique to this would be the patient needs to cover the mirrors. So, usually if you look at the, in your health pathways, we would tell you to actually cover your mirrors in the when you're at home. So, you avoid going to that. And then, of course, lifestyle modifications, um, CBT. The rest are all just follows. If the CBT don't work, come back to me. Give suicide sent for SSRI. Go to a psychiatrist for any kind of SSRI. It's pharmacological. So we've run the management at the beginning of the session when we started it. So very basic management. Only difference is the um mirror that I want to tell you guys. So most of you miss out the mirror part. So cover your mirrors so you avoid looking at them.

Now, these are some of the differentials. Um, H, I have it on the slide. These are your differentials for body dysmorphic disorder or or generally someone who comes with a um anxiety, which is why substance abuse is up. I have a few of the questions you can take a look as well. Well, you will get the slides at the end of it, so don't worry. So have to go for sad history because substance abuse is very big. Please rule out your head injury as well. This is easily might have just been a frontal lobe problem. And some candidates when they see this body dysmorphic disorder station, they start thinking that maybe inside hallucination, delusion is not necessary, but I would say she might just be hallucinating this. So, one question on hallucinations. Um, do you think you are seeing, feeling, hearing things other people might not appreciate? One question enough for you to rule out that hallucination concept and not even stress you about, is this going towards a schizo case? Is she seeing something she's not supposed to see? That is what you want to do. And um, back to the history of presenting complaint or at the top of the history in this station, please ask for the bra size. Very relevant will actually tell you, is the bra size really getting big? So, even if stations, the patient said, "Oh, doctor, I think I'm getting very fat, doctor." "Oh, do you think your clothes has been getting a little bit more tighter than usual?" You want to make sure the problem actually um exists in reality. All right. Um, let me share with you other, I scribbled down other um BDD questions. So body dysmorphic disorder questions. You have the crooked nose station. Again, for the crooked nose station, please spend time establishing exploring why someone might have a crooked nose. So trauma, congenital problems. You also want to look out for breathing problems, complications of the uh crooked nose that he might be having, how long has been happening, right? Go for uh any kind of masses. So you want to rule out cancer, nasopharyngeal carcinoma, any mass that might be pushing, causing a crooked nose, you want to rule out for all of that. Any previous surgeries that might have been done causing a crooked nose, you want to go for that.

Now, if you have the other station of hair loss, so in the handbook, you have this patient who comes to you with hair loss. It is actually body dysmorphic disorder. But again, you're a very good doctor, so you're going to spend time asking them or thinking why someone might have hair loss. So in the chat box, tell me why can someone have hair loss and what would be the questions you can ask a patient who's coming to you, "Doctor, I'm losing so much of hair." It's a very common problem, especially females. I don't know how many girls we have today, but men, it's a real girl problem. Yes, PCOS, yes, nutrition, anemia can cause uh that as well. A PCOS may be more of excessive hair growth in the facial area, not really a hair loss in your hair at the top. More reasons, genetic definitely, autoimmune alopecia definitely. So more genetic conditions. So go for family history, right? Any kind of balding, thyroid, yes, can cause thinning of your hair, stress, number one, definitely all of us. I think most of us who are doing for the AFC susceptible to uh hair loss. My mom always complains. She's like, "Love, your hair is all over the place." It's like, "Yeah, ma." All right. The other reasons now, uh, that you guys might have missed, dandruff, oily scalp. Okay? Any kind of, not say medications, but products that are being used in your hair that can also cause hair. So, add that up into your differentials, right? New products used to the hair. Uh, dandruff can cause. So go for any kind of itchiness in your hair. Any kind of white, uh, dandruff that might be falling off your hair. Yes, dermatitis as well can cause. Any medications as well. So any new medications can cause um hair loss. Um, well, the other one is that, uh, there's a case that came recently where they did, it's a contact dermatitis. It's a dermatitis case, but she used a new hair dye. It was a hair dye station. So please explore if they've done anything weird or unique in recent times. Okay, people like to color their hair quite a bit in Australia as well. They're quite funky with that. So please explore that. Um, for oily scalp as well, you can say, "Have you touched your hair? Is it very oily when you touch it?" You know, you can do that. Or if you have a py, then you can explore a little bit more of that. So please go for these differentials first. Then go for, this is body dysmorphic disorder. But in that case, the guy will make it more relatable and relevant. He will take his head. You'll be like, "Oh, doctor, we'll show you one strand of hair." Be like, "Oh, doctor, look. My hair is falling off every single day." Then you know this is going towards a BDD station. Right.

Now, the other ones, let me see if I missed out anything else. Yeah, essentially these are the ones. And yes, for someone with hair loss, the other good question would be, um, has anyone else mentioned that your hair has been dropping heavily or you're losing a lot of hair? You can ask that question for hair loss. However, when it comes to the breast, if you want to make this station relevant back to the breast reduction station, it's a bit funny because not many people go around commenting about people's breast. I don't go, "Oh, wow. Yours looks really big." I, I mean, no, man. Someone probably bash me up if I end up doing that. Okay. So, if you ask the picture, "Anybody told you if your breast is big?" Because this is going to be like, "Nobody talks about my breast, doctor. It's just something that I've noticed." So, the bra size is a better question in that station. So be very careful. It will be quite funny after you ask the question, you realize it was not a really a very, was quite a stupid question. So please think about your questions. Things I want to mention in this case, this lady comes with a surgical or with a referral for letter for surgery. You can still tell her that I will write a letter for surgery. However, let us try this methods first called the CBT and then try covering the mirrors and other lifestyle modifications and see if it works. If you think it doesn't work, then definitely you can go to a surgeon. However, when you go for surgery, right, surgery has its own set of complications. You have an anesthetic risk as well. Your body has to go through under anesthesia. Your body has to go through under cuts and that might cause infections for you. So we want to try to avoid that to our best as possible. So let's see if this works first. So don't tell her no. Okay? Explain it the way that I explained. It shows that you are still patient-centered. You still love your patient so much, and you're going to scare her a little bit very nicely about the surgery and say, "Hey, but I don't want this for you because I really love you, you know? I don't want these problems for you." So we're not going to go for surgery, okay? So try that method a little bit. See if it works in your other stations. All right. Yeah, poor hygiene too harsh. That is also people have hair loss because of that.

Now we're going to move on to panic attack, panic disorder, and then we will wrap up anxiety cluster and then we'll take a little break and then we'll go for the MSE stuff. Now, for panic attack versus panic disorder, I've got a question. So, have a read on this question and then we will explore it together. Okay, first of all, if I didn't tell you it's a panic attack station, you wouldn't even know it's a panic attack station because it comes with all your med search complaints, which means in the exam, if you get this station, you won't know it's psychiatry. If you look at the task, it's not an MSSE presentation. So even in the depression station with tiredness, you can smoke your way.

And identify it is, um, psychiatry and not med search. Here, you won't know. You have no clue this is med. I mean, this is psychiatry until you realize you have no diagnosis left in med search. So it's good to not know sometimes. Here in this station, you need to rule out my, uh, MI, okay? Have to rule out MI. Have to rule out thyroid disorders because you have palpitations and sweating. You have to rule out hypoglycemia. You have to rule out pheochromocytoma. Now, in the AMC, or in general clinically, okay, clinically, there are only a couple of diagnoses. Correct me if I'm wrong, okay? Please correct me or add on if I'm wrong. A couple of diagnoses which has more than one symptom them clustered together, and that is usually your, um, hypoglycemia, pheochromocytoma, and panic attack. These three is the one that comes with a lot of symptoms going on, and the presenting complaint gets very crazy, and you now need to, uh, explore so many things. But otherwise, most of your other stations, not so much. MI as well, together as well. But otherwise, other differentials, other diagnosis, not really.

So if you, the reason why I'm saying this is because if you see more than one presenting complaint up there in your stem, think about these guys first. Your MI, your hypoglycemia, pheochromocytoma, panic attack. Rule out these guys first, and then you start exploring all the other things in your history. So in this history, you would be doing, um, you wouldn't establish confidentiality at the beginning because you have no clue this is psych. You'll be going for more about asking the episode. So when did this happen? Okay. How often does this happen? Ideally, if someone who spends time exploring history or presenting complaint, you would realize this is not the first episode. You would realize that this has happened more than one time and it happens suddenly. However, for a candidate who goes directly and says, "Oh, tell me more about the palpitations. When did you feel them? How did you feel them? Can you tap them for me on the table?" Um, well, you wouldn't be able to get the episode repeated for your panic attack, panic disorder differential, okay? So that is where, that's why I'm telling you, spending time on HOPC will help you know which direction your station is going in, and then spend time asking all your med search differentials. Then you move on.

Here, when you look at panic attack, panic, um, disorder. For panic attack, your pointers for panic attack is this: the symptoms come out out of the blue. Okay? Please remember this. Yes, you would do hemodynamic stability in this session, definitely, because you have no clue what's going on. And the minute you think of MI, Hob, uh, HDS, hemodynamic stability is up there for you. So now you would ask your panic attack questions, right? Uh, do these symptoms come out of the blue? Did you think you were going to die? Or did you think it was the end of the world? Right? And of course, what were you doing exactly when this episode happened? This is where you get your, is she at work while she gets her panic attack? Is there a particular triggering factor that gives her a panic attack? And then you now understand it's panic attack. Ask about other symptoms. So usually they have more than, they have at least five symptoms when you have a panic attack. Right? So all the ones listed here are the common symptoms that you get when you have a panic attack.

Then you move on to identify, is this now a panic disorder? So what about a panic disorder? For panic disorder, you need to ask if they are already thinking. So, are you already anticipating your next episode? Okay. Are you already anticipating your next episode? Are you worried about the consequences of the next attack? Now, if they say yes, yes, now that makes it a panic disorder station, a panic disorder diagnosis. Many people think that just because I get multiple panic attacks for a long, for more than a month, equals to panic disorder. But no, the diagnosis or term for panic disorder would be your recurrent attacks for at least one month, okay, with anxiety or future attacks. Now, that is your panic disorder station, not your panic attack. So you need to know the difference. Just because they're having it for three months doesn't equal your panic disorder. They need to be worried about the next one. That is your key factor. And the duration here will be one month. If you need me to re-explain the panic attack, panic disorder difference, let me know and I'll explain it again because I've seen many.

