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College of Medical and Dental Sciences

M4-PAN-Y18

Clinical Psychiatry and Neurology Rotation Handbook and Notebook This book belongs

to:

If found please

contact:

Every effort has been made to ensure that the information contained in this document is correct at the time

of going to press. However, it will not form part of any contract between the College and a student.

Any updates and alterations will be posted on Canvas, accessed at: https://canvas.bham.ac.uk/

Should you notice any inaccuracies, omissions or have any comments, please email

David Morley, Medical Education Developer, Year 4 at [email protected]

Rotation Co-ordinators – Dr Pavan Mallikarjun (Psychiatry) and Dr Hani BenAmer (Neurology)

Date of Origin: May 2017

https://canvas.bham.ac.uk/

mailto:[email protected]

Contents

INTRODUCTION ...................................................................................................................................................................... 1

MBCHB YEAR 4 PSYCHIATRY .......................................................................................................................................... 1 MBCHB YEAR 4 NEUROLOGY .......................................................................................................................................... 2

STRUCTURE OF ROTATION ................................................................................................................................................ 3

CLINICAL CORE 3 MODULE LEARNING OUTCOMES ..................................................................................................... 4

PSYCHIATRY .......................................................................................................................................................................... 6

REQUIRED PRIOR LEARNING ............................................................................................................................................. 6 LEARNING OUTCOMES - PSYCHIATRY ............................................................................................................................... 7 PSYCHIATRY LOGBOOK ................................................................................................................................................. 11 PSYCHIATRY CASE PRESENTATION ................................................................................................................................ 12 EXTENUATING CIRCUMSTANCES .................................................................................................................................... 13 PROFESSIONAL BEHAVIOUR AND ATTITUDES (PBA) FORM .............................................................................................. 13 SUBMISSION OF PSYCHIATRY DOCUMENTATION .............................................................................................................. 13

PSYCHIATRY PRESENTATION ASSESSMENT ............................................................................................................... 14

PSYCHIATRY LOGBOOK EXAMPLE PAGES .................................................................................................................. 15

CLINICAL RECORD SHEET .............................................................................................................................................. 15 CLINICAL RECORD SHEET: ADDITIONAL CLINICAL EXPERIENCES ...................................................................................... 17

PSYCHIATRY LOGBOOK .................................................................................................................................................... 18

CLINICAL RECORD SHEET .............................................................................................................................................. 18 CLINICAL RECORD SHEET: ADDITIONAL CLINICAL EXPERIENCES ...................................................................................... 30

NEUROLOGY ........................................................................................................................................................................ 33

OVERVIEW .................................................................................................................................................................................... 33 REQUIRED PRIOR LEARNING .......................................................................................................................................... 33 LEARNING OUTCOMES ................................................................................................................................................... 34 KEY PRESENTATIONS .................................................................................................................................................... 35 KEY CLINICAL SKILLS .................................................................................................................................................... 37 KEY INVESTIGATIONS..................................................................................................................................................... 38 KEY MEDICATIONS ........................................................................................................................................................ 38 KEY CLINICAL AREAS OR ACTIVITIES .............................................................................................................................. 39 LEARNING MATERIALS ................................................................................................................................................... 40 PORTFOLIO ACTIVITIES .................................................................................................................................................. 41 (SUMMARY OF THINGS YOU SHOULD HAVE COMPLETED FOR YOUR PORTFOLIO) ................................................................. 41 NOTES .......................................................................................................................................................................... 46 NOTES .......................................................................................................................................................................... 47 NOTES .......................................................................................................................................................................... 48

M4-PAN-Y18 1

Introduction PLEASE READ THIS HANDBOOK CAREFULLY

This is a combined nine-week clinical rotation, which will give you experience of both Psychiatry and

Neurology. For Psychiatry, the teaching programme included within your pack along with the tutorial

programme, will provide the opportunity to gain clinical experience and knowledge of general Psychiatry.

For Neurology you will be scheduled to attend outpatient and inpatient teaching sessions. Coupled with this

you will be expected, through self-directed learning, to study the teaching materials relating to the sub-

specialities of Psychiatry and Neurology which have been placed on the Year 4 website.

MBChB Year 4 Psychiatry

The aim of the Psychiatry Rotation in Year 4 is to introduce you to the basic principles of Psychiatric

practice. This will include history-taking, interviewing techniques, mental state examination, and the

process of differential diagnosis, treatment and management of the most common and severe psychiatric

disorders.

Psychiatry, more than any other medical specialty, demands that the doctor take a holistic perspective of

the patient’s problem. This means that the theoretical basis of the subject is as significantly influenced by

biological sciences as by psychology, sociology, anthropology, philosophy & ethics, and law. Advances in

neuroscience, particularly neuroimaging, pharmacology, and molecular genetics, are rapidly improving our

understanding of the biology of the major psychiatric disorders such as schizophrenia and bipolar affective

disorder.

It is likely that you will experience the complexity and richness of psychiatry as a discipline during this 9-

week Rotation. For those students who wish to consider psychiatry as a career, further information relating

to psychiatric training is available at The Royal College of Psychiatrists website:

http://www.rcpsych.ac.uk

Anyone who is interested in a career in psychiatry should discuss it with their teams on clinical attachment

and may also contact:

Professor Femi Oyebode, Head of Clinical Teaching Academy for Psychiatry, The Barberry

Tel: 0121 301 2354

Dr Abdul Patel & Dr Floriana Coccia, Deputy Heads of Teaching Academy for Psychiatry, The Barberry

Tel: 0121 301 2350

http://www.rcpsych.ac.uk/

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MBChB Year 4 Neurology

Neurology is combined with psychiatry in this rotation and students will be allocated to firms containing both

psychiatrists and neurologists. Neurology and psychiatry fit very well together since many patients have

disorders producing symptoms in both disciplines. Studying both subjects together should give a much

clearer idea of the neurological basis of many psychological disorders such as delirium and acute toxic

brain insults and experience of how they present. The learning objectives are detailed later in this

handbook but we are hoping to teach the basic localisation in neurology that will allow you to interpret

history and physical signs to locate pathology anatomically. This will considerably reduce the differential

diagnosis. The equivalent of three weeks fulltime neurological teaching should give you an opportunity to

practise this localisation and also to be confident in your ability to give another clinician an accurate

summary of a neurological patient as you will have to do as an F1.

