Clinical Case Reviews 2016

8/15/2019 Clinical Case Reviews 2016

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MEDI3004

MENTAL HEALTH

CLINI CAL CASE REVIEWS

2016

Copyright © - The University of

Queensland


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MEDI3004. Clinical Case Reviews 2016 1

Dear student,

Welcome to MEDI3004, the clinical rotation in which you learn about Mental Health.

These cases form an important part of your learning in this course. The cases are designed to

enhance your clinical reasoning and knowledge about common conditions so that you feel

confident and competent when you encounter these conditions in your future role as a juniorintern.

What topics are covered in the cases?

In several cases the Clinical Case Review Discussions cover in more detail and complexity

the clinical issues raised during Years 1 and 2 of the medical program.

Topics have been selected to reflect the prevalence of disorders in the community and the

associated burden of disability:

Schizophrenia

Depression

Anxiety

Personality disorder

Eating disorders

Dementia

In MEDI3004 you are expected to develop the knowledge and skills to be able to discuss

differential diagnosis, predisposing and precipitating factors, as well as assessment of risk.

The cases are designed to encourage hypothesis generation and testing, and the formulation

of clinical management plans.

What is the format for the case discussions?You will receive a timetable for the case discussions. They are conducted in small-group

format and a clinical tutor is present to guide you in developing your clinical reasoning. Case

discussion sessions last for 60-90 minutes. You are expected to read the case for each week

prior to the tutorial session so that you can take an active role in discussion. All of the cases

include detailed prompts to assist you. The written case is provided as a guide to assist you to

learn about the topic, including the type of depth of knowledge required. Contributing

discussion about cases you have seen clinically is also strongly encouraged.

Each CCRD includes learning tips, an example of an assessment item for that topic, and

discussion of potential pitfalls to avoid in assessment. Al l h yperl in ks are checked at the

beginn ing of the rotation – please advise the Cour se Coordinator if you f ind that a linkdoes not work ( [email protected]). Links on Blackboard require you to log in to

the site. You need the knowledge and skills to be able to diagnose each condition and

develop a comprehensive management plan at the level of a junior hospital-based

intern.

Each case includes prompts to guide self-reflection about any issues which may affect

you personally and to guide you in developing enhanced understanding of your own

responses to patients.

Best wishes for the rotation

Jane Turner

MEDI3004 Course Coordinator

mailto:[email protected]:[email protected]:[email protected]:[email protected]


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MEDI3004. Clinical Case Reviews 2016 Page 2

CLINICAL CASE REVI EW 1

SCHIZOPHRENIA


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Presentation:You are an intern working in the Department of Emergency Medicine at a metropolitan

teaching hospital. You are asked to assess Lyall, a 25 year-old man brought to hospital by the

police. The police were called because Lyall was shouting at passers-by in the city. When the

police arrived Lyall had removed his shirt, was gesturing oddly, and he seemed confused.When you start to interview Lyall you are aware that he smells of alcohol and he is mildly

ataxic. He is unable to provide an account of the events which led up to the police being

called. He denies any memory of being brought to hospital by the police.

Mental state examination:Tall, thin man with poor self-care and poor oral hygiene. He appears older than his stated

years. He is wearing filthy trousers and has dirty pieces of paper and some decaying food in

his pockets. Poor eye contact. Irritable mood. His speech is loud and pressured. He makes

threats against the hostel manager who has threatened him with eviction. No behavioural

evidence of hallucinations. Appears to have delusions relating to his special role in exposing

a senior member of parliament who he believes is collaborating with a bikie gang to

distribute crystal meth. He says that he knows about the politician and his relationship with

the gang because of messages he has received from the internet.

Physical findings: Swollen lower lip and superficial graze to (L) elbow.

Afebrile.

PR 88/min, regular. BP 145/85. JVP not elevated. HS x 2, nil added.

RR 26/min. Chest clear.

No signs of chronic liver disease.

Oriented to time, person and place. Mild ataxia. No focal neurological signs, reflexes present and equal, plantars down-going.

You access his medical records which reveal that Lyall was treated as an inpatient 18 months

ago. A diagnosis of manic phase of Bipolar Disorder was made on the basis of elevated

mood, grandiosity, and arrogant and intrusive behaviour towards staff and patients. He

remained insightless and grandiose throughout his admission, and was non-compliant with

lithium. The notes indicate that he did not attend for outpatient follow-up.

You recommend to Lyall that he be admitted to hospital.

Clinical reasoning: What differential diagnoses are likely on the basis of this presentation? Think as broadly

as possible and include organic and psychiatric conditions;

How would you differentiate between these? Think about aspects of the MSE, history,

mode of presentation, past history, physical signs and investigations;

What factors would you take into account in determining whether or not to admit Lyallto hospital? List the circumstances in which a patient can be admitted under the Mental

Health Act. Note that you could be asked thi s in assessment;

List the signs of chronic liver disease.


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Further history:Lyall becomes agitated following discussion of admission to hospital, and verbally threatens

the nurse in the reception area. Security staff are urgently called to assist, and Lyall

undergoes acute sedation.

Clinical reasoning and acute management: Describe in detail how you would assess risk – think about static and dynamic factors

(refer to Workshop in Orientation week);

Describe how you would approach an agitated patient, including strategies to try to de-

escalate the situation;

Describe the process of acute sedation in detail. List the specific drugs, dose, route ofadministration, and side-effects. Describe the precautions which must be taken when

sedating a patient in this manner. Download resource on Blackboard: Acute Sedation

Guidelines

Progress in hospital:Lyall is admitted to hospital under the Mental Health Act. He is placed on close observation

to ensure his safety and that of others. He undergoes full physical examination and

investigations are conducted. He is treated with IMI thiamine 100 mg tds.

Investigations:

U&E; FBC; LFT’s; TFT’s; CXR; urine drug screen; CT scan brain - all NAD.EEG: alpha rhythm present bilaterally at 10 to 10.5 Hz. Changes of drowsiness were noted.

There was no significant change on over-breathing. EEG reported as within normal limits.

Further history: Lyall reveals that he has been homeless for two years. He is estranged from his family but

refuses to discuss the circumstances surrounding this. He has recently found temporary

accommodation at a hostel, but says that other residents have been stealing his cigarettes and

talking about him. Lyall gives permission for the Social Worker to visit the hostel to collect

some personal belongings. The Social Worker reports that Lyall’s room is filthy and strewn

with newspaper clippings and decaying food.

Learning tip

Watch the YouTube clip: http://www.youtube.com/watch?v=bWaFqw8XnpA

Review the slides on Mental Status Examination on Blackboard to help you practicepresenting a Mental Status Examination (MSE) for each of the videos. You might

find it helpful to watch the clips with other students and practice presenting the

MSE to each other.

