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  • Question 1 - A 30-year-old woman is brought to the Emergency Department after attempting to end...

    Correct

    • A 30-year-old woman is brought to the Emergency Department after attempting to end her life by jumping from a height. On examination, she is conscious and has significant bruising over the occiput region. She reports that her parents are recently divorced and it has caused significant strain on her current relationship and as a result, is failing to do well at work. She has no significant medical history, apart from an incident when she was 17 where she was admitted to the hospital after intentionally taking too many paracetamol.
      Which of the following from the patient’s history is most associated with an increased risk of repeated attempts of self-harm/suicide?

      Your Answer: Previous attempted suicide

      Explanation:

      Risk Factors for Repeated Self-Harm and Suicide Attempts

      Previous suicide attempts or episodes of self-harm are the biggest predictor of future attempts, with 15% of people attempting again within a year and 1% succeeding in committing suicide. Strained relationships with partners or dissatisfaction with work alone have not been linked to repeated attempts. However, significant life events such as parental divorce, bereavement, abuse, or family breakdown may increase the risk. Age alone, particularly for adults in their twenties, has not been associated with repeated self-harm or suicide attempts.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 26-year-old man is admitted to your psychiatric ward in a state of...

    Incorrect

    • A 26-year-old man is admitted to your psychiatric ward in a state of distress saying that he knows for certain that his colleagues are plotting to have him dismissed from work. He says they are spreading malicious rumours about his sexuality and, with the help of the CIA, have bugged his office. In the first week of his admission, he is observed to be responding to unseen stimuli when alone in his room. His family state that he is a lovely lad who never gets into any trouble with drink or drugs. They are very worried because in the last 3 months he has told them he can hear people talking about him to each other when he lies in bed at night. He has no significant medical history.
      Which one of the following courses of action would be most appropriate?

      Your Answer: Commence chlorpromazine

      Correct Answer: Commence olanzapine with lorazepam and procyclidine as required

      Explanation:

      Treatment Options for Schizophrenia

      Schizophrenia is a serious mental disorder that requires prompt treatment. The following are some treatment options for schizophrenia:

      Commence Olanzapine with Lorazepam and Procyclidine as Required
      Olanzapine is an atypical anti-psychotic that carries a lower risk of extrapyramidal side-effects. However, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk further. The anti-psychotic action of olanzapine may take up to 10 days to begin, so short-acting benzodiazepines such as lorazepam may be prescribed for sedation.

      Do Not Just Observe with Sedation as Required
      Observing with sedation is not a definitive treatment for schizophrenia. It is essential to commence anti-psychotic medication promptly.

      Commence Chlorpromazine
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, atypical anti-psychotics are usually preferred as first-line treatment.

      Commence Clozapine
      Clozapine is the most effective medication for treatment-resistant schizophrenia. However, it carries a small risk of serious complications such as fatal agranulocytosis, myocarditis or cardiomyopathy, and pulmonary embolus. Therefore, it is usually reserved for patients who have not responded to two anti-psychotics given at an appropriate dose for 6-8 weeks.

      Commence Chlorpromazine with Lorazepam and Procyclidine as Required
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk. Short-acting benzodiazepines such as lorazepam may also be prescribed for sedation.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 3 - A 60-year-old patient with a history of bipolar disorder visits your GP clinic...

    Correct

    • A 60-year-old patient with a history of bipolar disorder visits your GP clinic for routine blood tests. Despite feeling completely fine, he wants to check his health status. Upon clinical examination, there are no signs of splenomegaly or lymphadenopathy.
      The following are the results:
      - Hb 140 g/L Male: (135-180) Female: (115 - 160)
      - Platelets 160 * 109/L (150 - 400)
      - WBC 14 * 109/L (4.0 - 11.0)
      - Na+ 144 mmol/L (135 - 145)
      - K+ 4.7 mmol/L (3.5 - 5.0)
      - Urea 5.4 mmol/L (2.0 - 7.0)
      - Creatinine 114 µmol/L (55 - 120)
      - Thyroid stimulating hormone (TSH) 5.2 mU/L (0.5-5.5)
      - Free thyroxine (T4) 9.5 pmol/L (9.0 - 18)
      - Lithium level 0.75 mmol/L (0.6 - 1.2)

      What advice would you give to this patient?

      Your Answer: Safety net to return if symptoms develop, arrange repeat blood tests as per usual, under the normal monitoring schedule

      Explanation:

      Lithium, a mood-stabilizing drug commonly used in bipolar disorder, can lead to various health complications such as thyroid, cardiac, renal, and neurological issues. One of the common side effects of lithium is benign leucocytosis, which is also associated with other drugs like corticosteroids and beta-blockers. In this case, it is appropriate to continue with the normal monitoring schedule and safety netting for any signs of infection or malignancy, as there are no indications of either. Antibiotics would not be necessary. Malignant leucocytosis is unlikely as there are no accompanying symptoms such as night sweats, weight loss, bleeding, lymphadenopathy, or bone pain. Withholding lithium would not be advisable as it is effectively managing the patient’s condition. The psychiatric team should be consulted before making any decisions regarding the medication.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant 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 and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. 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:

      • Psychiatry
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  • Question 4 - A 39-year-old man, with a history of severe depression, is admitted unconscious to...

    Incorrect

    • A 39-year-old man, with a history of severe depression, is admitted unconscious to the hospital, following a suicide attempt where he stabbed himself with a knife, with significant intent of causing death. His past psychiatric history suggests that this is his fifth suicide attempt, with the four previous attempts involving taking an overdose of his antidepressants and paracetamol. During this admission, he needed surgery for bowel repair. He is now three days post-operation on the Surgical Ward and is having one-to-one nursing due to recurrent suicidal thoughts after his surgery. The consulting surgeon thinks he is not fit enough to be discharged, and a referral is made to liaison psychiatry. After assessing the patient, the psychiatrist reports that the patient’s current severe depression is affecting his capacity and that the patient’s mental health puts himself at risk of harm. The psychiatrist decides to detain him on the ward for at least three days. The patient insists on leaving and maintains that he has no interest to be alive.
      Which is the most appropriate section for the doctor to use to keep this patient in hospital?

