TRAINING THE TRAINERS

MENTAL HEALTH TRAINING PROGRAMME

SRI- LANKA

Role Plays

National Institute of Mental Health Angoda Teaching Hospital

ROLE PLAYS FOR MENTAL HEALTH TRAINING PROGRAMME

1. INVOLUNTARY ADMISSION

Role play to practice negotiating transfer to hospital for assessment and admission when
patient does not want to go

Patient Name: Chitrangani

Age: 26 years
Occupation: Clerk
Marital Status: Married
Total No. of children: 2

Medical History
• Has had several episodes of acute mental disturbances leading to self harm, harm to
others and destruction to property. Most of these episodes are managed by joint effort
of the local PHC staff and the local traditional healers.
• Reason for Encounter
• Current spell is severe and patient has been violent and destructive to property.

Reactions of the Patient

• Held by relatives
• Struggling to get free
• Irritability
• Anger
• Acting out
• Chanting traditional songs and dancing to rhythm

Health Worker
• You are the Health Worker in a Division in Kalutara?
• Chitrangani has just been brought to you while acutely disturbed.

Please assume you have assessed mental state, suicidal risk and risk of violence to others,
and have ascertained that she is a serious risk to herself and others.

Now interact with her and her relative in order to negotiate short (and longer) term
management plan including admission to the nearest mental health unit in first instance (to
which patient does not agree)
2. COMMUNICATION SKILLS
• (Role play to practice eliciting personal information courteously but speedily)
• Instructions to Health Workers
• In groups of twos, gather some general information about your partner, so that you
can introduce your partner to your class.

3. PSYCHOSOCIAL SUPPORT (role play to give patient support)

Patient
Name: Simon
Age: 46 years
Occupation: Farmer
Marital Status: Married
Total No. of children: 3

Medical History
• No major medical illness.

Reason for Encounter

• Spells of life-stock thefts have been going on in his area. His life-stock in various parts
of the division has been serially stolen. Last week he lost his last and prime stock from the
home yard, and his two sons were killed by the raiders.
• Currently the family is undergoing a difficult spell due to lack of resources.

Reactions of the Patient

• Visibly distressed
• Irritability
• Anger
• Acting out
• Dissociation
• Chanting traditional songs and moving slowly to rhythm

Patient: Simon

Health Worker
• You are the Health Worker in a Division in Hambantota.
• Simon has come to you to seek your assistance.
• Please interact with him in order to clarify his problems, give him psychosocial support
and negotiate a management plan.
4. BREAKING BAD NEWS

Patient
Name: Caroline
Age: 35 years
Marital status: Married with 4 children (3 sons, 1 daughter)
Occupation: Fish vendor
Residence: Batticoloa

Social History:
• You have been an average business lady for over the last five years. Your four (4)
children are all in School and your husband is in the fish transport business.
• While waiting for your regular fish supply at the Lagoon landing point at about 10 a.m,
news have reached the site to the effect that a road traffic accident has occurred in the
general area of your husband’s operations. The actual details of the accident are
scanty. However, a man seems to have been seriously injured and has been taken to
hospital near the site of the accident.
• You decide to drop all your business activities and head to hospital for more news.

Different Reactions of the Wife

• Shock and Denial
• Wailing and Shouting and singing
• Rolling on the floor and generally uncontrollably
• Pulling on her hair and tearing her clothes.
• Calling on others to assist

Health Worker
• You are a health worker attached to the hospital receiving an RTA at around 10 a.m
today. Mr. Jude arrived in a comatosed state and has since died.
• Mrs Caroline has just arrived to enquire on her husband’s state.
• Break the bad news of her husband’s death, using communication and supportive
skills, and offer further support as necessary.
5. ANTIDEPRESSANT SIDE EFFECTS
(role play to practice explaining and discussing management of side effects with patient)

Personal Details

Nandani (Patient) Sanath (Husband)

40 years old • 45 years old
Housewife • Husband
Mother of 4 Children • Father of the 4 teenagers
• A Primary School teacher in a near home school

Medical History of patient

• You are newly diagnosed with severe depression and have been put on anti-
depressants in order to treat your depression.
• You are about to start this treatment. You request whether the drugs have any
adverse effects on your health.

