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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. Critical Essay Question In essay form, critically discuss this quotation from different points of view and provide your conclusion. 40 marks “Social media is only the latest disruptor in the history of medical and scientific communication” Reference: #BJPsych and social media – likes, followers and leading? Harrison et al. The British Journal of Psychiatry (2019) Vol 214, 245–247. doi: 10.1192/bjp.2019.6 Fellowship Competency 1. Communicator

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. Fellowship Competency 3. Medical Expert, Communicator, Scholar

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. Fellowship Competency 5. Medical Expert, Health Advocate, Professional

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. Fellowship Competency 6. Professional

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Fellowship Competency 8. Medical Expert, Collaborator, Manager

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. Fellowship Competency 9. Medical Expert, Communicator, Scholar

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. MEQ 1 You are a junior consultant working in the CL department of a metropolitan teaching hospital. You receive a referral from the neurology team of a 19 year old single woman, Jenny, who has been in hospital for 2 days. Jenny lives alone and works as a hairdresser. Her parents and siblings live interstate. On the evening of the admission, Jenny had an argument with her boyfriend who allegedly slapped her across the face. Jenny fell backwards, hitting her head on bitumen, momentarily losing consciousness. She recalls suddenly being unable to move both her legs, and bystanders called an ambulance. Jenny has a long history of tonic clonic seizures, which in recent years have been very well controlled. There was no observed seizure at the time of the altercation. The neurologist says that they are still investigating Jenny as she is still unable to move her legs. He wonders if there is a psychological component to her presentation and wants your opinion. Q 1.1 Outline (list and justify) how you would proceed with the assessment. 12 marks

Setting the scene introduce yourself and assure her that it is a usual practice for psych team to assess patients in neurology ward and does not mean that she is mentally ill. Ask her whether she was informed of our visit by the neurology team

2

Get her account of what happened 1

Her account of usual functioning 1

Developmental history 1

History of similar weakness in the past and whether any of her family members had it 1

Epilepsy control and medications taken for that and compliance 1

Social supports 1

History of trauma in the past 1

Other stressors ie work, financial 2

Quality of relationship with boyfriend 1

Mental status exam esp mood disorder 1

Collateral information from the old notes, GP, family, nursing staff on the ward 1

/ 12 marks Comments

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are a junior consultant working in the CL department of a metropolitan teaching hospital. You receive a referral from the neurology team of a 19 year old single woman, Jenny, who has been in hospital for 2 days. Jenny lives alone and works as a hairdresser. Her parents and siblings live interstate. On the evening of the admission, Jenny had an argument with her boyfriend who allegedly slapped her across the face. Jenny fell backwards, hitting her head on bitumen, momentarily losing consciousness. She recalls suddenly being unable to move both her legs, and bystanders called an ambulance. Jenny has a long history of tonic clonic seizures, which in recent years have been very well controlled. There was no observed seizure at the time of the altercation. The neurologist says that they are still investigating Jenny as she is still unable to move her legs. He wonders if there is a psychological component to her presentation and wants your opinion. Two days later the neurology registrar contacts you and says that they have ruled out organic causes for her lack of leg movement. Q 1.2 Outline (list and justify) the likely differential diagnosis

Conversion disorder/functional neurological symptom disorder History of sudden onset, does not confirm to the known features of organic paraplegia, not under voluntary control

4

Somatic symptom disorder Excessive thoughts, feelings and behaviours associated with the somatic symptom

2

Factitious disorder if proven to be under voluntary control with the intention getting some gain

2

Personality disorder – Cluster B versus Cluster C 2

Dissociative disorders 1

Malingering 1

Ongoing organic condition that is being missed 1

/10 marks Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are a junior consultant working in the CL department of a metropolitan teaching hospital. You receive a referral from the neurology team of a 19 year old single woman, Jenny, who has been in hospital for 2 days. Jenny lives alone and works as a hairdresser. Her parents and siblings live interstate. On the evening of the admission, Jenny had an argument with her boyfriend who allegedly slapped her across the face. Jenny fell backwards, hitting her head on bitumen, momentarily losing consciousness. She recalls suddenly being unable to move both her legs, and bystanders called an ambulance. Jenny has a long history of tonic clonic seizures, which in recent years have been very well controlled. There was no observed seizure at the time of the altercation. The neurologist says that they are still investigating Jenny as she is still unable to move her legs. He wonders if there is a psychological component to her presentation and wants your opinion. Two days later the neurology registrar contacts you and says that they have ruled out organic causes for her lack of leg movement. You reassess the patient. The neurology team now insist that you transfer the patient to a psychiatry unit. Unfortunately there are no vacant beds in the psychiatry unit. You further explain that the CL team will assist with managing the patient on the neurology ward. Q 1.3 Describe (list and explain) how the CL team will contribute to the management of this patient on the neurology ward?