Okay, let me explain again. So for panic attack, I'll give you the symptoms again. For panic attack, it's your brief episode of anxiety. Happens out of the blue. You have more than four to five physical symptoms. They will tell you that, "Doctor, I feel like dying. I felt like it was the end of the world, doctor." Okay? And then these things actually, ideally, panic attack peaks in 10 minutes, subsides in 30 minutes. That is your panic attack. Now, when we go to panic disorder, very similar because at the end of the day, it's just repeated panic attacks. But the difference is this: they will be worried about future attacks. So your question would be, "Are you worried about future attacks?" And they are also worried about the consequences of the future attack. These two positive plus panic attack multiple times for, um, at least a month, then equals to panic disorder. That is the difference. So please know the difference. People make this mistake very, um, often in the exam. Otherwise, any questions? I think I have a, this is a sample question I have now.

With regards to this station, when it comes to management here, super important for you to do an ECG. You, so people here, I have candidates who do this station, they know that they've ruled, they do a very nice job ruling out their med search. Now in management, they know it's a panic attack, right? So they start diving into, "Oh, luck, it's a panic attack station." I'm, they forget about MI. They forget about everything else. So here, management investigations, ECG for MI, thyroid, TFT because you're concerned about thyroid. Then you can then explain about your CBT or your exposure and desensitization techniques that you have. Then you can move further into telling, "If you get another attack, what do you do?" So remind yourself the basic stuff. So remind yourself that the symptoms will pass off. They're just uncomfortable for a bit. It's a flight and fight moment that our, uh, our body is going into. Ask them to count reverse from 100. So count from 100 backwards. Think about your favorite song. Do breathing techniques. These are all the management you will give this patient. If all of this still doesn't work, then you can say, "I might refer you to a psychiatrist for, uh, medications like SSRIs." Okay? So that will be the management for your panic attack, panic disorder station. Any, any, any questions for your mood disorders? Was it depression? Was it mania? Was it anxiety cluster? Anxiety cluster? Quite a fair bit of things. Oh, sorry. These are the recalls that have been coming up. Yeah, I forgot to tell you about them. But yes, uh, one in 16 may come with chest pain, which means very important to do your ECG at the end of it. Ask enough chest pain. Do your Secura first. If chest pain is presenting complaint, do your Secura. Then when you realize that this has been, is it the first time? The patient will tell you, "No, it's not the first time, doctor." This is where you catch it. It's either probably unstable angina because they've been getting it multiple times because they probably exercise, or aortic stenosis is one of it. Or it can easily be a panic attack session. So be very clear with the questions you're asking. If not, let's take a little break. I'll see you guys in about eight minutes, okay? I'll put a 8-minute prompt timer up and then we will come back. Meantime, feel free to, um, ask me any questions. Um, I'll be here. I wouldn't go anywhere. Put in the chat box or you can, well, uh, you don't have to do a drop level because you 100% will know it is not an MI with your history taking. You're only doing an ECG because it can be mass MI. So ECG will be your screening. But if this patient has pain and your symptoms become very positive and you really now don't know, uh, then you can start thinking of an alpha drop level, but it's not necessary.

Welcome. Yes, Hush, I will explain this one. I actually wanted to open my mouth to explain about this differential thing. Let me just reply my messages one second, and then I will, uh, I'll answer your question. I think someone didn't join because they didn't join the link. Now I'm panicking. Okay, let me see. Okay. So for this question that Hash has asked, I mean, if you guys are around, you guys can listen to it. Yes. So you need to rule out your differentials in your history taking. If there's no task of, uh, let me, let me rethink how to say this. Yes. So if a task of differential is asked, what the examiner wants to know is whether you are able to rank your differentials in a way to make it as relevant as possible to the station. That is why they're asking you, "Give your differentials." However, if the task says doesn't ask you anything about differentials, you still need to rule out differentials in your history taking because when your result slip comes, you will realize that diagnosis and differentials was marked, and you would have scored very low because you didn't ask for differentials just because it wasn't a task. So typical as a clinician, without ruling out differentials, how can you confirm a diagnosis? You can't. You need to rule out differentials. You need to ask diagnostic questions, and then you tell someone, "This is the problem that you have." So that's what you need to do in your, in your stations. Now, even if they say diagnosis with no, don't, you don't have to explain. They'll tell you, "Mention differentials." Um, sometimes when you ask differentials with reasons, they want you to think about diagnostic formulation. Why? If not, just list them off, but list them off and rank them, please. Very, very important. Rank them. Many candidates forget to rank them, which is why even though you give 15, 20, 20 differentials, you still don't pass the station because it's not about how much you can give, but how smartly you can give your differentials. And even if you give 15 to 20, you didn't even rule them out in your history, so how can I as a doctor now think about like whether you know about it? Are you just listing off or memorizing and vomiting? So that's the thing that they're looking for in the exam. Okay, the next half will be a bit heavy, people. So please drink a little bit of water. Take a little bit of sugar. So if they just ask DDX, then yeah, yeah, yeah, just name them. Listen, the, the, the, the task in AMC is super clear. Like you won't even have a doubt. Okay, let me, let me just stop share for a bit. I'm going to send the psychiatry revision PE to those that I missed. Okay. So, I'm going to stop share for a bit. I'm going to email the rest. All right, I have to send it. Okay, two people. Three people. Oh my god, so many. Okay, if you guys haven't filled out the form on the link with your email, please fill it up so I know your email and I can add you into the notes. Um, the notes definitely has way more than what we're discussing today. Um, it has the other classes as well. So feel free to just, um, explore. Of course, please. I know you guys are really kind. Um, I know you guys love to share with people. Um, if you want, you can, but of course, I would wish you didn't. But if you did the same thing to me, in your shoes, I'll definitely share like a, take it, man, 'cause I'm just like that. But of course, uh, if they can reach out to me and they can get the file from me, I'll be more grateful to you. Okay, let me add the rest. Just give me a couple of minutes to finish this. For some of you who joined the group late and you're not in the, you didn't get, you didn't post, you didn't fill up a Google form, please text me personally. I will send you the notes. Okay. I think I filled out most of it. Yeah, that's what I missed. Some of you might get double because I feel like copy and paste is more than I should have. In case you get double, please apologies. Okay, I've sent the, I think there's remaining five of you who were supposed to send me an email. I would have just emailed you the, check your Gmails. The emails you gave me. All right, let me continue sharing my screen. Okay, we're just in time. Okay, a few of you texting me. I will send you the link, um, after. Okay. I would, I really will after. All right. Okay. I know, um, MSE is a very, um, scary thing to approach, but let me tell you, MSE is not very difficult. It's my favorite. I love MSE. So, I hope after this, you guys also love the MSE. Oh my god. Before that, are you guys back? I forgot to ask that. Just put in the chat box if you guys are back. I'll be just talking to myself. Let me know if you guys are back. Oh, you guys need a longer break. Okay. Yes, you, you're back. Okay.

Now, the MSE, um, is very important. It's been coming up super, super commonly at least once a week. The versions it comes out with is with video or with, uh, history taking. So, both of it is there. But remember this, and the reason, let the reason why AMC loves the MSE so much is because it is one of the best ways to to understand if you're actually a good clinician and a good doctor. You, because you don't only talk about or think about a diagnosis based on the history you are taking. You're also using the appearance, the behavior, everything that you see. So your eyes, ears, everything needs to be sharp when you're doing a mental state examination. And when people do the mental state examination, they start telling me things they don't see during the station. All right? Now, not necessary, because an MSE is here for you to present on what exactly has happened and what exactly you have seen during the station. I mean, during the the consult itself. So no point telling me all the extra stuff. And when you have done the MSE, the history taking, rather, you should have more or less gotten into a diagnosis for this patient. Which is why when I always explain the, oh my god, why is my mouse not moving? Not here. Yeah, sorry. Okay, I'll just reverse this a little bit. Okay, I've done this a little bit. So, not so important. We'll focus on content. Which is why when I always explain the MSE, I would tell you guys to put an introduction in front. Introduction to just very quickly tell you about who my patient is. So, I have a 50-year-old patient named Jennifer. Her presenting history of presenting complaint was, let's say, T, let's use a Tina station. Yeah, tiredness for six months. My provisional diagnosis is major depressive disorder, or my provisional diagnosis is whatever. Say it at the beginning. This is my MSE presentation. And then you start listing off, right? In appearance, in behavior, in speech, in emotions. So some of you guys might be new to, um, MSE. So for those of you who are new, let me take a step slower. This is the mnemonic we use when we want to present the MSE, right? The mental state examination. It's the easiest to memorize. Work, um, also present in Tellana, also matched it with the handbook. The, I know many candidates who have done, um, uh, psychiatry with other organizations, they might not teach you the three R at the back, but let me tell you, the three R is super important. It's, it's here in your guidelines. We do look at it very often. We, it's also there in your handbook. I don't know if I took a screenshot of it today, but it's in your handbook, which means it is important for you to establish in your MSE presentation. It's also there in Tellio Corner. So I don't know why many of us have not speak about the three R at the back. So I always say ABIC J3R. That is the mnemonic that I memorized when I use the MS for the MSE presentation. Now, let's go a little bit deeper and I'll explain to you. So, we did a lot on psychiatry history. When we hit, uh, cont, thought, content, I would take a step and explain about delusions and come back to you as, as promised. But let's take it further from the top. In appearance. Now, in appearance, or first things first, when you look at the MSE presentation, appearance, behavior, and speech. You do not need to be a doctor to tell me someone's appearance, behavior, and speech. You can pull off any medical student in your clinic, any medical student in your hospital. They would be able to do appearance, behavior, and speech. But what makes you very unique as a doctor is to tell me more about emotions and below. That is where your clinical thinking and the phrasing of your question matters so much. And the unique things you see in appearance, behavior, and speech is what you need to pick up. So, for example, under appearance, I mean, appearance is very easy. It's just telling me how the patient is dressed or what they are wearing. But as long as you say, "Patient is well-dressed to weather," good enough in generic stations. But there are stages of very specific. So, there's this acne depression case which has come up. It came up on 19th of August. It came up on 20th of March. That's the only two I remember because I've candid then. The others I can't really remember. But this station is very unique because the can, uh, the patient was wearing a black hoodie. Patient was wearing black shoes, black t-shirt. Hoodie was all put up. Now, that is very significant. One, the color is significant because they are dark colors. And two, uh, they all sit in a very stooped posture. They're all covered up. So that is key for you to explain appearance. Behavior. Not really about, "Oh, he is, uh, he's not having any kind of meal flush. He's not having any kind of, um, alcohol behaviors or alcohol use behavior." A lot of people like to put these things, but unnecessary. You don't need that at all. So appearance, only something is unique. So in your mania patients, if you have any kind of green, bright yellow, or they're wearing something very, very unique, you know, then that's something you want to mention. If not, "Patient well-dressed to weather enough," move on. Go to your behavior. Behavior essentially wraps up about eye contact, whether patient is cooperative with you, and body posture. In eye contact, usually patients with depression struggle to hold eye contact, right? Or people with anxiety, they can hold eye contact, but they're looking around. They're looking for things, right? And people who are schizophrenic, they are now responding to external stimuli. That's the word you would use, "responding to external stimuli." Therefore, they will not have eye contact with you. Yeah. So that, so now for Josephine mentioned, "My patient had food smeared on clothes." That is unique for you. That is something you would mention in appearance. If they're holding some kind of food in their hand and they're toppling all over and not being able to be balanced, maybe because alcohol induced, that is something you want to imagine in behavior. So pick out unique things that would make your case stand out, not the normal things, and don't bother telling me things that are not there. MS is presenting what you see. Then for body posture, you want to talk about stooped body posture for usually in depression patients. Anxiety patients can tend to have that moving. They keep moving up and down because they are anxious. That is unique for you to pick up, right? Or even those, uh, people who are responding to external stimuli, like they're like listening or they're looking, they look very agitated. You want to talk about those when it comes to behavior. Now, cooperation is just about whether the patient is there, responding to you as and when you need it. So, a schizo patient, they will not be very cooperative because they are busy responding to external stimuli. Okay? But when it comes to rap, later part when we talk about rap, patient can have rap with you. Rap just means I am answering your questions. Cooperation means am I delaying the answering of questions? Am I taking my time? Am I doing other things? Am I distracted? But I still answer your questions. So that's rap, but I'm not as cooperative. I still get the job done, but just not as cooperative. That's about it. So that is for behavior.