Husband
• You are accompanying your wife to the Health Centre where she reports for the first
time with severe depression. She is assessed and put on tablets to treat her
depression. You are concerned about the effects of these drugs on your wife.

Health Worker
• You have just visited Nandani, the patient at her home. She was found to be
moderately depressed and was started on antidepressants (amitryptiline/Fluoxetine)
by the MOMH yesterday.
• You are expected to review her weekly as she lives nearby and has the adequate
family/domestic support to monitor her progress.
• Please discuss with patient and husband the following issues
• Side effects of antidepressants
• How to adjust time of medicine so sedation occurs at night rather than in day
• When to expect antidepressant effects to start
• Supervision of medication, and prevention of overdose
6. ANTI PSYCHOTIC SIDE EFFECTS
(role play to practice discussion of antidepressant side effects)

Patient
Name: Sirisoma
Age: 45 years old
Marital status: Husband
Occupation: Father of 2 teenagers

You are about to start this treatment. You request whether the drugs have any adverse
effects on your health.

Wife
Name: Mallika
Age: 45 years old
Marital status: Housewife
Occupation: Mother of the 2 teenagers

You are accompanying your husband to the Health Centre where he reports for the first time
with acute psychosis. He is assessed and put on tablets to treat his acute psychosis. You
are concerned about the effects of these drugs on your husband.

Health Worker
You have visited Sirisoma, the patient, and found him to have acute psychosis.
The MOMH has decided to start him on an antipsychotic and requests you to review him
weekly or PRN as he lives nearby and has the adequate domestic support to monitor his
progress.

Discuss with patient and wife the following issues.

a) effects of medication
b) side effects of medication, and when to consult in case further mediation needed to
manage side effects
c) supervision of medication
d) importance of compliance
e) importance of regular review
7. MANAGING VIOLENCE/AGGRESSIVENESS
(role play to manage violent person in clinic)

Patient
Name: Rama
Age: 28 years
Marital Status: Married for 3 years (2 children aged 1 and 2 years)
Employment: Bus Conductor (over the last 5 years)
Residence: Nuwara Eliya

Social History
• You are married to a house wife (Mary) who has currently run away to her parents home
because of your frequent battering to her. She has left two children, which your parents
are currently assisting in taking care of them.
• You are a Bus conductor where you work from 5.30 am to 9.00 p.m. You pass by a
regular bar every night and take some alcohol.
• When you eventually get home, it is usually around or past mid night.

Medical History
• No major illness.

Reason for Encounter

• Your father has brought you to the clinic because you have been irritable,
argumentative, and destructive to furniture and other property at home. You burned your
wife’s clothes and destroyed 200 tea plants. You have also been unable to sleep and
have spent the last two days moving up and down the village with no particular purpose
other than smoking cigarettes.

You are now restrained by 2 family members:

• hyper-active
• increased speech – volume, speed
• very irritable
• threatening to kick, bite and head-butt anybody that comes near you
• verbal insults - plenty

Health Worker
Rama has just been brought to you accompanied by his father. This is his 1st time to come to
your clinic.

• please take history from him and his father,

• conduct mental state examination including risk of suicide and violence to others
• negotiate a management plan with patient and father.
8a. DEPRESSIVE DISORDER
(role play to practice assessment and management)

Patient
Name: Mr. Wariyapola
Age: 60 years
Marital Status: Married for 30 years
Children: Five children aged between 18 and 35 years
One boy and four girls
Employment: Now jobless after being retired six months ago as an accountant.
Residence: Matale

Social History
• Used to work as an accountant in Ministry of Health Headquarters
• 30 years. You have moved to your rural home after retirement.
• You are married to a primary school teacher who is currently supporting the
• entire family.
• Your wife is always quarrelling with you for finding you at home doing nothing but
listening to the radio. The children (3 unmarried and unemployed), whose standard of
living has dropped ,have no respect for you and keep on asking you why you are not
going to work.
• You have no friends in the village and even your relatives hardly visit you any more.
• You have been unable to pay house expenses . For the last two weeks you have
been telling your wife that you are preparing to take a long journey. Your wife did not
take the hint and just wished you a safe journey.

