Clinical Case Reviews 2016

MEDI3004
MENTAL HEALTH
CLINICAL CASE REVIEWS

2016
Copyright - The University of

Queensland
Dear student,
Welcome to MEDI3004, the clinical rotation in which you learn about Mental Health.
These cases form an important part of your learning in this course. The cases are designed to
enhance your clinical reasoning and knowledge about common conditions so that you feel
confident and competent when you encounter these conditions in your future role as a junior
intern.
What topics are covered in the cases?
In several cases the Clinical Case Review Discussions cover in more detail and complexity
the clinical issues raised during Years 1 and 2 of the medical program.
Topics have been selected to reflect the prevalence of disorders in the community and the
associated burden of disability:
Schizophrenia
Depression
Anxiety
Personality disorder
Eating disorders
Dementia
In MEDI3004 you are expected to develop the knowledge and skills to be able to discuss
differential diagnosis, predisposing and precipitating factors, as well as assessment of risk.
The cases are designed to encourage hypothesis generation and testing, and the formulation
of clinical management plans.
What is the format for the case discussions?
You will receive a timetable for the case discussions. They are conducted in small-group
format and a clinical tutor is present to guide you in developing your clinical reasoning. Case
discussion sessions last for 60-90 minutes. You are expected to read the case for each week
prior to the tutorial session so that you can take an active role in discussion. All of the cases
include detailed prompts to assist you. The written case is provided as a guide to assist you to
learn about the topic, including the type of depth of knowledge required. Contributing
discussion about cases you have seen clinically is also strongly encouraged.
Each CCRD includes learning tips, an example of an assessment item for that topic, and
discussion of potential pitfalls to avoid in assessment. All hyperlinks are checked at the
beginning of the rotation please advise the Course Coordinator if you find that a link
does not work (jane.turner@uq.edu.au). Links on Blackboard require you to log in to
the site. You need the knowledge and skills to be able to diagnose each condition and
develop a comprehensive management plan at the level of a junior hospital-based
intern.
Each case includes prompts to guide self-reflection about any issues which may affect
you personally and to guide you in developing enhanced understanding of your own
responses to patients.
Best wishes for the rotation
Jane Turner
MEDI3004 Course Coordinator
MEDI3004. Clinical Case Reviews 2016
CLINICAL CASE REVIEW 1

SCHIZOPHRENIA
Page 2
Presentation:
You are an intern working in the Department of Emergency Medicine at a metropolitan
teaching hospital. You are asked to assess Lyall, a 25 year-old man brought to hospital by the
police. The police were called because Lyall was shouting at passers-by in the city. When the
police arrived Lyall had removed his shirt, was gesturing oddly, and he seemed confused.
When you start to interview Lyall you are aware that he smells of alcohol and he is mildly
ataxic. He is unable to provide an account of the events which led up to the police being
called. He denies any memory of being brought to hospital by the police.
Mental state examination:
Tall, thin man with poor self-care and poor oral hygiene. He appears older than his stated
years. He is wearing filthy trousers and has dirty pieces of paper and some decaying food in
his pockets. Poor eye contact. Irritable mood. His speech is loud and pressured. He makes
threats against the hostel manager who has threatened him with eviction. No behavioural
evidence of hallucinations. Appears to have delusions relating to his special role in exposing
a senior member of parliament who he believes is collaborating with a bikie gang to
distribute crystal meth. He says that he knows about the politician and his relationship with
the gang because of messages he has received from the internet.
Physical findings:
Swollen lower lip and superficial graze to (L) elbow.
Afebrile.
PR 88/min, regular. BP 145/85. JVP not elevated. HS x 2, nil added.
RR 26/min. Chest clear.
No signs of chronic liver disease.
Oriented to time, person and place. Mild ataxia.
No focal neurological signs, reflexes present and equal, plantars down-going.
You access his medical records which reveal that Lyall was treated as an inpatient 18 months
ago. A diagnosis of manic phase of Bipolar Disorder was made on the basis of elevated
mood, grandiosity, and arrogant and intrusive behaviour towards staff and patients. He
remained insightless and grandiose throughout his admission, and was non-compliant with
lithium. The notes indicate that he did not attend for outpatient follow-up.
You recommend to Lyall that he be admitted to hospital.
Clinical reasoning:
What differential diagnoses are likely on the basis of this presentation? Think as broadly
as possible and include organic and psychiatric conditions;
How would you differentiate between these? Think about aspects of the MSE, history,
mode of presentation, past history, physical signs and investigations;
What factors would you take into account in determining whether or not to admit Lyall
to hospital? List the circumstances in which a patient can be admitted under the Mental
Health Act. Note that you could be asked this in assessment;
List the signs of chronic liver disease.
Page 3
Learning tip
Watch the YouTube clip: http://www.youtube.com/watch?v=bWaFqw8XnpA
Review the slides on Mental Status Examination on Blackboard to help you practice
presenting a Mental Status Examination (MSE) for each of the videos. You might
find it helpful to watch the clips with other students and practice presenting the
MSE to each other.
As you progress through the rotation try to discipline yourself to use a systematic
approach to differentiating between your differential diagnoses, challenging
yourself to prove why it is your favoured diagnosis rather than another.
Further history:
Lyall becomes agitated following discussion of admission to hospital, and verbally threatens
the nurse in the reception area. Security staff are urgently called to assist, and Lyall
undergoes acute sedation.
Clinical reasoning and acute management:
Describe in detail how you would assess risk think about static and dynamic factors
(refer to Workshop in Orientation week);
Describe how you would approach an agitated patient, including strategies to try to deescalate the situation;
Describe the process of acute sedation in detail. List the specific drugs, dose, route of
administration, and side-effects. Describe the precautions which must be taken when
sedating a patient in this manner. Download resource on Blackboard: Acute Sedation
Guidelines
Progress in hospital:
Lyall is admitted to hospital under the Mental Health Act. He is placed on close observation
to ensure his safety and that of others. He undergoes full physical examination and
investigations are conducted. He is treated with IMI thiamine 100 mg tds.
Investigations:
U&E; FBC; LFTs; TFTs; CXR; urine drug screen; CT scan brain - all NAD.
EEG: alpha rhythm present bilaterally at 10 to 10.5 Hz. Changes of drowsiness were noted.
There was no significant change on over-breathing. EEG reported as within normal limits.
Further history:
Lyall reveals that he has been homeless for two years. He is estranged from his family but
refuses to discuss the circumstances surrounding this. He has recently found temporary
accommodation at a hostel, but says that other residents have been stealing his cigarettes and
talking about him. Lyall gives permission for the Social Worker to visit the hostel to collect
some personal belongings. The Social Worker reports that Lyalls room is filthy and strewn
with newspaper clippings and decaying food.
Page 4
Lyall discusses with nursing staff his belief that he has a role investigating the politicians
links with the bikie gang. He says he has collected evidence which is at the hostel, but the
hostel manager thinks it is a fire hazard and has told him to remove it. He is convinced that
members of the bikie gang know where he is and are trying to have him killed while he is in
the mental health unit.
Clinical reasoning:
In light of this information which is the most likely diagnosis?

