Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Assessment of Mood. Key concepts: Symptoms, syndromes, episodes, and disorders. Depressive symptoms. Manic Symptoms. Mood Episodes and Disorders: Major Depressive Disorder, Bipolar Disorder. Screening for depression. Assessment of Anxiety. Main Anxiety Disorders: Specific Phobia; Social Phobia (aka social anxiety disorder); Panic Disorder with/without Agoraphobia; Generalized Anxiety Disorder; Obsessive Compulsive Disorder; Post-traumatic Stress Disorder.

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

By the completion of this presentation, attendees will be able to describe risk factors for suicide; be familiar with key components of a suicide risk assessment; be aware of questions to use in a suicide risk assessment.

Fergie is a 23-year-old single woman with no children who lives with her parents. She completed university with difficulty, taking time off frequently but eventually completing her degree. She reports having difficulties with relationships since middle school and not knowing who she really is affects her mood, attention and concentration. This had an impact upon her schooling but she managed to finish with a huge effort. However, she has been unable to ever work in any capacity since finishing University a year ago. Fergie was referred by her family physician for a psychiatric consultation because she frequently presented to the family physician or student health with low mood and suicidal ideations. At times her family doctor had to send her to ER for urgent assessment following disclosure of taking an overdose or cutting her arms. She is hoping that some medications like an antidepressants will be prescribed for her and that you will believe she is unwell and needing help. She has a huge hope that you will see her regularly, and provide her with answers as to why she is not feeling happy, why she feels empty, and why she is unable to control her anger. She is also considering bipolar disorder as she heard from student health counsellor that she may have a bipolar disorder because she reported increased spending, increased sexual activity, and reckless driving. And she also informed you that she has an eating disorder when she binge eats at times. She is well read on mental health and has attended many counsellors since middle school including private therapists that her parents took her to see.

