Psych. ~ Short Answer

Question 1.

The police bring a 13 year old girl to your emergency department following an argument with her mother. She is agitated, combative, crying, and has self-inflicted lacerations to both arms. The mother is en route to the emergency department.

 

A.) What factors need to be addressed in your risk assessment of this patient?

Show Answer

  • Extent of lacerations, bleeding
  • Medical cause of behaviour e.g. Drugs, delirium
  • Suicidality
  • Reason for self-harm
  • Is this child at risk at home?

(5 marks)

 

B.) What high risk features would you look for in this patient when assessing suicidality?

Show Answer

  • Stating her intent was suicidal
  • Plan for killing herself including planning (i.e. notes, sorting out affairs)
  • Previous suicide attempts
  • Lethality of attempts
  • Family Hx of suicide, conflict
  • Friends/associates that have suicided
  • Trouble at school
  • Drug/alcohol abuse
  • Hx of mental illness
  • Feeling hopeless, helpless
  • Flat/inappropriate affect
  • Hard to engage
  • Poor insight
  • Lack of support

(8 marks)

 

You manage to de-escalate the situation verbally. You find that she has lacerations that require suturing but not further surgery. She tells you and she wanted to kill herself because her mother is physically abusing her. Her mother has just arrived and is demanding to see her daughter.

 

C.) What is your management now in regards to the patient?

Show Answer

  • Reassure patient that she does not need to see mother if she does not want to
  • Keep child safe in ED and organise admission for psychiatric and safety reasons
  • Mother not to be allowed to see child unless agrees and will need chaperone
  • Suture wounds as necessary
  • Referral to adolescent mental health and paediatrics for joint admission
  • Referral also to social work
  • Notification to Children’s Services for investigation and to find ultimate safe place for patient

 

(5 marks)

 

D.) How will you manage the mother?

Show Answer

  • Open disclosure
  • Explain that her daughter is safe and well and will be kept in hospital for further treatment
  • Explain that she does not want to see her mother and we are respecting her wishes
  • Explain that she has made an allegation of abuse and that we have notified Children’s Services who will investigate

(4 marks)

Author: J Haire

Ref: Tintinalli p. 1944-46


 

Question 2.

A 35 year old male with no previous psychiatric history is brought to the Emergency Department handcuffed under Police escort.  Police were called because he had been violent towards his parents.

 

A.) What issues need to be addressed in your assessment of this patient?

Show Answer

  • Safety of staff and patient
    • Does the patient need physical/chemical restraint?
    • Search for weapons
  • Is the underlying cause psychiatric or organic or behavioural (first presentation)?
  • Does the patient pose a risk to himself/others/parents?

(4 marks)

 

B.) Outline how you would manage his aggression?

Show Answer

  • Safety of patient and staff
  • PPE staff
  • Security to help
  • Verbal de-escalation initially
  • See if will take oral sedatives initially
  • Then physical followed by parenteral chemical restraint

(4 marks)

 

C.) Describe how you would physically restrain him?

Show Answer

  • Explain what you are going to do to patient and why
  • Team response
  • Code Black or similar
  • 5 person team
    • 1 on head
    • 1 each limb
  • Held down in safe room i.e. bare room
  • Better supine if going to give chemical restraint

(4 marks)

 

D.) Describe how you would chemically restrain him?

Show Answer

  • IV access
  • Titrated sedative medication
    • 5mg IV Haloperidol initially, can repeat
    • 5 mg IV midazolam then incremental doses to effect
  • Once calm apply monitoring
  • CO2 monitoring or sats with no O2
  • Close nursing

(4 marks; reasonable and safe approach)

 

E.) What features of his mental state exam would indicate a psychotic disorder?