      Your Answer: Section 2

      Correct Answer: Section 5(2)

      Explanation:

      The Mental Health Act has several sections that allow doctors and mental health professionals to keep patients in hospital for assessment or treatment. Section 5(2) can be used by doctors to keep a patient in hospital for at least 72 hours if they have a history of severe depression, previous suicide attempts, or recurrent suicidal thoughts. Section 2 is used by approved mental health professionals for assessment and allows for a maximum stay of 28 days. Section 4 is used in emergencies and allows for a 72-hour stay. Section 5(4) can be used by mental health or learning disability nurses for a maximum of six hours. Section 3 can be used for treatment for up to six months, with the possibility of extensions and treatment against the patient’s will in the first three months.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 5 - A 28-year-old man presents to his GP with ongoing sleep issues due to...

    Incorrect

    • A 28-year-old man presents to his GP with ongoing sleep issues due to tension in his relationship with his girlfriend. He feels she is distant and suspects she is spending time with her ex-boyfriend who works in the same office. Upon further questioning, he reveals a history of feeling uninterested in past relationships and struggles with mood swings. He expresses feeling alone in the world and that even his friends are against him. Although he self-harms, he denies any suicidal thoughts. A referral to psychiatry leads to a diagnosis of borderline personality disorder. What is the most appropriate treatment for this patient?

      Your Answer: Cognitive behavioural therapy (CBT)

      Correct Answer: Dialectical behaviour therapy (DBT)

      Explanation:

      Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder, as it is specifically designed to help individuals who experience intense emotions. Cognitive behavioural therapy (CBT) is not a targeted therapy for personality disorder patients and is more beneficial for those with depression or anxiety-related conditions. Exposure and response prevention therapy (ERP) is a treatment option for patients with obsessive-compulsive disorder, while eye movement desensitisation and reprocessing therapy (EMDR) is a treatment option for patients with post-traumatic stress disorder.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically 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 (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - A 42-year-old woman visits the clinic with her husband, who is worried about...

    Correct

    • A 42-year-old woman visits the clinic with her husband, who is worried about her recent change in behavior. For the past two weeks, she has been acting out of character, spending large amounts of money on credit cards and wearing bold makeup and clothes that she wouldn't normally choose. She has also been experiencing insomnia, often staying up late at night to work on important projects that she can't disclose to her husband. The patient has a history of depression, and her mother was hospitalized for mental illness. What is the most probable diagnosis for this patient?

      Your Answer: Bipolar Disorder

      Explanation:

      Differentiating Mental Disorders: Understanding the Symptoms

      Bipolar Disorder:
      A patient showing signs of mania, such as inflated self-esteem, pressured speech, reduced need for sleep, and engaging in high-risk behaviors, may be diagnosed with bipolar disorder. A manic episode requires a disturbed mood plus three of the above symptoms. A history of depression and a family history of psychiatric conditions, such as bipolar disorder, further support this diagnosis.

      Personality Disorder:
      Personality disorders are maladaptive mental disorders that typically develop at an early age. A patient in their mid-forties who has recently started experiencing mood-related symptoms, such as depression and mania, is unlikely to have a personality disorder. Types of personality disorders include paranoid, schizoid, schizotypal, borderline, histrionic, narcissistic, and obsessive-compulsive.

      Anxiety Disorder:
      Symptoms of anxiety include social withdrawal, excessive worry, and avoidance of risk. A patient exhibiting symptoms of mania, such as high energy and engaging in risky behaviors, is not displaying signs of anxiety disorder. However, anxiety disorder may coexist with bipolar disorder.

      Depression:
      Depression is characterized by low mood, lack of enjoyment in activities, difficulty concentrating, and suicidal thoughts. A patient who has a history of depression but is currently experiencing symptoms of mania is not exhibiting signs of depression.

      Schizophrenia:
      Schizophrenia is a complex mental disorder that requires several criteria for diagnosis. Symptoms include hallucinations, disordered speech and thought, paranoia, and social withdrawal. A patient who does not exhibit these symptoms is not eligible for a differential diagnosis of schizophrenia.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 7 - A 16-year-old male comes in for a psychiatric check-up for his depression and...

    Correct

    • A 16-year-old male comes in for a psychiatric check-up for his depression and reports frequently losing his train of thought, attributing it to the government stealing his ideas. What is the symptom he is displaying?

      Your Answer: Thought withdrawal

      Explanation:

      Schizophrenia is a mental disorder that is characterized by various symptoms. Schneider’s first rank symptoms are divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can involve thought insertion, thought withdrawal, or thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or actions/impulses/feelings that are imposed on the individual or influenced by others. Delusional perceptions involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.

      Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that schizophrenia can manifest differently in each individual, and not all symptoms may be present.

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      • Psychiatry
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  • Question 8 - A 78-year-old man comes to see you, struggling to cope after his wife...

    Correct

    • A 78-year-old man comes to see you, struggling to cope after his wife passed away suddenly 5 months ago. He appears sad and spends most of the appointment looking down, but answers your questions. He expresses concern that he may be losing his mind because he has started seeing his wife sitting in her old chair and sometimes talks to her when he is alone. He confirms that he can hear her voice responding to him. He says he mostly talks to her while cooking in the kitchen or when he is alone at night. Despite these experiences, he knows that what he sees and hears is not real. He reports occasional memory loss and some abdominal pain due to his irritable bowel syndrome, but is otherwise healthy. He has no history of psychiatric conditions in himself or his family. What is the most likely diagnosis?

