All Q&A except 2012 Akld and RANZCP.docx

**MEQ 1: Mrs. Smith in Emergency Department** **Scenario**: You are a junior consultant psychiatrist providing after-hours cover to the Emergency Department. Your registrar calls you to discuss Mrs. Smith, a 69-year-old retired receptionist, who was asked to come to the Emergency Department by her...

**MEQ 1: Mrs. Smith in Emergency Department** **Scenario**: You are a junior consultant psychiatrist providing after-hours cover to the Emergency Department. Your registrar calls you to discuss Mrs. Smith, a 69-year-old retired receptionist, who was asked to come to the Emergency Department by her family doctor. She has presented with her husband and has requested that he join her in the assessment. Mrs. Smith reports she has been her husband's primary carer for the last 3 years (he has dementia). Mrs. Smith reports that she has not been feeling her usual self -- she feels more irritable and gets flustered easily. She says her sleep is disturbed. 1. **Question 1.1** (8 marks): Describe (list and explain) the salient features of history and examination you would like your psychiatric registrar to focus on when assessing Mrs. Smith. (a list with no explanation will not receive any marks) 2. **Question 1.2** (3 marks): Describe (list and explain) the key areas of concern in regard to risk. (a list with no explanation will not receive any marks) 3. **Question 1.3** (6 marks): Describe (list and explain) the issues your registrar should consider to determine if Mrs Smith requires admission under the Mental Health Act. (a list with no explanation will not receive any marks) 4. **Question 1.4** (8 marks): Discuss (list and debate) the pertinent ethical considerations in any decision to admit Mrs Smith. (a list with no debate will not receive any marks) **MEQ 2: Hugo in Emergency Department** **Scenario**: You are a junior consultant psychiatrist working in the CL team in a busy general hospital. You are called to review a patient in the Emergency Department (ED) admitted under the Toxicology team. The patient, Hugo, is a 19-year-old man studying Veterinary Science. He normally lives with his mother. He has a difficult relationship with his father following his parents' separation when he was aged six. Their separation was acrimonious and was due to his father's excessive alcohol use and violence towards Hugo and his mother. Hugo has a history of self-harm and has made a couple of previous suicide attempts by overdose requiring brief hospitalisation. The first overdose was in the context of his father remarrying when he was aged 16 and the second after an argument with an ex-girlfriend one year ago. Following his first suicide attempt his GP started him on fluoxetine which he took for 3 months before stopping because he didn't feel that it helped. Hugo has a recent history of recreational drug use, mostly MDMA at university parties. He also occasionally binge drinks alcohol. On this occasion, Hugo has been brought to hospital by ambulance following an overdose of promethazine. The ambulance report states that his girlfriend had called emergency services after he sent her a text message with a photograph of several empty pill packets. This was in the context of their relationship ending a few days earlier. In ED, Hugo appears to be drowsy, disorientated and he is picking at the air as though something is there. He is awaiting transfer to the Toxicology ward. However, they have requested your input prior to this. 1. **Question 2.1** (8 marks): Describe (list and explain) your approach to the situation and the advice you would provide regarding short term management while Hugo is in hospital. (a list without any explanation will not receive any marks) 2. **Question 2.2** (7 Marks): Outline (list and justify) the primary diagnosis and differential diagnoses you would discuss with Hugo. (a list without any justification will not receive any marks) 3. **Question 2.3** (4 marks): Describe (list and explain) the key task needed so as to arrange this family meeting, and the issues you will raise at the meeting. (a list without any explanation will not receive any marks) 4. **Question 2.4** (4 marks): Describe (list and explain) the types of psychotherapy that may be suitable for Hugo. (a list without any explanation will not receive any marks) **MEQ 3: Kylie in Private Practice** **Scenario**: You are a junior consultant working in private practice in the community. A 32-year-old recently married woman, Kylie, comes to see you. She was diagnosed with ADHD in high school and has been intermittently followed up by other doctors over the last 15 years, sometimes with stimulant medication which does help her. Kylie is a school teacher and is having difficulty organising herself at work. She's behind on her paperwork and says school reports are due soon but she hasn't started writing them. She's been off stimulant medication for the last 3 years. At home, she's having difficulty managing to look after her 4-year-old stepson by marriage. She wants to try and get pregnant this year. 1. **Question 3.1** (6 Marks): List the symptoms and signs of ADHD you would be looking for, to clarify whether Kylie has ADHD. 2. **Question 3.2** (8 marks): Describe (list and explain) what further issues you would explore with Kylie. (a list without explanation will not receive any marks) 3. **Question 3.3** (4 marks): Describe (list and explain) your approach to management. (a list without explanation will not receive any marks) How would you access the most recent information on this? 4. **Question 3.4** (7 marks): Outline (list and justify) the management strategies you would consider implementing. (a list without justification will not receive any marks) **MEQ 4: Jake in Emergency Department** **Scenario**: You are a generalist junior consultant psychiatrist on duty for the Emergency Department. You have been asked to assess a 14-year-old boy, Jake, brought by the police and ambulance to the ED. The police documentation indicates "domestic dispute with his mother Mary. Has punched holes in the wall and set furniture on fire. According to his mother, he has also been threatening to kill the family cat and has tried to poison it in the past." The ED psychiatry registrar has seen Jake and described him as sullen and sitting with his arms crossed, refusing to speak. His mother was seen in the ED yelling at him \"if you keep doing this, you'll never be allowed to come home. I've had enough!" 1. **Question 4.1** (3 marks): Describe (list and explain) how you would approach the interview with Jake as part of a comprehensive psychiatric assessment. (a list without any explanation will not receive any marks) 2. **Question 4.2** (8 marks): Describe (list and explain) the aspects of history that you need to explore with Jake. (a list without any explanation will not receive any marks) 3. **Question 4.3** (4 marks): Describe (list and explain) the main information you need to obtain from Jake's mother or from any other sources. (a list without any explanation will not receive any marks) 4. **Question 4.4** (2 marks): Outline (list and justify) the main differentials of your principal diagnosis. (a list without any justification will not receive any marks) 5. **Question 4.5** (5 marks): Outline (list and justify) your initial management plan, including which services you would refer Jake to. (a list without any justification will not receive any marks) **MEQ 5: Marcie in Youth Community Public Mental Health Centre** **Scenario**: You are working as a junior consultant psychiatrist in a Youth Community Public Mental Health Centre. You have received a referral letter from a GP (with input from the school counsellor) regarding Marcie, an 18-year-old student who is in year 12 at the local co-ed high school. Marcie lives with her mother -- her father died when she was two and she has no siblings. The GP's letter states that Marcie started at her current school in year 9 -- she was previously in an all-girls school. Marcie was previously well, engaged in a range of sports and had no academic concerns. However, her grades for the last term have been very poor. Lately, teachers have raised concerns about her lack of engagement with other students, and reported that she has suffered panic attacks when asked to speak in front of others. They say she has been reluctant to come to any sports or swimming events this year. She prefers to wear her loose-fitting sports uniform to school every day. In addition, Marcie recently cut her hair very short. There has also been a steady decline in her body weight from 70 kg to 60 kg and to a BMI of 20 from a previous 23. Marcie appears reluctant to mix with her previous friends. A brief same-sex relationship earlier this year did not go well. Staff have not witnessed any bullying at school. The school counsellor has raised possible concerns about alcohol use and use of diuretics but was unsure and said this could just be school gossip. Marcie has recently been referring to herself as "Marc" rather than Marcie. Marc/Marcie has asked to see you on their own today. 1. **Question 5.1** (9 marks): Describe (list and explain) the details of your assessment. (a list without explanation will not receive any marks) 2. **Question 5.2** (5 marks): Based on the information provided, outline (list and justify) the differential diagnoses you would consider. (a list with no justification will not receive any marks) 3. **Question 5.3** (8 marks): Outline (list and justify) treatment options that you would consider and discuss with Marc, his mother, and the GP. (a list without any justification will not receive any marks) This should cover all the MEQ questions from the provided exam paper. MEQ-Paper-2022-NSW-(NZ\_version)-answers.pdf PDF Analyse this past exam paper for my psychiatry exams. Create a list of the questions and answers you find that are labelled as \"MEQ\", \"modified essay questions\", \"Key feature\" or \"short answer\". Ignore questions and answers which appear to be \"essay\" or \"extended matching question\" or \"critical analysis\". In your list include the stem of the question (the scenario the questions are about). Also include the number of marks each question is worth. ChatGPT Here is a list of the questions and answers labeled as \"MEQ\" (Modified Essay Questions) and \"Short Answer\" from the provided document, including the question stems, scenarios, and number of marks each question is worth. **MEQ 1: Mr. Green in a Small District Hospital** **Scenario**: You are a junior consultant psychiatrist providing consultation-liaison services in a small District Hospital. Your registrar has been asked to see Mr Green, an 85-year-old retired bus driver, regarding his failure to engage with rehabilitation after repair of a right-sided fractured neck of femur. Mr Green was admitted to hospital a week ago following a fall after ingesting over thirty 5mg Diazepam tablets. Mr Green usually lives independently in a retirement village. His only family is a 90-year-old brother who lives in another city and suffers from dementia. Mr Green was prescribed the Diazepam to assist with