Mock exam theme

Question 1

Important points cultural- assessment

Answer 1

Clarify any cultural issues with the family, involve cultural team/cultural worker in the assessment

Question 2

Important points- CL psychiatry- urgent request to review

Answer 2

Clarify referral, what is the specific question they want answered
Collateral information-> medical file notes, home team discussion, discussion with nursing staff. Ensure patient aware of referral
Medical status-> reason for medical admission etc/current medical status/past history, urgency-> may make full assessment difficult, sx may overlap with psychiatric sx, differential and likelihood of psych diagnoses different, prescribing will be different
Past psychiatric history, medications/substance
MSE
Capacity
Documentation of findings- acts to document clinical contact and communicate findings
Aim to specifically answer their questions
Collateral from family- clarify onset, severity, duration and temporal course

Management of staff/ward:
explain the issues around treatment, discuss with team how to manage behaviour/etc, write a clear pla , ask the charge nurse to ensure all nurses know the plan, reassure staff

*cognitive sx of depression more important in physically unwell

Question 3

Important points- risks CL

Answer 3

immediate risk to others- access to weapons, risk of accidental harm to others, threats, aggression
The immediate risk of harm to self- treatment refusal, self harm, suicidal ideation, accidental SH (inability to keep self calm)

Question 4

Important points- delirium

Answer 4

1:1, single room, avoid bright lights, low dose AP as needed with IM options, benzo’s cautiously (may worsen confusion), frequent re-orientation, distraction, delirium rating scale 4AT, 3D CAM

Question 5

Important points- patient lacking capacity needing life saving care

Answer 5

Medicolegal issues- legal framework ‘duty of care’ , decisions taken as required for life preserving treatment, family involved in in treatment decisions , principle they make decisions on his behalf on his wishes if he had decision-making capacity, use an EPOA if this exists,

discuss with hospital legal team, discuss delivery of these options in these conditions with a peer/peer group

Family interventions- discuss with family delivery of care given pt lacks capacity, psychoeducation about current condition, if family distressed, arrange additional support- regular discussion, extended family support, social work, counselling

Cultural intervention- involve a cultural advisor/cultural team

Question 6

Important points- CL request to move patient to psych, potential factors

Answer 6

Lack of uderstanding
Struggling to manage disturbance
Inadequate management strategies
Hospital systemic
Racism

Question 7

Important points- community pt relapse/worsening, assessment,, reasons for deterioration

Answer 7

Assessment:
Assess the risks
re-evaluate sx and history
reasons for non-compliance
clarify current function
re-evaluate diagnosis
get collateral from family, GP
Investigations to exclude differentials

Reasons:
Substances
Poor medication adherence
Treatment resistance illness
Relapse of primary illness
Medication interactions- cyt p450 interaction, smoking, caffeine
Stressors
Co-morbid
Undisclosed/unidentified medical condition

Question 8

Important points- weight loss

Answer 8

Clarify diagnosis
Physical examination
Investigations
Collateral
Risks

Question 9

Important points- OCD mx

Answer 9

Therapeutic alliance
Psychoeducation
Pharmacotherapy- high dose SSRI, clomipramine, low dose AP-> can increase dose, consider combination
Psychotherapy- CBT exposure response prevention, graded heirachy of symptom triggers, homework assignments
Monitoring- YBOCS
GP involvement
Continued involvement with family

Question 10

Important points- weight loss, low BMI, management (not related to eating disorder)

Answer 10

Communicate clearly with pt and family
Amange risks- physical, self care
Admission to IP vs outpatient
Consider MHA
Supervise and encourage med adherence, food and fluid, monitor physical health and weight
Inbolve a dietician and monitor re-feeding
Re-evaluate diagnosis

Question 11

Important points- medication management in relapse

Answer 11

Assess adequacy of dose
Ix and manage reasons for serum (cloz, li) being low-> poor adherence
Adherence mx- blister packs, medication delivery service, smoking resumption, medication interaction, might mean need larger dose, side effects (sedation, hating blood tests, constipation)
Consider change in medication regime- depot if oral adherence isn’t possible/prefers depot
Augmentation to treat any co-morbidities