As you progress through the rotation try to discipline yourself to use a systematic

approach to differentiating between your differential diagnoses, challenging

yourself to “prove” why it is your favoured diagnosis rather than another.

https://learn.uq.edu.au/bbcswebdav/pid-1654990-dt-content-rid-8404022_1/courses/MEDI3004S_6620_21052/Acute%20sedation%20guidelines.pdfhttps://learn.uq.edu.au/bbcswebdav/pid-1654990-dt-content-rid-8404022_1/courses/MEDI3004S_6620_21052/Acute%20sedation%20guidelines.pdfhttps://learn.uq.edu.au/bbcswebdav/pid-1654990-dt-content-rid-8404022_1/courses/MEDI3004S_6620_21052/Acute%20sedation%20guidelines.pdfhttps://www.health.qld.gov.au/clinical-practice/guidelines-procedures/clinical-staff/mental-health/resources/factsheets-poster/default.asphttps://www.health.qld.gov.au/clinical-practice/guidelines-procedures/clinical-staff/mental-health/resources/factsheets-poster/default.asphttps://www.health.qld.gov.au/clinical-practice/guidelines-procedures/clinical-staff/mental-health/resources/factsheets-poster/default.asphttp://www.youtube.com/watch?v=bWaFqw8XnpAhttp://www.youtube.com/watch?v=bWaFqw8XnpAhttp://www.youtube.com/watch?v=bWaFqw8XnpAhttp://www.youtube.com/watch?v=bWaFqw8XnpAhttps://www.health.qld.gov.au/clinical-practice/guidelines-procedures/clinical-staff/mental-health/resources/factsheets-poster/default.asphttps://learn.uq.edu.au/bbcswebdav/pid-1654990-dt-content-rid-8404022_1/courses/MEDI3004S_6620_21052/Acute%20sedation%20guidelines.pdfhttps://learn.uq.edu.au/bbcswebdav/pid-1654990-dt-content-rid-8404022_1/courses/MEDI3004S_6620_21052/Acute%20sedation%20guidelines.pdf


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Lyall discusses with nursing staff his belief that he has a role investigating the politician’s

links with the bikie gang. He says he has collected evidence which is at the hostel, but the

hostel manager thinks it is a fire hazard and has told him to remove it. He is convinced that

members of the bikie gang know where he is and are trying to have him killed while he is in

the mental health unit.

Clinical reasoning:

In light of this information which is the most likely diagnosis?

Why has he been given thiamine?

What clinical concerns arise in relation to his expressed persecutory ideation? How

would you explore this further?

Describe in detail your approach to management.

o Discuss pharmacological treatments including antipsychotics (specific drug, dose,

mechanism of action, potential benefit, side-effects) and benzodiazepines for

agitation. Note that you could be asked thi s in a viva examination.

o Non-pharmacological including psychoeducation, role of case management etc. What factors would you take into account in determining his prognosis?

What treatments could be considered if he fails to respond to initial antipsychoticmedication?

How would you explain the condition to the parent of a young adult newly-diagnosed

with schizophrenia? This could be included in assessment, for example in the viva or a

Year 4 OSCE examination.

Learning tip

Elyn Saks is a Professor of Law who movingly describes her experience of psychosis

and stigma:

http://www.youtube.com/watch?v=f6CILJA110Y&list=PLJMiZcdl04Z9-

DWpmB0x-42CGaL1rZ1gb

You are expected to be able to describe the comprehensive management of a patient

with schizophrenia. This includes discussion of medication and non-

pharmacological interventions. Remember the role of expressed emotion and the

importance of community-based treatment including case management, as well as

the ethical aspects of treating patients who may lack insight into their condition.

Think about factors associated with a good prognosis.

Assessment tip – sample MCQ:

Which of the following predicts a favourable outcome for a patient with

schizophrenia?

A. Low intelligence

B. Family history of schizophrenia

C. Stable premorbid personality

D. Absence of a precipitating factorE. Absence of mood s m toms

http://www.youtube.com/watch?v=f6CILJA110Y&list=PLJMiZcdl04Z9-DWpmB0x-42CGaL1rZ1gbhttp://www.youtube.com/watch?v=f6CILJA110Y&list=PLJMiZcdl04Z9-DWpmB0x-42CGaL1rZ1gbhttp://www.youtube.com/watch?v=f6CILJA110Y&list=PLJMiZcdl04Z9-DWpmB0x-42CGaL1rZ1gbhttp://www.youtube.com/watch?v=f6CILJA110Y&list=PLJMiZcdl04Z9-DWpmB0x-42CGaL1rZ1gbhttp://www.youtube.com/watch?v=f6CILJA110Y&list=PLJMiZcdl04Z9-DWpmB0x-42CGaL1rZ1gb


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Pitfalls to watch for in assessment:

Especially in a viva examination you must be curious about the reason

for presentation and be able to generate hypotheses related to this (why

has this person presented with these problems at this time?). For

example if parents bring their son to DEM late at night because they

“are concerned” you should wonder if there has been a critical incident

such as a threat of violence which has precipitated presentation.

You must be able to confidently discuss assessment of risk in detail (for

example asking about command hallucinations, identifying persecutory

delusions). Simply saying “I would assess r isk ” is insufficient – you need

to say how you would do this. In order to achieve well in the viva

examination it is important to highlight issues of risk and incorporate

these into your presentation rather than requiring the examiners to ask

you. Remember that your management plan must include strategies to

manage the risks you have identified.

Failure to consider the reasons for a relapse of psychosis is common –

remember to consider non-compliance with medication as well as

social/environmental factors such as expressed critical emotion,

substance abuse, inter-current medical illness.

You must be able to discuss pharmacological treatment in detail.

Remember that benzodiazepines are useful for treatment of behaviour

disturbance in an agitated patient who is psychotic.

REMEMBER THAT ASSESSMENT AIMS TO DETERMINE IF YOU

COULD WORK INDEPENDENTLY AS AN INTERN TO MAKE A

SAFE ASSESSMENT OF A PATIENT, INCLUDING ASSESSMENT

OF RISK AND DEVELOPING A PRIORITIZED MANAGEMENT

PLAN.

Personal reflection: for you to think about and NOT necessarily

for discussion in the CCRD:

Have you previously interviewed a patient with psychosis?

How does it make you feel to be in contact with a person whose ideas do

not make sense?

What is it like to be in the Department of Emergency Medicine assessinga patient who is agitated and uncooperative? How will you handle this

when you are an intern?


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DEPRESSION


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Presentation:You are the intern working in a Coronary Care Unit of a large metropolitan teaching hospital.

Hugh Richards is a 52 year-old man who was admitted to the Unit four days ago after a

myocardial infarct. His course has been complicated by unstable rhythms and cardiac failure.