Show Answer

  • Positive symptoms
    • Hallucinations (auditory; other more likely to indicate organic cause)
    • Delusions
    • Disorganised speech
    • Disorganised behaviour
    • Catatonic behaviour
  • Negative symptoms
    • Blunted affect
    • Emotional withdrawal
    • Lack of spontaneity
    • Anhedonia
    • Attentional impairment
  • Functional decline
  • Dishevelled appearance
  • Bizarre behaviour
  • Poor judgment
  • Lack of insight
  • Loosening of associations

(10 marks)

Author: J Haire

Ref: Tintinalli p. 1949


 

Question 3.

A 30 year old known schizophrenic is brought in to the emergency department by police. He is aggressive and has been handcuffed. You have been asked to “medically clear” him.

 

A.) What are the goals of medical clearance?

Show Answer

  • To find out if the presentation is due to a medical or psychiatric condition
  • Are there any co-existing medical disorders?
  • Any medical disorders that are a complication of the psychiatric disorder?

(3 marks)

 

B.) List 4 of the medical mimics of psychiatric presentations.

Show Answer

  • Toxicity
    • Stimulants
    • Anticholinergic syndrome
    • Serotonin syndrome
  • Drug withdrawal
  • Neurotrauma
  • Neuro disorder e.g. Temporal lobe epilepsy, Huntington’s
  • Encephalitis
  • Sepsis e.g. UTI
  • Metabolic/endocrine disorder e.g. hyperthyroidism, porphyria
  • Dementia

(4 marks)

 

C.) What aspects of history raise the possibility of a medical/organic disorder?

Show Answer

  • Rapid onset change in change in behaviour, mood, thought or decline
  • Confusion, altered level of consciousness, fluctuating LOC
  • Changes in patterns of substance abuse
  • Changes in medications
  • Recent medical problem
  • Medical symptoms e.g. fever, cough, abdo pain
  • Frist presentation

(4 marks)

 

D.) What aspects of physical examination raise the possibility of a medical/organic disorder?

Show Answer

  • Indicating delirium
    • ALOC
    • Fluctuating LOC
    • Disorientation
    • Inattention
    • Memory impairment
    • Language disturbance
    • Visual/tactile/olfactory hallucinations
    • Disorganised delusions
    • Perseveration, confabulation, circumstantiality, Concretism, illusions
    • Psychomotor agitation/retardation
    • Altered sleep-wake cycle
    • MME < 20 or fall of > 2
  • Abnormal vitals
  • Abnormalities in other aspects of exam – resp, CVS, GIT, neuro
  • Indications of trauma esp. head injury

(6 marks)

 

E.) What investigations would you order to “medically clear” this patient?

Show Answer

  • Guided by clinical findings
  • None if clearly deterioration in function due to schizophrenia

(2 marks)

 

F.) Missed medical diagnosis in psychiatric patients has been reported as up to 45%. What are the main pitfalls that you can see in the “medical clearance” process?

Show Answer

  • Often difficult to do a thorough medical exam in ED i.e. patient agitated, may need sedation etc. so difficult to get an accurate history and do a full physical exam
  • Failure to seek collateral history
  • Failure in physical exam
    • No vitals
    • No MMSE
    • No neuro exam
  • Uncritical acceptance of medical clearance by psych staff
  • Failure to re-evaluate over time

(4 marks)

Author: J Haire

Ref: Tintinalli p. 1940-43 + 1948; Dunn 4th Ed p. 721-2; Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup, West J Emerg Med. 2012;13(1):3–10.


 

 Question 4.

A 34 year old man presents stating that he has taken 30 x 450 mg slow release lithium tablets.

 

A.) What are the symptoms and signs of acute lithium toxicity?

Show Answer

  • Small doses often asymptomatic
  • GIT symptoms with larger ingestions i.e. nausea, vomiting, abdo pain, diarrhoea
  • Can get fluid losses
  • Usually no neuro symptoms/signs if normal renal function and < 25g ingested
  • Neuro Sx delayed
    • Earliest tremor and rarely progress beyond that in acute toxicity
    • Can get hyperreflexia, agitation, muscle weakness, ataxia ? stupor, rigidity, hypertonia, hypotension ? coma, seizures, myoclonus
  • Minot ST and TW changes on ECG

(4 marks)

 

B.) What investigations would you perform in this patient?

