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vikkywhite

CASC 14TH SEP, 2012

16 posts in this topic

CASC (14TH SEP, 2012)

1. Early Psychosis

Youare the ST4 at the community mental health team.16 year old Cecilia Reece referred by GP. Assess her mental state and take history to come to possible diagnoses. GP thinks she has psychotic symptoms. Her Intelligence is normal.

Take her history and assess her mental state.

Role player:

You are Cecilia Reece who is a University student studying English and for last 10 days who have been experiencing that you are without head and sometimes you think that people can open your face and can see through it.

You feel there is ‘a presence’ around you. You are struggling to put all these experiences into words and you tell this to the doctor.

Few days ago you were walking on the road and who heard people talking about you and when you looked around there was nobody.

You don’t think people can put thoughts in your head or take away thoughts from your head. You have no experience that somebody can control your thoughts, feeling and action.

You have been stressed because of your exam and that’s why you smoked cannabis to calm yourself. You spend £50 every week on cannabis.

You live with your parents. They do not know that you smoke cannabis and you confirm that the candidate will not tell your parents about it.

Your mood is good. You have good energy level and have been able to enjoy things.

Medication & medical history:

You are not taking any medication and have no medical condition.

Family history:

Your 2 uncles have some mental illness but you don’t know the name of the condition.

Personal history:

You had normal development. Your childhood has been good and you did well in your school.

Forensic history:

None

Psychiatric history:

You have never seen any mental health professional in the past.

2. Early Psychosis Management

You will be discussing management with consultant in the next station. The finding of the patient was confirmed by her parents and university teacher.

Role player:

You the consultant and ask the doctor following questions.

What is your diagnosis?

How will you manage the patient?

Keep on asking what else? What else?

3. Self Harm Social history Risk Assessment

Overdose by teacher (64 Paracetamol) found by friend Take the social history and do the relevant risk assessment.

Don’t take history of the overdose or do mental state examination

Role player: Sarah Jones

You are English teacher and took OD of 64 paracetamol tablets 3 days ago.

You are a single teacher aged 35 years of age. You were admitted to a medical ward 2 days ago following an overdose of paracetamol tablets. You will meet with a psychiatrist who will ask you about what happened and other aspects of your life.

Mood

You have been feeling increasingly low in mood over the last year since you split up with your boyfriend after a three year relationship. You took this badly as you thought that the two of you might get married and his decision to end the relationship was a shock.

Your mood has been particularly bad over the past 3 months whilst the school has been preparing for an inspection visit which is due to take place next week. This has caused a lot of additional work and stress for you and your colleagues. You have also had problems with maintaining discipline in classes and this has also caused you a lot of stress. You have found it increasingly difficult to cope, especially as the work stress and your depression seem to worsen each other in a vicious circle.

Over recent weeks you have felt low in mood for most of the time. Your mood is especially bad first thing in the morning and you have found it difficult to get up and face the day ahead. You are frequently tearful. You feel tired for most of the time. You find it difficult to get off to sleep as you are kept awake by worries and you wake in the morning at 5am rather than the usual 7am. Your appetite is poor and you think that you have lost about one stone in weight over the last three months. You find it difficult to concentrate, both at work and home. You take little interest and pleasure in anything, including watching the TV soaps or gardening, which you used to enjoy. Your sex drive (libido) has gone completely. You were never especially sociable, but you did enjoy meeting up with work colleagues. However, now you shut yourself away and have not been out with friends for at least two months. You tend to blame yourself for how you feel. Your self esteem and self confidence are very low.

You have not seen a doctor about you low mood and have not taken any antidepressant medication, nor had any counselling or psychotherapy.

Suicidal ideation and self harm

For the past three months you have had frequent thoughts that you want to run away and escape from your situation. Over the past month you have had occasional thoughts that you would be better off dead than feeling the way you do. For the past week you have had thoughts of ending your own life by taking an overdose.

Things came to a head about a week ago when you were unable to control a class of unruly pupils. The head teacher came into the class to find out what the noise was. She found you in tears and sent you home. You have not been back to work since.

Whilst at home you have been ruminating on your problems and two days ago decided to end your life. The immediate trigger to this was receiving a letter from the school asking you to attend a meeting with the head teacher. You are sure that you will be sacked.

You took the OD of paracetamol at age 16 yrs in GCSE when you were stressed.