Students will have at least one bedside teaching session in Neurology per week plus experience in

neurosurgery, neuroradiology, and neurophysiology. Outpatient clinics take one or at the most two students

per clinic and you will be allocated to both general and specialist clinics.

There are lectures on the most common neurological diseases available on Canvas and you are advised to

read a small text book of neurology designed for medical students.

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Structure of Rotation Week 1

The first week of the combined rotation begins with two days of lectures and one day of clinical case

conference organised by Psychiatry. This is quite intensive, but will provide essential background

knowledge for clinical placements. There will be an induction programme where students will receive

information about placements.

An induction for neurology will take place also during the first week and include location and timing of

neurology outpatient clinics and firm attachments. The learning objectives will be confirmed and

opportunities for special study over and above the core course outlined.

Weeks 2-9

Students will be allocated to a Psychiatry and Neurology Firm and will spend the next eight weeks split

between psychiatry clinical placements attached to a consultant-led multidisciplinary team (approx.60%)

and neurology teaching sessions and clinics (approx. 40%). You should ensure that you see as wide a

range of conditions as possible, using the Learning Outcomes sections of this Handbook to guide you.

In Psychiatry, you will also be assigned to a tutorial group led by a Psychiatry Tutor (usually a Specialist

Registrar/ST4-6) which should meet weekly for approximately one hour. The tutorials are semi-structured,

utilising a number of case vignettes as well as allowing for student input on the topics to be covered.

Students often use the groups to consolidate learning from lectures and clinical placements. The sessions

are important and allow you to take an active role in directing your learning. They may be given precedence

over the clinical commitments of your team. Student feedback about the tutorial system has always been

extremely positive, and the groups are considered a valuable component of the rotation.

There are no assigned neurological tutors for the module, but you can contact your neurological

consultants for further advice during the attachment.

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Clinical Core 3 Module Learning Outcomes

The doctor as a scholar and scientist 1. Demonstrate an understanding of the basic sciences and the key concepts of clinical sciences and

apply them in their clinical learning in specialist clinical settings: recognising the importance of both to

the study of medicine and to clinical practice in all settings.

2. Demonstrate a scientific understanding of an agreed range of common and less common diseases,

their causes and prevention, mechanisms, clinical presentation, investigation and evidence-based

management in the specialist clinical setting.

3. Demonstrate an understanding of the physical, psychological, sociological factors influencing mental

health, and the psychological and social effects of serious physical illness and hospitalisation.

The doctor as a practitioner 4. Demonstrate good interpersonal / communication skills when interviewing and negotiating with patients

and their families in a range of specialist settings and competence in undertaking and recording a

physical and mental state examination that is appropriate to the setting and the circumstance.

5. Demonstrate critical thinking in synthesising the information gained from the patient, considering

possible diagnoses and proposing investigations which may confirm or support a diagnosis / exclude

other diagnoses or narrow the diagnostic field.

6. Demonstrate an understanding of the therapeutic options available in specialist clinical placements in

relation to an agreed range of presentations / conditions and of the decision making processes whereby

clinical management decisions are made.

7. Demonstrate a commitment to the involvement of the patient and their family in decisions about their

clinical management and recognition of the particular responsibilities placed on the doctor in those

limited circumstances where this is not possible.

8. Demonstrate the required progress / competence in the range of clinical procedures as set out in the

Clinical Skills Passport, showing an understanding of the use of the procedure in common situations.

9. Practice as a clinical learner in a manner that demonstrates awareness of and commitment to the

patient safety agenda as it applies to the particular circumstances of their specialist clinical placements:

ensuring that all precautions are taken to minimise the particular risks inherent in the individual clinical

environment.

The doctor as a professional 10. Use information effectively in a clinical learning context, making use of ICT to support clinical learning

and recognising the growing importance of ICT in the management of clinical care.

11. Meet the requirements of confidentiality / data protection legislation and codes of practice for the Trust

and the programme, demonstrating recognition of the importance of these matters in professional

learning and practice.

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12. Demonstrate knowledge of and commitment to the ethical and legal principles which inform and

regulate professional learning and practice, and behaviour in relation to patients, fellow health care

workers and the general public.

13. Demonstrate the skills and attitudes required to make appropriate use of the opportunities presented by

a range of specialist clinical learning environments and in the primary care setting.

14. Demonstrate a developing knowledge of the roles fulfilled by other health care professionals in a range

of specialist clinical environments and a commitment to working effectively as part of the multi-

professional team.

15. Demonstrate an understanding of the organisation of the NHS and health care provider bodies in

primary, secondary and tertiary care, and an awareness of and commitment to the service improvement

agenda.

16. Demonstrate an understanding of the current limits of their professional competence and a commitment

to working within these.

M4 PAN Y17 6

Psychiatry

Required prior learning Before starting this Rotation you should ensure that you have revised / reviewed the following knowledge

and skills, previously covered in Years 1-3. This minimum level of understanding and competence will be

assumed and built upon in this Rotation.

Basic knowledge of the psychiatric history and mental state examination.

Understanding of the medical model, the concept of diagnosis and its implications. Including

attitudes to mental illness, prejudice and stigma.

Routine laboratory tests and imaging used in Psychiatry.

Risk factors associated with suicide, and the principles of assessing risk of suicide.

