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rajeevkrishnadas

PMPs... Starting from Spring 2007

20 posts in this topic

This one was posted by lad...

22 yaer old women,referred by the gp because of heroin use and now want to stop.

she tells you that she is irritable and violent towards her children aged 1 and 3.

how will you manage?

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Answer posted by OM in the previous thread...

Key issues

1. Child protection - to deal with Immediately and urgently... inform Social services

2. Any other risks to self or any others...

3. Substance use

4. Comorbidity

I think I agree with it... anything else guys...

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1. 29 yr old junior doctor.    delivered 3 wks ago     unplanned pregnancy     child premature

  needed incubator     husband also doctor     complaining wfe is irritable, lethargic

probes: how will you differentiate mat blues, post partum psychosis and post partum dep.

    where will you manage??

    what are the non pharmacological options?

    does the fact that the baby is in incubator have any significance?  

    whats the significance of both being doctors??

    what will you do for husband?

   

2. intravenous heroine addict    arrives at 2am in AE     no corraborative info     no previous psych history     threatening to committ suicide if not admitted

Probes: what will you tell the staff on admission

    (i told regarding risks-suicide, withdrwals and aggression to other patients but he  

    wanted me to speak about personality which totally skipped my mind)

    how will you manage heroine withdrawal?

3. 26 yr old man      on ward for 9 mnths      tried on full doses of 2 antipsychotics and one depot

   still floridly psychotic      how would you manage??

Probes: what is maintaining this illness

    what apart from clozapine?

    side effects of clozapine

    how will you manage siallorhea?

    what will u do if patient says he has put on 5 kilos?

    non pharmacological options in the management of this case

4. Young man with diagnosis of schizophrenia who is stable on typical neuroleptic

presents with partner saying he wants to stop his medication. How do you assess and

manage.

They probed into the nuts and bolts of EPSE and other S/E of antipsychotics.

Also asked why someone who has relapsed would want to stop medications.

Lastly, asked what i would do if the patient refuses to change his mind and insists on

stopping the meds.

5. Man with learning disability who lives with elderly mother and attends day centre

has recently become irritable and aggressive. Also rubbing genitalia agaist furniture

and masturbating openly on occasions. He has also begun to approach school children

on the primary school nearby.

Probed me on what concerns i would have about his sexual behaviour and exactly how

one would asses risk in this case including 'instruments' that could be used.

6. Psychiatric nurse who has been involved in an accident which threatened her life

presents with poor sleep and nightmares...cannot remember exact details.

After i mentioned PTSD as main differential probes included exact ICD-10 criteria

for PTSD, Treatment for PTSD, bad prognostic factors in PTSD and lastly which was

more effective pharmacological or psychological tx, in this condition.

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26 yr old man on ward for 9 mnths tried on full doses of 2 antipsychotics and one depot

still floridly psychotic how would you manage??

The main issues would be to determine the cause of non response, establishing treatment resistance. give importance to psychological therapies and discuss augmentation. '' RISK'' - may not be relevant here but worth a mention

Treatment resistance flow chart - given in some books

Revisit the diagnosis

Is the patient on adequate dosage for adequate length of time.

Any side effects that need addressng

Is compliance an issue.

comorbid substance misuse

comorbid mental illness, medical illness.

talk about 2 nd opinion

thorough neurological examination.

MSE

How do we treat

Thorough medication summary

which drug worked best , how many were tried.

Clozapine , CBT for resistant delusions, compliance therapy, addressing high EE in the family, psychoeduction, relapse signatures. Augmentation strategies.

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5. Man with learning disability who lives with elderly mother and attends day centre

has recently become irritable and aggressive. Also rubbing genitalia agaist furniture

and masturbating openly on occasions. He has also begun to approach school children

on the primary school nearby.

Main Issues

Supporting this gentleman in this situation at the same time, giving importance to the risk that he poses to school children and to his elderly mother.

Background info

Onset of behaviour, is it a new behaviour or has it occured before. app, sleep patterns, activities at the day centre, change in behaviour , how is mum coping, has he made any attempt to physically touch childen. Behaviour analysis.