sleep after his wife died six months ago. 1. **Question 1.1** (8 marks): Outline (list and justify) the most salient aspects of assessment that you would like the registrar to focus on. (a list with no justification will not receive any marks) 2. **Question 1.2** (3 marks): Outline (list and justify) other differential diagnoses that could be considered for Mr Green. (a list with no justification will not receive any marks) 3. **Question 1.3** (6 marks): Describe (list and explain) the key elements of the management plan you would like the registrar to focus on. (a list with no explanation will not receive any marks) 4. **Question 1.4** (6 marks): Outline (list and justify) appropriate actions that you might undertake to support Mr Green as the consulting psychiatrist. (a list with no justification will not receive any marks) **MEQ 2: Hemi in a Regional Town Community Mental Health Clinic** **Scenario**: You are a junior consultant psychiatrist working in a community mental health clinic in a regional town. Your patient, Hemi, is a 41-year-old unemployed Māori man who is separated from his partner. They have a 7-year-old son, whom he sees fortnightly. He currently lives alone in a private rental unit owned by his elderly parents who live nearby. Hemi was admitted to the local public hospital a year ago after he threw himself in front of a bus due to constant derogatory auditory hallucinations. He sustained multiple injuries requiring surgery. Hemi was discharged from hospital on Paliperidone depot which was changed to oral Olanzapine in the community due to a lack of therapeutic response. Six months ago, Hemi was readmitted for three weeks for a Clozapine trial due to ongoing psychotic symptoms. He still experiences auditory hallucinations, although they have significantly reduced since he started Clozapine. 1. **Question 2.1** (12 marks): Outline (list and justify) the key factors you would consider while completing a risk assessment for Hemi. (a list with no justification will not receive any marks) 2. **Question 2.2** (6 marks): Outline (list and justify) strategies to optimise Hemi's clozapine treatment. (a list with no justification will not receive any marks) 3. **Question 2.3** (6 marks): Describe (list and explain) how you would address Hemi's current concerns. (a list with no explanation will not receive any marks) **MEQ 3: Tim in a Metropolitan Hospital Emergency Department** **Scenario**: You are a junior consultant psychiatrist covering the Emergency Department of a metropolitan hospital. Tim is a 42-year-old man who is serving a 25-year sentence after being convicted for the murder of his father. He has a diagnosis of mild intellectual disability and while in prison, was diagnosed with schizophrenia seven years ago. Tim is treated with Zuclopenthixol Decanoate 400mg IMI every 2 weeks and Quetiapine 400mg PO nocte. He has remained stable on these medications but due to a weight gain of 15 kgs over recent years, his treating team reduced and ceased the Quetiapine. Approximately three months after the cessation of Quetiapine, the prison guards report that Tim is increasingly paranoid and hostile. He is reassessed by a forensic psychiatrist in prison, who orders Zuclopenthixol Acetate 150 mg as a stat dose. Tim continues to deteriorate, refusing any oral intake and becoming incontinent of urine and faeces, prompting his transfer to the medical wing. The next morning, nursing staff find him with a reduced Glasgow Coma Scale (GCS) of 12, prompting an urgent transfer to the nearby Emergency Department. His observations at triage are: Heart rate 105 bpm, Blood pressure 135/85 mm Hg, Temperature 37.9 degrees C, Respiratory rate 15 bpm. You attend the Emergency Department with your registrar to assess Tim. 1. **Question 3.1** (9 marks): Outline (list and justify) the key information you wish to gain in your initial assessment of Tim. (a list with no justification will not receive any marks) 2. **Question 3.2** (5 marks): List the most relevant investigations you would want ordered for Tim. (a list with no justification will not receive any marks) 3. **Question 3.3** (14 marks): Describe (list and explain) your approach to this situation and your management plan. (a list with no justification will not receive any marks) **MEQ 4: Lara in an Outpatient Clinic** **Scenario**: You are working as a junior consultant psychiatrist in an outpatient clinic in a metropolitan city. A local General Practitioner (GP) has referred a patient, Lara, a 25-year-old single woman in a clerical job, for review and advice. Lara has a diagnosis of low mood and of alcohol use disorder. She has just been charged with driving under the influence with a mid-range level of alcohol. This is her second such charge and her lawyer has suggested she seek counselling and psychiatric review. 1. **Question 4.1** (10 marks): Describe (list and explain) the key aspects you would cover in your assessment of Lara's alcohol use disorder. (a list with no explanation will not receive any marks) 2. **Question 4.2** (8 marks): Outline (list and justify) your differential diagnoses for Lara, other than alcohol use disorder. (a list with no justification will not receive any marks) 3. **Question 4.3** (7 marks): Describe (list and explain) your further management of Lara. (a list with no explanation will not receive any marks) **MEQ 5: Mikayla in a Small Suburban Hospital Emergency Department** **Scenario**: You are a Junior Consultant Psychiatrist covering the Emergency Department (ED) of a small suburban hospital. The triage nurse gets a call in the morning from a local boarding school saying they are sending a 16-year-old Māori girl, Mikayla, to the ED with one of their teachers. Mikayla is in the care of her great-grandmother who lives in a rural area. Child Protection Services are involved and she has a case manager. Mikayla saw the school counsellor today and said she was feeling suicidal. She has been prescribed Fluoxetine 20 mg daily by her General Practitioner which she apparently takes intermittently. Your Stage 1 registrar is planning to go to the ED to assess Mikayla and requests your guidance. 1. **Question 5.1** (9 marks): Outline (list and justify) what collateral information you would want the registrar to obtain to guide Mikayla's assessment. (a list with no justification will not receive any marks) 2. **Question 5.2** (8 marks): Describe (list and explain) what further advice you would want to give the registrar regarding assessing Mikayla at the ED. (a list with no explanation will not receive any marks) 3. **Question 5.3** (8 marks): Describe (list and explain) your recommendations for further management for Mikayla. (a list with no explanation will not receive any marks) **Short Answer Questions** 1. **SAQ 1**: Define and discuss the concept of \"therapeutic alliance\". (5 marks) 2. **SAQ 2**: Explain the key principles of cognitive-behavioral therapy (CBT). (5 marks) 3. **SAQ 3**: Discuss the pharmacological management of major depressive disorder. (5 marks) 4. **SAQ 4**: Describe the diagnostic criteria for schizophrenia according to DSM-5. (5 marks) 5. **SAQ 5**: Outline the risk factors for suicide in adolescents. (5 marks) This list captures the relevant MEQ and Short Answer questions from the provided exam paper. The list should contain all the MEQ and Short answer questions and answers from the provided paper. Please check that it does. ChatGPT **Full List of Questions and Answers from the Provided Exam Paper** **MEQ 1: Mr. Green in a Small District Hospital** **Scenario**: You are a junior consultant psychiatrist providing consultation-liaison services in a small District Hospital. Your registrar has been asked to see Mr Green, an 85-year-old retired bus driver, regarding his failure to engage with rehabilitation after repair of a right-sided fractured neck of femur. Mr Green was admitted to hospital a week ago following a fall after ingesting over thirty 5mg Diazepam tablets. Mr Green usually lives independently in a retirement village. His only family is a 90-year-old brother who lives in another city and suffers from dementia. Mr Green was prescribed the Diazepam to assist with sleep after his wife died six months ago. 1. **Question 1.1** (8 marks): Outline (list and justify) the most salient aspects of assessment that you would like the registrar to focus on. - **Answer 1.1**: - Assessment of depressive symptoms: Sleep disturbance, fatigue, psychomotor retardation, loss of interest in living, hopelessness, memory and concentration problems, weight and appetite changes. - Assessment of symptoms associated with grief: Preoccupation with his wife, longing for his wife, missing his wife, seeking or avoiding reminders of his wife, guilt about what he did or did not do for his wife. - Past psychiatric history: Earlier experience of depression increases risk of later-life depression. - Recent and past medical history: Pain, hypothyroidism, medications, any other recent illness associated with depression or lethargy. - Recent functioning: ADL/IADL functioning (instrumental activities of daily living), social functioning. - Mental state examination: Level of engagement and rapport, symptoms/signs of depression, mania, anxiety, psychosis, current intoxication. - Cognitive function: Cognitive screening results, features or pattern of cognitive changes. - Cerebral imaging: Looking for focal/generalized atrophy; cerebrovascular changes. - Laboratory investigations: FBC, TFT, Urea Electrolytes & Creatinine. 2. **Question 1.2** (3 marks): Outline (list and justify) other differential diagnoses that could be considered for Mr Green. - **Answer 1.2**: - Adjustment Disorder: Low mood followed the death of his wife and the stress of his injury. - Dementia/Cognitive Impairment: Needs consideration in his age group. - Substance use/withdrawal: Concern due to him taking diazepam tablets. - Pain: Suboptimal analgesia could account for his inability to engage with rehabilitation. - Demoralization: Could account for his inability to engage with rehabilitation. - Physical illness: Must be considered given his age and physical state. 3. **Question 1.3** (6 marks): Describe (list and explain) the key elements of the management plan you would like the registrar to focus on. - **Answer 1.3**: - Risk management: Ongoing reassessment, managing suicide/self-harm risk, managing risks from declining physical health, managing other risks. - Antidepressant: Need an effective antidepressant with an appropriate safety profile. - Adjunctive or alternative treatment: Lithium, antipsychotic, ECT if there\'s failure to respond or a further decline in his mental state. - Psychological interventions: CBT, supportive psychotherapy, grief counseling. - Continuing or resuming physical rehabilitation: Adapting it by setting smaller steps in goals, connecting physical goals to his lifestyle or personal goals. 