Medical History
• No previous major illness. After retirement you have been visiting local clinics
with complaints of difficulty in sleep, body aches, a burning sensation in head, and lack
of appetite. Recently you have been thinking about killing yourself.

Reason for encounter

• Your wife has brought you to the clinic for trying to commit suicide.

Presentation of Patient
• depressive and tired
• slow in movement and answering questions
• no longer interested in life
• low-esteem
• feeling of worthlessness
• feeling hopeless
• feeling helpless
• has multiple body pains

Instructions for Health Worker

• this patient comes to you for the first time.
• take history
• assess mental state and suicidal risk
• negotiate a bio-psycho-social management plan based on home care.?? Do we omit
home care given the high risk factors
8b. DEPRESSION
(discussion of case below and preparation of a management plan)

Patient
Name: Joseph
Age: 56 years
Occupation: Retired Railways Clerk (currently a shopkeeper)
Marital Status: Married, has 3 children
Residence: Amparai

Summary
• An average shopkeeper in local village in a location in Amparai.
• Over the last three weeks, he has not been feeling well.
• Started by sleeping too much. He was slowed down in his personal and shop keeping
activities.
• Seemed to have no drive for any matter in his life. Was not interacting much with
customers and started having difficulties with giving correct change.
• Last week, he did not participate in shop keeping activities. He just lay in bed, hardly
ate or drank anything. Has been slow in speech and activity.
• He says he hears voices of people unknown to him calling him a sinner who will surely
burn in hell. They also tell him to hang himself.
• Also he feels that his body organs e.g. the heart and brain are not working at all. He
believes they are rotten. He is tired most of the time. He feels sad. Has no plan for
future. He is hopeless and helpless. He does not see why he should continue with life,
as it is such a big bother. He wants to die and rest forever.

Instructions to groups

In your groups, please discuss

a) differential diagnosis
b) investigations
c) management plan
9. SOMATIZATION DISORDER
( ?Would expect this man to be referred to the specialist for clarification of diagnosis as the
history is also suggestive of a depressive disorder)
(role play of assessment and negotiating a management plan)

Patient
Name: Mr. Asitha
Age: 36 years
Marital Status: Married for 12 years
Children: Three children aged between 3 and 9 years
One boy and two girls
Employment: Trader
Residence: Kataragama

Medical History
• Long standing history of body pains which shift from place to place. Feels sharp
electric like discharges passing from one end of the body to another. Has frequent
attacks of numbness on all limbs. The top of the head has burning sensations from
time to time. Is frequently constipated. Gets frequent attacks of hot and cold spells.
Frequently gets burning sensation when he passes urine. This has been going on for
the last 4 years. He has seen various clinicians but has not been well assisted. Most
investigations have been unrevealing. Most of the times is treated for clinical malaria.
Recently he has been thinking about killing himself.

Reason for encounter

• Wife has brought him to the PHC for trying to commit suicide.

Different Reactions of the Patient

• Has multiple body pains
• Low-esteem
• Feeling of worthlessness
• Feeling hopeless
• Feeling helpless

Health Worker
a) this patient comes to you for the first time
b) take history
c) assess mental state
d) what investigations, if any, would you do?
e) make bio-psycho-social management plan
10a. ANXIETY - GENERALISED ANXIETY DISORDER
(Role play of assessment and management)

Patient
Name: Miss Jennifer
Age: 18 years
Marital Status: Single
Employment: Advanced level student:
Residence: Jaffna

Social History
• A/Level student awaiting final examinations. Parents are university graduates who
demand that daughter does well in the final examination so as to acquire university
education. After getting the results of the mock examination, daughter is afraid she will
not do well enough in finals. Recently she has fallen in love with the chemistry teacher,
She is unable to concentrate on studies, and is worried she might be pregnant.