      Your Answer: Normal grief reaction

      Explanation:

      Pseudohallucinations may be a normal part of the grieving process, and differ from true hallucinations in that the individual is aware that what they are experiencing is not real. While pseudohallucinations can be distressing, they are not considered pathological unless accompanied by urinary symptoms, which would require further investigation. The patient in question displays low mood and avoids eye contact, but responds well to questioning and is able to prepare food independently. While depression with psychotic features can involve true hallucinations, there are no other symptoms to suggest this diagnosis. Lewy-body dementia, which can cause visual hallucinations, Parkinsonian features, and cognitive impairment, is not a likely explanation for this patient’s symptoms. Abnormal grief reactions are typically defined as persisting for at least six months after the loss.

      Understanding Pseudohallucinations

      Pseudohallucinations are false sensory perceptions that occur in the absence of external stimuli, but with the awareness that they are not real. While not officially recognized in the ICD 10 or DSM-5, there is a general consensus among specialists about their definition. Some argue that it is more helpful to view hallucinations on a spectrum, from mild sensory disturbances to full-blown hallucinations, to avoid misdiagnosis or mistreatment.

      One example of a pseudohallucination is a hypnagogic hallucination, which occurs during the transition from wakefulness to sleep. These vivid auditory or visual experiences are fleeting and can happen to anyone. It is important to reassure patients that these experiences are normal and do not necessarily indicate the development of a mental illness.

      Pseudohallucinations are particularly common in people who are grieving. Understanding the nature of these experiences can help healthcare professionals provide appropriate support and reassurance to those who may be struggling with them. By acknowledging the reality of pseudohallucinations and their potential impact on mental health, we can better equip ourselves to provide compassionate care to those who need it.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 9 - A 44-year-old man is being evaluated on the psychiatric ward due to a...

    Correct

    • A 44-year-old man is being evaluated on the psychiatric ward due to a worsening of his mental health condition. Upon admission, the patient was diagnosed with a major depressive disorder accompanied by hallucinations.
      Lately, the patient has been persistently expressing the belief that he is deceased. Consequently, he has ceased eating and displays obvious signs of self-neglect. The patient has no known medical conditions other than his mental health problems.
      What is the name of the syndrome that this patient is experiencing?

      Your Answer: Cotard syndrome

      Explanation:

      Cotard syndrome is a psychiatric disorder that is characterized by a person’s belief that they are dead or do not exist. This rare condition is often associated with severe depression or psychotic disorders and can lead to self-neglect and withdrawal from others. Treatment options include medication and electroconvulsive therapy.

      Capgras syndrome is a delusional disorder where patients believe that a loved one has been replaced by an identical impostor. This condition is typically associated with schizophrenia, but it can also occur in patients with brain trauma or dementia.

      Charles Bonnet syndrome is a visual disorder that affects patients with significant vision loss. These patients experience vivid visual hallucinations, which can be simple or complex. However, they are aware that these hallucinations are not real and do not experience any other forms of hallucinations or delusions.

      De Clérambault syndrome, also known as erotomania, is a rare delusional disorder where patients believe that someone is in love with them, even if that person is imaginary, deceased, or someone they have never met. Patients may also perceive messages from their supposed admirer through everyday events, such as number plates or television messages.

      Understanding Cotard Syndrome

      Cotard syndrome is a mental disorder that is characterized by the belief that the affected person or a part of their body is dead or non-existent. This rare condition is often associated with severe depression and psychotic disorders, making it difficult to treat. Patients with Cotard syndrome may stop eating or drinking as they believe it is unnecessary, leading to significant health problems.

      The delusion experienced by those with Cotard syndrome can be challenging to manage, and it can have a significant impact on their quality of life. The condition is often accompanied by feelings of hopelessness and despair, which can make it challenging for patients to seek help. Treatment for Cotard syndrome typically involves a combination of medication and therapy, but it can take time to find an effective approach.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 10 - You are part of the mental health team assessing a 65-year-old woman in...

    Correct

    • You are part of the mental health team assessing a 65-year-old woman in the emergency department who has presented with an intentional paracetamol overdose. She is a retired teacher and a devout Christian. She lives alone in a house and her two adult daughters live in a different state. When you ask her, she says that she regrets taking the paracetamol, but is not sure if she would try to do it again.

      What factor decreases her likelihood of carrying out another attempt in the future?

      Your Answer: His religious beliefs

      Explanation:

      Protective factors against completed suicide include religious beliefs, social support, regretting a previous attempt, and having children living at home. However, older age, male gender, and lack of social support are risk factors for suicide. While women are more likely to attempt suicide, men are more likely to die by suicide, possibly due to stigma and different suicide methods. In the case of the individual mentioned, his children living far away may increase his risk of suicide due to a lack of social support.

      Suicide Risk Factors and Protective Factors

      Suicide risk assessment is a common practice in psychiatric care, with patients being stratified into high, medium, or low risk categories. However, there is a lack of evidence on the positive predictive value of individual risk factors. A review in the BMJ concluded that such assessments may not be useful in guiding decision-making, as 50% of suicides occur in patients deemed low risk. Nevertheless, certain factors have been associated with an increased risk of suicide, including male sex, history of deliberate self-harm, alcohol or drug misuse, mental illness, depression, schizophrenia, chronic disease, advancing age, unemployment or social isolation, and being unmarried, divorced, or widowed.

      If a patient has attempted suicide, there are additional risk factors to consider, such as efforts to avoid discovery, planning, leaving a written note, final acts such as sorting out finances, and using a violent method. On the other hand, there are protective factors that can reduce the risk of suicide, such as family support, having children at home, and religious belief. It is important to consider both risk and protective factors when assessing suicide risk and developing a treatment plan.

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      • Psychiatry
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  • Question 11 - A 28-year-old unemployed man is evaluated by the Community Psychiatry Team due to...

