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  • Question 1 - What option indicates managing depression through monitoring and providing general guidance only? ...

    Incorrect

    • What option indicates managing depression through monitoring and providing general guidance only?

      Your Answer: Symptoms of short duration

      Correct Answer: No obvious trigger factors

      Explanation:

      Managing Depression Symptoms

      A patient experiencing symptoms of depression for less than two weeks or with intermittent symptoms can initially be managed through non-invasive methods. This approach is also suitable if there is a clear stressor or if the patient has good social support. However, if the patient has a family history of depression or has had suicidal thoughts, more active intervention may be necessary. It is important to carefully assess each patient’s individual situation and provide appropriate treatment to ensure the best possible outcome.

    • This question is part of the following fields:

      • Mental Health
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  • Question 2 - A 56-year-old gentleman with a history of depression comes to see you. Last...

    Incorrect

    • A 56-year-old gentleman with a history of depression comes to see you. Last month he was admitted to hospital after having taken a paracetamol overdose as a suicide attempt.

      Which of the following factors suggests the greatest chance of his making another attempt on his life?

      Your Answer: He visited a solicitor and made a will the previous week

      Correct Answer: He consumed the paracetamol whilst inebriated

      Explanation:

      Assessing Suicidal Intent: Factors to Consider

      There are several factors to consider when assessing current and ongoing suicidal intent. Being unemployed and living alone may increase the risk, but they are not the strongest indicators of actual intent. Consuming a large quantity of alcohol at the same time may also complicate the risk assessment. To determine actual suicidal intent, it is important to inquire about the planning of the act, attempts made not to be discovered, the location of the attempt, the presence of a suicide note, and how the patient perceives the potential harm of their actions.

      A suicide note indicates a serious attempt at suicide and suggests that considerable thought has gone into the attempt. However, notes are also common in parasuicides as a cry for help and are often not found in completed suicides. Visiting a solicitor to make a will in advance of the attempt demonstrates the highest likelihood of a subsequent attempt, as it shows considerable planning and forethought. By considering these factors, healthcare professionals can better assess the level of suicidal intent and provide appropriate interventions to prevent future attempts.

    • This question is part of the following fields:

      • Mental Health
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  • Question 3 - A 15-year-old girl is brought to her General Practitioner by her mother and...

    Correct

    • A 15-year-old girl is brought to her General Practitioner by her mother and she complains that she resists going to school because she wants to stay with her mother. She becomes terrified whenever her parents leave the house. During the day she worries that her family may never come back home.
      What is the disorder most closely associated with these symptoms in adulthood?

      Your Answer: Panic disorder

      Explanation:

      The Relationship Between Childhood Separation Anxiety and Mental Disorders

      Separation anxiety disorder is a condition characterized by excessive anxiety related to separation from an attachment figure, such as a mother. Studies have shown that this disorder is a strong risk factor for developing mental disorders, particularly panic disorder and depression, in people aged 19-30 years. However, there is no proven link between childhood separation anxiety and irritable bowel syndrome, obsessive-compulsive disorder, schizophrenia, or somatic symptom disorder. While negative childhood experiences may play a role in the development of some mental disorders, separation anxiety in childhood is not directly related to these conditions.

    • This question is part of the following fields:

      • Mental Health
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  • Question 4 - A 39-year-old teacher is being evaluated after starting an antidepressant. She initially presented...

    Incorrect

    • A 39-year-old teacher is being evaluated after starting an antidepressant. She initially presented with various symptoms of depression and a PHQ-9 score of 18. She has experienced several significant life events leading up to her diagnosis.

      She is married with a daughter in college, but has a strong support system from her family. You decided to initiate treatment with sertraline 50 mg, but she reports no improvement in her depression and your assessment agrees.

      Despite the lack of effectiveness in her treatment thus far, she appears to be tolerating the medication without any adverse effects.

      Based on NICE guidelines for depression treatment, at what point in her treatment would you consider increasing the dosage if she has not responded?

      Your Answer: Four to six weeks

      Correct Answer: Six to eight weeks

      Explanation:

      Treatment for Depression: Considerations for Medication Adjustment

      When treating depression, it is important to monitor the patient’s response to medication. If there is no improvement within three to four weeks, it may be necessary to increase the dose or switch to a different antidepressant. However, if there is some improvement at four weeks, it is recommended to continue treatment for an additional two to four weeks before making any further changes.

      In this particular case, the patient is tolerating the medication well and has support from her husband. Therefore, the focus should be on adjusting the medication. This recommendation is based on NICE guidance on Depression in adults (CG90) and is supported by other publications. By closely monitoring the patient’s response and making appropriate adjustments, healthcare providers can help improve outcomes for those struggling with depression.

    • This question is part of the following fields:

      • Mental Health
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  • Question 5 - A 58-year-old woman is brought to see you by her son, who reports...

    Correct

    • A 58-year-old woman is brought to see you by her son, who reports that the family is at their wit's end. She has always been prone to 'melancholy', but over the last few months has become excitable, spending large amounts of money on a television shopping channel and booking a number of expensive holidays for herself and her family. Although she seems to have boundless energy, her home is very untidy and she is irritable when criticized.
      Select from the list the single most likely diagnosis.

      Your Answer: Bipolar disorder

      Explanation:

      Understanding Bipolar Disorder: Types, Prevalence, and Symptoms

      Bipolar disorder, previously known as manic-depressive psychosis, is a mental health condition that is characterized by alternating episodes of mania and depression. There are two types of bipolar disorder: Bipolar I and Bipolar II. Bipolar I is characterized by severe manic episodes that result in impaired functioning and frequent hospital admissions, interspersed with major depressive episodes. On the other hand, Bipolar II patients experience hypomanic episodes that are less severe than full mania and do not have psychotic symptoms.

      Studies suggest that bipolar disorder has a lifelong prevalence rate of 2.4%. When hallucinations and delusions are present during the manic phase, it can be difficult to differentiate from schizophrenia. However, this patient’s age suggests that it is unlikely to be schizophrenia. Additionally, periods of melancholy suggest interspersed depressive episodes. There is no indication of cognitive dysfunction, and the recent marked change in behavior doesn’t suggest someone who is normally a bit high.

      In conclusion, understanding the types, prevalence, and symptoms of bipolar disorder is crucial in identifying and treating this mental health condition.

    • This question is part of the following fields:

      • Mental Health
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  • Question 6 - A 70-year-old man contacts his primary care physician for advice. He lost his...

    Incorrect

    • A 70-year-old man contacts his primary care physician for advice. He lost his wife to cancer and has been a widower for 6 months. The patient has a supportive family and is not clinically depressed, but he was very emotional after his wife's passing. He sometimes feels indifferent and down, but this has improved significantly over time. However, he has been hearing his late wife's voice on several occasions for the past 2 weeks. He also believed he saw her once while shopping with a friend, but he knows this is impossible.

      What is the most appropriate course of action for managing this situation?

      Your Answer:

      Correct Answer: Reassure and safety-net

      Explanation:

      It is possible for pseudo hallucinations to be a normal part of the grieving process. People who are grieving may experience hearing, seeing, or even smelling their deceased loved one. These occurrences are often associated with acute grief but can happen at any stage of bereavement. Therefore, the patient in question can be reassured.

      Since there is no evidence of an organic cause for the patient’s symptoms, it would be inappropriate to arrange blood tests and urinalysis.

      While antidepressants may be used to treat severe or atypical cases of grief, they are unlikely to provide significant benefits for a patient who is not clinically depressed. Additionally, they may cause harm due to their adverse effects.

      The patient is fully aware of the situation and has insight into their condition. Therefore, there is no need for urgent involvement from a psychiatrist or for the patient to be sectioned under the Mental Health Act 1983.

      Understanding Pseudohallucinations: A Controversial Topic in Mental Health

      Pseudohallucinations are a type of false sensory perception that occur in the absence of external stimuli. Unlike hallucinations, the affected person is aware that they are experiencing a false perception. However, there is no clear definition of pseudohallucinations in the ICD 10 or DSM-5, leading to controversy among mental health specialists.

      Some experts argue that it is more helpful to view hallucinations on a spectrum, ranging from mild sensory disturbances to full-blown hallucinations. This approach can prevent misdiagnosis or mistreatment of symptoms. For example, hypnagogic hallucinations, which occur during the transition from wakefulness to sleep, are a common type of pseudohallucination that many people experience. These hallucinations are fleeting and can be either auditory or visual.

      The relevance of pseudohallucinations in mental health practice is that patients may need reassurance that these experiences are normal and do not necessarily indicate the development of a mental illness. Pseudohallucinations are also commonly experienced by people who are grieving, which can add to the confusion and distress of the grieving process.

      In conclusion, while the definition and role of pseudohallucinations in mental health treatment remain controversial, it is important for mental health professionals to be aware of this phenomenon and provide appropriate support and reassurance to those who experience it.

    • This question is part of the following fields:

      • Mental Health
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  • Question 7 - A 60-year-old man is brought to his General Practitioner (GP) by his son....

    Incorrect

    • A 60-year-old man is brought to his General Practitioner (GP) by his son. The son complains that his father's personality has changed completely over the past year. Even at his best, he is forgetful and ‘switched off’. At worst, he is drowsy and unresponsive. He is particularly concerned that his father has been claiming to 'see things that aren't really there'. Over the past few weeks, he has also been tripping a lot on the carpet and is no longer safe on the stairs going to his bedroom unaccompanied. The GP gave the patient a small dose of a neuroleptic which 'made things a million times worse'.
      On examination, he has an inexpressive face, with a mild resting tremor and some axial rigidity. There is no other focal neurology. On mini-mental state examination, he scores 20/30.
      What is the most likely primary brain pathology?

      Your Answer:

      Correct Answer: Lewy bodies

      Explanation:

      Understanding Lewy Body Dementia: A Comparison with Other Neurological Conditions

      Lewy body dementia is a neurological condition characterized by extrapyramidal signs, visual hallucinations, and a variable symptom profile. Patients with this condition are also highly sensitive to the anticholinergic side-effects of neuroleptics. The presence of eosinophilic inclusions bodies called Lewy bodies in the limbic areas of the brain is a hallmark of this condition.

      It is important to differentiate Lewy body dementia from other neurological conditions that may present with similar symptoms. Normal brain is an unlikely diagnosis given the neurological symptoms seen in patients with Lewy body dementia. Multiple infarcts in the grey matter, on the other hand, typically have a stepwise course with an acute onset and patchy cognitive impairment. Neurofibrillary tangles are characteristic of Alzheimer’s disease, which presents with early impairment of memory that evolves into more general deficits in concentration and attention. Finally, Pick bodies are associated with fronto-temporal dementias and tend to involve disinhibition as an early feature.

      In summary, understanding the unique features of Lewy body dementia and its differences from other neurological conditions is crucial for accurate diagnosis and appropriate management of patients.

    • This question is part of the following fields:

      • Mental Health
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  • Question 8 - Which one of the following is least acknowledged as a possible negative outcome...

    Incorrect

    • Which one of the following is least acknowledged as a possible negative outcome of electroconvulsive therapy?

      Your Answer:

      Correct Answer: Epilepsy

      Explanation:

      There is no long-term risk of epilepsy associated with electroconvulsive therapy, despite the fact that it induces a controlled seizure.

      Electroconvulsive therapy (ECT) is a viable treatment option for individuals who suffer from severe depression that doesn’t respond to medication, such as catatonia, or those who experience psychotic symptoms. The only absolute contraindication for ECT is when a patient has raised intracranial pressure.

      Short-term side effects of ECT may include headaches, nausea, short-term memory impairment, memory loss of events that occurred before the treatment, and cardiac arrhythmia. However, these side effects are typically temporary and subside after a short period of time.

      Long-term side effects of ECT are less common, but some patients have reported impaired memory. It is important to note that the benefits of ECT often outweigh the potential risks and side effects, and it can be a life-changing treatment for those who have not found relief from other forms of therapy.

    • This question is part of the following fields:

      • Mental Health
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  • Question 9 - What is the main diagnostic core symptom of depression? ...

    Incorrect

    • What is the main diagnostic core symptom of depression?

      Your Answer:

      Correct Answer: Fatigue or loss of energy

      Explanation:

      Core Symptoms of Depression

      Depression is a mental health condition that affects millions of people worldwide. One of the defining characteristics of depression is the presence of core symptoms that are present for more than two weeks. These core symptoms include persistent feelings of sadness or hopelessness, as well as a marked loss of interest or pleasure in activities that were once enjoyable.

      It’s important to note that while there are other symptoms of depression, such as changes in appetite or sleep patterns, these are classified as other symptoms and are not considered core symptoms. This means that someone may experience these symptoms without necessarily meeting the criteria for a diagnosis of depression.

      If you or someone you know is experiencing persistent feelings of sadness or loss of interest in activities, it’s important to seek help from a mental health professional. Depression is a treatable condition, and with the right support, individuals can learn to manage their symptoms and improve their quality of life.

    • This question is part of the following fields:

      • Mental Health
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  • Question 10 - You receive a letter from the consultant psychiatrist about one of your elderly...

    Incorrect

    • You receive a letter from the consultant psychiatrist about one of your elderly patients. The psychiatrist advises that the patient has bipolar disorder and should be started on lithium carbonate.

      Assuming the patient is otherwise fit and well, which one of the following is correct in terms of monitoring when on lithium?

      Your Answer:

      Correct Answer:

      Explanation:

      To ensure safe use of lithium therapy, the BNF recommends regular monitoring of various parameters. This includes checking body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months. In particular, thyroid function should be monitored more frequently if there is any indication of deterioration. Similarly, renal function should be assessed at baseline and then every 6 months, with more frequent monitoring if there are any signs of decline or if the patient is taking medications such as ACE inhibitors, NSAIDs, or diuretics that increase the risk of renal impairment.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in refractory depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate or cAMP formation.

      Common adverse effects of lithium include nausea, vomiting, diarrhea, fine tremors, and nephrotoxicity. It may also cause thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, and hyperparathyroidism.

      Monitoring of patients on lithium therapy is crucial to prevent toxicity. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until concentrations are stable. Once established, lithium levels should be checked every 3 months. Thyroid and renal function should be checked every 6 months. Patients should be provided with an information booklet, alert card, and record book. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

    • This question is part of the following fields:

      • Mental Health
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  • Question 11 - A 28-year-old woman presents with dry, eczematous hands. She reports being a very...

    Incorrect

    • A 28-year-old woman presents with dry, eczematous hands. She reports being a very hygienic person, but since the onset of the covid-19 pandemic, she has been washing her hands excessively - up to 50 times a day. She is aware that this is causing her skin to become dry and irritated, but her attempts to reduce her hand washing have led to increased anxiety and a return to her previous routine. She works in a hospital and is worried about her colleagues noticing her frequent hand washing. Given her symptoms, what treatment options are available for her?

      Your Answer:

      Correct Answer: Cognitive behavioural therapy

      Explanation:

      Understanding Obsessive-Compulsive Disorder (OCD)

      Obsessive-compulsive disorder (OCD) is a mental health condition that affects 1 to 3% of the population. It is characterized by the presence of obsessions, which are unwanted intrusive thoughts, images, or urges, and compulsions, which are repetitive behaviors or mental acts that a person feels driven to perform. These symptoms can cause significant functional impairment and distress.

      Risk factors for OCD include a family history of the condition, age (with peak onset between 10-20 years), pregnancy/postnatal period, and a history of abuse, bullying, or neglect.

      The management of OCD involves classifying the level of impairment as mild, moderate, or severe using the Y-BOCS scale. For mild impairment, low-intensity psychological treatments such as cognitive behavioral therapy (CBT) including exposure and response prevention (ERP) are recommended. If this is insufficient, a course of an SSRI or more intensive CBT (including ERP) can be offered. For moderate impairment, a choice of either an SSRI or more intensive CBT (including ERP) is recommended, with clomipramine as an alternative first-line drug treatment to an SSRI if necessary. For severe impairment, referral to the secondary care mental health team for assessment is necessary, with combined treatment of an SSRI and CBT (including ERP) or clomipramine as an alternative while awaiting assessment.

      ERP is a psychological method that involves exposing a patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. This helps them confront their anxiety, leading to the eventual extinction of the response. Treatment with an SSRI should continue for at least 12 months to prevent relapse and allow time for improvement. Compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response.

    • This question is part of the following fields:

      • Mental Health
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  • Question 12 - A 32-year-old man with schizophrenia reports that thoughts are leaking out of his...

    Incorrect

    • A 32-year-old man with schizophrenia reports that thoughts are leaking out of his head and being read by others around him.
      What is the correct term for this symptom?