Assessment of Mood. Key concepts: Symptoms, syndromes, episodes, and disorders. Depressive symptoms. Manic Symptoms. Mood Episodes and Disorders: Major Depressive Disorder, Bipolar Disorder. Screening for depression. Assessment of Anxiety. Main Anxiety Disorders: Specific Phobia; Social Phobia (aka social anxiety disorder); Panic Disorder with/without Agoraphobia; Generalized Anxiety Disorder; Obsessive Compulsive Disorder; Post-traumatic Stress Disorder.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Assessment of Mood. Key concepts: Symptoms, syndromes, episodes, and disorders. Depressive symptoms. Manic Symptoms. Mood Episodes and Disorders: Major Depressive Disorder, Bipolar Disorder. Screening for depression. Assessment of Anxiety. Main Anxiety Disorders: Specific Phobia; Social Phobia (aka social anxiety disorder); Panic Disorder with/without Agoraphobia; Generalized Anxiety Disorder; Obsessive Compulsive Disorder; Post-traumatic Stress Disorder.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Fergie is a 23-year-old single woman with no children who lives with her parents. She completed university with difficulty, taking time off frequently but eventually completing her degree. She reports having difficulties with relationships since middle school and not knowing who she really is affects her mood, attention and concentration. This had an impact upon her schooling but she managed to finish with a huge effort. However, she has been unable to ever work in any capacity since finishing University a year ago. Fergie was referred by her family physician for a psychiatric consultation because she frequently presented to the family physician or student health with low mood and suicidal ideations. At times her family doctor had to send her to ER for urgent assessment following disclosure of taking an overdose or cutting her arms. She is hoping that some medications like an antidepressants will be prescribed for her and that you will believe she is unwell and needing help. She has a huge hope that you will see her regularly, and provide her with answers as to why she is not feeling happy, why she feels empty, and why she is unable to control her anger. She is also considering bipolar disorder as she heard from student health counsellor that she may have a bipolar disorder because she reported increased spending, increased sexual activity, and reckless driving. And she also informed you that she has an eating disorder when she binge eats at times. She is well read on mental health and has attended many counsellors since middle school including private therapists that her parents took her to see.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Mrs. Tammy Polk is very difficult to interview. She is an extremely vague and difficult historian. Her family tell you that she was diagnosed with breast cancer 5 years ago and had a mastectomy at that time. Her husband died 6 months ago and she has never really recovered. Over the past week, the family have been worried that she is "developing Alzheimer's" because of memory problems and agitation. Past psychiatric history is notable for mild depression, treated with paroxetine 20mg daily, and sleep difficulties that are chronic and date back to her days as an alcoholic. One month ago, she was started on 50 mg of quetiapine at bedtime for sleep by her family doctor. Two weeks ago, she was given Oxybutinin (Ditropan) to help with some urinary incontinence, with good effect on her bladder problem. She is admitted to hospital for further medical work-up. The 1 pm nursing note reads: "quiet, resting comfortably, oriented x 3." The results of CBC, serum electrolytes and urinalysis are pending. The medical resident calls for psychiatric consultation at 4:05 pm because the patient has become agitated and has voiced suicidal ideation. The consult note reads: "medically cleared, please transfer to psychiatry for treatment of emotional instability and psychotic depression." The psychiatric resident arrives at 5 pm and finds that the patient is visually hallucinating and disoriented.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Desta Ayo is a 42 year old woman, on disability pension and married to a disabled man. She was brought to the hospital by ambulance after she called 911 to report she was dying. After running a few tests, the ER physician could not find anything wrong with her. He referred her to psychiatry because the problem was obviously "all in her head." On interview, Desta sits motionless in the chair, opening her eyes and speaking with dramatic effort. She believes she is again suffering with another kidney infection, like the one that almost killed her 10 years ago. She describes "passing out" almost every day for the last 2 weeks, feeling too weak to walk, and experiencing crippling back pain. She denies anxiety and depression but continues to take paroxetine for chronic pain and Trazodone for sleep. She says she has arthritis throughout her back, frequent migraines, temperomandibular joint pain, chronic fatigue, and recurrent sinusitis that eats away at her nasal bones. She also reports a history of gynaecological problems since age 22, with breast cyst and ovarian cyst surgery, endometriosis, and uterine fibroids. She reports an early childhood history of sexual and physical abuse. She remembers her mother as an alcoholic, a distant and cruel woman. Inquiries about current stress in her life reveal major financial problems and an argument with her mother on the phone 2 weeks ago. She says that she doesn't think her mother will ever talk to her again.

Today, Siobhan came in sobbing, dragging a reluctant 8-year-old Skylar behind her. She wailed, "He's turning out just like his Dad. Before you know it he'll be in jail for assault, I'm scared of both of them." Siobhan explains that Skylar punched a boy in the face today and was suspended for 3 days. Evidently, there have been numerous incidents at school where the Grade 3 teacher claimed Skylar was the aggressor. This implied information about Skylar 's father was news to you and you suspect that there was more going on in the home than Siobhan had shared with you in the past. You wonder how to approach Siobhan about this.

Fergie is a 23-year-old single woman with no children who lives with her parents. She completed university with difficulty, taking time off frequently but eventually completing her degree. She reports having difficulties with relationships since middle school and not knowing who she really is affects her mood, attention and concentration. This had an impact upon her schooling but she managed to finish with a huge effort. However, she has been unable to ever work in any capacity since finishing University a year ago. Fergie was referred by her family physician for a psychiatric consultation because she frequently presented to the family physician or student health with low mood and suicidal ideations. At times her family doctor had to send her to ER for urgent assessment following disclosure of taking an overdose or cutting her arms. She is hoping that some medications like an antidepressants will be prescribed for her and that you will believe she is unwell and needing help. She has a huge hope that you will see her regularly, and provide her with answers as to why she is not feeling happy, why she feels empty, and why she is unable to control her anger. She is also considering bipolar disorder as she heard from student health counsellor that she may have a bipolar disorder because she reported increased spending, increased sexual activity, and reckless driving. And she also informed you that she has an eating disorder when she binge eats at times. She is well read on mental health and has attended many counsellors since middle school including private therapists that her parents took her to see.

