Oci Notes

• Place: name of this place/type of place

• Immediate registration: 5 items = Name and address

• Concentration: months of year backward, serial 7’s.

• Construction: Clock face

• General knowledge: Prime minister

• Current events • Short term memory: recall of 5 items

•Parietal

o Three stage command

o Written command eg ‘Please close your eyes'

o Apraxia

o Confrontation naming

• Complex parietal

o Intersecting pentagons

o Paper reconstruction

o Clock drawing test – “draw a clock face, put in the numbers and then draw the time as ten past three”

o Bisect a line

• Frontal

o Trail making B (lateral convex) – “join the dots, going from 1st letter, to 1st number, to 2nd letter, to 2nd number, and so on.”

o Luria's fist-palm-side (lateral convex) and pattern repetition test

o Verbal fluency (medial) FAS and animals, normally >15 in 60sec

o Primitive reflexes – grasp (palm contralateral to lesion), pout and snout (when stroke upper lip).

Physical examination

Abnormal Involuntary Movement Scale = 10 areas scaled 0 (none) to 4 (severe):

• Face (facial, perioral, jaw, tongue), upper limb, lower limb, trunk, global (overall, incapacity caused, patient awareness of abnormal movements)

• Check mouth is empty

• Watch with hands on knees, then hands hanging between legs

• Open mouth, observe tongue in mouth, stick out tongue

• Tap thumb to each finger, watch facial and leg mvt

• Rigidity – flex and extend arms

• Tremor – arms out in front, palms down. Look also at trunk, legs and mouth

• Gait

• Glabellar tap

Palpation – look goitre, moves up on swallow. Parotid swelling.

Anorexia – height, weight (BMI), pulse (arrhythmia), BP, temp of hands, erosion of teeth, pale conjunctivae (anaemia), lanugo hair, Russell’s sign (purging).Presentation

The most salient features of this case are... [2 min]:

• Demographics

• Current symptoms

• Risk issues • Consequences... Role functioning, work, relational, parenting

• Current treatment

• This presentation occurred after... [Precipitants]

• Past psychiatric history, D&A and/or medical Hx [Multiple relapses, chronicity, DSH, poor inter-episodic function], FHx, forensic Hx

• Personality

MSE revealed... [Full MSE and cognition= 2 min]

Formulation

[1 min]

In formulation, this is a [age] year old [occupation] who presents after a [presenting complaint]. That “represented the culmination of”/”was brought about by” an illness manifest by [features of the HPI]. This occurs in the context of [recent aetiological factors] and on the background of [distant aetiological factors].

This in a [sex] with [describe personality features], related to [family Hx, disruptive family background, childhood trauma, rejection, lack of an enduring attachment figure, empathic failure, familial models, perpetuating family dysfunction, early assumption of responsibility, maternal deprivation, loss of a parent...]

It seems that dynamically...

Repetition of losses, unfounded fears realised, re-emergence of repressed feelings, themes of failure, they had the position of peacemaker in the family, idealised transference to females puts them at risk of being devalued, ? may have arrested his emotional development, the illness threatened his integrity, disrupted his care systems and limited existing resources, leaving his ongoing development a signif challenge, unresolved ambivalent feelings about her father and guilt over his death, her choice of occupation may be symbolic of her internal unfulfilled needs.

Key issues / Barriers here relate to...

• Risk to self or others (dependents), neglect, misadventure, reputation, spending, sexual, substances, iatrogenic harm, violence risk HCR-20

o Historical 10 (static): previous violence, young age at first violent incident, relationship instability, employment problems, substance use problems, major mental illness, psychopathy, early maladjustment, personality disorder, prior supervision failure

o Clinical 5 (dynamic): lack of insight, negative attitudes, active symptoms of major mental illness, impulsivity, unresponsive to treatment

o Risk Management 5 (future): plans lack feasibility, exposure to destabilisers, lack of personal support, non-compliance with remediation attempts, stress

• Why now? Compliance, dementing process

• Co morbidity, eg epilepsy +/- substance misuse

• Personality style engenders dependence, may push boundaries (need explicit limits, expectations), acting out

• Diagnostic uncertainty – contradictions in Hx, inconsistency btw Hx vs. MSE, overlap Axis II

• Management – engagement, counter-transference, compliance, treatment resistance, aim to minimise harm

• Rural, low SES, difficult family

• Prognosis – guarded due to poor insight and significant forensic history

4 P's X Biological Psychological Socio-cultural

Predisposing

(B) Family history HI, epilepsy Disability(P)Personality vuln (perfectionist) DV, CSA, maltreatment, low esteem Attachment disruption – family(S-C)Carer dysfunction, EE Low SES, low education Isolation, access to services

Precipitating

(B)Non-compliance D&A, illness Perinatal(P)Stress, bereavement Loss, conflict Breakdown, divorce(S-C)Family EE Losses, role change Migration

Perpetuating

(B)Non compliance D&A Negative symptoms Cognitive deficits(P)Poor insight, high EE Negative cognitive style Poor affect regulation, stress Mx Personality style (pessimistic, selfdefeating, impulsive, erratic)(S-C)Isolation, Unemployment NESB, Low SES Access to care, Rural/remote Cultural issues in presentation and beliefs re: disorder

Protective

(B)Compliance No D&A Physical health(P)Secure attachments Engagement, IQ Good insight, premorbid functioning(S-C)Support networks, accommodation, employment, spirituality, cultural resources, education, IADL.Gaps

[30 sec]: “There are a number of things I still need to know...”

• past psychiatric history, developmental history to better understand the trajectory of the illness

• forensic history, “is critical to risk assessment and management”, court reports, MSE @ time of offence

• further frontal lobe testing, in view of D&A, HI, Sz.