Question 12

Important points- medication mx insomnia, on request

Answer 12

Prescribing accedes to request, enhances therapeutic engagement,
ineffective in psychosis, risk of dependence
consider alternatives- melatonin, non-medication strategies, sleep hygiene education (might be difficult during psychotic relapse)

Question 13

Important points- driving request, mental illness

Answer 13

Maintain supportive/realistic, plan as positive recovery goal regarding work/supporting family, balancing any risks from driving

Take a driving history- risky behaviour, traffic offences, past convictions, DUIs, history/current use of substances

Consider current degree of recovery- symptoms likely to affect driving- poor attention/concentration, mood abnormalities, suicidal ideation, delusions, any risks

Get collateral- driving history, views on him, need for driving support

Consider any medico-legal issues while on TA- local driving authority

Refer to specialist assessment of driving skills- as part of risk assessment

Question 14

Important points- aware of pt breaking the law

Answer 14

Raise concerns about issue with pt
Explain to pt, restrictions- esp with MHA
Try to get pt to agree not to do it
Persude pt to do the right thing
contact agency responsible- police- may need to breach privacy to support public safety
consider speaking with family

Question 15

Important points- differential, older pt, low mood and disorientation

Answer 15

MDD
Demntia
Organic mood- hypothyrpod, low B12/folate, CVA
Alcohol- low mood, disorientation

Question 16

Important points- using an interpreter, option of using family member

Answer 16

1. using trained interpreter
   - proper training , techniquem less likely to translate inaccurately or with bias
   - disA: pt and family may be ashamed to have another person of culture know anything about their problems, may fear gossip
2. Using family member
   - may be more acceptable, need to include in meeting and reviews
   - disA: may not be able to translate accurately if embarrassed by replies, may withhold information so as to not upset family mmeber

Practicalities:

• discuss process with interpreter first, esp if untrained
• face pt, with interpreter beside, do not address them directly
• decide if sequential or simultaneous translation
• explain accuracy is important, need verbatim, not censory even if speech disorganised, or feeling embarassed

Question 17

Important points- approach/information to family about (vascular) dementia

Answer 17

Approahc: empathic, supportive, practical approach,

Biological interventions
(medication to improve physical health risks, avoid meds that increase confusion/low mood, avoid sedatives, medication to improve cognition
important to review atherosclerotic ischemic disease-> antihypertensive, beta blockers, antiplatelet, lifestyle modification, statin

Psychological interventions: psychoeducation and support re diagnosis, practical advice re managing disorientation and forgetfullness- how to interact using orientation, reminiscing, avoiding confrontation
Need for stable daily routine, cues like a clock/calendar/lists/reminders
OT input to support resuming hobbies/cognitively stimulating activities

Social and cultural interventions:
social work input to link in to local dementia support organisations, suitable support groups, help setting up EPOA if still has capacity.
involve local cultural service

Follow-up:
regular follow up with older persons mental health team, self, social worker, OT, psychologist

Carer support

Overview:
1. Supportive treatment-> carer support, referral to community service
Simple measures to modulate behaviours-> explaining the caregiving actions in advance, putting clothes on or helping with showerin, written instructions, comorbid conditions appropriately addressed by physican/nurses, pain controlled, calendare/sclocks, lighting, safe environment unnecessary furniture removed,
Communication strategies-> short simple, explain things, decrease distractions, close ended,

2. Environmental control measures-> home safety evaluation, assess transport driving, self care by OT
   Risk for falls (esp with medications, and behaviour, gait)_. assess falls risks and interventions to mitigate
   ID bracelet, sound/motion detectors,
3. Cholnesterase inhibitors/memantine
4. Antidepressant-> comorbid, impacts on cognitive function, increasing care stress
5. Antipsychotics-> may help behaviours, although increased stroke risks, falls, EPSE
6. Management insomnia- trazodone
7. Mx end stage/palliative care-> discussing goals
8. BPSD-> non pharm and pharm

