10 psychiatric case studies - let's hear your answers! :)

[bargaindoctor]

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These are british as you may tell from some terminology. Each question worth 10 marks. Enjoy!

Question 1
A 54-year-old married woman is admitted for varicose vein surgery. On admission she says she has longstanding ‘problems with her legs’ and is noted to be mildly ataxic and slightly dysarthric. Two days post-operatively she has a grand mal seizure. She has been investigated neurologically in the past three months with no abnormality found.
a) What are the main diagnostic possibilities here? (3)
b) What other features would you seek? (3)
c) What is your immediate management plan? (4)

Question 2
A 27-year-old married woman becomes sleepless and over excited four days post partum while in the maternity unit. You are the psychiatrist on call. When you see her she is shouting loudly; her speech is pressurised and hard to follow but she seems to think she is the Virgin Mary; she is rushing up and down the ward clutching the baby in her arms.
a) What do you think might be wrong with her? (2)
b) What would be your immediate plan of action? (4)
c) Once the immediate situation has been resolved what outstanding issues
do you think would be important? (4)

Question 3
You are asked by colleagues in paediatrics to assess an unsupported mother who is staying in the children’s ward with her 3 year old son who is failing to thrive. The staff think, although they have no proof, that she is interfering with the child’s feeding regime.
a) what diagnostic possibilities do you see here? (3 marks)
b) how would you differentiate between these? (7)

Question 4
You are a GP. A 30 year old woman comes to see you to say that her 58 year old mother has been admitted to a psychiatric ward following an overdose. ECT has been mentioned as a possible treatment for her mother. She does not know what to think about this but friends have told her it is old fashioned and barbaric. How would you advise her:
a) upon the range of severity and possible consequences of depressive illness; (3 marks)
b) the possible treatments for depressive illness; (4)
c) her own and her mother’s rights in respect of confidentiality and consent to
treatment. (3)

Question 5
A 52-year-old woman with depression and a history of pulmonary embolus, on
Warfarin, wants to take St John’s Wort. Do you envisage any problems with this, and if so, what ? (2)
A woman with hypertension treated with diuretics has a second episode of mania having had one major episode of depression in the past. She asks about mood stabilisers and whether these would help her and which would be the most suitable. What would you tell her? (3)
A 50- year-old man with schizophrenia has been treated with thioridazine for years and has found the particular side effects of the trifluoperazine to which he was changed difficult to tolerate. He wishes to change to a more modern drug but has a history of angina and maturity onset diabetes and some ischaemic changes on ECG. He wants to know what the pros and cons of the different antipsychotic options are. What would you tell him? (5)

Question 6
You are an SHO in psychiatry and at 11pm are called by the casualty officer to see two medical students who have presented. One has brought his friend (the patient) who returned to their flat four days previously after the summer holidays. Initially he just seemed quieter than usual but over the last 48 hours has been talking about being under threat by international terrorists, keeping the flat in darkness and refusing to go to bed in case he is harmed while asleep. The patient says he is giving no information to you or anyone else and behaves in a watchful but calm manner.
What is the differential diagnosis? (4)
What are your immediate plans for management? (6)

Question 7
Reduction in rates of suicide and self-harm is a major priority.
a) Give one intervention that you know has been put into practice and has
reduced death rates by at least one method. (2)
b) Give three other interventions which could realistically be suggested
and indicate how you think they would work. (8)

Question 8
You are a G.P. A 30-year old married woman comes into your surgery with facial bruising. Six months ago she had a black eye which she attributed to walking into a clothesline. You ask her about the situation and after some delay she tells you that both injuries were actually the result of her husband punching her.
a) What questions do you think you should ask her? (3)
b) What diagnostic possibility in the husband would give you particular
cause for concern? (2)
c) How would you manage this situation? (3)
d) If your enquiries lead you to believe that there is a significant risk of serious
harm coming to this woman what should you do? (2)

Question 9
Summarise the evidence that the following groups of drugs which may be used recreationally may precipitate psychotic illness:
(a) alcohol (2)
(b) opiates/benzodiazepines (2)
(c) stimulants (amphetamines and cocaine) (2)
(d) dance drugs (e.g. ecstasy, ketamine) (2)
(e) cannabis (2)

