Clinical challenge

Case 1: Emily Gutenberg

Emily is 28 years of age and is 30 weeks pregnant. This is her first pregnancy. She has a past history of depression but is not currently on any medication. Emily was reluctant to attend today but has been brought in by her brother, who is concerned about her behaviour. From your assessment you believe she may have bipolar affective disorder.

Question 1

Which of the following statements regarding mental illness in pregnancy is TRUE?

1. The incidence of anxiety and depression in late pregnancy is approximately 6%.
2. A high score on the Edinburgh Postnatal Depression Scale indicates the presence of psychiatric illness.
3. Aversion to taking medication while pregnant is unlikely to contribute to a woman’s reluctance to seek help.
4. A diagnosis of bipolar affective disorder cannot be made during pregnancy or the postpartum period.
5. Ideally, women with pre-existing mental illness should be stable for 1 year prior to conception.

Question 2

All of the following are possible risk factors for Emily developing bipolar affective disorder during pregnancy, EXCEPT:

1. previous completion of a university degree
2. a socially isolated partner
3. a history of childhood abuse
4. a perfectionist personality style
5. a past history of depression.

Question 3

Which of the following regarding the risks of bipolar affective disorder during Emily’s pregnancy is TRUE?

1. Her child has a lower risk of developing a mood disorder.
2. She is at higher risk of self-harm.
3. She is less likely to drink alcohol.
4. Her child is less likely to need admission to neonatal intensive care.
5. Her child is less likely to experience neglect.

Question 4

You believe Emily would benefit from medication, but she is concerned about side effects for the baby. Which of the following statements is CORRECT?

1. Lithium has a 5% absolute risk of cardiac malformation.
2. SSRIs cause a 10-fold increase in the absolute risk of persistent pulmonary hypertension in the newborn.
3. Sodium valproate has a 17% risk of serious malformation.
4. Clozapine is safe to use in breastfeeding.
5. Olanzapine is contraindicated in pregnancy because of a high risk of teratogenicity.

Case 2: Srinath Sridhar

Srinath is a 4-year-old boy who is well known to you. He has a severe form of cerebral palsy. Over the past year, his health has deteriorated. He experiences frequent prolonged seizures and recurrent lower respiratory tract infections requiring hospital admission and ventilator support. He has been relatively well for the past 2 weeks and is seeing you today for his routine immunisations.

Question 5

Which of the following statements is TRUE regarding Srinath’s care?

1. There is no role for palliative care currently as end of life is not imminent.
2. He is not suitable for palliative care as this is generally reserved for those with progressive incurable conditions.
3. Discussion about palliative care at this stage should be avoided as it may signify giving up hope.
4. He is not suitable for palliative care as this is generally reserved for those with malignancies.
5. It would be appropriate to discuss the goals for Srinath’s ongoing care with his family at this appointment.

Question 6

Which of the following should trigger consideration of paediatric palliative care (PPC) involvement for Srinath?

1. There is uncertainty about his prognosis.
2. His family needs support to manage his complex care.
3. His symptoms become difficult to manage.
4. Answers A, B and C are correct.
5. Answers B and C are correct.

Question 7

You decide to refer Srinath to a PPC service. Which of the following statements regarding PPC services is TRUE?

1. PPC services can provide GPs with individualised management plans.
2. Specialist PPC services provide direct care for children in their communities.
3. PPC services primarily comprise paediatricians with training in palliative care.
4. PPC services have a limited role in facilitating communication between team members.
5. Patients linked to a PPC service are less likely to feel they have a choice over the location of end-of-life care.

Question 8

Several weeks later, Srinath is linked with the local PPC service. Which of the following regarding your role in his palliative care is FALSE?

1. You should discuss the family’s goals for end-of-life care.
2. There is no need for GP involvement in his palliative care once a specialist PPC service takes on care.
3. You may prescribe palliative medications for use at home.
4. You can provide support for the community PPC team.
5. You may need to manage any intercurrent illnesses he develops.

Case 3: Archie Phillips

Archie is a boy aged 8 years who has presented to your clinic on multiple occasions with abdominal pain. No organic cause has been identified. Today he is here with his father. You ask some further questions about his behaviour and academic progress at school.

Question 9

Which of the following might indicate difficulties at school?

1. Poorer academic performance than his older sister
2. Not being invited to a classmate’s birthday party
3. Mood swings
4. Teachers’ reports of disruptive behaviour in class
5. All of the above.

Question 10

You are concerned that Archie may be experiencing significant learning and behavioural difficulties at school. All of the following are risk factors for Archie having such problems EXCEPT:

1. high socioeconomic status
2. epilepsy
3. language delay
4. autism
5. type 1 diabetes.

Question 11

Which of the following is a potential outcome of Archie’s school difficulties?

1. Decreased motivation for learning
2. Lower employment prospects later in life
3. Poor-self esteem
4. Early school leaving
5. All of the above.

Question 12

What is the most appropriate next step in assessing Archie?

1. Reassure his father that these problems are common in Archie’s age group and he is likely to grow out of them.
2. Undertake a detailed developmental assessment.
3. Advise his father to read to him more after school.
4. Arrange referral for multidisciplinary developmental assessment.
5. Suggest keeping a behaviour diary for the next month.

Case 4: Allen Jeffries

Allen, aged 40 years, was recently diagnosed with young onset dementia. He presents today with his wife, Cynthia, to discuss his diagnosis.

Question 13

Which of the following statements about dementia is TRUE?

1. It is expected that almost 90 000 Australians will be living with dementia by 2050.
2. One in ten people over 85 have dementia.
3. Dementia is the third leading cause of death in Australia.
4. On average, symptoms are noticed by families approximately 6 months before a firm diagnosis is made.
5. There are around 2400 Australians with young onset dementia.

Question 14

Cynthia asks you if there are any treatments for dementia. Which of the following statements is true regarding potential interventions for Allen?

1. Cognitive behavioral therapy should be considered.
2. Cholinesterase inhibitors slow down progression of dementia.
3. Haloperidol is a first-line agent for behavioural and psychological symptoms.
4. Risperidone has few significant side effects.
5. Group-based psychological therapies have no impact on quality of life.

Question 15

Which of the following would be important to consider for Allen?

1. The need for a Webster pack
2. Whether Allen has an Advanced Health Directive in place
3. The need for an occupational therapist driving assessment
4. The need for a case manager
5. All of the above.

Question 16

Which of the following factors is likely to be an additional source(s) of stress for a younger person with dementia such as Allen?

1. Having a substantial mortgage
2. Pressure to improve his work performance
3. Concerns about genetic risk
4. Having young children
5. All of the above.