Question:

How would you confirm patient have psychosis?

Answer:
We will do a detail assessment of a patient to confirm that he or she is having psychosis by
asking about the following:
1. Symptoms of psychosis:
1) Changes in speech
2) Abnormal beliefs (Delusions)
3) Abnormal perceptions (Hallucinations)

4) Changes In emotions
5) Changes in social Behaviour
6) Changes In behavior

2. Ask about previous/current episodes and treatment

Ask both the person and the family about;

o Is this first episode or a relapse?

o Symptoms worsened?

o History of previous or current treatment

o Within the last 3 months? ( 3 < acute, 3 > chronic)

3. Rule out:
• Psychotic symptoms caused by substance use e.g., cannabis or alcohol
• Psychotic symptoms caused by delirium due to acute medical conditions e.g., cerebral
malaria, systemic infection, sepsis, head injury etc.

Typical antipsychotics are more likely to cause extrapyramidal side effects in which
motor control is sometimes severely impaired, causing tremors, spasms, muscle rigidity, and
the loss of control and coordination of muscle movement. In some cases, the symptoms may
become permanent even after the treatment is stopped.
Fluphenazine (Long acting) 2.5 mg
Haloperidol (short acting) 2 mg
Chlorpromazine 200 mg

Atypical antipsychotics are far less likely to cause extrapyramidal side effects. With
that being said, they are known to cause weight gain, metabolic problems, and sexual side
effects, among others.
Aripiprazole 10 mg
Olanzapine 5 mg
Quetiapine 150 mg
Resperidone 2 mg
Clozapine 12.5 mg
A 30 years old lady has been brought to the OPD clinic by her family members. For last 2 weeks she has
been talking more than usual and her voice has gone hoarse due to excessive talking. She remains
persistently active most of the day and fails to take more than two hours of sleep during night. She has
been spending recklessly on shopping and has been buying stuff that she doesn’t necessarily need. She
claims that she is in charge of the family and others must follow her instructions at all times. On mental
state examination, she has pressure of speech and racing thoughts. She is overconfident and over
familiar. She shakes hand with the doctor which is otherwise considered culturally inappropriate. She
has over inflated ideas about herself and her wealth. She doesn’t believe that she has any illness and
insists on going back home.
What is the most likely diagnosis? (1)

Bipolar affective disorder with manic episode.

How would you assess this patient to confirm your diagnosis? (4)

1 . For the confirmed diagnosis i will consider medical test at 1st thumb rule either there is any
underlying physical cause for this particular problem.

2. I will rule out the symptoms of psychosis like identify 1st rank symptoms delusions, hallucinations
and behavioral problems.

3 . Ask about previous or current episodes and treatment like ask about mania and effective bipolar
symptoms were present or not (overactive, delusions or increased level of energy).

4 . I will rule out either psychotic symptoms caused by alcohol or delirium due to acute medical
conditions.

Like check out cerebral malaria, sepsis, hypothyroidism, anemia, hypertension, diabetes and
medications use.

5. i will confirm through monitoring the entire test like blood Cp test, renal function test, liver function
test, weight, plasma glucose, prolactin, ECG and blood pressure.

Please enlist the available medications? Which medications will you choose? Describe the dose and the
reason for your choice? (5)

Lithium, sodium valpurate, carbamazepine, aripiprazole, olanzapine

Preferably Medications

1. It totally depends on the assessment and client verbatim if she has a proper commitment for taking
medications then it is a 1st choice to choose lithium according to rule. Because it really has a good
response for the effective bipolar disorder. If client have no proper compliance, then i will jump another
medication.

2. I have another option for medications like i will use a combination of antipsychotics and mood
stabilizers because the client has acute symptoms of mania/psychosis. So, i will start with the sodium
valproate (Epival).
What information will you provide to the patient and family about the medications? (5)

1. It is important to maintain compliance and being communicated with me with proper engagement
once you will start your medications. You will follow my pattern of taking medications which i have
prescribed and you will do proper check ups on regular basis.