Why has he been given thiamine?
What clinical concerns arise in relation to his expressed persecutory ideation? How
would you explore this further?
Describe in detail your approach to management.
o Discuss pharmacological treatments including antipsychotics (specific drug, dose,
mechanism of action, potential benefit, side-effects) and benzodiazepines for
agitation. Note that you could be asked this in a viva examination.
o Non-pharmacological including psychoeducation, role of case management etc.
What factors would you take into account in determining his prognosis?
What treatments could be considered if he fails to respond to initial antipsychotic
medication?
How would you explain the condition to the parent of a young adult newly-diagnosed
with schizophrenia? This could be included in assessment, for example in the viva or a
Year 4 OSCE examination.
Learning tip
Elyn Saks is a Professor of Law who movingly describes her experience of psychosis
and stigma:
http://www.youtube.com/watch?v=f6CILJA110Y&list=PLJMiZcdl04Z9DWpmB0x-42CGaL1rZ1gb
You are expected to be able to describe the comprehensive management of a patient
with schizophrenia. This includes discussion of medication and nonpharmacological interventions. Remember the role of expressed emotion and the
importance of community-based treatment including case management, as well as
the ethical aspects of treating patients who may lack insight into their condition.
Think about factors associated with a good prognosis.
Assessment tip sample MCQ:

Which of the following predicts a favourable outcome for a patient with
schizophrenia?
A. Low intelligence
B. Family history of schizophrenia
C. Stable premorbid personality
D. Absence of a precipitating factor
E. Absence of mood symptoms
Page 5
Personal reflection: for you to think about and NOT necessarily

for discussion in the CCRD:
Have you previously interviewed a patient with psychosis?
How does it make you feel to be in contact with a person whose ideas do
not make sense?
What is it like to be in the Department of Emergency Medicine assessing
a patient who is agitated and uncooperative? How will you handle this
when you are an intern?
Pitfalls to watch for in assessment:

Especially in a viva examination you must be curious about the reason
for presentation and be able to generate hypotheses related to this (why
has this person presented with these problems at this time?). For
example if parents bring their son to DEM late at night because they
are concerned you should wonder if there has been a critical incident
such as a threat of violence which has precipitated presentation.
You must be able to confidently discuss assessment of risk in detail (for
example asking about command hallucinations, identifying persecutory
delusions). Simply saying I would assess risk is insufficient you need
to say how you would do this. In order to achieve well in the viva
examination it is important to highlight issues of risk and incorporate
these into your presentation rather than requiring the examiners to ask
you. Remember that your management plan must include strategies to
manage the risks you have identified.
Failure to consider the reasons for a relapse of psychosis is common
remember to consider non-compliance with medication as well as
social/environmental factors such as expressed critical emotion,
substance abuse, inter-current medical illness.
You must be able to discuss pharmacological treatment in detail.
Remember that benzodiazepines are useful for treatment of behaviour
disturbance in an agitated patient who is psychotic.
REMEMBER THAT ASSESSMENT AIMS TO DETERMINE IF YOU
COULD WORK INDEPENDENTLY AS AN INTERN TO MAKE A
SAFE ASSESSMENT OF A PATIENT, INCLUDING ASSESSMENT
OF RISK AND DEVELOPING A PRIORITIZED MANAGEMENT
PLAN.
Page 6

DEPRESSION
Page 7
Presentation:
You are the intern working in a Coronary Care Unit of a large metropolitan teaching hospital.
Hugh Richards is a 52 year-old man who was admitted to the Unit four days ago after a
myocardial infarct. His course has been complicated by unstable rhythms and cardiac failure.
Nursing staff tell you that Mr Richards is sleeping poorly, and he is extremely reluctant to
mobilise.
When you talk with Mr Richards about modifiable risk factors for heart attacks he becomes
irritable, stating that he has tried to give up smoking in the past. He says that there is no point
trying to lose weight as he knows he will die from a heart attack anyway. When you ask why
he thinks that, Mr Richards responds that his father and two uncles all died from heart attacks
when they were in their 50s. Mr Richards tells you that he was mowing the lawn at home
and stopped because he was feeling short of breath. He then experienced crushing chest pain
which he knew was a heart attack. He called for his wife Gwen to call an ambulance but
thought he might die before the ambulance arrived.
Moderately obese man who offers little spontaneous speech. Looks mildly depressed but on
specific questioning denies this, becoming irritable and saying: Ive just have a bloody heart
attack what do you expect? No psychotic symptoms, fully orientated for time and place.
Clinical reasoning:
What factors might influence the way in which an individual responds to a potentially
life-threatening illness? Consider factors such as personality style, past experiences and
social context, roles and responsibilities. You will find these issues covered in the
resource Response to Adversity on Blackboard;
How would you distinguish between Adjustment Disorder and Major Depression in
someone with a serious medical illness?
Why is it important to make this distinction?
How does Major Depression influence the clinical course following myocardial
infarction?
Outpatient review:
Hugh refuses to attend cardiac rehabilitation, as he does not see the point. In response to
pressure from Gwen he attends a cardiology outpatient appointment. Gwen tells the
cardiologist she is concerned that Hugh is depressed. Hugh reluctantly agrees to a referral to
Consultation-Liaison Psychiatry.
During the assessment session with the psychiatrist, Hugh is reserved and downplays any
concerns. He says he tends not to talk about how he feels, but admits that he has thought
recently about his health, and felt pessimistic about the future because of his strong family
history of heart disease.
Gwen says that Hugh was devastated by the death of their only child, Ben, from a drug
overdose 7 years ago. Gwen said that Hugh refused to talk about what had happened. She
said that he had seemed sad and withdrawn and very different from his normal self: Hes
really never been the same person. Gwen feels that since his heart attack Hugh has become
even more withdrawn and quiet than usual.
Page 8
Learning tip
Review your learning from Year 2 about theories of depression, including
psychodynamic, psychosocial, cognitive and biological.
As you see patients in this rotation, try to think about the complex interplay of
factors which might have contributed to the development of depression. Think
about personality factors and social issues which need to be taken into account in
devising a management plan.
The following is a link to a 2013 BBC documentary on depression:
https://www.youtube.com/watch?v=F5YubjEqbZ8
Clinical reasoning:
What is the role of a consultation-liaison psychiatry service in a general hospital?