4. **Question 1.4** (6 marks): Outline (list and justify) appropriate actions that you might undertake to support Mr Green as the consulting psychiatrist. - **Answer 1.4**: - Psychoeducation of treating team: Educate/inform them regarding his condition/prognosis/timeline of response to treatment. - Advocate for continued stay in the rehabilitation ward: Effective treatment will take more time. - Explore suitability for management in an older person's mental health ward. - Offer to increase the frequency/intensity of psychiatry input. - Seek access for Mr Green to an independent advocate. - Clarify Mr Green's capacity and need for an independent consent provider. **MEQ 2: Hemi in a Regional Town Community Mental Health Clinic** **Scenario**: You are a junior consultant psychiatrist working in a community mental health clinic in a regional town. Your patient, Hemi, is a 41-year-old unemployed Māori man who is separated from his partner. They have a 7-year-old son, whom he sees fortnightly. He currently lives alone in a private rental unit owned by his elderly parents who live nearby. Hemi was admitted to the local public hospital a year ago after he threw himself in front of a bus due to constant derogatory auditory hallucinations. He sustained multiple injuries requiring surgery. Hemi was discharged from hospital on Paliperidone depot which was changed to oral Olanzapine in the community due to a lack of therapeutic response. Six months ago, Hemi was readmitted for three weeks for a Clozapine trial due to ongoing psychotic symptoms. He still experiences auditory hallucinations, although they have significantly reduced since he started Clozapine. 1. **Question 2.1** (12 marks): Outline (list and justify) the key factors you would consider while completing a risk assessment for Hemi. - **Answer 2.1**: - Historical and static risk factors: Male, past high-lethality suicide attempt, previous violence, history of instability in relationships, treatment-resistant psychotic illness, possible maladaptive personality traits, possible cognitive deficits from schizophrenia. - Clinical factors: Residual psychotic symptoms, possible impairment of insight and judgment, mood & self-esteem changes, chronic pain or disability after his suicide attempt, potential side effects due to clozapine. - Psychosociocultural factors: Low socioeconomic status, lack of meaningful occupation, relative social isolation, limited access to services and supports, possible cultural alienation, cultural beliefs around mental illness. - Protective factors: Contact with his son, past treatment adherence, no evidence of past substance use. 2. **Question 2.2** (6 marks): Outline (list and justify) strategies to optimise Hemi's clozapine treatment. - **Answer 2.2**: - Optimisation of clozapine: Help with smoking cessation, clozapine serum levels, clozapine/norclozapine ratio, cautiously consider adding metabolic inhibitors. - Adjuncts to clozapine therapy: Augment with a second antipsychotic medication, consider use of mood stabiliser and/or antidepressant, consider psychotherapeutic interventions, consider ECT. 3. **Question 2.3** (6 marks): Describe (list and explain) how you would address Hemi's current concerns. - **Answer 2.3**: - Optimise symptom control: Optimise pharmacological management, address clozapine-induced side effects, arrange psychotherapy, referral to pain specialist or orthopaedic specialist and physiotherapist. - Arrange socio-cultural supports: Engage Hemi's parents or ex-partner, arrange OT input, refer him for peer support, refer him to the local Māori cultural support team. **MEQ 3: Tim in a Metropolitan Hospital Emergency Department** **Scenario**: You are a junior consultant psychiatrist covering the Emergency Department of a metropolitan hospital. Tim is a 42-year-old man who is serving a 25-year sentence after being convicted for the murder of his father. He has a diagnosis of mild intellectual disability and while in prison, was diagnosed with schizophrenia seven years ago. Tim is treated with Zuclopenthixol Decanoate 400mg IMI every 2 weeks and Quetiapine 400mg PO nocte. He has remained stable on these medications but due to a weight gain of 15 kgs over recent years, his treating team reduced and ceased the Quetiapine. Approximately three months after the cessation of Quetiapine, the prison guards report that Tim is increasingly paranoid and hostile. He is reassessed by a forensic psychiatrist in prison, who orders Zuclopenthixol Acetate 150 mg as a stat dose. Tim continues to deteriorate, refusing any oral intake and becoming incontinent of urine and faeces, prompting his transfer to the medical wing. The next morning, nursing staff find him with a reduced Glasgow Coma Scale (GCS) of 12, prompting an urgent transfer to the nearby Emergency Department. His observations at triage are: Heart rate 105 bpm, Blood pressure 135/85 mm Hg, Temperature 37.9 degrees C, Respiratory rate 15 bpm. You attend the Emergency Department with your registrar to assess Tim. 1. **Question 3.1** (9 marks): Outline (list and justify) the key information you wish to gain in your initial assessment of Tim. - **Answer 3.1**: - Past medical history: Any falls, head injuries, assaults, bleeding, urinary symptoms, GI or respiratory symptoms, medications. - Collateral history: From the prison, from his family. - Drug and alcohol history: Evidence of access and use in prison. - Mental state examination: Catatonia/NMS, delirium/NMS, signs/symptoms of psychosis or mood disorder. - Physical observations: Repeat his vital signs looking for tachycardia, fever, hypertension, autonomic instability. 2. **Question 3.2** (5 marks): List the most relevant investigations you would want ordered for Tim. - **Answer 3.2**: - Bloods: Creatinine kinase, full blood count, urea electrolytes & creatinine. - ECG: Tachycardia, cardiac dysfunction. - CT or MRI Brain: Rule out acute processes. - Lumbar puncture: Rule out autoimmune condition or other encephalitis. - Urine MCS: Rule out infection, check renal functioning. 3. **Question 3.3** (14 marks): Describe (list and explain) your approach to this situation and your management plan. - **Answer 3.3**: - Request an urgent MDT meeting and educate staff. - Advocate for Tim and manage stigma. - Liaise with hospital clinicians. - Ensure daily bloods for Creatinine Kinase. - Ensure close observations. - Medication management: Stop antipsychotics, lorazepam trial, consider other muscle relaxants, consider dopamine agonist. - Ensure ward team closely monitors and manages his vitals. - Consider urgent ECT. - Consider legal issues. - Liaise with prison/forensic clinicians. **MEQ 4: Lara in an Outpatient Clinic** **Scenario**: You are working as a junior consultant psychiatrist in an outpatient clinic in a metropolitan city. A local General Practitioner (GP) has referred a patient, Lara, a 25-year-old single woman in a clerical job, for review and advice. Lara has a diagnosis of low mood and of alcohol use disorder. She has just been charged with driving under the influence with a mid-range level of alcohol. This is her second such charge and her lawyer has suggested she seek counselling and psychiatric review. 1. **Question 4.1** (10 marks): Describe (list and explain) the key aspects you would cover in your assessment of Lara's alcohol use disorder. - **Answer 4.1**: - Lara's attitude to the referral and to counselling. - Full substance use history. - Psychiatric history and mental state. - Risk assessment. - Full medical history. - Personal history, social situation and supports. - Forensic history, current legal situation. - Assessment/examination regarding the physical and cognitive impacts of her alcohol use. 2. **Question 4.2** (8 marks): Outline (list and justify) your differential diagnoses for Lara, other than alcohol use disorder. - **Answer 4.2**: - Major depressive disorder. - Persistent depressive disorder. - Alcohol-induced mood disorder. - Personality disorder. - Bipolar disorder. - Adjustment disorder. - No mental illness. 3. **Question 4.3** (7 marks): Describe (list and explain) your further management of Lara. - **Answer 4.3**: - Psychoeducation about borderline personality disorder. - Discuss expectations for treatment and the indications for Quetiapine. - Discuss recommendations for Lara's treatment. - Liaise with the counsellor. - Liaise with Lara's GP. **MEQ 5: Mikayla in a Small Suburban Hospital Emergency Department** **Scenario**: You are a Junior Consultant Psychiatrist covering the Emergency Department (ED) of a small suburban hospital. The triage nurse gets a call in the morning from a local boarding school saying they are sending a 16-year-old Māori girl, Mikayla, to the ED with one of their teachers. Mikayla is in the care of her great-grandmother who lives in a rural area. Child Protection Services are involved and she has a case manager. Mikayla saw the school counsellor today and said she was feeling suicidal. She has been prescribed Fluoxetine 20 mg daily by her General Practitioner which she apparently takes intermittently. Your Stage 1 registrar is planning to go to the ED to assess Mikayla and requests your guidance. 1. **Question 5.1** (9 marks): Outline (list and justify) what collateral information you would want the registrar to obtain to guide Mikayla's assessment. - **Answer 5.1**: - Teachers: Check the circumstances surrounding Mikayla being sent to ED. - School Counsellor: Current history, psychiatric history, whether any specialist input in the past, any risk issues identified. - Great Grandmother: Cultural history, developmental history, family history, current problems, level of support and coping. - Child Protection case worker: Circumstances around Mikayla's removal from parental care, current child protection arrangements, and support for her great grandmother. - GP: Clarify when the prescription was given and any medical issues or past history. - School Principal: Clarify whether Mikayla can return to the boarding school and what the school expects from the assessment. - Any other health, mental health or cultural specialists/professionals involved. 2. **Question 5.2** (8 marks): Describe (list and explain) what further advice you would want to give the registrar regarding assessing Mikayla at the ED. - **Answer 5.2**: - Engaging an adolescent: Be non-judgmental, create a safe space to talk, explain confidentiality and its limits. - Risk assessment: Discuss key aspects of Mikayla's risk assessment. - Risk management: Call the School Principal and/or the Child Protection case worker. - Liaison with Whänau: Include her great-grandmother in the discussion. - Consent issues: Mikayla has the legal ability to give consent provided her capacity is not impaired. 3. **Question 5.3** (8 marks): Describe (list and explain) your recommendations for further management for Mikayla. - **Answer 5.3**: - De-escalation: Advise ED staff to make Mikayla feel less threatened. - Importance of avoiding (further) trauma: Mention trauma-informed care. - Legal issues: Discuss acting in Mikayla's best interests without her consent if there's an urgent medical need. - Communication/Liaison: Close liaison with registrar, ED, paediatrics, toxicology/Poisons Centre, social worker, whänau, case manager. - Risk management: Urgent physical care/medical assessment. - Support for registrar and medical staff: Offer to come in and review Mikayla yourself. **Short Answer Questions** 1. **SAQ 1**: Define and discuss the concept of \"therapeutic alliance\". (5 marks) - **Answer 1**: The therapeutic alliance refers to the collaborative and trusting relationship between a therapist and a patient. Key elements include agreement on therapy goals, tasks, and the bond between therapist and patient. This alliance is crucial for effective therapy and patient outcomes. 