4. Self harm Social History Risk Discussion

Talk to friend Ms Veronica Stake and address her concerns.

Role player:

You are friend of Ms Sarah Jones.

You are a teacher. You have brought your friend to the hospital. Your friend works with you in the same school. She has been finding work stressful lately. She also broke up with her boyfriend recently. You knew that they both were planning to get married. The break up came as a shock to her. She has been feeling low ever since. You have been helping her with work and trying to cheer her up.

You have known her for the past few years. She is a bubbly person, who is happy go lucky. You have not been able to contact her recently. You both have been busy at work.

She has also denied socialising outside school hours.

Your school has an inspection due next week. Your friend was seen crying in the class and was sent home few days back. You wanted to see how she is getting on at home. She did not know that you were coming to see her. You went to see her.

You rang the doorbell but she didn't answer the door. So you looked through the letterbox and saw her lying on the floor and called the police and an ambulance. You are about to see the doctor who is treating her. You want to know what happened. You are also keen to know when she will get better.

1. How is she? Can you tell me what happened?

2. When will she get better?

3. What should I tell work? When will she get fit to work again?

4. What should I tell her family?

5. How long will it take for her to return to her normal self?

6. How will you treat her?

7. What options are available?

8. Will she get unwell again?

9. How can I help her?

10. What risks should I be aware of?

5. MCI Assessment

72 yr old Lady with memory problems, History and cognitive examination.

Role player: Ms Jane Jenkins

You are 64 year old. Your husband has been concerned over your forgetfulness but you don’t think that this is a problem.

You at times forget where you have kept your things. You struggle to find your glasses. You last week went for the shopping and forgot the way to home.

You have difficulty in remembering the names of family members though you can recognise their faces.

You don’t have any problems in finding words to speak.

You sometimes forget appointments.

You are good in remembering the date of anniversary, DOB.

You go for swimming with your husband every weekend.

You share 2 bottles of wine with your husband which you finish every week.

You don’t smoke.

You are on bendrofluazide for high blood pressure.

You are currently driving and have no difficulty in it.

Cognitive exam

You can’t remember date, 2 things to recall.

6.MCI Explanation

The patient had CT scan which showed mild cognitive impairment. You are going to meet her husband who has come after 1 week for the review.

Talk to him and discuss about the diagnosis and management plan. Address his concerns.

Role player:

You are Mr Jenkins, husband of Mrs Jane Jenkins. Your wife’s GP has informed you the result of the CT scan that she suffers from MCI and you did search on the internet and through Alzheimer’s society that MCI can later cause dementia.

You have following questions

· What is MCI?

· What medication you are going to prescribe for my wife?

· Does she need any precaution?

· Will she get dementia?

7. Adult ADHD Assessment:

Mr Ken Jones, 19 yr old Judo player who has come to see you in the outpatient clinic to get the exemption certificate from you so that he can participate in the forthcoming Olympic game as the Judo association told him he should not participate in competition as he is on banned substance. He has been on methylphenidate since age 7 yrs and then later he was started on Stattetra (atomoxetine) but had abnormal liver function test. He is now again on methylphenidate.

Take history to find out that whether he has ADHD.

Discuss his concerns.

Role player:

You are 19 yr old Judo player and you were diagnosed with ADHD when you were 7 yr old. At that time you were overactive and running from one place to another. You would not listen to anybody and was disruptive in home as well as in class. Teachers were always complaining to mum that I would blurt out the answer without my turn. My concentration was poor and could not study for more that 5 min. At home I could not concentrate on the TV program and if someone would ask me I was not able to remember the details of the program. I was always fighting with my peers. I don’t remember for how long I was having these behaviours.

I was seen by a hospital doctor and he started me on Ritalin (methylphenidate) after which I was well settled. I became calmer, my concentration improved. I was frequently seen by the doctor. I did not experience any side effect of headache or growth problem.

I continued on Ritalin till 11 yrs and was given atomoxetine which I continued till 16 yrs. I was told by my GP that I have developed liver strain due to the medication and now I am again on Ritalin. I have now again started to feel better.

Family history: none

Personal history: normal

Drugs and alcohol: none

8. Adult ADHD Link:

You are now going to see Ken Jones coach Mr Patrick

Talk to him and discuss his ideas, concern and expectation.