Nursing staff tell you that Mr Richards is sleeping poorly, and he is extremely reluctant tomobilise.

When you talk with Mr Richards about modifiable risk factors for heart attacks he becomes

irritable, stating that he has tried to give up smoking in the past. He says that there is no point

trying to lose weight as he knows he will die from a heart attack anyway. When you ask why

he thinks that, Mr Richards responds that his father and two uncles all died from heart attacks

when they were in their 50’s. Mr Richards tells you that he was mowing the lawn at home

and stopped because he was feeling short of breath. He then experienced crushing chest pain

which he knew was a heart attack. He called for his wife Gwen to call an ambulance but

thought he might die before the ambulance arrived.

Mental state examination:Moderately obese man who offers little spontaneous speech. Looks mildly depressed but on

specific questioning denies this, becoming irritable and saying: “ I’ve just have a bloody heart

attack – what do you expect?” No psychotic symptoms, fully orientated for time and place.

Clinical reasoning: What factors might influence the way in which an individual responds to a potentially

life-threatening illness? Consider factors such as personality style, past experiences and

social context, roles and responsibilities. You will find these issues covered in the

resource Response to Adversity on Blackboard; How would you distinguish between Adjustment Disorder and Major Depression in

someone with a serious medical illness?

Why is it important to make this distinction?

How does Major Depression influence the clinical course following myocardial

infarction?

Outpatient review:Hugh refuses to attend cardiac rehabilitation, as he does not see the point. In response to

pressure from Gwen he attends a cardiology outpatient appointment. Gwen tells the

cardiologist she is concerned that Hugh is depressed. Hugh reluctantly agrees to a referral to

Consultation-Liaison Psychiatry.

During the assessment session with the psychiatrist, Hugh is reserved and downplays any

concerns. He says he tends not to talk about how he feels, but admits that he has thought

recently about his health, and felt pessimistic about the future because of his strong family

history of heart disease.

Gwen says that Hugh was devastated by the death of their only child, Ben, from a drug

overdose 7 years ago. Gwen said that Hugh refused to talk about what had happened. She

said that he had seemed sad and withdrawn and very different from his normal self: “He’s

really never been the same person”. Gwen feels that since his heart attack Hugh has becomeeven more withdrawn and quiet than usual.

https://learn.uq.edu.au/bbcswebdav/pid-1654993-dt-content-rid-8431085_1/courses/MEDI3004S_6620_21052/Adversity%20Intro%281%29.mp4https://learn.uq.edu.au/bbcswebdav/pid-1654993-dt-content-rid-8431085_1/courses/MEDI3004S_6620_21052/Adversity%20Intro%281%29.mp4https://learn.uq.edu.au/bbcswebdav/pid-1654993-dt-content-rid-8431085_1/courses/MEDI3004S_6620_21052/Adversity%20Intro%281%29.mp4https://learn.uq.edu.au/bbcswebdav/pid-1654993-dt-content-rid-8431085_1/courses/MEDI3004S_6620_21052/Adversity%20Intro%281%29.mp4


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Clinical reasoning:

What is the role of a consultation-liaison psychiatry service in a general hospital?

What is the significance of Gwen’s observation that Hugh withdrew and seemed sadfollowing Ben’s death, including her statement that he was “not the same person”?

How do you think Hugh’s family history of heart disease and his son’s death might have

contributed to the development of depressed mood now?

Further progress:At his next appointment, Hugh says that he feels “sort of empty inside”. He feels he has lost

his confidence and is apprehensive about returning to work. He has wondered if Gwen would

be better off without him, and he feels guilty about what he is putting her through. He has

wondered what was ahead of him, and had briefly thought he could just “cut out the waiting ”

rather than deteriorate over several years as his father had done. He feels ashamed that hefeels so low, and describes himself as “weak ” for not being able to cope.

Clinical reasoning:

What thoughts does a depressed person have (remember Beck’s negative cognitive

triad). How does this influence their behaviour?

How would you assess his risk of suicide and how would you respond if you thought hewas at risk of self-harm?

What is cognitive behaviour therapy (CBT)? Describe how this could be helpful in this

case. Details about therapy are available in the Manual of Mental Health Care

available on Blackboard (page 83); Describe the pharmacological treatment of depression in a patient with medical illness.

What factors would you need to take into account in selecting a specific drug and the

dose? List the drugs which might be useful in this case including the dose. What

information would you give Hugh about side-effects? There is a resource on Blackboard

giving an overview of issues to consider in choosing antidepressant treatment for patients with medical illness.

Does treatment of depression alter the outcome after acute coronary syndrome? Which

patients are likely to benefit most?

How might stigma about mental illness affect patterns of presentation?

How would you discuss antidepressant treatment with a patient who felt that needingtreatment was a sign of weakness?

Learning tip

Review your learning from Year 2 about theories of depression, including

psychodynamic, psychosocial, cognitive and biological.

As you see patients in this rotation, try to think about the complex interplay of

factors which might have contributed to the development of depression. Think

about personality factors and social issues which need to be taken into account in

devising a management plan.

The following is a link to a 2013 BBC documentary on depression:

https://www.youtube.com/watch?v=F5YubjEqbZ8

https://learn.uq.edu.au/bbcswebdav/pid-1654989-dt-content-rid-7882719_1/courses/MEDI3004S_6620_21052/Learning%20Resources/Core%20Lectures%20Workshop%20Lecture%20Notes%20Psychotherapy%20%20CBT%20Workshop/PsychotherapyCBT%20Workshop%20-%20Manual%20of%20mental%20health%20care.pdfhttps://learn.uq.edu.au/bbcswebdav/pid-1654989-dt-content-rid-7882719_1/courses/MEDI3004S_6620_21052/Learning%20Resources/Core%20Lectures%20Workshop%20Lecture%20Notes%20Psychotherapy%20%20CBT%20Workshop/PsychotherapyCBT%20Workshop%20-%20Manual%20of%20mental%20health%20care.pdfhttps://learn.uq.edu.au/bbcswebdav/pid-1655000-dt-content-rid-8431907_1/courses/MEDI3004S_6620_21052/Special%20populations.mp4https://learn.uq.edu.au/bbcswebdav/pid-1655000-dt-content-rid-8431907_1/courses/MEDI3004S_6620_21052/Special%20populations.mp4https://learn.uq.edu.au/bbcswebdav/pid-1655000-dt-content-rid-8431907_1/courses/MEDI3004S_6620_21052/Special%20populations.mp4https://www.youtube.com/watch?v=F5YubjEqbZ8https://www.youtube.com/watch?v=F5YubjEqbZ8https://www.youtube.com/watch?v=F5YubjEqbZ8https://learn.uq.edu.au/bbcswebdav/pid-1655000-dt-content-rid-8431907_1/courses/MEDI3004S_6620_21052/Special%20populations.mp4https://learn.uq.edu.au/bbcswebdav/pid-1654989-dt-content-rid-7882719_1/courses/MEDI3004S_6620_21052/Learning%20Resources/Core%20Lectures%20Workshop%20Lecture%20Notes%20Psychotherapy%20%20CBT%20Workshop/PsychotherapyCBT%20Workshop%20-%20Manual%20of%20mental%20health%20care.pdf


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Learning tip

You are expected to be able to describe the management of a patient with depression

and demonstrate that you can tailor your management to the specific case. For

example if the person is severely ill, your management might include discussion ofprognosis and ability to live independently or even end-of-life issues.

