PMPs - General Adult Psychiatry

GAP 02

The accident and emergency department has asked you, as the duty psychiatrist, to assess a 32-year-old woman, who has presented in a dishevelled state and is behaving oddly. She is clutching an infant who appears to have a number of bruises.

How would you assess and manage this situation?

Suggested probes

1. How would you tackle any risk to the child?
2. Who else would you involve?
3. What impact might the mother’s clinical state have on the child?

Guide to marking

he following areas are relevant to this vignette but are not necessarily all-inclusive. This list is not exhaustive.
1. Child protection issues - including issues around confidentiality and disclosure.
2. Child protection procedures, involving social services and paediatrics.
3. Some knowledge of the nature and injuries in physical abuse.
4. Likely diagnoses and management plans for the mother.
5. The mother’s ability to care for the child, including the impact of clinical features/diagnosis on the child.

GAP 18

A 19-year-old single man in his first year at university is referred for emergency admission by a general practitioner. The patient is perplexed, frightened and expresses ideas of persecution, but is willing to be admitted to hospital. He lives in a student flat.

Outline how you would assess and manage him in hospital for the next 48 hours, and what you would say to his parents who ask you what is wrong with him; they wonder if it might be schizophrenia.

Suggested probes

How are you going to clarify the diagnosis?
Would you prescribe medication?
Would you see the parents on their own and what would you say to them?

Guide to Marking

The following areas are relevant to this vignette but are not necessarily all-inclusive. This list is not exhaustive.
1. History to include academic performance and assessment from the university and anyone sharing his flat.
2. Discussion of the physical assessment and drug screen.
3. Discussion of ward management including pros and cons of withholding neuroleptic medication.
4. Issues of consent for discussion with his parents.
5. The only truthful answer to the parents’ question is that it is too early to tell. The information should be given sensitively.

GAP dc1 *

A 30-year-old lady attends the outpatient clinic with her partner. She has bipolar affective disorder and is currently stable on lithium. They want to start a family.

What do you advise, in terms of risks and treatment options?

Suggested Probes

1. She decides to stop lithium and becomes pregnant. How would you treat a manic relapse in pregnancy?
2. How would you treat her if she relapsed in the postnatal period?
3. What is the risk to the foetus of the treatment options you have suggested?

GAP dc3

A patient is admitted under your care with schizophrenia. He has failed to show response to at least 4 different antipsychotics, but the notes are unclear about doses etc.

What is your next step?

Suggested Probes

1. How would you initiate treatment with clozapine?
2. What are the important side effects?
3. Are there any contraindications?
4. After a few weeks on the ward, the patient is well enough to be allowed to go on leave for 3 days. When he returns, he admits that he didn't take his medication.

• How will you manage his prescription?
• He tells you that hypersalivation is a problem. Is there anything you can do to help this side effect?

Guide to Marking

1. Full medication review (? involve pharmacy)
2. Discussion with patient about clozapine, involving family
3. Importance of gradual titration
4. Awareness of procedure for dose missed for >48 hours

GAP dc5 *

A patient is admitted with a relapse of schizophrenia and gets better with treatment. When you review him in the outpatient clinic one week after discharge, he asks you whether he can drive his car. What answer will you give him?

Suggested Probes

1. Two days later, his CPN contacts you. The patient has been witnessed driving dangerously down the main road. What do you do?
2. What are the issues involved?
3. Who else would you discuss this with?

Guide to Marking

1. Discussion of DVLA rules about driving again after psychotic illness
2. Awareness of conflict between patient confidentiality and duty to protect others
3. Mention of informing patient beforehand about breaking confidentiality
4. Awareness of need to document everything, and to discuss with defence union

GAP dc6

You see a 43-year-old man in the clinic. He has been referred by his GP who thinks that he is depressed. He is an insulin-dependent diabetic, but admits that he hasn’t been taking his insulin for months. He tells you that he doesn’t want to take it, and that you can’t make him.

Describe how you would assess this man.

Suggested Probes

1. What is your differential diagnosis, and how would you determine what the problem is?
2. He scores 13 on the Hamilton, and 16 on the MADRS rating scales. What treatment would you offer?
3. What powers do you have to make him take his insulin?

Guide to Marking

1. Differential diagnosis to include depressive illness, psychotic illness, and suggestions about how to differentiate them.
2. Involvement of informant history and possibly involving diabetic team.
3. Awareness that he is unlikely to be severely depressed and may retain capacity to refuse his insulin.
4. Discussion about assessing his ability to make an informed choice.