Malcolm Lowry presents to the ED of the Hamilton General Hospital accompanied by his wife, Vita. He is seen by a second-year resident in Emergency Medicine and a clinical clerk. Mr. Lowry is a 47-year-old businessman. This afternoon, he collapsed in front of his wife, who observed that both arms and legs were shaking and that his eyes were rolled back. After 30-60 seconds the shaking stopped, but he was unresponsive for several minutes and remained drowsy and confused for half an hour. Vita called 911 and Malcolm was taken to the Emergency Department. The patient states that this has never happened to him before. He had no warning symptoms prior to collapsing. He does not remember collapsing. He did not soil himself or bite his tongue, but his muscles are sore. His past health has been good. He does not have hypertension, diabetes or other chronic health problems. He has never been hospitalized and he is not on any medications. He denies recent head trauma, febrile illness, headache or neurological symptoms. He has no family history of epilepsy. Vita states that Malcolm has been drinking alcohol heavily for a number of months but stopped two days ago after she removed all the alcohol from the house. Today he was so tremulous that he could hardly button his shirt. Malcolm points out that he has stopped alcohol for a day or two several times in the past few months, and although he has felt shaky he has never had a seizure.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Beau is a 3-year-old boy, the youngest of three children. His father manages a local bank and his mother is a stay-at-home mom. He has two older sisters, Theresa age 7 and Gracie age 9. His parents are in their late 30s. Beau is the focus of the entire family's attention and the apple of everyone's eye. His sisters behave like 2 additional mothers, to the point that they anticipate his every need. His parents have even noted that his language development seemed slightly slower than his sisters' as he did not need to use language to have his needs met. He now speaks well but it just seemed to be slower than his sisters (who his mother described as early talkers). Beau's mother's pregnancy was unexpected but welcomed. The pregnancy was uneventful with no history of substance use. Beau was full term and the delivery was uneventful. Beau was a cute and cuddly infant. He breastfed well and developed predictable routines for both sleeping and feeding. He appears quite adaptable. For instance, when family visits other family or friends, Beau smiles, plays and amiably engages children and adults alike. He has even slept well at these homes if needed. He needed only his favourite blanket in those situations to assist him with settling down to sleep.

Desta Ayo is a 42 year old woman, on disability pension and married to a disabled man. She was brought to the hospital by ambulance after she called 911 to report she was dying. After running a few tests, the ER physician could not find anything wrong with her. He referred her to psychiatry because the problem was obviously "all in her head." On interview, Desta sits motionless in the chair, opening her eyes and speaking with dramatic effort. She believes she is again suffering with another kidney infection, like the one that almost killed her 10 years ago. She describes "passing out" almost every day for the last 2 weeks, feeling too weak to walk, and experiencing crippling back pain. She denies anxiety and depression but continues to take paroxetine for chronic pain and Trazodone for sleep. She says she has arthritis throughout her back, frequent migraines, temperomandibular joint pain, chronic fatigue, and recurrent sinusitis that eats away at her nasal bones. She also reports a history of gynaecological problems since age 22, with breast cyst and ovarian cyst surgery, endometriosis, and uterine fibroids. She reports an early childhood history of sexual and physical abuse. She remembers her mother as an alcoholic, a distant and cruel woman. Inquiries about current stress in her life reveal major financial problems and an argument with her mother on the phone 2 weeks ago. She says that she doesn't think her mother will ever talk to her again.

