Psychiatry Flashcards
How you would manage this patient’s low mood?
I would take a biopsychosocial approach to manage this patient, consulting my senior and involving members of the MDT.
I would first consider an organic screen to rule out medical causes, and use a rating scale such as PHQ-9 to assess severity.
From a social perspective, I would direct this patient towards support groups such as “mind”, and involve a care coordinator.
For psychological therapy, I would refer this patient to IAPT for CBT/online self-guided CBT to target their negative thoughts, feelings and behaviour cycles.
In terms of pharmacological therapy, I would like to consider an SSRI such as Sertraline, and would provide information on side effects and R/V the patient in 2 weeks time for suicidal ideation.
Thinking about the setting of treatment, I do see an element of risk in this case but I see that this could be managed in the community with a CMHT referral/as part of a home treatment team. There are also some protective factors at home such as familial support.
OR
I have considered whether this patient could be managed in the community however I am concerned that this patient is at particular risk to self therefore in this case I would arrange admission, either informally or following assessment under section 2 of the mental health act.
How would you manage this patient with psychosis?
I would take a biopsychosocial approach to manage this patient, consulting my senior and involving members of the MDT.
Thinking about the setting of treatment, I do see an element of risk in this case but I see that early intervention service in the community would be a suitable option for this patient, considering the protective factors at home.
OR
I have considered whether this patient could be managed in the community by the early intervention service, however I am concerned that this patient is at particular risk to self therefore in this case I would like to discuss admission with the patient and arrange
assessment under section 2 of the mental health act
I would also consider an organic screen to rule out medical causes, and use the Brief Psychiatric Rating Scale to assess severity.
From a social perspective, I would like to consider care coordination for this patient, and in the longer term think about rehabilitation into work.
For psychological therapy, I would consider CBT to help the patient rationalise their thoughts, feelings and behaviours. Family therapy may also be a good option here.
In terms of pharmacological therapy, I would like to consider an antipsychotic such as risperidone, counselling the patient on side effects and would review the patient for response.
How would you manage this mother with postpartum depression?
I would take a biopsychosocial approach to manage this patient, consulting my senior and discussing with the safeguarding team.
Thinking about the setting of treatment, I do see an element of risk in this case but I see that Rx in the community would be a suitable option for this patient, considering the protective factors at home.
OR
I have considered whether this patient could be managed in the community, however I am concerned that this patient is demonstrating suicidal intent/evidence of psychosis/risk to baby therefore in this case I would seek immediately psychiatric opinion and with view to potential admission to a mother and baby unit.
I would also consider an organic screen to rule out medical causes, and use a rating scale such as the Edinburgh postnatal depression screen to assess severity.
From a social perspective, I would like to involve the health visitor and direct the patient to support groups such as PANDAS.
For psychological therapy, I would refer this patient for online guided self-help/CBT to target their negative thoughts, feelings and behaviour cycles.
In terms of pharmacological therapy, I would like to consider a breastfeeding safe SSRI such as Sertraline, and would provide information on side effects.
I would like to ask this patient to come back in a week’s time for a review.
How would you manage this patient with anxiety?
I would take a biopsychosocial approach to manage this patient, consulting my senior and involving members of the MDT.
I would first consider an organic screen to rule out medical causes (drugs/medications, hyperthyroidism), and use a rating scale such as the Beck Anxiety Inventory to assess severity.
From a social perspective, I would direct this patient towards support groups such as “mind”, and involve a care coordinator.
For psychological therapy, I would refer this patient to IAPT for CBT/online self-guided CBT to target their negative thoughts, feelings and behaviour cycles.
In terms of pharmacological therapy, I would like to consider an SSRI such as Sertraline, and would provide information on side effects and R/V the patient in 2 weeks time for suicidal intent.
Thinking about the setting of treatment, I do see an element of risk in this case but I see that this could be managed in the community with a CMHT referral/as part of a home treatment team. There are also some protective factors at home such as familial support.
OR
I have considered whether this patient could be managed in the community however I am concerned that this patient is at particular risk to self therefore in this case I would arrange admission, either informally or following assessment under section 2 of the mental health act.
Hx from a patient presenting with low mood
Explore PC
How have you been feeling lately?
What are your energy levels like?
Are you able to enjoy things like you used to?
How’s your sleep been lately?
What’s your appetite been like?
Have you notice yourself becoming forgetful?
How’s your concentration?
You’ve told me how things feel now, but how do you feel about the future?
Sometimes people feel so down they feel like they want to harm themselves, or that life isn’t worth living. Has this happened to you?
Do you ever feel like harming other people?
Do you feel safe at home and when you’re out and about?
*Do you feel anxious?
*This may seem like a strange question, but have you ever seen or heard things that other people don’t notice, or something that has struck you as odd?
What do you think is going on here?
Is there something in particular that worries you?
How would you like us to help you?
Hx from a patient presenting with delusions
PARANOID, GRANDIOSE, THOUGHT INTERFERENCE, IDEAS OF REFERENCE, THOUGHT BROADCAST, PASSIVITY
Is anyone trying to make life difficult for you?
Do you ever notice a special meaning, just for you, in things you see or hear?
Do you ever feel like someone is controlling you? Is anyone controlling or interfering with your thoughts?
Do you ever feel like people can hear what you’re thinking?
Hx of patient with hallucinations
This may seem like a strange question, but have you ever seen or heard things that other people don’t notice?
Do you know who’s speaking? What do they say? (to you or about you, make comments, tell you to do things)
*What will happen if you don’t do x?