2. **SAQ 2**: Explain the key principles of cognitive-behavioral therapy (CBT). (5 marks) - **Answer 2**: CBT is based on the principles that thoughts, feelings, and behaviors are interconnected. Key principles include identifying and challenging negative thought patterns, developing problem-solving skills, and engaging in behavioral activation to change maladaptive behaviors and improve mood. 3. **SAQ 3**: Discuss the pharmacological management of major depressive disorder. (5 marks) - **Answer 3**: The pharmacological management of major depressive disorder typically involves the use of antidepressants such as SSRIs, SNRIs, tricyclic antidepressants, and MAOIs. Treatment selection is based on patient response, side effect profiles, and any comorbid conditions. Regular monitoring and adjustments are essential. 4. **SAQ 4**: Describe the diagnostic criteria for schizophrenia according to DSM-5. (5 marks) - **Answer 4**: According to DSM-5, schizophrenia is diagnosed based on the presence of two or more of the following symptoms for a significant portion of time during a one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms. At least one symptom must be delusions, hallucinations, or disorganized speech. There must be significant impairment in social or occupational functioning. 5. **SAQ 5**: Outline the risk factors for suicide in adolescents. (5 marks) - **Answer 5**: Risk factors for suicide in adolescents include a history of previous suicide attempts, mental health disorders (such as depression and anxiety), substance abuse, family history of suicide, exposure to violence or trauma, lack of social support, and access to means of suicide. Early identification and intervention are critical for prevention. ​ 1. - ​ MEQ-Paper-2021-NZ-answers.pdf PDF Analyse this past exam paper for my psychiatry exams. Create a list of all of the questions and answers you find that are labelled as \"MEQ\", \"modified essay questions\". Ignore questions and answers which appear to be \"essay\" or \"extended matching question\". In your list include the stem of the question (the scenario the questions are about). Also include the number of marks each question is worth. ChatGPT Here is a list of the Modified Essay Questions (MEQ) from the provided exam paper, including the question stems, scenarios, and number of marks each question is worth. **MEQ 1: Jacob in an Inpatient Service** **Scenario**: You are a junior consultant working for an inpatient service at a psychiatric hospital. You are meeting the family of Jacob, a 22-year-old university student who was admitted the previous night. He was brought in by his family who were concerned that he was becoming increasingly paranoid about his flatmates over the previous few weeks. He accused one of his flatmates of poisoning his food and another of taking things from his room. He has been socialising less with friends and his family haven\'t seen him as much in recent weeks. Jacob agreed to come into hospital voluntarily "for a break" as he was feeling stressed by the situation at his flat. 1. **Question 1.1** (8 marks): Outline (list and justify) what specific information you would ask Jacob\'s family, to assist with making a diagnosis. - Recent History and Functioning: Details about his flatting situation, recent events, stressors, symptoms, prior functioning, and any changes. - Mood Symptom Screening: Symptoms of depression or mania. - Psychotic Symptom Screening: Delusions, auditory hallucinations, thought disorder. - Past Psychiatric History: Previous presentations, past diagnoses, and treatments. - Family History: History of psychosis or mood disorder in the family. - Substance Use History: Recent substance use, dependence, or withdrawal. - Medical History and Physical Health: Neurological symptoms, head injuries, significant medical history. 2. **Question 1.2** (8 marks): Discuss (list and debate) the factors you would consider when deciding whether to allow Jacob to leave hospital. - Risk Assessment and Likely Outcome: Nature of psychosis, risk to self or others, prior functioning, history of violence or suicide risk, likely illness trajectory. - Ethical Issues and Capacity: Capacity to make decisions, weighing autonomy vs. beneficence. - Mental Health Act: Grounds for compulsory treatment, impact on future treatment. - Support and Care Available: Family support, community respite, intensive home care, community mental health services. - Family\'s Viewpoint: Family\'s wishes and concerns. 3. **Question 1.3** (5 marks): Outline (list and justify) how you might approach this situation to improve the chances of Jacob taking medication. - Psychoeducation: Educate about psychosis and medication, ensure understanding, motivational interviewing. - Clarify Barriers: Discuss concerns, offer different medication options. - Engage Family: Provide psychoeducation to family, collaborate on persuasion and monitoring. - Consider Other Supports: Cultural or peer support to reassure Jacob. **MEQ 2: Caleb in a Forensic Service** **Scenario**: You are a junior forensic psychiatrist working in a service covering a men's prison. During a prison clinic, you are asked by the guard for advice about a young man recently arrested and currently held on remand. The guard is concerned that the prisoner, Caleb, may be mentally unwell. Caleb is a 24-year-old indigenous man. He faces charges of assault with a weapon, wilful damage, and trespass. He has been increasingly distressed, especially about the security cameras. 1. **Question 2.1** (9 marks): Outline (list and justify) what you would tell the prison guard to watch for when supervising Caleb in prison. - Signs of Mental Illness: Sleep disturbance, hypervigilance, talking to himself, unusual speech or behavior, responding to unseen stimuli, refusing food, paranoid behavior. - General Behavior and Coping: Interactions with others, consistency of behavior, communication ability, degree of organization. - Evidence of Substance Abuse: Past substance abuse signs, withdrawal symptoms. - Signs of Medical Problem: Symptoms like headache, fever, pain, confusion, fever, sweats. - Signs of Increasing Risk: Self-harm or suicide risk, threats or aggression, poor self-care. 2. **Question 2.2** (9 marks): Outline (list and justify) what you would assess in the interview with Caleb to determine if he is fit to stand trial. - Grasp of Court Report Purpose: Understanding confidentiality and the use of gathered information. - Presence of Active Mental Illness: Delusions, hallucinations, mood disorder, poor insight, thought disorder. - Intellectual Disability: Assess for intellectual impairment. - Medical Illness: Assess for active medical illness including substance abuse or withdrawal. - Court Process Understanding: Understanding roles in court, charges, plea meanings, communication with lawyer. - Cultural or Language Issues: Assess for language or cultural barriers, access to supports. 3. **Question 2.3** (4 marks): Describe (list and explain) your response to this request. - Inappropriateness of Request: Ethical, privacy, and legal concerns, conflict of interest, potential harm to engagement with services. - Discuss with Clinical Director: Seeking guidance and supervision. - Concerns about Lawyer's Competency: Seek further steps if serious concerns remain after discussion. **MEQ 3: Gemma in a Community Outpatient Team** **Scenario**: You are a Consultant Psychiatrist working in a community outpatient team and are about to assess Gemma. Gemma is a 20-year-old woman who has been referred by a locum General Practitioner (GP) who wonders whether she has adult Attention Deficit Hyperactivity Disorder (ADHD). 1. **Question 3.1** (11 marks): Outline (list and justify) the information you would want to get from Gemma in this assessment to clarify the diagnosis. - Assess DSM-5 or ICD-10 Criteria: Symptoms of hyperactivity, impulsivity, and inattention, age of onset, developmental history, impairment in multiple settings. - Rule out Psychiatric Differentials: Antisocial personality disorder, borderline personality disorder, anxiety disorder, depression. - Rule out Medical Differentials: Hearing or vision impairment, thyroid dysfunction, hypoglycemia, sleep disorder, fetal alcohol spectrum disorder. - Substance Use History: Assess for prescribed medications or substance abuse. 2. **Question 3.2** (6 marks): Outline (list and justify) the management options you would want to discuss with Gemma. - Psychoeducation: Information about ADHD and treatment. - Pharmacological Treatment: Stimulants (methylphenidate, lisdexamfetamine), non-stimulant (atomoxetine), once-daily dose options. - Psychological Interventions: CBT, mindfulness training. - Practical/Social Interventions: Changes to environment, activity scheduling, reducing distractions. - Treat Substance Use Disorder: Address cannabis and other substance use, refer to Drug and Alcohol services. 3. **Question 3.3** (5 marks): Describe (list and explain) possible explanations for the situation the GP describes. - Medication Side Effects: Appetite suppression and weight loss. - Abuse of Prescribed Medication: Using more than prescribed. - Substance Abuse: Direct effects or secondary to malnutrition. - Medical Causes: Endocrine disorders, infections, gastrointestinal issues, malignancy. - Undiagnosed or Emergent Eating Disorder: Higher prevalence in females with ADHD. - Social Factors: Financial hardship, access to food. **MEQ 4: Jack in Emergency Department** **Scenario**: You are a junior consultant psychiatrist attached to a Consultation-Liaison team, called to the Emergency Department (ED) of a large metropolitan hospital. Jack, aged 20, has presented multiple times with collapses while running, marked postural hypotension, and restrictive dietary intake. 1. **Question 4.1** (7 marks): Outline (list and justify) the key information you need to elicit in your assessment with Jack. - Assessment for Eating Disorders: Overvalued ideas about weight/shape, excessive dieting, over-exercising, purging behaviors, stimulant or laxative abuse. - Screening for Comorbidities: Symptoms and MSE for depression, anxiety, substance abuse. - Cognitive Changes: Memory impairments, cognitive slowing. - Risk Assessment: Thoughts of suicide or self-harm, history of risk to self. 2. **Question 4.2** (9 marks): Describe (list and explain) your approach to Jack's request for discharge from the Emergency Department. - Assessment of Capacity: Understanding medical risks, appreciating consequences, rational decision-making. - Engagement and Supports: Collaborative treatment planning, engaging family, motivational interviewing, psychoeducation. - Determination of Treatment Setting: Admission to general medical ward, significant medical risk. - Medico-Legal Issues: Consideration of Mental Health Act, guardianship legislation. 