Fergie is a 23-year-old single woman with no children who lives with her parents. She completed university with difficulty, taking time off frequently but eventually completing her degree. She reports having difficulties with relationships since middle school and not knowing who she really is affects her mood, attention and concentration. This had an impact upon her schooling but she managed to finish with a huge effort. However, she has been unable to ever work in any capacity since finishing University a year ago. Fergie was referred by her family physician for a psychiatric consultation because she frequently presented to the family physician or student health with low mood and suicidal ideations. At times her family doctor had to send her to ER for urgent assessment following disclosure of taking an overdose or cutting her arms. She is hoping that some medications like an antidepressants will be prescribed for her and that you will believe she is unwell and needing help. She has a huge hope that you will see her regularly, and provide her with answers as to why she is not feeling happy, why she feels empty, and why she is unable to control her anger. She is also considering bipolar disorder as she heard from student health counsellor that she may have a bipolar disorder because she reported increased spending, increased sexual activity, and reckless driving. And she also informed you that she has an eating disorder when she binge eats at times. She is well read on mental health and has attended many counsellors since middle school including private therapists that her parents took her to see.

Today, Siobhan came in sobbing, dragging a reluctant 8-year-old Skylar behind her. She wailed, "He's turning out just like his Dad. Before you know it he'll be in jail for assault, I'm scared of both of them." Siobhan explains that Skylar punched a boy in the face today and was suspended for 3 days. Evidently, there have been numerous incidents at school where the Grade 3 teacher claimed Skylar was the aggressor. This implied information about Skylar 's father was news to you and you suspect that there was more going on in the home than Siobhan had shared with you in the past. You wonder how to approach Siobhan about this.

Desta Ayo is a 42 year old woman, on disability pension and married to a disabled man. She was brought to the hospital by ambulance after she called 911 to report she was dying. After running a few tests, the ER physician could not find anything wrong with her. He referred her to psychiatry because the problem was obviously "all in her head." On interview, Desta sits motionless in the chair, opening her eyes and speaking with dramatic effort. She believes she is again suffering with another kidney infection, like the one that almost killed her 10 years ago. She describes "passing out" almost every day for the last 2 weeks, feeling too weak to walk, and experiencing crippling back pain. She denies anxiety and depression but continues to take paroxetine for chronic pain and Trazodone for sleep. She says she has arthritis throughout her back, frequent migraines, temperomandibular joint pain, chronic fatigue, and recurrent sinusitis that eats away at her nasal bones. She also reports a history of gynaecological problems since age 22, with breast cyst and ovarian cyst surgery, endometriosis, and uterine fibroids. She reports an early childhood history of sexual and physical abuse. She remembers her mother as an alcoholic, a distant and cruel woman. Inquiries about current stress in her life reveal major financial problems and an argument with her mother on the phone 2 weeks ago. She says that she doesn't think her mother will ever talk to her again.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

Malcolm Lowry presents to the ED of the Hamilton General Hospital accompanied by his wife, Vita. He is seen by a second-year resident in Emergency Medicine and a clinical clerk. Mr. Lowry is a 47-year-old businessman. This afternoon, he collapsed in front of his wife, who observed that both arms and legs were shaking and that his eyes were rolled back. After 30-60 seconds the shaking stopped, but he was unresponsive for several minutes and remained drowsy and confused for half an hour. Vita called 911 and Malcolm was taken to the Emergency Department. The patient states that this has never happened to him before. He had no warning symptoms prior to collapsing. He does not remember collapsing. He did not soil himself or bite his tongue, but his muscles are sore. His past health has been good. He does not have hypertension, diabetes or other chronic health problems. He has never been hospitalized and he is not on any medications. He denies recent head trauma, febrile illness, headache or neurological symptoms. He has no family history of epilepsy. Vita states that Malcolm has been drinking alcohol heavily for a number of months but stopped two days ago after she removed all the alcohol from the house. Today he was so tremulous that he could hardly button his shirt. Malcolm points out that he has stopped alcohol for a day or two several times in the past few months, and although he has felt shaky he has never had a seizure.