      Your Answer:

      Correct Answer: Thought broadcast

      Explanation:

      Understanding Different Types of Thought Experiences

      There are various types of thought experiences that individuals may encounter. One of these is thought broadcast, where others can seemingly hear or read one’s thoughts as they are being broadcasted from the individual. On the other hand, thought insertion and withdrawal refer to the experience of having thoughts inserted into or taken out of one’s mind by an external force. In thought blocking, individuals may suddenly find themselves unable to continue speaking as their minds go blank. Meanwhile, thought echo involves hearing one’s own thoughts being spoken aloud after thinking them. Finally, auditory hallucinations refer to the perception of hearing sounds or voices without any external stimulus. Understanding these different types of thought experiences can help individuals better recognize and cope with them.

    • This question is part of the following fields:

      • Mental Health
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  • Question 13 - A 58-year-old woman is brought to the doctors by her son. Three weeks...

    Incorrect

    • A 58-year-old woman is brought to the doctors by her son. Three weeks ago her husband died from pancreatic cancer. She reports being tearful every day but her son is concerned because she is constantly 'picking fights' with him over minor matters and issues relating to their family past. The son also reports that she has on occasion described hearing her husband talking to her and on one occasion she set a place for him at the dinner table.

      Despite this she has started going to yoga classes again with friends and says that she is determined to get 'back on track'.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Normal grief reaction

      Explanation:

      Understanding Grief Reactions

      Grief is a natural response to the loss of a loved one, but it can be helpful to have an understanding of the potential stages a person may go through while grieving. One popular model divides grief into five stages: denial, anger, bargaining, depression, and acceptance. However, not everyone will experience all five stages.

      Abnormal or atypical grief reactions are more likely to occur in women and when the death is sudden or unexpected. Other risk factors include a problematic relationship before death or a lack of social support. Delayed grief, which occurs when grieving doesn’t begin for more than two weeks, and prolonged grief, which can last beyond 12 months, are features of atypical grief reactions.

      It is important to note that grief doesn’t necessarily need to be medicalized, but understanding the potential stages and risk factors can help determine if a patient is experiencing a normal grief reaction or if they may need additional support.

    • This question is part of the following fields:

      • Mental Health
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  • Question 14 - You see a 26-year-old male patient with erectile dysfunction. He is typically healthy...

    Incorrect

    • You see a 26-year-old male patient with erectile dysfunction. He is typically healthy and doesn't take any regular medications. He is a non-smoker and drinks alcohol in moderation.

      You proceed to gather a more comprehensive history of his issue and conduct a thorough psychosexual evaluation.

      Which of the following history findings would indicate a psychogenic origin rather than an organic cause for his condition?

      Your Answer:

      Correct Answer: A history of premature ejaculation

      Explanation:

      Erectile dysfunction (ED) is a condition where a person is unable to achieve or maintain an erection that is sufficient for satisfactory sexual performance. The causes of ED can be categorized into organic, psychogenic, or mixed, and can also be caused by certain medications.

      Symptoms that indicate a psychogenic cause of ED include a sudden onset, early loss of erection, self-stimulated or waking erections, premature ejaculation or inability to ejaculate, relationship problems or changes, major life events, and psychological issues.

      On the other hand, symptoms that suggest an organic cause of ED include a gradual onset and normal ejaculation.

      Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

      To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.

    • This question is part of the following fields:

      • Mental Health
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  • Question 15 - A 25-year-old woman reports that she regularly needs to check items. She will...

    Incorrect

    • A 25-year-old woman reports that she regularly needs to check items. She will return repeatedly to check a door is locked or an iron unplugged or an oven switched off etc. She has even occasionally returned to the house after leaving to check things.
      Select from the list the single most correct statement concerning obsessive-compulsive disorder (OCD) in this patient.

      Your Answer:

      Correct Answer: Obsessions or compulsions must be a source of distress or interfere with functioning for the diagnosis to be made

      Explanation:

      Understanding and Treating Obsessive-Compulsive Disorder

      Obsessive-compulsive disorder (OCD) is a mental health condition characterized by obsessive thoughts and compulsive behaviors. While many people may exhibit some obsessive or compulsive tendencies, the key to diagnosing OCD is whether it causes distress or interferes with daily functioning.

      Cognitive behavioral therapy, specifically exposure and response prevention, is the first-line treatment for OCD. This type of therapy helps individuals confront their fears and learn to resist the urge to engage in compulsive behaviors. If a patient cannot participate in therapy or if it is not effective, selective serotonin reuptake inhibitors (SSRIs) may be prescribed. Clomipramine is an alternative medication to SSRIs.

      It is important to note that OCD can affect anyone, regardless of gender, and typically has an onset in adolescence or early adulthood. If you or someone you know is struggling with OCD, seeking professional help can lead to effective treatment and improved quality of life.

    • This question is part of the following fields:

      • Mental Health
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  • Question 16 - A 35-year-old man presents with weakness of his right arm - he cannot...

    Incorrect

    • A 35-year-old man presents with weakness of his right arm - he cannot move the arm at all.

      The weakness came on suddenly. He sees a neurologist but no neurological illness can be found. He is a soldier and has just returned from a tour of duty. He has no history of illness and has not missed a day off work for two years. The weakness has been present for nine days.

      Which one of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Multiple sclerosis

      Explanation:

      Diagnosis of a Soldier with Paralysis

      The soldier in this case has a previously good sickness record but is now experiencing muscle paralysis. It is reasonable to assume that he has been exposed to considerable stress in the recent past. After seeing a neurologist, it can be concluded that there is no neurological disease present.

      This situation is indicative of a conversion disorder, which is a psychological condition where physical symptoms cannot be explained by medical examination. Muscle paralysis is a common symptom of this disorder, and the signs do not support the symptoms. In fact, tone may seem to be increased due to simultaneous flexor and extensor contraction.

      Given the soldier’s history and symptoms, it is unlikely that he is malingering. Instead, psychological factors are likely to be important in this case. Overall, the most likely diagnosis for this soldier is a conversion disorder.

    • This question is part of the following fields:

      • Mental Health
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  • Question 17 - A 50-year-old woman with a known history of depression, previously well controlled for...

    Incorrect

    • A 50-year-old woman with a known history of depression, previously well controlled for some time with fluoxetine, has started to suffer from anxiety, loss of interest and reduced appetite. She also complains of insomnia.

      She claims to taking her medications regularly according to prescription.

      What will be the most appropriate management for her?

      Your Answer:

      Correct Answer: Switch to another group of antidepressant

      Explanation:

      Switching Antidepressants: Consider Mirtazapine

      When a patient stops responding to fluoxetine, switching to another group of antidepressants is a feasible approach. One such option is mirtazapine, a newer antidepressant that exhibits both noradrenergic and serotonergic activity. Studies have shown that mirtazapine is effective in treating a substantial proportion of patients who did not respond well to selective serotonin reuptake inhibitors (SSRIs) or found them difficult to tolerate. Therefore, if a patient is no longer responding to fluoxetine, it may be worth considering switching to mirtazapine.

    • This question is part of the following fields:

      • Mental Health
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  • Question 18 - You are asked to visit a 52-year-old businessman at home, following a phone...

    Incorrect

    • You are asked to visit a 52-year-old businessman at home, following a phone call from a worried neighbour. He lives alone and has been struggling for the past six months with the collapse of his financial services business.

      He saw a colleague six weeks ago and was given a prescription for citalopram 20 mg, but this was not renewed and he has not been seen since.

      Upon arrival at his home you notice that the curtains were all drawn and there were dirty plates piled high behind the sofa. There are several empty cans of beer strewn across the floor but he is not intoxicated and you cannot smell alcohol on his breath.

      Your patient is unshaven and dishevelled. He talked in a low, monotone voice and there was no eye contact. He attributed the collapse of his business to the direct intervention of the Prime Minister, who had been placing hidden cameras in his home. He says that he can hear the whirring of the cameras at night and has not slept for three days. He is not actively suicidal but feels that his life is pointless.

      There is no family support and the neighbour who alerted you said that she did not want to get involved.

      Which one of the following would be the most appropriate way of managing this man?

      Your Answer:

      Correct Answer: Increase the dose of citalopram to 40 mg

      Explanation:

      Management of Patients with Significant Mental Health Problems

      In reality, the management of patients with significant mental health problems often involves a number of options – drug therapy, psychological support and psychotherapy, to name but a few.

      However, when a patient lives alone, exhibits psychotic symptoms, and shows evidence of self-neglect, urgent action is required. In such cases, the mental health team should be contacted immediately for an assessment.

      It is important to note that this patient has been non-compliant with previous treatment, and there is no guarantee that he would take any medication prescribed at this visit. Additionally, there are clues that he may be drinking heavily, but prescribing without additional support would be inappropriate.

      Although there is no evidence of active suicidal ideation, there are a number of risk factors for suicide. Therefore, urgent involvement of the mental health team is strongly recommended.

    • This question is part of the following fields:

      • Mental Health
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  • Question 19 - A 40-year-old man with schizophrenia is prescribed a monthly zuclopenthixol depot injection in...

    Incorrect

    • A 40-year-old man with schizophrenia is prescribed a monthly zuclopenthixol depot injection in the community. He visits his General Practitioner two weeks after receiving the third dose, reporting an uncomfortable internal feeling of restlessness. He explains it as a strong urge to move and seems unable to stay still, which is causing him significant distress.
      What is the side-effect of antipsychotic medications that the patient is experiencing? Choose ONE answer.

      Your Answer:

      Correct Answer: Akathisia

      Explanation:

      Understanding Common Side Effects of Antipsychotic Medications

      Antipsychotic medications are commonly used to treat a variety of mental health conditions, but they can also cause a range of side effects. It’s important for patients and healthcare providers to be aware of these potential side effects and how to manage them.

      One common side effect is akathisia, which is severe restlessness that can occur within the first few months of treatment. This can be distressing for patients and increase the risk of suicide, but it typically responds to dose reduction.

      Tardive dyskinesia is another potential side effect, which can present as abnormal movements such as sucking, chewing, and choreoathetosis. It’s more common in women and those with diffuse brain pathology, and only responds to cessation of medication in about 50% of cases.

      Acute dystonia is a type of stiffness and rigidity that can occur shortly after taking antipsychotics, particularly phenothiazines and butyrophenones. It’s more common in young men.

      Anticholinergic side effects can also occur with antipsychotics, including constipation, urinary retention, dry mouth, blurred vision, and cognitive impairment.

      Finally, Parkinsonism can present as rigidity, tremors, stooped posture, and a shuffling gait. It may not appear for several months and can occasionally resolve on its own.

      By understanding these potential side effects and how to manage them, patients and healthcare providers can work together to ensure the best possible outcomes for those taking antipsychotic medications.

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      • Mental Health
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  • Question 20 - A 30-year-old man presents to his General Practitioner at the suggestion of his...

    Incorrect

    • A 30-year-old man presents to his General Practitioner at the suggestion of his solicitor. He has recently been charged with assault and criminal damage and is facing a custodial sentence. His solicitor thinks he may have mental health problems and hopes that this may result in a lenient sentence. He admits he has always been impulsive, irritable and had a short temper, which frequently results in fights. He has no close friends and admits to being lonely. Reviewing his notes there are several episodes of deliberate self-harm usually provoked by arguments. There is no evidence of thought disorder.
      What the single most likely diagnosis?

      Your Answer:

      Correct Answer: Borderline personality disorder

      Explanation:

      Common Mental Health Disorders: Characteristics and Symptoms

      Borderline Personality Disorder, Schizophrenia, Attention-deficit Hyperactivity Disorder, Bipolar Disorder, and Depression are some of the most common mental health disorders that affect individuals worldwide. Each disorder has its own set of characteristics and symptoms that can significantly impact an individual’s daily life.

      Borderline Personality Disorder is characterized by extreme fear of abandonment, unstable relationships, an inability to maintain friendships, an unstable sense of self, powerful emotions that change quickly and often, feelings of emptiness, frequent dangerous behavior, and self-harm. Men with this disorder may also exhibit aggressive behavior, seek to control others by criticism, demonstrate extreme jealousy, and be reluctant to share emotional experiences.

      Schizophrenia is a psychotic illness that is characterized by delusions, hallucinations, thought disorder, and lack of insight.

      Attention-deficit Hyperactivity Disorder is a developmental condition of inattention and distractibility, with or without accompanying hyperactivity. The hyperactivity decreases in adulthood, but impulsivity, poor concentration, and risk-taking can get worse. These can interfere with work, learning, and relationships with other people. Depressions, anxiety, feelings of low self-esteem, and drug misuse are more common in adults with the condition.

      Bipolar Affective Disorder is characterized by periods of deep, prolonged, and profound depression that alternate with periods of an excessively elevated or irritable mood known as mania.

      Depression involves both low mood and/or absence loss of interest and pleasure in most activities, accompanied by an assortment of emotional, cognitive, physical, and behavioral symptoms.

      In conclusion, understanding the characteristics and symptoms of these common mental health disorders is crucial in identifying and seeking appropriate treatment for individuals who may be struggling with them.

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      • Mental Health
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  • Question 21 - A 79-year-old woman presents to her General Practitioner with disorientation and restlessness. She...

    Incorrect

    • A 79-year-old woman presents to her General Practitioner with disorientation and restlessness. She lives independently and has previously seemed mentally alert. However, she has been increasingly unwell for the past month. She has long-standing hypertension, overactive bladder, osteoarthritis and depression. Physical examination and blood tests are unremarkable.
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Polypharmacy

      Explanation:

      Differential diagnosis of delirium in an elderly patient with multiple co-morbidities

      Delirium is a common and serious condition in older adults, especially those with multiple chronic illnesses and medications. It is characterized by acute and fluctuating changes in cognition, attention, and consciousness, and can be caused by various factors, including infections, medications, metabolic disturbances, and organ failure. Distinguishing delirium from dementia, depression, or other cognitive disorders is important for appropriate management and prognosis.

      In this case, the patient presents with delirium, as evidenced by her confusion, disorientation, and agitation. The history and examination suggest that the most likely cause of delirium is polypharmacy, i.e., the use of multiple medications that may interact or have side effects, such as sedation, dizziness, or serotonin syndrome. Therefore, a medication review and optimization should be a priority, with attention to reducing the overall burden of medications and avoiding potentially harmful combinations.

      Other potential causes of delirium, such as accidental poisoning, alcohol withdrawal, Alzheimer’s disease, or chest infection, are less likely based on the available information. However, it is important to keep an open mind and consider further investigations or referrals if the patient’s condition doesn’t improve or worsens. Follow-up assessments of the patient’s cognitive and functional status are also recommended to monitor for any residual or long-term effects of delirium.

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      • Mental Health
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  • Question 22 - A 55-year-old male presents with a 12 month history of deteriorating memory.

    He...

    Incorrect

    • A 55-year-old male presents with a 12 month history of deteriorating memory.

      He has otherwise been well and takes no medication.

      Which one of the following is most typical of frontal lobe dysfunction?

      Your Answer:

      Correct Answer: Inability to perform serial 7s

      Explanation:

      Understanding Different Manifestations of Neurodegenerative Conditions

      Frontal lobe dementia is a common neurodegenerative condition that typically affects individuals between the ages of 45 and 65. One way to test for frontal lobe dysfunction is to assess a patient’s ability to generate a list rapidly, such as naming animals in 60 seconds or words beginning with a specific letter.

      Dyscalculia, on the other hand, is a manifestation of the dominant parietal lobe. This condition affects an individual’s ability to perform mathematical calculations and solve problems. Sensory inattention is another manifestation of parietal lobe dysfunction, which can cause an individual to ignore or neglect one side of their body or environment.

      Visual field defects are also common manifestations of neurodegenerative conditions. Homonymous hemianopia, which is a loss of vision in one half of the visual field, is typically associated with occipital lobe dysfunction. Superior quadrantanopia, which is a loss of vision in one quarter of the visual field, is associated with temporal lobe dysfunction. Finally, inferior quadrantanopia, which is also a loss of vision in one quarter of the visual field, is associated with parietal lobe dysfunction. Understanding these different manifestations can help healthcare professionals diagnose and treat neurodegenerative conditions more effectively.

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      • Mental Health
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  • Question 23 - A woman in her 50s comes to you with symptoms of moderate depression....

    Incorrect

    • A woman in her 50s comes to you with symptoms of moderate depression. She has experienced severe side effects from SSRIs and you are considering prescribing a tricyclic antidepressant instead. Before doing so, you review her medical history for any potential contraindications to taking tricyclics.

      Which of the following conditions could be a contraindication to using tricyclic antidepressants?

      Your Answer:

      Correct Answer: Migraine

      Explanation:

      Tricyclic Antidepressants and Heart Issues

      Tricyclic antidepressants, specifically amitriptyline, may cause arrhythmias and heart block. These issues can occur occasionally and should be avoided if there is a high risk of arrhythmia. It is important to be aware of the potential heart-related side effects when considering tricyclic antidepressants as a treatment option. If there is a history of heart problems or a high risk of arrhythmia, alternative medications should be considered. It is always important to discuss any concerns or questions with a healthcare provider before starting any new medication.

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      • Mental Health
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  • Question 24 - A 65-year-old patient presents five days after abruptly discontinuing diazepam, which he had...