Medical History
• Dysmenorrhoea, treated in the school clinic.

Reason for the Encounter

• After getting the mock examination results, student started sweating, having chest
pains, trembling, feeling tense and nervous.

Patient
• Feeling dizzy
• Fast pounding heart
• Restlessness
• Poor concentration
• Wide open eyes

Health Worker
• this patient comes to you for the first time
• please take history
• assess mental state
• make bio-psycho-social management plan
10b. ANXIETY (case vignette for discussion)

Patient
Name: Renuka
Age: 35 years
Marital Status: Married, has2 children (1 boy, 1 girl)
Occupation: Pradeshiya sabha representative

• A highly organised woman who has little patience with people who are slovenly and do
not keep time.

• Recently, she has developed more stringent behavior. She feels uncomfortable if she
wears any piece of clothing twice without washing it. She is over concerned about the
use of her utensils at home.

• Over the last month, she has been having panic attacks (i.e. shortness of breath,
dizziness, trembling, shaking, sweating, palpitations, numbness, flushing, chills, chest
discomfort, fear of going crazy or dying) whenever she was confronted with a situation
of addressing a meeting or the usual political crowds. She has since avoided public
appearances in order to stem these attacks. She now is seeking help from the health
centre.

Please discuss
• diagnosis
• management
10 c Post Traumatic Stress Disorder
(role play)

Patient
Name: Mohamed Hameed
Age: 43 years
Occupation: Trader
Marital Status: Married – 4 children
Residence: Batticoloa

History
• Was in Colombo to collect supplies 3 months ago. You traveled back home in a
regular bus to Batticloa.
• On the way, the bus was ambushed by gunmen, all tyres were shot flat, you were all
beaten, robbed and left stranded for 24 hours without food, water and cover.
Eventually a military convoy found you and rescued you to Batticoloa.
• You lost most of your investment in your trade goods. You have been re-experiencing
this episode for the last 3 months.

Symptoms
• Reliving the event both in the day time and in dreams at night
• Dissociation during the 1st one month
• Avoidance of any reminders of the event
• Emotionally numb lately
• Sympathetic hyper arousal persists

Health Worker
take history
conduct mental state examination
plan management
11a. SLEEP PROBLEMS WITH UNDERLYING SOMATISING DEPRESSION
(role play of assessment and management)

Patient
Name: Mrs. Hemalatha
Age: 46 years
Marital Status: Married
Children: three grown up children.
Employment: House wife
Residence: Moneragala, own village house

Medical History
• Long standing history of disturbed sleep. Has difficulties in initiating and maintaining
sleep. Wakes up in the middle of the night and does not fall asleep easily. Keeps
tossing in bed. while fully awake, gets the occasional wink early in the morning. Even
this is not refreshing. Over the last one month, she is getting muddled in thought and is
functioning poorly in doing regular chores.

Reason for encounter

• Your husband has brought you to the clinic for this problem.

Symptoms
• Multiple body pains
• Low-esteem
• Sad
• Irritable
• Feeling worthless, hopeless and helpless

Health worker
• conduct mental state examination
• make diagnosis
• negotiate management plan
12. EATING DISORDER-NOT YET AVAILABLE
13. FEMALE SEXUAL AROUSAL DISORDERS -ANORGASMIA
Patient
Name: Mrs. Teckla
Age: 37 years
Marital Status: Married with 3 children: all girls
Employment: House wife (self employed)
Residence: Modera

Medical History
You have been undergoing treatment-using tablets for 4 years to control your diabetes.

Reason for The Encounter

Your sexual life is currently frustrating, as you are no longer able to achieve orgasm. You
have come to the local clinic with complaints of dissatisfaction with your sexual life and
feeling generally irritable for the last 6 months.