2. you are not alone and you can recover with the proper treatment and support.

3. I will gave key message to her family like avoid any type of criticism and hostility towards the
person. Gave medications regularly and coming up for follow up visit. Please avoid any type of
discrimination usually people do due to this illness. You will do some test like blood cp test, BP, Renal
function test , ECG , blood pressure, weight according to my prescription and consult me on time.
70 year old male presents to the ER with a history of two seizures. His wife described her

husband was making an odd gurgling noise with his head deviated to the left and left arm was

stiffened. This was followed by generalized body jerking and history of tongue bite. Patient was

unresponsive. Event lasted 2 minutes with 10 minutes until full recovery.

Q. What is the most probable diagnosis?

Epilepsy.

Q. How would you proceed with the assessment?

Assessment

Ask the person, and carer, if the person has had any of the following symptoms:

 Convulsive movements lasting longer than 1–2 minutes,

 loss of or impaired consciousness
 stiffness or rigidity of the body or limbs lasting longer than 1–2 minutes,
 bitten or bruised tongue or bodily injury
 loss of bladder or bowel control during the episode.
 After the abnormal movements, the person may demonstrate confusion, drowsiness, sleepiness or
abnormal behaviour.
 The person may also complain of fatigue, headache, or muscle ache.

Assessment question 1:

Does the person meet the criteria for convulsive seizure?

 The person meets the criteria for a convulsive seizure if there are convulsive movements
 and at least 2 other symptoms from the above list.

Assessment question 2:

In the case of convulsive seizure, is there an acute cause?

 Check for signs and symptoms of neuro infection:

Fever, headache, meningeal irritation (e.g. stiff neck).
 Check for other possible causes of convulsions:
head injury, metabolic abnormality (e.g. hypoglycaemia, hyponatraemia) alcohol or drug
intoxication or withdrawal.

If there is an identifiable acute cause of convulsive seizure, treat the cause.

Maintenance treatment with antiepileptic medications is not required in these cases.
Refer to a hospital immediately if neuro infection, head injury or metabolic abnormality is suspected.

Assessment question 3:
In the case of convulsive seizure without an identified acute cause, is this epilepsy?
 It is considered epilepsy if the person has had 2 or more unprovoked, convulsive seizures on 2
different days in the last 12 months.
 If there was only 1 convulsive seizure in the last 12 months without an acute cause, then
antiepileptic treatment is not required.
 Follow up in 3 months.

Q. What information would you provide to the person and carers about the condition?

Psychoeducation:

Explain: What epilepsy is and what causes it:

Epilepsy is a chronic condition, but with medication three out of every four people can be seizure-free.
Epilepsy involves recurrent seizures.
A seizure is a problem related to abnormal electrical activity in the brain.
Epilepsy is not caused by witchcraft or spirits.
Epilepsy is not contagious. Saliva does not transmit epilepsy.

What the relevant lifestyle issues are:

People with epilepsy can lead normal lives:

They can marry and have healthy children.
They can work productively and safely at most jobs.
Children with epilepsy can go to school.

People with epilepsy should avoid:

Jobs that require working near heavy machinery or fire.

Cooking over open fires.
Swimming alone alcohol and recreational drugs.
Looking at flashing lights.
Changing sleep patterns (e.g. sleeping much less than usual).

What to do at home when seizures occur (message to carers):

If a seizure starts while the person is standing or sitting, help to prevent a fall injury by gently
Assisting them to sit or lie on the ground.
Make sure that the person is breathing properly.
Loosen the clothes around the neck.
Place the person in the recovery position
Open the person’s airway by gently tilting his or her head back and lifting the chin, and check that
nothing is blocking the airway.
Do not try to restrain or hold the person to the floor.
Do not put anything in the person’s mouth.
Move any hard or sharp objects away from the person to prevent injury.
Stay with the person until the seizure stops and the person regains consciousness.
Q. What medications are available for treatment?