    Incorrect

    • A 65-year-old patient presents five days after abruptly discontinuing diazepam, which he had been taking for more than two years. He reports feeling generally unwell. What symptom would indicate a condition other than benzodiazepine withdrawal syndrome?

      Your Answer:

      Correct Answer: Hypothermia

      Explanation:

      Benzodiazepine withdrawal syndrome doesn’t include hypothermia as a symptom.

      Benzodiazepines are drugs that enhance the effect of the neurotransmitter GABA, which has an inhibitory effect on the brain. This makes them useful for a variety of purposes, including sedation, anxiety relief, muscle relaxation, and as anticonvulsants. However, patients can develop a tolerance and dependence on these drugs, so they should only be prescribed for short periods of time. When withdrawing from benzodiazepines, it is important to do so gradually, reducing the dose every few weeks. If patients withdraw too quickly, they may experience benzodiazepine withdrawal syndrome, which can cause a range of symptoms including insomnia, anxiety, and seizures. Other drugs, such as barbiturates, work in a similar way but have different effects on the duration or frequency of chloride channel opening.

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      • Mental Health
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  • Question 25 - A 25-year-old female presents for follow-up of her depression. Despite taking citalopram 20...

    Incorrect

    • A 25-year-old female presents for follow-up of her depression. Despite taking citalopram 20 mg once daily for 4 months, she has not experienced any significant improvement in her symptoms. The decision is made to switch her medication to imipramine. What is the recommended approach for transitioning to imipramine?

      Your Answer:

      Correct Answer: Period of cross-tapering of the two drugs

      Explanation:

      Guidelines for Switching Antidepressants

      When switching antidepressants, it is important to follow specific guidelines to ensure a safe and effective transition. If switching from citalopram, escitalopram, sertraline, or paroxetine to another selective serotonin reuptake inhibitor (SSRI), the first SSRI should be gradually withdrawn before starting the alternative SSRI. However, if switching from fluoxetine to another SSRI, a gap of 4-7 days should be left after withdrawal due to its long half-life.

      When switching from an SSRI to a tricyclic antidepressant (TCA), cross-tapering is recommended. This involves slowly reducing the current drug dose while slowly increasing the dose of the new drug. The exception to this is fluoxetine, which should be withdrawn before starting TCAs.

      If switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine, it is important to cross-taper cautiously. Starting with a low dose of venlafaxine (37.5 mg daily) and increasing very slowly is recommended. The same approach should be taken when switching from fluoxetine to venlafaxine.

      Overall, following these guidelines can help minimize the risk of adverse effects and ensure a smooth transition when switching antidepressants.

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      • Mental Health
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  • Question 26 - A 42-year-old woman presents with a potassium reading of 2.9 mmol/L. As there...

    Incorrect

    • A 42-year-old woman presents with a potassium reading of 2.9 mmol/L. As there is no obvious cause, you schedule an in-depth assessment. During the history-taking, you discover that she experiences strong urges to consume large amounts of food and frequently engages in binge eating. She also admits to using laxatives but denies inducing vomiting. These episodes occur approximately three times per week, and her body mass index is 19.5 kg/m2. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Bulimia nervosa

      Explanation:

      Diagnosis and Explanation of Bulimia Nervosa

      The case history presented suggests that the patient is suffering from bulimia nervosa. This disorder is characterized by recurrent episodes of binge eating, followed by compensatory behaviors such as purging or the use of laxatives. While anorexia is more common in teenagers, bulimia is often seen in older patients, typically in their 20s or beyond.

      The patient’s urges to eat large amounts of food, frequent use of laxatives, and low potassium levels are all indicative of bulimia nervosa. It is important to note that this behavior is not a normal variant and requires medical attention. While the patient is only marginally underweight, a BMI of 20 kg/m2 is considered the lower limit of normal.

      It is unlikely that the patient is experiencing refeeding syndrome, which is a rare condition typically associated with parenteral nutrition in a hospital setting. Enteral nutrition may also lead to refeeding syndrome after a prolonged period of starvation. However, this is not the case for the patient in question. Overall, a diagnosis of bulimia nervosa is the most appropriate for this case.

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      • Mental Health
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  • Question 27 - During a ward round consultation, the Psychiatrist was assessing a 12-year-old patient's current...

    Incorrect

    • During a ward round consultation, the Psychiatrist was assessing a 12-year-old patient's current mental state. The patient's reply to most of the questions consisted of sentences which did not make any sense such as - 'painting pizza prince bus brush'. This is a good example of which of the following thought disorder?

      Your Answer:

      Correct Answer: Word salad

      Explanation:

      Disordered speech, such as word salad, neologisms, perseveration, and echolalia, is commonly linked to psychosis and mania.

      Understanding Psychosis: Symptoms and Associated Features

      Psychosis is a term used to describe a person’s experience of perceiving things differently from those around them. This can manifest in a variety of ways, including hallucinations, delusions, thought disorganization, alogia, tangentiality, clanging, and word salad. These symptoms can be associated with agitation, aggression, neurocognitive impairment, depression, and thoughts of self-harm.

      Psychotic symptoms can occur in a number of conditions, including schizophrenia, depression, bipolar disorder, puerperal psychosis, brief psychotic disorder, neurological conditions like Parkinson’s disease and Huntington’s disease, and as a result of prescribed drugs or certain illicit drugs like cannabis and phencyclidine.

      The peak age of first-episode psychosis is around 15-30 years. It is important to understand the symptoms and associated features of psychosis in order to recognize and seek appropriate treatment for those experiencing these symptoms.

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      • Mental Health
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  • Question 28 - A 55-year-old man has been drinking alcohol heavily for over 20 years but...

    Incorrect

    • A 55-year-old man has been drinking alcohol heavily for over 20 years but now needs to drink more to feel drunk as well as to avoid being irritable. He works as a bank manager and gave up driving 5 years ago at the insistence of his wife. There is no evidence of chronic liver disease on physical examination. Assessment of his mental state reveals episodes of low mood. He no longer goes out with friends.
      Select from the list the single most correct diagnosis.

      Your Answer:

      Correct Answer: Alcohol dependence

      Explanation:

      Alcohol Dependence and Social Withdrawal: Understanding the Symptoms

      Alcohol dependence is a syndrome characterized by withdrawal symptoms, tolerance, and loss of control over alcohol use. The CAGE questionnaire is a useful screening tool for alcohol-related disorders. Episodes of low mood may be related to alcohol dependence. Social withdrawal is a feature of various mental health conditions, including schizophrenia, personality disorders, autism spectrum disorders, depression, social anxiety disorder, and traumatic brain injury. Understanding the symptoms of alcohol dependence and social withdrawal can help individuals seek appropriate treatment and support.

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      • Mental Health
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  • Question 29 - A 65-year-old lady who you have looked after during her recent breast cancer...

    Incorrect

    • A 65-year-old lady who you have looked after during her recent breast cancer diagnosis and treatment comes to see you one year after undergoing a total mastectomy followed by chemotherapy and radiotherapy.

      Her disease is now in remission and she is taking tamoxifen. She has a history of a perforated duodenal ulcer and has had bouts of paroxysmal atrial fibrillation. She complains of feeling very tearful and low in mood, and feels traumatised by her experiences. She is also having some chest wall neuropathic type pain, probably due to the radiotherapy. A PHQ9 depression questionnaire confirms that she is suffering from moderately severe depression.

      Which of the following would be most appropriate to treat her?

      Your Answer:

      Correct Answer: Amitriptylline

      Explanation:

      Treatment for Depression in a Patient with Previous Medical History

      When treating a patient with depression who has a previous medical history, it is important to consider potential drug interactions and contraindications. In the case of a patient with a history of gastric bleeding and atrial fibrillation, SSRIs and tricyclic antidepressants should be avoided due to their associated risks. Fluoxetine should also not be prescribed as it reduces the efficacy of tamoxifen.

      Instead, the best course of action would be to offer an antidepressant and a high-intensity psychological intervention. This approach addresses the patient’s mood problems stemming from her experiences during diagnosis and treatment, while also avoiding potential harm from medication. It is important to note that using amitriptyline for neuropathic pain in this case would be off license and carries a higher risk of arrhythmias.

      In summary, when treating depression in a patient with a previous medical history, it is crucial to carefully consider the potential risks and benefits of medication options and to include psychological intervention as part of the treatment plan.

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      • Mental Health
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  • Question 30 - A 32-year-old teacher comes to see you because she feels depressed. She was recently...

    Incorrect

    • A 32-year-old teacher comes to see you because she feels depressed. She was recently given a new class to teach and feels overwhelmed. She believes that her colleagues think she is not capable of handling the class and that her teaching is not up to par. She has started to wake up in the early hours and then worry about her job. Her reason for coming to the clinic is that she has been feeling irritable and short-tempered with her students, and her partner thinks she should seek help. She doesn't smoke or drink alcohol. How would you evaluate her symptoms of depression?

      Your Answer:

      Correct Answer: A PHQ-9 questionnaire

      Explanation:

      Questionnaires are commonly used in general practice to detect and assess the severity of illnesses. One such questionnaire is the PHQ-9, which is a nine-item depression scale that assists general practitioners in diagnosing depression and monitoring treatment. The PHQ-2, a two-item questionnaire, is also used for screening depression.

      The CAGE questionnaire, on the other hand, is a screening test for alcohol problem drinking and is not used to assess depression. The GPCOG assessment is a screening tool for symptoms of dementia, while the GPPAQ questionnaire is a validated short measure of physical activity commissioned by the Department of Health.

      It is important to note that the IPSS questionnaire, which is an international prostate symptom score questionnaire, is not relevant to the assessment of depression. Overall, these questionnaires serve as powerful tools for general practitioners in diagnosing and monitoring various illnesses.

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  • Question 31 - A 55-year-old man is a frequent attender with abdominal pain that has been...

    Incorrect

    • A 55-year-old man is a frequent attender with abdominal pain that has been extensively investigated and no cause found. He still finds the symptoms very distressing. They are the focus of his attention and he says they are restricting normal activities; he also fears he may have bowel cancer.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Somatic symptom disorder

      Explanation:

      Understanding Somatic Symptom Disorder and its Distinctions from Other Conditions

      Somatic symptom disorder (SSD) is a condition characterized by distressing somatic symptoms and excessive thoughts, feelings, and behaviors related to those symptoms. These symptoms must persist for at least six months to be diagnosed with SSD. In contrast, illness anxiety disorder is a preoccupation with having or acquiring a serious illness without significant somatic symptoms. Colon cancer is unlikely in this patient as extensive investigations have found no cause. Generalized anxiety disorder is characterized by anxiety about a variety of things, while this patient’s focus is on his abdominal pain and fears of bowel cancer. Irritable bowel syndrome causes abdominal pain, diarrhea, and constipation, but the patient’s symptoms and concerns are more consistent with somatic symptom disorder. Understanding the distinctions between these conditions is crucial for accurate diagnosis and effective treatment.

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      • Mental Health
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  • Question 32 - A 36-year-old woman comes in for a follow-up appointment. She had previously visited...

    Incorrect

    • A 36-year-old woman comes in for a follow-up appointment. She had previously visited with complaints of worsening headaches and insomnia, which you diagnosed as tension-type headaches after ruling out any red flags. Her sleep pattern has continued to deteriorate over the past few months, with early morning waking being a prominent issue. She denies any substance misuse or excessive alcohol consumption.

      During today's visit, she reports experiencing a few episodes of palpitations and occasional dizziness. These symptoms do not occur during exercise, and there are no red flags present. Her cardiovascular and neurological exams are unremarkable, and her blood pressure is normal.

      All of her blood tests, including full blood count, urea and electrolytes, liver function tests, and thyroid function tests, come back normal.

      What would be the most appropriate next step?

      Your Answer:

      Correct Answer: Consider generalised anxiety disorder as a potential underlying diagnosis and explore if psychological distress present

      Explanation:

      Generalized anxiety disorder (GAD) can manifest in various ways, including presenting solely with physical symptoms. Patients with GAD may experience headaches, muscle tension, gastrointestinal symptoms, back pain, and insomnia, without reporting any psychological distress or worry. Therefore, it is important to explore the presence of psychological distress during consultations.

      Based on the history and examination provided, there is no indication for urgent cardiology referral, and it would not be an appropriate use of resources.

      While beta-blockers may be a suitable treatment option for GAD, further discussion with the patient is necessary before reaching a diagnosis, especially in the presence of somatic symptoms.

      Similarly, SSRI may be an appropriate treatment option, but it is important to have a thorough discussion with the patient before prescribing.

      In this case, prescribing a sleeping tablet is not the most appropriate option. Secondary insomnia resulting from GAD should be treated, and a sleeping tablet should only be prescribed at the lowest possible dose for the shortest period of time, with regular review. Treatment should not exceed 2-4 weeks due to the risk of tolerance and addiction. Depending on the circumstances, other treatment options such as individual guided self-help, psychological interventions, or cognitive behavioural therapy may be considered.

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing psychiatric disorders such as anxiety. Hyperthyroidism, cardiac disease, and medication-induced anxiety are important alternative causes. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a stepwise approach for managing generalised anxiety disorder (GAD). The first step is education about GAD and active monitoring. The second step involves low-intensity psychological interventions such as individual non-facilitated self-help, individual guided self-help, or psychoeducational groups. The third step includes high-intensity psychological interventions such as cognitive behavioural therapy or applied relaxation, or drug treatment. Sertraline is the first-line SSRI recommended by NICE. If sertraline is ineffective, an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the person cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under the age of 30 years, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach. The first step is recognition and diagnosis, followed by treatment in primary care. NICE recommends either cognitive behavioural therapy or drug treatment. SSRIs are the first-line treatment. If contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered. The third step involves reviewing and considering alternative treatments, followed by review and referral to specialist mental health services in the fourth and fifth steps, respectively.

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  • Question 33 - You are seeing a teenage patient who has been diagnosed with PTSD.

    He...

    Incorrect

    • You are seeing a teenage patient who has been diagnosed with PTSD.

      He has previously been treated with sertraline but wants to stop because of a rash.

      He has a review appointment with a psychiatrist in 3 months. Assuming any appropriate cross tapering and initiation, what alternative treatment could you prescribe instead?

      Your Answer:

      Correct Answer: Buspirone

      Explanation:

      NICE Guidance on Drug Treatments for PTSD in Adults

      The NICE guidance on the management of PTSD was updated in 2018, and there were a few changes from earlier guidance. One of the changes was regarding drug treatments for adults with PTSD. According to the latest NICE guidance NG116, benzodiazepines should not be offered as a drug treatment to prevent PTSD in adults. However, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, can be considered for adults with a diagnosis of PTSD if they have a preference for drug treatment. It is important to review this treatment regularly.

      In addition, antipsychotics such as risperidone can be considered, along with psychological therapies, to manage symptoms for adults with a diagnosis of PTSD if they have disabling symptoms and behaviors, such as severe hyperarousal or psychotic symptoms, and their symptoms have not responded to other drug or psychological treatments. It is important that antipsychotic treatment is started and reviewed regularly by a specialist.

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      • Mental Health
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  • Question 34 - A 50-year-old man is admitted for haematemesis after consuming 100 units of alcohol...

    Incorrect

    • A 50-year-old man is admitted for haematemesis after consuming 100 units of alcohol per week. What is the time frame for the highest occurrence of seizures during alcohol withdrawal?

      Your Answer:

      Correct Answer: 36 hours

      Explanation:

      Symptoms of alcohol withdrawal can occur within 6-12 hours, including seizures.

      Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. This is due to the fact that chronic alcohol consumption enhances GABA-mediated inhibition in the central nervous system (CNS), similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. When alcohol consumption is stopped, the opposite occurs, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission.

      Symptoms of alcohol withdrawal typically start within 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at around 36 hours, while delirium tremens, which is characterized by coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, is most likely to occur at around 48-72 hours.

      Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.

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      • Mental Health
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  • Question 35 - A 6-year-old boy is brought to the General Practice Surgery by his father...

    Incorrect

    • A 6-year-old boy is brought to the General Practice Surgery by his father with a 3-month history of nocturnal enuresis. On examination, there is bruising on his inner thigh. On further questioning, his father is unable to explain why the boy has bruises and also mentions that teachers have raised concerns about inappropriate sexual behaviour towards classmates.
      Which is the single most appropriate intervention?

      Your Answer:

      Correct Answer: Contact the local children’s Social Care Team

      Explanation:

      Appropriate Actions for Child Welfare Concerns

      When dealing with concerns about a child’s welfare, it is important to take appropriate actions to ensure their safety and wellbeing. Here are some scenarios and the recommended actions:

      Actions for Child Welfare Concerns

      1. Contact the local children’s Social Care Team if there are unexplained bruises on a child’s inner thigh and inappropriate sexual behavior. This could indicate sexual abuse, and an urgent referral to Social Services is necessary.

      2. Refer to the specialist Continence Service if a child has bladder and bowel problems that are not resolved by behavioral strategies. This service offers assessment, treatment, advice, and support.