Presentation
Hesitant in answering questions
Trying to find out the possible cause of your problem
Asking whether the problem is treatable
Feeling shy

Health Worker
Mrs Teckla comes to you seeing assistance.

a) conduct history and mental state

b) what physical examination and investigations would you do
c) negotiate management plan
14. MALE SEXUAL AROUSAL DISORDERS (SECONDARY IMPOTENCE)

Patient
Name: Mr. Mohamed
Age: 47 years
Marital Status: Married with 3 children: all girls
Employment: Cattle trader (self employed)
Residence: Tissamaharama

Social History
• You have been married and had a lucrative business buying and selling cattle in your
local area over the last 15 years. Unlike fellow Muslims you frequently other meet
people mostly over a drink. You mainly drink arrack on a regular basis.

Medical History
• You have been undergoing treatment using tablets for 4 years to control an elevated
Blood Pressure.

Reason for The Encounter

• Your wife has brought you to the local PHC with complaints of being aggressive for the
last 3 months.
• She also informs she is very keen to have a son and the husband does not cooperate.

Further Information
• You are a regular drinker of arrack.
• You have been having problem in initiating and maintaining erection. For this reason
you have been coming home late while drunk so as to avoid sexual contact with your
wife.
• She insists on sex because she wants a baby boy and you turn aggressive and start
beating her.

Reaction of the Patient

• Demanding your wife to leave so as to agree to be interviewed
• Being hesitant in answering questions
• Trying to find out the possible cause of your problem
• Asking whether the problem is treatable
• Feeling shy

Health Worker
You are a Health Worker in the local PHC. Mr Mohamed comes to you accompanied by his
wife.
a) Take enough history to assist you know the problem that Mr Mohamed is having. You
must demonstrate good communication skills.
b) Make a management plan for Mr. M to be assessed within his environment and
possible referral.
15. ALCOHOL ABUSE
(role play assessment and management)

Please construct a case scenario yourselves, and demonstrate

Patient
Name:
Age:
Marital Status:
Employment:
Residence:

Social History

Medical History

Reason for The Encounter

Further Information

Reaction of the Patient

Health Worker
16. DRUG ABUSE (role play assessment and management)
(role play assessment and management)

Please construct a case scenario yourselves, and demonstrate

• establishment of weekly quantity, frequency and type of substances

• physical, psychological and social problems
• negotiate a management plan

Patient
Name:
Age:
Marital Status:
Employment:
Residence:

Social History

Medical History

Reason for The Encounter

Further Information

Reaction of the Patient

Health Worker
17. CASE FORMULATION
Discussion of diagnosis, differential diagnosis, investigations, causes and management
(Answers on next page!)

Description:
Mr. Hassan is a twenty-three year-old unmarried self-employed. He was admitted as an
emergency one week ago after being taken to the casualty department by his neighbours. He
had shown increasingly disturbed behaviour in the last three months, with persecutory
delusions of being followed by the CIA, and believed that they were using laser beams to
control his actions. He had heard voices discussing plans to kill him, and on the day of
admission had destroyed most of his possessions whilst apparently searching for a video
camera, which he thought, had been ‘planted’ in his room. He had started to become
withdrawn socially four years previously, in his final year at high school. He has been an
above average student. He had cared for himself adequately but showed little motivation or
interest in social activities. Apparently he has been taking some drugs secretly on regular
basis.

On mental state examination he appeared fully conscious, his clothes were untidy, and he
was suspicious in manner, and he paced the room. There was no spontaneous speech and
he appeared secretive when answering questions, but talk was coherent and relevant. His
mood was subjectively ‘all right’ but he appeared tense and frightened and sweated
profusely. He was secretive about the recent destruction of his possessions. During the
interview he appeared to be distracted, listening and talking to voices on several occasions,
but denied this when asked. He was correctly oriented in time and place. He would not
cooperate with formal tests of cognitive function but correctly identified and had learned the
names of the ward staff and gave an accurate account a recent visit from his parents. He
thought he was not ill but needed help- ‘probably police protection’ and was willing to remain
in hospital because he said he felt safer.