Question 10
You are a psychiatrist. You are asked by a GP colleague to advise a female patient aged 45 who has consulted him about issues relating to Alzheimer’s disease in her own family. Her mother aged 72 has been hospitalised for one year with the disorder. She can no longer communicate and requires assistance with all areas of activity. Her mother’s sister died from Alzheimer’s aged 73, two years ago. The woman wishes to know if:
a) Cognitive enhancers would help her mother and how should her need for these be assessed (3)
b) What the risks are to herself and if any genetic or other testing would help (3)
c) If it would be useful for her to take cognitive enhancers on a prophylactic
basis now (2)
d) If her own two children aged 8 and 10 could have any form of genetic or
other predictive testing (2)

 

[50960]

Interesting, but who has the time to write out such questions?? Do tell.

cheers 😀

 

[bargaindoctor]

They are from past papers. Anyway, no one up to the challenge so far? Surely someone knows their psychiatry! 🙂 Would like to hear some answers from psychiatrists or students who've finished this rotation.

 

[Anasazi23]

These are british as you may tell from some terminology. Each question worth 10 marks. Enjoy!

Question 1
A 54-year-old married woman is admitted for varicose vein surgery. On admission she says she has longstanding ‘problems with her legs’ and is noted to be mildly ataxic and slightly dysarthric. Two days post-operatively she has a grand mal seizure. She has been investigated neurologically in the past three months with no abnormality found.
a) What are the main diagnostic possibilities here? (3)
b) What other features would you seek? (3)
c) What is your immediate management plan? (4)

I'll answer some of these slowly, as I have time and interest... 🙂

I know this is just a quiz you had, but a good medical history is essential here. "Problems with her legs" needs to be fettered out. Sounds like this lady could have portal hypertension and/or liver problems. For answer purposes, one should consider a a hyperammonia encephalopathic state with associated electrolyte abnomalities. Management...get an ammonia level, INR, CBC, calcium, phosphorous, urea, liver function tests, glucose, CMP, ESR, and eeg. If found to be hyperammonic, treat accordingly with whatever works for you....ie. lactulose. Check for other diseases that pique your suspicion like multiple myleoma, etc. If the neuro exams are normal, as you say, you can think about other zebras, not stuff like hydrocephalus or cerebrovascular disease, depending on how extensive the neuro workup was. Otherwise, I would agree to consider those, as well as about 30 other disease states, as well.

 

[Anasazi23]

These are british as you may tell from some terminology. Each question worth 10 marks. Enjoy!


Question 2
A 27-year-old married woman becomes sleepless and over excited four days post partum while in the maternity unit. You are the psychiatrist on call. When you see her she is shouting loudly; her speech is pressurised and hard to follow but she seems to think she is the Virgin Mary; she is rushing up and down the ward clutching the baby in her arms.
a) What do you think might be wrong with her? (2)
b) What would be your immediate plan of action? (4)
c) Once the immediate situation has been resolved what outstanding issues
do you think would be important? (4)

Reproductive-related mood disorders have been reported to have an incidence of over 30% in females with a bipolar diathesis according to some studies. This woman, barring any additional information, is most likely suffering from post-partum (either new onset or exacerbation) bipolar disorder with psychotic features. Immediate plan of action is to remove the infant from her care, and start psychiatric treatment. It seems to me that too many defer to the mother-infant bonding issues and make life difficult by taking the risk of starting medications that are not excreted in breast milk. I find it easier to simply bottle feed the child for that duration of the illness. You can bring the mother back under control much quicker with lithium, VPA, with or without additional mood stabilizers.

Others will argue to pump milk prior to the am dose, or try a 200mcg transdermal estrogen patch to prevent recurrance.

Of course, educate the mother and father, if available, about the side effects of these medications, get a baseline behavioral level of the baby, etc, etc.