What is the significance of Gwens observation that Hugh withdrew and seemed sad
following Bens death, including her statement that he was not the same person?
How do you think Hughs family history of heart disease and his sons death might have
contributed to the development of depressed mood now?
Further progress:
At his next appointment, Hugh says that he feels sort of empty inside. He feels he has lost
his confidence and is apprehensive about returning to work. He has wondered if Gwen would
be better off without him, and he feels guilty about what he is putting her through. He has
wondered what was ahead of him, and had briefly thought he could just cut out the waiting
rather than deteriorate over several years as his father had done. He feels ashamed that he
feels so low, and describes himself as weak for not being able to cope.
Clinical reasoning:
What thoughts does a depressed person have (remember Becks negative cognitive
triad). How does this influence their behaviour?
How would you assess his risk of suicide and how would you respond if you thought he
was at risk of self-harm?
What is cognitive behaviour therapy (CBT)? Describe how this could be helpful in this
case. Details about therapy are available in the Manual of Mental Health Care
available on Blackboard (page 83);
Describe the pharmacological treatment of depression in a patient with medical illness.
What factors would you need to take into account in selecting a specific drug and the
dose? List the drugs which might be useful in this case including the dose. What
information would you give Hugh about side-effects? There is a resource on Blackboard
giving an overview of issues to consider in choosing antidepressant treatment for
patients with medical illness.
Does treatment of depression alter the outcome after acute coronary syndrome? Which
patients are likely to benefit most?
How might stigma about mental illness affect patterns of presentation?
How would you discuss antidepressant treatment with a patient who felt that needing
treatment was a sign of weakness?
Page 9
Learning tip
You are expected to be able to describe the management of a patient with depression
and demonstrate that you can tailor your management to the specific case. For
example if the person is severely ill, your management might include discussion of
prognosis and ability to live independently or even end-of-life issues.
A Formulation is a description of who the person is and why they are presenting
now with these problems. Can you make a formulation of Hughs case?
Check the VOPP on Formulation on Blackboard and read the article by Selzer and
Ellen Formulation for beginners.
You must be able to describe the necessary modifications to antidepressant
medication in patient with medical illness (for example SSRIs interact with
warfarin).
You must be able to describe how CBT works and its application to a particular
case.
MoodGYM is an interactive website developed by the Centre for Mental Health
Research at ANU. Registration is free and allows you to find out more about CBT:
https://moodgym.anu.edu.au/welcome.
e-couch is another initiative of ANU and can be accessed free of charge at:
https://ecouch.anu.edu.au/welcome
Assessment tip synopsis of a sample viva vignette:

Donald Olsen is a previously-fit 29 year-old man who is an inpatient in hospital
following a boating accident. The boat in which he was fishing caught fire and he
and his friend, Roy, jumped overboard. His friend is missing, presumed drowned.
Donald sustained burns to his arms, hands and face. He has required skin grafts to
his arms. The occupational therapist in the burns unit expresses concern about
Donalds lack of motivation with exercises aimed at maximizing optimal hand
function and asks you as the intern for advice. She says she has tried to encourage
him, but she feels that he has given up.
On MSE Donald has poor eye contact and offers no spontaneous speech. When
asked about the accident says Well maybe Roy is the lucky one. At least he doesnt
have to face all of this.
Page 10
Personal reflection for you to think about and NOT necessarily

Have you or has anyone you care about ever experienced depression?
Have self-harm or suicide ever had an impact for you personally? If so,
what support and assistance have you obtained to handle this?
Depression is very common in the community and even more common
in doctors and students.
Depression is treatable. Students sometimes worry that seeking help is a
sign of weakness or that this will damage their career. Being depressed is
too awful to tolerate. If you have problems with your mood see a GP.
There are psychiatrists who are interested in treating medical students,
and they will often provide a bulk-bill service.
Pitfalls to watch for:

Students commonly present everything they know about depression in a
viva examination but dont apply it to the specific case.
In the example above, it is vital to explore risk as Donalds comment in
the vignette about his friend raises serious concerns.
Management must include attention to issues of grief and loss (and
maybe guilt did either of the men contribute to the fire, had they been
drinking etc.). But you also need to think about the circumstances of
the accident in more detail trauma, waiting for help etc.
Will Donald be able to work again what work did he do beforehand?
What about relationships etc. If he is single does he feel that he is too
damaged to engage in a relationship? His response to the accident
will be influenced by his young age.
Another issue to be aware of in management is countertransference - if
it is considered that he contributed to the accident staff may blame or
avoid him. Conversely staff may feel that his injuries are not lifethreatening and so dismiss or devalue his concerns.
PLAN.
Page 11