Question 18

Important points- single parent

Answer 18

Assess relationship between parent and child

Check guardianship arrangements`

Question 19

Important points- providing psychoeducation

Answer 19

Supportive and empathic manner, tailor interactions to level of understanding
Explain rationale for diagnosis and treatment
Potential side effects and potential benefits
Check no relevant family/medical hx, allergy
Physical examination

For GP- maintain a professional and supportive manner with GO and advise GP can refer back to you if…

Question 20

Important points- getting history about diagnosis

Answer 20

Screening for features of diagnosis
Recent triggers/stressors
Symptoms of possible differentials/comorbidities
Get collateral from family/friends/GP
History from clinical records

Practicalities of assessment- privacy/confidentiality, therapeutic engagement (non-confrontational), validate distress encourage safe behaviour, take into account raport of interviewing clinician

Question 21

Important points- therapist possible breach boundary , BPD in ED

Answer 21

Collateral
Check therapusts current formulatioin/treatment strategy
Inappropriate nature- boundary breach, damage to therapeutic relationship, after hours contact in crisis rewards and encourages future acting out, unable to maintain safety, risk to therapist and family
Negotiate agreement for more appropriate place
Crisis team follow up
Aim for plan that is safe, preserves the therapeutic relationship

Question 22

Important points- decision about admission to hospital, information expected + BPD pt- multiple presentations, disagreement with police/family/patient request

Answer 22

Recent history- lead up to crisis, presentation/behaviour
Risk assessment- self/others/AWA/failed d/c/vulnerability (patient and non-patient factors)
Mental state examination
Supports and social situation
Collateral infomation
Crisis plan

Maintaiin professional relationship between police/MHS- validation of concerns still making decisions based on clinical need
Ensure family understand concerns heard while highlighting potentially adverse effect of admission, especially if against patient wishes, runs counter to principles of BPD
Consider need to case conference including family/different agencies, particularly if ongoing presentations, inadequacy of crisis plan

Question 23

Important points- junior registrar deciding to admit

Answer 23

might be under or over estimate risk, might be pressured by more experienced staff or ED staff
support the registrar who may feel they are in the middle- clarify risks, consider attending

Question 24

Important points- school observation

Answer 24

features of possible diagnoses
interactions with peers
interactions with teachers and other staff
level of support/teaching style in classroom
on-task behaviour and distractiond
playground behaviour vs classroom behaviour
volatility

Question 25

Important points- acute behaviouural disturbance ward

Answer 25

Manage stigmatisation and staff attitudes- discussions with staff, education, consensus on management plan- negative attitudes are common esp with unwell pts/personality disorders/substance use Manage consequences- charges for damage/assault, may be pressured to call police etc Containment- HDU nursing, possible seclusion, not open ward. Medical/sef harm risks of securing, containment if aggression to others/disinhibition, reduce level of activity Medication for agitation and psychosis- pros and cons Physical care- vitals, check self, care, food/fluid Manage substance withdrawal/intoxication Close nursing care, frequent medical reviews- move to less intensive nursing when able

Question 26

Important points- general principles/medico-legal with information sharing

Answer 26

Privacy and maintenecy of pt's autonomy, aim to get consent to share information Obligations to inform child welfare where there are issues of child protection Obligations to inform vehicle licensing authorities about unsafe driving Medical clearance for return to work- need to clarify roles & responsibilities for work and provide formal certificate If discussion with lawyer/probation officer etc- clarify role whether as treating psychiatrist or otherwise

Question 27

Important points- medication review

Answer 27

review all past medication use- trials, duration, adequacy, compliance, side effects, reasons for stopping psych history- symptoms, response to treatment, comorbidities, complicating substance use Efficacy measures- functioning- coping, social engagement, meaningful activity Collateral- notes, family, psychometric measures Patiens own experience- preference, reasons, acceptability

Question 28

Important points- options for treatment poor response psychotic disorder (TR)

Answer 28

Change to clozapinr Continue current- watch and wait, focus on non-pharmacologial mx options Augmentations ECT If history mood- consider role of mood stabiliser/antidepressant Augment with OMega 3 although limited evidence