Psychological theories of normal attention, memory and learning.

Understand normal conscious awareness and perception.

Psychological theories of emotion, and models of coping with stress.

Attachment theory and theories of social behaviour.

The principles of pharmacology, particularly as applied to the brain.

The principles underlying the pharmacological treatment of psychosis, depression and anxiety.

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Learning Outcomes - Psychiatry

At the end of the experience, the student should be able to:

I can do this (tick when complete)

1. ASSESSMENT SKILLS Interviewing Skills 1. Conduct a psychiatric interview in a manner that facilitates information gathering

and formation of a therapeutic alliance.

Psychiatric History, Physical, and the Mental State Examination

2. Demonstrate the ability to obtain a complete psychiatric history, recognise

relevant physical findings, and perform a complete mental state examination.

3. Elicit and clearly record a complete psychiatric history.

4. Recognise the importance of, and be able to obtain and evaluate, historical data

from multiple sources (family members, community mental health resources, old

records, etc.)

5. Demonstrate a level of understanding of the effect of developmental issues on the

assessment of patients

6. Elicit, describe, and precisely record the components of the mental state

examination.

7. Use terms associated with the mental state examination appropriately.

8. Make a clear and concise case presentation of a psychiatric case.

9. Recognise physical signs and symptoms that accompany classic psychiatric

disorders.

10. Demonstrate an appreciation of the implications of the high rates of general

medical illness in psychiatric patients, and state reasons why it is important to

diagnose and treat these illnesses.

11. Assess for the presence of general medical illness in psychiatric patients, and

determine the extent to which a general medical illness contributes to a patient’s

psychiatric problem.

12. Recognise and identify the effects of psychotropic medication in the physical

examination.

Diagnosis, Classification and Treatment Planning

13. Identify abnormalities; formulate accurate differential and working diagnoses;

develop appropriate assessment and treatment plans for psychiatric patients.

14. Demonstrate a working knowledge of a classification system, such as ICD-10

Diagnostic Testing

15. Use laboratory testing, imaging tests, psychological tests, and consultation to

assist in diagnosis and be aware of their limitations.

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2. PSYCHIATRIC EMERGENCIES

1. Identify the clinical and demographic factors associated with a statistically

increased risk of suicide in general and clinical populations; develop a differential

diagnosis, conduct a clinical assessment, and recommend management for

patients exhibiting suicidal thoughts or behaviour.

2. Recognise signs and symptoms of potential violence and develop a differential

diagnosis, conduct a clinical assessment, and state the principles of management

of a person with potential or active violent behaviour.

3. Recognise and manage other emergencies related to mental disorder or induced

by treatments used for mental disorders.

3. DISORDERS Delirium, Dementia, and Amnestic and other Cognitive Disorders

1. Recognise the psychiatric manifestations of brain disease of known aetiology or

pathophysiology. Describe the evaluation and initial management of these

disorders.

Substance-related Disorders

2. Identify, clinically evaluate, and manage the consequences of substance misuse

and dependence.

Schizophrenia and Other Psychotic Disorders

3. Recognise, evaluate, and state the treatment of psychosis associated with

schizophrenia and other psychotic disorders.

Mood Disorders

4. Recognise, evaluate, and state the treatments for patients with mood disorders.

Anxiety Disorders

5. Recognise, evaluate, and state the treatments for patients with anxiety disorders.

Personality Disorders

6. Recognise maladaptive traits and interpersonal patterns that typify personality

disorders, and discuss strategies for caring for patients with personality disorders.

7. Summarise the neurobiological, genetic, developmental, behavioural, and

sociological theories of personality disorders.

8. Describe the pattern of co-morbid psychiatric disorders in patients with personality

disorders.

M4-PAN-Y18 9

4. MANAGEMENT Psychopharmacology

1. Summarise the indications, basic mechanisms of action, common side effects and

drug interactions of each class of psychotropic medications, and demonstrate the

ability to select and use these agents to treat mental disorders.

Psychotherapies

2. Understand the principles and techniques of the psychosocial therapies sufficient

to explain to a patient and make a referral when indicated.

Collaboration The student will be able to:

3. Participate as a member of a multi-disciplinary patient care team.

4. Summarise the special skills of a psychiatric nurse, psychologist, psychiatric social

worker, occupational therapist and others involved in the care of the patient;

demonstrating respect for, and appreciation of, the contributions of others

participating in patient care.

5. Participate in a family meeting with other members of the treatment team.

6. Participate in discharge planning and referral of a patient to an ambulatory setting

or to another inpatient facility.

Practice of Psychiatry 7. Discuss the community focus of much of psychiatric management.

8. Discuss the primary / secondary care interface for mental disorders.

9. Discuss the role of Psychiatry as a medical specialty.

5. PSYCHIATRIC SUBSPECIALTIES Child and Adolescent Psychiatry

1. Summarise the unique factors essential to the evaluation of children and

adolescents.

2. Demonstrate an appreciation of the key features of common child psychiatric

disorders.

Eating Disorders

3. Summarise the distinguishing features, evaluation, and treatment of patients with

eating disorders.

Forensic Psychiatry

4. Demonstrate an understanding of mental health legislation.

5. Describe the ethical aspects of psychiatric practice.

6. Describe the psychiatric aspects of offending behaviour.

M4-PAN-Y18 10

Learning Disability Psychiatry 7. Discuss the aetiologies, epidemiology, clinical features and psychiatric co-

morbidity of learning disability.

8. Summarise the unique factors essential to the evaluation of people with learning

disability.

Liaison Psychiatry

9. Understand the nature of the interface between psychiatry and the other medical

specialties including referral processes and the psychiatric morbidity found in the

general hospital setting.

10. Describe the assessment and management of the psychiatric consequences of

physical illness.