On physical examination he was thin, with evidence of self-neglect, but no other abnormality.
Probable response for case formulation: Mr. Hassan

1. Differential Diagnosis
a) Paranoid Schizophrenia: Characterized by the persistent delusions of persecution,
control and auditory hallucinations discussing the patient. The history prior to this
suggests the slow development of apathy, lack of motivation, social isolation and
gradual development of hallucinations. Drug abuse may be secondary to
Schizophrenia.
b) Psychotic disorder due to drug abuse (symptomatic schizophrenia). The symptoms
that have occurred in the last three months are consistent with the acute psychoses,
which are associated with cannabis particularly following prolonged use. The
possibility of other drug and alcohol effects must also be considered despite the
patient’s denial of abuse.
c) Psychosis secondary to other organic conditions.

2. Aetiology
• Predisposing factors: Family history indicates that his maternal uncle is having
mental health problem (treated at Mathari Hospital), and one of his brothers has
shown social deterioration similar to the patient’s, so there may be a genetic
predisposition to schizophrenia. There is no evidence of perinatal or developmental
problems or of personality problems before the last four years.
• Precipitating factors: The social withdrawal and deterioration started in his final
year at high school when he had the stress of impending Final Examinations followed
by death of his father. The more recent deterioration followed within weeks of the
broken relationship with his girlfriend.
• Maintaining factor: Cannabis use

3. Investigations
• Medical records of the uncle and brother (if possible)
• Further history from his parents, particularly concerning his family history,
childhood development, and pre-morbid personality, and from his neighbours about his
recent state.
• Psychological. Observation of his beliefs, perceptions and behaviour- including
possible drug or alcohol ingestion. Examination of cognitive aspects of mental state. It
will also be necessary to assess his insight into psychosis and drug abuse and his
likely compliance with management.
• Physical investigations should include haematology,
• Social. Observation of the extent of his social withdrawal on the ward and of
relationships with his family, girlfriend, neighbours and workmates. Consider whether
there is evidence of ‘high expressed emotion’. When his mental state improves,
assess his abilities and strengths in occupational and other settings in order to plan
aspects of rehabilitation, including self-care, occupation and recreation.

4. Treatment
• Depending on the setting, if dispensary the patient should kept under observation for
24 hours as he was willing to be admitted and accept treatment. If is at Health center
the patient should be admitted as a voluntary patient.
• Physical. Start drug treatment such as Chlorpromazine or Haloperidal on regular
basis, a dose which will have to be adjusted depending on response and possible
 unwanted effects. The client is likely to require long-term medication preferably with
depot injections to improve adherence. He will need counseling regarding the effects
of drug abuse and encouragement to remain abstinent.
• Psychological and social. Initially he should be allowed to avoid pressures of
involvement in a group activities, but as psychotic symptoms settle down there should
be increasing emphasis on rehabilitation e.g. self-care and social activities. The patient
and family members will need information on the condition and how they can
contribute to its management. Follow- up at OPD for depot medication is important.

5. Prognosis
• Factors suggesting a poor outcome include insidious onset, prolonged duration, and
negative symptoms.
• However, there are also some favourable factors- the lack of problems in his pre-
morbid personality, his good educational record and work, and support from family.
• If cannabis abuse has been an important cause and he becomes abstinent this will
greatly improve the outcome.
18. EARLY RELAPSE OF PSYCHOSIS
(Role play of relapse prevention by prompt action on EARLY WARNING SYMPTOMS)

Patient
Name: Nimal Jayantha
Age: 40 years old
Marital Status: Married, 3 children
Employment: Community Development Officer
Residence: Lives alone at work station

Health Worker: Matara Malani, 40 years old

Medical History
You are a known to suffer from Paranoid Schizophrenia over the last five (5) years.
The condition is currently well controlled by monthly injections which you normally get at the
health centre after arranging for these to be so administered through the District Mental
Health Unit.
From previous experience, you have noted that if you miss the monthly injection, you usually
become restless, irritable, argumentative and have poor concentration at work and
accomplish less. At house where your only company is a day house boy, you are even
worse. Your house keeping is poor, you do not have a clear grasp of what is happening at
home.
You start having vague noises in your ears and sometimes you feel you are in danger even
though you do not know the actual source. Sleep becomes a problem and at times you have
to go to the canteen for a drink to find sleep. But the beer there tastes liked it has been
doctored and you are sure that records show that you have missed the injections of the last 2
months.