Question 29

Important points- wellness recovery plan

Answer 29

Plan to develop collaboratively- written in plain English, shared with pt, team, family/carers Contact information including NOK, community team case manager, psychiatrist, other key supports Key legal information- MHA, EPOA, AHD List of medication, potential side effects and advice on how and when to use PRN Activity schedule, weekly diary, description of self and how he maintains that wellness List of suitable resources to maintain wellness- Wellness toolbox- social supports, peer counselling, exercise, relaxation, stress reduction techniques, diet, social support Emergency contacts for MHS EWS relevant Pt preferences- directives for emergencies Post crisis plan- what will happen to get him back to where pt was, additional supports, regular review

Question 30

Important points- prescribing in pregnancy approach

Answer 30

Safety of medication in pregnancy - consult with perinatal psychiatrist, refer to updated safety medical information, review previous treatment and response- use lowest effective dose and avoid polypharmacy Specific risks of medication type - lower birth weight, prematurity, PPMN, cardiac abnormalities in first trimester - delayed neonatal adaptation/neonatal adaptation syndrom - slight increased risk of postpartum hemorrhage Consent - provide written information - involve father in discussion - document risks/benefits Communication - ensure clinicians responsible for maternity care are aware Follow-up - regular fllow-up to check response to antidepressant - planning around childbirth- may be more likely to have transitional problems in the newborn period

Question 31

Important points- struggling single pregnant mother

Answer 31

Safety- risk - harm to self, children, bonding/coping with care, sleeping- not co-sleeping, risks from partner (DV, substances), other risks Child welfare involvement- consider referral, family connect Placement/respite - family or friends able to support - consider if respite available Social/family interventions - family meeting, family supports, financial support/welfare, review accommodation - referral to parenting support agency/childcare - support worker General health advice' Therapy- mother/infant

Question 32

Important points- practical and ethical issues involved in using an interpretor

Answer 32

Right to be assessed in own language Confidentiality and consent - might fear that interpreter may breach her confidentiality locally, align with past oppressors, stigma and shame Need for initial triage assessment before to assess competency, get agreement, waiting for interpreter may take some time, may be medically unwell Using interpreter can give fuller picture, better translation, nuances, clarify if disorganised and confused Issues with interpreters- bias, inaccuracy ``` When using family member: Inhibition Distortion Inexperience and innacuracy Need to train interpreter ```

Question 33

Important points- parental mental illness affect on children assess

Answer 33

Approach- empathic, non-judgmental Reassess pt symptoms and risk assessment-> involvement of children in delusions, rituals etc, awareness of impact on children, further collateral about how the children are coping Practical solutions/education/problem solving Collateral from children Collateral from school Advice from colleagues/peers Child welfare involvement

Question 34

Important points- elderly patient "not coping", poor self care, home a mess- differential, specific risks and management

Answer 34

COgnitive impairment- dementia, stroke, delirium Other psychiatric- depression, OCD, psychosis, hoarding, alcohol Psychological cause0 Cluster A, eccentric, avoidant- not help seeking Physical illness or disability Social isolation/lack of social support Low IQ Risks: Physical illness-> examination, history, symptoms, weight loss/malnutrition, diet, food in cupboards/fridge, bloods Physical environment- falls, view home, fire risk, rubbish near heat sources, smoke alarms Vulnerability- from others, get collateral, risk of eviction, discuss with landlord Medication compliance problems with living alone- check pills, system dispensing, understanding Assistance with assessment- OT, social workers Assess the urgency- need for immediate action balanced against a possibly less stressful assessment over time

Question 35

Important points- capacity for elderly to remain at home (if needing to be cleaned etc)

Answer 35

General assessment to detect psychiatric issues which may impact on insight, judgement and decision making Need for cognitive screen Optimise capacity assessment process- building rapport, optimise cognition, quiet room, involve family' Aware of concerns, risks of decision, good rationale, communicate decision