DD

Difficulty in undrestanding normal sexual expression and social rules[ LD]

Abuse [ Physical or sexual]

Organic causes like infection, genital pahology, uncontrolled epilepsy, substance use[ Possible?]

Mania would be an important differential, psychosis, depression ,

You can add other bits if you want.

Full history and mental state examination. Mental state examination should be tailored to risk, does he have unusual sexual fantasies, especially related to children, fetishes, look out for pressure of speech, flights of ideas or psychosis. Sexual history as to his sexual preferences could also be important.

Rx

Inpatient as you need to assess him, manage risk to children an if needed, get a forensic opinion.

Investigations

usual format, bio, psycho social, dont forget eeg for epilepsy, thorough physical examination for bruises, genital examination.

Treatment

RX Underlying Mental Illness , sex education, victim empathy by means of videos . Involve behaviour team . Be readyto talk about mood stabilisers as they discussed it with me. Rapid cycling is common in LD, read some stuff surrounding that issue. Forensic opinion. Gradual trial leaves to home. If risk is sustained or too high, consider placements. Always involve patient and family in decision making.

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I am sure most of us can handle the PTSD nurse scenario very well. we may forget some practical points.

If you are gonna admit this woman, it would not be to the same ward where she worked or is working.[ Conflict of interest and all sorts of things]. Basically, treat her in a different setting to where she worked.

involvement of occupational health department [ Ask her to seek additional help and assessments from them as well].

Recognise the importance of increased suicide risk in professionals like doctors and nurses as thet can have access to stuff.

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1. 29 yr old junior doctor. delivered 3 wks ago unplanned pregnancy child premature

needed incubator husband also doctor complaining wfe is irritable, lethargic

probes: how will you differentiate mat blues, post partum psychosis and post partum dep.

where will you manage??

what are the non pharmacological options?

does the fact that the baby is in incubator have any significance?

whats the significance of both being doctors??

what will you do for husband?

Issues:

Acknowledge the sensitivity (doctors....Husband aswell)

Mention to consider perpeural disorder on top of D/D

Need to liaise closely with the paediatrician and establish the access to mother/baby unit

Risk to her and child (background of un planned pregnancy)

Probes

1) Mat.Blues---Mild depressive features in the first 72 hours post delievery

PPP.....Psychosis with affective component from from day 4/5 post delievery

PPD...From 2/52 onwards

2) Mother/baby unit

3)Supportive counselling for both, Psychoeducation, CBT in medium term

4)Yes..Bonding issues

5)Confidentiality, Need to treat away from their employing authority if they desire, support for husband aswell

6)Ensure he has family/social network, any children at home!

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5. Man with learning disability who lives with elderly mother and attends day centre  

has recently become irritable and aggressive. Also rubbing genitalia agaist furniture    

and masturbating openly on occasions. He has also begun to approach school children     on the primary school nearby.

General principles of LD Assessment

HISTORY

Depends on verbal communication and ability to describe ‘internal world’ (feeling, thoughts, emotions)

3rd party information - detailed history

Alternative methods of communication

1. Exclude physical illness

Pain

Infection (ear, chest, UTI, teeth)

Constipation

Side effects

Investigations - e.g. Thyroid function

Exclude epilepsy:

1/3 of those with LD

Complicated (pre/peri/post/ictal)

2. Has something changed in the environment?

‘Challenging behaviour’ does not imply person is mentally ill - what is it telling us?

