Psychiatry patient OSCE exam

Psychiatry
by Medical Educator Psychiatry

Our patient station below focusses on a patient who presents in casualty, accompanied by police. Test your understanding in this patient-focussed OSCE example.

Table of Contents

Presentation

A patient is accompanied by the police into the casualty department.
You Introduce yourself and he responds as follows:

“Hello doctor. I’m not quite right. Fright they nearly scared me to death. Grim reaper and the like. But I doughnut like you do I?”

It turns out the police are actually with him to take a statement from him because he was assaulted by a football hooligan in the city centre.

What problem is suggested?

  • Delusion
  • Hallucination
  • Formal Thought disorder
  • Illusion
  • Obsession
  • Mood disorder
  • Overvalued Idea
  • None of the listed answers here

This is a thought disorder and he’s demonstrating loosening of associations between his thought processes. His train of thought is difficult to understand . You can see the distractions in the though processes.

e.g.
Rhyming (right fright)
Puns (doughnut for do not)
Associations: “scared to death” –> grim reaper

Diagnosis

In the absence of alcohol or drugs what is his most likely diagnosis?

  • Personality disorder
  • Mania
  • Schizophrenia
  • Depression with psychosis
  • Organic illness

Schizophrenia

For the purposes of the exam he is exhibiting features of a formal thought disorder and therefore top of the list is schizophrenia. Second would be depression with psychosis but this is less likely and therefore less right.

Event

You turn to write your initial clerking. When you turn round the patient is attempting to stab himself with a chest drain trochar that he has picked out of a sharps bin.

Security have removed it from him but the patient is shouting aggressively. They ask “what legal right do we have to restrain him?”

  • Common Law
  • Mental Health Act
  • They have no legal right but in this situation its the right thing to do
  • Organic illness

Common Law

The patient is at immediate risk to both himself and others. There is no time for filling out forms or using complex legal legislation: this is common law territory and he can be restrained under that legislation.

Struggle

He struggles with security and you are concerned that he is at serious risk to himself as he attempts to bang his head repeatedly against the floor of the cubicle. A nurse holds a pillow under him whilst 3 security guards try and restrain him.

The A&E senior doctors are all dealing with a multiple trauma road traffic accident in the ED rescuscitation room.

Can you give an antipsychotic medication without either:

Sectioning him under the mental health act or Arranging a psychiatry opinion?

  • Yes
  • No
  • It is illegal but in the circumstances probably in the patient’s best interests

Yes

Again this is common law: the patient is at significant risk to himself: give the medication.

Medication route

What is the most appropriate route of administration for a rapid acting antipsychotic in this situation?

  • Intramuscular
  • Intravenous
  • Per Rectum
  • Inhaled
  • Oral

Intramuscular

IV medication is a risk here:

He has to be restrained. He would need a tourniquet. There would be a cannula needle to be taken out of the IV cannula whilst the dressing is secured. This is putting both yourself and other care workers at risk.

Given this: an IM injection is the most appropriate.

Medication choice

What is the most appropriate drug to administer in IM (intramuscular) form?

  • Diazepam
  • Morphine
  • Olanzipine
  • Haloperidol
  • Lithium

Haloperidol

Generally the drugs of choice would be: midazolam and haloperidol.

The initial dose of haloperidol for severely disturbed patients is 2-18mg.

Diazepam an benzodiazepines in general are fat soluble and therefore not absorbed as quicklybas you might expect. Diazepam should not generally be used for this reason.