You report to the nearest PHC and after a physical and mental assessment, you are injected
and released home with your neighbour to monitor progress.
In three days time, you have settled down and are back to willing to go back to work.
19. BIPOLAR DISORDER – MANIA
(role play)

Patient
Name: Jaya shantha
Age: 48 years
Marital Status: Married, has 3 children,
Employment: Casual labourer .
Residence: Domestic Home in Ambalangoda

Medical History
You have a 5 years history of attacks of manic and depressive episodes, which alternate.
Initially these were once a year, then twice a year and now (this year) you have had 4 of them
(2 manic, 2 depressive). You are not very good at drug compliance. Drugs are also not
readily available in the PHC.

Social History
You are married to a supportive wife and children. You used to work for a building contractor
in your Province but now you have shifted home where you do subsistence farming and
casual jobs in the area.
You used to take alcohol, smoke tobacco and sniff some. Your children are all at home, have
not done well academically due to lack of school fees.
They are currently employed as casuals in the catchment area. The wife is mainly a
housewife.

Symptoms
• Slovenly attired
• Hyper active (Psychomotor)
• Pressured speech/increased flow, disinhibited
• Mood – Elevated/irritated
• Flight of ideas
• Grandiose delusions
• Perceptual disorders (Hallucinations, depersonalized, derealization)
• Cognition, orientation-poor
• Judgment - poor
• Insight - Lacking
• Other – Over generous with own property.

Health Worker
a) You are a health worker in the local PHC in Jayashantha’s catchment
area. J is brought to you by two of his sons.
b) Proceed to take adequate history, do an examination and make plans
to adequately address his problems with in the area of catchment.
19. EPILEPSY (? Omit)
(Role play of management of fit)

Patient
Name: Fatuma Ali
Age: 36 years
Marital Status: Divorced - has 3 children (1 son, 2 daughters)
Employment: Trader in textiles
Residence: In a Manyata 100 kilometers from Isiolo Town

Medical History
• A known epileptic (Generalized seizure type) for the last 5 years.
• Husband divorced you after you became epileptic.
• Fits have been investigated at District Hospital and you have been on Phenobarbitone
tablets 60 mg twice daily.
• You collect your drugs from your PHC. You have missed collections once due to lack
of supply caused by heavy rains and floods in your area.
• You are off drugs over the last 3 weeks.
• Fits have become frequent and severer every time they occur.

Symptoms
Seated on a bench in the PHC waiting room
Feeling dizzy, nauseated, with abdominal discomfort
Loud Scream
Falls off the wooden bench on to the earth floor
Becomes stiff, breathless, bites tongue
Starts thrashings
Frothing from the mouth
Passes urine
Passes stool
Stops thrashings
Becomes still
Goes into deep sleep
Wakes up
Movements are automatic (Occupation related)
Poor level of awareness (disorientated STP)
Has headache
Has muscle pains all over.

Health Worker
You are the Health Worker in a PHC in a division in Isiolo District of Kenya. Fatuma Ali has
just had a Grand Mal type of a fit in the waiting room in your PHC.
a) Proceed to manage the fit as necessary.
20. DEMENTIA
(Role play of supporting the carer)

Patient
Name: Aisha Ali
Age: 56 years
Marital Status: Married
Employment: Housed wife
Residence: In Kadugannawa

Medical History
• Husband is aged 67 years and has been in poor mental health over the last four years.
• Insidiously progressive mental loss has bee noted.
• Started as difficulty in remembering where he had placed most of his normal use
items.
• Then was unable to dress properly. Currently he wonders away from home and does
not return unless brought back by well wishers in the village. He does not remember
most of the names of his immediate family.
• He at times forgets to feed self. Aisha, his wife has been taking care of her husband,
Yusuf Ali, during all this happenings. She also has been ensuring that he comes for
routine reviews at the PHC. Today she seems rather distressed.

