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Can someone crack this PMP please?

35 posts in this topic

Surgeon refers lady who is 33y; She had an appendicectomy 2 weeks ago; now she is an in patient; Sice last night she has become very aggressive and irritable. Assess and managethis case.

I failed in this station eventhough i discussed delirium due to surgical and anaesthetic complications, infection, drug and alcohol withdrawl. The examiner kept pointing out that she was kept in the ward 2 weeks post appendicectomy and that made me think she hasd an infection or other surgical complications. I went on management of delirium lines, but they werent very happy. The feedback didnt mention anything about this case except i failed .

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I will do this PMP as you did and go along lines of managment of delirium as a first possibility. In addition to your DDs, we can consider(I will consider them) exacerbation of psychotic illness, psychosis, Depression (stressful event: surgery), adjustment disorder.

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Thanks Vij for that answer. Yes, i should have thought of depression and adjustment disorder as a possibility. The examiner kept throwing me off track by saying,'what will you tell the Medic when you hand this patient over to them?' I told him whatever i could think of, but he wanted me to say what was in his mind! I am a poor mindreader and I couldnt get what he wanted me to say. By then the time was up . I dont blame him for being irritable, for he was there all three days and i was one of the last few candidates on the last day.

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I am not sure if they can keep a patient in general ward for just depression or adjustement disorder

DT , wernicke's encephalopthy ? may keep patient for 2 weeks , not sure?

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I'm pretty sure drugs and alcohol should be top of the list for most of these liaison questions, it certainly was both times I did PMPs.

Ok infection is a possibility but this is after all a psychiatry exam and I don't think the examiners are very interested in post-op infection. It's much more likely to be one of drugs or alcohol because they're the ones you can talk about the most!

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Issue: Potential psychiatric emergency.

Risk to self and others particulary other patients.

Clarify:with the medical ward about how agitated she is and has she attacked somebody.Also find out if its safe to assess her when she is agitated?If she is aggressive then the security/police should be involved and she should be assesd in a safe environment.

Before i see her i would make sure that all her physical investigations are normal.then i would take a detailed psychiatric history paying particular attention to her alchol use and use of any other substances and also would emphasise on psychotic symptoms paying attention to any hallucination,thought disorder and also assess any risk to self or others.

aLSO DO a mse looking for any mood symptoms,psychotic symptoms.

Any history of similar complaints in the past.find out if she is touch with cmht or any other psychiatric services and if so who is her care coordinator.I would gather more info from gp,cmht,family.

The rst would be management.

[highlight]The key in this pmp is that of risk to self and others particularly other patiens in the ward.I think if you pick this up you pass the pmp.[/highlight]

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if she was there for 2 weeks u think she might be withdrawing  from substance abuse?

psychosis

adjustment

personality issues

maybe shes a total nutter

maybe she had a phobia for MRSA and wanted out of the place

anyway why was she is so long?

she only had her appendix out.

in all seriousness

i think the key to answering this pmp is paying particular attention to the mental state

and attention to issues of risk and safety to staff patient other patients and yourself.

You want to know if this beahviour is secondary to mental illness or is there an organic cause. when i say organic cause I would be think... and blurt out your list...

then address the safety issues .. and concerns b4 you are happy about appraching patient to assess them.. just let it flow... and I guess keep the examiners with you (as if thats easy!)

find out

when did this behaviour start./

what are the aggravating factors?

was there a gradual change in behaviour? mood? then

is she responding to hallucinations both aud/visual

distracted?

listening to u at all? any signs of passivity? any previous forensic history?

can she be talked down in a safe environment?

alternatively is she dangerous? has she made threats? to who? when?

in what context? has she had any visitors is she aggressive with them?

blah blah

if it isnt a delirium

or a mental illness per se

such as an agitated depression or psychosis,

agjustment disorder?

personality disorder?  any evidence?

known to services>?

manage according to your findings

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I think you're right to a point but I also think you'd need to talk about management more.

For both my liaison PMPs, done at different exam sittings, and similar scenarios to this one, the examiners started scribbling furiously as soon as I mentioned chlordiazepoxide, thiamine, doses, reducing regimes, blah blah blah.

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33 year old who is 2 weeks post-appendicectomy and an in-patient who has become irritable and aggressive.

I'd suggest that she is angry at being kept in hospital against her will for 2 weeks after a minor op. There is not necessarily any psychiatric disorder evident from the vignette, and hence first job would be to clarify with referrer why she has become aggressive.