    Correct

    • A 28-year-old unemployed man is evaluated by the Community Psychiatry Team due to a decline in his schizophrenia. The patient was initiated on medication two months ago after being diagnosed with the condition. However, he was unable to tolerate the initial treatment prescribed, and the patient's mother reports that her son's psychotic symptoms have persisted and may have even slightly worsened, despite starting a different type of medication. What is the most potent antipsychotic for stubborn psychotic symptoms?

      Your Answer: Clozapine

      Explanation:

      Antipsychotic Medications: Types and Side Effects

      Antipsychotic medications are commonly used to treat psychotic symptoms such as delusions and hallucinations. There are different types of antipsychotics, including typical and atypical medications. Here are some of the commonly used antipsychotics and their side effects:

      Clozapine: This medication is effective for resistant psychotic symptoms, but it is not used as a first-line treatment due to potential adverse effects. It requires haematological monitoring and can cause serious side effects such as neutropenia and thromboembolism. Common side effects include sedation, constipation, and weight gain.

      Olanzapine: This atypical antipsychotic is commonly used for schizophrenia and bipolar disorder. Its major side effect is weight gain, and patients should have their lipids and blood sugars monitored regularly.

      Risperidone: This medication is helpful for acute exacerbations of schizophrenia, bipolar disorder, and irritability in autism. It is a qualitatively atypical antipsychotic with a relatively low risk of extrapyramidal side effects.

      Haloperidol: This typical antipsychotic is used for schizophrenia, tics in Tourette’s, mania in bipolar disorder, and nausea and vomiting. It should be avoided in Parkinson’s disease and can cause tardive dyskinesia, QT prolongation, and neuroleptic malignant syndrome.

      Quetiapine: This atypical antipsychotic is used for schizophrenia, bipolar disorder, and major depressive disorder. Common side effects include sleepiness, constipation, weight gain, and dry mouth.

      In conclusion, antipsychotic medications can be effective in treating psychotic symptoms, but they also come with potential side effects that need to be monitored. It is important to work closely with a healthcare provider to find the right medication and dosage for each individual.

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      • Psychiatry
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  • Question 12 - A 27-year-old woman visits her General Practitioner for a follow-up appointment after being...

    Correct

    • A 27-year-old woman visits her General Practitioner for a follow-up appointment after being diagnosed with depression. She is currently undergoing treatment with citalopram and has started a course of cognitive behavioural therapy (CBT).
      What is used to assess the effectiveness of treatment in patients with depression?

      Your Answer: Patient Health Questionnaire (PHQ-9)

      Explanation:

      Common Screening Tools Used in Primary Care

      Primary care physicians often use various screening tools to assess their patients’ mental and physical health. Here are some of the most commonly used screening tools:

      1. Patient Health Questionnaire-9 (PHQ-9): This tool is used to monitor the severity of depression and the response to treatment.

      2. Mini-Mental State Examination (MMSE): This questionnaire is used to identify cognitive impairment and screen for dementia.

      3. Alcohol Use Disorders Identification Test (AUDIT): This screening tool is used to identify signs of harmful drinking and dependence on alcohol.

      4. Generalised Anxiety Disorder Questionnaire (GAD-7): This tool consists of seven questions and is used to screen for generalised anxiety disorder and measure the severity of symptoms.

      5. Modified Single-Answer Screening Question (M-SASQ): This is a single question alcohol harm assessment tool designed for use in Emergency Departments. It identifies high-risk drinkers based on the frequency of consuming six or more units (if female) or eight or more units (if male) on a single occasion in the last year.

      By using these screening tools, primary care physicians can identify potential health issues early on and provide appropriate treatment and care.

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      • Psychiatry
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  • Question 13 - A 75-year-old woman is admitted to a medical ward and the medical team...

    Incorrect

    • A 75-year-old woman is admitted to a medical ward and the medical team is concerned about her mental health in addition to her urgent medical needs. The patient is refusing treatment and insisting on leaving. The team suspects that she may be mentally incapacitated and unable to make an informed decision. Under which section of the Mental Health Act (MHA) can they legally detain her in England and Wales?

      Your Answer: Section 2

      Correct Answer: Section 5 (2)

      Explanation:

      Section 5 (2) of the MHA allows a doctor to detain a patient for up to 72 hours for assessment. This can be used for both informal patients in mental health hospitals and general hospitals. During this time, the patient is assessed by an approved mental health professional and a doctor with Section 12 approval. The patient can refuse treatment, but it can be given in their best interests or in an emergency. Section 2 and 3 can only be used if they are the least restrictive method for treatment and allow for detention for up to 28 days and 6 months, respectively. Section 135 allows police to remove a person from their home for assessment, while Section 136 allows for the removal of an apparently mentally disordered person from a public place to a place of safety for assessment. Since the patient in this scenario is already in hospital, neither Section 135 nor Section 136 would apply.

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      • Psychiatry
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  • Question 14 - A 25-year-old man with Down syndrome is brought to see the General Practitioner...

    Correct

    • A 25-year-old man with Down syndrome is brought to see the General Practitioner (GP) by his mother to discuss his acne. His mother takes care of all his medications, as he cannot understand the instructions. He lives with his parents and depends on them to do all his cooking and washing. He does not work but attends a day centre a few days per week, where he enjoys craft activities and has a number of close friends. The staff report he is always very polite and interacts well with everyone at the centre. His mother says he is unable to be left alone in the house and cannot go out on his own without the support of another adult.
      Which one of the following conditions does he have?

      Your Answer: Learning disability

      Explanation:

      The patient is unable to function independently and relies on his parents for daily care, indicating a possible diagnosis of a learning disability. This condition is defined by the Department of Health as a significant reduction in the ability to learn new skills and understand complex information, leading to a decreased ability to cope independently. Symptoms must have started before adulthood and have a lasting impact on development. Other potential diagnoses, such as ADHD, autism spectrum disorder, learning difficulty, and oppositional defiant disorder, do not fit the patient’s symptoms and behaviors.

