Simulated Patient Scenario

Teenager - First Presentation Acute Psychosis

Scenario Details

Scenario: First Presentation Acute Psychosis

Simulated Patient: 16-year-old

Actor/Actress: Student Actor (Patient), Student Actor (Parent)

MDT Information

Urgent Response - Behavioral Disturbance / Altered Mental State
16yo male acting bizarrely
Family concerned for safety
Patient is awake, breathing normally, distressed

On Arrival

You arrive at a suburban home. A distressed parent meets you at the door and leads you to the living room. The patient, a 16-year-old male, is pacing the room, talking intermittently to himself. He appears dishevelled, suspicious, and fearful. The room is tidy, with no obvious hazards.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Appears distressed, agitated, potentially fearful. Physically stable.
Response	Awake but distractible, responds intermittently to voice, appears internally preoccupied (AVPU='V', but consider psychosis).
Airway	Clear and self-maintained.
Breathing	Rate appears slightly elevated but unlabored, normal chest rise and fall.
Circulation	Skin appears normal colour and temperature, radial pulse strong.
Disability	Obvious altered mental state - disorganized thoughts, potential hallucinations/delusions.
Exposure/Environment	Indoor home environment, appears safe. No obvious signs of trauma or injury.

Secondary Survey and Simulation Progression

History (obtained primarily from parent)

Allergies	NKDA
Medications	None prescribed. Parent unsure about recreational drug use but found vape paraphernalia recently.
Past Medical History	Generally healthy. No previous psychiatric history. No significant medical conditions. Normal development milestones.
Last Oral Intake	Parent thinks he ate breakfast (~4 hours ago) but has refused food since. Unsure about fluids.
Events Preceding	Parent reports noticeable decline over the past 2-3 weeks: social withdrawal, decline in school performance, odd behaviour, poor sleep, increasing paranoia (believes neighbours are spying on him). Became acutely distressed and agitated this morning, talking nonsensically. No specific trigger identified. Possible recent stressor (school exams). Family history: Paternal uncle has schizophrenia.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	20
Lung Sounds (L/R)	Clear bilaterally
SpO2 (%)	98% (Room Air)
EtCO2 (mmHg)	Not indicated unless sedated/airway concerns
Pulse Rate (/min.)	110, regular
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Not initially indicated unless specific concerns arise (e.g., toxin ingestion)
BP (mmHg)	130/75
Skin	Normal colour, warm, dry
Pain (/10)	Not complaining of pain, difficult to assess reliably.
GCS (/15: E,V,M)	Difficult to assess formally due to thought disorder/paranoia. E=4, V=Approx 3-4 (confused/disorganised), M=6. (Score ~13-14, but note limitations).
BGL (mmol/L)	5.8
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive
Temp. (°C)	36.8

Physical Examination

Mental State: Appears anxious, hypervigilant. Poor eye contact. Speech may be rapid, tangential, or show poverty of content. Thought content reveals paranoid delusions (being watched/followed). Possible auditory hallucinations (responding to unseen stimuli). Poor insight into illness. Cognition difficult to assess formally but appears disoriented to situation.
Neurological: Gross motor function appears intact (pacing). Cranial nerves grossly intact (if assessable). No focal deficits noted.
General: No signs of trauma. No obvious signs of toxidrome (pupils normal, skin normal). Appears physically healthy but dishevelled.
Abdomen/Chest/Limbs: Unremarkable on visual inspection.

Assessment and Treatment

Appropriate Management Focus

Prioritize safety: Ensure safety of patient, crew, and family. Maintain calm environment.
Communication: Attempt to build rapport using calm, clear, concise language. Validate distress without confirming delusions. Active listening. Engage with parent for history and support.
De-escalation: Use verbal techniques primarily. Avoid confrontation. Maintain safe distance.
Assessment: Thorough history (collateral essential). Mental state examination. Vital signs. BGL. Consider and exclude organic causes (hypoglycaemia, substance use, head injury, infection – although less likely given history).
Supportive Care: Reassurance. Offer supportive presence.
Consultation/Referral: Recognize need for urgent psychiatric assessment. Transport to Emergency Department equipped for mental health assessment. Consider early notification to receiving hospital. Involve family in decisions where appropriate.
Restraint/Sedation: Avoid if possible. Consider only if severe agitation poses immediate danger despite de-escalation, following local protocols (unlikely focus for basic OSCE unless specified).
Teamwork: Shared mental model, clear roles, communication with partner.

Debrief Focus Points

Communication strategies with psychotic patients.
Importance of collateral history.
Risk assessment (patient, crew, others).
De-escalation techniques.
Recognizing limitations of prehospital assessment for psychosis.
Appropriate destination and referral pathways.
Teamwork and scene management.