      3. Arrange a meeting with the child’s teacher to improve communication between all services. However, if there are concerns about sexual abuse, this will be handled by the police and Social Services.

      4. Prescribe desmopressin for nocturnal enuresis only after addressing concerns about sexual abuse. Behavioral strategies are the first line of treatment for this condition.

      5. Refer to the school nurse for support with nocturnal enuresis only after addressing concerns about sexual abuse. School nurses are specialists in improving the health and wellbeing of school-aged children.

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      • Mental Health
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  • Question 36 - A 53-year-old unemployed man has been seeing you for the past six months...

    Incorrect

    • A 53-year-old unemployed man has been seeing you for the past six months as a newly registered patient with depression. He lives alone without support.

      He has suffered from depression since he was a young man, taking citalopram 20 mg for the past five months but has frequently defaulted review appointments with you. He last saw a colleague of yours as an emergency appointment eight weeks ago but did not attend follow up with you one week later as advised.

      On this occasion, you have been asked to visit by a neighbour who fears that he may have died, because his curtains have been drawn for seven days and when she last saw him, through his lounge window, he looked 'absolutely awful and has lost a lot of weight'.

      You phone his house, but there is no reply. You decide to visit, fearing the worst, but he finally answers the door when you shout your name through his letterbox.

      On examination he appears to have lost a significant amount of weight and is unshaven. He says that he has not slept or eaten for four days and feels very depressed. He says that he doesn't feel suicidal and that he is still taking the antidepressants, but you notice that there is an unopened box of tablets on his kitchen table. His house is very unkempt.

      What is the best way of managing this patient?

      Your Answer:

      Correct Answer: Tail off citalopram and switch to dosulepin

      Explanation:

      Consider Inpatient Treatment for High-Risk Patients

      You should consider inpatient treatment for individuals who are at a significant risk of suicide, self-harm, or self-neglect. According to the NICE guidance on Depression in adults (CG90), inpatient treatment should be considered for those who are at high risk.

      In this case, the patient is showing signs of self-neglect and has little social support. He has missed appointments and may not be taking his medication as prescribed. These factors increase the risk of suicide, although this has not been explicitly stated in the patient’s history.

      Changing the patient’s medication may not be appropriate since there is no guarantee that he will comply. Asking a neighbor to check on him may provide some support, but it may not be enough.

      Given the available information, the most appropriate course of action would be to consider emergency admission by contacting the mental health team. This will ensure that the patient receives the necessary care and support to manage his risk of self-harm or suicide.

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      • Mental Health
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  • Question 37 - What is a true statement about obsessive compulsive disorder (obsessional neurosis)? ...

    Incorrect

    • What is a true statement about obsessive compulsive disorder (obsessional neurosis)?

      Your Answer:

      Correct Answer: The onset is usually after the age of 50 years

      Explanation:

      Understanding Obsessional Neurosis and Obsessional Compulsive Disorder

      Obsessional neurosis is a mental health condition characterized by repetitive rituals, persistent fears, and disturbing thoughts. Patients with this disorder maintain insight and often find the illness distressing, which can lead to depression. On the other hand, obsessional compulsive disorder typically starts in early adulthood and has equal sex incidence. Patients with this disorder have above-average intelligence.

      It is important to note that Sigmund Freud’s theory that obsessive-compulsive symptoms were caused by rigid toilet-training practices is no longer widely accepted. Despite this, understanding these disorders and their symptoms can help individuals seek appropriate treatment and support. By recognizing the signs and symptoms of these disorders, individuals can work towards managing their symptoms and improving their overall quality of life.

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  • Question 38 - A 43-year-old woman comes to the clinic. She has been feeling down for...

    Incorrect

    • A 43-year-old woman comes to the clinic. She has been feeling down for the past 10 weeks, experiencing a loss of appetite, weight loss, and waking up at 4 am every morning. She often struggles to focus.

      She was laid off from her job four months ago, and her elderly father recently suffered a stroke. Her partner is supportive but works odd hours, so he cannot accompany her today. Her daughter is away at college, and she has not talked to anyone about her current issues.

      She had a bout of moderate depression five years ago and was successfully treated with Fluoxetine for two years. She currently has no suicidal thoughts and is eager to seek help early this time. You discuss CBT with her, and she agrees to it.

      What other intervention is likely to be the most helpful for her?

      Your Answer:

      Correct Answer: Arrange to see her again in one week

      Explanation:

      Treatment Plan for a Patient with Depression and a Recent Life Event

      This patient has a history of moderate depression that responded well to SSRI treatment. She is currently experiencing cognitive and biological symptoms of depression, likely exacerbated by a recent life event – redundancy. Additionally, her mother’s illness is a concern and her potential role as a caregiver will need to be explored. While her partner is supportive, their shift work may make providing day-to-day support difficult.

      To address her symptoms, the patient will require frequent support and advice on sleep hygiene, as well as medication. Given her previous successful treatment with fluoxetine, this will be the first medication to try. A tricyclic antidepressant is less likely to be well-tolerated and carries a higher risk of overdose.

      If the patient is at significant risk of self-harm, has psychotic symptoms, or has complex disease, referral to specialist mental health services is recommended for expert opinion on treatment and management.

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      • Mental Health
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  • Question 39 - A 70-year-old woman is brought to the General Practitioner by her carer. She...

    Incorrect

    • A 70-year-old woman is brought to the General Practitioner by her carer. She lives in sheltered accommodation and has carers twice a day to help with washing, dressing and meal preparation. Typically, she enjoys crosswords and is able to mobilise around the house with the help of a walking stick. Over the past two days, she has become restless and agitated. When the carer arrived that morning, she had been very combative and refused to get dressed.
      Given the likely diagnosis, what is the most appropriate intervention?

      Your Answer:

      Correct Answer: Arrange admission to hospital for assessment, monitoring and treatment

      Explanation:

      Managing Delirium in Hospitalized Patients

      When a patient presents with delirium, it is important to take immediate action to ensure their safety and well-being. Admission to the hospital for assessment, monitoring, and treatment is typically necessary. The decision to admit should take into account the patient’s clinical and social situation, as well as the input of family members or caregivers. If the patient lacks capacity, decisions should be made in their best interests using the Mental Capacity Act 2005.

      Once the patient has recovered from delirium, it is important to review them to ensure there are no underlying memory concerns that would warrant a referral to the Memory Clinic. Physical restraints, such as cot sides, should be avoided in patients with delirium. Instead, strategies to maintain safe mobility should be employed, such as encouraging walking or active range of motion exercises.

      A computed tomography head may be indicated if there has been a recent head injury or a subdural hematoma is suspected, or if the patient may have underlying dementia. However, if an acute cause is suspected, the patient needs admission to the hospital. If dementia is suspected, then referral to the Memory Clinic once the patient has recovered from delirium is recommended.

      Pharmacological measures are a last resort for severe agitation or psychosis that may be recommended by specialists. Short-term, low-dose haloperidol may be suggested, but benzodiazepines are not usually recommended. By following these guidelines, healthcare professionals can effectively manage delirium in hospitalized patients.

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      • Mental Health
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  • Question 40 - A 30-year-old man with schizophrenia has recently started taking clozapine after struggling to...

    Incorrect

    • A 30-year-old man with schizophrenia has recently started taking clozapine after struggling to find an effective Antipsychotic treatment. His full blood count results are as follows:
      Hb 152 g/l
      MCV 87 fL
      WBC 2.0 x 109/L
      Neutrophils 0.9 x 109/L
      Lymphocytes 1.0 x 109/L
      Platelets 322 x 109/L
      What is the most suitable action to take in this case?

      Your Answer:

      Correct Answer: Stop Clozapine

      Explanation:

      Agranulocytosis and Neutropenia in Clozapine Treatment

      Clozapine is a medication used to treat schizophrenia. However, it carries a risk of agranulocytosis and neutropenia, which are conditions that affect the white blood cells. Agranulocytosis occurs in approximately 1% of patients taking clozapine, while neutropenia occurs in about 3%. The highest risk of developing these conditions is between 6 and 18 weeks after starting clozapine treatment.

      Before starting clozapine treatment, blood counts must be normal. During the first 18 weeks of treatment, a full blood count is required weekly. Afterward, the frequency can be reduced to every 2 or 4 weeks after 12 months. If the leucocyte count falls below 3000/mm or the absolute neutrophil count falls below 1500/mm, the medication should be stopped, and the patient should be referred to a haematologist.

      Patients taking clozapine should report any symptoms of infection immediately. However, an exception is made for patients with benign ethnic neutropenia. If a haematologist approves, they may be started on the medication. It is essential to monitor blood counts regularly to prevent the development of agranulocytosis and neutropenia.

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      • Mental Health
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  • Question 41 - A 70-year-old man has recently started taking amitriptyline for the management of depression,...

    Incorrect

    • A 70-year-old man has recently started taking amitriptyline for the management of depression, and you suspect he may be experiencing symptoms of the anticholinergic syndrome.
      Choose the accurate statement regarding the anticholinergic syndrome.

      Your Answer:

      Correct Answer: Hot, dry skin occurs

      Explanation:

      Anticholinergic Syndrome: Symptoms and Treatment

      Anticholinergic syndrome is a condition that is commonly caused by certain medications such as tricyclic antidepressants, atropine, anti-parkinsonian drugs, antispasmodics, and H1-antihistamines. The symptoms of this syndrome include hot and dry skin, hypertension, tachycardia, dry mouth, urinary retention, dilated pupils, and agitated delirium.

      In the past, physostigmine was recommended as a treatment for anticholinergic syndrome. However, recent studies have shown that it is ineffective and can even increase the risk of cardiac toxicity. Therefore, the recommended treatment now is supportive and symptomatic care. Once the medication causing the syndrome has been excreted, the symptoms usually subside.

      It is important to be aware of the symptoms of anticholinergic syndrome and to seek medical attention if you suspect that you or someone you know may be experiencing it. With proper care and treatment, the condition can be managed effectively.

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      • Mental Health
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  • Question 42 - A 20-year-old woman with a history of anorexia nervosa has a body mass...

    Incorrect

    • A 20-year-old woman with a history of anorexia nervosa has a body mass index (BMI) of 16 kg/m2. She has lost 2 kg steadily over the past four weeks. She is unable to sit up from lying flat without using her hands or to stand from the squatting position without using her hands. Lanugo is present. Her hands feel cold to the touch.
      Which feature of the patient’s physical examination would be most suggestive of impending high risk to life?

      Your Answer:

      Correct Answer: Inability to sit up or squat without using the hands

      Explanation:

      Identifying High Risk Factors in Anorexia Nervosa

      Anorexia nervosa is a serious eating disorder that can lead to life-threatening complications. The Royal College of Psychiatrists in the United Kingdom has issued guidance on recognising medical emergencies in eating disorders. Here are some key factors to consider when assessing the risk to life in anorexia nervosa:

      Sit up–Squat–Stand (SUSS) test: This test involves asking a patient to sit up from a lying position and to stand up from a squatting position without using their hands. Inability to do this is associated with impending high risk to life.

      Rate of weight loss: A weight loss of 500-999 g per week presents a moderate risk to life, whereas weight loss of >1 kg per week confers a high risk.

      BMI: A BMI of greater than 15 kg/m2 represents a low impending risk to life, whereas a BMI of <13 kg/m2 is a high risk. Cool peripheries: Although cool peripheries may be seen on examination in anorexia nervosa, they are not associated with a high risk to life. However, a core temperature of less than 35 °C is. Lanugo: Lanugo is a covering of soft downy hair often seen in people with anorexia, but it is not identified as being associated with an increased risk to life in anorexia nervosa. By considering these factors, healthcare professionals can identify high-risk patients and provide appropriate interventions to prevent life-threatening complications.

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      • Mental Health
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  • Question 43 - A 68-year-old man is brought to the General Practitioner by his daughter, who...

    Incorrect

    • A 68-year-old man is brought to the General Practitioner by his daughter, who is a Psychiatric Nurse, for a consultation. The daughter reports that she and other relatives have noticed a change in the patient’s behaviour and believes that he is experiencing ‘delirium, but certainly not dementia’.
      Which of the following findings is most likely, assuming the daughter’s assessment of the patient is correct?

      Your Answer:

      Correct Answer: Altered consciousness

      Explanation:

      Distinguishing Delirium from Dementia: Key Differences to Note

      When it comes to altered consciousness, delirium often causes wild fluctuations in consciousness level, while dementia typically only affects consciousness in severe cases. Additionally, delirium has an acute onset over hours to days, while dementia develops more gradually over months to years. Delirium is usually diagnosed within days of onset, while dementia is typically diagnosed 2-3 years after symptoms begin. Symptoms of delirium tend to fluctuate over the course of 24 hours, while dementia symptoms slowly worsen over time. Finally, while delirium can be reversible with early treatment of the underlying cause, dementia cannot be reversed, though treatment may slow its progression.

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      • Mental Health
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  • Question 44 - A 23-year-old man with a history of bipolar disorder is scheduled for a...

    Incorrect

    • A 23-year-old man with a history of bipolar disorder is scheduled for a medication review. When inquiring about his current state, he starts discussing the vast array of emotions that exist and wonders if everyone has experienced all of them. Eventually, he spontaneously mentions that he is feeling quite good.

      What is the patient exhibiting in this scenario?

      Your Answer:

      Correct Answer: Circumstantiality

      Explanation:

      The patient’s lengthy response to the question suggests circumstantiality, which can be a symptom of anxiety disorders or hypomania.

      It is important to note that the patient has not derailed from the topic at hand, indicating that this is not an example of derailment. Incoherence would involve the patient providing nonsensical responses, which is not the case here.

      While it is difficult to determine from a text-based question, pressured speech would involve the patient speaking rapidly and producing an excessive amount of spontaneous speech. Therefore, it may not be the most appropriate answer in this scenario.

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing psychiatric disorders such as anxiety. Hyperthyroidism, cardiac disease, and medication-induced anxiety are important alternative causes. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a stepwise approach for managing generalised anxiety disorder (GAD). The first step is education about GAD and active monitoring. The second step involves low-intensity psychological interventions such as individual non-facilitated self-help, individual guided self-help, or psychoeducational groups. The third step includes high-intensity psychological interventions such as cognitive behavioural therapy or applied relaxation, or drug treatment. Sertraline is the first-line SSRI recommended by NICE. If sertraline is ineffective, an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the person cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under the age of 30 years, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach. The first step is recognition and diagnosis, followed by treatment in primary care. NICE recommends either cognitive behavioural therapy or drug treatment. SSRIs are the first-line treatment. If contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered. The third step involves reviewing and considering alternative treatments, followed by review and referral to specialist mental health services in the fourth and fifth steps, respectively.

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      • Mental Health
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  • Question 45 - A 75-year-old nursing home resident, with advanced dementia, has become increasingly verbally disruptive...

    Incorrect

    • A 75-year-old nursing home resident, with advanced dementia, has become increasingly verbally disruptive at meal times, often shouting out incoherent phrases at staff and other residents. A general examination, urine dipstick and baseline blood tests were normal.

      What is the SINGLE MOST appropriate NEXT management step?

      Your Answer:

      Correct Answer: Restrain the patient at meal times in case of violent behaviour

      Explanation:

      Managing Behavioural and Psychological Symptoms of Dementia

      With Behavioural and Psychological Symptoms of Dementia (BPSD), it is crucial to identify and treat any reversible causes. However, in cases where there are no other symptoms and normal examination and investigations, empirical antibiotics should be avoided as they may lead to adverse clinical events such as Clostridium difficile. If conservative measures fail, it is advisable to seek advice from an elderly care physician who may recommend short-term use of medications such as haloperidol or lorazepam. It is important to note that restraining the patient during anticipated bad behaviour is not appropriate. By following these guidelines, we can effectively manage BPSD and improve the quality of life for patients with dementia.

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      • Mental Health
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  • Question 46 - A 33-year-old male patient with a history of paranoid schizophrenia was admitted under...

    Incorrect

    • A 33-year-old male patient with a history of paranoid schizophrenia was admitted under the Mental Health Act due to a decline in his mental health. During his inpatient stay, it was decided that Clozapine would be the most appropriate Antipsychotic for him and he was started on this medication. After his mental state stabilized, he was transferred to a rehabilitation unit. However, it was discovered that he had missed his Clozapine doses for two consecutive days. What is the recommended course of action to address these missed doses of Clozapine?

      Your Answer:

      Correct Answer: Re-titrate the Clozapine doses again slowly

      Explanation:

      If a patient misses their clozapine doses for more than 48 hours, they will need to slowly restart their dose as if they were starting the medication for the first time. This process should be supervised by a Psychiatrist. Restarting clozapine after a break of more than 48 hours can exacerbate side effects such as changes in blood pressure, drowsiness, and dizziness. If the treatment gap exceeds 72 hours, the patient may require more frequent blood tests for a brief period.