ANXIETY
Page 12
Presentation:
You are working as an intern in the Department of Emergency Medicine of a metropolitan
teaching hospital. You are asked to assess Rosie Ward, a 19 year-old single woman who has
presented complaining of shortness of breath, a pounding heart and feeling faint. Rosie works
as a retail assistant in a fashion outlet in the city. This episode occurred at work after she
challenged a customer who she thought may be shoplifting.
Rosie says that she has had several episodes like this over the past two months since she
witnessed an accident whilst on the bus to work. In the accident a motor cyclist was fatally
injured when struck by a truck. This episode has been the most intense she has experienced
and Rosie says she thought that she might die. Rosie says that she is worrying all the time
about her health and keeps thinking she could have an accident. She has been reluctant to go
out with friends, preferring to stay at home. She requests a medical certificate because she
feels she cannot return to work.
Fashionably-dressed woman who is tearful and slightly tremulous. Sighs frequently, and says
that she is a nervous wreck. Says that she worries about absolutely everything, adding
that she is terrified of having a panic episode on the bus.
Physical findings:
Afebrile.
PR 96/min regular; BP 130/90.
No other abnormalities.
Clinical reasoning:
What are the core features of a Panic Attack? What is Generalised Anxiety Disorder?
What are the features of Post-Traumatic Stress Disorder?
What further aspects of history would help to clarify the diagnosis?
What other conditions would account for her symptoms? Consider a broad range of
possibilities including psychiatric illness, and medical conditions. What investigations
should be conducted?
What is the significance of her reluctance to go out with friends?
Learning tip
Think about different contexts in which PTSD could develop a person affected by
a natural disaster such as bushfire, being a witness to an armed hold-up, a person
involved in an industrial accident, someone who experiences awareness during
anaesthesia.
Think about the patients you may encounter as an intern who could be experiencing
PTSD.
This YouTube video explores some of the issues facing police officers and the
development of Post-Traumatic-Stress:
http://www.youtube.com/watch?v=wYO5_ai-8jo. Note in particular the difficulty
for those affected to seek assistance.
Page 13
Further history:
Physical examination and all investigations including Thyroid Function Tests are normal.
Rosie reveals that she has always been anxious. Last year when her mother was diagnosed
with breast cancer she lost it and had to take time off from work because of anxiety. She
consulted a General Practitioner who recommended relaxation training but Rosie did not feel
that it was helpful. Her mother has completed treatments and is well, with no evidence of
disease. However during her chemotherapy her oncologist prescribed some Alprazolam. On
two occasions her mother has given Rosie some of her Alprazolam. Rosie says that this was
like magic and she would like a prescription for some more Alprazolam.
Clinical reasoning:
What is relaxation training? What evidence is there for its effectiveness as a treatment
for anxiety? Describe how you would conduct this with a patient.
What co-morbidities are common in people with anxiety disorders and why?
Discuss the risks and benefits of use of benzodiazepines.
Learning tip
Beyondblue was established in Australia in 2000 with the aim of moving the focus on
depression away from mental health service issues and towards one which is
understood, acknowledged and addressed by the wider community.
It is recommended that you look at the video: My name is Anxiety:
http://www.beyondblue.org.au/the-facts/anxiety
This video describes one persons experience of social phobia:
http://www.youtube.com/watch?v=SBPQdvRF9g0
headspace is an initiative of the National Youth Mental Health Foundation and
includes narratives from young people: http://www.headspace.org.au/
Psychologist review:
Despite initial reluctance, Rosie agrees to see a clinical psychologist who obtains some
background history. Rosie is an only child whose father was killed in a motor vehicle
accident when she was 10 years of age. Her mother subsequently became depressed and
tended to spend time alone in her bedroom. She has intermittently taken benzodiazepines
since that time to help with sleep. Rosie isolated herself at school rather than have to explain
why she didnt have a father.
Rosie tells the psychologist that she worries about her future, and has become concerned
about her health and that of her mother. She accepts the offer of some cognitive therapy.
Page 14
Clinical reasoning:
Discuss how the death of her father might have affected Rosie. Think about her
mothers response to bereavement when Rosie was 10 years of age;
What cognitive distortions is Rosie likely to have and how would they impact on her
functioning?
How would avoidance of social situations compound the problem?
How would you explain the diagnosis to Rosie? How would you facilitate referral in
someone with low self-esteem and anxiety?
What would cognitive behaviour therapy involve for a patient like Rosie?
When would medication be an appropriate treatment? Discuss the pharmacological
management of panic and anxiety including specific drugs, dose, likely response and
side-effects.

Mike Harper is an obese 56 year-old man who has a history of alcohol abuse. He
presents to the Department of Emergency Medicine after experiencing a sudden

episode of palpitations, shortness of breath and tightness in his throat. The episode
lasted for about 10 minutes. He did not feel fearful or apprehensive during the
episode.
Which of the following is the most likely diagnosis:
A. Panic Attack
B. Generalised Anxiety Disorder
C. Major Depression
D. Myocardial ischaemia
E. Sleep apnoea
Clinical reasoning: Absence of fear or apprehension during the episode effectively
excludes a panic attack and symptoms do not fit the other options. He has risk
factors for cardiac disease.
Personal reflection for you to think about and NOT necessarily

Some degree of anxiety can help us to meet deadlines and accomplish
tasks. More extreme anxiety can be very distressing and affect ability to
learn and perform in examinations.
In MEDI3004 you will be assessed in a Viva Examination. Is this an
examination format which is likely to make you feel very anxious?
One technique to reduce this is to engage in relaxation techniques and
practice doing a lot of vivas.
If performance anxiety is a serious issue for you seek professional
assistance UQ Psychology offers a clinical service.
Page 15

It is not appropriate to use benzodiazepines as first-line
pharmacological management of anxiety disorders. Benzodiazepines
with a short half-life can cause rebound anxiety.
NOTE: If you mention benzodiazepines before you mention SSRIs in a
viva examination, the examiners will assume that is your first line
treatment.
Practice stating reservations before suggesting benzodiazepines, e.g.
These would not be my first choice because of the risk of dependence and
rebound anxiety. However in some cases brief treatment with
benzodiazepines may be required to cover the initial exacerbation of
anxiety commonly experienced with SSRIs.
Identification of avoidance is important and commonly overlooked in
viva examinations.
Always be aware of the risk of comorbid problems such as alcohol abuse
and doctor-shopping for benzodiazepines.
If your clinical attachment has been in a public hospital you have been
exposed to case management for people with schizophrenia. Case
management is generally not appropriate for people with anxiety
disorders.
PLAN.
Page 16

