Formulation for Final year Diagnosticear postgraduates 04-03-23.pptx

Formulation for Final year

1. Diagnostic Formulation and Management Plan Dr Parthasarathy, MD , Associate Professor, Department of Psychiatry, Pondicherry Institute of Medical Sciences. Editor-in-Chief, JCRSM. 04-03-2023 Diagnostic formulation and management plan 1

2. 04-03-2023 Diagnostic formulation and management plan 2 Diagnostic formulation

3. Guiding principles Interpret your findings on history and MSE Don’t give textbook description Aim towards the diagnosis or differential diagnosis Incorporate feedback given by examiners 04-03-2023 Diagnostic formulation and management plan 3

4. Elements of diagnostic formulation Socio-demographic details Onset, course and precipitating factor Key symptoms that support the diagnosis Risk of harm to self or others Key points in negative history Medical and psychiatric comorbidity Treatment history – Adequate trial, improvement and side-effects Past and family history – positive findings Premorbid personality – interpretation 04-03-2023 Diagnostic formulation and management plan 4

5. Elements of diagnostic formulation Positive findings on physical examination Positive findings on MSE Positive findings on cognitive functions Judgment Insight Diagnosis/Differential diagnosis Management plan Prognosis 04-03-2023 Diagnostic formulation and management plan 5

6. Tips Duration – Approximately 5 minutes Highlight the important aspects that aid your diagnosis or management Prepare template for common diagnoses and get it corrected by your consultants Write before going in for your exam Present clearly and boldly 04-03-2023 Diagnostic formulation and management plan 6

7. Example 1 – BPAD CE Mania without psychotic symptoms + NDS + Obesity 30 year old married hindu male, educated up to BE, currently working in a private company hailing from an urban background presented with a total duration of illness of 4 years, episodic illness with 3 episodes in the past 4 years, inter-episode interval patient reached premorbid self with normal functioning; each episode characterised by persistent elevated mood, increased psychomotor activity, increased goal directed activity, reduced need for sleep and grandiose ideas and 3 year history of nicotine use in the form of smoking 10 cigarettes per day with craving, withdrawal symptoms and use despite negative consequences in the absence of organicity with no significant family history and a well-adjusted premorbid personality 04-03-2023 Diagnostic formulation and management plan 7

8. Example 1 – BPAD CE Mania without psychotic symptoms + NDS + Obesity Physical examination revealed a BMI of 35 kg/m2 and Mental status examination revealed increased psychomotor activity, increased tone, tempo and volume of speech with reduced reaction time, irritable affect, flight of ideas and grandiose ideas and impaired concentration, impaired personal and social judgment and insight of 1/5 Hence I would like to make a diagnosis of Bipolar affective disorder – Current episode Mania without psychotic symptoms + Nicotine dependence syndrome – currently abstinent in a protected environment + Obesity 04-03-2023 Diagnostic formulation and management plan 8

9. Diagnosis or differential diagnosis Based on ICD-10 criteria Use information presented in long case presentation and then highlighted in the formulation Provide full diagnosis – including psychiatric comorbidity and medical comorbidity Be prepared to give a multi-axial diagnosis if the examiner asks for it Justification of the diagnosis 04-03-2023 Diagnostic formulation and management plan 9

10. Diagnosis or differential diagnosis Avoid Giving differential diagnosis for the sake of giving one Multiple differential diagnosis Non ICD-10 terms for diagnosis Grossly different differential diagnosis 04-03-2023 Diagnostic formulation and management plan 10

11. Example 2 –Cannabis dependence syndrome + Cannabis induced psychotic disorder versus schizophrenia 35 year old male, educated up to BA, currently unemployed, hailing from MSES of rural Tamil Nadu Presented with 3 year history of cannabis use with prominent craving, tolerance, loss of control and use despite harmful consequences; average use – 5 joints per day; last use 20 days back; previous abstinent periods lasting less than 10 days And 1 year history of psychotic symptoms thought broadcasting, auditory hallucinations – voices discussing type, delusion of persecution and reference, impaired socio-occupational functioning In the absence of persistent mood, anxiety symptoms or features of organicity 04-03-2023 Diagnostic formulation and management plan 11

12. Example 2 –Cannabis dependence syndrome + Cannabis induced psychotic disorder versus schizophrenia Previous good response to Olanzapine up to 15 mg per day; full resolution of psychotic symptoms when he was on medications; discontinued medications after 3 months due to sedation No significant past history Family history suggestive of psychotic illness in maternal uncle Well adjusted premorbid personality Physical examination was normal MSE reveals normal PMA, normal speech, constricted affect, thought broadcasting, delusion of persecution and reference, auditory hallucinations – voices discussing type, impaired personal and social judgment and insight of 2/5 04-03-2023 Diagnostic formulation and management plan 12

13. Example 2 –Cannabis dependence syndrome + Cannabis induced psychotic disorder versus schizophrenia I would like to make a differential diagnosis Cannabis dependence syndrome + Cannabis induced psychotic disorder And a differential diagnosis of Cannabis dependence syndrome + Undifferentiated schizophrenia 04-03-2023 Diagnostic formulation and management plan 13