      Patients taking antipsychotic medication require extensive monitoring in addition to clinical follow-up. The British National Formulary (BNF) recommends regular testing of full blood count (FBC), urea and electrolytes (U&E), and liver function tests (LFT) at the start of therapy and annually thereafter. Clozapine requires more frequent monitoring of FBC, initially weekly. Lipids and weight should be tested at the start of therapy, at 3 months, and annually. Fasting blood glucose and prolactin should be tested at the start of therapy, at 6 months, and annually. Blood pressure should be monitored frequently during dose titration, and an electrocardiogram and cardiovascular risk assessment should be done at baseline and annually. The BNF provides specific recommendations for individual drugs, and patients should consult their healthcare provider for more information.

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      • Mental Health
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  • Question 47 - A young man arrives at the emergency department after taking a paracetamol overdose...

    Incorrect

    • A young man arrives at the emergency department after taking a paracetamol overdose following a recent break-up. He has entered into a new relationship but is struggling with frequent outbursts of anger. The patient has a history of childhood abuse and struggles with maintaining healthy relationships. He reports experiencing frequent mood swings between low and elevated states. The overdose was not premeditated and the patient has a history of similar incidents. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Borderline personality disorder

      Explanation:

      The young woman who overdosed on paracetamol after breaking up with her boyfriend is now in a new relationship that is plagued by her frequent angry outbursts, indicating borderline personality disorder. This disorder is characterized by rapidly changing intense emotions, difficulties in maintaining relationships, feelings of emptiness, fear of abandonment, impulsive behavior, and self-harm. Bipolar affective disorder is not the correct diagnosis as it involves periods of depression and mania, which are not reported in this case. Dependent personality disorder and histrionic personality disorder are also not applicable as they have different symptoms such as low confidence, difficulty making decisions without support, and a need for attention.

      Personality disorders are a set of maladaptive personality traits that interfere with normal functioning in life. They are categorized into three clusters: Cluster A, which includes odd or eccentric disorders such as paranoid, schizoid, and schizotypal; Cluster B, which includes dramatic, emotional, or erratic disorders such as antisocial, borderline, histrionic, and narcissistic; and Cluster C, which includes anxious and fearful disorders such as obsessive-compulsive, avoidant, and dependent. These disorders affect around 1 in 20 people and can be difficult to treat. However, psychological therapies such as dialectical behaviour therapy and treatment of any coexisting psychiatric conditions have been shown to help patients.

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      • Mental Health
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  • Question 48 - A 7-year-old girl is constantly in trouble at school. She will not sit...

    Incorrect

    • A 7-year-old girl is constantly in trouble at school. She will not sit still and be quiet or get on with her work. She is equally troublesome at home and her mother cannot take her anywhere. She wonders if she has attention-deficit hyperactivity disorder (ADHD).

      Select from the list the single correct statement about ADHD.

      Your Answer:

      Correct Answer: Some impairment from symptoms must be evident in two or more settings

      Explanation:

      Understanding ADHD: Symptoms, Diagnosis, and Comorbidities

      Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and impulsivity that is more severe than what is typically observed in individuals at a comparable level of development. In the UK, ADHD affects between 2-5% of children, with boys being more commonly affected. Diagnosis is usually made in children aged 3-7 years, but it can also be recognized later in life.

      To diagnose ADHD, symptoms of hyperactivity/impulsivity and/or inattention should be present. However, the ICD-10 classification requires all three problems of attention, hyperactivity, and impulsiveness to be present. About 70% of children with ADHD also have other conditions, such as learning difficulties, dyspraxia, Gilles de la Tourette syndrome, or tic disorder. Oppositional defiant disorder or conduct disorder is present in most children with ADHD, and depression and anxiety are common comorbidities.

      While about 1 in 3 children with ADHD can grow out of their condition and not require any treatment when they are adults, the remainder either continue with ADHD or retain some symptoms and functional impairment. Therefore, early diagnosis and appropriate management are crucial to improve outcomes for individuals with ADHD.

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      • Mental Health
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  • Question 49 - A 32-year-old woman who is six weeks postpartum visits her General Practitioner with...

    Incorrect

    • A 32-year-old woman who is six weeks postpartum visits her General Practitioner with complaints of feeling emotionally unstable and lacking energy. What factor in her medical history would suggest the presence of postnatal depression?

      Your Answer:

      Correct Answer: Presence of guilty thoughts

      Explanation:

      Identifying Postnatal Depression: Symptoms and Screening

      Postpartum depressive illness affects around 10-15% of women and typically begins within the first three months after childbirth. Symptoms of major depression, including depressed mood, anhedonia, and thoughts of worthlessness, are present. Anxiety about the baby’s health is common, but anxiety alone doesn’t indicate postnatal depression. Guilty thoughts are a specific symptom of depression and may be the most indicative of postnatal depression. Midwives commonly use the Edinburgh postnatal Depression Scale to screen for depression, with a score of 10 or more indicating possible depression. Inability to sleep post-delivery may be due to various factors, but if it persists alongside other symptoms, it may be an important part of screening for postnatal depression. The onset of symptoms at four days post-delivery may be indicative of baby blues, which is a common and temporary condition that doesn’t necessarily lead to postnatal depression.

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      • Mental Health
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  • Question 50 - A 55-year-old man with schizophrenia becomes highly agitated while shopping in a supermarket...

    Incorrect

    • A 55-year-old man with schizophrenia becomes highly agitated while shopping in a supermarket and begins to yell and hurl canned goods off the shelves. The authorities are promptly notified. Which section of the Mental Health Act can be utilized?

      Your Answer:

      Correct Answer: Section 136

      Explanation:

      If a person with a mental health condition poses a risk of harm to themselves or others, they can be assessed under the Mental Health Act. Section 136 of the Act permits the police to detain the individual at their current location or take them to a safe place, such as their home or a police station, if they refuse to cooperate.

      During this time, the patient should undergo a formal mental health assessment. The Section 136 detention lasts for 24 hours, but it can be extended for an additional 12 hours. After this period, the patient may either be discharged or transferred to a different section of the Mental Health Act.

      Understanding Sectioning under the Mental Health Act

      Sectioning under the Mental Health Act is a legal process used for individuals who refuse to be admitted voluntarily for mental health treatment. This process involves different sections, each with its own set of rules and regulations.

      Section 2 allows for admission for assessment for up to 28 days, which is not renewable. An Approved Mental Health Professional (AMHP) or the nearest relative (NR) can make the application on the recommendation of two doctors, one of whom should be an approved consultant psychiatrist. Treatment can be given against the patient’s wishes.

      Section 3 allows for admission for treatment for up to 6 months, which can be renewed. An AMHP, along with two doctors who have seen the patient within the past 24 hours, can make the application. Treatment can also be given against the patient’s wishes.

      Section 4 is a 72-hour assessment order used in emergencies when a section 2 would involve an unacceptable delay. A GP and an AMHP or NR can make the application, which is often changed to a section 2 upon arrival at the hospital.

      Section 5(2) allows a doctor to legally detain a voluntary patient in the hospital for 72 hours, while Section 5(4) allows a nurse to detain a voluntary patient for 6 hours.

      Section 17a, also known as Supervised Community Treatment (Community Treatment Order), can be used to recall a patient to the hospital for treatment if they do not comply with the conditions of the order in the community, such as taking medication.

      Section 135 allows a court order to be obtained to allow the police to break into a property to remove a person to a Place of Safety, while Section 136 allows the police to take someone found in a public place who appears to have a mental disorder to a Place of Safety for up to 24 hours while a Mental Health Act assessment is arranged.

      Understanding the different sections of the Mental Health Act can help individuals and their loved ones navigate the legal process of sectioning and ensure that they receive the necessary treatment and support for their mental health.

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  • Question 51 - A 75-year-old male patient who lives independently experiences recurrent episodes of enjoyable visual...

    Incorrect

    • A 75-year-old male patient who lives independently experiences recurrent episodes of enjoyable visual hallucinations without any impairment of consciousness or disorientation. He acknowledges that the hallucinations are not real. Apart from visual impairment, he is generally healthy.

      What is the probable ophthalmic condition that he is suffering from?

      Your Answer:

      Correct Answer: Age-related macular degeneration

      Explanation:

      Patients with severe visual impairment often have coexisting CBS and may experience recurrent, persistent, or episodic visual or auditory hallucinations. The most prevalent ophthalmological condition linked to CBS is age-related macular degeneration, making it the correct answer.

      While glaucoma, cataract, and other ophthalmic conditions can also cause CBS, they are less common than age-related macular degeneration.

      It is crucial to understand that these hallucinations are a result of deteriorating eyesight and not indicative of an underlying psychiatric disorder.

      Understanding Charles-Bonnet Syndrome

      Charles-Bonnet syndrome (CBS) is a condition characterized by complex hallucinations, usually visual or auditory, that occur in clear consciousness. These hallucinations persist or recur and are often experienced against a background of visual impairment, although this is not always the case. People with CBS typically retain their insight and do not experience any other significant neuropsychiatric disturbances.

      Several factors can increase the risk of developing CBS, including advanced age, peripheral visual impairment, social isolation, sensory deprivation, and early cognitive impairment. The condition affects both sexes equally and doesn’t appear to have any familial predisposition. Age-related macular degeneration is the most common ophthalmological condition associated with CBS, followed by glaucoma and cataract.

      Complex visual hallucinations are relatively common in people with severe visual impairment, occurring in 10-30% of cases. The prevalence of CBS in visually impaired individuals is estimated to be between 11 and 15%. Although some people find the hallucinations unpleasant or disturbing, CBS is typically a long-term condition, with 88% of people experiencing it for two years or more. Only 25% of people experience a resolution of their symptoms after nine years.

      In summary, CBS is a condition that can cause complex hallucinations in people with visual impairment. Although the hallucinations can be distressing, most people with CBS retain their insight and do not experience any other significant neuropsychiatric disturbances. The condition is relatively common in visually impaired individuals and tends to be a long-term condition.

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  • Question 52 - A 20-year-old woman from Sierra Leone comes to your clinic and reveals that...

    Incorrect

    • A 20-year-old woman from Sierra Leone comes to your clinic and reveals that she underwent female genital mutilation (FGM) at the age of 16 and is still struggling with the trauma. She mentions that her three sisters also went through the same procedure but don't appear to be affected mentally. She feels embarrassed that she is the only one struggling while her sisters seem to be doing fine.

      What would be the best course of action in this situation?

      Your Answer:

      Correct Answer: Refer to local safeguarding procedures and refer to mental health services

      Explanation:

      If a female under 18 discloses that she has undergone genital mutilation, the mandatory reporting duty applies. However, in this case, the individual is over 18, so the duty doesn’t apply, and there is no need to involve the police.

      Instead, it is important to follow local safeguarding procedures and refer the individual to mental health services. It is recommended to refer her to mental health services rather than suggesting she self-refer or seek private counseling, as she may be hesitant to do so on her own. It is crucial to provide support and resources to help her cope with her feelings and experiences.

      If the individual chooses to involve the police, it is her decision to make.

      Understanding Female Genital Mutilation

      Female genital mutilation (FGM) is a practice that involves the partial or total removal of the external female genitalia or other forms of injury to the female genital organs for non-medical reasons. This practice is classified into four types by the World Health Organization (WHO). Type 1 involves the partial or total removal of the clitoris and/or the prepuce, while Type 2 involves the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3 involves the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris. Type 4 includes all other harmful procedures to the female genitalia for non-medical purposes, such as pricking, piercing, incising, scraping, and cauterization. It is important to understand the different types of FGM to raise awareness and prevent this harmful practice.

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  • Question 53 - A 38-year-old teacher has been seeking your help for the past four weeks...

    Incorrect

    • A 38-year-old teacher has been seeking your help for the past four weeks due to symptoms of mild depression. You have prescribed an antidepressant and would like to suggest cognitive behavioural therapy (CBT) as an additional treatment. However, access to CBT in your area is limited. During your latest appointment, the patient has mentioned finding some online CBT therapies and would like your advice on the most suitable options. Which computer-based CBT therapies (CCBT) are recommended by NICE for managing mild to moderate depression?

      Your Answer:

      Correct Answer: Beating the Blues

      Explanation:

      CCBT Approved by NICE for Depression and Anxiety Treatment

      In 2002, NICE did not recommend any form of computerized cognitive behavioral therapy (CCBT). However, the current packages have been reviewed and two have been approved. Beating the Blues has been recommended as an option in the treatment of mild to moderate depression and should be made available free to all NHS patients. Although approved by NICE, Fear Fighter is aimed at the treatment of panic and phobia. NICE consider that there is insufficient evidence to recommend the use of COPE and Overcoming Depression as clinically cost-effective options, but this may change should further trials prove successful. OC Fighter (previously known as BTSteps) is used to supplement treatment of obsessive-compulsive disorder.

      If you are a healthcare professional, do you use CCBT in the management of your patients? If so, it is important to note that Beating the Blues is now available for free to all NHS patients with mild to moderate depression. Patients can access this treatment through their GP or mental health professional. It is important to stay up-to-date with NICE guidelines and recommendations for the use of CCBT in the treatment of mental health conditions.

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  • Question 54 - A 27-year-old woman comes to see you. She is 31 weeks pregnant and...

    Incorrect

    • A 27-year-old woman comes to see you. She is 31 weeks pregnant and lives with her partner. The pregnancy has so far been uneventful.

      She says that over the past few days she has started to feel anxious and tearful, and is finding it hard to concentrate. She is not sure if this is just 'normal' at this stage of pregnancy. She denies any disturbance of sleep or appetite, and her PHQ-9 score is only five. She has had no thoughts of self-harm.

      Her parents, and her older sister have been treated for depression and she suffered a brief depressive episode in her early teens.

      Which of the following statements is correct?

      Your Answer:

      Correct Answer: Only women at high risk for postnatal depression, like this lady, need active monitoring of their mood in the postnatal period

      Explanation:

      Managing Depression in Pregnancy and Postpartum

      This patient has a history of depressive illness and is at high risk for developing a depressive episode during pregnancy or postpartum. While her current symptoms are common in later pregnancy, close monitoring is necessary to detect any changes that may require treatment. If treatment is necessary, SSRIs such as Sertraline are now considered safe for use during pregnancy.

      Postpartum depression is a common concern, and all patients should be closely monitored by health visiting teams and community midwives. GPs should also have a low threshold for considering depression in mothers of young babies and should inquire about the mother’s mood at the six-week postnatal check. If a mother experiences tearfulness and difficulty sleeping at six weeks postpartum, this should be taken seriously, as the baby blues typically resolve by 10 days postpartum. Early detection and treatment can greatly improve outcomes for both mother and baby.

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  • Question 55 - A 28-year-old male comes to the Emergency Department with suicidal thoughts following the...

    Incorrect

    • A 28-year-old male comes to the Emergency Department with suicidal thoughts following the end of his relationship two weeks ago. He expresses fear of being alone as his partner had always made important decisions for him, as he feels incapable of making the right choices. He has attempted to find a new partner through online dating but has been unsuccessful despite going on several dates. He discloses that he has previously been diagnosed with a personality disorder. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Dependent personality disorder

      Explanation:

      The correct diagnosis for the patient in the question is dependent personality disorder. This personality disorder is characterized by a need for excessive reassurance from others, a tendency to seek out relationships, and a reliance on others to make major life decisions. Patients with this disorder often struggle to take care of themselves and become anxious when left to do so. They cope best when in a relationship and will urgently seek out new relationships if one fails. They tend to passively comply with the wishes of others.

      Borderline personality disorder, on the other hand, is characterized by emotional instability, impulsive behavior, and intense but unstable relationships with others. While patients with borderline personality disorder may fear abandonment, they do not typically seek out excessive reassurance and are able to make life decisions.

      Paranoid personality disorder is another incorrect answer. Patients with this disorder are often suspicious of others, reluctant to confide in friends and family, and may be unforgiving.

      Finally, narcissistic personality disorder is also an incorrect answer. Patients with this disorder have an inflated sense of self-importance, lack empathy, and often feel entitled.

      Personality disorders are a set of maladaptive personality traits that interfere with normal functioning in life. They are categorized into three clusters: Cluster A, which includes odd or eccentric disorders such as paranoid, schizoid, and schizotypal; Cluster B, which includes dramatic, emotional, or erratic disorders such as antisocial, borderline, histrionic, and narcissistic; and Cluster C, which includes anxious and fearful disorders such as obsessive-compulsive, avoidant, and dependent. These disorders affect around 1 in 20 people and can be difficult to treat. However, psychological therapies such as dialectical behaviour therapy and treatment of any coexisting psychiatric conditions have been shown to help patients.

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      • Mental Health
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  • Question 56 - A 69-year-old man comes to see you. He is tearful and clearly upset....

    Incorrect

    • A 69-year-old man comes to see you. He is tearful and clearly upset. On review of his notes you see has a history of recurrent depression and he has been taking citalopram 20 mg once daily for the last 12 months. You can also see that he was referred for psychological therapies.

