Sample Vignettes
The following are two
examples of case vignettes of a style and content similar to those to be used
in the vivas. A candidate would be presented with a
number of vignettes, given a few minutes to check relevant texts, and then
asked some questions. You will see that there is a marking grid, with
discretion for the panel to award marks for additional information.
College
of Mental Health Pharmacists
Sample Case Vignette 1
CR is a 38 year old woman diagnosed with schizophrenia 10
years ago. Continuous
admission for last two years since stopping clozapine (well for 6 years on
this). Presently she exhibits
florid positive symptoms including delusions of grandeur and somatic
hallucinations.
Drug
therapy:
Flupenthixol decanoate 200mg/week (recently increased from 100mg/2
weeks)
Procyclidine 10 mg tds
Chlorpromazine 25mg IM PRN
Patient
has received 3 x IM chlorpromazine in last two
days. Given 2nd
weekly dose of 200mg decanoate at 1300 despite being
physically unwell (anxious, sweating, palpitations (95bpm)). At 1330, patient is found collapsed, cyanosed
and not breathing. On transfer to
medical unit, patient is declared brain dead.
Post mortem suggests natural causes can be excluded.
Questions
1. How might drug therapy have
contributed to the patient’s death?
1. Generally speaking, which antipsychotics might be recommended in order to reduce the
risk of sudden death?
Additional information
available
1. Patient has previously received
haloperidol, chlorpromazine, thioridazine and quetiapine, often in combination.
2. No previous episodes of collapse.
3. PM revealed only pulmonary and
cerebral oedema consistent with respiratory arrest.
4. No family history of sudden cardiac
death.
5. No cardiac abnormalities at PM.
|
Discuss
QTc prolongation, torsade
des pointes and sudden cardiac death. Mention QTc
units and ‘safe’ range of values. |
4 marks |
|
Discuss
possibility of intravasation of depot as cause of death
by oily bolus injection. |
1 mark |
|
Discuss differential effects of other antipsychotics
on QTc. Support
recommendations with knowledgeable argument. |
3 marks |
|
Other
cogent recommendations or information not covered by above. |
2 marks |
College
of Mental Health Pharmacists
Sample case Vignette 2
LH is a
43 year old, recent divorcée, with a diagnosis of bipolar affective
disorder. She has had two manic
relapses, of which one had been catastrophic - she lost custody of her children
and had to sell her house. For the last
two years she has been stable and has a new partner. She now wants to stop lithium therapy, having
been maintained on it for 3 years. She
ha no obvious side effects, except that she feels “mentally dulled”.
Questions
1.
What
are the monitoring requirements for lithium?
2.
What
are the therapeutic options for LH?
Discuss their relative merits and licensed indications.
3.
What
additional considerations would be necessary if LH wanted to become pregnant?
Additional information
1.
Dose
is 800mg/day; 12
hour plasma level 0.85 mmol/L.
2.
No
other medications; U&Es, etc. OK.
Answer guide
|
Discuss
use of 12 hour plasma level every 3-6 months.
U&Es, thyroid, etc. Mention therapeutic range |
3 marks |
|
Lithium,
carbamazepine, valproate
(& conventional antipsychotics) Mention
therapeutic and adverse effects. |
3 marks |
|
All
drugs cause foetal abnormalities; no one drug clearly safer. Mention Ebstein’s
anomaly and neural tube defects (& use of folate). |
3 marks |
|
Any
additional information not mentioned above |
1 mark |