Can be caused by change of staff/co-sharer/ accommodation/routine etc

MDT assessment:

Behavioural analysis - ABC’s

Predisposing/Precipitating/Perpetuating factors

Behavioural Mx - e.g. reward systems

3. Is there an underlying mental health problem?

Organic & reversible (e.g. hypothyroidism)

Schizophrenia

Schizo-affective disorder

Affective disorder

‘Neurotic, stress-related and somatoform disorders’

Personality disorders

Pervasive Developmental Disorders - Autism

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8-) Very good responses and answers and thanks to all contributors so far, especially ohceedee, lad and dorian-----

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in the case of man , LD who lives with, elderly mother, sexualised behaviour, school children

very good answers ,but

what about risk to mother ,to self and others

-i would cnosider forensic assessment for the risk to children

-what about mental health act for admission

-what about genetic testing,

my answer key issues: level of LD

-DD (investigations,physical,mental,psychological)

-change in individual and environment

-risk to self,mother ,children,other risks (fire setting,property)

-ttt: medical,psychological,psychoeducation to staff and family

behavioural management ,placement

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As Dorian stated- his post was to clarify 'general principles' of LD assessment- not a specific answer for this case. And thanks for that, Dorian...LD and forensic are the things I have least experience in and the basics are much appreciated! :D

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No answers for the question about the heroin addict yet.....

I would suggest - usual stuff full history and examination etc

only agree to admission if signs of psychiatric illness

probably not admit if PD or pure manipulation

If you do admit - drug screen (in fact I would drug screen all admission given a chance you would be suprised at the results)

Depending on results of drug screen detox can be done with lofexidine, subutex, methadone or dihydrocoedine (subutex probably best option if benzo -ve).

NB Beware concurrent use of benzos in all drug addicts

In real life I would never admit this patient as an emergency as unplanned detox's always fail

If dont admit arrange follow up with local drug services etc

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I am very bad at structuring stuff... I have made a structure around diagnostic/assessemnt management PMPs

1. Key issues

2. Setting I will see the patient in – why and with who

3. Collateral information GP; notes, CPN, carers, partner, family, police, other staff

4. Acknowledge possible sensitive and difficult issues I may encounter

5. Immediate Risks and immediate management if any for eg: child/suicide/homicide issues

6. &nbsp:lol:ifferential diagnosis that comes to my mind

7. History in order of ODP and Past/Family/Personal/PMP– in the order to rule out each DD

8. Physical exam

9. MSE

10. Investigations

11. Primary diagnosis – why - diagnostic criteria

12. Management – of Axis 1; 2;3;4

Where; when; why; what; how – OPD; Admission; MHA why

Pharmac; Psychotherapy and Social

Please comment...

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The one which I thought is...

Issues - Diagnosis,Management,Risk,capacity/confidentiality

Pre Assessment - Seek more information/clarify risk in particular,consider main/differentials/problem diagnosis,consider where to assess and with whom

Assessment - Usual Psych history with mental state (tailor it as according to your D/D)

Mx -  

                Consider what is immediately required in terms of Inv and Rx (Bio/Psycho/Socio)

                Consider how to followup/build up on the immediate actions already taken

                Consider maintenance,contingency plans and CPA in long term

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hi all,

got a pmp here which i need some help with - appeared in prev exams

An ASPD comes to your clinic. He says he's got a gun with him.. etc (can't remember what the exact details were)

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It is difficult to say without the rest of the details- which must give you a bit more evidence about risk- but I would start by ensuring the safety of myself and other staff (and general public)- if nec tell other staff to get out and ring police, while I ?explain to him that I cannot see him if he is carrying a weapon/ ?get out straightaway and phone police. Don't be a hero. Anyone who says they have a gun needs to be assessed in a considerably more controlled environment than the average OPD! Inform police that he says he is armed but you have not seen a weapon etc. Get them to reel him in, search him etc then assess in police cells. It might be a big fuss over nothing, but everyone stays alive...

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8-) Good answer Ros.

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I would add request police arrest on s136 . any further assessment needs to be done from a place of safety ie. the cells.

then proceed as per normal asessment and management

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Just as a point of interest- can you ask the police to use a forensic section? I thought that decision was entirely within their jurisdiction. I've just heard rumours of the police getting shirty with psychs asking them to section under 136...(Obviously you'd give advice if asked ;))

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I think that the fact he has turned up at your op is enough suspicion of a mental disorder (perhaps he even thinks you could cure him) coupled with the risk of harm to self /others mean that the police can use 136. If they were to refuse (?paperwork) then they could just plain arrest him for the firearms crime.

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