MH SAQ practice Psych
A 60 year old man comes to the ED with his sister. She says he has been
withdrawn and quiet lately, and has been saying he wants to die.
a. Give 6 features in assessing his risk of suicide. (6 marks)
Sex
Age
Depression- H/O
Previous attempt at suicide
Excessive alcohol/drugs
Rational thinking loss
Separated/divorced/widowed
Organised/serious attempt
No social support
Suicide intent for the future
b. What are 4 important aspects of the mental health act in the state where you
work? (2 marks)
No model answer provided
c. How would you ensure this patient could make a decision regarding his
treatment? (2 marks)
No model answer provided
The ambulance service has brought a 23 year old man to your ED. He was found wandering
the
streets naked. He became aggressive while being transported to hospital.
On arrival to the triage desk, he is swearing loudly and trying to leave.
He is known to have a history of schizophrenia and drug use.
1. Give the 2 legislative principles of care that might allow you to keep this man against his
will. For each principle of care, list 2 main conditions that must be met. (6 marks)
2. List 5 main steps in restraint of this man, in escalating order. Where appropriate, give
initial doses of medications. (5 marks)
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During the management of this patient, one of your junior doctors has received a needle-stick
injury
from a hollow-bore needle used on the patient.
3. Complete the table about risk of transmissible disease in this scenario. (3 marks)
1.
Duty of care
- Have a physical condition causing behavioural disturbance
- Be at risk to himself or others
Mental Health Act
- Suspected mental health disorder
- No less restrictive means available
1 mark for each principle, 1 mark for each condition
Pass 4/6
2.
Verbal de-escalation
Oral sedation eg diazepam 10mg
Show of force
Physical restraint – isolation or with manual handling
Chemical restraint eg droperidol 10mg
Pass 3 of 5
3.
Hep B 30-60%
Hep C 3%
HIV 0.3%
(accept answers that are close)
Pass 2 of 3
Total pass 9/14 corrects to 6/10
A 38 year old man walks up to the triage desk. He is agitated, shouting and uncooperative
with simple instructions He is poorly kempt, clammy and tremulous.
1. List five differential diagnostic categories you would consider when trying to assess
this man?
Give two examples from each category.
2. Briefly describe two different strategies for gaining the cooperation of this man?
3. List the legal principles that guide your management?
Answers
Q 1.
Category
Trauma
1.
Toxidrome
2.
1.
Acute withdrawal
Electrolyte disorder
Environmental
Psychiatric
Endocrine
Sepsis
Post-ictal
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
Q2.
Example
Major visceral injury with blood
loss
Head injury (bleed, concussion)
Amphetamines, opiates, cannabis,
usual antipsychotic medication e.g.
Lithium
Alcohol, serotonin syndrome
Alcohol, cannabis
Opioids
Hypo/hyperglycemia
Hyponatremia, hypercalcemia
Snake bite
Red back spider bite
Schizophrenia
Acute mania
Hyperthyroidism
Adrenal crisis
CNS
Infective endocarditis
Known epilepsy, related to causes
above
Withdrawal seizure
Physical versus chemical


Q3.
Five person physical restraint
Chemical restraint: benzodiazepine, butyrophenone, phenothiazine
Autonomy vs duty of care


Competence
Informed consent
A 40 year old man is brought to the Emergency Department after taking an overdose of
prescribed medication.
1. List seven (7) features on history that indicate a heightened risk for completed
suicide.
2. Provide a list of investigations which would be completed prior to referral to the
psychiatric services including three (3) mandatory tests and four (4) optional tests
determined by the details on assessment. Include detail on how the investigations
will aid assessment.
Test
How test will aid
assessment
Mandatory test 1
Mandatory test 2
Mandatory test 3
Optional test 1
Optional test 2
Optional test 3
Optional test 4
3. List two (2) absolute and two (2) relative indications for admission.
Answers
Q1
S – Sex: 1 if male; 0 if female; (more females attempt, more males succeed)
A – Age: 1 if < 20 or > 44
D – Depression: 1 if depression is present
P – Previous attempt: 1 if present
E –Ethanol abuse: 1 if present
R – Rational thinking loss: 1 if present
S – Social Supports Lacking: 1 if present
O – Organized Plan: 1 if plan is made and lethal
N – No Spouse: 1 if divorced, widowed, separated, or single
S – Sickness: 1 if chronic, debilitating, and severe
Q2
Test
Mandatory test 1
Mandatory test 2
Glucometer
ECG
Mandatory test 3
Optional test 1
Serum paracetamol
LFT’s
How test will aid assessment
?oral hypoglycaemic ingestion
Features of sodium channel
blockade, TCA ingestion, Beta
blocker/CCB ingestion, K high
or low
‘Silent’ toxicity
If unknown time of ingestion,
ALT can guide risk of delayed
Optional test 2
Other serum drug level
Optional test 3
CXR
Optional test 4
Renal function
Breath/blood alcohol level
INR/coags
ABG/VBG
presentation of paracetamol
ingestion,
Anti-epileptics, digoxin,
lithium
Features of aspiration
pneumonitis
Baseline for risk of poor
clearance (cf Lithium),
monitoring for drugs causing
ARF
Impact on conscious level,
time before ‘medically
cleared’
Warfarin overdose, NOAC
ingestion
Monitor pH when treating
sodium channel blockers
Q3
Absolute:
 Score of > 7 on sad persons scale or similar scoring system
 Requiring ongoing treatment for ingestion i.e. NAC, dialysis, ICU monitoring/care
Relative:
 Poor social situation
 Potential for delayed onset toxicity
 Stabilisation of underlying medical condition
The police bring a 13 year old girl to your emergency department
following an argument with her
mother. She is agitated, combative, crying, and has self-inflicted
lacerations to both arms. The
mother is en route to the emergency department.
1. What are your options for treating her agitation?
- verbal deescalation
- show of force
- oral chemical
- IM chemical
- physical restraint
2. What features on assessment would indicate a need for
inpatient treatment?
- threat to self
- threat to others
- significant underlying psychiatric illness
- social circumstances
- physical injuries requiring inpatient management
3. How does her age impact on your management?
- consent issues
- disposition
- notification to family services
A 40 year old man presents with suspected acute alcohol withdrawal.
1. What are the features of Delerium Tremens?
- hallucinations
- disorientation
- tachycardia
- hypertension
- hyperthermia
- agitation
- diaphoresis
2. What important alternative diagnoses should you consider in an alcoholic
patient with features of Delerium Tremens?
- infection (meningitis)
- trauma (intracranial bleed)
- metabolic derangements (hypoglycaemia)
- drug overdose
- hepatic failure with encephalopathy
- gastrointestinal bleeding
3. What is your treatment of severe acute alcohol withdrawal?
- benzodiazepines
- intravenous fluids
- thiamine / nutritional supplements
- alcohol withdrawal scale / ongoing clinical assessment
- monitor for complications / treat as occur – rhabdo, seizures
A 30 year old known schizophrenic is brought in to the emergency department by
police. He is aggressive and has been handcuffed.
1. According to DSM-5 diagnostic criteria, 2 or more of a list of characteristic
symptoms must be present for a significant portion of time. List these characteristic
symtpoms
- delusions
- hallucinations
- disorganised speech
- grossly disorganised of catatonic behaviour
- negative symptoms
2. What factors need to be considered when initially assessing this patient
- safety – patient, staff, other patients
- underlying organic cause
- threat to self or others
- current schizophrenic state – actively psychotic vs bad
- need for sedation
- when to remove handcuffs / alternative physical restraints
3. What medication would you use to control this man’s aggression if deemed
medically necessary?
- droperidol / olanzapine