Role player:

· Be irritable

· Don’t shake hand with the doctor and tell him that you are a busy man

· Ask: what has happened to ken? I think he is just making it up. He is a naughty person

· Don’t believe when doctor say that ken has ADHD.

· Tell the doctor that if you would have seen ken when he was young then he would have disciplined him.

· You have done lot of search on the internet and have found a drug ‘rizoid’ which is a Chinese herbal medication which has proven to be effective treatment since 1965. You have already ordered it from china.

· Challenge the doctor that he/she is not well informed.

· Tell the doctor that you know Ken takes ecstasy. You have seen him taking the drugs.

Single:

1) Anorexia Prognosis

Assess this young woman Sarah Jones, with anorexia nervosa for

Both good and bad prognostic factors.

She is currently an inpatient in an eating disorders unit and is making

Good progress with her treatment

Role Player:

You are the only child of your parents. Your childhood was good. Your father was always away as he was travelling due to the nature of his job.

You don’t speak to them. They live in London. They even don’t know that you have been admitted to the hospital for anorexia.

You were never abused

You went to school and did GCSE with good grades. You were never bullied nor were a truant.

You took OD of paracetamol when you were in university due to stress.

You had one relationship which ended 1 year ago after 3 years of courtship after that you have been cutting your wrist at times to cope with the stress.

You started to cut down on your food only after the breakdown of your relationship

You don’t have a role model.

2) Rehabilitation Disagreement:

You are about to see the mother of 35 year old Gary, admitted compulsorily 6 months ago from a squalid flat. He has treatment resistant schizophrenia and started clozapine three months ago.

His alcohol dependent brother Tommy was supposedly caring for him, but was spending all his benefits on drink, keeping Gary quiet with alcohol. Gary was underweight and his liver function tests were deranged on admission. Gary is more coherent but remains hallucinated, still pacing up and down much of the time. He requires supervision will all daily activities including eating, drinking, washing, changing clothes etc.

Gary's mother wants him discharged to her care at her house 30 miles away: the team has decided against this as Gary needs continuing nursing care. The mother has a full time job in a cafe: her husband, Gary's father, is at home, unemployed and a heavy drinker.

Discuss the team's decision with the patient's mother and explain why it has been arrived at. Answer any further points she makes to support her views.

Role player:

You are Mrs Bright , a 55 year old cafe assistant living with your husband in a rural town. Your 35 year old son Gary has been in a psychiatric rehabilitation unit for six months. He is compulsorily detained for treatment.

Gary has always been a very odd person - in fact his nickname at school was 'The Crazy'. He never worked and had quite a few admissions to hospital, you were told he had schizophrenia and would not live an ordinary life.

You have a younger son, Tommy, whom you say is 'a rough diamond'. Two years ago Tommy persuaded Gary to leave his mental health charity supported accommodation to get a flat in the city, 30 miles away from you. Tommy did all the talking to landlords etcetera. He moved Gary into the flat and then moved in himself. He became Gary's 'carer' and received a carer's allowance and had access to all Gary's benefits as well.

The city assertive outreach team then became involved. They were a real nuisance. They complained to Tommy about the state of the flat, and said that Tommy was drunk all the time and was getting Gary drunk as well. They said that Gary was in a filthy state and was not being fed by his brother: that he was left locked in for hours or days at a time while Tommy went drinking. They said that Tommy was not giving Gary his medication. They even accused Tommy of exploiting Gary and spending Gary's benefits on himself. They said that if matters did not improve then Gary would have to be taken to hospital.

You feel that you were expected to keep an eye on things but how could you what with working and living so far away. Also, the boys' dad drinks a lot too and you have your hands full with him. Overall you minimize the conditions Gary was said to be living in, 'it can't have been that bad' etc. Really good candidates will point out that you were not there to see for yourself.

Six months ago the assertive outreach staff 'lifted' your son and took him to see the

consultant. She said he was seriously mentally and probably physically ill and detained him under the mental health act against your wishes. You wanted to discharge him but she said she would stop you and you decided not to try after all. She is 'a right b****'.

Since then Gary seems the same to you although you admit he is making much more sense in conversation. To your disgust, the Benefits Agency are now investigating Tommy and his carer's allowance has been stopped.