A Formulation is a description of who the person is and why they are presenting

now with these problems. Can you make a formulation of Hugh’s case?

Check the VOPP on Formulation on Blackboard and read the article by Selzer and

Ellen “Formulation for beginners”.

You must be able to describe the necessary modifications to antidepressant

medication in patient with medical illness (for example SSRIs interact with

warfarin).

You must be able to describe how CBT works and its application to a particular

case.

MoodGYM is an interactive website developed by the Centre for Mental Health

Research at ANU. Registration is free and allows you to find out more about CBT:

https://moodgym.anu.edu.au/welcome.

e-couch is another initiative of ANU and can be accessed free of charge at:

https://ecouch.anu.edu.au/welcome

Assessment tip – synopsis of a sample viva vignette:

Donald Olsen is a previously-fit 29 year-old man who is an inpatient in hospital

following a boating accident. The boat in which he was fishing caught fire and he

and his friend, Roy, jumped overboard. His friend is missing, presumed drowned.

Donald sustained burns to his arms, hands and face. He has required skin grafts to

his arms. The occupational therapist in the burns unit expresses concern about

Donald’s lack of motivation with exercises aimed at maximizing optimal hand

function and asks you as the intern for advice. She says she has tried to encourage

him, but she feels that he has given up.

On MSE Donald has poor eye contact and offers no spontaneous speech. When

asked about the accident says “Well maybe Roy is the lucky one. At least he doesn’t

have to face all of th is .”

https://learn.uq.edu.au/bbcswebdav/pid-1654988-dt-content-rid-8428124_1/courses/MEDI3004S_6620_21052/Selzer%20%26%20%20Ellen.pdfhttps://moodgym.anu.edu.au/welcomehttps://moodgym.anu.edu.au/welcomehttps://ecouch.anu.edu.au/welcomehttps://ecouch.anu.edu.au/welcomehttps://ecouch.anu.edu.au/welcomehttps://moodgym.anu.edu.au/welcomehttps://learn.uq.edu.au/bbcswebdav/pid-1654988-dt-content-rid-8428124_1/courses/MEDI3004S_6620_21052/Selzer%20%26%20%20Ellen.pdf


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Pitfalls to watch for:

Students commonly present everything they know about depression in a

viva examination but don’t apply i t to the specific case .

In the example above, it is vital to explore r isk as Donald’s comment in

the vignette about his friend raises serious concerns.

Management must include attention to issues of grief and loss (and

maybe guilt – did either of the men contribute to the fire, had they beendrinking etc.). But you also need to think about the circumstances of

the accident in more detail – trauma, waiting for help etc.

Will Donald be able to work again – what work did he do beforehand?

What about relationships etc. If he is single does he feel that he is too

“damaged” to engage in a relationship? His response to the accident

will be influenced by his young age.

Another issue to be aware of in management is countertransference - ifit is considered that he contributed to the accident staff may “blame” or

avoid him. Conversely staff may feel that his injuries are not life-

threatening and so dismiss or devalue his concerns.





PLAN.

Personal reflection – for you to think about and NOT necessarily


Have you or has anyone you care about ever experienced depression?

Have self-harm or suicide ever had an impact for you personally? If so,

what support and assistance have you obtained to handle this?

Depression is very common in the community and even more common

in doctors and students.

Depression is treatable. Students sometimes worry that seeking help is a

sign of weakness or that this will damage their career. Being depressed is

too awful to tolerate. If you have problems with your mood see a GP.

There are psychiatrists who are interested in treating medical students,

and they will often provide a bulk-bill service.


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ANXIETY


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Presentation:You are working as an intern in the Department of Emergency Medicine of a metropolitan

teaching hospital. You are asked to assess Rosie Ward, a 19 year-old single woman who has

presented complaining of shortness of breath, a pounding heart and feeling faint. Rosie works

as a retail assistant in a fashion outlet in the city. This episode occurred at work after she

challenged a customer who she thought may be shoplifting.

Rosie says that she has had several episodes like this over the past two months since she

witnessed an accident whilst on the bus to work. In the accident a motor cyclist was fatally

injured when struck by a truck. This episode has been the most intense she has experienced

and Rosie says she thought that she might die. Rosie says that she is worrying “all the time”

about her health and keeps thinking she could have an accident. She has been reluctant to go

out with friends, preferring to stay at home. She requests a medical certificate because she

feels she cannot return to work.

Mental state examination:

Fashionably-dressed woman who is tearful and slightly tremulous. Sighs frequently, and saysthat she is a “nervous wreck”. Says that she worries about “absolutely everything”, adding

that she is terrified of having a panic episode on the bus.

Physical findings:Afebrile.

PR 96/min regular; BP 130/90.

No other abnormalities.

Clinical reasoning:

What are the core features of a Panic Attack? What is Generalised Anxiety Disorder?

What are the features of Post-Traumatic Stress Disorder?

What further aspects of history would help to clarify the diagnosis?

What other conditions would account for her symptoms? Consider a broad range of

possibilities including psychiatric illness, and medical conditions. What investigations

should be conducted?

What is the significance of her reluctance to go out with friends?

Learning tip

Think about different contexts in which PTSD could develop – a person affected bya natural disaster such as bushfire, being a witness to an armed hold-up, a person

involved in an industrial accident, someone who experiences awareness during

anaesthesia.

Think about the patients you may encounter as an intern who could be experiencing

PTSD.

This YouTube video explores some of the issues facing police officers and the

development of Post-Traumatic-Stress:

http://www.youtube.com/watch?v=wYO5_ai-8jo. Note in particular the difficulty

for those affected to seek assistance.

http://www.youtube.com/watch?v=wYO5_ai-8johttp://www.youtube.com/watch?v=wYO5_ai-8johttp://www.youtube.com/watch?v=wYO5_ai-8jo


15/34


Further history:Physical examination and all investigations including Thyroid Function Tests are normal.

