MSE Cases Flashcards
Differentials for hypomania
- Delirium
- Drugs and alcohol
- Space occupying lesions
- Metabolic disturbances
Bipolar I vs II
Management of hypomania
- Manage risks identified
- Consider need for admission - need to show can’t be managed in community if using MHA
- Can be managed in community if agree to stop driving, take additional medication, see Crisis team daily, stop work for period of time (if affects job)
- Driving is an important risk to address - difficult to manage in community if lack insight as they will not agree to stop
How to ask re hallucinations?
- Do you ever see things that other people say they can’t see?
- Do you ever hear people talking to you when other people are not around? - avoid using ‘voices’
Command hallucinations and risk
- Command hallucinations increase risk of self harm and suicide if they are telling the patient to do this
Differentials for auditory hallucinations occuring with alcohol
- Alcoholic hallucinosis - can occur on withdrawal or intoxication
- Space occupying lesion
- Schizophrenia
Medications for alcohol withdrawal
- Benzodiazepines - high dose, wean over days
- IV/IM Pabrinex (thiamine) - prevent wernickes (reversible) and korsakoff (non reversible)
- Antipsychotics are sometimes used alongside wean of alcohol
How long do psychotic symptoms need to be present for to diagnose schizophrenia?
1 month
When do you do paracetamol blood test level?
4 hours after overdose
Check can interpret graph
What if someone with overdose refuses treatment?
- Do not want to let the person die
- Need to consider capacity but do this later
Reasons for overdose
- Unintentional
- To commit suicide
- Cry for help
- To self harm
Questions to ask re overdose to assess if high risk
- Did they take steps to avoid being discovered?
- Made arrangements - pets, finances, wills, children
- How much planning as been done?
- Writing notes
- Severe mental illness - schizophrenia
- Middle aged men highest risk - choose violent methods
- Chronic health condition
- Living alone
- FH severe mental illness (sometimes includes suicide attempts)
- How did she get to hospital?
- How does she feel about it now?
Other questions re overdose
- ODPARA - triggers, onset thoughts etc
- What led up to the event?
- Plans to do it again?
- Drinking heavily at the time?
- Vomitted?
- How long ago?
- Current mental state
- Psychiatric history
- PMH
- SH - support at home?
Wording of seeing patient alone
- Need to speak to patient alone - eg go and grab a coffee, I would like to speak to your wife on her own and then I will speak to you both together
Common delusions of depression
- Nihilism
- Guilt
- Poverty
Psychotic symptoms of depression
- Auditory hallucinations - command
- Delusions - NGP
Antidepressants post A&E
- A&E do not start these as they need f/u
- Crisis team or GP can start as they can monitor patient at f/u
Questions for police re disturbance?
- Describe what happened?
- Have they ever been called to address before?
- Appearance - why does he seem to be unwell?
- Is there a risk of violence? - how is he likely to be with us?
What drugs tend to cause psychosis?
- Mainly stimulants
- Cocaine - visual hallucinations
- LSD
- Cannabis if smoke enough
- MDMA
- Mephedrone
- Amphetamines
Perceptual abnormlaities
- Illusions - not pathological
- Hallucinations - can be non pathological if waking up or drifting off to sleep
How to assess if someone has delusions? - FINISh
- Is there anything thats worrying you at the moment?
- Usually thinking about them quite a lot
- Do you ever worry that people are out to harm you? Watching you? Spying on you?
- When you listen to the radio or watch TV, are there ever any special messages just for you? - reference delusions (normal audio but think its for them)
How to ask about thought insertion, broadcast or withdrawal? - FINISH
- If yes - diagnosis is schizophrenia
How to ask re insight?
- If know diagnosis - ask about this, how do they feel about this?
- Are they taking their medication
- Do they think there is any chance they are becoming unwell like they have in the past?
Requesting criminal records of patients
- Can request - assessed to check is in best public interest to share it with psychiatrist
- Does tell you offences and charges
- Does not tell sentences etc
Differentials for psychosis episode
- Schizophrenia
- Substance misuse
- Schizoaffective disorder - schizophrenia symptoms and affective disorder (eg depression/mania)
- Delirium
- SOL
How does it work if crisis team think patient needs admission?
- They talk to AMP - approved mental health practitioner - social workers, liase to get two other doctors to do assessment to do MHA and see if need to be sectioned
DVLA rules of driving mania nad hypomania
- Must be no driving during acute illness
- Must inform DVLA of diagnosis and be stable for 3 months to be allowed to drive
- Lack of insight that would affect driving ability results in ban from driving