Can you hear them now?
Have you noticed any odd feelings in your body?
INSIGHT - what do you think is going on here? Sometimes people feel so overwhelmed that their minds play tricks on them, could that be happening to you?
Hx from mother with suspected postnatal depression
It’s good that you are reaching out.
Who supports you at home? Are they aware of what you’re going through? Are they helping out?
How do you feel when you look at your baby?
Do you ever worry there might be something wrong with them?
It can be very stressful to care for a baby. Do you ever feel like you can’t cope?
How do you picture things in a months time?
Do you have any worrying thoughts about your baby?
Hx from a manic patient- and how would you manage them?
Aspects of history to remember- Grandiose delusions (lots of brilliant ideas, on top of the world), more risky behaviour without thought for consequences e.g. sex (increased sex drive?), money, gambling, drugs?, decreased sleep, increased energy? do you feel your thoughts are racing away from you recently? Affect on life or work or relationships?
DDx: schizoaffective (psychotic Sx precede + outweigh), cyclothymia (highs and lows but less severe)
I have considered whether this patient could be managed in the community however I am concerned that this patient is at particular risk to self therefore in this case I would arrange admission for safety and stabilisation, likely under section 2 of the mental health act. If hypomanic, I would make a routine referral to CMHT.
I would take a biopsychosocial approach to manage this patient, consulting my senior and involving members of the MDT.
I would first consider an organic screen to rule out medical causes, hyperthyroidism, rec drugs such as amphetamines or medication. Exam, bloods, UDS. I’d stop any causative drugs such an antidepressants.
In terms of pharmacological therapy, for acute mania 1st line Tx would be an atypical antipsychotic, and the patient may require benzodiazepine and lithium. In the long term, the patient would be put on a mood stabiliser such as lithium or valproate, or kept on ATAP such as olanzapine, taking into account risk vs benefit.
For psychological therapy, I would refer this patient to for CBT to target their negative thoughts, feelings and behaviour cycles.
From a social perspective, I would direct this patient towards support groups such as “mind”, and involve a care coordinator. I would also refer for support for substance abuse.
How would you approach this patient with self-harm or suicide attempt?
Screen for low mood, mania, psychosis
BEFORE, DURING, AFTER
“You’ve been through a lot. It may be hard to talk about but could you tell me what happened?”
Before - triggering events, planning (note, told someone), precautions to not be found *past attempts
During - what/why/when/where/how, how were they found, intoxication?
“Did you hope that this would kill you, or did you hope for something else?”
After - feelings now (angry, regretful), feelings about the future (if you went home now, what would you do?), do you have any further plans? do you have people to talk to?
*RFs - male, unemployed, lack of support, chronic illness, alcohol abuse
Lithium side effects
Fine tremor, D&V, polydipsia, polyuria, renal and thyroid damage. Teratogenic.
If overdose, coarse tremor, ataxia, weakness, hyperreflexia, myoclonus and weakness
TW= 0.4-1mmol/l
Antipsychotic side effects
Atypical AP's weight gain sedation prolactinemia dyslipidaemia QT prolongation If clozapine- agranulocytosis, hepatotoxicity
Typical AP’s
extrapyramidal SE’s i.e. parkinsonism (dystonia, dykinesia)
Neuroleptic malignant syndrome=
high fever
autonomic dysfunction- tachycardia/ tachypnoea, sweating, labile BP
Muscle rigidity
On bloods, super high CK as rhabdomyolysis occurs and AKI
Eating disorder history
“how do you feel about your current weight”
“are you trying to lose weight at the moment? how are you doing that?”
“can you take me through an average day”
““how does the thought of not exercising today make you feel- do you worry you’ll lose control if you relax the rules a little?”
“do you ever lose control and binge?”
“what do your family and friends think about your weight?”
“how do you feel about the social side of eating, such as going to restaurants”
PHYSICAL- periods, libido, dizziness, weakness, cold sensitivity, digestive problems.
SOCIAL- how has this affected school/career/relationships
SCOFF questions
“do you ever make yourself sick because you feel uncomfortably full”
“do you worry you have lost control over how much you eat”
“have you recently lost more than one stone over a 3 month period”
“do you beleive yourself to be fat even one others say you are too thin”
“would you say that food dominates your thoughts”
How would you manage a patient with an eating disorder
From a biological perspective, I would focus on nutritional management and weight restoration, with realistic weekly targets. A target weight and an eating plan would also need to be established, and in some cases patient a may come in as day cases to be refed.
If the patient had a BMI<13, serious physical complications or high suicide risk, they may need inpatient admission into a specialist eating disorders unit and the mental health act may occasionally be used for compulsary feeding.
Additionally, co-morbid psychiatric illnesses such as depression, OCD or substance abuse may need to be treated alongside.
For psychological therapy, I would refer this patient for eating disorder based CBT, to explore their thought processes behind eating behaviours, and issues surrounding control and low self esteem. For children, anorexia focused family therapy shows greatest response. Psycho-education on nutrition and health would also be crucial.
From a social perspective, I would direct this patient towards support groups such as those run by the charity BEAT.
Comment on this patients mental state
ASEPTIC appearance/behaviour speech emotions (mood+affect) perceptions thoughts insight cognition
This patient is dressed appropriately with good eye contact and posture. Their seech is normal in rate, rhythm and tone. They appeared objectively low, and subjectively reported low mood with sleep disturbance and low energy. There was no disturbance of perception or thought and they had good insight. Cognition was grossly intact.