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      • Psychiatry
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  • Question 15 - Which of the following symptoms may suggest mania instead of hypomania? ...

    Correct

    • Which of the following symptoms may suggest mania instead of hypomania?

      Your Answer: Delusions of grandeur

      Explanation:

      Understanding the Difference between Hypomania and Mania

      Hypomania and mania are two terms that are often used interchangeably, but they actually refer to two different conditions. While both conditions share some common symptoms, there are some key differences that set them apart.

      Mania is a more severe form of hypomania that lasts for at least seven days and can cause significant impairment in social and work settings. It may require hospitalization due to the risk of harm to oneself or others and may present with psychotic symptoms such as delusions of grandeur or auditory hallucinations.

      On the other hand, hypomania is a lesser version of mania that lasts for less than seven days, typically 3-4 days. It does not impair functional capacity in social or work settings and is unlikely to require hospitalization. It also does not exhibit any psychotic symptoms.

      Both hypomania and mania share common symptoms such as elevated or irritable mood, pressured speech, flight of ideas, poor attention, insomnia, loss of inhibitions, increased appetite, and risk-taking behavior. However, the length of symptoms, severity, and presence of psychotic symptoms help differentiate mania from hypomania.

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      • Psychiatry
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  • Question 16 - A 42-year-old man presents to his GP with a sense of sadness and...

    Correct

    • A 42-year-old man presents to his GP with a sense of sadness and emptiness. He lost his job 8 months ago and has been struggling to focus on his daily activities ever since. 'I'm just not the same person I used to be,' he tells the doctor. He has no interest in finding a new job and spends most of his time at home. He denies any thoughts of suicide. His sleep is disturbed and he wakes up feeling tired. He also reports a decreased interest in sex with his partner. His medical history is significant only for a bilateral hand tremor that worsens with movement. He is a non-smoker and only drinks socially. What is the most likely diagnosis?

      Your Answer: Major depressive disorder

      Explanation:

      Distinguishing Major Depressive Disorder from Other Conditions

      Major depressive disorder is a psychiatric condition characterized by symptoms such as anhedonia, sadness, lack of concentration, sleep impairment, social withdrawal, and hopelessness. It is often triggered by a significant stressor, such as job loss. While severe depression can also be a component of adjustment disorder, the duration of symptoms beyond 6 months following a stressor suggests a diagnosis of major depressive disorder. Anhedonia, a significant lack of interest in once pleasurable activities, is a symptom rather than a diagnosis by itself and is often present in major depressive disorder. Drug abuse can be a cause or effect of depression, but in this case, the patient’s recent stressor makes drug-related depression less likely. The patient’s hand tremor, worsened by movement, is more likely related to essential tremor than Parkinson’s disease, which typically presents with a resting hand tremor, rigidity, and bradykinesia. Accurately distinguishing major depressive disorder from other conditions is crucial for effective treatment.

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      • Psychiatry
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  • Question 17 - A 28-year-old male with bipolar disorder is currently under the care of his...

    Correct

    • A 28-year-old male with bipolar disorder is currently under the care of his psychiatrist as an outpatient. During the review, the psychiatrist observes that the patient's speech mostly follows a logical sequence, but at times, the patient uses a seemingly inappropriate series of rhyming words. For instance, when asked about his activities the previous day, he responded, I went for a run, had some fun, saw the sun, and then I was done.

      What is the most appropriate term to describe the speech abnormality exhibited by the patient?

      Your Answer: Clanging

      Explanation:

      Language Disturbances in Mental Illness

      Clanging, echolalia, neologism, perseveration, and word salad are all language disturbances that may occur in individuals with mental illness. Clanging is the use of words that sound similar but are not related in meaning. This is often seen in individuals experiencing mania or psychosis. Echolalia is the repetition of words or phrases spoken by others. Neologism is the creation of new words that are not part of standard language. Perseveration is the repetition of a word or activity beyond what is appropriate. Finally, word salad is a completely disorganized speech that is not understandable.

      These language disturbances can be indicative of underlying mental illness and can be used as diagnostic criteria. It is important for mental health professionals to be aware of these language disturbances and to assess their presence in patients. Treatment for these language disturbances may involve medication, therapy, or a combination of both. By addressing these language disturbances, individuals with mental illness may be better able to communicate and function in their daily lives.

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      • Psychiatry
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  • Question 18 - A 39-year-old male has been taking olanzapine for the last 3 years. After...

    Incorrect

    • A 39-year-old male has been taking olanzapine for the last 3 years. After experiencing an episode of tardive dyskinesia, he researched the potential side-effects of the medication. What is the most probable biochemical side-effect that this patient may experience?

      Your Answer: Hypoprolactineamia

      Correct Answer: Hypercholesterolaemia

      Explanation:

      Antipsychotics have been found to cause metabolic side effects such as dysglycaemia, dyslipidaemia, and diabetes mellitus. Olanzapine, along with other antipsychotics, is known to primarily cause hyperlipidemia, hypercholesterolemia, hyperglycemia, and weight gain. These drugs act as dopamine antagonists, leading to hyperprolactinemia as dopamine is a prolactin antagonist. However, they do not have any impact on parathyroid hormones or electrolytes.

      Antipsychotics are a group of drugs 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. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

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      • Psychiatry
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  • Question 19 - A 35-year-old male with a history of daily alcohol consumption for the last...

    Correct

    • A 35-year-old male with a history of daily alcohol consumption for the last five years is admitted to the hospital emergency room. He is experiencing acute visual hallucinations, seeing spiders all around him, and is unable to recognize his family members. He is also exhibiting aggressive behavior and tremors. The patient had stopped drinking alcohol for two days prior to admission. On examination, he has a blood pressure of 170/100 mmHg, tremors, increased psychomotor activity, fearful affect, hallucinatory behavior, disorientation, impaired judgment, and insight. What is the most likely diagnosis?