Different Reactions of Patient

Tearful
Feeling weak,dizzy, nauseated, with general fatigue
Has muscle pains all over

Health Worker
You are the Health Worker. Aisha Ali has just brought her demented husband for a routine
review.

b) Proceed to assess her current needs and plan for their management.
21. DELIRIUM
(Role play of diagnosis and management plan)

Patient
Name: Mutu Banda
Age: 42 Years
Marital Status: Married, two children (2 sons)
Employment: Casual Labourer
Residence: Badulla

Medical History
• You work with an NGO in you Division that is involved in Domestic violence.
• One week ago you were marooned in a village that was surrounded by floodwater and
could not get out of the site for 2 days. After you were free to wade out of the village,
you went back home.
• You have been not sleeping and becoming restless and your friends have brought you
to the health centre for management.

Reaction of the Patient

Over active, agitated
Incoherent mumbling speech
Severely disorientated in space, time and person
Anxious, irritable mood
Muddled thought and perplexed
Visual and somatic illusions, hallucinations
Poor immediate and recent memory
No insight

Health Worker
You are a Health Worker in a PHC. M is brought to you by his friends, wife and son.
a. Interact with them to ascertain Mutu’s medical condition and proceed to make plans for
his management.
22. CHILDHOOD OR ADOLSECENT EMOTIONAL DISORDER
(Role play –please construct a scenario and demonstrate health worker interaction with child
and parent )
23. CHILDHOOD DISORDERS – CONDUCT DISORDER
(role play)

Patient
Name: Kusum
Sex: Male
Age: 10 years
Occupation: Pupil (Class 4)

Medical History
• You are a pupil in a primary school, standard 4.
• Your relationship with your friends has been tumultuous ever since you came to std 1.
There have been periods of fistfights, wrestling and use of weapons. You seem to
start most of the scuffles you are involved in.
• At ten your body has many scars. You seem to always have a wound somewhere on
your body. You regularly smoke. Occasionally you drink the local brew. These are
funded by regular thefts. You regularly run away from school on account of conflicts
with other pupils.

Reasons for this Encounter

• Your parents have brought you to the PHC because they found you confused after you
smoked some ganja.

Symptoms
• Aggressive towards people
• Destructive to property, setting fires and breaking things
• Deceitful, stealing
• Serious rule violations, lying
• Running away from home and school
• Smoking cigs, smoking ganja and drinking local brew
• Frequent fights with injuries

Health Worker
You are the Health worker. His parents have brought Kasund into your centre.

a. Please interact with the 3 in order to find out Kasun’s problem and make a plan of
management, and demonstrate the following skills
• social and communication skills training
• anger control
• Goal Setting, Self – monitoring and planning
• parent training in how to deal with the child
• plan booster sessions to prevent relapses
• collaboration with schools when needed
24. MENTAL RETARDATION
(role play)

Patient
Name: Nuwan
Age: 18 years
Marital Status: Single
Occupation: Nil
Residence: Kaduwela

Medical History
You are severely mentally retarded currently you live with your parents and you are one of
their 4 sons. Your sibs also assist in your care.

Symptoms
• Unable to live alone
• Verbal communication is impaired but possible especially with family members who
are familiar with your peculiar mode of communication.
• Left school in nursery as was unable to be socialized in school life.
• Can conduct simple domestic tasks
• Can read some words eg. Stop, Go, No, Yes, Men, Women.
• Sometimes becomes irritated and aggressive
• Of late has been masturbating openly within the house

Health Worker
a) Interact with this patient who is currently brought to your PHC in order to understand
her condition and make plans for her management.