TP1 2022 Psych VIVA Memorandum

POW
1. Vasc Dementia
2. DT (in ATSI)
3. Mental health act + suicidality
a. Nominated Carer
b. Sectioning
4. Neuroleptic malignant syndrome
5. Alcoholism + Intoxication/withdrawal
6. Postnatal Psychosis
7. ADHD

Station 1.
Station 2.

Station 3.
Station 4. NMS

Management Station description:

You are the intern in ED and you are asked to check on a 23 year old young man with known bipolar
disorder who was brought to the Emergency Department the day before after he was found at the
beach, wandering in an agitated manner, wearing only underpants and responding rapidly and
excitedly to unseen voices. On arrival he was noted to be severely sunburnt. His urine drug screen
was positive for amphetamines but negative for antipsychotics. It was very busy in the ED and he
was quickly prescribed a regime of 10mg droperidol imi stat followed by risperidone 1-2mg q 6
hourly prn and diazepam 10mg po stat and then 5-10mg q6hly prn after which he fell asleep.
Overnight he was given more medication when he woke up and received another dose in the
morning.

You observe that he is confused, febrile (38.5˚C), tremulous and sweaty. He is disoriented and has
increased muscle tone in all limbs. His pulse rate is labile (60-130) and his blood pressure is
elevated (170/100). You note that the urine bottle beside the bed contains urine that is much darker
than usual. You check his morning bloods and they report the following results.

WCC 11.7 x 109/L (1.2-4 x 109/L)

Neutrophil count 9.9 x 10 (2-7.5 x 109/L)

AST 82 U/L (<35 U/L)

Creatine 150 mmol/L (60-110 mmol/L)

Urea 10 mmol/L (3-8 mmol/L)

CK 8000 U/L (22-198 U/L)

HCO3 18 mmol/L (22-32)

Please discuss with the examiner:

• What further information you would require to refine the probable cause of the patient’s
deterioration and possible differential diagnoses

• Your evaluation of the patient’s clinical status, including how you would assess the extent and
severity of his condition

• which factors, if any may have contributed to the development of the patient’s condition.

And,

• Formulate and communicate a management plan for the identified condition, which includes
consideration of the concurrent management of the patient’s acute psychotic symptoms in this
context.
Station 5. Management Station description:
You are the night intern and you are called to review a 52-year-old divorced, recently retrenched,
businessman. He was admitted to the orthopedic ward 2 days earlier after falling at home and
sustaining a hip fracture requiring surgery. The nurse tells you that he is agitated and confused and
has been awake for most of the night and keeps telling them that someone wants to hurt him. You
observe him to be confused, sweating and tremulous and that he is gesturing and talking to himself.
He is tachycardic (110 bpm) with elevated blood pressure (170/100) and a fever of 38C. There was
no history suggestive of head injury or loss of consciousness associated with his fall though his
notes report previous head injuries and black outs. He is too distracted to answer your questions but
his daughter reports a history of increasingly heavy alcohol use over recent years and that he has
recently lost his license for a Driving Under the Influence of alcohol offense. You note that on his
bloods he had a GGT of 330 IU/L (0-50 IU/L); ALT 110 IU/L (<45 IU/L); AST 88 IU/L (<45 IU/L) but
no other abnormalities.

Please discuss with the examiner:

• What further pertinent information (history, examination and investigations) you would seek in order
to develop a diagnostic formulation of the patient’s presentation.
• the level of risk that the patient poses to himself and others as a result of his condition.
• Your immediate and medium/long term management plan.

Station 6. Postnatal psychosis

Insert case

Station 7. ADHD

You are a GP. Joshua is a 24-year-old who has attended the practice for many years with his family.
He is employed part time as a trainee real estate agent and is in his second year of a part time
Bachelor of Business degree at a local university. He self-presents expressing increasing frustration
because of difficulty managing workplace demands and study. He reports longstanding difficulties
with organisation and time management, persistent difficulty concentrating on reading tasks, and
trouble retaining revised materials for exams. He has a reputation for being late and is beginning to
lose friendships because of his unreliability and erratic behaviour. He has a childhood history of
Attention Deficit Hyperactivity Disorder (ADHD), and received methylphenidate and biofeedback
treatments between 8-13 years. However, he refused all treatments as a teenager and refused
further visits to the paediatrician because he did not believe he had a problem. Now he thinks he
might need medication again.

Please discuss with the examiner:

1. What further information you would seek in order to make a diagnosis and consider differential
diagnoses
2. The key issues in this young man’s presentation

3. The management options you would discuss with Joshua

Liverpool

STG
Neuroleptic malignant syndrome
Postnatal psychosis

Sutho

Vinnies

Vascular dementia (same as POW)