Psychiatry

Question 1

Anorexia nervosa - red flags for admission

Answer 1

Rapid weight loss > 1kg/week

Weight for height < 75% or BMI < 2nd centile

Medically compromised
- Syncope
- Seizures
- Cardiac failure

Severe dehydration

Electrolyte abnormalities (low)

Severe bradycardia < 50 bpm

Hypotension < 80/50 mmHg

Hypothermia <35˚C

Severe psychiatric upset or resistance to outpatient treatment

Question 2

Anorexia nervosa - diagnosis and management

Answer 2

Restrictive energy intake relative to needs leading to low body weight
- Intense fear of gaining weight with subsequent behaviours to interfere with weight gain
- Aberrant/dysmorphic self image

Features:
- Intense fear of weight gain
- Behaviours to prevent weight gain
- Low BMI (< 18.5)
- Dry hair, lanugo
- Bradycardia, hypotension, hypotension
- Fatigue
- Peripheral oedema
- Hypothalamic amenorrhoea
- Low LH, FSH, oestradiol
- Constipation
- Signs of bingeing/purging e.g. Russell’s sign, dental eroision, palatal scratches or petechiae

Management:
- Family therapy
- Structured refeeding as inpatient
- Manage in open bay with 1:1 if needed
- Maintain bed rest with monitoring for 1hr
post-meals
- Cautious fluid balance
- Treat hypotension with 10 ml/kg/hr oral
or NG bolus, avoid IV
- Aim weight gain of 1 kg/week

Question 3

Anorexia nervosa - investigations

Answer 3

Investigations
- SUSS impaired
- ECG - sinus brady
- Bloods
- anaemia, low WCC
- low phosphate, low potassium, low
magnesium
- hypothalamic amenorrhoea

Question 4

Splitting

Answer 4

Psychological separation of all good qualities into one individual and all bad qualities into another

Most commonly seen in EUPD

Question 5

Lithium level monitoring

Answer 5

Weekly after initiation or any dose change until levels stable

Then 3-monthly for the first year

Then 6-monthly

Question 6

Lithium toxicity

Answer 6

Risk factors:
- Overdose
- Impaired excretion e.g. dehydration, ACEi, diuretics, hyponatraemia

Features:
- Levels > 1.5:
- Vomiting
- Diarrhoea
- AKI
- Weakness
- Confusion
- Levels > 6
- Ataxia
- Dysarthria
- Clonus
- Fasciculations
- Hyperreflexia
- Tremors
- Convulsions

Investigations:
- ECG - prolonged QT, ST depression
- Bloods - renal function, lithium levels

Management:
- Hydration
- Sodium polystyrene
- Haemodialysis
- Serum lithium > 5
- Serum lithium > 4 with renal impairment
- Decreased GCS, seizure, or other life-
threatening complications