14. 04-03-2023 Diagnostic formulation and management plan 14 Management plan

15. Management plan 1. Outpatient or inpatient care – reason 2. Clarification of history, serial MSEs, review of treatment records 3. Investigations – Mention specific investigations 4. Rating scale – baseline and weekly 5. Consultations 6. Pharmacological management – specific drug, dose, titration 7. Non-pharmacological management – Psychoeducation, MET, CBT, Family therapy 04-03-2023 Diagnostic formulation and management plan 15

16. Management plan Avoid “Routine investigations” Broad statements – second generation antipsychotic, psychotherapy Hypothetical statements Management as if you have seen the patient previously 04-03-2023 Diagnostic formulation and management plan 16

17. Example 3 – Severe depression without psychotic symptoms I would like to manage this patient on inpatient basis in view of recent suicide attempt. After admission, I will instruct the ward staff to follow all the precautions to prevent suicide attempt. I would like to send the following investigations – complete blood count, blood urea, serum creatinine, liver function tests, thyroid function tests, fasting blood sugar, postprandial blood sugar, fasting lipid profile, Electrocardiogram(ECG) 04-03-2023 Diagnostic formulation and management plan 17

18. Example 3 – Severe depression without psychotic symptoms I will rate the patient on Hamilton Depression rating scale – at baseline to assess the severity and weekly to assess the improvement I will start the patient on Tab Escitalopram 5 mg and titrate the dose to 10-20 mg per day based on response and tolerability In addition, I will start the patient on Tab Clonazepam 0.25 mg in the morning to reduce her anxiety and emotional distress and 0.5 mg at night to improve her sleep 04-03-2023 Diagnostic formulation and management plan 18

19. Example 3 – Severe depression without psychotic symptoms Non pharmacological management – I will educate the patient and family members regarding the nature of illness, course of illness, treatment options available, time course of improvement and side-effects of medications 04-03-2023 Diagnostic formulation and management plan 19

20. Management plan Mention indication of admission Avoid abbreviations Management plan tailored to the individual patient( eg past history of good response to particular medication, avoid expensive medication for patients from poor socio-economic status) Avoid hypothetical statements( eg if the patient worsens, I will give ECT) Avoid talking about specific psychotherapy unless indicated in the patient 04-03-2023 Diagnostic formulation and management plan 20

21. Example 4 – Alcohol dependence syndrome – Uncomplicated withdrawal + Nicotine dependence syndrome + SHTN + DM I would like to admit the patient in view of previous failed outpatient treatments and for the evaluation of medical comorbidity I will send the following investigations – Complete blood count, blood urea, serum creatinine, liver function tests, fasting blood sugar, postpradial blood sugar, fasting lipid profile, HbA1c, urine albumin, sugar and microscopy, ultrasound abdomen I will rate the patient on Clinical Institute Withdrawal Assessment – Alcohol revised at baseline to assess the severity of withdrawal; subsequently I will rate the patient daily to assess the improvement of withdrawal symptoms till the score remains less than eight consistently 04-03-2023 Diagnostic formulation and management plan 21

22. Example 4 – Alcohol dependence syndrome – Uncomplicated withdrawal + Nicotine dependence syndrome + SHTN + DM I will obtain medicine consultation for management of the medical problems namely hypertension and diabetes mellitus I will start the patient on Tab Lorazepam 2 mg 1-1-1-2 for the control of alcohol withdrawal symptoms; subsequently I will reduce the dose of lorazepam by 2 mg every 1-2 days based on CIWA- Ar score In addition, I will start the patient on Inj Thiamine 300 mg and multivitamin injection intravenously I will also start the patient on Tab Pantoprazole 40 mg twice daily to control symptoms of gastritis 04-03-2023 Diagnostic formulation and management plan 22

23. Example 4 – Alcohol dependence syndrome – Uncomplicated withdrawal + Nicotine dependence syndrome + SHTN + DM In addition, I will initiate Nicotine chewing gums 2 mg 6 times a day and sos to control features of nicotine withdrawal and craving I would like to re-evaluate the patient’s level of motivation to quit alcohol and nicotine after his withdrawal symptoms subside I will initiate motivation enhancement therapy to improve the patient’s motivation to quit alcohol and nicotine 04-03-2023 Diagnostic formulation and management plan 23

24. Example 4 – Alcohol dependence syndrome – Uncomplicated withdrawal + Nicotine dependence syndrome + SHTN + DM I will offer the option of disulfiram to this patient as the motivation level improves. After explaining the actions of disulfiram and the precautions to be followed, I will get written informed consent from the patient and his wife. Then, I will start Tab Disulfiram 250 mg once daily to be administered by the patient’s wife. During follow-up sessions, I will discuss relapse prevention strategies with the patient. 04-03-2023 Diagnostic formulation and management plan 24

25. What is the prognosis of this patient? Good prognostic factors Poor prognostic factors Short term prognosis Long term prognosis 04-03-2023 Diagnostic formulation and management plan 25

26. Parting thoughts Interpret your findings on history and MSE Aim towards the diagnosis or differential diagnosis Incorporate feedback given by examiners Management plan in a systematic manner Practise, practise and practise.! 04-03-2023 Diagnostic formulation and management plan 26

27. Suggested reading Kuruvilla K, Kuruvilla A. Diagnostic formulation.  Indian J Psychiatry . 2010;52(1):78-82. doi:10.4103/0019-5545.58905 04-03-2023 Diagnostic formulation and management plan 27