Shelley is an 18-year-old female who lives with her parents and her younger brother. She had graduated from a local high school in June. Shelley received ODSP (Ontario Disability Support) when she turned 18 years of age because of her intellectual disability. Soon after, this young woman started working part-time at a local grocery store after completing a work placement but had taken a sick leave as of November. Her hobbies included painting, journaling, and video games. She has a few close friends she has known from grade 8 whom she sees over Skype. She has a younger brother, 16 years of age, Tom. Tom has always excelled in school, is popular, and plays on many sports teams. Her parents are Jennifer (42 years of age) and Peter (43 years of age). Her parents are Black Caribbean first-generation immigrants from Trinidad. Her father worked full time in the steel industry for many years until about a year ago when he took sick leave due to cardiovascular disease. Her father was described as being somewhat distant and critical of Shelley. Shelley described a very close relationship with her mother, who provided most of the instrumental and emotional support to Shelley over the years. Her mother was recently laid off in March from a restaurant where she worked as a waitress. Then she was quarantined for two weeks at home in her room in March with COVID. Shelley’s mother had residual fatigue and cough after recuperating from the acute symptoms of COVID. None of the other family members tested positive for COVID, but they all had vitamin D deficiency and started taking supplements.

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Desta Ayo is a 42 year old woman, on disability pension and married to a disabled man. She was brought to the hospital by ambulance after she called 911 to report she was dying. After running a few tests, the ER physician could not find anything wrong with her. He referred her to psychiatry because the problem was obviously "all in her head." On interview, Desta sits motionless in the chair, opening her eyes and speaking with dramatic effort. She believes she is again suffering with another kidney infection, like the one that almost killed her 10 years ago. She describes "passing out" almost every day for the last 2 weeks, feeling too weak to walk, and experiencing crippling back pain. She denies anxiety and depression but continues to take paroxetine for chronic pain and Trazodone for sleep. She says she has arthritis throughout her back, frequent migraines, temperomandibular joint pain, chronic fatigue, and recurrent sinusitis that eats away at her nasal bones. She also reports a history of gynaecological problems since age 22, with breast cyst and ovarian cyst surgery, endometriosis, and uterine fibroids. She reports an early childhood history of sexual and physical abuse. She remembers her mother as an alcoholic, a distant and cruel woman. Inquiries about current stress in her life reveal major financial problems and an argument with her mother on the phone 2 weeks ago. She says that she doesn't think her mother will ever talk to her again.

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

Fergie is a 23-year-old single woman with no children who lives with her parents. She completed university with difficulty, taking time off frequently but eventually completing her degree. She reports having difficulties with relationships since middle school and not knowing who she really is affects her mood, attention and concentration. This had an impact upon her schooling but she managed to finish with a huge effort. However, she has been unable to ever work in any capacity since finishing University a year ago. Fergie was referred by her family physician for a psychiatric consultation because she frequently presented to the family physician or student health with low mood and suicidal ideations. At times her family doctor had to send her to ER for urgent assessment following disclosure of taking an overdose or cutting her arms. She is hoping that some medications like an antidepressants will be prescribed for her and that you will believe she is unwell and needing help. She has a huge hope that you will see her regularly, and provide her with answers as to why she is not feeling happy, why she feels empty, and why she is unable to control her anger. She is also considering bipolar disorder as she heard from student health counsellor that she may have a bipolar disorder because she reported increased spending, increased sexual activity, and reckless driving. And she also informed you that she has an eating disorder when she binge eats at times. She is well read on mental health and has attended many counsellors since middle school including private therapists that her parents took her to see.

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

An outlined approach to understanding and assessing social determinants of health by examining how children's environments affect their biology and their pathways in health.

Beau is a 3-year-old boy, the youngest of three children. His father manages a local bank and his mother is a stay-at-home mom. He has two older sisters, Theresa age 7 and Gracie age 9. His parents are in their late 30s. Beau is the focus of the entire family's attention and the apple of everyone's eye. His sisters behave like 2 additional mothers, to the point that they anticipate his every need. His parents have even noted that his language development seemed slightly slower than his sisters' as he did not need to use language to have his needs met. He now speaks well but it just seemed to be slower than his sisters (who his mother described as early talkers). Beau's mother's pregnancy was unexpected but welcomed. The pregnancy was uneventful with no history of substance use. Beau was full term and the delivery was uneventful. Beau was a cute and cuddly infant. He breastfed well and developed predictable routines for both sleeping and feeding. He appears quite adaptable. For instance, when family visits other family or friends, Beau smiles, plays and amiably engages children and adults alike. He has even slept well at these homes if needed. He needed only his favourite blanket in those situations to assist him with settling down to sleep.