Explore how psychologically minded is the patient 1

Provide psychoeducation to the medical, nursing and physiotherapy staff 1

Biological treatment of depressive symptoms and anxiety if required 2

Psychological exploring the conflict and minimising negative behaviour 2

Physiotherapy - graded mobilisation 1

Establishing support networks 1

Acknowledge the distress 1

Reassure her that there is a reason for the paralysis. It may not be physical but can be psychological

1

/8 marks Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. MEQ 2 You are the Junior Consultant on call for a metropolitan hospital who is called at 2am by the Psychiatry Registrar on call in the Emergency Department (ED). The registrar speaks to you about Sarah, a 34-year-old nurse who is 2 weeks post-natal. She has presented to ED with her husband James after calling an ambulance due to feeling dizzy, shaky and lightheaded. The ED registrar has asked for a mental health review as Sarah is presenting anxious and agitated. James describes Sarah as highly organised and high functioning but being prone to being highly self-critical. He also tells you that the pregnancy was planned and uneventful. Sarah is currently breastfeeding and reports feeling very thirsty. She also feels anxious about the baby’s health and has found it difficult to sleep since the birth. In ED she was found to be hyponatraemic with an elevated systolic blood pressure. Q 2.1 Outline (list and justify) the possible differential diagnoses you would expect the Psychiatry Registrar to be considering.

Primary organic/ medical cause Hyperthyroidism- High BP, tremor and thirst Adrenal insufficiency Autoimmune disease

3

Primary DSM 5 disorder Post-partum depression/anxiety - primary presenting symptoms anxiety and anxiety around baby’s health Postpartum psychosis

3

Drug/ Alcohol withdrawal or intoxication 1

Possible Cluster C personality disorder 2

/7 marks

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are the Junior Consultant on call for a metropolitan hospital who is called at 2am by the Psychiatry Registrar on call in the Emergency Department (ED). The registrar speaks to you about Sarah, a 34-year-old nurse who is 2 weeks post-natal. She has presented to ED with her husband James after calling an ambulance due to feeling dizzy, shaky and lightheaded. The ED registrar has asked for a mental health review as Sarah is presenting anxious and agitated. James describes Sarah as highly organised and high functioning but being prone to being highly self-critical. He also tells you that the pregnancy was planned and uneventful. Sarah is currently breastfeeding and reports feeling very thirsty. She also feels anxious about the baby’s health and has found it difficult to sleep since the birth. In ED she was found to be hyponatraemic with an elevated systolic blood pressure. Sarah is treated for the hyponatremia, which was mild, in ED. All other investigations were normal. The Psychiatry registrar has obtained collateral information from the husband including a change in Sarah’s behaviour postnatally. She has not been sleeping well, often waking up and checking on the sleeping baby. Sarah has taken the baby to see the GP three times as she is convinced that a small spot on baby’s back is a severe rash indicating meningitis. James also reports that Sarah is more irritable with him and he is worried as he returns to work tomorrow. Q 2.2 Describe (list and explain) the areas of concern in regard to risk.

Patient Risks of Emerging PND or psychosis Risk reoccurrence of hyponatremia secondary to polydipsia Risk to relationships with family/ husband Risk to attachment to infant Occupational risk as she is a nurse ( currently on maternity leave so doesn’t need to report to AHPRA)

5

Baby Physical safety Risk of iatrogenic harm due to over medical investigations Difficulties with attachment if mother unwell and untreated

3

Husband Carer stress Risk to employment if needs to take more time off work to care for wife or baby