You have offered to take Gary to live with you. You do not understand how the treatment can help him get any better and think that he will always be the same. Neither do you think it is fair to lock up someone because of alcohol, after all they do not send all the drunks on the streets to hospital, do they? You think the family is being picked on. You know that what Tommy did was far from ideal but you feel in the middle of them, and guilty because it was Tommy who offered to look after Gary while you went out to work and lived at a distance. You want Gary home but will admit that he has not expressed this desire to the nurses.

You do not understand that Gary still needs help and prompts with the simplest tasks, and remains so hallucinated and disorganized in his behaviour that he needs someone with him at all times, who has skills in looking after mentally ill people. You do not understand about the new treatment, which is called clozapine. You think that if Gary became difficult or disturbed at home you could leave him locked in the conservatory while you went out to get a break. Or his dad could watch him while you were at work. Do make a point of telling the doctor about your job. how far away you live and your unemployed heavy drinking husband even if they don't ask. as part of your offer to take Gary home.

If the doctor talks down to you, become rather irritated and slightly confrontational. Really good candidates will explain that Gary has much potential for further improvement on his clozapine, but right now he needs skilled 24/7 care which it would not be fair to expect you to provide. Become more amenable if the doctor suggests that although you cannot meet his needs at the moment this is not a criticism.

The doctor may say that Gary could go home for the day or even overnight on leave once

he is well enough and the consultant is satisfied that he would not be at risk. Respond

very positively to this and become touchingly grateful and more co-operative.

Opening line: why can't my son come home?

· Why does he need to stay in hospital?

· Are you going to lock him up for ever?

· The consultant said his liver was better, so he can be discharged can't he?

· He'll never be any different no matter how long you keep him.

· It wasn't that bad with Tommy, Tommy did his best

· I don't think medication has ever made any difference, he's been like this for years

· How would you feel if your son was taken away?

· That consultant is an interfering old cow, how would she like it?

Play the role as a rather prickly lady who is not very bright and who has been downtrodden all her life. She is not particularly well mannered and can be quite coarse (especially when describing the consultant). She is prepared to argue about the son and his treatment -

and to complain to the hospital if not satisfied.

3) Dementia Genetics Explanation:

You are seeing Mr Alistair Turner, a 55 yr old man in the memory clinic.

His mother was diagnosed with Alzheimer’s dementia at 80 years.

Explain Alzheimer’s dementia risk of inheriting the disorder.

Role player:

You are 55 yr old engineer. You don’t have any memory problem. You are very worried after your mum was diagnosed with Alzheimer’s dementia at 80 years. Her 2 sister’s at the age of 78 and 79 yrs were also diagnosed with this condition.

Ask the doctor:

· Is there any test which can tell me that I will also get AD?

· What are the changes of me getting the AD?

· Can smoking cause AD?

· Is there any special diet to prevent AD?

4) Somatoform Pain disorder:

You have been asked to see this 41 year old man Mr David Johnson who has a history of chronic back pain. He had a range of tests and investigations done, but no cause for his pain has been found. He has also been seen in the pain clinic. He is reluctant to see a psychiatrist.

Role player:

You are 41 yr old accountant and you have been suffering with chronic pain in your rectum for last 5 years. You don’t remember how it started?

It started gradually. On a scale of 1-10 you score pain as 8/10. The pain is constant.

It doesn’t go anywhere and is relieved on standing up and worsen on sitting down.

You stand up while speaking.

You have no other problem.

You don’t have any other pain.

Your job is quite stressful and for last 4 months has not been able to go back to work due to pain. You don’t know why this pain is there?

You had loads of test and were given paracetamol, ibuprofen, tramadol etc but were not relieved.

You occasionally drink alcohol but don’t smoke.

You have a supportive wife and have no kids.

5) Psychodynamic Transference:

Ms Rachel Wood has been attending psychotherapy sessions with you and has attended for 10 months. She had lot of difficulties as a child when she was sexually abused by her uncle. She had few relationships which ended in a short span of time.

You had to cancel last appointment due to some unforeseen circumstances. She now wants to stop sessions.

Role player:

You want to stop the sessions.

Starting statement -‘thank you doctor for your help, I have really been benefitted from the therapy and from next week I won’t come’.

You don’t have any problem in arranging the transport .

You have enough time as you have not been working since last 1 year.

You don’t think that doctor is incompetent nor have difficulty in communicating.

When you came to know that doctor has cancelled the appointment you became very angry but thought that it is better to spent time with friends and do shopping. It reminded you of the past when your father left your mum. You have the same feeling of rejection.