      His grown up son has a severe learning disability and lives with him. He lacks social support and cites money problems and needs to work as a part time job as a cleaner. He is finding it difficult to function at work and he thinks that his employer wants to sack him, so he needs a 'sick note'. His son attends a day centre twice a week.

      He tells you that he has had suicidal thoughts on and off for years and at the moment he feels like just ending it all. He says that he is not sure how he would do this but could take some tablets or something I suppose. He tells you that last year when he was feeling very low he drank a bottle of whiskey and took pain killers as he felt suicidal.

      Which of the following suggests the greatest risk of suicidal intent?

      Your Answer:

      Correct Answer: Duration of suicidal thoughts

      Explanation:

      Assessing Suicide Risk in Patients: Importance of Therapeutic Alliance and Individualized Assessment

      Assessing suicide risk in patients can be challenging, but establishing a therapeutic alliance and trusting relationship between the professional and patient is crucial. Patients need to feel comfortable enough to disclose suicidal thoughts, and having such discussions can be protective against suicide. A sensitive but thorough enquiry into the details can help identify and compassionately respond to identified risk. It is essential to ask all patients presenting with low mood/anxiety about suicidal thoughts.

      Taking any suicidal ideas seriously and conducting a risk assessment is vital. Exploring protective factors, such as responsibilities for loved ones, can also help in assessing risk. While established risk factors and risk groups for suicide at a population level are useful, clinicians should not rely solely on this knowledge when assessing risk in specific individuals. Suicidal thoughts and risk can vary over a short time, and the assessment of suicide risk needs to be individually focused and conducted regularly.

      A patient’s acute presentation can be a significant factor in considering an impulsive act that may not necessarily translate into significant suicide risk. The duration of suicidal thoughts is not as strong a risk factor as a previous suicide attempt. If suicidal thoughts are uncovered, the clinician needs to decide whether the patient needs to be referred to the Crisis team or is safe to review in 1 or 2 days (‘active monitoring’). The request for a sick note and agreement to plan future care shows that the patient is thinking about the future and wants help.

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  • Question 57 - A 43-year-old woman, who lived alone, scheduled a follow-up appointment with her GP....

    Incorrect

    • A 43-year-old woman, who lived alone, scheduled a follow-up appointment with her GP. She had been self-isolating at home for several months due to the COVID-19 pandemic and continued to feel anxious about going out even after the lockdown was lifted.

      Before the pandemic, she had experienced a traumatic event that left her struggling with post-traumatic stress disorder (PTSD). She had also been dealing with chronic pain and had to quit her job as a result.

      During a telephone consultation with her GP 4 weeks ago, she was diagnosed with moderate depression and referred for computerised cognitive behavioural therapy. She was also advised to try to incorporate more physical activity into her routine.

      However, her mental health had been worsening and she was now experiencing insomnia, early morning awakening, and occasional thoughts of self-harm. She expressed reluctance to pursue one-to-one therapy, as she found it difficult to engage with.

      The GP and patient discussed the next steps in managing her depression.

      What treatment options should be considered?

      Your Answer:

      Correct Answer: Commence citalopram

      Explanation:

      For patients with moderate depression and worsening mental health despite low-level therapy, SSRIs are the recommended first-line antidepressant. In this case, the patient has already received CBT and declined psychological treatments, making an antidepressant necessary. While mirtazapine and venlafaxine are valid options, they are not typically used as first-line treatments due to the likelihood of side effects and higher cost compared to SSRIs. These medications are usually reserved as second-line options if the patient doesn’t respond well to an SSRI. NICE guidelines suggest offering an SSRI first-line due to their effectiveness and lower incidence of side effects. As the patient has not expressed suicidal plans or intent, referral to a crisis team is not necessary at this time.

      NICE Guidelines for Managing Depression

      The National Institute for Health and Care Excellence (NICE) has updated its guidelines for managing depression in 2022. The new guidelines classify depression severity as less severe and more severe based on a PHQ-9 score of <16 and ≥16, respectively. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and least resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient's preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy (CBT), group behavioral activation (BA), individual CBT, individual BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy (IPT), selective serotonin reuptake inhibitors (SSRIs), counseling, and short-term psychodynamic psychotherapy (STPP). For more severe depression, a shared decision should be made between the patient and healthcare provider. Treatment options for more severe depression include a combination of individual CBT and an antidepressant, individual CBT, individual BA, antidepressant medication (SSRI, SNRI, or another antidepressant if indicated based on previous clinical and treatment history), individual problem-solving, counseling, STPP, IPT, guided self-help, and group exercise.

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  • Question 58 - A 42-year-old female patient has been diagnosed with bipolar disorder and is being...

    Incorrect

    • A 42-year-old female patient has been diagnosed with bipolar disorder and is being discharged on lithium at a dose of 400 mg daily after a prolonged period of inpatient treatment. You receive a discharge summary requesting that you continue her blood monitoring in primary care as long term lithium treatment is planned.

      What would be the most suitable monitoring regimen?

      Your Answer:

      Correct Answer: Measure renal function or thyroid function only if clinically indicated (for example, if intercurrent infection/dehydration or symptoms of hypothyroidism develop)

      Explanation:

      Lithium Monitoring

      Lithium is a medication with a narrow therapeutic index, which means that it requires close monitoring. The dosage is adjusted to achieve a serum lithium concentration of 0.4-1 mmol/L. Lithium toxicity can cause symptoms such as blurred vision, ataxia, coarse tremor, nystagmus, dysarthria, and gastrointestinal disturbance (vomiting and diarrhea). Severe toxicity can lead to convulsions, renal failure, and circulatory failure. Therefore, serum lithium levels should be measured every three months on stabilised regimens.

      Renal failure and hypothyroidism are potential side effects of lithium use. As such, renal and thyroid function should be measured six monthly on stabilised regimens. Patients should be informed of the symptoms of hypothyroidism and advised to seek medical review if these symptoms develop. It is also important to note that lithium should be prescribed by brand rather than generically because different lithium preparations vary widely in their bioavailability.

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  • Question 59 - A 30-year-old man has started citalopram because of moderate depression. He has no...

    Incorrect

    • A 30-year-old man has started citalopram because of moderate depression. He has no suicidal intent. He has now returned for review and says he doesn't feel any better.

      NICE guidance recommends that if the person's depression shows no improvement with the first antidepressant, you should check that the drug has been taken regularly and in the prescribed dose.

      What is the recommended time interval for this review?

      Your Answer:

      Correct Answer: 1 to 2 weeks

      Explanation:

      Checking for Proper Medication Adherence in Treating Depression

      According to NICE guidance, it is important to ensure that the prescribed antidepressant has been taken regularly and in the correct dosage if the person’s depression doesn’t improve within 2 to 4 weeks of starting the medication. This step is crucial in determining whether the lack of improvement is due to medication non-adherence or if a different treatment approach is needed. By checking for proper medication adherence, healthcare professionals can ensure that patients are receiving the full benefits of their prescribed treatment plan.

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  • Question 60 - A 25-year-old crystal healer who lives alone says she doesn't have a best...

    Incorrect

    • A 25-year-old crystal healer who lives alone says she doesn't have a best friend and thinks that people judge her unfairly. She says that the power of crystals will cure leukaemia and sometimes feels that her life story appears in magazine stories.
      Select from the list the single best description of her personality type.

      Your Answer:

      Correct Answer: Schizotypal

      Explanation:

      Understanding Personality Disorders: Clusters and Characteristics

      Personality disorders are not easy to diagnose, but they can be seen as extreme versions of normal behavior that affect an individual’s social functioning. Psychotherapy and cognitive behavior therapy can be helpful, and medication may be used in some cases. These disorders can be grouped into three clusters: odd, dramatic, and anxious. The odd PDs include paranoid, schizotypal, and schizoid. The dramatic PDs include histrionic, borderline, narcissistic, and antisocial. The anxious PDs include dependent, obsessive-compulsive, and avoidant. Borderline personality disorder is characterized by fear of abandonment, unstable relationships, and dangerous behavior. Histrionic personality disorder is characterized by excessive attention-seeking behavior and a need for approval.

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  • Question 61 - A 56-year-old woman presents to your clinic with concerns about her recent blood...

    Incorrect

    • A 56-year-old woman presents to your clinic with concerns about her recent blood test results. She reports feeling unwell for the past month, experiencing rapid heart rate, hot flashes, and tremors. She also notes sweating and an inability to sit still during these episodes. She reports that these symptoms began after an episode of shingles. Thyroid function tests, full blood count, fasting glucose, and renal function are all normal. On examination, she appears slightly agitated with a pulse of 98 bpm and blood pressure of 155/98. She has a history of severe depression, which has been in remission for two months, and post-herpetic neuralgia. She denies alcohol use and has never had elevated blood pressure in the past. Her current medications include Sertraline 200 mg, Gaviscon as needed, topical ibuprofen cream for osteoarthritis, paracetamol for osteoarthritis, and carbamazepine 100 mg four times daily for post-herpetic neuralgia. How would you manage this patient?

      Your Answer:

      Correct Answer: Refer her to a neurologist

      Explanation:

      The patient’s symptoms suggest serotonin syndrome, which can be caused by excessive stimulation of serotonergic receptors due to interactions or overdosage of serotonergic drugs. The offending drug in this case is carbamazepine, which should be withdrawn. Other drugs that can interact with SSRIs include lithium, triptans, codeine, and St John’s wort. It is not appropriate to withdraw the patient’s Sertraline or prescribe nifedipine for her mildly elevated blood pressure. There is no basis for stopping the paracetamol. Referring to a neurologist or repeating her thyroid function is also not necessary.

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  • Question 62 - A 35-year-old woman presents to the clinic with her husband. They are concerned...

    Incorrect

    • A 35-year-old woman presents to the clinic with her husband. They are concerned because she has become increasingly fixated on cleaning, which is interfering with her other responsibilities and straining their relationship.

      She has installed a nail brush in the downstairs bathroom to scrub her skin after using the toilet and has prohibited guests from using any of the upstairs bathrooms. She also requires visitors to remove their shoes outside and has banned eating from any area outside the kitchen. Most recently, she has begun waking up at 5:30 am every day to clean.

      What is the most appropriate initial treatment for her?

      Your Answer:

      Correct Answer: Counselling

      Explanation:

      Treating OCD with CBT and SSRIs

      CBT and SSRIs are the main treatments for obsessive-compulsive disorder (OCD). CBT involves challenging the ritualistic behavior of OCD through exposure and response prevention, which exposes the patient to stimuli that usually provoke their behavior and challenges their irrational thinking. On the other hand, SSRIs are the main pharmacological therapy for OCD. Counseling alone is not usually focused enough to provide significant impact on symptoms. A comprehensive treatment plan that includes CBT and SSRIs can help individuals with OCD manage their symptoms and improve their quality of life.

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  • Question 63 - A 50-year-old woman with a known history of depression, previously well controlled with...

    Incorrect

    • A 50-year-old woman with a known history of depression, previously well controlled with fluoxetine, has started to suffer from anxiety, loss of interest and reduced appetite. She also complains of insomnia.

      She claims that she is taking her medications regularly according to prescription. You conclude that her depression has not responded to treatment.

      What will be the most appropriate management for her?

      Your Answer:

      Correct Answer: Switch to another SSRI

      Explanation:

      Treatment for Non-Responsive Depression

      When a patient fails to respond to fluoxetine, which is a selective serotonin reuptake inhibitor (SSRI), it is recommended to switch to another SSRI first. If this doesn’t work, the NICE update on depression (2010) suggests trying a newer generation antidepressant that is better tolerated. It is important to find the right medication for each individual patient, as depression can have a significant impact on their quality of life. Therefore, healthcare professionals should closely monitor patients and adjust their treatment plan accordingly.

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  • Question 64 - You receive a clinic letter from psychiatry regarding a 65-year-old patient who you...

    Incorrect

    • You receive a clinic letter from psychiatry regarding a 65-year-old patient who you referred with severe depression. The psychiatrist would like you to switch from fluoxetine to venlafaxine (a serotonin-norepinephrine reuptake inhibitor).

      What is the most appropriate way to make this change?

      Your Answer:

      Correct Answer: Cross-taper sertraline and imipramine

      Explanation:

      Cross-tapering is recommended when switching from an SSRI to a TCA to avoid interactions and the risk of serotonin syndrome. Completing withdrawal of sertraline without introducing imipramine is not advised. Direct switch and waiting periods are not appropriate. Waiting 7 days is only necessary when switching from fluoxetine to a TCA.

      Guidelines for Switching Antidepressants

      When switching antidepressants, it is important to follow specific guidelines to ensure a safe and effective transition. If switching from citalopram, escitalopram, sertraline, or paroxetine to another selective serotonin reuptake inhibitor (SSRI), the first SSRI should be gradually withdrawn before starting the alternative SSRI. However, if switching from fluoxetine to another SSRI, a gap of 4-7 days should be left after withdrawal due to its long half-life.

      When switching from an SSRI to a tricyclic antidepressant (TCA), cross-tapering is recommended. This involves slowly reducing the current drug dose while slowly increasing the dose of the new drug. The exception to this is fluoxetine, which should be withdrawn before starting TCAs.

      If switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine, it is important to cross-taper cautiously. Starting with a low dose of venlafaxine (37.5 mg daily) and increasing very slowly is recommended. The same approach should be taken when switching from fluoxetine to venlafaxine.

      Overall, following these guidelines can help minimize the risk of adverse effects and ensure a smooth transition when switching antidepressants.

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  • Question 65 - A 35-year-old former soldier with a past of post-traumatic stress disorder comes in...

    Incorrect

    • A 35-year-old former soldier with a past of post-traumatic stress disorder comes in for a follow-up. Despite undergoing an unsuccessful treatment of eye movement desensitisation and reprocessing therapy, he is hesitant to attempt cognitive behavioural therapy. Which of the following medications could potentially benefit individuals in his situation?

      Your Answer:

      Correct Answer: Venlafaxine

      Explanation:

      When CBT or EMDR therapy prove to be ineffective in treating PTSD, the initial pharmacological interventions typically involve prescribing either venlafaxine or an SSRI.

      Understanding Post-Traumatic Stress Disorder (PTSD)

      Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include natural disasters, physical or sexual assault, or military combat. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of triggers associated with the event, hyperarousal, emotional numbing, depression, and substance abuse.

      Effective management of PTSD involves a range of interventions, including watchful waiting for mild symptoms, trauma-focused cognitive behavioral therapy (CBT), and eye movement desensitization and reprocessing (EMDR) therapy for more severe cases. While drug treatments are not recommended as a first-line treatment for adults, venlafaxine or a selective serotonin reuptake inhibitor (SSRI) such as sertraline may be used. In severe cases, risperidone may be recommended. It is important to note that single-session interventions, also known as debriefing, are not recommended following a traumatic event.

      Understanding PTSD and its symptoms is crucial in providing effective support and treatment for those who have experienced trauma. With the right interventions, individuals with PTSD can learn to manage their symptoms and improve their quality of life.

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  • Question 66 - A 35-year-old female is initiated on haloperidol for treatment-resistant schizophrenia. She visits her...

    Incorrect

    • A 35-year-old female is initiated on haloperidol for treatment-resistant schizophrenia. She visits her primary care physician complaining of neck pain and limited neck movement for the past 24 hours. Upon examination, she displays normal vital signs except for a mild tachycardia of 105 and neck stiffness with restricted range of motion. Her neck is involuntarily flexed to the right, but her facial movements are normal. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Torticollis

      Explanation:

      The patient is experiencing acute dystonia, which is a sustained muscle contraction resulting in torticollis or oculogyric crisis. This is likely due to the recent initiation of a typical antipsychotic medication, specifically haloperidol. Torticollis, or a wry neck, is diagnosed when there is unilateral pain and deviation of the neck, restricted range of motion, and pain upon palpation.

      While neuroleptic malignant syndrome is a medical emergency that can occur in patients taking antipsychotics, this patient’s mild tachycardia is likely due to pain rather than altered mental state, generalised rigidity, fever, fluctuating blood pressure, and high temperature, which are the hallmark symptoms of this condition. However, it should still be considered in patients taking antipsychotics.

      Another example of acute dystonia is an oculogyric crisis, which involves sustained upward deviation of the eyes, clenched jaw, and hyperextension of the back/neck with torticollis. However, since the patient doesn’t exhibit any facial signs or symptoms, torticollis alone is the more appropriate diagnosis.

      Tardive dyskinesia is a condition that occurs in patients on long-term typical antipsychotics and is characterised by uncontrolled facial movements, such as lip-smacking.

      Antipsychotics are a type of medication used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. However, they are known to cause extrapyramidal side-effects such as Parkinsonism, acute dystonia, akathisia, and tardive dyskinesia. These side-effects can be managed with procyclidine. Other side-effects of typical antipsychotics include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients due to an increased risk of stroke and venous thromboembolism.