2

Comments /7 marks

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are the Junior Consultant on call for a metropolitan hospital who is called at 2am by the Psychiatry Registrar on call in the Emergency Department (ED). The registrar speaks to you about Sarah, a 34-year-old nurse who is 2 weeks post-natal. She has presented to ED with her husband James after calling an ambulance due to feeling dizzy, shaky and lightheaded. The ED registrar has asked for a mental health review as Sarah is presenting anxious and agitated. James describes Sarah as highly organised and high functioning but being prone to being highly self-critical. He also tells you that the pregnancy was planned and uneventful. Sarah is currently breastfeeding and reports feeling very thirsty. She also feels anxious about the baby’s health and has found it difficult to sleep since the birth. In ED she was found to be hyponatraemic with an elevated systolic blood pressure. Sarah is treated for the hyponatremia, which was mild, in ED. All other investigations were normal. The Psychiatry registrar has obtained collateral information from the husband including a change in Sarah’s behaviour postnatally. She has not been sleeping well, often waking up and checking on the sleeping baby. Sarah has taken the baby to see the GP three times as she is convinced that a small spot on baby’s back is a severe rash indicating meningitis. James also reports that Sarah is more irritable with him and he is worried as he returns to work tomorrow. Q 2.3 Describe (list and explain) what aspects of management plan you would want your Psychiatry Registrar to address.

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Patient a) General

Psychoeducation Community vs inpatient treatment Vol vs MHAct if required Referral to CMHT/ Acute care team Liaison with GP

b) Biological treatment Consideration of best antidepressant given BF- sertraline/ citalopram SSRI > SNRI> TCA. Advice from? Pharmacy/ Mothersafe. ECT also indicated if PN Psychosis emerges or prefers not to take medication as breastfeeding

c) Psychological treatment encourage bonding with baby vs risks to baby if any. CBT Relaxation/ mindfulness Family therapy- focus on attachment

2 2 2

Baby Referral to PIMHS worker Child safety concerns – contact child wellbeing unit to discuss

2

Husband Psychoeducation Support- link in with carer support eg FACES, PANDA, GP

2

/8 marks Comments

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. MEQ 3 You are a junior consultant and your registrar calls about a patient he had assessed in the emergency department. Scott is a 19 year old unemployed man living at home with his parents who has recently stopped his university course. He was brought in by police after an altercation with his family which was precipitated by his parents turning off the home Wi-Fi saying that he is “addicted to gaming”. They are also angry about his THC use and want the registrar to admit him to hospital. Q 3.1 Outline (list and justify) the key elements of history you would expect your registrar to explore on assessment

History of presenting complaint (carefully describing the sequence of events in the lead up to the altercation)

2

Screen for major mental illness that could account for the presentation e.g. anxiety, depression, psychosis, personality.

1

Although not an official diagnosis, consideration of excessive gaming as a method of self soothing, or distraction.

1

Explore substance use history, not only THC but other substances too - contributing to Scott’s impulsivity

1

Explore personality construct – emotional regulation, maladaptive coping strategies. Is this an exacerbation of a vulnerable personality style?

1

Explore developmental hx – trauma, education, friendships, milestones. Ascertain what it means for Scott and his family that Scott to have stopped university and not in employment.

1

Assessment of risk including suicide and violence (examine past altercations) 1

Explore other aspects of social functioning – relationships, work, employment, interests, ADLs

1

Collateral hx from parents – this will also assist in assessment of family dynamics 1

/7 marks

Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are a junior consultant and your registrar calls about a patient he had assessed in the emergency department. Scott is a 19 year old unemployed man living at home with his parents who has recently stopped his university course. He was brought in by police after an altercation with his family which was precipitated by his parents turning off the home Wi-Fi saying that he is “addicted to gaming”. They are also angry about his THC use and want the registrar to admit him to hospital. Q 3.2 Outline (list and justify) the differential diagnosis you would discuss with the registrar

Psychosis – reduction in functioning could be a sign of a psychotic prodrome 2

Depression and Anxiety disorder – Depression manifesting as reduced motivation, anhedonia. Social anxiety disorder may account for increasing social isolation.

2

Personality disorder – emotional dysregulation, with young people often using THC or anger outbursts to reduce distress.

2

Substance abuse/dependence – established pattern of substance use. 2

Neurodevelopmental comorbidity - ASD, ADHD– ASD is associated with social isolation and emotional dysregulation

1

No psychiatric disorder – this is manifestation of family and social issues. E.g. there could be conflict between parents which has resulted in Scott being involved in a relationship triangle and scapegoated.