When the doctor forms the link about the cancellation of appointment which led to the feeling of rejection with the similar experience in the past then mention that is something you never thought.

If the doctor offers you to attend the next session for further discussion then accept the offer.

6) Motor Coordination Examination:

Mr Brian 62 yr old alcoholic person had his MRI done showed cerebellar atrophy.

Do the relevant neurological examination.

7)Alzheimer's Treatment Explanation:

Ms Edwards, 55 yr old lady mother was diagnosed with Alzheimer’s Dementia.

Discuss the pharmacological treatment and its side effect.

Address her concern

Role player:

You look anxious as you don’t have much information about the medication.

Ask doctor will the medication cure memory completely?

How long my mum has to take?

What are the side effects?

Who will see her to review her memory?

8) Psychosis MSE- Bizarre Behaviour:

18year old Rachel Wood brought by father after a festival, concerned about mental health. Perform mental state examination.

Role player:

You look suspicious.

Jump from sitting position to bring your legs on the chair. When the candidates enquire then say that there is fire from hell all over the place.

Look around and say that you can hear Jesus speaking to you. His voice is as clear as the candidate.

Tell that the devil is trying keeping you away from Jesus.

Say that even the doctor is part of conspiracy and doesn’t want her to meet Jesus.

Mumble at times.

Your mood is terrible. You have recurrent thoughts of joining Jesus. You will not tell your plans now. You have access to knife.

You have poor sleep and have not been eating and drinking well for few days.

You don’t drink alcohol or smoke.

You know that you are in a hospital in Sheffield. You don’t know the date and month/ year.

You don’t think that you need any help from doctors and you are sure that medications are going to kill you.

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wow you have given an amazing collection of the questions of CASC exam. well done.

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thanks for ur efforts

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It was so useful to read these stations' scenarios, I sat the exam that day and passed 11/16. Many thanks.

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What was the preferred diagnosis for the early psychosis station?

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Hello Mei,

I did pass the first link station and my Dx was drug induced psychosis. In the second link stn I did not say in the management about referral to early intervention service and my formulation was also not structured.

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Hello Mei,

I did pass the first link station and my Dx was drug induced psychosis. In the second link stn I did not say in the management about referral to early intervention service and my formulation was also not structured.

Thank you, Vikas. I also thought that the history sounds like drug-induced psychosis. Were you instructed to mention the diagnosis in the 1st station? Actually if it's drug-induced psychosis, do you refer drug/substance department or early intervention service?

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hello Mei,

u were not supposed to tell the DX in the 1st stn but in the second stn u have to tell to the consultant.

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hello Mei,

as the age of onset of psychotic sx is 20 yrs therefore early intervention service has to be contacted.

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Hi Guys,

regarding the OD 1st station--- It says : Take the social history and do the relevant risk assessment.

Don’t take history of the overdose or do mental state examination

Does it mean that we

a) do not need to ask about 4Ps at all ? and also

B) NO need to explore PSYCHOPATHOLOGY(i.e Depressive Cognitions)???

I would appreciate ur valuable feedback Folks ..

Thanks

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Hi Guys,

regarding the OD 1st station--- It says : Take the social history and do the relevant risk assessment.

Don’t take history of the overdose or do mental state examination

Does it mean that we

a) do not need to ask about 4Ps at all ? and also

.... NO need to explore PSYCHOPATHOLOGY(i.e Depressive Cognitions)???

I would appreciate ur valuable feedback Folks ..

Thanks

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I think what they mean is probably don't have to take a detailed MSE. You still need to screen for depression, psychosis, PD.

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Hi Guys,

regarding the OD 1st station--- It says : Take the social history and do the relevant risk assessment.

Don’t take history of the overdose or do mental state examination

Does it mean that we

a) do not need to ask about 4Ps at all ? and also

.... NO need to explore PSYCHOPATHOLOGY(i.e Depressive Cognitions)???

I would appreciate ur valuable feedback Folks ..

Thanks

Are you sure the task was as you you mentioned?

If you don't take history of overdose, how can you do proper risk assessment? You have to ask about overdose in details to decide the suicide risk. Or if it was the task like you have mentioned, it may be a joke?

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I don't think the task mentioned not to take overdose history, reason as ryukenden has mentioned. I think they told you not to do MSE (but still have to screen briefly).

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