Rosie reveals that she has always been anxious. Last year when her mother was diagnosed

with breast cancer she “lost it” and had to take time off from work because of anxiety. She

consulted a General Practitioner who recommended relaxation training but Rosie did not feel

that it was helpful. Her mother has completed treatments and is well, with no evidence ofdisease. However during her chemotherapy her oncologist prescribed some Alprazolam. On

two occasions her mother has given Rosie some of her Alprazolam. Rosie says that this was

“like magic” and she would like a prescription for some more Alprazolam.

Clinical reasoning:

What is relaxation training? What evidence is there for its effectiveness as a treatment

for anxiety? Describe how you would conduct this with a patient.

What co-morbidities are common in people with anxiety disorders and why?

Discuss the risks and benefits of use of benzodiazepines.

Psychologist review:Despite initial reluctance, Rosie agrees to see a clinical psychologist who obtains some

background history. Rosie is an only child whose father was killed in a motor vehicle

accident when she was 10 years of age. Her mother subsequently became depressed and

tended to spend time alone in her bedroom. She has intermittently taken benzodiazepines

since that time to help with sleep. Rosie isolated herself at school rather than have to explain

why she didn’t have a father.

Rosie tells the psychologist that she worries about her future, and has become concerned

about her health and that of her mother. She accepts the offer of some cognitive therapy.

Learning tip

Beyondblue was established in Australia in 2000 with the aim of moving the focus on

depression away from mental health service issues and towards one which is

understood, acknowledged and addressed by the wider community.

It is recommended that you look at the video: My name is Anxiety :

http://www.beyondblue.org.au/the-facts/anxiety

This video describes one person’s experience of social phobia:

http://www.youtube.com/watch?v=SBPQdvRF9g0

headspace is an initiative of the National Youth Mental Health Foundation and

includes narratives from young people: http://www.headspace.org.au/

http://www.beyondblue.org.au/the-facts/anxietyhttp://www.beyondblue.org.au/the-facts/anxietyhttp://www.youtube.com/watch?v=SBPQdvRF9g0http://www.youtube.com/watch?v=SBPQdvRF9g0http://www.headspace.org.au/http://www.headspace.org.au/http://www.headspace.org.au/http://www.headspace.org.au/http://www.youtube.com/watch?v=SBPQdvRF9g0http://www.beyondblue.org.au/the-facts/anxiety


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Clinical reasoning: Discuss how the death of her father might have affected Rosie. Think about her

mother’s response to bereavement when Rosie was 10 years of age;

What cognitive distortions is Rosie likely to have and how would they impact on her

functioning?

How would avoidance of social situations compound the problem?

How would you explain the diagnosis to Rosie? How would you facilitate referral insomeone with low self-esteem and anxiety?

What would cognitive behaviour therapy involve for a patient like Rosie?

When would medication be an appropriate treatment? Discuss the pharmacological

management of panic and anxiety including specific drugs, dose, likely response and

side-effects.


Mike Harper is an obese 56 year-old man who has a history of alcohol abuse. He

presents to the Department of Emergency Medicine after experiencing a sudden

episode of palpitations, shortness of breath and tightness in his throat. The episode

lasted for about 10 minutes. He did not feel fearful or apprehensive during the

episode.

Which of the following is the most likely diagnosis:

A. Panic Attack

B. Generalised Anxiety Disorder

C. Major Depression

D.

Myocardial ischaemiaE. Sleep apnoea

Clinical reasoning: Absence of fear or apprehension during the episode effectively

excludes a panic attack and symptoms do not fit the other options. He has risk

factors for cardiac disease.

Personal reflection – for you to think about and NOT necessarily


Some degree of anxiety can help us to meet deadlines and accomplish

tasks. More extreme anxiety can be very distressing and affect ability to

learn and perform in examinations.

In MEDI3004 you will be assessed in a Viva Examination. Is this an

examination format which is likely to make you feel very anxious?

One technique to reduce this is to engage in relaxation techniques and

practice doing a lot of vivas.

If performance anxiety is a serious issue for you seek professional

assistance – UQ Psychology offers a clinical service.


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It is not appropriate to use benzodiazepines as first-linepharmacological management of anxiety disorders. Benzodiazepines

with a short half-life can cause rebound anxiety.

NOTE: If you mention benzodiazepines before you mention SSRIs in a

viva examination, the examiners will assume that is your first line

treatment.

Practice stating reservations before suggesting benzodiazepines, e.g.

“These would not be my f irst choi ce because of the risk of dependence andrebound anxiety. However in some cases brief treatment with

benzodiazepines may be required to cover the initial exacerbation of

anxi ety commonly experienced with SSRIs.”

Identification of avoidance is important and commonly overlooked in

viva examinations.

Always be aware of the risk of comorbid problems such as alcohol abuse

and doctor-shopping for benzodiazepines.

If your clinical attachment has been in a public hospital you have been

exposed to case management for people with schizophrenia. Case

management is generally not appropriate for people with anxiety

disorders.




OF RISK AND DEVELOPING A PRIORITIZED MANAGEMENTPLAN.


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PERSONAL ITY DISORDER


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Presentation:You are working in the Department of Emergency Medicine assessing Jesinta, a 22 year old

woman who was brought to hospital by ambulance. Jesinta’s friend Suri called the ambulance

after she found Jesinta collapsed at home with self-inflicted lacerations of both wrists. Jesinta

is initially reluctant to discuss the reason for this episode of self-harm, but later says that she

cut herself after she found out on Facebook that a former boyfriend is now in a newrelationship and his partner is pregnant.

Nursing staff recognize Jesinta as “a regular”. Her medical file reveals multiple presentations

with self-harm, ranging from overdoses to wrist lacerations. She has on one occasion required

admission to ICU following an overdose. Jesinta has not sustained tendon or nerve damage

and the lacerations have been sutured.

Mental status examination:Thin young woman, with multiple tattoos and body piercings. Multiple scars across both

forearms. Poor eye contact, with irritable manner. Looks depressed. Refuses to cooperate

with history-taking, shouting: “ Just leave me alone. I’m sick of everyone. You doctors are just full of it.” She demands to leave hospital.

Clinical reasoning:

Why do people harm themselves?

What factors are likely to underpin Jesinta’s pattern of repeated self -harm? What feelings are likely to be aroused in health professionals involved in the care of

patients like Jesinta? How might health professionals respond to Jesinta? How will this

affect Jesinta’s behaviour?

Further history:Jesinta has had several inpatient admissions to the mental health unit after episodes of self-

harm. She has been offered outpatient follow-up but has never consistently attended.

Clinical reasoning: What is personality? What factors shape the development of personality?

What are the common personality traits? Consider how these can be adaptive and inwhich circumstances they are not adaptive;

When do personality traits constitute personality disorder?

What are the risks and benefits of making a diagnosis of personality disorder?

