Sarah Vical
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You are the resident Psychiatry junior doctor and have been asked to go and review a patient in MAU who has been admitted with an overdose. You have limited information about the case.
Please take an appropriate history, including a risk assessment.
Your name is Sarah Vical, a 34 year old Chemistry teacher.
HPC: You were admitted after your friend from work spotted you through the flat letterbox, collapsed on the floor. You took a Paracetamol overdose of 30 tablets, which you have collected over the past month, planning to end your life. Around a month ago, you broke up with your long term boyfriend, and shortly afterwards, your best friend at work was made Deputy headteacher – a position you have been after for some time. You did not drink alcohol at the time of the attempt, but sent text messages to your sister and mother, explaining that this was “the end.” If asked whether you would attempt suicide again, respond with confirmation that you would. You have been considering other methods since you have been in hospital, including crashing your car. Recently your mood has been low. Your appetite is unaffected but you have been waking early from sleep and some of your students have mentioned you look “tired.” Last week, things came to a head when you had a large argument with a particularly mischievous student and the Biology teacher in the neighbouring classroom had to come and intervene. You do not enjoy the job you once loved.
PMH/PPH: You suffer from asthma and have a salbutamol inhaler, which you rarely use. You have previously attempted to take your life when you were a teenager in college, under the stress and pressures of your A level exams.
FH: Nil of note
PH: Your father left when you were two years old and you have not seen him since. You have been well educated and brought up by your mother, who struggled to look after you and your sister as well as working as a cleaner.
Forensic H: A previous altercation for drunk and disorderly at university, where you broke into the Campus chemistry labs to steal some Bromic acid for your home experiments.
Please try and maintain a negative and depressed persona when interviewed for the purposes of a mental state examination.
The student should take a focussed history, sensitively dealing with this lady’s suicidal risk. A good candidate will approach before, during and after the incident as well as going on to elicit the ICD-10 criteria for depression. When assessing risk it is important to mention suicide, self harm and risk to others. It is not unreasonable to ask about self-neglect or exploitation risk given the context of this scenario. Ask them to feedback an MSE. Although there are not many positive findings in this scenario, it is good practice to run through. The student’s differentials should sound something like this: ‘My main differential for this lady’s presentation is attempted suicide secondary to a moderate to severe depressive episode. I would want to rule out a personality disorder and take a more detailed history before making a firm diagnosis. This lady is at high risk of suicide at present and should not be discharged without a senior psychiatric review. Topics for discussion could include: • What is this lady’s risk? • How would you manage her? (Bio/psycho/social aspects of depression, when directly managing this situation it is important to mention probable admission to a psychiatry hospital for further assessment) • If this patient wanted to leave, what mental health act could you evoke as an F2 (and above) doctor? • How would you differentiate whether this was an episode of depression or a personality disorder?