Now for speech, I know there's that a whole lot of words out there, um, but let me tell you, rate, volume, tone, enough, man. Rate, whether fast rate, slow rate. So depression patients usually, rate will be a bit slower, volume will be softer as well, tone will be monotonous in your depression patients. Now, don't worry, I know I'm throwing a lot of words, but I have a chart summarized with all of this. I will share the chart with you at the end of it, so don't worry. Then for volume, so we talked about rate, volume, and tone. I have candidates who do speak about rhythm. We are not musicians. We are clinicians. So no need rhythm, people. Okay. No need, and you guys tell me smooth rhythm. I'm like, I wasn't listening to your music. I was saying somebody talk. So be careful. Not super necessary. I, people who talk about quality. So my question is, what do you understand what you mean when you say quality of speech? And how was that different from someone having a good volume, good rate, and good tone, and me understanding what they are speaking? Is that what you mean by quality? So not very sure what you mean by quality. Yes, if you, yes, if you have dysarthria, you can talk about it, right? You can talk about not being able to pronounce words, that will be falling under speech. My patient was not able to pronounce the words very clearly, but that will be more of a language problem rather than in a problem. But you will still talk about it in the speech, definitely. My patient's words were not coherent. My patient was not able to speak very well because they were struggling to understand my language. So in aborigine patients, in your immigrant patients, definitely you will have that. It's going to be a struggle for all of us. In fact, us understanding the patient itself might be a struggle. So go case by case basis when it comes to such situations. So any questions about appearance, behavior, and speech? I don't spend so much of time because it is not very key unless there is something super unique about it in the AMC exam. If not, less than 30 seconds, guys. 10 seconds, 10 seconds, 10 seconds. You should be done with A, B, and S. No need to spend time.

Emotions is where I really need you to spend time explaining perception, thought form, thought content. I need you there with me. So in emotions, we usually break it down into mood and effect. Mood, no matter what the patient says, whatever word they use, you need to copy and paste that word into mood. So if they tell you, "Oh doctor, I feel very meh." When you tell the examiner, you have to say, "My patient claimed his mood was meh." Exactly. Copy paste. Patient says, "Oh, I'm okay." "Okay, doctor." "Okay" will be the word you use right there. So please, so for me, um, when I tell you guys, when I do MSE with you guys, I always write down what I say. Likewise, when you are doing your exam, you should write down the exact what the patient says because there are tendencies we change the word. Sometimes patient says they are worried, and then we go, "Oh, the patient is feeling anxious." Well, yes, not super wrong. Okay, if you do dive into Oxford dictionary, maybe there's a very big difference, but for me, I'm not super sure about the difference, but it's always best to use the word the patient uses. Don't go and change or into something you perceive might be correct, right? So, that is mood. And when you explain emotions, it will be under emotions. My patient's mood is, or under mood. My patient claims he is feeling okay, or patient claims mood is meh. Patient claims is low. So always give your headers first. The marking scheme is the same as the header. So the examiner needs to know where you are in your ABIC J3R mnemonic. Then you move on to effect. Now, effect is what you as a doctor believe the patient's mood to be. That's where you come in right here. You can spend time explaining a little bit more. So if, let's say, this patient was low, the mood was low, and you think the effect was congruent. So congruent just means same. Not congruent just means not same. So easy way to basic score your effect would be congruent or not congruent. But if you want to take time and spend a little bit more here, then that would be, "It was congruent because my patient had a blunted effect. His, uh, he did seem like he was depressed because of." Explain a little bit more on your symptoms that you managed to catch. So spend more time identifying why you think the patient was depressed here. But again, not more than 15, 20 seconds you spend again on emotions. Ideally, the entire MSE presentation from intro to the 3R will take you 2 minutes 15 seconds or 2 minutes 20 seconds, depending on your speed and pace of how you present it. So, practice it. Please practice MSE. If you don't practice and you do it first time in the exam, not going to work at all. You need to get used to saying it the right way. All right. I have a few candidates who say that, "Yes, love, I know what to put inside the the brackets, but now I've not practiced it before." And then when you practice it, you realize that actually you're so far from what we imagined ourselves to be. You know, the whole reality versus expectation memes you see online. Somehow when you do an MSE, those ones become to come true, you know. So please practice MSE.

Now under perception, it is all of your hallucinations. Your visual, auditory, tactile, also your olfactory, and you also have your gustatory hallucinations. All right. Here, when you talk about, you can ask the patient, "Have you had any kind of, do you see, feel, hear things that other people can't appreciate?" That is the question you would ask for hallucination. But when you present it, you need to understand, see is visual, hear is auditory, feeling is tactile. Need to make that interchange. If there's no hallucination present in that particular station, you would just go, "No." Under perception, "No hallucination present." Please do not say perception is normal. Examiner needs to know you know that perception is part, hallucination is part of perception. So you say, "No hallucinations present." And let's say in a schizo case, your auditory hallucination is positive. So you would go, "Auditory hallucinations present." But then you can explore visual, tactile, olfactory, not present. Or if auditory was present, go for, "However, there was no command given by the halluc, by the auditory hallucination." In the auditory hallucinations. So give whatever you've explored further. Again, as we explored in hallucinations, if auditory is positive, spend time identifying if the command is given. What is the command that's given? All right. So please, I go further deeper into it.

Now thought form, thought content. You would tell the examiner under thought form, explain your form. Under thought content, explain your content. But let me tell you the difference first, and then we will look at the delusions part. Now, thought content essentially, if you have this cup, if you guys can see me, I, I blocked my mirror, but thought content essentially is what's inside the cup, right? What's inside the brain? What are they thinking of? That is thought content. Now, thought form, rather, is the way the thoughts are forming. Okay, let me explain that. So, thought form is the way the thoughts are forming. So you would start saying words or using words like, "It was monosyllabic" because the form of the thought is coming in one word. Or if you can't remember the word monosyllabic, no problem. Go and say, "Oh, the patient was, the word, the thought form was in one word." The examiner will understand what you're trying to mean. So don't worry if you can't memorize these big words out there because there are multiple ways to break it down and put your point across. Just maybe a bit longer you will take, but no worries. I would rather you take longer here than to stress, panic, and don't even do thought form, thought content, and not clear your MSE station. So I would prefer you to go for the longer version if you can. All right. Other words you can use are flight of ideas. So what is flight of ideas? So their thoughts are forming in flight of ideas, which means they're thinking of all the different things. That suddenly I'm talking about A, suddenly I'm talking about C, then I go back to B, then I go to Z. That's what flight of ideas. Very common in your mania patients. Okay, mania patients will have flight of ideas. They'll be talking of so many things. Now, loosening of associations in thought form is this patient is not in touch with reality. Their their thought form is not with reality. Usually for schizo patients, you use loosening of associations. So that is thought form.