Neuropsychiatry

11. Describe the assessment and management of the psychiatric consequences of

neurological disorders.

Old Age Psychiatry

12. Apply a cognitive screening evaluation to assess and follow patients with

cognitive impairment and state their limitations.

13. Compare and contrast the clinical presentation of depression in elderly patients

with that of younger adults.

14. Summarise the special considerations in prescribing psychotropic medications in

the elderly and the effects of polypharmacy.

Perinatal Psychiatry

15. Describe the psychiatric conditions specific to the perinatal period.

16. Understand the complexity and risks of managing conditions during pregnancy

and breastfeeding.

M4-PAN-Y18 11

Psychiatry Logbook

During your placement, you will be expected to clerk a substantial number of patients and to present them

to your Consultant or other medical staff. The placement should give you plenty of experience of patients

with neurotic and psychotic illness, but it is important that you show initiative in making use of the

opportunities at your placement to see as wide a range of patients as possible. The logbook provides you

with somewhere to record all these experiences in a structured manner. Minimum requirements are

provided, but the more activities you undertake, the more you will enhance the knowledge and skills you

acquired from the Teaching Programme sessions, weekly Tutorial Group sessions and your reading around

the subject.

During your placement you should have achieved the following at a minimum:

Fully clerk at least six patients with as wide a range of disorders as possible. You should clerk in-

patients, day patients and new outpatients, accompany your Consultant on domiciliary visits and see

referrals from a general hospital. It is hoped that you will see some emergencies and acute admissions

even though these are less frequent than in some other specialities. Psychiatric diagnoses are

conventionally divided into categories and you should try to cover as many as you are able to. The list

below is not exhaustive and serves only as a guide:

Organic mental disorder – delirium, dementia, amnestic syndromes and organic mood or

personality disorders

Mental disorders due to psychoactive substance misuse – harmful use, dependence or

withdrawal from cannabis, alcohol or other opioids

Psychotic disorders – schizophrenia, delusional disorder or schizoaffective disorders

Mood disorders – mania, bipolar affective disorder, depressive disorders or recurrent depressive

disorder

Neurotic disorders – including phobias, generalised anxiety disorder, OCD, PTSD, dissociative or

somatoform disorders

Personality disorders, perinatal psychiatric disorders, eating disorders, learning disabilities,

autistic spectrum disorders

For all cases you should also document psychopharmacological agents prescribed for the patient – the

name, class and indication, as well as two side effects, should be documented in the table provided.

These case summaries should be entered into the Clinical Record Sheets. An example of a completed

Clinical Record Sheet is given in the Logbook.

You should find out how ward nurses, community psychiatric nurses, occupational therapists and social

workers work. It is important to gain an understanding of how these other disciplines fit into, and work

within, a multi-disciplinary team.

Document and reflect on at least six clinical experiences on the relevant sheets in the logbook (Clinical

Record Sheet: Additional Clinical Experience). This section should include activities you have

undertaken other than history taking. Examples are listed below.

Domiciliary visits with the Consultant or other team members

Observing the work of:

Community Psychiatric Nurses

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Social Workers

Clinical Psychologists

Occupational Therapists

Art or Drama Therapists

Attending:

Electroconvulsive therapy (ECT)

Relaxation, anxiety management or other behavioural treatment

Day hospital sessions

Psychotherapy assessment sessions or groups

Prisons, forensic units or bail hostels

Barberry Film Club (see separate Reflection Sheet for this activity)

Please note that these experiences are placement-dependent and are not compulsory

An example of a completed Clinical Record Sheet: Additional Clinical Experience is given in the Logbook.

When working on the wards, you should make yourself known to the nursing staff responsible for providing

a therapeutic milieu. When important or confidential information is given to you by a patient, you must

always bring it to the attention of the nursing or medical staff. Remember that the personal details revealed

are highly confidential. You should never remove identifiable records, whether paper-based or electronic,

from the ward or gossip about your patients.

Please bear in mind the University’s code of conduct with regards to dress and always wear your Medical

Student badge.

During the placement, your Consultant, in conjunction with the Head of Academy for Psychiatry, is

responsible for ensuring that your educational experience is satisfactory. If, for any reason, you experience

difficulties or feel dissatisfied with the experience you are getting, please immediately inform the Head of

Academy for Psychiatry, via the Undergraduate Coordinator.

You are required to submit a word processed copy of the Logbook for assessment, on the final

Friday of the Psychiatry & Neurology rotation – hand written copies will not be accepted. An

electronic copy is available on Canvas.

Please ensure both you and your Consultant/Supervising Doctor has signed and dated your Logbook as an

accurate reflection of your activity during the Rotation. Logbooks will be marked by one of the Academy

Tutors. If the logbook has not been completed to a satisfactory standard, you will be asked to re-submit the

logbook within a two-week period for re-marking.

Psychiatry Case Presentation On the Friday of week nine students will be split into small groups for the psychiatry case presentations. All

students are expected to present, for around ten minutes, a case summary typical of the patients they have

seen whilst on clinical attachment. To aid presentation, each student should produce in advance, a one-

side only A4 handout to which they can speak. This will be followed by five minutes of questions about the

presentation. During the sessions, the presentations will be assessed by a Clinical Tutor, to whom you

should provide a copy of your handout. A copy of the Assessment Sheet, with the elements that need to be

M4-PAN-Y18 13

considered, is included in this handbook. It is important that students actively participate in the brief

discussions following each presentation, to the mutual benefit of the students in the group.

In the event of an ‘unsatisfactory’ performance in the case presentation, you will be required to re-present

this part of the In Course Assessment within two weeks. You will be required to select a different case to

that presented at the first sit.

Extenuating Circumstances If you have accepted extenuating circumstances for either of the above In Course Assessment

expectations then individual arrangements will be made to ensure that you have the chance at two attempts

if necessary.