What comorbidities are common amongst people with personality disorders? How do you balance the assessment of acute vs. chronic risk? What are the potential

advantages and disadvantages of admitting a patient like Jesinta to a mental health unit

following an episode of self-harm? Remember issues such as regression and the risk of

splitting.

Learning tip:

Think about personality characteristics (for example obsessionality, narcissism) and

reflect on situations in which these characteristics could be helpful, or when they

could pose a burden.


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Further history:The social worker in the Psychiatric assessment unit has seen Jesinta previously, and gives

some details of her developmental history. Jesinta is the youngest of 7 children. Her father

abused alcohol and was violent, frequently assaulting Jesinta’s mother and the children. He

died from injuries sustained in a fight when Jesinta was 6 years of age. Her mother had

multiple partners before re-marrying when Jesinta was 12 years of age. Her step-fathersexually abused Jesinta until she ran away from home at 14 years of age. Since then Jesinta

has been involved in multiple relationships, several of which involved violence.

Jesinta is offered a new appointment for outpatient follow-up with the Psychiatry registrar.

She says she doesn’t think she’ll bother attending as everyone just criticises her and tells her

what to do.

Clinical reasoning: What are the possible consequences of childhood sexual abuse? What factors are likely

to play a part in long-term outcomes? How might her past experiences affect Jesinta’s attitude towards psychiatric treatment?

How could you respond to Jesinta when she says she won’t bother to attend her

outpatient appointment? What treatments are likely to be of benefit for people with personality disorders?

Discuss specific treatments such as DBT for those with borderline personality disorder.

What potential comorbidities should be taken into account when treating Jesinta?

What evidence is there regarding the benefits or risks associated with pharmacological

treatments in patients with personality disorders?

Consider how personality traits might modify presentation with medical conditions, and

how health professionals might need to modify their responses depending on these traitse.g. how would a person with narcissistic traits respond to a diagnosis of hypertension?

Learning tip:

This clip describes briefly the importance of attachment in providing a secure

foundation for subsequent personality development:

http://www.youtube.com/watch?v=6bul1meciGE

The Harvard Centre on the Developing Child has a rich suite of resources including

this one which describes the impact of neglect on brain development:

http://developingchild.harvard.edu/resources/multimedia/videos/inbrief_series/inbri

ef_neglect/. The Science of Adversity and Resilience resource on this site also

provides interesting reading.

When thinking about personality it is useful to identify defense mechanisms. TheVOPP on Adversity includes discussion of defences, as does this YouTube clip:

http://www.youtube.com/watch?v=FnRBAU6Yg2A

Splitting is commonly observed in hospital wards - you must be able to describe

what splitting is, and how it can be prevented and responded to.

http://www.youtube.com/watch?v=6bul1meciGEhttp://www.youtube.com/watch?v=6bul1meciGEhttp://developingchild.harvard.edu/resources/multimedia/videos/inbrief_series/inbrief_neglect/http://developingchild.harvard.edu/resources/multimedia/videos/inbrief_series/inbrief_neglect/http://developingchild.harvard.edu/resources/multimedia/videos/inbrief_series/inbrief_neglect/http://www.youtube.com/watch?v=FnRBAU6Yg2Ahttp://www.youtube.com/watch?v=FnRBAU6Yg2Ahttp://www.youtube.com/watch?v=FnRBAU6Yg2Ahttp://developingchild.harvard.edu/resources/multimedia/videos/inbrief_series/inbrief_neglect/http://developingchild.harvard.edu/resources/multimedia/videos/inbrief_series/inbrief_neglect/http://www.youtube.com/watch?v=6bul1meciGE


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Assessment tip - synopsis of a sample viva vignette:

Ellie Frost is a 22 year old woman who has been brought to the Department of

Emergency Medicine after she was found unconscious at a nightclub in the city. She

is assessed and considered to be intoxicated. After a period of medical observationshe is referred for psychiatric assessment. Ellie is reluctant to be interviewed, saying

that no-one has ever bothered with her, and she doesn’t see why this time will be

any different.

There are extensive notes in her hospital file.

She has presented with self-harm on several occasions, ranging from overdoses to

cigarette burns. On each occasion she has been offered psychiatric outpatient

follow-up, but has always declined.

Ellie never knew her father. Her mother was in a series of abusive relationships

during Ellie’s childhood. Hospital files document physical abuse from one of hermother’s partners, including severe beatings resulting in a fractured arm on one

occasion. Ellie ran away from home aged 14 years, and has no ongoing contact with

her mother.

On Mental Status Examination she is a thin woman with multiple scars and

cigarette burns of varying ages across both forearms. Poor eye contact, and sullen

manner. Dysphoric mood. Limited verbal responses to questions, often just

shrugging.



Personality traits or characteristics are what make us unique. Think

about your own characteristics. Many students are obsessional and this

is an asset in terms of achieving objectives. But being highly obsessional

can also mean that we set goals that are unrealistic, leading to

disappointment and even depression.

Being obsessional can mean it is hard to delegate or even let others helpus, as we feel “I should be able to do this” and we don’t want others to

think we are weak.

In MEDI3004 there is no such thing as a “dumb question” or request for

guidance/assistance!

Being exposed to the suffering of others is distressing and if we have

experienced personal trauma or loss it can be especially challenging. If

this is an issue for you, it can be helpful to discuss this with your clinical

teacher in confidence to make sure this doesn’t adversely impact your

learning.


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EATING DISORDERS


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Presentation:Grace is an 18 year-old woman in her first year of an Occupational Therapy degree at

University. She presents to the General Practice where you are completing your General

Practice clinical rotation. Your supervising GP asks you to take a history from Grace who

says that she wants help with binge-eating. The problem has been steadily getting worse since

she started University, and she is finding the pressure of assessment especially difficult. Shefeels that the binge-eating is now dominating her life. She failed a subject last semester and is

wondering if she has chosen the right course, but feels uncertain about what she should do.

She says that she was not really prepared for the pressures of University study. She finds it

hard to fit in with the other students who already seem to have established networks of

friends. Grace has been binge-eating and vomiting for about 18 months, usually twice per

day. For the last 2 months she has been taking up to 6 coloxyl with senna tablets/day.

Mental state examination:Grace presents as a casually-dressed woman whose hair is untidy. She has puffy eyes as

though she has been crying. Says she feels miserable and ashamed, and that she cannot

confide in anyone. She demonstrates some reactivity of affect. She denies thoughts of self-

harm. No psychotic features.

Clinical reasoning:

What is binge-eating and when does it become a clinical problem?

How would you distinguish Bulimia Nervosa from Anorexia Nervosa?

What are the common precipitants for binge-eating, and the common cognitive and

behavioural responses to binge-eating?

What are the potential medical complications of Bulimia Nervosa and Anorexia Nervosa?

What investigations are appropriate?