3. **Question 4.3** (4 marks): Describe (list and explain) what you would want to explain to his family about your management plan for Jack during the admission, regarding his over-exercising. - Close Follow-Up: C-L team providing close follow-up. - Psychoeducation: Educating Jack and family about anorexia nervosa. - Limited Use of Psychological Therapies: Focus on behavioral and anxiety-management strategies. - Nursing Watch: Arranging gender-appropriate nursing watch. - Collaborative Approach: Working with medical, dietitian, and nursing teams. - Least Restrictive Approach: Balancing risks and limiting Jack's autonomy during acute phase. **MEQ 5: Tanisha in a Child and Adolescent Mental Health Team** **Scenario**: Tanisha, a 15-year-old girl with severe anxiety and selective mutism, has been treated for a year without significant improvement. You are reviewing her case record for possible discharge. 1. **Question 5.1** (7 marks): Outline (list and justify) the key areas you would want to explore in Tanisha\'s case record. - Developmental History: Delays, repetitive behaviors, interests. - Educational Performance and IQ: School attendance, academic functioning, IQ testing. - Social Functioning: Information from parents and teachers. - Anxiety Symptoms: PTSD, anxiety disorders, functional impairment. - Family History: Mood, anxiety, neurodevelopmental disorders. - Mood Symptoms: Rule out mood disorders. - Risk Assessment: Risk to self, others, social and emotional development. 2. **Question 5.2** (4 marks): Describe (list and explain) the issues to consider in making a diagnosis of intellectual disability in Tanisha, given that she was mute during psychometric testing. - History of Intellectual Functioning: Significant deficits in reasoning, problem-solving, learning. - History of Adaptive Functioning: Significant deficits in personal independence and social functioning. - Timing of Onset: Developmental period onset, pre-dating house fire. - Consider Autism Spectrum Disorder: Higher likelihood with ID. 3. **Question 5.3** (7 marks): Outline (list and justify) the areas you would most want to assess during a home visit. - Mental State: Assess speech, behavior, videos from mother. - Adaptive Functioning: Tasks, room state. - Social Interactions: Deficits in social interactions and relationships. - Evidence of ASD: Restricted or repetitive behaviors, sensory inputs. - Anxiety Symptoms: Evidence of anxiety disorders. 4. **Question 5.4** (4 marks): Outline (list and justify) the issues you would need to discuss with Tanisha\'s mother when responding to this question. - Improvement with Sertraline: Assess anxiety improvement, not just mutism. - Problems with Sertraline: Adverse effects, stress from administration. - Current Anxiety Symptoms: Consider increasing dose or alternative SSRI. - Practical and Psycho-Social Interventions: Previous supports, need for more support. - Developmental Disorders and Anxiety: Explain anxiety linked with ASD. **MEQ 6: Richard in a Residential Care Facility** **Scenario**: Richard, an 83-year-old man with dementia and a recent stroke, is exhibiting disruptive behavior in a residential care facility. The facility requests advice on managing his behavior. 1. **Question 6.1** (10 marks): Outline (list and justify) the key information that you would expect Tom to have gathered from the staff and from Richard\'s records, at the residential care facility. - Presenting Complaint: Duration, pattern, management of disruptive behavior, efficacy, and adverse effects of medications. - Delirium Screening: Features, possible causes, examinations, investigations. - General Functioning: ADLs, sensory or communication deficits. - Environmental and Social Factors: Noise, overstimulation, routine changes, family visits. - Psychiatric Disorder Screening: Symptoms of psychosis, anxiety, mood disorder, past psychiatric history, substance use history. - Risk Assessment: Aggression, suicidal ideation, falls, legal framework for restraints. 2. **Question 6.2** (8 marks): Describe (list and explain) what you would want to discuss with Tom regarding non-pharmacological management planning in Richard\'s case. - General Approach: Collaborate with Richard, family, and staff, acknowledge concerns, use non-pharmacological and pharmacological management together. - Environmental Improvements: Activity scheduling, sensory modulation, personalizing room, use of headphones. - Psychological Interventions: Validation therapy, reminiscence therapy. - Sleep Hygiene: Use of sleep diary, addressing physical or environmental issues. - Behavioral Management: Education, ABC model, reviewing and implementing plans. - Practical Interventions: Review 1:1 staffing, consistent carers, higher level of care if needed. This list covers all the Modified Essay Questions (MEQ) from the provided exam paper. Essay-Paper-2020-NZ-answers.pdf PDF Analyse this past exam paper for my psychiatry exams. Create a list of the questions and answers you find that are labelled as \"MEQ\", \"modified essay questions\", \"Key feature\" or \"short answer\". Ignore questions and answers which appear to be \"essay\" or \"extended matching question\". In your list include the stem of the question (the scenario the questions are about). Also include the number of marks each question is worth. ChatGPT Here is the list of questions and answers labeled as \"MEQ\" (Modified Essay Questions) from the provided exam paper, including the question stems, scenarios, and number of marks each question is worth. **MEQ 1: John in a Large General Hospital** **Scenario**: You are a junior consultant working in the consultation-liaison service at a large general hospital. You have been asked by your general medical colleagues to urgently see John, a 41-year-old Samoan man under their care. John was transferred back 3 days ago from the regional neurosurgical unit and has a peripherally inserted central cannula (PICC) in situ as he requires four weeks of treatment with intravenous antibiotics. The treating physician reported that John repeatedly stated that morning that he didn't need antibiotics because he was 'cured' and that "the bandage on my head proves it". He is increasingly irritable with nursing staff trying to give him medication and has attempted to leave on two occasions today. On his second attempt to leave, he required security to contain him. John is 6\' 2\" and strongly built. 1. **Question 1.1** (9 marks): Outline (list and explain) the specific information you need to gather in your assessment of John to safely manage the escalating situation. - **Answer 1.1**: - **Risk**: Immediate risk to others given his presentation, risk of accidental harm to self, immediate risk of harm to self. - **Capacity**: Assess his current capacity to make decisions about his treatment options. - **Medical Status**: Current medical status including vital signs, screening for delirium, past medical history. - **Mental State Examination and Past Psychiatric History**: Evidence for primary psychiatric disorder vs. organic condition. - **Medications**: Any medications that might precipitate acute behavioral change. - **Alcohol and Substance Use History**: Possible substance withdrawal. - **Collateral Information**: From family and medical staff regarding recent presentation and usual coping behavior. - **Cultural Assessment**: Involve an appropriate cultural team/cultural worker. 2. **Question 1.2** (9 marks): Outline (list and explain) how you would manage the situation, given that John still requires life-saving care. - **Answer 1.2**: - **Medico-legal Issues**: Decisions for life-preserving treatment, involving family in decisions, discussing with hospital legal team. - **Management of Delirium**: Arrange 1:1 watch, move to a single room, use low dose antipsychotics, frequent re-orientation, distraction techniques. - **Management of the Ward/Staff**: Explain issues to nursing team, clear plan in notes, reassurance to staff. - **Family Interventions**: Discuss delivery of care, psychoeducation about cognitive impairment, support for distressed family. - **Cultural Intervention**: Involve a cultural advisor/team. 3. **Question 1.3** (4 marks): Outline (list and explain) the potential factors that may have led to the charge nurse's request. - **Answer 1.3**: - **Lack of Understanding**: About John's delirium. - **Staff Struggling**: To manage behavioral disturbance. - **Inadequate Management Strategies**: For his behavior. - **Hospital Systemic Issues**: Pressure to move John. - **Racism**: Potential racial bias and fear. **MEQ 2: Joanne in a Community Mental Health Clinic** **Scenario**: You are a junior consultant working in a community mental health clinic and have been asked to review Joanne, an unemployed 28-year-old woman who lives with her parents. Joanne was referred to your team one month ago by her GP, and was diagnosed with Obsessive Compulsive Disorder (OCD) by the psychologist on your service and a locum psychiatrist. She recently commenced psychological treatment. The psychologist has asked you to see Joanne because she has stopped medication (fluoxetine 40mg mane, previously prescribed by her GP), and is now doing poorly. She has also lost weight in the past month. 1. **Question 2.1** (10 marks): Outline (list and explain) what you will include in Joanne\'s assessment. - **Answer 2.1**: - **Develop Therapeutic Alliance**: Interaction with Joanne. - **Assess Risks**: Especially risk to self. - **Re-evaluate History and Symptoms**: Clarify history of obsessions and compulsions, reasons for stopping medication. - **Clarify Poor Performance**: Reasons for and rapidity of weight loss. - **Re-evaluate Diagnosis**: Screen for differentials such as psychosis or mood disorder. - **Collateral History**: From parents with her permission. - **Liaise with GP**. - **Physical Examination**: Weight, BMI, BP, heart rate, neurological exam. - **Blood Tests**: Including electrolytes. - **Consider Neuroimaging**: To exclude organic brain disease. 2. **Question 2.2** (6 marks): Outline (list and explain) the key elements of your treatment plan for Joanne at this point. - **Answer 2.2**: - **Consolidate Therapeutic Alliance**: Regular follow-up. - **Pharmacotherapy**: Restart medication, high dose of antidepressant, consider antipsychotic augmentation. - **Psychotherapy**: Regular CBT follow-up. - **Medical Follow-Up**: Monitor weight and physical wellbeing, continued liaison with GP. - **Involve Family**: With her consent. 