Show Answer

  • Screening
    • BSL
    • Paracetamol
    • ECG
  • Specific
    • U&Es check renal function
    • Serum lithium level at 4-8 hours to confirm ingestion and monitor progress

(4 marks)

 

C.) What is your management of this patient?

Show Answer

  • Fluids
    • Replace deficit from dehydration
    • Maintain hydration and Na i.e. UO > 1 mg/kg
  • Monitor fluid balance and electrolytes
  • Monitor for features of neurotoxicity

(3 marks)

 

D.) Is activated charcoal indicated?

Show Answer

  • No, lithium will not bind

(1 mark)

 

E.) Would you consider enhanced elimination in this patient?

Show Answer

  • Can use haemodialysis but not needed with patient with normal renal function
  • Haemodialysis for those that have renal failure and present late with features of neuro toxicity

(2 marks)

 

F.) When would you decide to discharge him?

Show Answer

  • No clinical evidence of neurotoxicity and serum lithium < 2.5 mmol/L and falling
  • Psychiatric assessment done

(2 marks)

 

G.) How does chronic lithium toxicity usually develop?

Show Answer

  • Patient on lithium therapy that get renal impairment

(1 mark)

 

H.) What are the symptoms and signs of chronic lithium toxicity?

Show Answer

  • Neurological; graded
    • Grade 1
      • Tremor, hyperreflexia, agitation, muscle weakness, ataxia
    • Grade 2
      • stupor, rigidity, hypertonia, hypotension
    • Grade 3
      • coma, seizures, myoclonus
    • symptoms and signs of underlying medical condition precipitating lithium toxicity

(4 marks)

 

I.) What is the role of serum lithium levels in chronic toxicity?

Show Answer

  • Confirm toxicity
  • So not correlate with clinical severity

(2 marks)

 

J.) What are the main principles of treatment of chronic lithium toxicity?

Show Answer

  • Restoring renal function
  • Correcting fluid and Na deficits
  • Cease drugs that impair lithium excretion, decrease renal function
  • Haemodialysis

(3 marks)

 

K.) Is enhanced elimination useful in chronic lithium toxicity and, if so, what are the indications?

Show Answer

  • Neurological dysfunction and serum lithium > 2.5 mmol?

(2 marks)

Author: J Haire

Ref: Tox Handbook p. 260-5


 

 Question 5.

A 35 year old man is brought to your Emergency Department following two seizures. His observations are:

GCS 8 /min
BP 75/40 mmHg supine

Psychiatry Pix 1 SA

A.) List the abnormalities in this ECG

Show Answer

  • Broad complex tachycardia (rate approx. 140 bpm; QRS approx. 200 ms)
  • aVR
    • large terminal R
    • R/S ratio > 0.7
  • QT prolonged
  • ST depression V2-V6

(4 marks)

 

B.) What is the most likely diagnosis?

Show Answer

  • TCA overdose
  • Or Na channel blockage OD

(1 mark)

 

C.) List 6 drugs that could cause this.

Show Answer

  • TCAs
    • Amitriptyline
    • Desipramine
    • Dotheipin
    • Imipramine
    • Nortripityline
  • Antidysrhythmics
    • Class 1A
      • Procainamide
      • Quinidine
      • Disopyramide
    • Class 1 C
      • Flecainide
      • Encainide
    • Local anaesthetics
      • Bupivacaine
      • Cocaine
      • Ropivacaine
    • Phenothiazines
      • Thioridazine
    • Amantadine
    • Carbamazepine
    • Chloroquine
    • Hydroxychloroquine
    • Quinine
    • Diltiazem
    • Diphenhydramine
    • Propoxyphene/Dextropropoxyphene
    • Propranolol

(6 marks)

 

D.) What is the first line treatment for this arrhythmia?