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I am beginning to think you cant manage the patient unless u know whats wrong with her.

if its the DTs.. fine

I thought we had ascertained it wasnt?>

damned if i know

anyway can we move on to another PMP?

A recently widowed man wants to take his brother with schizophrenia home from a long stay psychiatric ward.

Assess and Manage,

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i think one possible reason why you mightve failed was because you jumped to conclusions.. and they dont really like that..

you didnt fully consider other differentials..

the part 2 does not want brilliant doctors..

it wants safe reliable doctors who consider all the likely and unlikely possibilities (which im sure you are in your day to day practise)..

its all a game really... best of luck this time man..

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A recently widowed man wants to take his brother with schizophrenia home from a long stay psychiatric ward.

Assess and Manage,

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Shan you havent read the question.its the brotherw who is widowed.

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Issue : complex situation.

Clarify from the notes who is the next of kin?find out from the staff if the brother has been visiting the patient?Speak to the patient about his brothers request to take him home.

speak to the brother and find out more information about why he wants to take him home?What are the motives behind taking him hom?Find out what the situation at home is ?will he be able to cope?what are the arrangement he has made for the brother to stay with him.

after this i would arrange for a mdt meeting with the brother and discuss the issue of taking the brother home.Would arrange for an ot to do a home visit to assess the situation at home.The team will also discuss if he can cope with his brother and also discuass with the bro his emotional state to see if he can cope with his brother?

Initially would send the brother home for a few hours and gradually incrase it to a day and the overnight and then a few night of leave.The discharge home iwll be a very slow one.Once discharged he will be followed up intensevely in the community.discharge cpa will be arraged where alll risks will discussed,relapase indicators,medications and its side effects,follow up arragements,contact details of professionals.

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Hi Guys,

Sorry to drag you all back to the post appendicectomy patient scenario.

As soon as the examiner read out the PMP to me, he said, 'look it is 2 weeks, normally after an appendicectomy the patient is sent home on the next day, if not the same day'.

This did throw me off the track a bit, but i still discussed the risks involved and also the alcohol and substance withdrawl. He then asked me , 'withdrawl after 2 weeks?' I replied there is a chance she could still be receiving drugs or alcohol smuggled in to the ward. As someone mentioned, iI didnt jump into any conclusion, i tried to remain as unbiased as possible, keeping al the options in mind. The examiners attitude in the begining itself threw me off the track and also he asked me if she is having withdrawl, why was she kept in a surgical post op ward for 2 weeks?

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Puzzling!

Like you, I would have looked into the various organic differentials, and of course considering any past psych hx, the functional psychiatric illnesses.

However, I would like the surgical team to tell me why she's still on the ward 2 weeks post-op, and has the irritabiity and aggression just started?

I wonder whether there is a delay in her wound healing, is she engaging in a form of DSH by picking at her surgical wound?

Would it be too far fetched to consider the possibility of the patient having swallowed foreign bodies leading to the appendicitis in the first place? And could she still be doing that??

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poss she had post op complications like abcess?

systemic infection

delirium?

rx to antibiotics

?

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hi there

i also had this PMP in the last clinical ( recently widowed brother) and did not Know how to start ( i basically panicked). but now I think I can give it a go

i think that the main issues are

legel statuse of both patient ( detained or informal) and his brother ( is he the next of kin etc)

the mental state of the patient , is he well enaugh to be discharged and if so what is his view

capacity to concent can also be discuseed and careres asessment

then I would start by gathering more info from nursng staff, psychiatric notes , Gp and brother himself ( after requesting patients consent)

then i'd review the patient looking for active psychotic symptoms and assess the risk to self and others looking fior suicidal or homicidal thoughts

i would also look for history od substance misuse

I would assess capacity to make a decision about living with brother.

also i'd talk abuot displacing the next of kin if he wanted to discharge the patient against medical advice

however if disharge was agreed then a CPA should be arranged and attended by all professionals involved including OT ( to assess ADL), nurse, social worker etc

any other thooights , please help!