3. **Question 2.3** (6 marks): Outline (list and explain) the key elements of your treatment plan for Joanne at this point. - **Answer 2.3**: - **Communicate Regularly**: With Joanne and her family. - **Manage Risks**: Consider admission to psychiatric unit vs. intensive home treatment. - **Consider Mental Health Act**: If needed for admission. - **Supervised Care**: Medication adherence, food and fluid intake, monitor weight and health. - **Involve Dietitian**: Monitor for re-feeding syndrome. - **Re-evaluate Diagnosis**: Consider a second opinion. **MEQ 3: Anton in a Community Mental Health Team** **Scenario**: You are a junior consultant psychiatrist working in a Community Mental Health Team. Anton is a 42-year-old man of European descent under your care. He has an 18-year history of paranoid schizophrenia and is currently on clozapine. He is treated compulsorily via the Mental Health Act. He lives alone in rental accommodation, receives long-term social services income due to his illness, and is supported by his elderly parents who live locally. Anton attends your clinic complaining that his neighbors have organized with the police to have him monitored and have installed an internet tracking device on the lamppost outside his flat. Anton reports they did this a year ago under the pretense of having fiber internet installed. He has been isolating himself at home and reports that he has no interest in going out and has lost weight because he is not eating. Anton says he has been more worried about the surveillance devices in the last three months and he can no longer sleep because of the fear. He wants zopiclone to help him sleep and a letter to the council to have the lamppost removed, as otherwise he will have to "take matters into my own hands.\" 1. **Question 3.1** (5 marks): List the potential reasons for Anton's presentation at this point. - **Answer 3.1**: - **Alcohol or Illicit Drugs**: Use of substances. - **Poor Medication Adherence**. - **Treatment Resistant Illness**. - **Relapsing Psychotic Illness**. - **Serum Clozapine Levels**: Dropped due to interaction. - **Unidentified Stressor**: Financial difficulties. - **Comorbid Depression**. - **Undisclosed Medical Condition**. 2. **Question 3.2** (7 marks): Outline (list and explain) the key points of your medication management for Anton. - **Answer 3.2**: - **Assess Clozapine Dose**: Check serum levels, clozapine - **Investigate Low Clozapine Levels**: Poor adherence, smoking resumption, manage side effects. - **Change Antipsychotic Regime**: Consider depot medication or augment with a second antipsychotic. - **Assist with Insomnia**: Consider melatonin, non-medication strategies. - **Treat Comorbid Mood Disorder**: Mood stabilizer or antidepressant if needed. 3. **Question 3.3** (7 marks): Outline (list and explain) your response to Anton's request to regain his Driver's License. - **Answer 3.3**: - **Supportive and Realistic Manner**: Recognize positive recovery goals. - **Driving History**: Risky behavior, past convictions, substance use. - **Current Degree of Recovery**: Symptoms affecting driving. - **Collateral Information**: From parents about driving history and need for support. - **Medico-legal Issues**: Driving restrictions due to compulsory treatment. - **Specialist Assessment**: Driving skills evaluation. 4. **Question 3.4** (4 marks): Outline (list and explain) your immediate response to Anton driving to the clinic under the influence. - **Answer 3.4**: - **Raise Concerns**: About his driving and drinking. - **Explain Driving Restrictions**: Due to compulsory treatment. - **Try to Get Agreement**: For him not to drive. - **Persuade to Hand Over Keys**. - **Contact Police**: If he drives away. **MEQ 4: Mrs. Chin in an Outpatient Clinic** **Scenario**: You are a junior consultant psychiatrist in an urban area and have been referred a new patient, Mrs. Chin, to be assessed in your outpatient clinic. She is a 75-year-old Chinese woman, married and living with her husband in their own home. She and her family emigrated from Hong Kong 30 years ago when she was in her mid-forties. Her son (her only child) lives locally with his family, in the same suburb. Her family is concerned that she has become unwell over the past four months. She is reported to be sad and to have lost interest in her usual hobbies (Mah Jong with friends, and calligraphy). Her sleep is poor and she can be disoriented at times. Her husband says that her memory is not as good as it used to be. Mrs. Chin was prescribed an antidepressant by her GP but without any improvement so far. 1. **Question 4.1** (6 marks): Outline (list and justify) your differential diagnoses at this point. - **Answer 4.1**: - **Major Depressive Episode**: Due to low mood, loss of interest, poor sleep. - **Dementia**: Poor memory and disorientation, likely Alzheimer's or Vascular Dementia. - **Organic Mood Disorder**: Due to age, possible hypothyroidism, low B12, CVA. - **Alcohol Abuse**: Rule out due to low mood and disorientation. 2. **Question 4.2** (4 marks): Discuss your approach to communicating with Mrs. Chin and her family. - **Answer 4.2**: - **Using Trained Interpreter**: Pros and cons, accuracy vs. potential shame and fear of gossip. - **Using Son as Interpreter**: Pros and cons, acceptability vs. reluctance and withholding information. - **Practicalities of Interpretation**: Arrange privacy, explain process, address Mrs. Chin and husband directly, ensure verbatim translation. 3. **Question 4.3** (8 marks): Outline (list and explain) your approach, and the information and medium-term treatment plan you would discuss with them. - **Answer 4.3**: - **Approach**: Empathic, supportive, use interpreter. - **Biological Interventions**: Treat cardiac risk factors, avoid medications that increase confusion, consider antidepressants. - **Psychological Interventions**: Psychoeducation, practical advice, OT input for hobbies. - **Social and Cultural Interventions**: Social work input, dementia support, cultural service involvement. - **Follow-up**: Regular follow-up with Old Age Mental Health team. **MEQ 5: Davey in a Child and Adolescent Mental Health Clinic** **Scenario**: You are a junior consultant psychiatrist and have been asked to see Davey, a 9-year-old boy referred by his school with concerns about his irritability, poor academic performance, and restlessness in the classroom. You see him with his mother, Shannon, who has raised him as a solo parent after his biological father absconded on hearing of her pregnancy. She has had no further contact with the father, and Davey is her only child. Shannon works full-time in a supermarket and Davey attends after-school care. Davey spends Saturday with his maternal grandmother while Shannon does a second job as a cleaner, to supplement their income. 1. **Question 5.1** (6 marks): List the key areas you need to assess in your initial work-up. - **Answer 5.1**: - **ADHD Symptom Screening**. - **Assess Learning Disorder/Cognition**. - **Security of Relationship with Mother**. - **Developmental History**. - **Family Psychiatric History**: Especially ADHD. - **Oppositional Defiant Disorder Screening**. - **Collateral History**: From home, school, and grandmother. - **Assess Sleep, Appetite, General Health**. 2. **Question 5.2** (1 mark): State why Davey should not have IQ testing first, before treatment for ADHD. - **Answer 5.2**: Need to ensure ADHD is treated first for valid IQ testing results. 3. **Question 5.3** (5 marks): Outline (list and explain) the key additional things you would need to assess prior to Davey starting stimulant treatment and your approach to gain consent. - **Answer 5.3**: - **Supportive Manner**: Tailor explanations for Shannon. - **Check Guardianship**: Ensure father has no say. - **Explain ADHD Diagnosis and Benefits of Treatment**. - **Explain Potential Side Effects**. - **Check for Cardiac History**. - **Physical Examination**: Heart, BP, pulse, weight, height, consider ECG. 4. **Question 5.4** (5 marks): Outline (list and explain) your management suggestions to Davey's GP regarding his lack of growth. - **Answer 5.4**: - **Check Centiles**: Ensure within acceptable range. - **Review Doses and Meals**. - **Dietary Advice**: Practical and in writing. - **Check for Other Medical Problems**. - **Consider Medication Holidays**. - **Refer to Dietitian**. - **Supportive Manner with GP**: Refer back if growth remains poor. 5. **Question 5.5** (6 marks): Outline (list and explain) your approach and what you would need to cover in your next review of Davey with Shannon. - **Answer 5.5**: - **Supportive Manner**: Tailor interactions for Shannon. - **Clarify Reasons for Behavior**. - **Discuss Shannon's Stress Levels and Support Needs**. - **Repeat Measurements**: Height and weight. - **Discuss Growth Problems and Medication Dose Reduction**. - **Consider Medication Timing**: Mix long-acting and short-acting. - **Discuss Dietary Interventions**. - **Discuss Medication Holidays**. - **Consider Alternative Medications**: Atomoxetine or clonidine. **MEQ 6: Abigail in the Emergency Department** **Scenario**: You are an on-call consultant psychiatrist called to assess Abigail (aged 23) in the Emergency Department (ED) on a Saturday. You are assisting with cover as the registrar was overloaded with other assessments. Abigail has presented to ED twice within the past 3 days, each time with overdoses of 10 paracetamol tablets. Abigail is well known to the ED with multiple past presentations of self-harm including lacerating her wrists, intoxication, and overdose. She has now been medically cleared for discharge from ED. The house officer\'s notes say that her current presentation was triggered by conflict with her father with whom she lives, as Abigail says he does not believe her report of childhood sexual abuse by a neighbor who was a friend of her father. Her father says Abigail has intense mood swings which are difficult to control or predict. 1. **Question 6.1** (4 marks): List the most likely differential diagnoses which might account for her presentation at this point, based on the above information. - **Answer 6.1**: - **Adjustment Disorder**. - **Bipolar Spectrum Disorder**. - **Borderline Personality Disorder**. - **Major Depressive Episode**. - **Post Traumatic Stress Disorder**. - **Substance Use Disorder**. 2. **Question 6.2** (8 marks): Outline (list and explain) the history you would take to confirm a diagnosis of Borderline Personality Disorder and how you would undertake this assessment. - **Answer 6.2**: - **Screening for Borderline Personality Disorder Features**. - **Clarify Recent Triggers/Stressors**. - **Rule Out Symptoms Better Explained by Another Diagnosis**. - **Collateral History**: With her permission. - **History from Clinical Records**. - **Practicalities of Assessment**: Arrange privacy, therapeutic engagement, validate distress, involve crisis team staff if needed. 