1

/8 marks

Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are a junior consultant and your registrar calls about a patient he had assessed in the emergency department. Scott is a 19 year old unemployed man living at home with his parents who has recently stopped his university course. He was brought in by police after an altercation with his family which was precipitated by his parents turning off the home Wi-Fi saying that he is “addicted to gaming”. They are also angry about his THC use and want the registrar to admit him to hospital. After a full assessment, you conclude there is no major mental illness aside from substance misuse. However, the family are reluctant to take him home.

Q 3.3 List what advice you would give the registrar on how to deal with the parents’ request.

Set up a family meeting with Scott and parents. 1

Use a non-judgemental stance. 1

Demonstrate that you have an understanding of the parent’s anxiety about having Scott home.

1

Facilitate communication between Scott and parents 1

Explore why parents do not want him home 1

Clarify that there is no Axis 1 dx (aside from substance misuse) and reasons to parents 1

Explain role of hospital - patient is no longer distressed, hospital not beneficial for this patient

1

Psychosocial interventions are best delivered in community. 1

/6 marks

Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are a junior consultant and your registrar calls about a patient he had assessed in the emergency department. Scott is a 19 year old unemployed man living at home with his parents who has recently stopped his university course. He was brought in by police after an altercation with his family which was precipitated by his parents turning off the home Wi-Fi saying that he is “addicted to gaming”. They are also angry about his THC use and want the registrar to admit him to hospital. After a full assessment, you conclude there is no major mental illness aside from substance misuse. However, the family are reluctant to take him home.

Scott and his family agree to discharge from hospital. They want to know what services could be accessed in the community.

Q 3.4 Describe (list and explain) the services you would like your registrar to have discussed with the family.

Connect with GP who can take over clinical care 2

Vocational and Educational Service that is able to provide Scott with some guidance for employment and/or education. Meaningful activity outside the family home will likely reduce conflict between parents and Scott.

2

GP to refer young person to psychologist to assist with developing distress tolerance 2

Refer family to family therapist to further explore conflict within the family. 2

Refer parents to “family and carers program” in the community for their own support. 1

Social groups in line with Scott’s interests that could improve his social functioning. Meaningful activity outside the family home will likely reduce conflict between parents and Scott.

1

Provide D+A service information – but to leave this with Scott to decide whether he would like help.

2

Online psychological and psychiatric services for people with excessive gaming 1

Services that can provide alternative housing arrangements 1

/11 marks

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. MEQ 4 32 marks You are a junior consultant in a local older adult community mental health team. Mrs Chi, a 77 year old lady who lives alone, was referred to the team by police after they were called by neighbours about the odour coming from her unit. Police conducted an initial assessment with the geriatric consultant who ruled out acute medical problems and suggested a psychiatric review due to Mrs Chi's distress and degree of clutter in the house. Q 4.1 Describe (list and explain) key aspects of your assessment.

Risks assessment (Environmental to self / others, physical health / falls, ability to attend to ADL’s)

2

History – mood, cognitive, psychotic, functioning 2

MSE-must include cognitive assessment 2

Ability to/likelihood of engaging with services 1

Degree of squalor / hoarding 1

Collateral history 1

Social supports 1

Capacity assessment 2

/10 marks Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are a junior consultant in a local older adult community mental health team. Mrs Chi, a 77 year old lady who lives alone, was referred to the team by police after they were called by neighbours about the odour coming from her unit. Police conducted an initial assessment with the geriatric consultant who ruled out acute medical problems and suggested a psychiatric review due to Mrs Chi's distress and degree of clutter in the house. On assessment, Mrs Chi denied mood disturbance but had evidence of derogatory auditory hallucinations. Q 4.2 Outline (list and justify) the differential diagnoses for Mrs Chi.

