A Lawyer With Elevated Mood

PART 1

100

Does Jakob C have Bipolar I, Bipolar II or something else?

Bipolar I, because this is an episode of mania which is the requirement for Dx of Bipolar I. This is mania rather than hypomania due to the severity of his symptoms and the functional impairment.

200

Does he need hospitalisation, or should he be managed as an outpatient?

2. Mania is a medical emergency, and given the severity of his symptoms he needs to be admitted on an inpatient basis. His finances, reputation and relationships are at significant risk. Factors to consider for admission are as following: presence of supportive family/carers, availability of public crisis or acute care services, presence of significant comorbidities such as substance abuse, treatment history.

300

What therapeutic interventions should be included in the initial management plan for this particular patient?

A mood stabilising therapy and/or an antipsychotic depending on severity. If the mental state of the patient allowed: psychoeducation. Given this patient’s agitated state I would also want a sedative/benzodiazepine.

400

What are the 6 grounds for involuntary admission under the Mental Health Act (2000)

Need all of 1. person suffering from mental illness 2. illness requires immediate treatment 3. treatment available at authorised mental health service 4. illness may give rise to imminent risk of harm to self or others OR illness may cause the person to suffer serious mental or physical deterioration 5. no less restrictive way to treat 6. person lacks capacity to consent OR has unreasonably refused treatment

PART 1

100

On the basis of the information provided in this vignette, what specific risks are already evident?

job loss, over spending/financial ruin, substance abuse (based on prior self medicating Hx), family history of suicide, relationship issues with wife

200

List 5 common adverse effects of risperidone

common adverse effects of risperidoen: somnolence, insomnia, agitation, anxiety, headache, rhinitis, fatigue, parkinsonism, akithsia, increased appetite, vomiting, drooling, urinary incontinence, tremor, nasopharyngitis

300

What initial dose of risperidone would you have used, assuming that the patient weighs 70kg?

Initial dose of risperidone: 2-3 mg/day PO

400

What initial dose of lorazepam would you have used? How frequently should it have been administered, and by what route of administration?

2 to 4 mg per day, taken in three to four divided doses. per oral

PART 2

100

True or False: Bipolar disorder is more common in men

False. Rates are effectively equal

200

Which mood stabilisers can be used instead of lithium carbonate?

Valproate, Carbamazepine

300

List 5 common adverse effects of lithium carbonate at therapeutic serum levels.

Leukocytosis (most patients) Polyuria/polydypsia (30-50%) (Nephrogenic diabetes insipidus ( decr ADH effect); manage with amiloride) Dry mouth (20-50%) Hand tremor (45% initially, 10% after 1 year of treatment) Confusion (40%) Decreased memory (40%) Headache (40%) Muscle weakness (30% initially, 1% after 1 year of treatment) Electrocardiographic (ECG) changes (20-30%) Nausea, vomiting, diarrhea (10-30% initially, 1-10% after 1-2 years of treatment)

400

List six manifestations of lithium toxicity.

• Tremors • Lethargy • Confusion • Seizures • Coma • Nausea • Vomiting • Crampy abdominal pain • Diarrhea • Hyperreflexia • Cardiovascular collapse

PART 2

100

Is bipolar more common in higher or lower socioeconomic status? What is the average age of presentation (within 5 years)?

More common in high SES, mean age 30

200

Is there any place for the use of electroconvulsive therapy (ECT) in the management of acute mania?

Electroconvulsive therapy — We suggest electroconvulsive therapy (ECT) for refractory patients whose manic episode does not respond to four to six medication combinations. Several studies suggest that ECT is effective for mania. ECT is generally safe and there are no absolute contraindications, even in patients whose general medical status is compromised

300

Is the THC likely to be implicated in his manic presentation?

Cannabis abuse prior to development of bipolar disorder has a significant effect on first-episode mania and on the course of the disease. Another study reported that using cannabis at baseline can significantly increase the risk for manic symptoms during follow up

400

What instructions should be given to the nursing staff when a patient is on lorazepam?

Benzodiazepine sedatives such as lorazepam may cause oversedationand loss of gag reflex, particularly when lorazepam is given parenterally, in large doses or in combination with other psychotropic medications. As a consequence, trained personnel should be monitoring the patient