PERSONALITY DISORDER
Page 17
Presentation:
You are working in the Department of Emergency Medicine assessing Jesinta, a 22 year old
woman who was brought to hospital by ambulance. Jesintas friend Suri called the ambulance
after she found Jesinta collapsed at home with self-inflicted lacerations of both wrists. Jesinta
is initially reluctant to discuss the reason for this episode of self-harm, but later says that she
cut herself after she found out on Facebook that a former boyfriend is now in a new
relationship and his partner is pregnant.
Nursing staff recognize Jesinta as a regular. Her medical file reveals multiple presentations
with self-harm, ranging from overdoses to wrist lacerations. She has on one occasion required
admission to ICU following an overdose. Jesinta has not sustained tendon or nerve damage
and the lacerations have been sutured.
Mental status examination:
Thin young woman, with multiple tattoos and body piercings. Multiple scars across both
forearms. Poor eye contact, with irritable manner. Looks depressed. Refuses to cooperate
with history-taking, shouting: Just leave me alone. Im sick of everyone. You doctors are just
full of it. She demands to leave hospital.
Clinical reasoning:
Why do people harm themselves?
What factors are likely to underpin Jesintas pattern of repeated self-harm?
What feelings are likely to be aroused in health professionals involved in the care of
patients like Jesinta? How might health professionals respond to Jesinta? How will this
affect Jesintas behaviour?
Further history:
Jesinta has had several inpatient admissions to the mental health unit after episodes of selfharm. She has been offered outpatient follow-up but has never consistently attended.
Clinical reasoning:
What is personality? What factors shape the development of personality?

What are the common personality traits? Consider how these can be adaptive and in
which circumstances they are not adaptive;
When do personality traits constitute personality disorder?
What are the risks and benefits of making a diagnosis of personality disorder?
What comorbidities are common amongst people with personality disorders?
How do you balance the assessment of acute vs. chronic risk? What are the potential
advantages and disadvantages of admitting a patient like Jesinta to a mental health unit
following an episode of self-harm? Remember issues such as regression and the risk of
splitting.
Learning tip:
Think about personality characteristics (for example obsessionality, narcissism) and
reflect on situations in which these characteristics could be helpful, or when they
could pose a burden.
Page 18
Further history:
The social worker in the Psychiatric assessment unit has seen Jesinta previously, and gives
some details of her developmental history. Jesinta is the youngest of 7 children. Her father
abused alcohol and was violent, frequently assaulting Jesintas mother and the children. He
died from injuries sustained in a fight when Jesinta was 6 years of age. Her mother had
multiple partners before re-marrying when Jesinta was 12 years of age. Her step-father
sexually abused Jesinta until she ran away from home at 14 years of age. Since then Jesinta
has been involved in multiple relationships, several of which involved violence.
Jesinta is offered a new appointment for outpatient follow-up with the Psychiatry registrar.
She says she doesnt think shell bother attending as everyone just criticises her and tells her
what to do.
Learning tip:
This clip describes briefly the importance of attachment in providing a secure
foundation for subsequent personality development:
http://www.youtube.com/watch?v=6bul1meciGE
The Harvard Centre on the Developing Child has a rich suite of resources including
this one which describes the impact of neglect on brain development:
http://developingchild.harvard.edu/resources/multimedia/videos/inbrief_series/inbri
ef_neglect/. The Science of Adversity and Resilience resource on this site also
provides interesting reading.
When thinking about personality it is useful to identify defense mechanisms. The
VOPP on Adversity includes discussion of defences, as does this YouTube clip:
http://www.youtube.com/watch?v=FnRBAU6Yg2A
Splitting is commonly observed in hospital wards - you must be able to describe
what splitting is, and how it can be prevented and responded to.
Clinical reasoning:
What are the possible consequences of childhood sexual abuse? What factors are likely
to play a part in long-term outcomes?
How might her past experiences affect Jesintas attitude towards psychiatric treatment?
How could you respond to Jesinta when she says she wont bother to attend her
outpatient appointment?
What treatments are likely to be of benefit for people with personality disorders?
Discuss specific treatments such as DBT for those with borderline personality disorder.
What potential comorbidities should be taken into account when treating Jesinta?
What evidence is there regarding the benefits or risks associated with pharmacological
treatments in patients with personality disorders?
Consider how personality traits might modify presentation with medical conditions, and
how health professionals might need to modify their responses depending on these traits
e.g. how would a person with narcissistic traits respond to a diagnosis of hypertension?
Page 19
Assessment tip - synopsis of a sample viva vignette:

Ellie Frost is a 22 year old woman who has been brought to the Department of
Emergency Medicine after she was found unconscious at a nightclub in the city. She
is assessed and considered to be intoxicated. After a period of medical observation
she is referred for psychiatric assessment. Ellie is reluctant to be interviewed, saying
that no-one has ever bothered with her, and she doesnt see why this time will be
any different.
There are extensive notes in her hospital file.
She has presented with self-harm on several occasions, ranging from overdoses to
cigarette burns. On each occasion she has been offered psychiatric outpatient
follow-up, but has always declined.
Ellie never knew her father. Her mother was in a series of abusive relationships
during Ellies childhood. Hospital files document physical abuse from one of her
mothers partners, including severe beatings resulting in a fractured arm on one
occasion. Ellie ran away from home aged 14 years, and has no ongoing contact with
her mother.
On Mental Status Examination she is a thin woman with multiple scars and
cigarette burns of varying ages across both forearms. Poor eye contact, and sullen
manner. Dysphoric mood. Limited verbal responses to questions, often just
shrugging.