End of Placement Review Form (EPR) Replacing the Professional Behaviour

and Attitudes (PBA) Form

The Consultant Psychiatrist to whom you have been attached will assess you under the following headings:

- Demonstration of attitudes

- Communication of attitudes

- Learning behaviour

- Attendance

- Appearance

Please remember that it is your responsibility to complete your sections of the form and ensure that you

forward the form to your Consultant for them to complete their sections, as well as arranging to meet with

them to discuss your progress. All instructions, guides and forms can be obtained from Canvas here:

https://canvas.bham.ac.uk/courses/30375/pages/end-of-placement-review

Submission of Psychiatry Documentation After the case presentation assessment on the Friday of the final week of the Psychiatry and Neurology

rotation you are required to hand in the following to the Undergraduate Office at The Barberry:

Logbook: signed and dated by you and your Consultant

Presentation Assessment sheet: signed by the Clinical Tutor

Professional Behaviour and Attitudes form: signed and dated by you and your Consultant

Trust access card: a charge for a missing card will be imposed

Feedback forms: we welcome feedback on all aspects of the Rotation and we will ask you to

complete anonymous feedback forms during and at the end of the Rotation

If, for any reason, you are unable to hand in any of the above documentation, you must inform the

undergraduate co-ordinator for Psychiatry, indicating the reason and requesting an extension.

If you have any queries, please contact the Psychiatry Undergraduate Office on 0121 301 2350 or

0121 301 2366.

https://canvas.bham.ac.uk/courses/30375/pages/end-of-placement-review

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Psychiatry Presentation Assessment Student Name: Student Reg No:

Date:

Title of Case Presentation:

Content Presentation

Elements to consider:

Underlying knowledge of the topic area

Knowledge of this particular case

Range of sources / background research

Consideration of wider context - e.g. patient’s

overall health and life

Understanding of the patient journey and of

the inter-professional and multidisciplinary

team approach to care.

Level of interest / originality of case chosen

Analysis / conclusions

Elements to consider:

Clear focus, appropriate timing

Structure (clear flow, with clear engaging start and

summary)

Delivery (eye contact, volume, speed, level)

Handout (appropriate and clearly written)

Interaction (involvement of audience, links to other

presentations)

Excellent Satisfactory Unsatisfactory

Excellent Satisfactory Unsatisfactory

Comments Comments

Overall Performance: Satisfactory Unsatisfactory

(please circle appropriate standard)

Students must achieve an overall satisfactory performance. Students who give an unsatisfactory

presentation will be required to present a different case within two weeks.

Lead Assessor……………………………. Signature……………………………...

M4-PAN-Y18 15

Psychiatry Logbook Example Pages

Clinical Record Sheet Demographics

Setting & Date

Male, 27 years. Unemployed. Single.

Outpatient Clinic dd/mm/yy

Diagnostic Category ICD-10 or DSM IV List at least three ICD-10 criteria present for each diagnosis noted

1) F31.3 Bipolar Affective Disorders – current episode mild or moderate depression ICD-10: low mood; loss of interest; decreased energy levels; decreased sleep & appetite; early morning awakening. 2) F60.3 Emotionally unstable personality disorder ICD-10: recurrent threats or acts of self-harm; liability to become involved in intense and unstable relationship often leading to emotional crises; chronic feeling of emptiness

Case Summary (History, Mental State Examination, Differential Diagnosis, Investigations and Bio-psycho-social treatment)

Presenting complaint Low mood for last 3 weeks History of presenting complaint Mood progressively worse over last 3 weeks. Increasingly tearful and irritable. Waking at 5h00. Memory and concentration poor. Appetite poor; lost 3 pounds. Lost interest in activities. No prominent guilt, no suicidal ideation, no worthlessness / hopelessness. Past psychiatric history Personality disorder In contact with MH services since age 20. Previously presented with recurrent episodes of self-cutting and impulsive overdoses. Diagnosis of Borderline Personality disorder made at age 22 following informal inpatient assessment. Reasonably stable since DBT completed (one year ago). Affective disorder First manic episode at age 25 – required admission under Section 2 MHA. Responded well to treatment, discharged to CMHT. Two previous depressive episodes, first episode shortly after discharge, second episode one year later. Both treated with fluoxetine, stopped soon after recovery. Currently sees CPN fortnightly – finds this helpful and has reduced crisis presentations to A&E.

Medical history Allergic to penicillin (anaphylaxis). No chronic illnesses. On olanzapine 10mg at night – weight gain of 1 stone.

Family history Mother (61) has bipolar disorder – sees psychiatrist and takes lithium. Father (65) has IHD and stroke. Two sisters and two brothers (all well). Gets on well with mother, estranged from father. Personal history Born in Huddersfield. Normal pregnancy, delivery and milestones.

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Abused (sexually) by father’s brother for 8 years (age 6-14). Father never intervened. Abuse stopped when patient physically able to stop uncle. GCSEs 5 grades C-D. Went to work in factory after leaving school. Sacked several times – poor relationship with work colleagues. Several short term volatile relationships – last ended 3 months ago after about 5 months.

Social history Lives in one bed council flat. On Jobseekers Allowance, no significant debts. Smokes 20/day. Alcohol 18 units/week (binges at weekend). Illicit substances: cannabis in past, nothing currently.

Forensic history Police caution for theft (age 18)

Premorbid personality ‘Never felt like I belonged’ Enjoys collecting vintage matchbox cards. No religious beliefs.

Mental State Examination Tall, well-built. Several tattoos on arms and neck. Alert, co-operative. No restlessness or agitation. Mood: subj low; obj low and occasionally tearful. Speech: normal rate and volume, somewhat monotonous. Thoughts: no disorder of form. Nil suicidal, nil delusions. Perceptual: no disturbances. Cognition: orientated to time and place. Insight: sought help when mood deteriorated. Tends to be compliant when depressed. Willing to engage in treatment.