Now for people who are confused with thought and perception. Okay. Perception is where your hallucinations are and where your illusions are. That's how the person, okay, perceives the world to be. How do they think the outside world looks like to them? So whether it's colorful, whether it's visual hallucination, that's how they think it might be. Okay. But that's not reality. But thought form and thought content or thought, rather, is how the patient is on their own. What are they, what's happening inside their brains? So perception is how they perceive the outside world to be. Thought form, thought content is how the, they themselves are. That is the difference. Many people get confused with this one. So if you think about this way, you wouldn't be so confused. And now let's go into thought content. Now, thought content includes delusions. Any kind of suicidal positives that you get goes under thought content because this is what's happening inside their brain. This is what they think is happening. So my next slide, um, Josephine, I think you asked a question. I am doing MMS later. It's the exact same question. So we will ponder about it then. Now for delusions, uh, some of you asked about delusions just now in the chat box. Can't remember who it was, but anyway, these are the various delusions that are out there. In a schizo case or in other cases with delusion, one, if one delusion is positive, I would encourage you to spend time exploring the other delusions. More likely, you might have more than one, and you need to show the examiner you know how to rule out and identify the different delusions. So if someone is about paranoia, about just paranoia, right? Someone is spying on you, someone's looking at you. So the question would be, "Do you think anyone is spying on you?" That that question should be enough for that. And they'd be like, "Oh, doctor. Yeah, they're spying on me. They're planning something big against me, doctor. They want to kill me and all that." And if they tell you they want to kill me, now that becomes paranoia plus persecutory, both of it, right? Because this person is also trying to harm you. So, you have to listen super carefully to the story the patient is telling you when it comes to delusions. Then, grandiosity. Usually for mania patients, you have grandiosity, or even for schizo patients, they can be grandiose. They think that, "Oh God is talking to me. I'm the best in the world." So these people believe that they have very high powers, special powers. They are God, in fact, or they are the child of God. Those are the words that you'd be using. Now, we did discuss a little bit about thought insertion and thought broadcasting. So in insertion is the one. Anybody, so you can ask, "Do you think anyone is putting thoughts into your head?" Wait for the answer. What about thoughts being broadcasted out into a TV or a radio from your head? Pause. Wait for an answer. Okay. For ideas of references. Usually when you shoot your, uh, paranoia questions, uh, these things will start to come. "Oh, doctor, do you know they're all doing this against me? They're all talking about me." So paranoia, persecution, and ideas of references can usually come together because it's like, "Oh, they are spying on me, doctor, because they want to kill me, doctor. They're also talking about me, doctor." Three different things. So please know the differences. The more layers you identify, the higher scope. That's about it. Um, usually in depression cases, you won't have grandiosity. You won't have, um, paranoia in these stations. In depression stations, I would recommend you to just screen your maybe thought in, thought broadcasting, if it's easier for you to ask or find a question, one question easy for you to ask, memorize that, and then throw that under delusions. If you think this is a schizo case, unfortunately, you have to dive into every single one. But in schizo, please, you have to ask everything because you just don't know what's going on in these patients. Any questions about delusions? If not, I will continue the mnemonic.

Okay. So, we did, um, thought form, thought content up till that we've done. Now, for insight, we discussed again in the history. So, these three we tackled in history. Yeah. How would you present insight? You would tell them, "Insight is impaired." Okay. "Insight is not intact." "Insight is poor." I, these are the same words you can use for insight and judgment. Intact, poor, impaired. These are the words. Please don't say, "Inside." Okay. "Inside good." No, give better words. Present, absent. Use these good words that you have. When you go for cognition, we talked about it. You have to say under cognition, "My patient is under cognition. Patient is oriented to place, person, and time." Now, for example, in the schizo case, I did discuss about your patient would not know. Let's say, "What time is it?" He goes to your doctor, "There's no, there's no windows here. How would I know what time is it?" Let's say you, you just panicked and you left it. So here you would say, "Patient was oriented to place and person. I couldn't assess time." If you're not able to assess something, do not give a random answer. Just be very honest and go, "I was not able to assess." Sometimes in your history taking, you forget your judgment question. Now, just because someone has insight or doesn't have insight doesn't mean you can immediately feel like, "Oh, this person has insight, so maybe they have good judgment." No, it doesn't work like that. Or this patient's insight is poor, so maybe their judgment is not good. Without asking the question, you could never tell the correct answer for judgment, which means if you didn't ask a question, go for judgment. "I was not, under judgment, I was not able to assess." Okay? And then move on. So I have a few candidates who start panicking because they realize that they didn't do insight, cognition, judgment questions in the history because they were exploring it. And then here when they come, they panic. They're like, "I didn't ask." So they stop. They stop at thought form, thought content. They wrap up their MSE. Now, that candidate will definitely get a lower score compared to someone else who saved themselves and said, "Insight was not assessed. Insight, cognition, and judgment, I was not able to assess them." Now, the examiner knows that you know these things exist. The examiner also knows that you were not able to assess them, and you know about it. And then you move on to the three Rs.

Now, these three Rs is risk, rapport, and reliability. Sorry, Anisha asked a question. In depression, well, in depression, usually you don't have any kind of delusions. So you just find one question that you like under delusion, keep that as your screening question and ask about it. If not, um, if you think it comes with psychosis, then unfortunately, you have to start as exploring more on your delusions. Now, when you talk about the three Rs, risk, rapport, and reliability. Risk, it is just not the diagnosis being a risk. If someone has suicidal ideations or suicidal plans, that is a risk. If someone has been drinking alcohol for long term or just chronic or alcohol abuse or substance abuse. Now, that is a risk. I want to take a pause here and explain to you about, uh, alcohol. Someone, alcohol abuse is risk. Your follow-up question in psychiatry stations should be, "Are you aware of the safe limits?" Reason is, someone who does not know the safe limits is also another risk factor. It's also another risk for you here. There's two risks under alcohol. Now, drugs is also a risk. Of course, smoking is not a risk. Well, smoking gives you lung problems, but it does not affect inside, does not affect judgment, does not affect your awareness. That's why smoking is not a risk here. Not having support is a risk. So please do your heads assessment, identify the amount of support that they have. No insight is also a risk. And please, whenever you say someone is at risk, explain why they are at risk or what pointers do they fall under. All right? And here, for example, in the depression case, um, the tightness depression case, which I showed you, that lady, she has suicidal ideations with no plans or previous attempts. So when you explain risk, it will be under risk. "My patient has suicidal ideations with no, uh, plans or previous attempts. My patient has also no insight and no support because she lives alone and she does not think that she needs treatment at this point in time." And then further develop a little bit more. "My patient also does not know the, uh, does not know the safe limits of alcohol, making it a further risk." Which means, um, even negligence as well. So self-negligence, that's another one that all comes under risk.

Now for rapport, it's very easy. As long as your patient answers you, okay, that means you have rapport. So you think your patient's answering all of your questions, you have rapport with that patient. So not very difficult. And let me just tap back on the difference between cooperation and rapport. So in under behavior, we talked about eye contact, posture, and cooperation. A schizophrenia patient can answer all of your questions, but the fellow will be looking here, finding for the voice, looking, talking to God, left and right. So he has good rapport with you, but he does not have good cooperation with you. So that is the difference between rapport and cooperation. Very subtle, but very interesting difference. Now, reliability. When you are a, when you are a patient, or when you're a doctor, sorry, when you're a clinician, I got confused between role player, clinician, and doctor, and all of these things. Now, when you are doing reliability as a doctor, okay, we always, always love history. Doctors love history because if you look at all, if you look at what's his name, anyway, all of your textbooks, or one of the textbooks, they have said that 80% of your diagnosis can be gotten from history. Beyond that is just confirmatory. Told you with history, you know your answers all the time, which means even if a history is reliable, or history is not reliable, you would still get collateral history. So, for example, in a case, my, the history from the patient was reliable. However, I would like collateral history from, we will talk about who this from is, because I want to better manage my patient. I want to better manage and diagnose my patient. Now, this from here, there are some cases where their parents will be involved. The parents will come to you and talk to you about it. There are some cases where the policeman would have brought the patient in. There are cases where the nurses will be there for you, or in some cases, they will tell you that, "Oh, doctor, you know, I went to work, I was tired." So you can get collateral history from the colleagues as well. So explain who you'll be getting this collateral history from. Don't just say, "I'm going to get collateral history." So if it's not reliable, of course, you need to explain who else you'll get it from. But even if it's reliable, so the history was reliable, but I would like more from, then explain who and then wrap it up. Well, well, if it's not reliable. So, patients who do not have insight, patients who are hallucinating, then it wouldn't be very reliable in the history taking. So, those are your situations. It won't be reliable. It will be very clear to you. Um, the patient also won't give you a lot of story. They like, "I don't know, doctor." "Oh, man, it's cool, doctor." They'll be so chill about it. They won't even bother answering your questions. Then, you know, nothing about it is reliable. You didn't really get any story from it. So, you need collateral history. Okay.

I hope I answered your questions. I'm going to leave. Any questions about the MSE? I'm going to do a wrap-up on it. Then I'll go through a couple of questions that are out there for you and show you a slide for it. Ideally, you would be asking your history in your MSE stations. Go for your presenting complaint. Rule out the organic causes and think of a few differentials. So when we discussed the psychiatry history, we learned how to put differentials very smoothly inside them. So under sleep again, you go for your early morning awakening, you go for your, uh, any thoughts keeping you up awake, and your nightmare flashback questions. Now, when you go for heads again, same mnemonic up there for you: home, employment, education, activities, and all of that. Sexual history again, I wrote social. I don't know why I changed it to sexual. And suicide. I think because I thought social was already covered under home and employment. So I changed it to suicide. And I'm so scared that you guys might forget suicide. Please don't ever forget suicide in any of your psychiatry stations. All right, very, very important. The minute you talk about suicide and you do a red flag about it, patients love you very much, or the examiners love you rather more than the patients. In the introduction of your MSE, you would be talking about the name, the age, the presenting complaint, ideally. All right. I know most of. So for you guys who have exam in September, okay, exam in September, don't bother reading doing the positives in heads and risk summary in your MSE presentation. You can still pass. But if you want to be super perfect, your exam is in October, you haven't gotten a date, or it's in November, I would say please, please spend time doing a bit positives in heads. So example, "My patient is a chronic alcohol abuse," or "My patient abuses alcohol and my patient uses drugs, recreational drugs. My patient is at risk because my patient has suicidal ideations." And then you move on explaining. But then, introduction should not take more than one minute, please. And I would say when you're, for me, when I, when I had an MSE station in my MSE station, I had six minutes to take a history. When I started, when I asked my patient's name, I already wrote the mnemonic ABIC J3R. All right. And then I, before after the six minutes prompt timer, I did not rush to tell the examiner the MSE. Instead, I re-looked at my mnemonic. I make sure that my mnemonic was right. I make sure I filled up all my pointers and I knew what I was going to say. So, don't worry or don't stress about taking that 10 seconds for yourself. That's only going to make you more stronger when you're presenting your MSE to the examiner. So, once I knew I was confident, I knew all my answers from MSE, then I turned my chair. I turned my chair, I looked at the examiner, I said, "This is my MSE." And then you just read it off very quickly. Right? This way, you, in fact, preparing more saves you time in your presentation because you're not panicking. That is the difference I want you to understand. So don't worry about taking time for yourself. So at this point in time, I want to show you, um, uh, this thing. I have this chart. I would definitely send you guys this chart. It is, I would, I need to make it a little bit better because, um, I've learned a few more things about, uh, perception and words to use. So I would change them.

