Psychiatry Station 4

 

Station 4

“Poison is in everything, and no thing is without poison” - Paracelsus

Ooooooo…deep quote

 

Candidate Instructions

Setting:

You are a Foundation doctor working in General Practice. This patient has presented with worsening hot flushes and mental fog.


Name: Janine Roberts


Tasks:

1.Take a brief history from the patient.

2.At 5 minutes the exminer will inform you of some clincal findings. At this point you should formulate a differential diagnosis and state this to the examiner.

3.Provide your inital management plan to the exmainer.

You are not required to examine the patient.

Simulated Patient Instructions

Briefing

Diagnosis: Serotonin Sydnrome

You are Janine Roberts, a 50 year old female patient, DoB 12/03/1974.

You have presented to your GP with worse hot flushes and mental fog.

Appearance and Behaviour

You are anxious to get an answer about what is causing this. You find it difficult to sit still, if you're a decent actor you can try and put on a mild tremor!.

Opening statement

"I’ve come in because I’m feeling awful - I’m boiling hot all day and I can’t think straight."

Information to Give Freely

So I’ve been having hot flushes and feeling rubbish for a while since I started going through the menopause and it’s been pretty static. Over the last day or so though I’ve been absolutely terrible, like one long hot flush. I can’t think straight, and my wife says I’ve been really scatterbrained the last couple of days. I know menopause can make me like that but it’s been different.

Presenting Complaint

For the last two days I’ve been feeling unbearably hot, and my heart has been racing. I’m constantly sweating, to the point where I take multiple showers in a day. Normally the flushes come and go, but this one has been constant.

I’ve been getting muddled - I just can’t think straight and it’s making me frustrated. I’m snapping at my family which really isn’t like me. I can’t sleep properly either, despite everything.

I’m losing my train of thought really easily, sometimes in the middle of a conversation. My memory is alright, I’m just a bit all over the place and get lost easily if I’m doing things around the house. I completely blanked in a meeting the other day, hallways through a presentation.

My wife has said I’m fidgeting as well, but I don’t feel like I can help it. I’m having these weird twitches - my arms are shaky and twitchy, like I’m suddenly tensing up. It’s in my arms and legs, but mostly my legs. I just feel like I can’t stay still and it’s driving me insane!

(Only reveal if asked about bowel habits) - I’ve had diarrhoea over the last two days. No blood, no mucus. Just loose stools, opening bowels about 3-4 times a day with mild nausea throughout the day. Appetite is reduced.

(Only reveal if asked about triggering events) - the only thing I’ve changed recently is that I started taking a new supplement to help me sleep - it’s “relax” gummies, I think it’s tryptophan.

There is no history of recent viral illness - other than perimenopausal symptoms, she has been in good health for a long time.

There is no evidence of mania, and no psychotic symptoms.

Past Medical History

Previous similar episodes - Hot flushes for approx 6 months, diagnosed as perimenopause, but no agitation, tachycardia, or tremors.

Other medical conditions:

  • Perimenopause
  • Hypertension

    • No previous involvement with mental health services

    Drug History

    Prescribed:

  • Fluoxetine 20mg OD
  • Ramipril 2.5mg

    • Over the counter:

  • “relax” tryptophan supplements
  • B complex multivitamins

    • No known drug allergies

    Family History

    Nil of note

    Social History

    Smoking history - Never smoked

    Alcohol - has a small glass of wine with dinner every other day or so

    Illicit drugs - Nil

    Job - Civil Engineer

    Home:

  • Lives in detached two storey house
  • Wife and two teenage children, one cat
  • Independently mobile
  • No issues with ADLs, other than lack of energy from poor sleep

    • Systems Review:

    General/red flags - Agitation, confusion, sweating, heat intolerance

    Neuro - Tremor - will describe as sharp “muscle twitches” and coarse unpredictable shakes

    Resp - Slightly out of breath quicker than usual

    Cardio - Tachycardia, palpitations

    GI - Diarrhoea, nausea but no vomiting

    Ideas / Concerns / Expectation

    Ideas - thinks the medication isn’t working, and I think it may be making these menopause symptoms worse.

    Concerns - This is going to disrupt my work - I can’t sleep properly and I’m always exhausted

    Expectations - Give me something else to sort these symptoms out!

    Discussion / Questions

    I measured my blood pressure at home and it seemed really high, is there anything you can give me to help?

    Examiner Prompts

    On candidate's entry into the station:

    State - You have 5 minutes to take a history from this patient, at which point I will stop you and ask you some questions.

    At 5 minutes:

    Inform the candidate of the following clinical findings:

  • Respiratory Rate - 22
  • Oxygen Saturation - 98% on room air
  • Heart Rate - 110 bpm
  • Blood Pressure - 160/95

    • The patient appears diaphoretic and visibly flushed. Her pulse feels fast but regular, normal volume and regular. She feels warm to the touch to her peripheries. She appears restless, and her legs shake constantly during the examination.

    On examination, she has rigidity in both upper and lower limbs bilaterally, more pronounced in the lower limbs. You are able to elicit clonus in both lower limbs for 6 beats on each side. Pupils are dilated at 6mm when under bright light, but equal and reactive. She has upgoing plantar reflexes bilaterally and is hyperreflexic on examination of lower limb reflexes. Upper limb reflexes are normal.

    Chest is clear, heart sounds normal and abdomen SNT. Bowel sounds are increased.

    After giving the above information, you should prompt the candidate for their differential diagnosis

    At 8 minutes (if the candidate has not already moved onto management):

    State "If this patient were experiencing serotonin syndrome, what would be your immediate management?"

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     

    Ellicits the following key symptoms:

    Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     

    Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Examiner Prompt - 5 minutes

     

    Please inform the candidate of the following examination findings and prompt them to give state and explain their differential diagnoses

    Diagnosis

     
  • Neuroleptic malignant syndrome
  • Anticholinergic toxicity
  • Malignant Hyperthermia
  • NMS - no evidence of recent neuroleptic drug commencement or dose increase
  • Anticholinergic toxicity - no anticholinergic drug use - no evidence of other key anticholinergic symptoms, e.g dry mouth, dry eye, urinary retention
  • Malignant Hyperthermia - no evidence of medication known to precipitate malignant hyperthermia, reports no recreational drug use e.g ecstasy

    • Examiner Prompt - 8 minutes

     

    If they have not done so already, please interrupt the candidate at 8 minutes and prompt them to move onto their management.

    Management

     

    Supportive Management - Agitation:

    Supportive Management - Hyperthermia:

    Definitive Management:

    Submit for Scoring

    Tags | Psych | Psychiatry | Serotonin Syndrome | Drug Toxicity

    Station Written by: Dr Tom Charles

    Peer Reviewed by: Dr Rishil Patel

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