      Your Answer: Delirium tremens

      Explanation:

      Delirium Tremens

      Delirium tremens (DT) is a severe and potentially life-threatening condition that can occur when someone abruptly stops drinking alcohol. Symptoms can begin within a few hours of cessation, but they may not peak until 48-72 hours later. The symptoms of DT can include tremors, irritability, insomnia, nausea and vomiting, hallucinations (auditory, visual, or olfactory), confusion, delusions, severe agitation, and seizures. Physical findings may be non-specific and include tachycardia, hyperthermia, hypertension, tachypnea, diaphoresis, tremor, mydriasis, ataxia, altered mental status, hallucinations, and cardiovascular collapse.

      It is important to note that not everyone who stops drinking alcohol will experience DT. However, those who have a history of heavy alcohol use or have experienced withdrawal symptoms in the past are at a higher risk. DT can be a medical emergency and requires immediate treatment.

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      • Psychiatry
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  • Question 20 - A 76-year-old man visits his doctor with his wife, who is concerned about...

    Correct

    • A 76-year-old man visits his doctor with his wife, who is concerned about his recent memory decline and difficulty concentrating. She also notes that he has become incontinent of urine and is walking with smaller steps. The patient's medical history includes a myocardial infarction one year ago, as well as hypertension and diabetes. There is no family history of similar symptoms. What is the probable diagnosis?

      Your Answer: Vascular dementia

      Explanation:

      Different Types of Dementia and Their Symptoms

      Dementia is a term used to describe a decline in cognitive function that affects daily life. There are several types of dementia, each with its own set of symptoms. Here are some of the most common types of dementia and their characteristic symptoms:

      1. Vascular dementia: This type of dementia is often associated with risk factors for vascular disease, such as hypertension and diabetes. Symptoms may include sudden or stepwise deterioration in cognitive function, early gait disturbances, urinary symptoms, changes in concentration, and mood.

      2. Alzheimer’s disease: Alzheimer’s disease is the most common cause of dementia. It typically results in progressive memory loss and behavioral changes, rather than sudden deterioration.

      3. Frontotemporal dementia: This type of dementia usually presents with personality changes, loss of insight, and stereotyped behaviors. It is a slowly progressive form of dementia, with onset usually before the age of 70 and a strong family history.

      4. Huntington’s disease: Huntington’s disease typically presents at a much younger age between 20 and 40 years old with psychosis, choreiform movements, depression, and later on dementia. There is also a strong family history.

      5. Lewy body dementia: Lewy body dementia typically presents with parkinsonian symptoms, visual hallucinations, and sleep behavior disorders.

      Understanding the different types of dementia and their symptoms can help with early diagnosis and treatment. If you or a loved one is experiencing cognitive decline, it’s important to seek medical attention to determine the underlying cause.

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      • Psychiatry
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  • Question 21 - A 32-year-old female is initiated on haloperidol for treatment-resistant schizophrenia. She visits her...

    Correct

    • A 32-year-old female is initiated on haloperidol for treatment-resistant schizophrenia. She visits her primary care physician with a complaint 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 towards the right. Her facial movements are normal. What is the probable diagnosis?

      Your Answer: Torticollis

      Explanation:

      The patient is exhibiting symptoms of acute dystonia, which is characterized by sustained muscle contractions such as torticollis or oculogyric crisis. In this case, the patient’s symptoms are likely a result of starting a typical antipsychotic medication, specifically haloperidol. Torticollis, or a wry neck, is present with 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, the patient’s lack of altered mental state and normal observations make it unlikely. An oculogyric crisis, which involves sustained upward deviation of the eyes, clenched jaw, and hyperextension of the back/neck with torticollis, is another example of acute dystonia, but the patient does not exhibit any facial signs or symptoms. Tardive dyskinesia, on the other hand, is a condition that occurs in patients on long-term typical antipsychotics and is characterized by uncontrolled facial movements such as lip-smacking.

      Antipsychotics are a group of drugs 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. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

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      • Psychiatry
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  • Question 22 - A 30-year-old woman, with a history of hearing voices, was brought to the...

    Correct

    • A 30-year-old woman, with a history of hearing voices, was brought to the Emergency Department by her family. She described the voices as telling her to kill her father as ‘he has the devil in him’. She also reported noting her intelligence being tapped through the Internet by a higher power. This has been going on for the past 6 months. Her family denies either depression or manic episodes. The patient was admitted to an inpatient Psychiatry Unit and started on haloperidol for her symptoms, after an evaluation and diagnosis of schizophrenia. Twelve hours after initiation of therapy, the patient started to have stiffness in the neck muscles and spine. Physical examination revealed muscular spasms in the neck and spine, a temperature of 37.2 °C, blood pressure 125/70 mmHg and a pulse of 80 bpm.
      What is the most likely diagnosis?

      Your Answer: Acute dystonia

      Explanation:

      Complications of Haloperidol: Acute Dystonia, Neuroleptic Malignant Syndrome, Serotonin Syndrome, and Meningitis

      Haloperidol is an anti-psychotic medication commonly used to treat schizophrenia. However, it can also cause various complications. Acute dystonia is a condition where the patient experiences muscle spasms in different muscle groups, which can occur shortly after taking haloperidol. Treatment for acute dystonia involves administering anticholinergics.

      Neuroleptic malignant syndrome is another complication that can occur as a result of taking anti-psychotic medication, particularly high-potency ones like haloperidol. Symptoms include abnormal vital signs, such as high fever, and treatment involves discontinuing the medication and managing symptoms with cooling measures and medications like dantrolene or bromocriptine.