Personality traits or characteristics are what make us unique. Think
about your own characteristics. Many students are obsessional and this
is an asset in terms of achieving objectives. But being highly obsessional
can also mean that we set goals that are unrealistic, leading to
disappointment and even depression.
Being obsessional can mean it is hard to delegate or even let others help
us, as we feel I should be able to do this and we dont want others to
think we are weak.
In MEDI3004 there is no such thing as a dumb question or request for
guidance/assistance!
Being exposed to the suffering of others is distressing and if we have
experienced personal trauma or loss it can be especially challenging. If
this is an issue for you, it can be helpful to discuss this with your clinical
teacher in confidence to make sure this doesnt adversely impact your
learning.
Page 20

You must be able to formulate a case such as Ellies and explain the
potential impact of abuse on Ellies personality development.
A common error in viva examinations of a case like this is failure to
demonstrate a full appreciation of the patients difficulties with trust
and establishment of a therapeutic alliance.
Another common error is failure to identify aspects of
countertransference which could compromise care it is possible that
medical comorbidities in a case like this are overlooked. Ellie is at
increased risk for the development of depression but this can be
overlooked, as can substance abuse.
You must be able to describe the essence of DBT and its application in
this setting.
Terms such as attention-seeking to describe self-harm are pejorative
and should be avoided.
It can be very challenging to determine risk in a case like Ellies and you
must be able to discuss this, including the risk of regression if she is
admitted to hospital, balanced against recognition that sometimes
admission may be necessary.
PLAN.
Page 21

EATING DISORDERS
Page 22
Presentation:
Grace is an 18 year-old woman in her first year of an Occupational Therapy degree at
University. She presents to the General Practice where you are completing your General
Practice clinical rotation. Your supervising GP asks you to take a history from Grace who
says that she wants help with binge-eating. The problem has been steadily getting worse since
she started University, and she is finding the pressure of assessment especially difficult. She
feels that the binge-eating is now dominating her life. She failed a subject last semester and is
wondering if she has chosen the right course, but feels uncertain about what she should do.
She says that she was not really prepared for the pressures of University study. She finds it
hard to fit in with the other students who already seem to have established networks of
friends. Grace has been binge-eating and vomiting for about 18 months, usually twice per
day. For the last 2 months she has been taking up to 6 coloxyl with senna tablets/day.
Grace presents as a casually-dressed woman whose hair is untidy. She has puffy eyes as
though she has been crying. Says she feels miserable and ashamed, and that she cannot
confide in anyone. She demonstrates some reactivity of affect. She denies thoughts of selfharm. No psychotic features.
Clinical reasoning:
What is binge-eating and when does it become a clinical problem?

How would you distinguish Bulimia Nervosa from Anorexia Nervosa?
What are the common precipitants for binge-eating, and the common cognitive and
behavioural responses to binge-eating?
What are the potential medical complications of Bulimia Nervosa and Anorexia Nervosa?
What investigations are appropriate?
Follow-up:
The GP asks you to conduct a thorough physical examination and asks what investigations
should be undertaken. Grace agrees to make an extended appointment to provide further
history and review results. In the interim she agrees to keep a diary of her eating behaviours
and thoughts.
Physical findings:
Wt. 61 kg. Ht. 170 cm (BMI = 21kg/m2).
PR = 80/min; BP = 110/70.
Some dental erosions.
No other abnormalities.
Investigations:
U&E; LFTs; TFTs; Haemoglobin; ECG all within normal limits
Learning tip:
You must know the physical complications of eating disorders;
You must know the biochemical and other abnormalities which commonly occur;
Further
history:
You must
understand the physiology of re-feeding syndrome.
Page 23
Further history:
Grace returns for the results of investigations and the GP explores her background in more
detail. Her father is a pharmacist and her mother a school teacher who live in a large rural
town. Grace felt that her parents had high expectations of her and she felt that she wasnt
good enough. She always felt that she wasnt as pretty as her younger sister.
When her friends started planning for the School Formal in Grade 12 Grace felt intensely
anxious about how she would look. She started to diet and after about four months she had
lost 4 kg in weight. Her friends commented favourably and she was feeling good at times, but
she was preoccupied with food. She was terrified that she would not be able to maintain her
dieting. One day she arrived home from school and had a spoonful of ice cream, and before
she was aware of what was happening she found that she had consumed the entire container.
She felt guilty and nauseated and made herself vomit. Since then she has been bingeing and
vomiting twice most days, although there have been intervals of two to three months when
she has been free of symptoms.
On at least two occasions she has consumed alcohol until she passed out, and she finds that
her appetite is poor the next day.
Clinical reasoning:
What factors commonly predispose to the development of eating disorders? What are the
common precipitating and perpetuating factors?

What are the main treatment modalities for Bulimia Nervosa? Describe the steps involved
in cognitive behaviour therapy
How will keeping a diary be of assistance in treatment?
How would you discuss her alcohol intake? What advice would you give her?
What are the core principles of management of patients with Anorexia Nervosa?
Learning tip:
The National Eating Disorders Association has information available about eating
disorders: http://www.nedc.com.au/eating-disorders-in-australia
It is challenging to understand eating disorders, exemplified by the comments of
Anna Westins father who movingly states that for some time he felt that his
daughter could simply decide not to do this anymore if she just had enough willpower. Anna died from an overdose in 2000. Her parents talk about her illness:
https://www.youtube.com/watch?v=kjFP_4P7EKc
The YouTube video Perfect Illusions provides insights into the complexities of
eating disorders: https://www.youtube.com/watch?v=eoEY1rhwobs.
Page 24

Which of the following is an expected finding in a young woman with anorexia
nervosa:
A. Tachycardia
B. Leucocytosis
C. Hypotension
D. Hypernatraemia
E. Polycythaemia

Eating disorders are common and you may have personal experience or
seen friends who have been affected.
Think about your responses to patients with whom you could identify
for a variety of reasons, and how you could deal with that as an intern.
Page 25

You must know the physical complications of eating disorders and be
aware of the risks associated with refeeding. You must recognise the
risk of comorbid depression.
Alcohol and other substance abuse can occur in the context of bulimia
leading to additional risks including the risk of assault/sexual violence.
You need to be able to discuss the application of CBT for patients with
bulimia. You need to be aware of the ethical aspects of a case of an
adolescent with an eating disorder, including consent to treatment.
PLAN.
Page 26