Follow-up:The GP asks you to conduct a thorough physical examination and asks what investigations

should be undertaken. Grace agrees to make an extended appointment to provide further

history and review results. In the interim she agrees to keep a diary of her eating behaviours

and thoughts.

Physical findings:Wt. 61 kg. Ht. 170 cm (BMI = 21kg/m2).

PR = 80/min; BP = 110/70.

Some dental erosions.

No other abnormalities.

Investigations:U&E; LFTs; TFTs; Haemoglobin; ECG – all within normal limits

Further history:

Learning tip:

You must know the physical complications of eating disorders;

You must know the biochemical and other abnormalities which commonly occur;You must understand the physiology of re-feeding syndrome.


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Which of the following is an expected finding in a young woman with anorexia

nervosa:

A. Tachycardia

B. Leucocytosis

C. Hypotension

D. Hypernatraemia

E. Polycythaemia



Eating disorders are common and you may have personal experience or

seen friends who have been affected.

Think about your responses to patients with whom you could identify

for a variety of reasons, and how you could deal with that as an intern.


27/34



You must know the physical complications of eating disorders and be

aware of the risks associated with refeeding. You must recognise the

risk of comorbid depression.

Alcohol and other substance abuse can occur in the context of bulimia

leading to additional risks including the risk of assault/sexual violence.

You need to be able to discuss the application of CBT for patients with

bulimia. You need to be aware of the ethical aspects of a case of an

adolescent with an eating disorder, including consent to treatment.





PLAN.


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DEMENTIA


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Presentation:You are an intern working in the Older Person’s Mental Health Service at a large teaching

hospital. Martin Quigley is an 84 year-old retired high school principal referred by his general

practitioner. The general practitioner is concerned that Mr. Quigley has started acting upon

hallucinations and persecutory delusions that he first developed approximately six months ago.

Mr Quigley is reluctant to speak to you, and says that the matter is a private one between him

and his wife. Mrs Quigley says that over the past 6 months or so her husband has angrily

accused her of having ‘a lover’, insisting that he has repeatedly seen ‘another man’ in their

home. Mrs. Quigley also reports that her husband has had memory difficulties for at least two

years and these seem to be becoming progressively worse.

Mental state examination: Mr. Quigley is neatly attired and superficially cooperative. He denies any problems with his

health or any problems with his memory or thinking. He has mild psychomotor overactivity, and

some word-finding difficulties. His mood is euthymic. He describes visual and auditory

hallucinations and secondary persecutory delusional beliefs. He is fully conscious and alert. He

is disorientated to time but with intact attention and concentration.

He has significant impairment of short-term memory and difficulty with simple calculations,

with impaired answers on a similarities and differences task. His verbal fluency is reduced. He

has little or no insight into the nature of his cognitive impairment. Impaired judgement.

Physical examination:Fit-looking 84-year-old man.

Pulse 84/minute; BP 160/90 lying, 150/80 standing.

RR 16/minute.Afebrile.

Detailed cardiorespiratory examination unremarkable.

Visual agnosia and dressing dyspraxia on detailed neurological examination, although no

cranial nerve, pyramidal tract or cerebellar signs.

Appendicectomy scar.

Learning tip:

This video produced by Michael Leighton gives poignant insights into the

experiences of people affected by dementia and their carers:

http://www.youtube.com/watch?v=bVXoA4uISp4

Another example: https://www.youtube.com/watch?v=LL_Gq7Shc-Y

Alanna Shaikh talks on TED about her father:

http://www.youtube.com/watch?v=J8FyHI00ELY

http://www.youtube.com/watch?v=bVXoA4uISp4http://www.youtube.com/watch?v=bVXoA4uISp4https://www.youtube.com/watch?v=LL_Gq7Shc-Yhttps://www.youtube.com/watch?v=LL_Gq7Shc-Yhttps://www.youtube.com/watch?v=LL_Gq7Shc-Yhttp://www.youtube.com/watch?v=J8FyHI00ELYhttp://www.youtube.com/watch?v=J8FyHI00ELYhttp://www.youtube.com/watch?v=J8FyHI00ELYhttps://www.youtube.com/watch?v=LL_Gq7Shc-Yhttp://www.youtube.com/watch?v=bVXoA4uISp4


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Clinical reasoning: What diagnostic possibilities would you consider and why? Consider medical conditions

which may present with apparent cognitive impairment.

How would you distinguish between these conditions?

What tests of cognitive function can be used to make a clinical assessment?

What is verbal fluency and how might this be useful?

What is the significance of word-finding difficulties?

What signs would you look for on physical examination?

Further history:

Mrs. Quigley says that her husband has had obvious difficulties with his memory and thinkingfor at least two years. Over the past twelve months in particular she has had to do more of the

general household tasks because her husband has become progressively more muddled and

inefficient. She has also had to take over driving their car recently as her husband’s driving had

deteriorated to the point where she felt quite anxious travelling with him when he was driving.

At times Mrs. Quigley now has to assist her husband with dressing as he has difficulty putting

on his clothes. Mr. Quigley has always been an independent, proud man who worked most of his

life as a high school English teacher, achieving the position of principal of a prestigious city high

school in his 50’s. His wife has been reluctant to seek medical assessment because of his

stubborn denial that there were any problems. However the recent accusations of infidelity have

distressed her greatly because they are untrue and because they have always enjoyed a closerelationship.

Mrs. Quigley says that her husband is otherwise in relatively good general health but he takes a

benzodiazepine at bedtime as well as an ACE inhibitor for longstanding hypertension. The nurse

practitioner recommends that Mr. Quigley undergo routine investigation for potentially

remediable factors that may be associated with dementia. The team also recommends that Mr

Quigley be prescribed low dose anti-psychotic medication and monitored closely for adverse

effects.

Learning tip:

Think about the areas of brain which are affected in Alzheimer’s disease and relate

these to function. Compare the cognitive deficits associated with Alzheimer’s with

Korsakoff’s syndrome and relate these to anatomical structures.

Practice conducting a full cognitive assessment including the Mini Mental Status

Examination, trail-making tests, and verbal fluency.

Describe how you would distinguish between dementia and pseudo-dementia due to

depression.


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Investigations:Mr. Quigley is initially reluctant to undergo any investigations as he feels there is nothing wrong

with him. With persuasion by his wife and his general practitioner, he agrees to have blood tests

and a CT head scan. The CT head scan shows moderate generalised atrophy more noticeable in

the temporal lobes and areas of marked periventricular hypodensity.

Full blood count (FBC) – normal.

Erythrocyte sedimentation rate (ESR) – normal.

Serum electrolytes – normal.

Thyroid stimulating hormone (TSH) – normal.

Liver function tests – normal.

Serum vitamin B12 and red cell folate – normal.

Syphilis serology – unreactive.

CT or MRI head scan – generalised atrophy plus periventricular hypodensities.