3. **Question 6.3** (6 marks): Discuss your response to the psychotherapist's request to take Abigail home. - **Answer 6.3**: - **Gather Collateral**: From the therapist. - **Check Therapist's Formulation and Strategy**. - **Discuss Concerns About Inappropriate Suggestion**: Boundary breach, damages therapeutic relationship, inability to ensure safety, possible risk to therapist and family. - **Negotiate Appropriate Discharge Plan**: Safe plan, crisis team/community team follow-up, resume usual psychotherapy appointments. This list captures all the relevant MEQ and Short Answer questions from the provided exam paper. Essay-Paper-2019-NZ-answers.pdf PDF Analyse this past exam paper for my psychiatry exams. Create a list of the questions and answers you find that are labelled as \"MEQ\", \"modified essay questions\", \"Key feature\" or \"short answer\". Ignore questions and answers which appear to be \"essay\" or \"extended matching question\". In your list include the stem of the question (the scenario the questions are about). Also include the number of marks each question is worth. ChatGPT **List of MEQ, Key Feature, and Short Answer Questions and Answers** **MEQ 1: Amy in a Crisis Admission** **Scenario**: You are a junior consultant on call overnight when you receive a call from a first-year registrar on call. The registrar has assessed Amy, a 19-year-old woman with a diagnosis of borderline personality disorder. Amy had self-discharged from the inpatient ward where she was an informal patient, the evening of the day before this presentation. The discharge occurred less than 24 hours into a 48-hour long crisis admission - part of her crisis management plan. Amy has now been brought to the hospital by police after a member of the public saw her cutting herself. The registrar says Amy reports feeling suicidal and wants to return to the hospital for her crisis admission. She told the registrar she would kill herself if not re-admitted. 1. **Question 1.1** (8 marks): Outline (list and elaborate) the information you expect the registrar to have obtained. - **Answer 1.1**: - **Recent History**: Details of the lead-up to the recent crisis admission, her presentation/behaviour on the ward, and reasons for self-discharge; What happened during the period between self-discharge and her re-presenting, e.g., any stressors or precipitants for her self-harm and return? - **Risk Assessment**: Harm to self -- current ideation/plan/intent and seriousness (e.g., medical complications of cutting -- is she medically cleared?), past risk to self-history including seriousness; Harm to others -- ideation/plan/intent, including any dependents under her care, and past risk to others history including seriousness. - **Mental State Examination**: Full mental state assessment including engagement, rapport, her insight, reflective capacity, judgement; Screening for symptoms of other disorders such as depression, intoxication or psychosis. - **Supports and Social Situation**: Living situation -- who she lives with, who are her main supports? e.g., friends, family, parents; Are any of these available acutely? - **Collateral Information**: Is there anyone who could give collateral information -- have they been contacted, are they likely to be reliable, can they clarify her risk history in the past when in similar circumstances? Ideally, mention the need to consider privacy issues as the patient is an adult. - **Crisis Plan**: What does the Crisis Plan say and are there any recommendations in it? e.g., regarding admission, stand down periods, use of compulsory treatment, etc. 2. **Question 1.2** (6 marks): Outline (list and explain) aspects of risk that may influence your decision whether to readmit Amy. - **Answer 1.2**: - **Patient Factors**: Dynamic -- level of distress, suicidal ideation - intent/plan/imminence, substance use or intoxication; Static -- age, sex, past life history, ongoing major mental illness or physical illness; Destabilising factors and stressors, e.g., changes or losses in supports, relationships, bereavements, employment problems, etc.; History of similar risk factors as predictors for current behaviour. - **Non-Patient Factors**: Counter-transference issues e.g., attitudes of staff on the ward, which may be unhelpful for the patient; The registrar is a 1st year -- might under- or over-estimate the risk, might be pressured by more experienced staff or by ED staff; Presence or absence of supports and safety for the patient outside hospital; Short-term vs long-term risk -- crisis plan with a view to modifying longer-term risk concerns -- vs immediate risk. 3. **Question 1.3** (3 marks): List the immediate management steps you may need to consider. - **Answer 1.3**: - Consideration of the need to alert the police. - Consideration of the need to implement the Mental Health Act. - Consideration of the need to alert her family. - Efforts to locate Amy -- e.g., phone her or ask security to search the grounds. - Planning ahead for scenarios of Amy returning or not returning overnight. 4. **Question 1.4** (6 marks): Outline (list and elaborate) your immediate and medium-term management plan. - **Answer 1.4**: - Support the junior registrar who may feel they are the 'meat in the sandwich'. As part of that and to clarify risks, consider attending in person to review Amy. - Maintain a professional relationship between police and MHS -- validation of police concerns while still making decisions based on clinical need. - Reassess the risks, taking into account the overall context of a series of presentations and Amy\'s current mental state. Linked with this, review whether the Crisis Plan is still appropriate, in light of the current presentation. - Ensure that Amy's mother understands her concerns are heard while highlighting the potential adverse effects of readmission, especially if this needs to be against Amy's wishes (loss of autonomy, runs counter to the principles of management for Borderline personality disorder). - Liaison with Amy\'s treating team as soon as possible and consider the need for a case conference including the family and different agencies, particularly if Amy is presenting frequently with similar scenarios. **MEQ 2: Jacek in Child and Adolescent Mental Health** **Scenario**: You are working for the local child and adolescent mental health service that provides liaison to the government child protection services. You are asked to see Jacek, an 8-year-old boy who has recently been placed with a new set of foster parents after his fourth placement broke down. He was removed from his mother aged 10 months, with concerns he was significantly neglected due to her substance use problems. His new foster parents Ian and Melinda have requested an early review with child psychiatry as they are aware of previous difficulties with Jacek at school and in his foster homes. Ian and Melinda are experienced foster parents with no other children currently placed with them. They have begun work on routines around eating and sleeping. So far Jacek has been quiet at home, wanting to retreat to his room. They have found packets of their dry pasta as well as biscuits moved from their pantry and placed under his bed. 1. **Question 2.1** (6 marks): List the key differential diagnoses you would plan to gather information on in your assessment. - **Answer 2.1**: - ADHD - Dyspraxia - Fetal Alcohol Spectrum Disorder (substance exposure in utero) - Intellectual Disability (or Learning Disorder) - Oppositional Defiant Disorder or Conduct Disorder - Poor learning due to behavioural difficulties - PTSD - Reactive Attachment Disorder - ASD 2. **Question 2.2** (6 marks): List the key information you would hope to gain from school observation. - **Answer 2.2**: - Features of ADHD versus other possible behavioural explanations - Features of ASD versus other possible behavioural explanations - Interactions with peers - Interactions with teachers and other staff - Level of support and the teaching style in the classroom - On-task behaviour and distractions - Playground behaviour versus classroom behaviour - Volatility 3. **Question 2.3** (4 marks): List the behavioural and psychiatric difficulties that may be associated with Fetal Alcohol Spectrum Disorder. - **Answer 2.3**: - Deficits in adaptive behaviour and daily functioning skills - Emotional volatility - Executive functioning difficulties - Features of ADHD - Low IQ - Social processing difficulties especially in adolescence 4. **Question 2.4** (2 marks): Outline (list and justify) the key possible problems with stimulant treatment for Jacek that would need to be discussed. - **Answer 2.4**: - Appetite restriction and growth retardation may be an issue (he\'s small already) - Sleep difficulties may cause problems (as his foster parents are trying to establish sleep routines) - Stimulants may be less likely to work (due to the underlying Foetal Alcohol spectrum disorder) 5. **Question 2.5** (3 marks): List the non-pharmacological management strategies you would suggest for Jacek. - **Answer 2.5**: - Consistent behavioural management - Letting him work in a low stimulus environment - People ensuring they have his attention when speaking to him - Seating him near the front of the class - Simple, short instructions 6. **Question 2.6** (3 marks): Outline (list and explain) the reasons why Jacek may be unsettled after seeing his mother. - **Answer 2.6**: - Different behavioural expectations in the foster-home versus during the visits - Visits may be stressing him due to reactivated attachment difficulties/distress about losing mother again after visit - Visits may be stressing him due to reactivated past trauma in the relationship with mother/difficult interactions with her during visit - Visits may be stressing him due to support during the visits being inadequate **MEQ 3: Liam in a Small Mental Health Service** **Scenario**: You are the on-call consultant for a small mental health service and you are asked to see Liam, a 35-year-old man brought to the hospital by the police. This follows an incident where he took his clothes off and exposed himself to neighbors. Liam presents with paranoid delusions of being under surveillance, as well as bizarre behaviour. His forearms are covered with sores where he has been trying to dig things out of his arms. He was recently discharged after an inpatient admission for a drug-induced psychosis after smoking methamphetamine and has not attended arranged follow-up. Liam recently lost access to his children and has been asked to leave the family home. He is now living with his sister who has young children. 