Beau is a 3-year-old boy, the youngest of three children. His father manages a local bank and his mother is a stay-at-home mom. He has two older sisters, Theresa age 7 and Gracie age 9. His parents are in their late 30s. Beau is the focus of the entire family's attention and the apple of everyone's eye. His sisters behave like 2 additional mothers, to the point that they anticipate his every need. His parents have even noted that his language development seemed slightly slower than his sisters' as he did not need to use language to have his needs met. He now speaks well but it just seemed to be slower than his sisters (who his mother described as early talkers). Beau's mother's pregnancy was unexpected but welcomed. The pregnancy was uneventful with no history of substance use. Beau was full term and the delivery was uneventful. Beau was a cute and cuddly infant. He breastfed well and developed predictable routines for both sleeping and feeding. He appears quite adaptable. For instance, when family visits other family or friends, Beau smiles, plays and amiably engages children and adults alike. He has even slept well at these homes if needed. He needed only his favourite blanket in those situations to assist him with settling down to sleep.

Today, Siobhan came in sobbing, dragging a reluctant 8-year-old Skylar behind her. She wailed, "He's turning out just like his Dad. Before you know it he'll be in jail for assault, I'm scared of both of them." Siobhan explains that Skylar punched a boy in the face today and was suspended for 3 days. Evidently, there have been numerous incidents at school where the Grade 3 teacher claimed Skylar was the aggressor. This implied information about Skylar 's father was news to you and you suspect that there was more going on in the home than Siobhan had shared with you in the past. You wonder how to approach Siobhan about this.

Today, Siobhan came in sobbing, dragging a reluctant 8-year-old Skylar behind her. She wailed, "He's turning out just like his Dad. Before you know it he'll be in jail for assault, I'm scared of both of them." Siobhan explains that Skylar punched a boy in the face today and was suspended for 3 days. Evidently, there have been numerous incidents at school where the Grade 3 teacher claimed Skylar was the aggressor. This implied information about Skylar 's father was news to you and you suspect that there was more going on in the home than Siobhan had shared with you in the past. You wonder how to approach Siobhan about this.

An outlined approach to understanding and assessing social determinants of health by examining how children's environments affect their biology and their pathways in health.

Psychotic symptoms are common in a wide variety of medical, psychiatric, and substance-induced disorders. They are important to illicit and have important implications for diagnosis, treatment and management.

Psychotic symptoms are common in a wide variety of medical, psychiatric, and substance-induced disorders. They are important to illicit and have important implications for diagnosis, treatment and management.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Psychotic symptoms are common in a wide variety of medical, psychiatric, and substance-induced disorders. They are important to illicit and have important implications for diagnosis, treatment and management.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Psychotic symptoms are common in a wide variety of medical, psychiatric, and substance-induced disorders. They are important to illicit and have important implications for diagnosis, treatment and management.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

Psychotic symptoms are common in a wide variety of medical, psychiatric, and substance-induced disorders. They are important to illicit and have important implications for diagnosis, treatment and management.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Mrs. Tammy Polk is very difficult to interview. She is an extremely vague and difficult historian. Her family tell you that she was diagnosed with breast cancer 5 years ago and had a mastectomy at that time. Her husband died 6 months ago and she has never really recovered. Over the past week, the family have been worried that she is "developing Alzheimer's" because of memory problems and agitation. Past psychiatric history is notable for mild depression, treated with paroxetine 20mg daily, and sleep difficulties that are chronic and date back to her days as an alcoholic. One month ago, she was started on 50 mg of quetiapine at bedtime for sleep by her family doctor. Two weeks ago, she was given Oxybutinin (Ditropan) to help with some urinary incontinence, with good effect on her bladder problem. She is admitted to hospital for further medical work-up. The 1 pm nursing note reads: "quiet, resting comfortably, oriented x 3." The results of CBC, serum electrolytes and urinalysis are pending. The medical resident calls for psychiatric consultation at 4:05 pm because the patient has become agitated and has voiced suicidal ideation. The consult note reads: "medically cleared, please transfer to psychiatry for treatment of emotional instability and psychotic depression." The psychiatric resident arrives at 5 pm and finds that the patient is visually hallucinating and disoriented.