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  • Question 67 - A 26-year-old man is prescribed a prolonged course of oral prednisolone for a...

    Incorrect

    • A 26-year-old man is prescribed a prolonged course of oral prednisolone for a flare-up of ulcerative colitis. What is the most commonly associated side effect of extended use of corticosteroids?

      Your Answer:

      Correct Answer: Insomnia

      Explanation:

      Long-term steroid use often leads to psychiatric issues.

      Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

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  • Question 68 - A 17-year-old female comes to see you with her mother. Her mother is...

    Incorrect

    • A 17-year-old female comes to see you with her mother. Her mother is concerned about her daughter's lack of self-confidence and lack of friends.

      You talk with the daughter who tells you that she is worried about her weight and feels that she needs to lose weight to be more attractive. She feels that she needs to lose at least another 2 stones for her 'ideal' body weight. Her mother tells you that she is pre-occupied with her eating habits and this has been a persistent problem for a 'long time'. You weigh her and her body mass index is 23.

      On clinical examination you note skin abrasions and some callous formation on the dorsum of her hands overlying the metacarpophalangeal joints and the presence of some dental erosion affecting the teeth.

      What is the underlying diagnosis?

      Your Answer:

      Correct Answer: Substance misuse

      Explanation:

      Bulimia Nervosa: Characteristics and Physical Signs

      Bulimia nervosa is an eating disorder characterized by persistent preoccupation with eating, cravings for food that cannot be resisted, episodes of binge eating, and compensatory methods to counter the effects of food on body weight and shape. Unlike anorexia nervosa, body weight may be normal with bulimia. Physical signs of bulimia include arrhythmias, electrolyte abnormalities, upper GI erosions, ulcers, and dental erosions. Russell’s sign, skin abrasions, lacerations, and calluses overlying the dorsal aspect of the small joints of the hands, is a clinical sign caused by repetitive friction between the teeth and skin when sufferers use their fingers/hand to self-induce vomiting. Bulimia is often associated with other psychiatric comorbidities such as depression and alcohol/substance misuse. This behavior is not normal adolescent behavior as it is persistent and causing significant psychological symptoms and demonstrable physical signs.

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  • Question 69 - A 50-year-old woman has a history of bipolar disorder. She is brought by...

    Incorrect

    • A 50-year-old woman has a history of bipolar disorder. She is brought by her husband who is concerned that she is entering a manic phase.
      Select from the list the single feature that would NOT suggest a diagnosis of mania.

      Your Answer:

      Correct Answer: Loss of interest in pleasurable activities

      Explanation:

      Understanding Mania and Hypomania in Bipolar Disorder

      Mania and hypomania are two terms used to describe the elevated mood states experienced by individuals with bipolar disorder. Mania is a more severe form of elevated mood, often accompanied by psychotic symptoms such as delusions and hallucinations. Hypomania, on the other hand, is a milder form of mania without psychotic symptoms.

      To diagnose mania, at least three of the following symptoms must be present: inflated self-esteem, decreased need for sleep, rapid and emphatic speech, flight of ideas, distractibility, psychomotor agitation, and excessive involvement in pleasurable activities without regard for consequences.

      It’s important to note that nearly all cases of mania will eventually lead to episodes of depression, which is why bipolar disorder is often grouped with mania. Understanding the symptoms of mania and hypomania can help individuals with bipolar disorder and their loved ones recognize when they may need to seek professional help.

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  • Question 70 - A 26-year-old male has been diagnosed with schizophrenia and is currently receiving olanzapine...

    Incorrect

    • A 26-year-old male has been diagnosed with schizophrenia and is currently receiving olanzapine depot injections to manage his psychotic symptoms. Prior to starting the treatment, his psychiatrist conducted a full blood count, urea and electrolytes, and liver function test. If the patient continues to take olanzapine in the long term, how frequently should these parameters be monitored?

      Your Answer:

      Correct Answer: Annually

      Explanation:

      Before starting a patient on antipsychotics and on an annual basis thereafter, it is recommended to conduct a full blood count, urea and electrolytes, and liver function test. Any other options presented in this scenario are incorrect. It is important to note that different antipsychotics may have varying monitoring requirements, and consulting the BNF is advised if unfamiliar with these drugs.

      Patients taking antipsychotic medication require extensive monitoring in addition to clinical follow-up. The British National Formulary (BNF) recommends regular testing of full blood count (FBC), urea and electrolytes (U&E), and liver function tests (LFT) at the start of therapy and annually thereafter. Clozapine requires more frequent monitoring of FBC, initially weekly. Lipids and weight should be tested at the start of therapy, at 3 months, and annually. Fasting blood glucose and prolactin should be tested at the start of therapy, at 6 months, and annually. Blood pressure should be monitored frequently during dose titration, and an electrocardiogram and cardiovascular risk assessment should be done at baseline and annually. The BNF provides specific recommendations for individual drugs, and patients should consult their healthcare provider for more information.

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  • Question 71 - A 32-year-old patient complains of nausea, headaches, and palpitations. He has been admitted...

    Incorrect

    • A 32-year-old patient complains of nausea, headaches, and palpitations. He has been admitted multiple times in the past 2 years with similar symptoms, but no organic cause has been identified. What type of disorder is likely to be the cause of these symptoms?

      Your Answer:

      Correct Answer: Somatisation disorder

      Explanation:

      Somatisation refers to the manifestation of physical symptoms that cannot be explained by any underlying medical condition. On the other hand, hypochondria is a condition where a person constantly worries about having a serious illness, often believing that minor symptoms are signs of a life-threatening disease such as cancer.

      Unexplained Symptoms in Psychiatry

      In psychiatry, there are several terms used to describe patients who present with physical or psychological symptoms for which no organic cause can be found. Somatisation disorder is characterized by the presence of multiple physical symptoms that persist for at least two years, and the patient refuses to accept reassurance or negative test results. Illness anxiety disorder, also known as hypochondriasis, involves a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results. Conversion disorder typically involves the loss of motor or sensory function, and the patient doesn’t consciously feign the symptoms or seek material gain. Dissociative disorder involves the process of separating off certain memories from normal consciousness, and may present with psychiatric symptoms such as amnesia, fugue, or stupor. Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms, while malingering refers to the fraudulent simulation or exaggeration of symptoms for financial or other gain. These terms help clinicians to better understand and diagnose patients with unexplained symptoms.

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  • Question 72 - A 64-year-old woman is noted to have poor self-care with symptoms of early...

    Incorrect

    • A 64-year-old woman is noted to have poor self-care with symptoms of early morning waking and decreased appetite. She has poor concentration and is easily agitated. There is a history of a recent death in the family. She also recently lost her job as a volunteer. She has difficulty answering short-term recall questions. Her family think that her symptoms have been deteriorating over the past 6 months.
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Depressive pseudodementia

      Explanation:

      Physical Signs and Symptoms of Depression in Elderly Patients

      Depression in elderly patients can manifest in various physical signs and symptoms. Early morning waking and decreased appetite are common symptoms, often accompanied by short-term memory loss. While memory loss is also seen in dementia, it improves with treatment of depression. Other physical signs include weight loss, constipation, loss of libido, impotence in men, fatigue, and body aches and pains. Retardation or agitation of behavior may also occur. These symptoms may be precipitated by life events and should be addressed promptly to improve the patient’s quality of life.

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  • Question 73 - A 54-year-old woman comes to the clinic complaining of an unrelenting itch. Despite...

    Incorrect

    • A 54-year-old woman comes to the clinic complaining of an unrelenting itch. Despite undergoing a thorough examination, blood tests, and a consultation with a dermatologist, no underlying cause has been identified. The patient reveals that she strongly believes in a particular explanation for her symptom.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Delusional parasitosis

      Explanation:

      Delusional parasitosis is the correct term for a patient who has a fixed, false belief that they are infested by bugs. This condition is characterized by persistent itching and the belief that there are insects crawling on or under the skin. Capgras delusion, Cotard’s syndrome, and De Clerambault’s syndrome are all different psychological conditions that are not related to delusional parasitosis.

      Understanding Delusional Parasitosis

      Delusional parasitosis is a condition that is not commonly seen, but it can be quite distressing for those who experience it. Essentially, it involves a person having a false belief that they are infested with some kind of bug or parasite, such as worms, mites, or bacteria. This belief is fixed and unshakeable, even in the face of evidence to the contrary.

      It is important to note that delusional parasitosis can occur on its own, but it may also be a symptom of other psychiatric conditions. Despite the delusion, many people with this condition are otherwise functional and able to carry out their daily activities. However, the belief can cause significant anxiety and distress, and may lead to behaviors such as excessive cleaning or avoidance of certain places or activities. Treatment for delusional parasitosis typically involves a combination of medication and therapy to address the underlying psychiatric condition and help the person manage their symptoms.

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      • Mental Health
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  • Question 74 - A 35-year-old male contacts his GP at 2PM to schedule his blood tests...

    Incorrect

    • A 35-year-old male contacts his GP at 2PM to schedule his blood tests following a recent visit to his psychiatrist. The psychiatrist has raised his dosage of lithium and requested that the GP arrange for lithium levels to be checked at the appropriate time after taking the medication. The patient took his first increased dose of lithium at 10AM (two hours ago).

      When should the GP schedule the blood test to be taken?

      Your Answer:

      Correct Answer: 8 hours

      Explanation:

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in refractory depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate or cAMP formation.

      Common adverse effects of lithium include nausea, vomiting, diarrhea, fine tremors, and nephrotoxicity. It may also cause thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, and hyperparathyroidism.

      Monitoring of patients on lithium therapy is crucial to prevent toxicity. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until concentrations are stable. Once established, lithium levels should be checked every 3 months. Thyroid and renal function should be checked every 6 months. Patients should be provided with an information booklet, alert card, and record book. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

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      • Mental Health
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  • Question 75 - A 27-year-old man presents to his GP for a review of his depression....

    Incorrect

    • A 27-year-old man presents to his GP for a review of his depression. He mentions that he recently applied for Universal Credit due to financial struggles after being made redundant. He requests a copy of his medical record to support his claim.

      The patient is currently single and resides alone in the UK. He was last employed six months ago with a private car detailing company, where he worked for over five years before leaving due to mental health issues. He has savings of approximately £20,000. He has no siblings or children, and his parents passed away in a car accident seven years ago.

      What is the probable outcome of his Universal Credit application?

      Your Answer:

      Correct Answer: He is not eligible as he has more than £16,000 in savings

      Explanation:

      If you have savings exceeding £16,000, you are not eligible to receive Universal Credit. To qualify for Universal Credit, you must be 18 or over (with some exceptions for 16 to 17-year-olds), have a low income or be unemployed, be under State Pension age (or have a partner who is), have savings of £16,000 or less between you and your partner, and live in the UK. While medical conditions or dependents do not impact your eligibility, they may affect the amount of payment you receive.

      Understanding Universal Credit: Benefits, Eligibility, and Controversies

      Universal Credit is a new benefit system in the UK that aims to simplify the welfare system by combining six benefits into one payment. It is designed to help people meet the cost of living and encourage them to work. To be eligible for Universal Credit, a person and their partner must live in the UK, be 18 years old or over, earn a low income or be out of work, have less than £16,000 in savings, and be below the age of receiving the state pension.

      The amount of money a person receives from Universal Credit depends on their circumstances. It includes a standard allowance and extra payments for up to two children, disability, or housing costs. However, there is a benefit cap that limits the total amount one can receive. The payment reduces as people earn money, but they have a work allowance of how much they can earn before their payment is decreased.

      Universal Credit is supposed to help people learn to budget their money and prepare them for having a job. It also allows people to work and still receive support through a ‘work allowance.’ Applying for Universal Credit is done online, which cuts down the cost of managing benefits to the government.

      Despite its supposed benefits, Universal Credit is controversial. Some people take issue with the fact that people have to wait five weeks to receive their first payment and then struggle due to only receiving payments every month. Childcare must be paid by parents upfront and is then refunded by Universal Credit. Many disabled people and households receive less than they did with the old benefits system. Universal Credit will only pay for the first two children for children born after April 2017, whereas the old benefits paid benefits for each child per year. Private tenants find it harder to rent.

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  • Question 76 - A 32-year-old male presents to the GP with persistent difficulty in leaving his...

    Incorrect

    • A 32-year-old male presents to the GP with persistent difficulty in leaving his home without performing a cleaning ritual that takes over 3 hours to finish. He has an intense fear that if he doesn't complete the process, his family will be harmed. The patient is currently undergoing cognitive behavioural therapy (CBT).

      What is the best course of action for managing this patient?

      Your Answer:

      Correct Answer: Prescribe sertraline

      Explanation:

      Obsessive-compulsive disorder (OCD) is the likely diagnosis for this patient, who is exhibiting symptoms of fear of harming her children and compulsive cleaning. The first-line treatment for OCD is cognitive behaviour therapy (CBT) or exposure and response prevention. However, since the patient has not responded to CBT and is still experiencing intrusive symptoms, it would be appropriate to prescribe an SSRI, such as sertraline.

      Continuing with CBT alone would not be appropriate for this patient, given her ongoing and intrusive symptoms. Therefore, the most suitable course of action is to add an SSRI to her treatment plan.

      Benzodiazepines are not recommended for this patient, as they have a high potential for addiction and are typically used for acute relief of panic attacks. The patient is not displaying any overt anxiety symptoms that would warrant a prescription of benzodiazepines.

      Zopiclone may be prescribed for severe sleeping difficulties, but it is not indicated for this patient, who is not experiencing any acute issues with sleeping.

      Since the patient has not responded to CBT, it is appropriate to add an SSRI rather than referring her for exposure and response prevention.

      Understanding Obsessive-Compulsive Disorder (OCD)

      Obsessive-compulsive disorder (OCD) is a mental health condition that affects 1 to 3% of the population. It is characterized by the presence of obsessions, which are unwanted intrusive thoughts, images, or urges, and compulsions, which are repetitive behaviors or mental acts that a person feels driven to perform. These symptoms can cause significant functional impairment and distress.

      Risk factors for OCD include a family history of the condition, age (with peak onset between 10-20 years), pregnancy/postnatal period, and a history of abuse, bullying, or neglect.

      The management of OCD involves classifying the level of impairment as mild, moderate, or severe using the Y-BOCS scale. For mild impairment, low-intensity psychological treatments such as cognitive behavioral therapy (CBT) including exposure and response prevention (ERP) are recommended. If this is insufficient, a course of an SSRI or more intensive CBT (including ERP) can be offered. For moderate impairment, a choice of either an SSRI or more intensive CBT (including ERP) is recommended, with clomipramine as an alternative first-line drug treatment to an SSRI if necessary. For severe impairment, referral to the secondary care mental health team for assessment is necessary, with combined treatment of an SSRI and CBT (including ERP) or clomipramine as an alternative while awaiting assessment.

      ERP is a psychological method that involves exposing a patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. This helps them confront their anxiety, leading to the eventual extinction of the response. Treatment with an SSRI should continue for at least 12 months to prevent relapse and allow time for improvement. Compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response.

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  • Question 77 - A 62-year-old man and his wife have come to the clinic with concerns...

    Incorrect

    • A 62-year-old man and his wife have come to the clinic with concerns about a new treatment he has recently started. He has a lengthy history of severe and debilitating depression that has not responded well to treatment with various selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. He was referred to specialist mental health services for further management.

      His wife reports that he has been prescribed a new medication called 'phenelzine'. Unfortunately, she was unable to attend the psychiatry appointment with him. He informed her that the psychiatrist had advised him to avoid certain foods, but he cannot recall them and left the information leaflet he was given on the bus by mistake.

      What is the best way to advise them?

      Your Answer:

      Correct Answer: He should avoid citrus fruits and bananas

      Explanation:

      Dietary Restrictions for Certain Medical Conditions

      Monoamine oxidase inhibitors (MAOIs) are not commonly prescribed in general practice due to the risk of hypertensive crisis when combined with certain foods or medications. Patients taking MAOIs must avoid tyramine-containing foods and should not take tricyclic antidepressants. Haemodialysis patients are advised to limit their intake of potassium-rich foods such as citrus fruits and bananas. Those with gout should avoid purine-containing foods like offal and shellfish. Patients with coeliac disease must avoid gluten-containing foods like wheat, barley, rye, and sometimes oats. Individuals with oxalate renal stones should avoid oxalate-containing foods like spinach, rhubarb, nuts, and chocolate. By following these dietary restrictions, patients can better manage their medical conditions and avoid potential complications.

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  • Question 78 - A 42-year-old man was robbed two weeks ago while walking home alone. He...

