After the event

November 2014

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Clinical Challenge

Volume 43, No.11, November 2014 Pages 815-816

Questions for this month’s clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated 4 Category 2 points (Activity ID:10981).

Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2014–16 triennium; therefore, the previous months answers are not published.

Case 1 – Madeline

Madeline, aged 29 years, is a marine navigator in the Australian Navy. While on leave between deployments she has been staying with her family, who are regular patients in your practice. Madeline’s mother is very concerned about her and brings her to see you today. Madeline is quite circumspect about her health, but her mother informs you that she has insomnia and her mood is persistently lowered. After listening to both Madeline and her mother, you become increasingly concerned that she may have post-traumatic stress disorder (PTSD).

Question 1

While taking a more substantive history, you are mindful of the recently altered DSM-5 diagnostic criteria for PTSD. Which of the following is no longer considered necessary to make a diagnosis of PTSD?

  1. Avoidance symptoms
  2. Negative cognitions and mood symptoms
  3. Experience of a traumatic event
  4. Experience of intense fear, helplessness or horror in response to traumatic event
  5. Minimum of six symptoms

Question 2

Every general practitioner plays an important role in managing newly diagnosed patients with PTSD. Which one of the following is LEAST likely to be part of this role?

  1. Initial assessment
  2. Prescription of initial pharmacotherapy
  3. Timely referral for specialist treatment
  4. Management of comorbid medical conditions
  5. Initiation of cognitive behavioral therapy

Further information

Madeline agrees that her symptoms are consistent with PTSD and is keen to begin medical treatment.

Question 3

Why might you consider the use of medications over psychological treatment for Madeline?

  1. Medications are more effective
  2. Lack of access to psychological therapies
  3. Absence of comorbid depression
  4. Medications give a more sustained response
  5. Medications have a more rapid response

Question 4

After further discussion, Madeline agrees to commence antidepressant medication. When compared to medications used for depression, which of the following is most appropriate for the treatment of PTSD, according to the evidence?

  1. Higher doses of selective serotonin reuptake inhibitors
  2. Slightly lower doses of tricyclic antidepressants
  3. Unchanged doses of serotonin and noradrenaline reuptake inhibitors
  4. Higher doses of monoamine oxidase inhibitors
  5. Lower doses of mirtazepine

Case 2 – Theresa

Theresa is a previously well woman, 27 years of age, who was struck by a vehicle from behind while riding her bicycle to work. Despite wearing an approved helmet, she sustained a significant head injury requiring a 14-week inpatient stay in the neurosurgery unit at a major metropolitan hospital. She was discharged yesterday to the care of her husband on a rehabilitation program and hopes to return to work as soon as possible.

Question 5

Theresa has an acquired brain injury (ABI). Which one of the following is NOT a mechanism for developing an ABI?

  1. Traumatic
  2. Vascular
  3. Metabolic
  4. Degenerative
  5. Infective

Question 6

Although management is always best planned with a firm diagnosis, there are no conclusive diagnostic tests for traumatic brain injury (TBI). Which one of the following computed tomography scan findings is most indicative of a TBI?

  1. Increasing brain volume over time
  2. Widening of the hippocampal gyrus
  3. Brain stem attenuation
  4. Decreasing brain volume over time
  5. Narrowing of the internal capsule membrane

Question 7

Theresa has come to ask your opinion about her future prognosis. Which one of the following is the most reliable indicator of TBI severity?

  1. Length of post-trauma amnesia
  2. Length of pre-trauma amnesia
  3. Time from trauma to intubation and definitive airway
  4. Time from trauma to IV steroids given in the initial phase
  5. Number of days requiring sedation and ventilation

Question 8

Theresa’s husband is most worried about the long-term impairments associated with TBI. Which one of the following is NOT a common long-term problem after 3 months in moderate-to-severe TBI?

  1. Cognitive impairment
  2. Functional impairment
  3. Post-traumatic communication changes
  4. Post-traumatic epilepsy
  5. Post-concussion syndrome

Case 3 – Elizabeth

Elizabeth presents to your practice without an appointment just before scheduled closing time. While you listen to her presenting complaints relating to non-specific gastrointestinal symptoms, you notice a number of bruises on her forearms and shins. These vary in size and duration since onset. Suspecting non-accidental trauma, you gently probe her with questions. She then feels able to reveal a long history of physical abuse from her husband.

Question 9

Elizabeth is the victim of interpersonal violence in the context of the family. This may occur through each of the following modalities EXCEPT:

  1. Physical
  2. Emotional
  3. Sexual
  4. Economic
  5. Co-dependency

Question 10

Direct questioning about partner violence needs to be handled with discretion and empathy, and be structured in a safe, supportive atmosphere. Which one of the following is the LEAST EFFECTIVE question(s) to ask in this first interview?

  1. As violence in the home is uncommon why do you think this is happening to you?
  2. Has your partner ever physically threatened or hurt you?
  3. Is there a lot of tension in your relationship? How do you resolve arguments?
  4. Are you afraid of your partner?
  5. Have you ever felt unsafe in the past?

Question 11

A number of psychological symptoms are commonly seen in people experiencing intimate partner violence. Which one of the following is NOT part of this set?

  1. Depression
  2. Substance abuse
  3. Anxiety
  4. PTSD
  5. Obsessive-compulsive disorder

Question 12

Having established a low immediate safety risk at the initial consultation, you are able to return to more detailed safety planning for Elizabeth at a subsequent consultation. Which of the following would be an element of this safety planning?

  1. Calling the police
  2. Referring the patient for psychological therapy
  3. Identifying a safe place to go and how to get there
  4. Strongly encouraging Elizabeth to leave her partner
  5. Empowerment counselling

Case 4 – Julio

Washington, one of your regular patients, contacts you to ask that you see Julio who is living at a local charity residence and has no Medicare card. Washington is concerned that Julio is hiding his poor health status as he is worried this may be used against him in the future and lead to deportation. As such, he requests that you see him as a private patient in confidence.

Question 13

Asylum seekers are at high risk of mental health problems. Which of the following factors, when present, warrant particular consideration of mood and anxiety disorders?

  1. Past history of witnessing loss of family members
  2. Past history of torture
  3. Past history of prolonged detention
  4. Presentation with memory loss
  5. All of the above

Question 14

While screening for mental health disorders, it is equally important to look for known protective factors against the development of these disorders. Which one of the following is NOT considered to be a protective factor?

  1. Strong sense of community
  2. No past history of mental health problems
  3. Forward-looking narrative of survival
  4. Religious focus
  5. Spiritual focus

Question 15

Asylum seekers may have poor English language skills, which makes it difficult to assess their mental health status. Which one of the following interpreters is most appropriate in helping you delve sufficiently deeply into a patient’s inner thoughts to accurately assess their mental health status?

  1. Telephone interpreter service
  2. Teenage son accompanying patient
  3. Partner of the patient
  4. Government-appointed case officer accompanying patient
  5. Another patient or asylum seeker who shares a common language and heritage

Correspondence afp@racgp.org.au

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