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usual approach:

issues:

Consent

stability of brothers illness long term on ward, medications, how will compliance be adhered, is he on depot? or orals? will he need depot first

any hx of violence? risk?

has he got capacity?

go thru the usual procedures?call a meeting

invite Gp to it

(useful info on other brother might be provided here, as he hasnt been referred and he might be unwell? bereavemebt rx? might find out why he wants his brother home from gp?)

needs assertive outreach, CPA?

key worker. OT assessment of home.

day care? rehab?

out patient f/u.

etc

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Hi

Just going back to the liaison PMP. One of the issues would be diagnosis, following the hierarchy. The other is that of risk. It might be useful to mention to the medical/surgical team as to what to do if she tries to leave - contact oncall psych SHO, use common law (if delirium) and use of S. 5(2) may be required. Also, clarify as to whether patient needs to stay in surgical ward and whether you would take over care if medically fit (of course, if is it clear it is delirium, she needs treatment in a medical ward). If it is delirium, I would definitely talk about identifiying and treating the cause, as well as medical and environmental management, ie, the usual plan for managing delirium.

M

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from Rcpsych website

in o/p clinic

25yr old married woman symptoms of depressed mood and anxiety over 2 year period. her marriage is under stress. She discloses to you that she was repeatedly abused by her stepfather between the ages of 8 and 12. She has never told anyone and insists that this info is confidential.

How would you assess and manage/.

does this pmp need an assessment of mood and anxiety symptoms or is it straight into disclosure child protection and marriage guidance?

it doesnt even state if her stepfather is alive or not/

any ideas how one would answer this pmp/

tx

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I would ask if father is alive? Access to other children? (grandchildren, neighbours' etc)

If he is, Inform social services-Tell her that I am dutybound to do this.

Take History of depressive symptoms and do mse (with assessment of potential selfharm, neglect, suicide or harm to others) to establish diagnosis of depression and exclude other DDs.

and offer antidep. meds. Give info on psychological input like CBT.

Look at any perpetuating factors like stress in marriage, talk about referring to RELATE or couple therapy. Explore her fears of husband knowing about abuse.

In the long term, she may benefit from psychological input if she is suitable for psychotherapy (understanding symptoms in psychological perspective, ego strength, ability to form therapeutic alliance, no substance misuse and no psychotic symptoms)

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Surgeon refers lady who is 33y; She had an appendicectomy 2 weeks ago; now she is an in patient; Sice last night she has become very aggressive and irritable. Assess and managethis case.

I failed in this station eventhough i discussed delirium due to surgical and anaesthetic complications, infection, drug and alcohol withdrawl.  The examiner kept pointing out that she was kept in the ward 2 weeks post appendicectomy and that made me think she hasd an infection or other surgical complications. I went on management of delirium lines, but they werent very happy.  The feedback didnt mention anything about this case except i failed .

Hold on a minute there! Have you considered that you may not have failed this particular PMP? Just because you FELT it went awfully and were grilled by the examiner, doesn't necessarily mean you failed this PMP. Sometimes they will keep asking you the same question to see if you stick to your guns or are easily swayed into saying something silly - (like in real life, people are always going to question your judgement, but you have to believe in yourself).

Maybe they didn't like the style in which you responded? Having done the exam 4 times and tried the PMPs in every style possible, I realised the style of your response is the key. It's not good to respond in a rigid, overinclusive and over-rehearsed manner. Keep it structured but say the important things first so the examiners know you have the grasp of the situation. The clues are in the PMP and mention them.

The mains issues are that of risk to self and other, clarification of why the lady is presenting the way she is 2 weeks post op and management.

Ensure the patient's safety, consider immediate risk and management of that risk- to self and others (transfer her to side room if poss with RMN to special her, plus all the conditions for delerium i.e. familiar object, reassurance, well lit room)

If needs sedation - advise on suitable prn (i.e not antipsychotic if naive)

Ensure surgical team knows of common law and their consultant or reg can use Section 5.2.

Then consider most likely diagnoses : organic vs functional, most likely first and why.

Organic - post=op infection, CVA, PE, reaction to meds, withdrawal of drugs and alc , electrolyte imbalance. Why after 2 weeks? - sudden PE / DVT / CVA, ongoing subclinical infection . physical reason, (remember almost anything is poss)

Functional - psychosis, affective dis, Personality

(No mental illness- dispute with another patient or staff?

Then information gathering. Background med and psych hx, current meds, latest nursing reports, GP, family / friends with pt's consent.

Then if poss, full psych history, MSE inclc thorough cognitive assessment.

Talk about parallel psych liaison, and if all physical causes exculded, transfer to psych ward for further investigation.

Is this any help?

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