      Serotonin syndrome is a condition that can occur when a patient takes multiple doses or an overdose of medications like selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or serotonin agonists like sumatriptans. Symptoms include muscular twitching, agitation, confusion, hyperthermia, sweating, hypertension, tachycardia, and diarrhea.

      Meningitis, on the other hand, is not a complication of haloperidol. It is an inflammation of the protective membranes surrounding the brain and spinal cord, usually caused by a bacterial or viral infection.

      Finally, malignant hyperthermia is a condition that can manifest with similar symptoms to neuroleptic malignant syndrome, but it usually occurs during anesthesia administration and is caused by an inherited autosomal dominant disorder of the ryanodine receptor gene in the skeletal muscle. Treatment involves using dantrolene and providing supportive care.

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      • Psychiatry
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  • Question 23 - A 30-year-old man visits his GP for a medication review. He began taking...

    Incorrect

    • A 30-year-old man visits his GP for a medication review. He began taking citalopram four months ago to treat his depression, and he now feels that his symptoms have significantly improved. He believes that he has returned to his usual self and no longer requires the antidepressant medication. What advice should the GP provide to minimize the risk of relapse?

      Your Answer: Gradually reduce citalopram dose over the next 4 weeks

      Correct Answer: Continue citalopram for 6 more months

      Explanation:

      Antidepressant medication should be continued for a minimum of 6 months after symptoms have remitted to reduce the risk of relapse. Therefore, the correct course of action is to continue treatment for 6 more months from the point of remission. Continuing for only 2 or 3 more months would not meet the recommended duration of treatment. Gradually reducing doses over 4 weeks is a suitable approach for weaning off SSRIs, but it should only be done after the 6-month period of treatment. Stopping citalopram abruptly is not safe and could lead to discontinuation syndrome or a relapse of depression.

      Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

      The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

      When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

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      • Psychiatry
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  • Question 24 - A 50-year-old man is brought to the emergency department by the authorities after...

    Incorrect

    • A 50-year-old man is brought to the emergency department by the authorities after causing a disturbance in public. He is visibly anxious and upset, insisting that there are bugs crawling under his skin and that your face is melting. Upon reviewing his medical history, it is evident that he has a history of alcohol abuse and has been in contact with Drug and Alcohol Services. What scoring system would be best suited for assessing this patient once he is stabilized?

      Your Answer: Alcohol Use Disorders Identification Test (AUDIT)

      Correct Answer: Clinical Institute Withdrawal Assessment (CIWA-Ar)

      Explanation:

      Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 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 to be less effective in treating alcohol withdrawal seizures.

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      • Psychiatry
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  • Question 25 - A 30-year-old female with a diagnosis of bipolar disorder visits her doctor to...

    Incorrect

    • A 30-year-old female with a diagnosis of bipolar disorder visits her doctor to discuss a headache. She starts explaining her issue with the following statement:
      I came here to talk about this headache, but I can't stop thinking about the dream I had last night where I was flying over a rainbow. It's funny because I haven't eaten pizza in a week, and I really miss it.
      What sign of thought disorder is evident in the patient's speech?

      Your Answer: Flight of ideas

      Correct Answer: Knight's move

      Explanation:

      The patient’s speech is indicative of thought disorder characterized by Knight’s move thinking, where there are illogical leaps from one idea to another without any discernible links between them. This is different from flight of ideas, where there are identifiable connections between ideas. It is important to note that the patient is not exhibiting neologisms or clang associations, and their speech is not a word salad.

      Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.

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      • Psychiatry
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  • Question 26 - A 27-year-old man is brought to the hospital by his sister after he...

    Incorrect

    • A 27-year-old man is brought to the hospital by his sister after he spent all of his savings on buying expensive gifts for strangers on the street, claiming that he is here to spread love and happiness. He insists that he is the chosen one to bring joy to the world and will do anything to achieve it. He is very restless, and the doctor cannot communicate with him to gather a medical history. His sister confirms that he has a known diagnosis of bipolar disorder and is currently on medication. For the past few days, the patient has not slept much and has been up all night planning his mission to spread love. There is no evidence of any overdose, but his sister says that he may have missed his medication while on a trip last week. The doctor decides to keep the patient in the hospital under a Section until tomorrow morning when an approved mental health professional can evaluate him.
      For how long can the patient be detained under the Section used?

      Your Answer: One year

      Correct Answer: 72 hours

      Explanation:

      Time Limits for Mental Health Detention in the UK

      In the UK, there are several time limits for mental health detention that healthcare professionals must adhere to. These time limits vary depending on the type of detention and the circumstances of the patient. Here are the time limits for mental health detention in the UK:

      Section 5(2): 72 hours
      A doctor can use Section 5(2) to keep a patient in hospital for a maximum of 72 hours. This cannot be extended, so an approved mental health professional should assess the patient as soon as possible to decide if the patient needs to be detained under Section 2 or 3.

      Section 5(4): 6 hours
      Mental health or learning disability nurses can use Section 5(4) to keep a patient in hospital for a maximum of six hours. This cannot be extended, so arrangements should be made for Section 2 or 3 if the patient is to be kept longer in hospital.

      Section 3: 6 months initially, renewable for one year at a time
      Section 3 can be used to keep a patient in hospital for treatment for six months. It can be extended for another six months, and then after that for one year for each renewal. During the first six months, patients can only be treated against their will in the first three months. For the next three months, the patient can only be treated after an ‘approved second-opinion doctor’ gives their approval for the treatment.

      Section 2: 28 days
      Approved mental health professionals can use Section 2 to keep a patient in hospital for assessment for a maximum of 28 days. It cannot be extended, so if a longer stay is required for treatment, Section 3 needs to be applied for.

      Section 3 Renewal: one year
      Section 3 can be renewed for a second time, after it has been renewed for a first time for six months after an initial six months upon application of the Section. The renewal is for one year at a time.