    Incorrect

    • A 42-year-old man was robbed two weeks ago while walking home alone. He frequently experiences flashbacks of the incident. His companions have observed that he is more cautious of his environment when they accompany him. He is having difficulty sleeping and refrains from going out by himself.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Acute stress disorder

      Explanation:

      Acute stress disorder is a type of acute stress reaction that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. This is different from post-traumatic stress disorder (PTSD), which is diagnosed after four weeks. Symptoms of acute stress disorder include intrusive thoughts, dissociation, negative mood, avoidance, and arousal. Intrusive thoughts may include flashbacks or nightmares, while dissociation may involve feeling like one is in a daze or experiencing time slowing down. Negative mood may manifest as feelings of sadness or hopelessness, while avoidance may involve avoiding places or people that remind one of the traumatic event. Arousal symptoms may include hypervigilance and sleep disturbance.

      The management of acute stress disorder typically involves trauma-focused cognitive-behavioral therapy (CBT) as a first-line treatment. Benzodiazepines may also be used to manage acute symptoms such as agitation or sleep disturbance, but caution should be exercised due to their addictive potential and concerns that they may be detrimental to adaptation. Overall, early intervention and treatment can help individuals with acute stress disorder recover and prevent the development of PTSD.

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  • Question 79 - A 38-year-old woman comes to your afternoon clinic. She has been feeling off...

    Incorrect

    • A 38-year-old woman comes to your afternoon clinic. She has been feeling off since losing her job 3 weeks ago. She is tearful during the consultation and reports having trouble sleeping, with early morning waking, a decreased appetite resulting in some weight loss, a decreased libido, and difficulty concentrating. She feels stuck in her current situation and is unsure if there is a way out. She occasionally has thoughts of how it might be better if I wasn't here and thinks about death, but these are fleeting and not associated with any specific thoughts or plans of suicide. When asked directly, she says she couldn't do that to her family. She tells you that her mother once took pills for nerves, but she can't remember anything else.
      Choose the most appropriate treatment from the list.

      Your Answer:

      Correct Answer: Citalopram

      Explanation:

      Treatment Options for Moderate Depressive Episode

      A woman is experiencing a moderate depressive episode, as evidenced by her low mood lasting for more than two weeks and the presence of a somatic syndrome. The most appropriate treatment option in this case is citalopram, a selective serotonin re-uptake inhibitor. However, some patients may experience a rise in anxiety and sleep disturbances during the initial titration, which can be managed by adding nocturnal sedation such as zopiclone for a short period.

      Other treatment options include risperidone, an antipsychotic with mood-stabilizing properties, and valproate, which can be used as a mood-stabilizer but should be used with caution in women of childbearing age. Tricyclic antidepressants like amitriptyline have more side-effects than SSRIs and are not typically used as first-line treatment. Mirtazapine, another antidepressant, is usually only used when an SSRI has failed.

      In conclusion, citalopram is the most appropriate treatment option for a moderate depressive episode, but it is important to monitor for potential side-effects and adjust the treatment plan accordingly.

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  • Question 80 - How can dissociative non-epileptic attacks (pseudoseizures) be differentiated from generalised tonic clonic seizures...

    Incorrect

    • How can dissociative non-epileptic attacks (pseudoseizures) be differentiated from generalised tonic clonic seizures based on their features?

      Your Answer:

      Correct Answer: Post episode sleepiness

      Explanation:

      Pseudoseizures vs. Genuine Seizures

      A gradual onset is indicative of non-epileptic attacks, while other features suggest genuine generalised tonic clonic seizures. However, pseudoseizures have additional characteristics, such as being mainly observed in females (8:1), previous illness behavior, and childhood physical and/or sexual abuse. Diagnosing pseudoseizures can be challenging and is typically not done with certainty in primary care. A neurologist is usually involved in the diagnosis, and video EEG can be helpful.

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  • Question 81 - A 25-year-old man presents with symptoms of low mood. Upon evaluation, you diagnose...

    Incorrect

    • A 25-year-old man presents with symptoms of low mood. Upon evaluation, you diagnose him with moderate depression and decide to initiate fluoxetine treatment. According to the latest NICE recommendations, when should you schedule a follow-up appointment with the patient?

      Your Answer:

      Correct Answer: After 1 week

      Explanation:

      NICE suggests that patients who are under 30 years old should be reviewed within one week.

      Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression, with citalopram and fluoxetine being the preferred options. They should be used with caution in children and adolescents, and patients should be monitored for increased anxiety and agitation. Gastrointestinal symptoms are the most common side-effect, and there is an increased risk of gastrointestinal bleeding. Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in certain patients. SSRIs have a higher propensity for drug interactions, and patients should be reviewed after 2 weeks of treatment. When stopping a SSRI, the dose should be gradually reduced over a 4 week period. Use of SSRIs during pregnancy should be weighed against the risks and benefits.

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  • Question 82 - A 35-year-old lady comes back to the clinic after four weeks of starting...

    Incorrect

    • A 35-year-old lady comes back to the clinic after four weeks of starting fluoxetine treatment for moderate depressive symptoms. She has no prior history of taking antidepressants and has no other medical conditions. During the assessment, she denies any suicidal thoughts and has good support from her partner at home. Despite taking fluoxetine regularly, she has not noticed any improvement in her symptoms and is considering switching to a different medication. She reports no adverse effects from fluoxetine but has heard positive feedback about St John's Wort from a friend. What would be the most appropriate action to take for this patient?

      Your Answer:

      Correct Answer: Change to a tricyclic antidepressant

      Explanation:

      Treatment Options for Patients with Minimal Response to SSRIs

      When a patient has been taking a Selective serotonin reuptake inhibitor (SSRI) for four weeks without benefit, it is important to consider alternative treatment options. Continuing at the current dose is not a satisfactory plan.

      There are essentially two options in addition to increasing the level of support: increasing the dose of the current antidepressant or changing to an alternative agent if there are side effects or the patient prefers. However, it is important to note that switching from fluoxetine to tricyclics requires great caution as it inhibits the metabolism. Therefore, a lower than usual starting dose of tricyclic would be required.

      Although there is some evidence of the benefit of St John’s Wort, it is not recommended that doctors prescribe or advocate its use due to the lack of clarity regarding doses, duration of effect, and variation in the nature of preparations. Additionally, there are serious drug interactions, particularly with oral contraceptives and antiepileptics.

      For moderate depression, Cognitive Behavioral Therapy (CBT) is recommended in addition to medication. It is important to monitor the patient’s response to treatment and adjust accordingly to ensure the best possible outcome.

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  • Question 83 - A 60-year-old woman with a 25-year history of treatment with antipsychotic medications for...

    Incorrect

    • A 60-year-old woman with a 25-year history of treatment with antipsychotic medications for schizophrenia complains of the onset of writhing tongue and finger movements.
      Select from the list the single most likely cause.

      Your Answer:

      Correct Answer: Tardive dyskinesia

      Explanation:

      Understanding Tardive Dyskinesia and Differential Diagnosis

      Tardive dyskinesia is a condition that can develop in patients who have been on long-term treatment with antipsychotic medications. It is characterized by choreoathetoid movements that typically start in the fingers and tongue before becoming more widespread. While Huntington’s disease and Wilson’s disease can also present with tremors and choreiform movements, they usually have an earlier onset than tardive dyskinesia. Parkinsonism, on the other hand, is characterized by resting tremors and bradykinesia, while akathisia is characterized by motor restlessness. It is important to note that antipsychotic medications can also cause Parkinson’s symptoms and akathisia. Therefore, a thorough differential diagnosis is necessary to accurately diagnose and treat tardive dyskinesia.

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      • Mental Health
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  • Question 84 - A 19-year-old woman presents to her General Practitioner because she is concerned about...

    Incorrect

    • A 19-year-old woman presents to her General Practitioner because she is concerned about her weight, which is 56 kg. Her body mass index (BMI) is 18 kg/m2. She also reports prolonged fasts, sometimes not eating for a few days. She denies using laxatives or diuretics to help her lose weight. She is scared of putting on weight and has missed her last three periods. She has no known medical comorbidities.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Anorexia nervosa

      Explanation:

      Understanding Eating Disorders: Differential Diagnosis

      Eating disorders are complex mental health conditions that can have serious physical and psychological consequences. When a patient presents with symptoms of an eating disorder, it is important to consider a range of differential diagnoses to ensure appropriate treatment. Here, we explore the key features of several eating disorders and related conditions, including anorexia nervosa, personality disorders, avoidant restrictive food intake disorder (ARFID), bulimia nervosa, and depression. By understanding the unique characteristics of each disorder, healthcare professionals can make an accurate diagnosis and provide effective support for patients with eating disorders.

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  • Question 85 - Olivia is a 27 year old who comes to you with symptoms of...

    Incorrect

    • Olivia is a 27 year old who comes to you with symptoms of severe obsessive compulsive disorder (OCD). As per NICE guidelines, what is the recommended first line pharmacological treatment for OCD?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      According to the 2005 NICE Guidance on the treatment of obsessive-compulsive disorder and body dysmorphic disorder, adults with OCD should be prescribed one of the following SSRIs as their first pharmacological treatment: fluoxetine, fluvoxamine, paroxetine, sertraline, or citalopram.

      Understanding Obsessive-Compulsive Disorder (OCD)

      Obsessive-compulsive disorder (OCD) is a mental health condition that affects 1 to 3% of the population. It is characterized by the presence of obsessions, which are unwanted intrusive thoughts, images, or urges, and compulsions, which are repetitive behaviors or mental acts that a person feels driven to perform. These symptoms can cause significant functional impairment and distress.

      Risk factors for OCD include a family history of the condition, age (with peak onset between 10-20 years), pregnancy/postnatal period, and a history of abuse, bullying, or neglect.

      The management of OCD involves classifying the level of impairment as mild, moderate, or severe using the Y-BOCS scale. For mild impairment, low-intensity psychological treatments such as cognitive behavioral therapy (CBT) including exposure and response prevention (ERP) are recommended. If this is insufficient, a course of an SSRI or more intensive CBT (including ERP) can be offered. For moderate impairment, a choice of either an SSRI or more intensive CBT (including ERP) is recommended, with clomipramine as an alternative first-line drug treatment to an SSRI if necessary. For severe impairment, referral to the secondary care mental health team for assessment is necessary, with combined treatment of an SSRI and CBT (including ERP) or clomipramine as an alternative while awaiting assessment.

      ERP is a psychological method that involves exposing a patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. This helps them confront their anxiety, leading to the eventual extinction of the response. Treatment with an SSRI should continue for at least 12 months to prevent relapse and allow time for improvement. Compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response.

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  • Question 86 - A 38-year-old woman comes in for evaluation. Her spouse reports that she had...

    Incorrect

    • A 38-year-old woman comes in for evaluation. Her spouse reports that she had a disagreement with their daughter, causing her to leave the house. Following this incident, she has been unable to speak. Physical examination of her chest and throat reveals no abnormalities. What is the most appropriate term to describe this scenario?

      Your Answer:

      Correct Answer: Psychogenic aphonia

      Explanation:

      Understanding Aphonia: The Inability to Speak

      Aphonia is a medical condition that refers to the inability to speak. It can be caused by various factors, including recurrent laryngeal nerve palsy, which can occur after a thyroidectomy. In this case, the nerve that controls the vocal cords is damaged, leading to difficulty in speaking.

      Another cause of aphonia is psychogenic, which means that it is related to psychological factors. This can include anxiety, depression, or other mental health conditions that affect the ability to communicate verbally.

      It is important to note that aphonia is different from mutism, which is the inability to speak due to a physical or neurological condition. In contrast, aphonia is typically a temporary condition that can be treated with appropriate medical or psychological interventions.

      Overall, understanding aphonia is crucial for identifying and addressing the underlying causes of this condition. Whether it is related to a physical or psychological issue, seeking medical attention can help individuals regain their ability to speak and improve their quality of life.

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      • Mental Health
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  • Question 87 - A 50-year-old woman comes to you complaining of experiencing electric shock sensations and...

    Incorrect

    • A 50-year-old woman comes to you complaining of experiencing electric shock sensations and dizziness in her arms and legs for the past three days. She has a medical history of chronic pain, depression, and schizophrenia. When you inquire about her medications and drug use, she seems hesitant to provide a clear response.

      What could be the probable reason behind her symptoms?

      Your Answer:

      Correct Answer: SSRI discontinuation syndrome

      Explanation:

      SSRI discontinuation syndrome can cause symptoms such as dizziness, electric shock sensations, and anxiety when SSRIs are suddenly stopped or reduced. It is possible that the woman in question has decided to stop taking her antidepressants. On the other hand, alcohol withdrawal typically results in anxiety, tremors, and sweating. Neuroleptic malignant syndrome is a rare reaction that can occur with antipsychotic use and may cause fever, confusion, and muscle rigidity. Opiate withdrawal may cause anxiety, sweating, and gastrointestinal symptoms like diarrhea and vomiting.

      Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression, with citalopram and fluoxetine being the preferred options. They should be used with caution in children and adolescents, and patients should be monitored for increased anxiety and agitation. Gastrointestinal symptoms are the most common side-effect, and there is an increased risk of gastrointestinal bleeding. Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in certain patients. SSRIs have a higher propensity for drug interactions, and patients should be reviewed after 2 weeks of treatment. When stopping a SSRI, the dose should be gradually reduced over a 4 week period. Use of SSRIs during pregnancy should be weighed against the risks and benefits.

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  • Question 88 - A 25-year-old woman requests medication from her General Practitioner as she has an...

    Incorrect

    • A 25-year-old woman requests medication from her General Practitioner as she has an overwhelming feeling of dread about her upcoming job interview. She becomes very anxious in situations where she is required to talk to people who are not very well known to her and usually tries to avoid such events. She is happily married and was very happy in her current job until she was made redundant.
      What is the single most likely diagnosis?

      Your Answer:

      Correct Answer: Social phobia

      Explanation:

      Differentiating Anxiety Disorders: A Brief Overview

      Anxiety disorders are a group of mental health conditions that can cause significant distress and impairment in daily life. Here are some key differences between the most common anxiety disorders:

      Social Phobia: This disorder is characterized by fear, worry, or embarrassment in social situations, leading to avoidance. Panic attacks are common, and symptoms are limited to social situations.

      Generalized Anxiety Disorder: This disorder is characterized by excessive, uncontrollable worry that is disproportionate to the situation. Physical and psychological symptoms may be present, but the worry is not limited to specific triggers.

      Obsessive-Compulsive Disorder: This disorder is characterized by intrusive thoughts or images (obsessions) and repetitive behaviors or mental acts (compulsions) that are performed to alleviate anxiety. These symptoms are not present in the scenario described.

      Panic Disorder: This disorder is characterized by sudden-onset acute anxiety symptoms, such as palpitations or hyperventilation. Panic attacks may occur without a specific trigger, but can also be triggered by specific situations.

      Post-Traumatic Stress Disorder: This disorder develops after exposure to a traumatic event and is characterized by hyperarousal, dissociation, flashbacks, and nightmares. There is no history of trauma in the scenario described, ruling out PTSD as a diagnosis.

      Understanding the differences between these anxiety disorders can help healthcare professionals make an accurate diagnosis and provide appropriate treatment.

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  • Question 89 - A 21-year-old woman presents to your morning clinic as an urgent addition. She...

    Incorrect

    • A 21-year-old woman presents to your morning clinic as an urgent addition. She is in tears and reports feeling very low. She has been experiencing poor sleep and loss of appetite.
      In accordance with the NICE guidelines for depression in adults (CG90), which category of depression is recommended for active monitoring for up to two weeks?

      Your Answer:

      Correct Answer: Mild depression

      Explanation:

      Active Monitoring for Mild Depression

      Active monitoring is a recommended approach for individuals who may recover without formal intervention, those with mild depression who do not want treatment, or those with subthreshold depressive symptoms who request an intervention. Practitioners should discuss the presenting problem(s) and any concerns the person may have about them, provide information about the nature and course of depression, and arrange a further assessment within two weeks. It is important to make contact if the person doesn’t attend follow-up appointments. This approach allows for a watchful waiting period, during which the individual’s symptoms can be monitored and evaluated for any changes or progression. By providing information and support, practitioners can help individuals make informed decisions about their mental health and well-being.

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      • Mental Health
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  • Question 90 - Which antidepressant is most likely to increase the risk of arrhythmia? ...

    Incorrect

    • Which antidepressant is most likely to increase the risk of arrhythmia?

      Your Answer:

      Correct Answer: Mirtazapine

      Explanation:

      Cardiotoxicity of Antidepressants

      Both dosulepin and venlafaxine are not recommended for patients with a high risk of arrhythmia due to their potential cardiotoxicity. However, a recent BMJ editorial suggests that venlafaxine may not be less safe than selective serotonin reuptake inhibitors (SSRIs) and that limiting its use based on cardiotoxicity alone may not be appropriate. Therefore, currently, dosulepin and all other tricyclic antidepressants are considered the most concerning in terms of cardiotoxicity. It is important to exercise caution when prescribing any antidepressant to patients with a history of cardiovascular disease or other risk factors. Proper monitoring and individualized treatment plans can help minimize the risk of adverse cardiac events.

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      • Mental Health
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SESSION STATS - PERFORMANCE PER SPECIALTY

Mental Health (2/5) 40%
Passmed