Management Psychopharmacology

Drug Indication Class S/E

Fluoxetine Improve mood SSRI Impotence, nausea

Olanzapine Mood stabilisation

Atypical antipsychotic

Weight gain, sedation

Psychosocial Regular review by CPN. CBT for depression. Psychoeducation regarding binge drinking.

Practice of Psychiatry in different settings (inc. collaboration with other professionals)

Role of CPN in supporting patient and monitoring mood for signs of mania. Also role in psychoeducation. GP: monitoring long-term side effects of olanzapine (diabetes, IHD). Involvement of psychological services for short term interventions when mood deteriorates

Learning Outcomes (i.e. Knowledge, Understanding, Skills)

Diagnosis of Personality Disorder – requires multiple assessments. Co-morbidities occur more frequently in personality disorders and should be treated.

Additional Information

Specific psychological treatments for Borderline Personality Disorder include CAT and DBT.

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Clinical Record Sheet: Additional Clinical Experiences (see page 11) Date: dd/mm/yy

Observation at ECT 1. Indications for ECT:

Rx resistant depression

Active suicidal ideations - severe and serious

Severe depression with psychomotor retardation

Post-natal depression

Catatonic schizophrenia

Rx resistant mania 2. Process: a. Administer GA (thiopentone) and muscle relaxant (suxamethonium) b. Electrodes placed bilaterally on skull (unilateral placement efficacy but also memory loss) c. Electric current passed through skull to induce a fit d. Duration of fit monitored by observing patient/EEG brace 3. Side Effects: Headache Short term memory loss 4. Risk: = anaesthetic associated with dental procedure

Date: dd/mm/yy

Discussion with Consultant Psychologist We discussed: 1. The role that psychotherapy has in the treatment of psychiatric disorders and its place in the NICE Guidelines 2. The elements of CBT in the treatment of obsessive compulsive disorders

Cognitive therapy: identification and intrusive thoughts, challenge of intrusive thoughts including using evidence to undermine the dysfunctional thought processes

Behavioural therapy exposure response prevention 3. The key elements of psychodynamic therapy – transference, patient led therapy sessions; time restraints (consultations a set time length); making links – experience in real world, experience in therapy and connections with the past

Date: dd/mm/yy

Discharge Planning Meeting, Unit Discussion of care plan: 1. Arrangement of patient’s care co-ordinator 2. Handover of patient’s care to community mental health team 3. Offer of out-patient services that Unit provides:

support group

day service

baby massage 4. Arrangement of an appointment to see patient within 7 days of discharge. (Government target)

Date: dd/mm/yy

Baby massage group, Unit The benefits of baby massage:

aids mother/baby bonding

improves baby’s sleep, circulation, lymphatic drainage, immune system, skin, digestion and waste excretion

reduces depression in mum; bonding experience; stimulates oxytocin release causing pain relief, relaxation and calming

Baby massage courses: 6 sessions Areas of baby’s body concentrated upon:

legs

stomach

chest

arms

face

back

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Psychiatry Logbook

Clinical Record Sheet

Clinical Record Sheet 1

Demographics Setting & Date



Presenting complaint History of presenting complaint Past psychiatric history Medical history Family history Personal history Social history Forensic history

M4-PAN-Y18 19

Premorbid personality Mental State Examination Management Psychopharmacology


Psychosocial




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Presenting complaint History of presenting complaint Past psychiatric history Medical history Family history Personal history Social history Forensic history

M4-PAN-Y18 21

Premorbid personality Mental State Examination Management Psychopharmacology


Psychosocial




M4-PAN-Y18 22





Presenting complaint History of presenting complaint Past psychiatric history Medical history Family history Personal history Social history

M4-PAN-Y18 23

Forensic history Premorbid personality Mental State Examination Management Psychopharmacology


Psychosocial




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Psychosocial




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Psychosocial




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Psychosocial




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Clinical Record Sheet: Additional Clinical Experiences

Date: dd/mm/yy

Date: dd/mm/yy

Date: dd/mm/yy

Date: dd/mm/yy

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Date: dd/mm/yy

Date: dd/mm/yy

Date: dd/mm/yy

Date: dd/mm/yy

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Barberry Film Club Reflection Sheet

Date

Film Title

Presenter/Chair

1. Provide a brief synopsis of the film. What was its relevance to mental health?

2. Based on your background reading or observations of clinical practice, do you think that the film shows a good portrayal of the particular mental health condition or treatment?

3. What were three your key learning outcomes from the discussion that ensued?

M4-PAN-Y18 33

Neurology

Overview

You will spend about a day and a half a week over 9 weeks doing Neurology as part of the PAN rotation.

Your module lead for Neurology is Dr Hani Benamer ([email protected]).

Your Undergraduate Co-ordinator is Amanda Brown ([email protected])

Required Prior Learning

1. Normal anatomy of the brain, spinal cord, peripheral nerves and muscle, including an understanding

of embryogenesis.

2. Knowledge of the cerebrospinal fluid pathways including the ventricular system, cerebrospinal fluid

production and absorption.

3. Knowledge of the blood circulation of the brain including arteries arising from the internal carotids

and vertebrals and venous drainage of the brain including the venous sinuses.

4. An understanding of the learning objectives from Neurones and Synapses (Yr 1) and from Brain and

Behaviour (Yr 2).

5. Awareness of the organisation of the motor and sensory systems and of the anatomical relations of

the cranial nerves.

6. Awareness of the principles of history taking and application of the aphorism of “Let the patient do

the talking when taking a history” i.e. keep the questions open and brief.

7. Basic knowledge of examination of the motor and sensory systems, higher cerebral function, cranial

nerves.