      Understanding Time Limits for Mental Health Detention in the UK

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      • Psychiatry
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  • Question 27 - A 35-year-old woman arrives at the emergency department with symptoms of restlessness and...

    Incorrect

    • A 35-year-old woman arrives at the emergency department with symptoms of restlessness and confusion that have been present for one day. Upon further examination, she is found to have an elevated heart rate and body temperature. The patient has a history of depression and has been taking sertraline for several years without any changes in dosage or overdose incidents. However, her partner reports that she was recently prescribed a new medication by her general practitioner, which may have interacted with her regular medication. What is the most likely medication responsible for this interaction?

      Your Answer: Levothyroxine

      Correct Answer: Zolmitriptan

      Explanation:

      Patients who are taking a SSRI should not use triptans.

      Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

      The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

      When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

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      • Psychiatry
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  • Question 28 - Samantha, a 35-year-old woman, arrives at the emergency department complaining of severe, sharp...

    Incorrect

    • Samantha, a 35-year-old woman, arrives at the emergency department complaining of severe, sharp pain on her left side that radiates to her lower abdomen and groin. The pain comes and goes in waves and has been ongoing for 10 hours. She also reports an increased frequency of urination and a burning sensation while urinating. A urine dip reveals haematuria but no signs of infection. You request the following blood tests:
      Calcium 3.3 mmol/L (2.1-2.6)
      Corrected Calcium 3.4 mmol/L (2.1-2.6)
      Phosphate 0.6 mmol/L (0.8-1.4)
      Magnesium 0.8 mmol/L (0.7-1.0)
      Thyroid stimulating hormone (TSH) 4.9 mU/L (0.5-5.5)
      Free thyroxine (T4) 9.5 pmol/L (9.0 - 18)
      Parathyroid hormone 85 pg/mL (10-65 )
      Which medication's long-term use is responsible for Samantha's condition?

      Your Answer: Clozapine

      Correct Answer: Lithium

      Explanation:

      Hyperparathyroidism and subsequent hypercalcaemia can occur with prolonged use of lithium. This can lead to the formation of kidney stones due to excessive calcium concentration. Amitriptyline, a sedative tricyclic antidepressant, is not likely to cause nephrolithiasis or explain the patient’s elevated calcium and parathyroid hormone levels. Similarly, clozapine, a second-generation antipsychotic, is not known to cause hypercalcaemia or hyperparathyroidism. Sertraline, a selective serotonin reuptake inhibitor, typically causes side effects during initiation or discontinuation, such as sexual dysfunction and gastrointestinal issues. Checking thyroid function tests may also be helpful as lithium use can lead to hypothyroidism.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant 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 and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

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  • Question 29 - You are discussing bipolar disorder with your consultant in a geriatric trainees teaching...

    Incorrect

    • You are discussing bipolar disorder with your consultant in a geriatric trainees teaching session as part of your psychiatry attachment.
      Which of the following is the most common medical treatment in the long-term management of bipolar disorder in older adults?

      Your Answer: Diazepam

      Correct Answer: Lithium

      Explanation:

      Pharmacological Treatments for Bipolar Disorder

      Bipolar disorder, also known as manic depression, is a mental health condition characterized by alternating episodes of mania and depression. Lithium is the most commonly used medication for long-term management of bipolar disorder. It helps to stabilize mood and prevent relapses of both manic and depressive episodes. However, it is important to note that medication alone is not enough to manage bipolar disorder effectively. Holistic care, including therapy and lifestyle changes, is essential for patients to cope with their condition.

      Carbamazepine is another medication used for mood stabilization in bipolar disorder, but it is less commonly used than lithium. Sertraline, on the other hand, is a selective serotonin reuptake inhibitor (SSRI) that is primarily used to treat depression, not bipolar disorder. Diazepam, a benzodiazepine, may be helpful in managing acute manic episodes, but it is not recommended for long-term use due to the risk of dependence.

      Clozapine is an atypical antipsychotic medication that is primarily used to treat treatment-resistant schizophrenia. It is not commonly used for bipolar disorder due to the risk of agranulocytosis, a potentially life-threatening condition that can occur with clozapine use. If clozapine is used for bipolar disorder, it should only be done under close monitoring and evaluation by a multidisciplinary psychiatric team.

      In summary, lithium is the most commonly used medication for long-term management of bipolar disorder, but holistic care is essential for effective management of the condition. Other medications may be used in certain situations, but they should be used with caution and under close supervision.

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      • Psychiatry
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  • Question 30 - A 36-year-old man is brought to the Emergency Mental Health Ward. He is...

    Incorrect

    • A 36-year-old man is brought to the Emergency Mental Health Ward. He is speaking rapidly, claiming to be the ‘new Messiah’ and insisting that he has the ability to cure acquired immune deficiency syndrome (AIDS) with the assistance of his friends who are providing him with undisclosed 'classified' knowledge.
      What medication would be appropriate to administer to this individual?

      Your Answer: Zopiclone

      Correct Answer: Olanzapine

      Explanation:

      Choosing the Right Medication for Psychosis: A Comparison of Olanzapine, Diazepam, Citalopram, Clozapine, and Zopiclone

      When a patient presents with psychosis, it is crucial to assess them urgently and rule out any organic medical causes. The primary treatment for psychosis is antipsychotics, such as olanzapine. While benzodiazepines like diazepam can be used to treat agitation associated with acute psychosis, they are not the first-line treatment. Citalopram, a selective serotonin reuptake inhibitor used for depression, would not be appropriate for treating psychosis. Clozapine, another antipsychotic, is only used on specialist advice due to the risk of agranulocytosis. Zopiclone, a hypnotic used for sleep, is not appropriate for treating psychosis. It is important to choose the right medication for psychosis to ensure the best possible outcome for the patient.

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      • Psychiatry
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SESSION STATS - PERFORMANCE PER SPECIALTY

Psychiatry (17/30) 57%
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