1. **Question 3.1** (14 marks): Outline (list and justify) your risk assessment for Liam. - **Answer 3.1**: - **Risk to self**: - Delusional ideas -- causing self-harm from digging into his skin (impaired insight and judgment) - Potential for suicide -- future risk of self-harm if his mood drops when withdrawing from methamphetamine - Medical risk -- risk of physical harm such as raised BP and CVA, arrhythmia, skin injuries & infection, exhaustion (no sleep & overactivity) - **Risk to others**: - Psychosis -- violence risk due to his paranoia and irritability - Vehicular risk -- risk to the public when driving while on methamphetamine - Exhibitionism & Child Welfare risk -- risk of disturbed or drug-affected behavior with sister\'s children (note he\'s lost custody of his own children) - **Other Risks**: - Impaired self-care -- chaotic lifestyle & homelessness risk if sister evicts him - Criminality -- may be involved in crime to pay for drugs - Difficulty in follow-up -- all the above risks are increased by his poor engagement with treatment services, worsened by unstable accommodation 2. **Question 3.2** (10 marks): Outline (list and justify) your short term management plan for this situation. - **Answer 3.2**: - Manage stigmatization and staff attitudes -- may suggest discussions with staff, education, and consensus on the management plan. - Manage consequences -- e.g., should he be charged for the property damage? Depends if he was competent which seems very unlikely. - Containment -- where should he be nursed. High Care Area/HDU or seclusion are likely. Not on open ward. - Medication for agitation and psychosis-- sedation via benzodiazepines, antipsychotic medication for the drug-induced psychosis. - Physical care -- check for signs of IV drug use and complications like infection at sites or of the self-inflicted sores, usual physical recordings, dehydration, and poor nutrition - monitor food & fluids. - Manage his withdrawal from methamphetamine-- or from any other substances. - Arrange close nursing care and frequent medical reviews -- move to less intensive nursing and to open ward once possible, but watch for a drop in his mood and increased suicide risk. 3. **Question 3.3** (6 marks): Describe your approach to managing information sharing in this situation, with Liam\'s sister, employer, and probation officer. - **Answer 3.3**: - **General principles & medico-legal issues (confidentiality)**: - Privacy and maintenance of Liam\'s autonomy, aim to get his consent to share information - Obligations to inform child welfare where there are issues of child protection - Obligations to inform vehicle licensing authorities about unsafe driving - **Discussion with his sister**: - If he\'s living with his sister and there are child protection issues his consent to share information is not needed - Consider the child's ADHD medication and about discussing keeping this safe with his sister, and about liaising with child's prescriber - Aim nonetheless to get Liam\'s permission to involve his sister in discharge planning. - **Discussion with his employer**: - For a medical clearance to return to work, would need to discuss with employer Liam's need to drive, the kind of job and responsibilities safe for him, and provide a formal certificate - Need to get Liam\'s permission to discuss this with employer. - **Discussion with Probation Officer**: - Clarify your role -- are you required to provide information as his treating psychiatrist e.g., linked with Liam\'s probation conditions? - Aim to get Liam\'s permission to provide information to Probation. **MEQ 4: William in Inpatient Rehabilitation Ward** **Scenario**: You are the consultant on an inpatient rehabilitation ward. One of your patients is William, a 55-year-old man recently admitted to the service. He has a long history of paranoid schizophrenia including auditory hallucinations, alcohol and cannabis use, and poor engagement with services over the last 25 years. He has been homeless for periods and has had several convictions over the years for minor offending -- shoplifting, public nuisance, and trespass. He is prescribed 40mg Olanzapine per day. He has previously been on Zuclopenthixol Depot, Risperidone, and Haloperidol. 1. **Question 4.1** (9 marks): Describe how you would undertake a medication review and what information you would be seeking. - **Answer 4.1**: - **Review all past medication use**: Previous medication trials -- how adequate were they re dose and time? Likelihood of compliance e.g., route of administration, efficacy versus side effects and reasons for stopping or changing medication. - **Psychosis history**: Psychotic symptoms -- degree of response to treatment, effects of comorbid substance use or abstinence on his response to medication and his compliance, consider mood symptoms, and whether these were ever present/treated. - **Efficacy measures (his functioning)**: His coping & social engagement in the community, ability to do meaningful activity if unable to work. - **Collateral sources**: Review old notes, consult past team and psychiatrist, consult family, use psychometric or objective measures e.g., PANS, HONOS, BPRS. - **Patient\'s own experience and view**: Patient preference and reasons for this, medication acceptability/tolerability versus side effects. 2. **Question 4.2** (10 marks): Outline (list and justify) your considered ongoing options to treat his psychotic disorder. - **Answer 4.2**: - Change to Clozapine -- he has a treatment-resistant illness, trialled at least 2 previous medications. May need laxatives, Metformin, re adverse effects. - Continue Olanzapine -- if length of use to date, dose, or compliance are inadequate for a proper trial. Consider a depot version. - Augmentation of Olanzapine -- Amisulpride has the best evidence. - ECT -- used for treatment-resistant psychosis. Consider whether he\'d need maintenance treatments and the acceptability, risk-benefits, and practicality of ongoing ECT. - If a history of mood symptoms considers augmentation for these -- role for a mood stabilizer or antidepressant. - Augment with Omega 3 -- but limited evidence. 3. **Question 4.3** (10 marks): Outline (list and elaborate) how you would develop this, and the information you would want to have in William's Recovery Plan. - **Answer 4.3**: - Plan to be developed collaboratively -- written in plain English with and for William, and shared with his clinical team, family, and carers. - Contact information including next of kin, community team key worker and psychiatrist, other key supports e.g., pharmacy, GP. - Key legal information -- MHA status, any EPOA. - List of medications, potential side effects, and advice on how/when to use any PRN medication. - Activity schedule, weekly diary -- William\'s description of himself when well and what he does to maintain that. - List of suitable resources to maintain wellness (Wellness Toolbox) -- social supports, peer counselling, exercise, relaxation, stress reduction techniques, diet, sleep support. - Emergency contacts for Mental health Services -- crisis numbers 24/7. - Early warning signs relevant to William. - William's preferences -- his directives for emergencies. - Post Crisis plan -- what will happen to help William get back to where he was, additional supports, reviews. **MEQ 5: Kylie in a Rural Community Team** **Scenario**: You are a general adult psychiatrist working in a rural community team. You have been asked by a GP to review Kylie, a 28-year-old woman who is 18 weeks pregnant. She is reporting low mood, tearfulness, and poor sleep. The GP tells you she was depressed after the birth of her first child (now aged 3) and overdosed on analgesic medication at that time. She is living with her partner who is the father of the two children, and there is some conflict as he was recently charged with a drink-driving offense. She has recently been to her GP with concerns about 'tantrums' in her 3-year-old. Following a comprehensive assessment of Kylie, you conclude that she has a severe depressive disorder and that antidepressant treatment is indicated. You decide to trial an SSRI. 1. **Question 5.1** (10 marks): Outline (list and justify) your approach to prescribing for Kylie, including the specific pregnancy-related risks of SSRIs that you would want to discuss. - **Answer 5.1**: - **Safety of medication in pregnancy**: Consult with a psychiatrist specializing in perinatal psychiatry re choice of medication and treatment, refer to updated medication information on safest SSRIs re breastmilk levels, review previous treatment and response -- use lowest effective dose and avoid polypharmacy. - **Specific risks of SSRIs**: Lower birth weight, prematurity, Persistent Pulmonary Hypertension of the Newborn, cardiac abnormalities (First trimester use), delayed Neonatal Adaptation/Neonatal Adaptation Syndrome, slight increased risk of postpartum hemorrhage. - **Consent**: Provide written information, involve the father in the discussion, document your discussion of the risk/benefits. - **Communication**: Ensure the clinicians responsible for maternity care are aware she\'s been started on medication. - **Follow-up**: Regular follow-up to check response to the antidepressant, planning around childbirth e.g., baby may be more likely to have transitional problems in the newborn period. 2. **Question 5.2** (8 marks): Discuss your approach at this point, focusing on assessing the risks and community-based non-medication options you would consider. - **Answer 5.2**: - **Safety -- Risk Assessment**: Review her thoughts or acts of harm to self, review her thoughts or acts of harm to the children, review her bonding with both children and her coping with their care, check \'Safe Sleeping\' e.g., not co-sleeping, baby on his back, assess risk to her and children from partner (aggression, substance use), assess other risks e.g., unresolved medical/trauma from the birth. - **Child Welfare Involvement**: Consider referral to Child Welfare agency (if Child Protection/Safety issues). - **Placement/Respite**: Family/friends able to provide support or stay to assist overnight, consider respite if available - either home-based or respite with baby. - **Social/family interventions**: Offer family meeting, explore family supports, financial support -- review eligibility for welfare support with partner leaving, review accommodation issues with partner leaving, referral to parenting support agency for 3-year-old/consider childcare, arrange a support worker. - **General health advice**: Sleep, diet, exercise e.g., taking baby out in pram. - **Therapy**: Mother-infant therapy or maternal focused CBT or IPT. **MEQ 6: Yasmin in the Emergency Department** **Scenario**: You work on a Liaison team and are called to the Emergency Department (ED) to assess Yasmin, a 25-year-old Iranian woman brought to hospital from a Women's Refuge, where she had been for 24 hours. She has two children aged 8 and 11, who have remained at the Refuge in the care of the staff. ED staff tell you that she has been badly beaten and has many bruises, and evidence of old fractures to facial bones. They have requested a consult as Yasmin has been largely mute since arrival at ED, often flinching away from staff, especially male staff. At times if left unattended she has gesticulated and muttered to herself and they feel she is confused and disoriented. The Refuge staff member accompanying her was not able to communicate with her while at ED and has had to return to the Refuge. Before leaving she told ED staff that a few hours ago Yasmin's speech and grasp of English seemed reasonable and they had not needed an interpreter. She described Yasmin as initially caring well for her children then becoming more withdrawn and complaining of a headache in the hours before coming to hospital, seeming confused, frightened and at times retching. Refuge staff had been unable to obtain much personal history except that she is married and afraid to return to her husband's household as she says he beats her. On glancing into the cubicle you see Yasmin is huddled on a gurney wearing a hospital gown, with her hands over her eyes. A uniformed male security watch is sitting beside the door to her room. 1. **Question 6.1** (6 marks): Discuss the practical and ethical issues involved in using an Iranian interpreter in your assessment of Yasmin. - **Answer 6.1**: - She has the right to be assessed in her own language (Autonomy). - Conf