But ultimately, when you go for a presentation of MSE, these are your different cases. You have depression, mania, PTSD, OCD, schizo cases. And these are the common words you can use. Hard, different. I will send a PDF copy to you guys, so don't worry. But I'm going to edit it a little bit more because I was not happy with, uh, see here, I wrote good, intact, and all. I think I was rushing. Uh, I want to put better words in these ones. So please don't take a screenshot of it yet. I'll send it to you by tonight or tomorrow. Um, words like impaired, lacking, they're all way better vocabulary to use when you want to explain your judgment and your insight.

Um, I have talked a little bit about risk here. If you go further inside, I do have PTSD pointers. I do ask you key points that I want you to take note. So, in this station, you need to rule out your OCD versus OCPD, which we discussed just now. So, those things will be present in your in these things. I also think I've shared this file. I can't remember, actually. Okay. So, I will share this. Don't worry. We'll go a little bit deeper into. Yeah. Someone asked, "All of these four steps need to cover psych?" Well, um, history and heads, yes. But the intro and abic J3R that I'm mentioning is for MSE presentation in specific. So, history was what we did before when we started our, uh, station today. So, I want to show you a couple of recalls. So here is a depression station. Let me just make it big for a bit. Oh my god. Why? Ah, here. So essentially, this is what you would say in a depression station. Very similar to the table I showed you. So, no, no worries about it. Um, Anisha, well, no, not enough. You need 2 minutes 15 seconds if you want to do intro plus MSE, which is why you are usually given a. But can be done. I've done it before, but you need to be very clear when you do it. No extra things, only what you need to say has to be inside. Then you can do it in 2 minutes. So I would say that's why I say practice so important.

Now, these are the recalls which have come out a little bit for depression stations. These are with history. Oh, forgot about that one. Yeah. So these will be the key things you want to mention. Uh, this is the difference I want to show between, uh, depression and mania. These are the different words that you can use. But ideally, the table that I'm going to give you will will cover that. So now, when you look at MSE stations, if you have six minutes, prom timer, 10 minutes, not 10 minutes, guys, 10 seconds to yourself. Make sure you're perfect in your. Then you start vomiting everything very clearly, very loudly, very confidently. Then you can do it in less than two minutes. If you know what you want to say, you can do it in less than two minutes. The reason why we end up taking more than two minutes is because we don't know what to say and we are thinking. But if you plan ahead, there'd be lesser thinking. That's why I said this exam is, you have no time to think. It's all about execution in the AMC. All right. Okay. Any questions about MSE before I dive into MMSE? Any questions before I dive into MMSE? People, no break, please. No break. This is the previous slide. Yeah. So, uh, recent times they have changed. Oh, they have changed the way they ask MSE stations. They do ask for the video, but it's a good mix though. I see an even balance between every month, a good balance between, um, videos and non-videos and normal history taking. Whenever I get lost, I always go back to this mind map for psychiatry. So, please, if you can find this, as a, always have a spot for you to go back and revise. So even before your exam, if you can look at this mind map, you can say everything out here. You know all the differences, you know the diagnostic criteria. Man, you are acing your psychiatry. You don't have to worry about psychiatry at all. Okay. So we talked about MSE. So this is a very quick. I have that in this. I'll send you all different slides, not a worry. Now, let's talk a little bit about mini mental state examination. But any questions so far though? Is it clear? They're confused? You can let me know. If not, we will go on. All right.

Now, the MMSE is, um, very interesting on its own. It, there's a couple of questions. Let me just. This is a sample question which, uh, someone posted just now. So please have a read while I find my slides back. Loosening of associations. Joseph, that's another one you can use for schizo. Uh, monos, form. Ideally, most of the patients are actually linear because there's no issues with their thinking, to be very honest with you. There's no issues with them. So, they would just tell you, um, they are fine, and it's usually linear. Only if it gets abnormal, then you want to talk about the other thought forms. But if I can find more, I can't remember off the top of my head, but if I can find more, I will. I will add it into the, uh, chat. I'll send it to you guys. And this is a station one of our doctors posted in the chat box just now. Quite a lot of things going on. So, which means you need to know how to explain what an MMSE is. You need to be able to perform the MMSE. Many people ask me, "Do I need to know the numbers, love?" So, um, yes, I, I would say you need to know the numbers. Reason is because and the scoring of it. Not because you need to score. So, so far, they've not asked us to score in the MMSE, but in some stations, they give you the scoring of MMSE, and if you don't know what it stands for, then it's so difficult for you. So, later at the end, I will give you a chart on the scoring system and how to easily know the numbers in in one chart. Okay. Well, we'll take that in a bit. Now, this is how this is essentially what the mini mental state is all about. Things that you need to remember, only a few key points. Okay, don't panic. You just need to know it's a bedside screening test. It is for you to identify if someone is having any acute, uh, delirium or any dementia that might be going on, chronic or acute condition going on. You want to check their cognition, orientation, attention, and registration. When you're doing this, it will take just 10 to 15 minutes for me to 5 to 10 minutes for me to run this test. And you tell the patient, it is scored upon 30. Are you happy for me to continue? You need to, you need to get consent from your patient to do this because it's still psychiatry at the end of the day. It's a testing. But before you start your MMSE, you need to ask the patient, apart from consent, are you having any troubles with vision or hearing? Reason is because in the MMSE, you, there'll be a point in time where you need to show the patient to read something. So vision needs to be good. You're also going to ask that, essentially, you're asking them questions most of the time, which means they need to be able to hear you very carefully. Make sure all of this is sorted, and then you go present, and then you start doing your MMSE. So once say, "Are you happy to continue?" and then you start. Here, when you're doing the MMSE, many times candidates like to add a lot of, I'll put on the slide first, like to add a lot of their emotions inside the MMSE when they're presenting, like, "Oh, very good, you're doing a good job." But remember this, at the end of the day, if you want to think about accuracy, how accurate are you? Or how accurate is your MMSE number one for patient A and your MMSE number 15 on patient, whatever D or C? You, there needs to be some kind of accuracy, some kind of similarity. There shouldn't be any kind of biasness. And if you are going to start giving comments in the middle, does it make your test accurate? It's going to make it biased. Now, you're going to start distracting your patient. So I would say when you are doing it in AMC, do not try to add your opinions inside while you are doing it. However, in reality, patients need encouragement a lot. In reality, they take breaks. Even they get so tired. I, I remember I did a cognition once. She got so tired. She's like, "Can I sit?" I was like, "Yeah, sure. You can sit." She waits for like 10 minutes. I come, I see another patient. I come back, and then I do the, I continue the MMSE. Of course, that thing is not supposed to be done ideally, but we have to adapt in reality. But in the AMC, you only have 8 minutes to pull this off. You have no time for those kind of drama that your patients will be doing. You have very cooperative patients in the in the AMC. Then you proceed.

Now, the first part of it, you'll be doing your orientation. So, "Just go, I'm going to be asking you a couple of questions. Just answer me as you can." Then you start. "What is the year? What is the season? What is the day?" So don't go high low. Just go monotone, normal, normal tone, like how you always talk. "Where are we?" And then ask your questions one by one like this. Please do not skip a question. Every state, every one of them is scored. So, five points, five points, 10 points for your orientation. Usually, orientation, if it's off, then that will be your delirium stations. So, find the AMC orientation is not off. You have good oriented cognition patients. Here is where the problems start coming up for you in the exam. Registration becomes a problem. Under registration, you got to say name three objects. I'll be naming three objects. Okay? You have to name three objects and take one, and you take one second to say each, and then you ask the patient to repeat them. Now, there are different, there are two sets here. It's not two and three like a follow-up. There are different versions of MMSE out there. So please use the one that you have on the day during the exam. The one on top is from the handbook. The one below is from the online website of, uh, some psychiatry website PDF Australia, something, I think dementia or something like that, or standardized mini Australia. So please know they're different versions, but you need to adapt to both. So in the first version, you would just go, "I'm going to tell you a few words. You got to repeat them once I'm done." So you go, "Apple, table, coin." Then you get your patient to repeat. If your patient struggles, right, the patient goes, "Apple, table, I don't know, doctor." You should not go, "Coin." Instead, you should repeat again from the beginning. "Apple, table, coin," and wait for the patient to repeat all three at one go. Okay? That is the first version of it. Now, if you look at the bottom version of it, the words used is, "B, ball, car, and men." In fact, you must understand the handbook was published about 20 years ago. That's the older version of it. Scientifically, okay, a bit of science here. The lower one is more of the, uh, updated version of it. The reason why they use words like ball, car, men, bell, ja, fan. Apparently, the brain recepts to this all, R, and all RN sounding a little bit more differently. They are one syllable words, which is why they put it up there for you. This is the updated, more scientific version of it. So go for, "Ball, car, and men." Repeat, maximum, I think here they wrote it. I can't remember. I can't remember if it's three or five. Yeah, maximum of five times. So do you see here at the bottom, "Josephine, allow 20 seconds to reply. If person does not repeat, you need to know how many times and only a maximum of five times, but you need to score them only on the first attempt." So if they only, so this one is scored usually over three. So if they say only one word, then only one over three or two over three depending. So only score them on the first attempt, but maximum five times. That's why this version is a bit better. There's a newer version. In fact, that's the older version. Not enough instructions were given. Doctors a bit left loose when they had the older version of it. And the words have also been changed. So I, I prefer the newer version, actually, to be honest. So repeat, and the reason why there's repeated use words, they're bell, jar, fan. So please, I have candidates who are really cute. They go, "Ball, car, men," and I'm like, "Ball?" And they, "Okay, next word, bell, jar, fan." So it's not for you to change it like that. It is just in case the patient comes to you in reality, right? They have done the MMSE with one doctor 10, 20 minutes ago, and now you got to repeat the MMSE again because it probably was inaccurate or they've come back with some problems or it wasn't completed. Then because you're afraid they might remember, you want to change the set of words, refresh words, that's when you pull off the bell, jar, and fan. If not, stick to your ball and man. If you're doing it for the first time. This is under registration. If your patient struggles with this, it'll be a problem. Registration. The next one is attention and concentration and recall. Yeah. If your patient either, you're going to ask them to spell. I prefer this one, spell "world" backwards. If they, so depending on the number of wrong words they spell, you would mark them accordingly. Well, you can use this one. Oh, wrong one, sorry. You can use this one, though. Uh, take seven and minus them from 100. I am not the strongest in math. I will be thinking together with the patient. So I think "world" is easier for me. But if you are a math person and you like numbers, please go for the serial sevens and ask them to take seven serially minus from 100. I just struggle with it. That's all. And again, you have to wait for them to go five batches because the "world" is also marked upon five, which means you need to reverse five times. So you go for 93, 86, 79. I honestly don't know what's the next one. Uh, 71. Yeah, you go for that one, and then you put 70. Yeah, 71, and then you put them there. Even that is wrong. 9 minus 7, what's that? 2. 72. So that's the reason why I don't pick that station, guys. If you struggle, don't be like me. Okay. Now, for recall is the when you're going to ask the patient to remember. So, "Can you please repeat the three words that I told you just here?" You will just ask them once. They don't remember. It's a zero. They remember all of it. Fantastic. Three upon three. That's how this part is marked. Any questions? So, I mean, any questions, just post in the in the in the chat box. If they cannot remember with five repeats, I will give Neil for registration. Let's reverse back a little bit. This question. Now, for registration, remember this. You're only going to score them on the first attempt. So, if, how do you get three points? So, if they, of course, me and you will get three points because I will tell you, um, "What's your name?" "Amisha." "Amisha, please can you repeat these words after me? Ball, kind, men." And you will tell me, "Ball, kind, men." Very good. Three upon three, first attempt. But however, if now you go, "Ball, her, laugh, I can't remember the other two words." Then score one. But then because you need to repeat this thing for, or you mean for the world, I'll, I'll explain that to you. Uh, you need to repeat this so many times. You need to five times to get your next recall right. For "world," it's hard to get, um, three for "world," three because you spell, you see W to use my brains, guys. Wait, because L is wrong. W is correct. What else is correct? You would mark them for the number of correct words in the correct position. So if you look at number five, everything is correct. The number of correct. So for this one is three because L is in the correct place. Uh, is it in the correct place? No, it's not. W, please, guys, do the math. But yeah, three words are in the correct position and three and two words are not. So the words are correct. You give the pointers. Yeah, because only L and O is wrong, right? The rest are correct. So that's why it's three because your W, R, and D is correct. That's how you mark your "world." So I usually write and then I will tick because I can't see and understand it. I will tick as they say it. So if you need to do that, please do that.