M4-PAN-Y18 34

Learning Outcomes

At the end of the experience, the student should be able to:

I think I can do this (tick when

complete)

1. Take a focussed neurologic history, with attention to (a) the symptoms that

help most with diagnosis and (b) those that are most problematic for the

patient.

2. Carry out an efficient neurologic examination including cranial nerves, higher

cerebral function and motor and sensory examination. Particular attention to

learning fundoscopy.

3. Anatomical localisation of the lesion using information from history and

examination.

4. Formulate a differential diagnosis and identify the most likely diagnosis.

5. Identify a logical investigation schedule to confirm or exclude differential

diagnoses.

6. Understand the basic principles of different neurological investigations and the

indications for and obtain consent for non-invasive procedures such as MRI

and EEG and know the outlines of consent for invasive procedures including

neurosurgery.

7. Understand the importance of team working (within discipline, multidisciplinary

and multi-agency), particularly in the management of long-term conditions

8. Understand the roles of physiotherapy, occupational therapy, speech therapy,

dietetic services, social services and palliative care services in management of

neurologic disorders.

9. Describe common presentations, investigations and principles of treatment of

the following neurodegenerative disorders: Parkinson’s disease, Motor

Neurone disease, Alzheimer’s disease.


the following neuroinflammatory conditions: Multiple sclerosis, meningitis,

encephalitis (both viral and autoimmune), Guillain Barre syndrome, chronic

inflammatory neuropathies.


the following headache and facial pain syndromes: Migraine (and its variants),

tension type headache, trigeminal neuralgia, headache of raised intracranial

pressure, thunderclap headache and subarachnoid haemorrhage.


the following disorders of consciousness or awareness: Epilepsy, syncope

including vasovagal, cardiac syncope.

13. Make a plan for investigation, urgent treatment and referral of a patient with

possible brain tumour or spinal cord compression.


the following head injury related problems: Concussion, Contusion, subdural

and extradural haemorrhage.

M4-PAN-Y18 35


myasthenia gravis.

16. Understand the principles of monitoring of type 2 respiratory failure in patients

with neuromuscular disease.

Key Presentations

I have seen these patients

Points to always bear in mind:

Acute headache. Is it subarachnoid haemorrhage?

Pyrexia and neck stiffness. Is it bacterial meningitis?

Serial seizures? Is it status epilepticus?

Neuromuscular disorder and respiratory failure

Sudden loss of consciousness. Think hypoglycaemia first

Diagnosis

Case 1 Case 2 Case 3 Case 4

Headache

Blackout

Tremor

Speech disturbance

Visual loss

Diplopia

Limb weakness

Limb numbness

Head injury

Incontinence of urine

M4-PAN-Y18 36

You may encounter some of the following conditions.

Key Conditions

Headache:

Acute – Subarachnoid haemorrhage, Thunderclap migraine, meningitis, encephalitis, Haemorrhagic stroke,

traumatic brain injury. In an older person, consider temporal arteritis.

Chronic – Migraine, Tension type headache, raised intracranial pressure (secondary to Idiopathic

Intracranial hypertension or to space occupying lesion). In an older person consider temporal arteritis.

Facial pain – Trigeminal neuralgia

Blackouts – Epilepsy, Vasovagal syncope, cardiac syncope

Extrapyramidal – Parkinson disease, Essential tremor, Dystonias, drug induced movement disorder,

Huntington’s disease as a model for guiding genetic counselling

Other degenerative disorders – Motor Neurone Disease, Alzheimer’s disease

Inflammatory disorders – Multiple sclerosis, Guillain Barre syndrome, Chronic immune mediated

neuropathies, vasculitis or other inflammatory autoimmune disorders

Muscle and nerve disorders – consider inflammatory or genetic muscle disorders. Disorders of the

neuromuscular junction such as myasthenia gravis. Learn about rarer disorders such as Lambert Eaton

Myasthenic Syndrome to inform learning of mechanism and location of antibody action. Diabetic, Vitamin

B12 deficiency or thiamine deficiency neuropathy

Brain Trauma – Learn criteria for hospital admission. Subdural haemorrhage, Extradural haemorrhage,

diffuse axonal injury

Ataxic disorders – Cerebellar, vestibular and proprioceptive. Cerebellar, vascular and mass lesions to

compare with cerebellar degenerations. Hearing disorders associated with unsteadiness e.g. Meniere’s.

Don’t forget that vitamin B12 deficiency causes sensory ataxia that is treatable if caught early.

Stroke – Localise the lesion clinically and then check against radiology. Distinguish between anterior

circulation (carotid territory) and posterior circulation (vertebral and basilar). Middle cerebral stroke

compared with Anterior cerebral stroke – what are the differences?

M4-PAN-Y18 37

Key Clinical Skills

I think I can do this (tick when complete)

1. Focussed history taking

2. Examination of cranial nerve 2 including visual acuity and fundoscopy

3. Examination of cranial nerves 3,4 and 6 and their brainstem connections

4. Examination of cranial nerves 5,7 and 8 (in the cerebellopontine angle)

5. Distinguishing between upper and lower motor neurone disturbance of the 7th

cranial nerve

6. Aspects of examination of the autonomic (esp. sympathetic) nervous system

7. Knowledge of the function of other cranial nerves e.g. to guide evaluation of

dysphagia

8. Localisation of hemisphere lesions

9. Use of anatomy of cranial nerve nuclei and long tracts to help with brainstem

lesion localisation e.g. to explain internuclear ophthalmoplegia

10. The clinical anatomy of dysarthria and the dysphasias

11. Localisation of cerebellar lesions

12. Localisation of basal ganglia disorders

13. Use of nerve root segment knowledge (dermatome and myotomes) and tendon

reflexes to localise high, mid and low cervical lesions; thoracic lesions and those

affecting the conus medullaris / cauda equina and lumbosacral roots.