GAP dc7

A patient attends casualty after taking an overdose of 100 Paracetamol tablets. He declines all investigations and treatment. The casualty officer rings you and says urgent life-saving treatment is required. He wants you to come and section the patient.

What advice will you give?

Suggested probes

1. The casualty officer then tells you the patient is making his way out of the hospital. What should he do?
2. What are the possible diagnoses, and how would you decide on the information that you have?
3. It is discovered later that the A&E doctor did in fact section the patient, but not get consent from a relative or a MHO. The patient is now on your ward. How do you manage the situation?

Guide to Marking

1. Clear knowledge of the Mental Health Act, with awareness of limitations of this Act. Awareness that psychiatrist is not required for detention.
2. Good, sensible advice about getting A&E doctor to assess mental state
3. Able to demonstrate knowledge about illegal detentions, and involvement of the Mental Welfare Commission

GAP 34

You are asked to do a domiciliary visit by a general practitioner (GP). The wife of a 45-year-old man had attended the surgery earlier that day. She was concerned about her own safety. The previous evening her husband was angry and challenging - he accused her of sleeping with a neighbour.

How would you assess and manage this situation?

Suggested Probes

1. Where would you get important additional information?
2. What factors might be relevant in a risk assessment in this case?
3. What management options might be necessary?

Guide to Marking

The following areas are relevant to this vignette but are not necessarily all-inclusive. This list is not exhaustive.
1. Necessary to obtain comprehensive background from the wife - and additional information from the GP regarding past history in particular.
2. The patient may refuse to be interviewed.
3. Demonstrate awareness of risk/ dangerousness to wife and perhaps others - psychodynamics within relationship.
4. Must discuss and elaborate on factors such as drug and alcohol misuse, formal mental illness/ delusional processes/ pathological jealousy, cognitive impairment. Allegations may be truthful.
5. Raise the possible need for involuntary admission and pre-discharge case conference, if necessary.

GAP dc7

Your consultant asks you to take over a young woman’s care shortly after you have joined the team. He tells you she has personality disorder and comorbid depression, and that he has been finding it increasingly difficult to help her. As her GP is concerned about her, he thinks that she should be seen by someone else.

In your second interview with her, she says that the consultant made sexually explicit remarks to her and tried to touch her breasts a few weeks ago.

How do you manage the situation?

Suggested probes

1. The patient says that she is going to sue you if you don’t do anything. What do you say?
2. Her casenotes suggest she has a history of false allegations and a history of intense sexual relationships with abusive men. Does this alter your course of action?
3. The following day, her mother calls you and demands to know what you are going to be doing. What do you tell her?

GAP dc8

You have been treating a young woman with a fragile bipolar disorder successfully with Lithium and Valproate. When you see her in the clinic with her partner, she tells you that she is 12 weeks pregnant. She has read about birth defects in relation to Valproate and Lithium and she doesn’t know what to do. She says that she is going to stop both of her mood stabilisers.

What do you say to her?

GAP dc9

It is the 3 a.m. and you have been called to see a 32-year-old mature student who has been brought up to A&E by her flatmates. They say that she has taken an overdose of paracetamol. She is Chinese and cannot/ will not speak English. She is muttering to herself in what you think is Cantonese. Shortly after you have walked into the cubicle, she gets up and walks out.

How do you proceed?

GAP dc10

You have just reviewed a 42-year-old man with a history of poorly-controlled schizophrenia. He has had frequent admissions to hospital due to non-compliance with medication and he is also misusing alcohol intermittently.

He is currently psychotic, with evidence of thought disorder. He believes that he is hearing the voice of God and is communicating with spirits. He believes that he is being influenced by them and that they are controlling his actions. You also suspect that he is experiencing auditory hallucinations, although he denies this. He does not think that he needs to be in hospital and is also refusing to take his medication. You are concerned about his welfare, as you had spoken to his CPN earlier who said that he was voicing suicidal thoughts involving firesetting. His consultant had also said casually that if he turned up for assessment, he might need to be detained.

You believe that he should be detained under the mental health act and ask a mental health officer (MHO) to see him. The MHO sees him, but does not believe that he should be detained. She says that a belief in spirits should not mean he should be detained and that she herself believes in similar things. She does not necessarily view him as being very ill at the current time.

How do you now proceed, bearing in mind that you have grave concerns over this man's welfare and safety?

* = PMP originally from superego-cafe.com