Fortunately patient's Strengths include...

Diagnosis

[1 min] Diagnostically, I feel Mr ___... has... “Major depression with melancholic features”.

Co morbid... Anxiety, Substance abuse or dependence disorder, Dementia Or rather than foreclose on one diagnosis, I feel the following differentials are pertinent: DDx

• Delirium, Substance induced disorder, ARBD

• Somatisation disorder, malingering, factitious disorder

• Dysthymia, Bipolar (rapid cycling = x4/year), Sz-aff, Delusional disorder, Body dysmorphic disorder

• Organic mood / psychotic disorder (eg. due to hypothyroidism)

With respect to his personality, there are some [specific traits] features or it may be that a [specific] personality disorder could explain all her symptoms on its own.

And medically there is the [obesity, EPSE]. DDx systemic illness (SLE, MS) is unlikely given the length of Hx.

Management

My action plan builds on the issues we have been discussing, in outline I will cover....1. Risk assessment and management

a) Establish the patient’s safety: hospital, outpatient or day patient?

i) Closed / open

ii) Voluntary or involuntary, MHA, Guardianship board

iii) Nursing observations q30min

iv) Search for weapons on admission (knife, guns)

b) Who is at risk? Self, neglect, reputation, others (family, object of delusion, staff, patients, ...)

c) Higher risk if mental illness, active paranoid symptoms, drug and alcohol, ASPD and past violence

d) Ax with clinical judgement vs. actuarial psychometric tools – PCLR, HCR-20 e) Mother-hood, baby care, mothercraft skills, Tresilian Units, admit for weeks, lactation nurses.

McNaghten?

g) Unfit to plea Presser criteria

h) Substantial impairment

i) Somatoform: focus on symptom Mx (not Dx and cure), not all physical symptoms have physical causes, rehab approach, limit unnecessary Ix & iatrogenic risk. DBT may be a useful model for this patient.2. Clarify diagnosis

a) Observations from nursing staff re: drug intoxication, withdrawal, affect, mood, suspiciousness, AH, negative symptoms (speech, affect, motivation), interaction with patients and staff.

b) Collateral objective history

i) Familiarise myself with the old notes, ward notes and discharge summaries

ii) GP – “ask why did you prescribe SSRI, what happened, what was the response?”. Check meds and medical problems

iii) Medical team, eg pain team.

iv) Family - patterns/dynamics of interaction. Inter-episode functioning, longitudinal history, psychosocial decline, developmental, conduct disorder

v) FHx clarifies Dx, informs Rx and alerts to children of mentally ill.

vi) CHC, case manager - peri admission events, compliance, D&A, past suicidal/homicidal acts

vii) Psychiatrist

viii) Court reports, witness statements, police charge sheets, fact sheets, criminal record

c) Physical exam of thyroid, EPSE, full neurological examination, neurology consult.

d) Investigations = routine screen with attention to...

i) Urine drug screen

ii) Bloods – EUC, BSL CMP, LFT, FBC, TFT, B12, folate

iii) Serology – Hep B, C, HIV (CD4, viral load if positive), syphilis

iv) CT head – SOL, CVA. MRI for first episode or late onset psychosis

v) EEG

vi) ECG (baseline QTc, pre-Li)

vii) Anorexia – ECG for arrhythmia (1st degree HB, ST, U waves, QTc), DEXA for osteoporosis, endocrinology reviews.

viii) Neuro psychometrics, IQ

3. Treatment

a) If [diagnosis, eg Sz] was the main issue, after a comprehensive assessment, this is what I would do:

b) Therapeutic alliance: pt involvement, informed consent, least restrictive Rx alternatives, empathic, build rapport, explain illness, support, reassure, involve family.

c) Goals of treatment:

i) Reduce and relieve symptoms

ii) Reduce negative cognitions

iii) Increase psychosocial function

d) Anorexia program ~12 weeks – supervise eating, graded re-feed with Dietician

i) Monitoring metabolic – EUC [K], [PO4] daily (re-feeding syndrome with hypo K).

ii) Supplement PO4 500mg bd, thiamine 100mg bd, KCl 1.2g/d, Mg 500mg/d, Zn 50mg/d, multivit.

iii) Aim +1kg/week, monitored graded exercises, behavioural program (consequences are bed rest, rewards = exercise privileges)

iv) NG feeds if severe, with consent by Guardianship board

v) Aim BMI to 16 prior to D/C.

e) Chronic pain Mx – multidisciplinary CNS, OT, physio, physicians. Increase Fx and activity, rehab.

i) Explain pain models – acute (tissue damage) vs. chronic (spinal cord and nerve changes)

ii) Take one-down approach, eg. We are de-skilling you here in hospital. This may or may not help.

iii) Venlafaxine has some evidence, b/c NAd action

iv) Anticonvulsants, valproate help with neuropathic pain and mood irritability

v) CBT – reframe hopeless to a difficult manageable one they can control by active involvement. Relaxation training, cognitive restructuring, coping skills and pacing activity helps pain.

f) Psychological

i) Psycho education – educate about the disorder, adverse effects of D&A

ii) Target the big issues, eg social phobia, AN = CBT

iii) Involve family or partner as a co-therapist. Alert to collusion, high EE.

iv) Specific CBT techniques– stress Mx, PMR, breathing, sleep hygiene, problem-solving

(a) Relapse prevention – learn their early signs of relapse, develop action plan to get help

(b) Antecedents, Behaviours, Consequences

(c) Patient derived goals, diary of behaviourspanic, safety behaviours