Show Answer

  • NaHCO3

(1 mark)

Author: J Haire

Ref: Tox book p. 115-117


Question 6.

A 72 year old woman is brought to your Emergency Department after a syncopal episode.

Psychiatry Pix 2 SA

A.) List the abnormalities in this ECG

Show Answer

  • First degree HB (PR approx. 280 ms)
  • Left axis
  • RBBB
  • QRS wide (about 160 ms)
    • intraventricular conduction defect
    • with L axis
    • = LAFB
  • ST depression V1-3
  • ST elevation 1 mm V5 + 6

(5 marks)

 

 B.) What is the diagnosis?

Show Answer

  • Trifascicular block
    • First degree block
    • RBBB
    • LAFB

(3 marks)

 

 C.) What is your management?

Show Answer

  • Investigate for underlying cardiac condition leading to this e.g. STEMI
  • Referral to cardiology for admission and pacemaker

(3 marks)

Author: J Haire

 


 

Question 7. 

A 32 year old woman is brought to your emergency department by her friend who believes her to have taken a deliberate overdose earlier that morning. The patient is drowsy and denies this. Her observations are normal.

Psychiatry Pix 3 SA

A.) List the abnormalities in this ECG

Show Answer

  • Bradycardia SR approx. 42 bpm
  • 2 x VPCs
  • QTc prolonged (approx. 576 ms)
  • U wave
  • TWI III

(3 marks)

 

B.) What type of toxicity causes this?

Show Answer

  • K channel blockade

(1 mark)

 

C.) List 6 drugs that could cause this.

Show Answer

  • Antipsychotic agents
    • Amisulpride
    • Chlorpromazine
    • Droperidol
    • Haloperidol
    • Olanzapine
    • Quetiapine
    • Thioridazine
  • Antidysrhythmics
    • Class 1 A
      • Quinidine
      • Procainamide
      • Disopyramide
    • Class 1 C
      • Flecainide
      • Encainide
    • Class III
      • Sotalol
    • TCAs
      • Amitriptyline
      • Desipramine
      • Dotheipin
      • Imipramine
      • Nortripityline
    • Other antidepressants
      • Mianserin
      • Citalopram
      • Escitalopram
      • Bupropion
      • Moclobemide
    • Antihistamines
      • Diphenhydramine
      • Astemizole
      • Loratadine
      • Terfenadine
    • Chloroquine
    • Hydroxychloroquine
    • Quinine
    • Macrolides

(6 marks)

 

 D.) What rhythm could this potentially deteriorate into?

Show Answer

  • Torsades de pointes

(1 mark)

 

 E.) What is the treatment of this?

Show Answer

  • Correct hypoxia
  • Correct hypokalaemia
  • MgSO4 10 mmol IV over 15mins
  • Is HR < 100 bpm start Isoprenaline infusion IV at 1-10 mcg/min
  • Or overdrive pacing to maintain HR 100-120 bpm

Author: J Haire

Ref: Tox Handbook p.116, 333


 

Question 8. 

A 70 year old man presents to the emergency department with pre-syncopal symptoms and central chest pain for the first time.

 Psychiatry Pix 4 SA

A.) List the abnormalities in this ECG

Show Answer

  • AF 55-75 bpm
  • Multiple VPCs
  • L axis
  • Q waves inferiorly
  • TWI I, aVL,
  • Borderline QRS with abnormal patter V2-3
    • intraventricular conduction delay – LAFB
    • OR LBBB

(4 marks)

 

B.) What is the most likely cause of these changes?

Show Answer

  • ACS/ischaemia

(1 marks)

 

 C.) What is your management?

Show Answer

  • Control CP
    • Opiates
    • Nitrates providing BP and pre-syncopal symptoms cope
  • Investigate for ischaemia
    • Tn
  • Likely STEMI
    • Anticoagulated
    • Antiplatelets
    • Refer for PCA
    • Cardiology

(6 marks)

Author: J Haire


 

 

 

 

 

 

 

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