A very quick search on pubmed reveals this full-text article, for those so inclined.
http://content.karger.com/produktedb/produkte.asp?typ=fulltext&file=PSP2003036005234

 

[Anasazi23]

These are british as you may tell from some terminology. Each question worth 10 marks. Enjoy!


Question 3
You are asked by colleagues in paediatrics to assess an unsupported mother who is staying in the children’s ward with her 3 year old son who is failing to thrive. The staff think, although they have no proof, that she is interfering with the child’s feeding regime.
a) what diagnostic possibilities do you see here? (3 marks)
b) how would you differentiate between these? (7)

Munchausen's by proxy no longer exists as a diagnostic entity in the DSM. The newer preferred term is factitious disorder by proxy. This diagnostic possibility, however, must include other differentials since you state in the first sentence that she is an "unsupported mother." This raises the possibility of secondary gain, and therefore forces you to think of a type of malingering by proxy, so to speak. Other diagnostic possibilities include borderline personality disorder, malingering, a psychotic disorder, or general medical condition. It is imperative that a full set of labs be drawn on the baby to start. The easiest way is to remove the baby from the mother's care for a few week and chart the baby's weight and get a baseline HC, which was presumably already performed.

Differentiating between the two would depend on the baby's ability to thrive when removed from the mother. Clinical interview will be met with great resistance, as these mothers are notoriously resistant to these allegations. If proven, CPS is notified, and appropriate aftercare plans are created.

 

[Anasazi23]

These are british as you may tell from some terminology. Each question worth 10 marks. Enjoy!



Question 4
You are a GP. A 30 year old woman comes to see you to say that her 58 year old mother has been admitted to a psychiatric ward following an overdose. ECT has been mentioned as a possible treatment for her mother. She does not know what to think about this but friends have told her it is old fashioned and barbaric. How would you advise her:
a) upon the range of severity and possible consequences of depressive illness; (3 marks)
b) the possible treatments for depressive illness; (4)
c) her own and her mother’s rights in respect of confidentiality and consent to
treatment. (3)

First off, considering ECT for a first onset depression seems awfully quick (assuming this is her first admission). She most likely deserves medication trials first. The range and severity of depressive illness obviously varies greatly from low-grade chronic dysthymic disorder to the aforementioned acute episode with suicide attempt. Consequences, likewise, vary greatly and range from minor decreased quality of life to anhedonia and hopeless/helplessness leading to the desire to kill oneself.

The treatments for depressive illness include pharmacotherapy (SSRIs, MAOIs, SNRIs, TCAs, etc), ECT, therapy, and the correction of any metabolic, endocrinological or other medical condition contribuing to depressive illness.

ECT has been shown incontrovertibly to be a safe, quick and effective mode of treatment for depressive disorders and other types of psychiatric conditions. However, one must be the proper candidate for this mode of treatment, which is too much to go into detail here.

Assuming her mother is competent and has capacity, the daughter has no say in the treatment. The patient should be informed of the risks and benefits, and a decision made accordingly. As always, confidentiality of the patient should be assured. The overbearing and unreasonable HIPPA policies are in place here in the states to help make physicians' lives harder and ensure confidentiality.

 

[Anasazi23]

These are british as you may tell from some terminology. Each question worth 10 marks. Enjoy!


Question 5
A 52-year-old woman with depression and a history of pulmonary embolus, on
Warfarin, wants to take St John’s Wort. Do you envisage any problems with this, and if so, what ? (2)
A woman with hypertension treated with diuretics has a second episode of mania having had one major episode of depression in the past. She asks about mood stabilisers and whether these would help her and which would be the most suitable. What would you tell her? (3)
A 50- year-old man with schizophrenia has been treated with thioridazine for years and has found the particular side effects of the trifluoperazine to which he was changed difficult to tolerate. He wishes to change to a more modern drug but has a history of angina and maturity onset diabetes and some ischaemic changes on ECG. He wants to know what the pros and cons of the different antipsychotic options are. What would you tell him? (5)

1. She is not to take St. John's Wort. Considering the comorbid medical issue (PE), it is unwise to start St. John's Wort due to the documented reduced anticoagulant effect of warfarin, which is thought to occur through inducing CYP2C9 activity. She can take another antidepressant that has no interaction with warfarin or factor IX.