Now for language, language is very easy. Um, just follow the instructions. Usually, they won't have any problem in language unless their Broca area is affected. But so far, don't have stroke, only your problems in languages. So go for "Name the following." So you have a pen on the, you would have a pen, you would have, you would have a watch. They would change. They might change it to something else that will be there around you. Paper, maybe a watch because you're looking the timing. You don't have any clocks in the AMC. Have the patient repeat. So you say, "Please repeat after me. No ifs and ifs, ends, or buts. Say it exactly." I have candidates who miss that entire station or entire step. So please try not to do that. Now for the part number C, you have to write. "Okay, close your eyes." On the on the on the paper. Part D, sorry. You write, "Close your eyes." In capital letter, face it to the patient and ask them to, uh, do what they see. Some of you guys are really cute. You put it in front of you. Doesn't make sense because now you can't even see the patient. So put it as a side of you so you know what exactly the patient is saying. And the patient actually closes their eyes and get them to open their eyes after that. Cuz you guys forget about it and you continue doing on your MMSE without telling your patients, "Please open your eyes." "You can open your eyes." Now the last part, this is another version of the language. There are quite a few versions. This version is a bit more clear. This is a newer version. In fact, it gives you very, very clear instructions. Even in fact, tells you what exactly to say to the patient to avoid any kind of biasness going on here. So same thing that's repetitive or whatever I said.

Now, the one thing that I want to tap on here, some stations require you or there are some, um, uh, tasks which tells you, "Please assess the frontal lobe functioning." And the MMSE, then you know it's going to be a bit difficult if you don't know about this, you're not going to be able to do the station. Here, you need to ask the patient to name, okay, words. I usually always say, "I'll give them an alphabet and I'll tell them, name as much as you can if animals or fruits or vegetable." I'll give them the category. I find that easier, even for myself, to find the the words. So the first one is, you give an alphabet. You tell them to name as many as possible. Okay? Or the second one is to, you can use the animals, fruits, or vegetables way easier that you can buy in a supermarket. And then you move on to telling them about proverbs. Uh, if I'm not wrong, you can find these proverbs in the notes that I have there for you. This thing, "Bird in the hen is worth," I can't see, "is worth two in the bush." To be honest, it took me very long to understand that. I prefer using other other ones. So, I'll show you that a little bit here. So, I have a couple of proverbs that you guys can use. And the, of course, ask something that you already know the meaning of. Don't ask something that you don't know the meaning of it. I like, "Don't cry over spilled milk." Very easy. "Don't, early bird catches the worm." But the one that they have provided in the exam is, "A stitch in time saves nine." It just means that if you do something immediately and quickly, you save all the other or you prevent all the other bigger problems that can happen later. So that is one thing, um, to note of. So it's a bit of English, unfortunately. I know that many of us are not very strong with English, but just have to remember these, guys. Sorry. Sorry. It's a bit difficult. I understand. Here you need to ask the differences in your patient. So ask them to identify differences. Usually, the one that I like is a bird and aeroplane. So, "What is the difference between a bird and an aeroplane?" Or and differences. If not, you can use all the other options here. Apple, banana, table, chair. As long as they give you about two to three, and you, you know that they know it's a different, good enough. Frontal lobe is working. Then you move on. The last one, people get confused about, is the motor sequencing test. So you need to do the Luria three-step movement as fast as possible, as back to back. This is the one, fist, edge, and then palm. So, fist, edge, palm. So you need to keep repeating that a couple of times and check that with the patient. If you don't know this exists, you will struggle with it. So I put a picture for that for you to understand how it's done. So if the MMSE asked you about frontal lobe, you need to add this on. Sometimes they do ask you. So if you don't know, it'll be very difficult. Any questions about the MMSE? And I'm going to go back to the to the question. Did I put it back? Yeah, I didn't. I didn't. No, no, we're not ending. Let me go back to the question. So, in this question here, you would realize that she has a problem with her recall. She has a problem with registration. She also has a little bit of problem with her attention because she won't be able to spell the word "world" backwards correctly or accurately with a lot of points. Here, your reasons are most likely because you have an alcohol-induced brain injury that has caused this. That's your number one cause of why this might be happening. And then you would tell her, however, you also have, um, uncontrolled DM, uncont, because you are non-diabetic but you haven't taken your medication. It's a possible cause of why you might be having this. And then you move on, dementia. So, old age can be another reason as to why you're having these, um, discrepancies or abnormalities in your MMSE. Um, yes, harsh, unfortunately for frontal lobe, you have to perform everything. That's why I said if you don't know, super difficult. You have to supplement them with one. So, it's either verbal fluency or semantic categories, which I prefer this one, the animals, fruits, and vegetables. Then you need to get them to check their prob. You need to know differences between, um, bird and, uh, aeroplane is very nice. Then you go for motor sequencing. All four have to be done. It's just not. This was taken from the handbook. This slide, this screenshot, which means AMC, they have been testing you before, though it's not, it's not new to AMC. Frontal function of MMSE. Any questions for MMSE? If not, we will go to alcohol and smoking counseling. I know it's a bit heavy. I will wrap it up in a couple. I might exceed by about 5 to 10 minutes, but if you guys have done many sessions with me, you know that I struggle to to stick to time. That's my biggest struggle is to, but I can do it in the AMC exam somehow. It helps. All right. So for this one, um, let me just open my slides on my side. Okay. This, yeah. I can ask about the registration and recall. Yeah. Yeah. Yeah. Go ahead. It's Josephine. So, like, if I give them the three words and then the first attempt, they don't remember any, I give them zero. Yeah, correct. Zero. Okay. But I keep going until five repeats. Okay. You keep going until five repeats, and then I ask them after some. Oh, until they remember all three. The goal is they need to remember all three. Reason is when it comes to, so this is registration, right? When it comes to recall, they need to say the word out loud again. So you need to make sure they've memorized it. But for recall, you only ask once. Okay? For registration, maximum five times. Make sense? So if, if I ask them like, at after five, after five repeats, then I ask them at after some time, and then they don't recall any, I just give them zero also. Zero, zero, zero. Oh, you have a very. Okay. Yes. Zero, zero, all of it. Thank you. No worries. All right. Uh, now for alcohol and smoking counseling, I will, I like to do them together side by side. So you have to pay a little bit close attention because we're talking about both. But of course, the details, I will do it separately. All right. So we usually take the 5A approach, um, found on teleconer, found on the handbook as well. They like this approach. Even, even if you look at health pathways and guidelines, they do divide it into these different forms for the, um, alcohol and smoking counseling. Now, you would ask me, what do we really ask about? The difference between alcohol and smoking is this. Alcohol, as we discussed, is a psychiatry concern, which means you have an alcohol counseling station very widely with history taking. You need to first establish his health problems. You need to get his sad history, which you can either do an assess or in sad history. You need to ask about his mood. Mood. You can skip sleep. You can skip appetite, but you have to go to insight, cognition, judgment, delusion, and hallucinations because alcohol affects all of them. Then you move on with head assessment, and you will add trouble with law in such a station. However, in smoking, you don't need to tap on your, uh, what is that thing called? On mood, on psychiatry, because smoking does not really affect psychiatry, does not affect your judgment, does not affect your cognition, none of that. However, the things you would add on in the smoking history taking would be your CVS risk factors. Spend time ex, ask asking a little bit more about DM, hypertension, your, your lung cancer questions, more of that. Now, people do struggle to do transitions when they have counseling stations with history taking. So, for example, this session can come with, "Oh, doctor, you know, I want to stop smoking, but I don't know. I came to talk to you about it." You can easily go, "Let's talk about your general health. Tell me more about it. How is? Do you have any kind of breathing problems?" Like, then go, "Any kind of shortness of breath? Have you know any kind of loss of weight?" Or you can go for, "Any kind of cough? Any kind of sputum that you might have?" Then you explore further. So make that transition very smooth. People just go dive straight into it and, "Okay, do you have shortness of breath?" Tell the patient why you are asking such a question. It's a bit more smoother when you do that. All right. Then we move on to assess. This is the most important part in the entire counseling station. There are cases in the AMC which comes with "Assess." "Assess substance abuse." That's it. That's your task number one. Then task number two is, "Discuss diagnosis." Here, you don't have to do ask, you don't have to do advice, no need. Assess, arrange. You only have to focus on assess. But assess divides into dependence, tolerance, and motivation. So for dependence, we will explore. It is different for alcohol and smoking. So I'll do that step by step. But essentially, it just means how, um, dependent they are on their smoking or their alcohol. How much they can't live without it. Then you go into tolerance. Tolerance is very similar for both alcohol and smoking. It's just, "Do you think you have needed more over the time, over the time of years, or from the time you started? Do you think you're drinking more?" So the guy would have drank just one glass of wine. Now he's drinking eight glasses of wine after 5 years. Now that is becoming less and less more tolerant to the, um, uh, drink as well. Motivation is the same for both. On a scale of 1 to 10, one meaning you're very motivated to quit, 10 being, oh, sorry, one being you're not motivated to quit. 10 being you're very motivated to quit. Where do you stand? That will be the question you would ask for motivation. So tolerance and motivation is the same for alcohol and smoking, but dependence will change, and we will explore that in a bit. So, not no much issues, but now, how do stations change and how does your consult change if someone is super motivated to quit? You don't have to spend so much time advising about it. Like, "Oh, doctor, 10 upon 10, doctor, I want to quit, doctor." No point telling them, "Oh, alcohol is bad for you." They already know it's bad. Your job is to skip and go to assist and arrange. And I'll start telling them, "Okay, now you, you're 10 upon 10, how do we move on and how do we stop?" But if your patient now tells you, "Oh, doctor, my wife is the one who wants me to quit. I, I don't want to quit." Maybe it's a one, doctor, no motivation. Then your job is to get this patient motivated. So direction of consult changes. You now spend time looking at advice. You need to tell him why it's bad for him. So scare him. Your job is to scare him, essentially, right? Scare the guy. Tell him the benefits of quitting. Will show him how rosy and beautiful life can be once you're a non-smoker or a non-alcoholic. Educate them a little bit more about the health problems, and then move on to telling them, "Well, when you are ready to quit, these are the things that we can do for you." That would be the emphasis, emphasis of your advice, plus what you can arrange for them. No need to spend time going so deep into nicotine replacement therapy or withdrawal techniques when it comes to alcohol. Okay. So this is the entire overlook of the 5A approach when it comes to alcohol and smoking counseling. Um, ideally during, um, advice, if your patient is super motivated, don't even bother to be very honest with you. Okay. These are the effects. I put sometimes. I don't know why. Okay.