14. Emphasise some spinal segments e.g. respiratory failure and high cervical

lesions, C8/T1 and lung apex, L5/S1 and sciatica

15. Common peripheral nerve lesions: ulnar, median and radial in upper limb and

common peroneal nerve in lower limb and Bell’s palsy in the face.

16. Clinical findings in peripheral neuropathy and myopathies

17. Disorders of the neuromuscular junction

18. A working knowledge of apraxia and agnosias

19. Familiarity with a clinical assessment tool for cognitive evaluation e.g. MMSE

and Addenbrooke’s Scale

20. Recognition of the causes of coma and familiarity with the Glasgow Coma Scale

M4-PAN-Y18 38

Key Investigations

I know about these

1. MRI (of brain and spine) and CT scanning (of head). Familiarise yourself with the

advantages and limitations of these modalities. See the procedure so you can

obtain informed consent from your patients and perhaps allay their fears.

2. Nerve conduction studies and electromyography. Know the difference between

these and as above know what the procedure involves.

3. For both the above, you should have outline knowledge of abnormal findings and

be able to compare your clinical localisation of lesions with the imaging or

neurophysiological localisation.

4. Angiography including CTA, MRA and catheter studies. Some of you will see an

interventional radiology procedure such as coiling of an intracranial aneurysm

following subarachnoid haemorrhage.

5. Electroencephalography. Familiarise yourself with the indications for and the

limitations of this test.

6. Appropriate use of specialised blood tests e.g. antiacetylcholine receptor

antibodies in myasthenia gravis.

7. Spinal fluid examination after lumbar puncture. Beware the common traps e.g.

missing out CSF glucose measurement, failing to record CSF opening pressure

and not sending a serum specimen for oligoclonal immunoglobulins.

Key Medications I have learnt about these

1. Treatment of headache – acute treatments to include triptans for migraine and

prophylactic treatments to include propranolol and topiramate.

2. Anticonvulsants – Find out which drug for a given type of epilepsy. Study a core

population of carbamazepine, sodium valproate, phenytoin, lamotrigine and

levetiracetam.

3. Anti-Parkinson medications – Study levodopa / carbidopa and levodopa /

benserazide combinations, monoamine oxidase inhibitors. COMT inhibitors, non-

ergoline dopamine agonists, and be aware of amantadine and injectable

dopamine agonist. Be aware of the limitations of use of anticholinergics.

4. Disease modifying drugs used for Multiple Sclerosis – Know about the principle

of Disease Modifying Drugs.

5. Dementia drugs – Find out about centrally acting anticholinesterases.

6. Immune modulatory medication – Be familiar with the use of corticosteroids,

intravenous immunoglobulins, azathioprine, methotrexate, ciclosporin,

cyclophosphamide and mycophenolate.

7. Symptom treatment in myasthenia gravis – Pyridostigmine. The possible place of

edrophonium in testing.

8. Strategies for lowering intracranial pressure – place of mannitol,

dexamethasone. Principles of anticoagulant management especially pre-lumbar

puncture or surgery.

M4-PAN-Y18 39

9. Treatment of acute meningitis – antibiotics to cover suspected organism – get

immediate advice from microbiology.

10. Treatment of viral encephalitis – Aciclovir.

11. Treatment of ruptured aneurysm subarachnoid haemorrhage – Nimodipine.

Key Clinical Areas or Activities I have done this

1. Neuroscience Outpatients, Area 1 , Ground Floor, QEHB

2. Ward 411 – Neurology and Stroke ward, 4th Floor, QEHB

3. Wards 409 and 407 – Neurosurgery wards, 4th Floor QEHB

4. Imaging, Ground floor, QEHB

5. Neurophysiology, Adjacent to Neuroscience Outpatients

6. Neuro Theatres, Operation Theatres 17,18 and 20, 2nd Floor, QEHB

M4-PAN-Y18 40

Learning Materials (Canvas)

Virtual Cases Neurology E- (mini) Lectures

Part 1

Part 2

Part 3

E Lectures (from Y3)

Intro to clinical neurology

EEG and EP eLecture

Epilepsy & Blackouts

Multiple sclerosis; nuts and bolts

How to deal with tremor patients?

Headache

Neuroradiology

Stroke

Videos

Neurological Examination

Cranial Nerves Abnormalities

Abnormal Gaits

Neurological Signs I

Neurological Signs II

Speech disorders

I have looked at this

M4-PAN-Y18 41

Portfolio Activities

(Summary of things you should have completed for your portfolio)

I have done this

1. Reflect on your experience in theatre

2. Reflect on your experience on the ward

3. Reflect on your experience in clinic

4. Reflect on your experience of witnessing a patient undergo neuro-imaging

M4-PAN-Y18 42

Notes on an experience in theatre

What procedure was being performed?

What did you learn about the procedure?

Preparation of the Patient for Surgery Use of Safe Surgery Checklists

Roles of various members of the theatre team

Communication during surgery Ergonomics of the operating theatre

Recovery of Patient

Indications for further learning

Learning to be undertaken Resources / experiences needed

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Notes on an experience on a neurology ward

What sort of patients are treated on a neurology ward?

Describe the roles of the various members of the clinical team that work of a neurology ward

Reflect on the patient’s (or their relatives or carer’s) experience in this part of the health service

Main things learnt from this experience?



M4-PAN-Y18 44

Notes on an experience during a neurology outpatients clinic

What sort of patients are seen in the neurology outpatients clinic?

Describe the roles of the various members of the clinical team that contribute to a neurology outpatients clinic.





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Notes on a neurophysiology and neuroradiology

Why did this patient need this imaging procedure performed, how were they prepared for the procedure, who performed the procedure, and how well do you think they did? Which other professionals were involved and what was their role?





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Notes

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Notes

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