DEMENTIA
Page 27
Presentation:
You are an intern working in the Older Persons Mental Health Service at a large teaching
hospital. Martin Quigley is an 84 year-old retired high school principal referred by his general
practitioner. The general practitioner is concerned that Mr. Quigley has started acting upon
hallucinations and persecutory delusions that he first developed approximately six months ago.
Mr Quigley is reluctant to speak to you, and says that the matter is a private one between him
and his wife. Mrs Quigley says that over the past 6 months or so her husband has angrily
accused her of having a lover, insisting that he has repeatedly seen another man in their
home. Mrs. Quigley also reports that her husband has had memory difficulties for at least two
years and these seem to be becoming progressively worse.
Mr. Quigley is neatly attired and superficially cooperative. He denies any problems with his
health or any problems with his memory or thinking. He has mild psychomotor overactivity, and
some word-finding difficulties. His mood is euthymic. He describes visual and auditory
hallucinations and secondary persecutory delusional beliefs. He is fully conscious and alert. He
is disorientated to time but with intact attention and concentration.
He has significant impairment of short-term memory and difficulty with simple calculations,
with impaired answers on a similarities and differences task. His verbal fluency is reduced. He
has little or no insight into the nature of his cognitive impairment. Impaired judgement.
Physical examination:
Fit-looking 84-year-old man.
Pulse 84/minute; BP 160/90 lying, 150/80 standing.
RR 16/minute.
Afebrile.
Detailed cardiorespiratory examination unremarkable.
Visual agnosia and dressing dyspraxia on detailed neurological examination, although no
cranial nerve, pyramidal tract or cerebellar signs.
Appendicectomy scar.
Learning tip:
This video produced by Michael Leighton gives poignant insights into the
experiences
of
people
affected
by
dementia
and
their
carers:
http://www.youtube.com/watch?v=bVXoA4uISp4
Another example: https://www.youtube.com/watch?v=LL_Gq7Shc-Y
Alanna Shaikh talks on TED about her father:
http://www.youtube.com/watch?v=J8FyHI00ELY
Page 28
Clinical reasoning:
What diagnostic possibilities would you consider and why? Consider medical conditions
which may present with apparent cognitive impairment.
How would you distinguish between these conditions?
What tests of cognitive function can be used to make a clinical assessment?
What is verbal fluency and how might this be useful?
What is the significance of word-finding difficulties?
What signs would you look for on physical examination?
Learning tip:
Think about the areas of brain which are affected in Alzheimers disease and relate
these to function. Compare the cognitive deficits associated with Alzheimers with
Korsakoffs syndrome and relate these to anatomical structures.
Practice conducting a full cognitive assessment including the Mini Mental Status
Examination, trail-making tests, and verbal fluency.
Describe how you would distinguish between dementia and pseudo-dementia due to
depression.
Further history:
Mrs. Quigley says that her husband has had obvious difficulties with his memory and thinking
for at least two years. Over the past twelve months in particular she has had to do more of the
general household tasks because her husband has become progressively more muddled and
inefficient. She has also had to take over driving their car recently as her husbands driving had
deteriorated to the point where she felt quite anxious travelling with him when he was driving.
At times Mrs. Quigley now has to assist her husband with dressing as he has difficulty putting
on his clothes. Mr. Quigley has always been an independent, proud man who worked most of his
life as a high school English teacher, achieving the position of principal of a prestigious city high
school in his 50s. His wife has been reluctant to seek medical assessment because of his
stubborn denial that there were any problems. However the recent accusations of infidelity have
distressed her greatly because they are untrue and because they have always enjoyed a close
relationship.
Mrs. Quigley says that her husband is otherwise in relatively good general health but he takes a
benzodiazepine at bedtime as well as an ACE inhibitor for longstanding hypertension. The nurse
practitioner recommends that Mr. Quigley undergo routine investigation for potentially
remediable factors that may be associated with dementia. The team also recommends that Mr
Quigley be prescribed low dose anti-psychotic medication and monitored closely for adverse
effects.
Page 29
Investigations:
Mr. Quigley is initially reluctant to undergo any investigations as he feels there is nothing wrong
with him. With persuasion by his wife and his general practitioner, he agrees to have blood tests
and a CT head scan. The CT head scan shows moderate generalised atrophy more noticeable in
the temporal lobes and areas of marked periventricular hypodensity.
Full blood count (FBC) normal.
Erythrocyte sedimentation rate (ESR) normal.
Serum electrolytes normal.
Thyroid stimulating hormone (TSH) normal.
Liver function tests normal.
Serum vitamin B12 and red cell folate normal.
Syphilis serology unreactive.
CT or MRI head scan generalised atrophy plus periventricular hypodensities.
ECG normal.
Urinalysis normal.
Clinical reasoning:
How would you discuss the diagnosis with Mrs. Quigley?

Consider the diagnosis in terms of both the syndrome and the likely underlying disease
processes.
What factors would you take into account in assessing the risk that Mr Quigley poses to
himself and others?
What information would you give Mrs. Quigley about responding to her husbands
accusations?
What are the benefits and risks of treating Mr. Quigley with antipsychotic medication?
Why would a low-dose of antipsychotic medication be prescribed? What factors affect the
ability of older patients to metabolise drugs? What evidence is there regarding the
effectiveness and side-effect profile of antipsychotic medication in the elderly?
What strategies might be helpful to reduce the burden of caring faced by Mrs. Quigley?
What support groups are available?
What medications are available to treat cognitive decline related to dementia? What is their
mechanism of action and side-effect profile?
What ethical factors need to be taken into account in this case? Consider issues which may
arise as his condition deteriorates.
Page 30
Learning tip:
Alzheimers
Australia
has
information
about
dementia:
http://www.fightdementia.org.au/
including models of care:
http://www.fightdementia.org.au/common/files/NAT/Paper_35_web_v2.pdf
Think about the burden posed for carers of people with dementia and ways they
could be assisted.
You should reflect on the burden dementia will increasingly pose as the population
ages, and the complex ethical and social issues which potentially arise, including
elder abuse and exploitation and decision-making, including at end of life.
Fantasy Fiction writer Terry Pratchett describes his own diagnosis of dementia and
his campaign for legal assisted dying: http://www.youtube.com/watch?v=CUKdxrJj74&list=PLDFAA1CAC0B15CFB7
Assessment tip synopsis of a sample viva vignette:

Mavis Jones is an 82 year-old woman brought for a consultation with her General
Practitioner by her husband, Max, after he found her wandering in the street in her
nightgown. Mr. Jones has been concerned about his wife for the past few months, as
she has been irritable at times, and has become increasingly reluctant to engage in
bathing and personal care.
Mrs. Jones was diagnosed as having dementia 4 years ago but has had no response
to pharmacological treatments. Mr. Jones assumes responsibility for shopping,
cooking and other domestic tasks.
Mrs. Jones has a long history of hypertension.
She fractured her (L) hip after falling in a shopping centre 5 years ago and her
husband felt that she was never the same again after surgery.
Myocardial infarct three years ago.
On MSE she is thin, wearing stained clothes. Her hair is lank. She is uncooperative
on interview. On questioning she is able to state her name, but is uncertain of the
day or date. When questioned further she becomes restless and irritable.
Page 31

Have you experienced dementia in your extended family?
How has that affected the people close to that person?
What feelings do you think you might have when assessing and treating
patients with cognitive impairment?
How will you deal with that as an intern?

Beware of ageist stereotypes. Dont assume that an older person will
require institutional care. You must be able to discuss the ethical
dimensions of care including substitute decision-making and Enduring
Power of Attorney.
In the vignette above, the patients vascular history is suggestive of
multi-infarct dementia. You must be able to explain likely reasons why
her husband felt she was not the same post-operatively, drawing on
your knowledge of basic physiology, response to trauma and surgical
treatment for a fractured hip.
You must be able to describe the reasons why older persons require
adjustment in doses of psychotropic medication
Be aware of the need to have multi-faceted strategies for management of
behaviour disturbance in a person with dementia. Anti-psychotic
medication is associated with increased risk of adverse events including
cardiac events and death.
The National Prescribing Service provided a media release in November
2011 outlining some of these risks:
http://www.fightdementia.org.au/common/files/NAT/20111118_Nat_MR_NPSWarn
ingAntipsychotics.PDF
NOTE: Continued over page
Page 32
Pitfalls to watch for (cont):

NOTE: Be aware of the risk of delirium in the older population who
may have reduced cerebral reserve.
Delirium features prominently in viva examinations and you must be
able discuss the likely causes of delirium, assessment (which always
includes a physical examination), investigation and pharmacological
and non-pharmacological management. Delirium is a medical
emergency. Patients with delirium must be managed in a medical
setting, not a mental health unit.
This video outlines strategies to reduce/prevent delirium in hospitalised
elderly patients: http://www.youtube.com/watch?v=mKcbeXVdygg
Although not typical of delirium, the description Agitated delirium is
increasingly used to describe confusion and behavioural disturbance,
often in relation to substance abuse/withdrawal in combination with
psychiatric and medical illness. This is a medical emergency and
confronts staff in DEM regularly.
This video is very confronting and demonstrates a fatal outcome:
http://www.youtube.com/watch?v=GdzpoS8pTks
PLAN.
Page 33

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MEDI3004

CLINICAL CASE REVIEWS

Copyright - The University of

CLINICAL CASE REVIEW 1

MEDI3004. Clinical Case Reviews 2016

MEDI3004. Clinical Case Reviews 2016

Clinical reasoning and acute management:

MEDI3004. Clinical Case Reviews 2016

In light of this information which is the most likely diagnosis?

Assessment tip sample MCQ:

Personal reflection: for you to think about and NOT necessarily

Pitfalls to watch for in assessment:

MEDI3004. Clinical Case Reviews 2016

CLINICAL CASE REVIEW 2

MEDI3004. Clinical Case Reviews 2016

What is the role of a consultation-liaison psychiatry service in a general hospital?

MEDI3004. Clinical Case Reviews 2016

Assessment tip synopsis of a sample viva vignette:

MEDI3004. Clinical Case Reviews 2016

Personal reflection for you to think about and NOT necessarily

Pitfalls to watch for:

MEDI3004. Clinical Case Reviews 2016

CLINICAL CASE REVIEW 3

MEDI3004. Clinical Case Reviews 2016

MEDI3004. Clinical Case Reviews 2016

Assessment tip sample MCQ:

presents to the Department of Emergency Medicine after experiencing a sudden

Personal reflection for you to think about and NOT necessarily

MEDI3004. Clinical Case Reviews 2016

Pitfalls to watch for:

MEDI3004. Clinical Case Reviews 2016

CLINICAL CASE REVIEW 4

MEDI3004. Clinical Case Reviews 2016

What is personality? What factors shape the development of personality?

MEDI3004. Clinical Case Reviews 2016

Assessment tip - synopsis of a sample viva vignette:

Personal reflection: for you to think about and NOT necessarily

MEDI3004. Clinical Case Reviews 2016

Pitfalls to watch for:

MEDI3004. Clinical Case Reviews 2016

CLINICAL CASE REVIEW 5

MEDI3004. Clinical Case Reviews 2016

What is binge-eating and when does it become a clinical problem?

common precipitating and perpetuating factors?

MEDI3004. Clinical Case Reviews 2016

Assessment tip sample MCQ:

Personal reflection: for you to think about and NOT necessarily

MEDI3004. Clinical Case Reviews 2016

Pitfalls to watch for:

MEDI3004. Clinical Case Reviews 2016

CLINICAL CASE REVIEW 6

MEDI3004. Clinical Case Reviews 2016

MEDI3004. Clinical Case Reviews 2016

MEDI3004. Clinical Case Reviews 2016

How would you discuss the diagnosis with Mrs. Quigley?

MEDI3004. Clinical Case Reviews 2016

Assessment tip synopsis of a sample viva vignette:

MEDI3004. Clinical Case Reviews 2016

Personal reflection: for you to think about and NOT necessarily

Pitfalls to watch for:

MEDI3004. Clinical Case Reviews 2016

Pitfalls to watch for (cont):

MEDI3004. Clinical Case Reviews 2016

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