Now, we'll spend time doing smoking. These are my notes when I did AMC. Uh, two, I have broken them down into ask, assess, advise, and arrange. And under the other side, where you see all the other questions, those are the key questions you should be asking when for someone who is smoking and the dependence questions, rather. So in ask, as we discussed previously, you would be going for shortness of, uh, shortness of breath. Now, for mood, don't have to really tap on it unless, okay, unless he's telling you, "My wife is bothering me, doctor. You know, I, I'm not getting, I'm not very happy at home." Uh, then you want to spend time talking about mood. Otherwise, no reason. Skip. Move on. You have other better things to do. And smoking counseling, you will then spend time asking about how many and how long he has been smoking for. It is nice to always find the reason for starting because when it comes to management, you can always play with that reason a little bit. And if, um, he started because he was a teenager, he was having fun. And in the story, let's say you identify his wife is going to get pregnant or she's a smoker and she's going to get pregnant. Um, being going to become a mom is one of the biggest, highest reasons for a success rate in smoking quitters and alcohol quitters, higher success rate. So if you can get that kind of an emotional reason, please use that in your management. Very, very soft spot for patients. Okay. And then you move on to unwaking. How quickly do you need the first cigarette? So don't confuse this with a CAGE questionnaire that we will be using in alcohol counseling. This is for smoking counseling. You want to know how dependent they are on this. And is the first cigarette hardest to quit? They will probably tell you yes. And if they are still smoking when they're ill, they're really, really dependent. We definitely have patients who are hospitalized, but then they will have the energy to take the lift, go down, smoke, and come back. That's when you know they're super dependent. Then you move on to identifying about "Ever tried quitting?" Why is this important? And why is the withdrawal symptoms important? This is going to change your management. If someone has ever tried quitting before, you want to know the symptoms they've had when they were when the withdrawal was going on. This will tell you, "Do I need a nicotine replacement therapy or emotional?" And just a set date is enough for me to stop my patient, and I don't need to look after my patient after that. So you need to know where this case is going for. And then you other question you can ask is, "Do you struggle to smoke in non-smoking areas?" Usually, very dependent people do struggle big time with that. When it comes to, um, under your dependence questions, they will be like, "Oh, doctor, I need to smoke anywhere, everywhere. I, I go to my car and I need to smoke secretly." Then you know they are super dependent on smoking. Those are these are your, uh, dependent questions for assess of smoking. Otherwise, tolerance and motivation, same as before. "Do you think you've needed more cigarettes from the time you have started?" "How many sticks do you smoke now?" Or what about when you started? "How many smoked sticks did you smoke?" Now, that itself is a comparison. Any way you can ask your question does not matter at all. Here, when you move on to advice, you would primarily talk about the bad stuff about smoking. And I'm sure by now, all of us should know the basic things about, uh, bad things about smoking and what are the benefits of quitting them. So I'm not going to spend so much time explaining on that. It's a CVS risk factor. So add your cardiovascular things into it. Um, add about the smell. Also, social things you can add about is, um, families can get broken if they're unhappy with each other when they are smoking. Even though it's more for alcohol, smoking, they are still more not accepting of it. Lesser family problems with in smoker families compared to alcohol families. And the other one is finances. A cigarette is not, is not cheap. It's not cheap, doctors. Uh, very, very expensive. Alcohol's also, alcohol is slightly cheaper. Cigarettes are quite expensive. So financial something can tap about under advice on both parts of the the story.

Now, we move on to assist a little bit more important because I want to talk about the nicotine replacement therapy. Now, when it comes to smoking, you have to set a definite date. You have to go cold turkey. But when it comes to alcohol, later when we discuss it, you can use the tapered down approach for alcohol. That is the first difference you need to know. The difference between the both of them. You need to start telling your patients under assist that, "I know that we're going to try to quit. So, let's find a particular date to stop. You need to stop cold turkey entirely. But there are going to be some symptoms you will experience. You might experience a little bit of a weight gain. You know, you might experience a little bit of of loness or sadness while you are quitting. You might feel a little bit of of discomfort while you're quitting. And you will want to go for the next cigarette." Very quickly, how I can help you is this. I'm going to introduce you to this thing called nicotine replacement therapy. They come in transdermal patches. They can be a patches. Okay? You can take the gum, or they have the inhaler version. Usually, we prefer the gum or the patches. And then the guy will ask you, "Oh, doctor, does that mean that I'm still getting nicotine?" You know, then you have to go, "No, it is not. This is not the the exact form of nicotine. The chemical formula has been changed to give you the same feeling and try to reduce your cravings and help your withdrawal symptoms as we are trying to quit smoking." So explain that very clearly to this patient. And you also tell them that this nicotine does not give them the same high because it does not have the carcinogens. It does not have the carbon monoxide that you get when you smoke. It does not have the tar, and so it doesn't have the carcinogen. That is the difference between nicotine replacement therapy versus the nicotine high that you would get when you do, um, smoking like the cigarette nicotine. Other things that you have, usually we talk about Champix here. So what does Champix do? So Champix is one of the, uh, nicotine replacement therapy you can use. It helps to reduce or, or rather say, um, prevent the pleasurable effect of smoking. So it doesn't make the high so high. And here you can use the fixed approach where you usually we plan for one to two weeks. So don't take too long from the concept. One to two weeks that you start, stop immediately, or you want to go gradual. So ideally, it's cold turkey, but in reality, it's hard to go cold turkey. If I mean, if you know, I'm sure you guys have patients who are smokers, it's so difficult. So they still prefer the tapered down approach. But please do not say that out loud in the exam, even though I know in reality it happens. You need to stick to your total abstinence. It's a very big guideline thing. So stick to it. But in reality, once you get your general registration, do whatever you want after. You want to go cold turkey, you want to taper down, up to you guys. Totally up to you. They're not going to question you as long as your patient is happy, then. And of course, as you give Champ or you give bupropion, you need to monitor for your side effects. And bupropion. So for Champ, for Champ, it gets, it doesn't get the high very high, but for bupropion, it reduces your withdrawal of symptoms and it reduces the urge to smoke. So a little bit more different concept between bupropion and Champ. So don't have to know the difference, just know that these two are available for your patients. And, um, recently in 2024, they brought a case for vaping. Was super new in the AMC, but we never saw that case ever again. It came once and it disappeared. But for vaping counseling, it's still the same. No changes. Same concept. Just that the first degree, uh, management for vaping would be Champix. Will be Champix. That's your first degree for, um, vaping. I don't know why. I don't know why it's different. Why is it not so open as, uh, normal smoking nicotine? But that's that's the theory. That's the guideline I found for for vaping. Any questions about, um, ah, yes. So this is the one. So still on smoking, yeah. So if I mean, essentially, I've already discussed this with all of you. If the patient is not willing or they're not sure about quitting, very much more different approach versus an approach of the patient is willing to quit. Then you're like, "Wow, very good, you're so amazing." And then you give all your pharmacotherapy and all your, your management that you have for the patient. Praise them. Makes them feel super loved for quitting. Now, this is your handbook case. Have a read on smoking counseling here. If you look at task number one, it just says, "Assess his motivation to stop smoking." Not super difficult to be honest. I mean, it's just asking your motivation scale, and he will talk about his wife and complain and stuff. And here, remember this, because he has come to you for a chest, he previously had a chest infection. You're a very good doctor, so stop. Spend time. "How, how was the infection? Have you recovered?" "Okay, fantastic." And then move on and counsel accordingly. These are other versions of the case. So again, this guy had bronchitis, came to the GP. This person, um, yeah, he's very motivated. But when you listen to the story, he will tell, "Oh, yeah." The next one. This is the other one. This fella, not motivated at all. Only the wife is concerned. Fella doesn't care about quitting smoking. Okay. So, essentially, this is the only way they can tweak. Concept still the same.