ECG – normal.

Urinalysis – normal.

Clinical reasoning:

How would you discuss the diagnosis with Mrs. Quigley?

Consider the diagnosis in terms of both the syndrome and the likely underlying disease

processes.

What factors would you take into account in assessing the risk that Mr Quigley poses tohimself and others?

What information would you give Mrs. Quigley about responding to her husband’s

accusations? What are the benefits and risks of treating Mr. Quigley with antipsychotic medication?

Why would a low-dose of antipsychotic medication be prescribed? What factors affect theability of older patients to metabolise drugs? What evidence is there regarding the

effectiveness and side-effect profile of antipsychotic medication in the elderly?

What strategies might be helpful to reduce the burden of caring faced by Mrs. Quigley?What support groups are available?

What medications are available to treat cognitive decline related to dementia? What is their

mechanism of action and side-effect profile?

What ethical factors need to be taken into account in this case? Consider issues which mayarise as his condition deteriorates.


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Learning tip:

Alzheimer’s Australia has information about dementia:http://www.fightdementia.org.au/

including models of care:

http://www.fightdementia.org.au/common/files/NAT/Paper_35_web_v2.pdf

Think about the burden posed for carers of people with dementia and ways they

could be assisted.

You should reflect on the burden dementia will increasingly pose as the population

ages, and the complex ethical and social issues which potentially arise, including

elder abuse and exploitation and decision-making, including at end of life.

Fantasy Fiction writer Terry Pratchett describes his own diagnosis of dementia and

his campaign for legal assisted dying: http://www.youtube.com/watch?v=CU-

KdxrJj74&list=PLDFAA1CAC0B15CFB7

Assessment tip – synopsis of a sample viva vignette:

Mavis Jones is an 82 year-old woman brought for a consultation with her General

Practitioner by her husband, Max, after he found her wandering in the street in her

nightgown. Mr. Jones has been concerned about his wife for the past few months, as

she has been irritable at times, and has become increasingly reluctant to engage in

bathing and personal care.

Mrs. Jones was diagnosed as having dementia 4 years ago but has had no response

to pharmacological treatments. Mr. Jones assumes responsibility for shopping,

cooking and other domestic tasks.

Mrs. Jones has a long history of hypertension.She fractured her (L) hip after falling in a shopping centre 5 years ago and her

husband felt that she was “never the same again” after surgery.

Myocardial infarct three years ago.

On MSE she is thin, wearing stained clothes. Her hair is lank. She is uncooperative

on interview. On questioning she is able to state her name, but is uncertain of the

day or date. When questioned further she becomes restless and irritable.

http://www.fightdementia.org.au/http://www.fightdementia.org.au/http://www.fightdementia.org.au/common/files/NAT/Paper_35_web_v2.pdfhttp://www.fightdementia.org.au/common/files/NAT/Paper_35_web_v2.pdfhttp://www.youtube.com/watch?v=CU-KdxrJj74&list=PLDFAA1CAC0B15CFB7http://www.youtube.com/watch?v=CU-KdxrJj74&list=PLDFAA1CAC0B15CFB7http://www.youtube.com/watch?v=CU-KdxrJj74&list=PLDFAA1CAC0B15CFB7http://www.youtube.com/watch?v=CU-KdxrJj74&list=PLDFAA1CAC0B15CFB7http://www.youtube.com/watch?v=CU-KdxrJj74&list=PLDFAA1CAC0B15CFB7http://www.fightdementia.org.au/common/files/NAT/Paper_35_web_v2.pdfhttp://www.fightdementia.org.au/


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Beware of ageist stereotypes. Don’t assume that an older person will

require institutional care. You must be able to discuss the ethical

dimensions of care including substitute decision-making and Enduring

Power of Attorney.

In the vignette above, the patient’s vascular history is suggestive of

multi-infarct dementia. You must be able to explain likely reasons why

her husband felt she was “not the same” post-operatively, drawing on

your knowledge of basic physiology, response to trauma and surgicaltreatment for a fractured hip.

You must be able to describe the reasons why older persons require

adjustment in doses of psychotropic medication

Be aware of the need to have multi-faceted strategies for management of

behaviour disturbance in a person with dementia. Anti-psychotic

medication is associated with increased risk of adverse events including

cardiac events and death.The National Prescribing Service provided a media release in November

2011 outlining some of these risks:http://www.fightdementia.org.au/common/files/NAT/20111118_Nat_MR_NPSWarn

ingAntipsychotics.PDF

NOTE: Continued over page



Have you experienced dementia in your extended family?How has that affected the people close to that person?

What feelings do you think you might have when assessing and treating

patients with cognitive impairment?

How will you deal with that as an intern?

http://www.fightdementia.org.au/common/files/NAT/20111118_Nat_MR_NPSWarningAntipsychotics.PDFhttp://www.fightdementia.org.au/common/files/NAT/20111118_Nat_MR_NPSWarningAntipsychotics.PDFhttp://www.fightdementia.org.au/common/files/NAT/20111118_Nat_MR_NPSWarningAntipsychotics.PDFhttp://www.fightdementia.org.au/common/files/NAT/20111118_Nat_MR_NPSWarningAntipsychotics.PDFhttp://www.fightdementia.org.au/common/files/NAT/20111118_Nat_MR_NPSWarningAntipsychotics.PDF


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Pitfalls to watch for (cont):

NOTE: Be aware of the risk of delirium in the older population who

may have reduced cerebral reserve.

Delirium features prominently in viva examinations and you must be

able discuss the likely causes of delirium, assessment (which alway s

includes a physical examination), investigation and pharmacological

and non-pharmacological management. Delirium is a medical

emergency. Patients with delirium must be managed in a medical

setting, not a mental health unit.

This video outlines strategies to reduce/prevent delirium in hospitalised

elderly patients: http://www.youtube.com/watch?v=mKcbeXVdygg

Although not typical of delirium, the description “Agitated delirium” is

increasingly used to describe confusion and behavioural disturbance,

often in relation to substance abuse/withdrawal in combination with

psychiatric and medical illness. This is a medical emergency and

confronts staff in DEM regularly.

This video is very confronting and demonstrates a fatal outcome:

http://www.youtube.com/watch?v=GdzpoS8pTks





PLAN.
http://www.youtube.com/watch?v=mKcbeXVdygghttp://www.youtube.com/watch?v=mKcbeXVdygghttp://www.youtube.com/watch?v=mKcbeXVdygghttp://www.youtube.com/watch?v=GdzpoS8pTkshttp://www.youtube.com/watch?v=GdzpoS8pTkshttp://www.youtube.com/watch?v=GdzpoS8pTkshttp://www.youtube.com/watch?v=mKcbeXVdygg

Clinical Case Reviews 2016

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