2. Since she needs to stay on a diuetic, lithium isn't a great choice. It could increase lithium levels and cause potential problems. Valproic acid is frequently given with diuretics, but caution should be advised, especially with the potassium sparers. If she had only one previous episode of depression, lamictal could probably wait. Most of the atypicals are now approved for mania. These are a possibility. The possibilities of these and other mood-stabilizers depends on the patient presentation and lab values, etc.

3. This answer could go on for 100 pages. Typicals and geodon don't seem like great choices for cardiac reasons and the (small) possibility of prolonged QtC. Since he now has DM, you'd have to go with one of the so-called weight neutral neuroleptics...one that also won't increase blood sugars. Abilify might be a good start. Other risks include weight gain, diabetes, somnolence, increased apetite, neuroleptic malignant syndrome, and myriad other conditions.

 

[50960]

I like your answers anasazi, but do you really think abilify works for bipolar? Have you seen this? I have a parkinsonian guy who is bipolar and we finally put him on that when ceased being able to walk, and was manic in a wheelchair!! It helped the parkinsonian sx, but manic rates were similar month to month as on olanzapine 20 mg qd. This could mean alot of things I know. What are your observations? BTW HIPPA is HIPAA, but it is still very annoying no matter how you spell it.

🙂

 

[Anasazi23]

No, I don't think Abilify works great for bipolar mania. I mentioned it because given his medical picture the recent onset of DM, he deserves at least a trial of it, since it is the most weight neutral and has a decent profile with blood glucose levels. I wouldn't give this guy zyprexa unless it was the only thing that worked for him. In my experience, diabetics on zyprexa will quicly gain lots of weight...more than the typical 10-15lbs. Also, lots of people don't dose abilify properly, and top out the dose too soon. How much is he taking and at what time? If he's on a lot of other meds, they may be lowering the levels. I'm suspicious of this since you say he got a similar effect on zyprexa...this is not typical in my experience. As a matter of fact, the reps say that they're going to be releasing a revised dosing regimin for abilify some time soon (they are with seroquel also). That should help somewhat.

The first double-blind placebo controlled study for an atypical in mania was recently released with zyprexa. I like the drug, especially when you load the dose. I've found few other medications as effective with similar side effect profiles...needless to say, real cautions must be taken with the drug, however. A good clinician will know how to manage the potential complications or stop/switch if and when it's necessary. I'm not sure how old your parkinson's patient was or what his labs or like, but you could consider upping the dose, or adding an adjunct. If it's a sundowning mania he's experiencing, then you'd almost certainly have to change the dosing or add the adjunct. When do his manic symptoms flare up? He'd probably benefit from divided doses rather than QD dosing. Is he not on lithium for a reason? This or others might be worth considering if the atypicals aren't holding him.

HIPAA is definately annoying and beyond. I acutally find it destructive in many respects. But that's a whole 'nother thread. 🙂

 

[Anasazi23]

These are british as you may tell from some terminology. Each question worth 10 marks. Enjoy!


Question 6
You are an SHO in psychiatry and at 11pm are called by the casualty officer to see two medical students who have presented. One has brought his friend (the patient) who returned to their flat four days previously after the summer holidays. Initially he just seemed quieter than usual but over the last 48 hours has been talking about being under threat by international terrorists, keeping the flat in darkness and refusing to go to bed in case he is harmed while asleep. The patient says he is giving no information to you or anyone else and behaves in a watchful but calm manner.
What is the differential diagnosis? (4)
What are your immediate plans for management? (6)

Differential and eventual rule-outs: (in no particular order)
Brief Psychotic disorder
Schizophrenia - Paranoid type
Paranoid personality disorder
Substance-induced psychotic disorder
Delusional Disorder
Schizotypal personality disorder
Psychotic disorder due to a general medical condition
You could make arguments for others...

Immediate plans are to begin medical workup, including utox and etoh level and barring any contraindications start a neuroleptic to assess response. Talk with the family to corroborate premorbid functioning, all that jazz.