Now, again, we will move on to my notes when we talk about alcohol counseling. Ask, everything is the same. We discussed a little bit about. We'll go back to assess, the same way we assessed smoking on how much, how long, very similar. But in alcohol, you need to identify the type of alcohol. Is it a hard liquor or is it a very more light like wine? Doesn't give you that high unless you drink so much compared to you drinking, uh, rum or gin or one of the harder liquor. So you need to know. I, I'm sure the men might be a bit more familiar with them. I went to read up about it. Uh, but yes, you need to know a bit of the differences to know how extreme your patient might be. And then get the pattern of drinking. Why you want to know pattern of drinking? Again, in management, you come back to it. If he's drinking with his, uh, colleagues, okay, or after work, it's a, it's a thing. After every day after work, doctor, I need to drink two to three glasses. Then you know there's something about work. Is there a stressor you need to solve so that the alcohol can be tapered down? Catch the reasons. Catch this. Will all help you in management. And please be aware of safe limits. Super, super, super, super important. It's a risk if you do not know the awareness of safe limits. Then we spend time asking a little bit more about the dependence. So more deeper in dependence. There's two versions of it. You can do the AUDIT-C questionnaire or you can do the CAGE questionnaire. I prefer the CAGE questionnaire again because AUDIT-C requires you to do math, and you know from just now, you know my math isn't fantastic. So I prefer CAGE because I can memorize it. Okay, just have you tried cutting down before? Are you annoyed when people talk to you about alcohol? Okay, are you guilty about drinking? And is it an eye opener? Every morning do you think alcohol is the first thing you reach out to? If you think about it, very similar to that question in smoking, right? Um, is, do you need to smoke the, what time? How early do you need to smoke? The first cigarette when you wake up in the morning? That difference. So, same thing. I will show you AUDIT-C first, and then I'll go back to going on the dependence questions. This is your AUDIT-C questionnaire. If you, I mean, I struggle with it, but if you are comfortable with it, please go ahead and do it. You'll be asking more on how often do they drink, and you will try to figure out whether it's monthly or whether it's a week and how often. You'll score them accordingly. You won't have the questionnaire in front of you, which makes it a bit difficult for you to know the scoring if you didn't memorize it. So if you want to save less memory, I mean, save brain power for other things, you can definitely not do this. Sorry, let me just reverse back to this first. Otherwise, other questions, binge drinking will be very important. Identify their pattern as we discussed in smoking counseling. You need to explore your try quitting and withdrawal symptoms here. Why is this so important? This is going to change the way you manage your patient. Am I going to do an inpatient admission for this page for her, for him or her, or am I going to do a home detox for this patient? Now, if someone, let me see if I can find the symptoms for you. Ah, here. Wonderful. This is how a home detox and an inpatient differs when it comes to alcohol counseling. Usually, you ask them about symptoms within 6 to 36 hours of their last drink. If someone has symptoms like, "Oh, doctor, I just have some kind of sweating, doctor, just a little bit of my heart feels a bit like it's pal, uh, having palpitations," that is very small. You

You will classify that under mouth. This person, you can consider impa—uh, you can consider home detox for this patient. But what do you mean by severe? So severe, you put them straight into inpatient. Severe means tremor at rest, seizures, hallucinations. Now, this patient is severe withdrawal symptoms. Therefore, they go straight into your inpatient detox. No chance for home detox. I hope that makes a little bit clear between the difference on identifying where your patient should stand between home detox and inpatient detox or rehab.

Then, when you go for assist, because again, you have to, once you have decided on whether it's inpatient or outpatient, you have to do bloods. You will do all your liver markers. You will do your alcohol markers. So we did discuss about LFT, vitamin B12, FPC for your megaloblastic anemia. You want to know what's going on. ECG again for your electrolyte imbalances because of your chronic drinking. You want to then educate them about it. So, 10 standard drinks. You can, if you, you're very strong with your, uh, safe limits, that's when you can educate. But I'm going to focus a little bit more about the, the post-op and how the counseling works and how we do it. And you will be getting these slides. So, um, not to worry too much.

Now, one thing I want to mention before I move on for home detox, right? It will be GP, let most of the time. And if you're doing a home detox, every day, yes, you see daily review for at least one week. So, from the time you decide to taper down, every single day you need to come and see the doctor. You need to ideally have someone 24/7 around you who knows that you are going through this, um, detox. And ideally, we would take bloods at the beginning and at the end because we are so afraid. You can, so people have been asking me, do you think, love, can we supplement them with a thiamine supplementation? So I checked the guidelines for it. You can consider thiamine supplementation two weeks before the planned withdrawals. That is the rule for, um, thiamine. So, two weeks before the planned withdrawal, you can supplement them with thiamine.

Otherwise, I'm going to discuss a little bit about, do I have slides for relapse? I don't. I'm going to talk a little bit about relapse. Now, to prevent relapse, there are a few drugs that you can use. So you can use, um, naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. Naltrexone. 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So for naltrexone, what it does is that it just reduces the rate of the relapse and allows you to abstain for a little bit more longer than usual when it comes to alcohol counseling. So remember, champix, bupropion for smoking, naltrexone for alcohol, and thiamine, you can consider that as well. Not really a drug, just a more supplementation to prevent delirium tremens or severe withdrawal symptoms. And apart from that, if there are other investigations you want to add above of it, you can add your urine drug screen on the assumption or with the history based on that this person has done recreational drugs or you suspect that they might have done recreational drugs due to the lack of judgment and lack of insight. Make it very justified and very clear why you're doing a urine tox. It's not something we do for almost everybody just like that. Explain to the examiner, justify your investigation for it. Um, then we have a couple of slides, right? So have a little read about this. So it's the CAGE questionnaire versus the AUDIT that can be used during the exam. Um, there are some other things you can use under advice. So you would talk about what a low risk, what a high risk is. You can counsel them about standard drinks. So ideally, we just go for 10 standard drinks for less than a week. I will show you a couple of questions that have come up before.

So this is your handbook station. I will show you the investigations in the next slide. In this handbook station, very clear, you do not need to take any history nor perform any investigation. They will say that in the next slide when I show you. So you have for a guy drinking. Now he wants to learn about alcohol. You know most of his past medical, past life history, in a way, you know about it. You also get to do his investigations, and you realize his gamma GGT is off the records, a little bit. His liver panel, a bit shaky. Not too shaky, but a bit shaky. You are having megaloblastic anemia. So your vitamin B12 deficiency will be up there for your patient as well. In this station, you have to explain the test results. So now, before that, I want to explain a little bit about this different, um, this history of presenting complaint and candidates who tell me that from the stem, from the history. Now, in this case, they specifically told you at the bottom, you do not need to take any other history. Here, I will tell you, you can tell the patient, from the history, I have noticed, from the notes, I have noticed. I give you a, I have no issues with that. But if nothing like that is stated and it's not given to you so beautifully in such sections, and history is, is warranted, you would please definitely ask about that as well. It can cause, yet without me, glob blast, it can cause just macro without any changes yet. So it, every picture is different when you look at it. But I guess AMC, for AMC, I guess they want to be more specific. They'll give you as much positive findings to give you your at max vitamin B12 deficiency for someone with chronic alcohol or heavy alcohol use. I'm sure task number two wouldn't be too difficult for you guys. So it should be okay. And counseling. Same thing. You would go from head to toe and then explain all of it. Give your home detox. Give your, uh, inpatient, inpatient detox. Explain the different options available for him. Explain the benefits of quitting and what happens if you don't quit. All of that, and it should be a very easy station actually.

Now, other stations that are up there for you. So this is another station. Now, in this station, uh, oh, it asks for further history. Fine. Have a little read. So this candidate has been binge drinking. Alcohol blood level now is 0.02. I now can't remember. I think 0.5. I think it's, it's a 5%. Let me just get the, if you guys, if you guys do know, please put in the chat box the alcohol level. I can't remember. I know it's a five at the back, or is it a one? And then this guy is high. I know it's high, but I just can't remember. Alcohol. Just Google it. If you guys know the numbers, please let me know. Let me see if I know the percentage. Yeah, 0.05% is the legal limit in Australia. But that's for driving, though. 0.05%. So in this case, well, his blood alcohol level now is 0.02, which means it's back to normal. So 0.05 is correct. But there's another case. Let me write the next case with you guys. I don't have that case too. But there's another case in the AMC which they'll give you 0.2, and you would know that is way above the safe limits of 0.05 blood alcohol percentage. This is another version here. He is, uh, concerned about alcohol drinking, but he is least bothered about it. Again, not motivated. My wife told me to come, doctor. I'm not motivated. And the other thing is this. This thing tells you, tell the patient your diagnosis with reasons. I want here, you would, when you do your history taking, you would spend a lot of time doing your dependence. In your dependence, you would have identified he is super, super dependent. Therefore, your diagnosis would be alcohol dependence. That is a diagnosis in the AM, in, in DSM criteria, alcohol dependence. Now, I also know other candidates use the term alcohol usage disorder. However, I did check that up on the DSM criteria. If you use alcohol usage disorder, that is mild, moderate, and severe, which means you must tell me, is it mild alcohol usage disorder, or moderate, or severe? I think it's very difficult to go and use your brains to memorize mild, moderate, severe, and the numbers for it. So if you can remember alcohol dependence, that is an ICD and psychiatric diagnosis, easy enough. In this station, if you, this goes with reasons, again, it's not asking you for differentials. It's asking you why you, as a clinician, now thought that this patient is dependent on alcohol. So you would explain, break down your entire dependence. Most of it will be positive. Your CAGE questionnaire would be, would be positive here as well.

Any questions about alcohol counseling or anything from today? Any particular questions? You can put it in the chat box. It's, of course, my favorite slide. I've managed to tap on, um, MSEMC, and then the second part was alcohol and smoking counseling, and then we did a couple of mood disorders, anxiety disorders, and, um, psychiatric history taking. Any questions you guys can put in the chat box, or you can turn on your mic and ask. No problem about these ones. Ideally, I always like to go back to the mind map because, um, where is that mind map now? Yeah, this gives you a very good summary of psychiatry, apart from the few more counseling stations I need to input into this. Yes, Josephine is helping us break down macrocytosis and megalob, vitamin B12 deficiency or megaloblastic anemia. So remember, one is just the size of the cell, and the other one, so it's very similar to how iron deficiency anemia is hypochromic microcytic. So one is the concentration of it, and one is the size of it. Know the difference. That will help you for med search. Not, not super psych, but for med search.

Any other questions? Oh my god. You guys seem, I'm so sorry if your brains look very dead at 10:00 p.m. If not, we will wrap up for today. I will stop the recording so I can upload. The video will be uploaded by today.