Best suited drugs should be chosen in this given case scenerio:

Sodium valproate (Epival 250 mg):
In adults start 400 mg daily in divided doses.
Carbamazepine (Tegral 200mg):
In adults start 400 mg daily in divided doses.

Q. Enlist the side effects with the medication used for the treatment of this disorder?

Li (Nurolith 400mg) Valproate Carbamazepine

GI Effects GI symptoms GI Effects

Weight gain. Weight gain Weight gain
Neurologic effects Neurologic effects Neurologic effects
Dermatologic effects Dermatologic effects Dermatologic effects

Renal effects Hyperammonemia Renal effects

Cardiac effects Thrombocytopenia Blood dyscrasias

Thyroid effects Hepatotoxicity Hepatitis

Pancreatitis
Somnolence in elderly
Polycystic ovarian disease
Teratogenicity
During pregnancy…. Fingernail
hypoplasia

1. Sodium valproate

Women who are pregnant or breastfeeding should be avoid and for older adults use lower doses.

Common: Sedation, headache, tremor, ataxia, nausea, vomiting, diarrhea, weight gain, transient

hair loss.

Serious: Impaired hepatic function, thrombocytopenia, leukopenia, drowsiness/confusion

(valproate-induced hyperammonemic encephalopathy, a sign of toxicity), liver failure,

hemorrhagic pancreatitis. Use with caution if underlying or suspected hepatic disease.

2. Carbamazepine

Common: Sedation, confusion, dizziness, ataxia, double vision, nausea, diarrhea, benign

leukopenia.

Serious: Hepatotoxicity, cardiac conduction delay, low sodium levels. Caution in patients with

history of blood disorders, kidney, liver or cardiac disease. Dose may need to be adjusted after 2

weeks due to induction of its own metabolism.

Case

A 27-year-old man is brought to the emergency department by his friends and his

roommate. The friends state that the patient had not slept for the past 3 or 4 weeks. They have

noticed that he stays up all night cleaning his apartment. He has bought new computer

equipment and a digital video disc player, although his roommate claims that the patient

cannot afford these kinds of items. The patient has also been bragging to his friends, behavior

very unlike his usual self, and he has been very irritable.

The friends state that they have not seen the patient using drugs, and they do not think

he has any medical problems or takes any prescription medication. They are not aware of any

family history of medical or psychiatric disorders. They state that the patient is a graduate

student in social work.

On a mental status examination, the patient is noted to be alternately irritable and

elated. He is wearing a bright-orange top and red slacks, and his socks are mismatched. He

paces the room and refuses to sit down when asked to do so by the examiner. His speech is

rapid and loud, and it is hard to interrupt him. He claims that his mood is “great,” and he is

very angry with his friends for insisting that he come to the emergency department. He states

that they have probably insisted that he come because “they are jealous of my success.” He

states that he is destined for greatness. His thought processes are rapid. He denies having any

suicidal or homicidal ideation, hallucinations, or delusions.

Questions

What is the next diagnostic step?

What is the most likely diagnosis?

What could be the initial treatment? What is the next diagnostic step?

Next diagnostic step

A 27 year old man presents to the hospital with the symptoms of mania but before

diagnosing mania all the other possible biological causes for the maniac episode should be

ruled out first.

The use of drugs is also to be ruled out. A urinalysis should be done to check
out any drug abuse.

Brief Psychotic episode, Schizophrenia, Schizoid Personality disorder,

Bipolar Affective Disorder, Depression with psychotic features must also be ruled out.

What is the most likely diagnosis?

Most likely diagnosis

Mania Without Psychotic Symptoms (F 30.1) (ICD-10).

What could be the initial treatment?

Initial treatment

Patient should be admitted to the hospital for emergency care.

He is suggested to be treated with a mood stabilizer such as Lithium, Valproate or Carbamazepine etc.
and an antipsychotic in case of psychotic symptoms.