Question 36

Important points- optimising understanding and decision making capacity

Answer 36

Optimise health and ability to take in information - vision, hearing, treat any complicating factors- depression infections, t maximise cognition, consider if medication impacting on capacity Presentation and discussion - clear, non-technical, consider IQ, education level, written information, encourage questions, consider time of day Allow enough time- may need to repeat information , reassess, give her time to rethinl decision Involve ithers as needed

Question 37

Important points-assessment ED someone intoxicated, suicidal

Answer 37

Limits of assessment given intoxicated, if youth- parents/guardians, contact caregivers, support Assess use/intoxication- history alcohol/substance use/overdose, signs of substance use- alcohol, paint, track marks, drug paraphernalia, determine cause of intoxications- UDS, alcohol breath Coomprehensive psychiatric assessment- as far as is possible when intoxicated sand in ED- from previous notes, ED assessment and own assessment- psychiatric illness +suicide risk, previous attempts, current mental state, stress/social circumstances Comprehensive physical assssment- general, indication of misadventure, head injury, self harm Collateral from parents/caregivers Approach to immediate safety/risk- ensure physical safety vulnerability, joint with crisis team, manage impulsive aggressive behaviour, consider need for security, nursing special

Question 38

Important points-negative transference issues with other clinicians toward patients

Answer 38

Maintain professional approach- acknowledge challenging situation Risks assessment Discuss options Use support systems

Question 39

Important points- minor in ED considerations

Answer 39

Ethical and medicolegal- minor, issues of consent, confidentiality, carer/guardian Relevant history re presenting complaint/risks, vulnerability Family and social situation/supports- Fhx, living situation/home/friends/stressors, abuse history Collaboration with or referral to other services- crisis team, child psych, CYMHS, addictions, GP, school counsellot Provide basic psychoeducation- risks, impact, vulnerability

Question 40

Important points-patient assaulted/incident on ward

Answer 40

Immediate managemeny - safety of pts and staff with environmental/pharmacologic restraints - information gathering-< documentation, details of assault, mental state, incident reporting - communication with the family, CD, police Assessment of pt and risk management - MSE specifical paranoia, ongoing violent ideation et, medication review- compliance, depot, short term anxiolytics - environmental management- manage away from others, HDU, direct observation, nursing ratio for approach Assess and support the victim - victim assessed and treated for possible physical injuiries - assess mental state- impact of incident, mood/psychotic/anxiety, desire to retaliate - ensure vitim receiving support- nursing staff, family, IPRA - contact family/caregivers to explain apologise, reassure, support complaints etc Staff - support staff/debriefings/needing time off Report to clinical director Document critical incident- Riskman Critical incident review- internal and possible external review Education to broader service with learnings Delivering the feedback about the incident

Question 41

Important points-pt appearing in court

Answer 41

Fitness to appear Risk mx and legal issues - MHA vs custodial, what happens after court decision - risk mx around transport and appearance in court - communication written of CLS with court to outline clinical/legal issues and plan after appearance.

Question 42

Important points- medicolegal aspects pt refusing assessment

Answer 42

1. Confidentiality/autonomy, privacy act 2. Risk- high to self or others 3. Mental health Act- can override refusal

Question 43

Important points- psychodynamic psychotherapy

Answer 43

Motivation, desire to change, capacity to attend appt Establish therapeutic relationship-> ability to trust, underlying attachment issues, likelihood of significant resistance Psychological mindedness- capacity to reflext Response to stress- reasonably frustration tolerance, delayed gratification Does not have significant co-morbid problems such as substance use, psychosis, self harm/suicidal Problems long standing Mature defences and coping Patient making significant decision in therapy- Mental state- anything that would impair judgement insight- manic, psychosis, substance Reiterate should not make any significant decisions in therapy Delay decision until explored feeligs and motivations in session Urgent supervision Help explore issues behind the feelings-> transference reactions, defendces, gain insight, splitting If adamant consider having both in session

Question 44

Important points- clinical governance

Answer 44

``` Leadership and culture Consumer partnerships Workplace Risk management Clinical practise ``` Patient Care team->healthcare professionals, family, others Organisation-> infrastructure, resources Environment->regulatory, market, policy frameworks