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

Mrs. Tammy Polk is very difficult to interview. She is an extremely vague and difficult historian. Her family tell you that she was diagnosed with breast cancer 5 years ago and had a mastectomy at that time. Her husband died 6 months ago and she has never really recovered. Over the past week, the family have been worried that she is "developing Alzheimer's" because of memory problems and agitation. Past psychiatric history is notable for mild depression, treated with paroxetine 20mg daily, and sleep difficulties that are chronic and date back to her days as an alcoholic. One month ago, she was started on 50 mg of quetiapine at bedtime for sleep by her family doctor. Two weeks ago, she was given Oxybutinin (Ditropan) to help with some urinary incontinence, with good effect on her bladder problem. She is admitted to hospital for further medical work-up. The 1 pm nursing note reads: "quiet, resting comfortably, oriented x 3." The results of CBC, serum electrolytes and urinalysis are pending. The medical resident calls for psychiatric consultation at 4:05 pm because the patient has become agitated and has voiced suicidal ideation. The consult note reads: "medically cleared, please transfer to psychiatry for treatment of emotional instability and psychotic depression." The psychiatric resident arrives at 5 pm and finds that the patient is visually hallucinating and disoriented.

Fergie is a 23-year-old single woman with no children who lives with her parents. She completed university with difficulty, taking time off frequently but eventually completing her degree. She reports having difficulties with relationships since middle school and not knowing who she really is affects her mood, attention and concentration. This had an impact upon her schooling but she managed to finish with a huge effort. However, she has been unable to ever work in any capacity since finishing University a year ago. Fergie was referred by her family physician for a psychiatric consultation because she frequently presented to the family physician or student health with low mood and suicidal ideations. At times her family doctor had to send her to ER for urgent assessment following disclosure of taking an overdose or cutting her arms. She is hoping that some medications like an antidepressants will be prescribed for her and that you will believe she is unwell and needing help. She has a huge hope that you will see her regularly, and provide her with answers as to why she is not feeling happy, why she feels empty, and why she is unable to control her anger. She is also considering bipolar disorder as she heard from student health counsellor that she may have a bipolar disorder because she reported increased spending, increased sexual activity, and reckless driving. And she also informed you that she has an eating disorder when she binge eats at times. She is well read on mental health and has attended many counsellors since middle school including private therapists that her parents took her to see.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

Malcolm Lowry presents to the ED of the Hamilton General Hospital accompanied by his wife, Vita. He is seen by a second-year resident in Emergency Medicine and a clinical clerk. Mr. Lowry is a 47-year-old businessman. This afternoon, he collapsed in front of his wife, who observed that both arms and legs were shaking and that his eyes were rolled back. After 30-60 seconds the shaking stopped, but he was unresponsive for several minutes and remained drowsy and confused for half an hour. Vita called 911 and Malcolm was taken to the Emergency Department. The patient states that this has never happened to him before. He had no warning symptoms prior to collapsing. He does not remember collapsing. He did not soil himself or bite his tongue, but his muscles are sore. His past health has been good. He does not have hypertension, diabetes or other chronic health problems. He has never been hospitalized and he is not on any medications. He denies recent head trauma, febrile illness, headache or neurological symptoms. He has no family history of epilepsy. Vita states that Malcolm has been drinking alcohol heavily for a number of months but stopped two days ago after she removed all the alcohol from the house. Today he was so tremulous that he could hardly button his shirt. Malcolm points out that he has stopped alcohol for a day or two several times in the past few months, and although he has felt shaky he has never had a seizure.

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.