Schizophrenia / schizoaffective disorder 2

Dementia / major neurocognitive disorder 2

Delirium 2

Psychotic depression 2

Psychotic disorder due to medical condition / medication 2

Squalor disorder 2

Bipolar affective disorder 1

/10 marks Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. You are a junior consultant in a local older adult community mental health team. Mrs Chi, a 77 year old lady who lives alone, was referred to the team by police after they were called by neighbours about the odour coming from her unit. Police conducted an initial assessment with the geriatric consultant who ruled out acute medical problems and suggested a psychiatric review due to Mrs Chi's distress and degree of clutter in the house. On assessment, Mrs Chi denied mood disturbance but had evidence of derogatory auditory hallucinations. During the assessment, Mrs Chi's daughter reported that she was diagnosed with schizophrenia at the age of 41 but has been having difficulty in medication compliance for the last 6 months including with her physical health medications. She has a history of hypertension, diabetes and bilateral cataracts. Q 4.3 Describe (list and explain) factors influencing the appropriate setting for initial management.

Ability to safely manage risks 2

Decision making capacity and ethical issues around this 2

Ability to safely initiate appropriate medications 2

Engagement in assessment and treatment 1

Legal status / guardianship status 1

Wishes of Mrs Chi and her family 2

Availability of services / supports 1

Medical comorbidities / falls 1

Distress and functional impairment related to her mental state 2

/12 marks

Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment. MEQ 5 You are a junior consultant in a community mental health centre. Your registrar is 2 months in their 6 month community psychiatry rotation. Several community case managers have spoken to you with their concerns with this psychiatry registrar. They have observed that the registrar is regularly late for work. He is observed to be staying late to complete notes, scripts and other administrative tasks. Despite working late, the case managers report that many tasks are often left undone. Q5.1 Outline (list and justify) what information you would like to obtain prior to meeting with the registrar.

information from previous supervisor -nature of the rotation and duties involved -overall clinical competence -workplace performance in the last term – arriving late, task completion

3

working with rest of MDT -knowledge and skill base -relationships with team members

3

- look up previous ITAs and EPAs - performance issues identified - meeting of fellowship competency to stage in training - areas of identified weakness -final pass/fail mark for rotation

3

-discuss and consult with DoT / SCoT - seek advice on course of action -longitudinal level of performance and functioning of trainee -exam results -stage of training

2

/8 marks

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment.

You are a junior consultant in a community mental health centre. Your registrar is 2 months in their 6 month community psychiatry rotation. Several community case managers have spoken to you with their concerns with this psychiatry registrar. They have observed that the registrar is regularly late for work. He is observed to be staying late to complete notes, scripts and other administrative tasks. Despite working late, the case managers report that many tasks are often left undone.

With the further information you obtain, you identify no previous performance concerns with the trainee and their last supervisor described them as “competent”. You arrange

to meet with your registrar where you have you opportunity to explore your concerns. The registrar explains that they are having trouble getting to sleep, waking late and

consequently arriving late at work.

Q 5.2 Describe (list and explain) possible contributors to what is going on with your registrar.

Sleep disorder 1

Medical history– medications, known illnesses that interfere with sleep – OSA, restless legs, thyroid problems, other general health

2

Drug and Alcohol use history – alcohol use – frequency, patter, amount; stimulant use, sedative use

3

Social circumstances – who they live with, supports, dependents 2

Recent Stressors – losses, relationship change, deaths in family, bullying and harassment, financial stress, HECS debt, relationship difficulties, housing stress, exam failure

3

Mental Illness – mood / depression; anxiety; vegetative symptoms; memory and concentration difficulties, hopelessness, suicidality, other mental illness

3

/12 marks

Comments:

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NB: Please circle the correct score and indicate total marks for that question. Please provide brief comment.

You are a junior consultant in a community mental health centre. Your registrar is 2 months in their 6 month community psychiatry rotation. Several community case managers have spoken to you with their concerns with this psychiatry registrar. They have observed that the registrar is regularly late for work. He is observed to be staying late to complete notes, scripts and other administrative tasks. Despite working late, the case managers report that many tasks are often left undone.

With the further information you obtain, you identify no previous performance concerns with the trainee and their last superv isor described them as “competent”. You arrange to

meet with your registrar where you have you opportunity to explore your concerns. The registrar explains that they are having trouble getting to sleep, waking late and

consequently arriving late at work.

MEQ 5.3 List the circumstances under which you are mandated to make a notification to the AHPRA / Medical Board.

Clinical Behaviours putting patients at risk

1

Coming to work intoxicated

1

Sexual relationship with a patient (or former patient)

1

Declining help or treatment for identified physical or mental health problem that could potentially impact on patient care

1

/4 marks Comments: