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MBChB - Full Clinical Topics > Psychiatry + Geriatrics > Flashcards

Psychiatry + Geriatrics Flashcards

1
Q

A 23-year-old man presents to his GP surgery asking to be referred to a plastic surgeon. He is concerned that his ears are too big in proportion to his face. He now seldom leaves the house because of this and has lost his job. On examination his ears appear to be within normal limits. What is the most appropriate description of this behaviour?

A

Body dysmorphic disorder (sometimes referred to as dysmorphophobia) is a mental disorder where patients have a significantly distorted body image

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2
Q

What is the first line tx for a 14 year old girl with anorexia?

A

Family based therapy

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3
Q

Name two common features of sleep paralysis?

A

1) Paralysis - this occurs after waking up or shortly before falling asleep
2) Hallucinations - images or speaking that appear during the paralysis

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4
Q

What is sleep paralysis and what treatment can be used?

A

Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep.

Tx: If needed clonazepam

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5
Q

What is the cut off for clozapine with regards to missed doses and needing to restart?

A

If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly

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6
Q

What is the general summary of investigation results for patients with anorexia?

A

Most blood results are low

Anything beginning with GorC is high (Growth hormone, cortisol, glucose etc)

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7
Q

What is the minimum length of symptoms that ICD-10 criteria can be used to diagnose depression?

A

2 weeks

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8
Q

A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?

A 
Start sertraline (first line SSRI if heart disease)
\+ lanzoprozole

As she is already taking aspirin, any NSAID + SSRI can give risk of GI bleed so needs cover with PPI

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9
Q

What are the main risks of using an SSRI (a) in the 1st trimester and (b) in the 3rd trimester

A

Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn

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10
Q

A 30-year-old female patient with previously diagnosed depression managed with fluoxetine presents to her GP having had terrifying hallucinations at night occurring most nights in the past week. These have been mainly auditory and woken her from sleep. They comprise of aggressive male voices which last for around 10 minutes after she is fully awake. What is the most likely diagnosis?

A

Hypnogogic (occurring from wakefulness to sleeping) and hypnopompic (occurring from sleeping to waking) hallucinations can occur as a normal physiological phenomenon, however there is a recognised association with depression and anxiety. They can also be associated with sleep paralysis. As these hallucinations have only been occurring at night over a one week period they are not a manifestation of psychosis associated with schizoaffective disorder or schizophrenia.

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11
Q

In what year was the Mental Health Act written and what year was it ammended?

A

Written 1983

Amended 2007

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12
Q

In what year did the mental capacity act come into place?

A

2005

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13
Q

When would a section 2 be used? How long does it last for?

Who approves it?

A

Detained in hospital for ASSESSMENT of mental health

Up-to 28 days

Approved by two doctors, one specialist?

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14
Q

Can a patient appeal a section 2, can it be renewed?

A

Can appeal in first 14 days

Can’t be renewed, but can be moved to a section 3

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15
Q

What is a section 3 used for?

How long does it last? Can it be renewed?

A

Detained in hospital for TREATMENT
- Up to 6 months

Renewed for periods of up to 1 year at a time

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16
Q

What is a section 4 used for and how long does it last? Who approves it?

A

Detained for emergency assessment

Up-to 72 hours

(needs only one doctor, but must have seen in last 24 hours)

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17
Q

When is a section 5 used? What are the subsections and how long does it last?

A

Stopped from leaving hospital for up to 72 hours

Done by doctor = Section 5 (2) - 72hrs

Done by nurse = Section 5 (4) - 6 hours

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18
Q

Of MHA sections 2/3/4/5, which can a patient be treated without consent, when can’t a patient be treated without consent?

A

Section 2 + 3 = Can treat without consent

Section 4+5 = Can’t treat without consent

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19
Q

What is a section 135 used for?

A

Warrant to gain access to premesis to remove patient to place of safety

One doctor + one police

  • Assessment only, no tx
  • Can only be used once
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20
Q

What is a section 136 used for?

A

Allow police to remove a person from public place to safety

  • Police power only
  • Assessment not tx
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21
Q

Name 3 risk factors for depression?

A 
Female
Past Hx
Significant physical illness
Other mental health conditions 
Afro-Caribbean or Asian
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22
Q

What are the depressive symptoms which should be covered in a hx?

A 
Sad (mood)
Apathy (loss of enjoyment)
Guilty 
Concentration
Loss of appetite
Agitation or slow movements
Sleep changes + fatigue
Suicide

BAP (Bipolar, alcohol/ drugs, psychosis)

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23
Q

How should mild/moderate depression be treated?

A

1) Watchful waiting (assess every 2 weeks)
2) Low intensity psychological i.e. online CBT, relaxation therapy
3) Only offer medication if persists after this

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24
Q

How should moderate to severe depression be treated?

A

Medication + high intensity psychological tx

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25
Q

What is first line medication for depression?

A

1) SSRI

- Sertraline, fluoxetine, citalopram etc

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26
Q

What is first line antidepressant medication in children or young people?

A

Fluoxetine

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27
Q

Name 3 common side effects of SSRI’s?

A 
GI upset + nausea (often resolve in 2 weeks)
Dry mouth
Drowsiness
Decreased sex drive
Agitation
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28
Q

Name 3 symptoms of SSRI withdrawal syndrome?

A 
Mood changes
Restlessness
Sleeping problems
GI (pain, cramping, D+V)
Parasthesia, sweating, unsteadiness
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29
Q

Give 3 example questions you could use to risk assess someone with depression?

A
  • Often when people feel down they can feel like life is no longer worth living, have you ever felt like this?
  • Have you ever had any thoughts of taking your life?
  • – If so, have you made any plans?
  • Have you ever thought about or tried to hurt yourself in anyway?
  • Are you managing to eat and drink as normal?
  • Has your alcohol intake changed at all?
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30
Q

What is the average length of a depressive episode?

A

6-8 months

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31
Q

How long do SSRI’s take for the patient to start feeling the benefit?

A

Up to 4 weeks

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32
Q

In an OSCE situation how would you assess capacity?

A

Informal conversation to check can the cover the 4 main domains

(understand decision, weight it up, retain it and communicate it back)

  • Always say you’d get a second opinion from a doctor who specialises in Care of the Elderly.
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33
Q

It’s Friday afternoon and you have a safeguarding concern about a patient on a home visit, name five steps you’d take?

A 
SMACK
S- Safety of patient
M- Medical problems
A- Ask a senior 
C- Contact social care (i.e. rapid access team)
K- Keep clear notes
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34
Q

If you have a safeguarding concern about a px and a relative is being obstructive, what do you do?

A

Explore reasons for being obstructive

Raise safeguarding concern

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35
Q

Name two risk factors for GAD?

A

Divorced/ separate

Living alone or as lone parent

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36
Q

What is the ICD-10 definition of GAD?

A

Excessive anxiety and worry occurring more days than not for at least 6 months, about a wide range of activities or events

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37
Q

What symptoms must be present to meet the diagnostic criteria for GAD?

A

Three or more of:

  • Restlessness/ on edge/ easy fatigued/ difficulty concentrating
  • Irritability, muscle tension, sleep disturbance

+ 4 physical manifestations
(SOB, fast HR, palpitations, sweating, trembling, dry mouth, nausea etc)

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38
Q

How do you distinguish between GAD and ‘panic disorder’?

A

Panic disorder has obvious triggers

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39
Q

What investigations should be performed in suspected GAD?

A

PHQ-9 for depression

Bloods (FBC to r/o anaemia, TFT’s to rule out hypothyroid, cortisol, B12 and folate)

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40
Q

What are the first three lines of management of GAD?

A

1) Identify + educate (avoid caffeine, alcohol, drugs, stimulants). Practice breathing exercises and do physical exercise
2) Low intensity pyschological support (guided self help or groups)
3) Offer CBT, if doesn’t work can offer SSRI (sertraline)

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41
Q

When starting sertraline for anxiety, name three factors the patient should be counselled on?

A
  • Inform patient about transient increase in anxiety on starting meds
  • Council on delayed onset of effect (4weeks or so), and likely to stay on for a year or so, don’t stop the drug abruptly
  • Review every 2-4 weeks for first three months then three-monthly thereafter
  • Side effects
    (GI for first 2 weeks, then dry mouth, drowsiness, low sex drive)
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42
Q

How do you define delirium?

A

Acute confusional state – it is a clinical syndrome involving abnormalities of thought, perception and levels of awareness. Delirium can be both hypoactive, hyperactive or both. It can occur acutely or sub-acutely, and many patients will not return to their baseline function.

43
Q

How is delirium classified?

A

Hypoactive: Apathy and quiet confusion > Often missed or confused with depression
Hyperactive: Agitation, delusions and disorientation prominent > Confused with schizophrenia
Mixed subtype: Patients vary between the two above

44
Q

What is the best way to screen for delirium?

A

4AT:
This is an abbreviated form of the AMTS. A score of 4 or above shows possible delirium +/- cognitive impairment. 1-3 is possible cognitive impairment and 0 means it’s unlikely.

45
Q

What are the components of the 4AT score?

A
  1. Alertness
    - Normal/ fully alert = 0
    - Abnormal (drowsy, hypoactive or agitated) = 4
  2. AMT4
    - Ask age, DOB, where you are now and current year
    - No mistakes = 0, 1 mistake= 1, 2+ mistakes= 2
  3. Attention
    - Ask to name months backwards starting from December
    - 7+ correct = 0, Less than 7 = 1, untestable = 2
  4. Acute and fluctuating course
    - No = 0/ Yes = 4
46
Q

Name 3 differentials for delirium?

A

Dementia (especially Lewy Body)
Depression
Functional pyschosis (schizophrenia)

47
Q

A patient has delirium, what investigations do you want to perform?

A

Full hx, examination and obs
Bloods (FBC, u+e, LFT)
Urine dip
ECG/ CXR

48
Q

What are the reversible causes of delirium?

A 
PINCH ME
Pain
Infection
Nutrition
Constipation 
Hydration/ hypoxia 
Medication
Environmental
49
Q

How should delirium be managed?

A

Supportive (familiarity), environmental

If above unsuccessful and risk to self/ others can consider benzo’s or haloperidol/ olanzapine after discussion with senior

50
Q

Name three descalation techniques which can be used for a px with delirium?

A
  • Listen to what Px says and repeat and agree
  • Listen to them, offer choices
  • Do not be argumentative or aggressive
51
Q

What is the best and quickest way to assess a patient for confusion?

A

AMTS10

52
Q

What are the main types of dementia and what are the key components in a history?

A

Alzheimers (50%) - Progressive, starts with memory loss, verbal ability, visospatial (lost)
Vascular (25%) - Raised BP, past strokes, focal CNS, stepwise pathology
Lewy Body (20%) - Fluctuating cognitive impairement, hallucinations
Frontotemporal (5%)- Behaviour and personality changes

53
Q

What medicines can be used for alzheimers dementia?

A

1st: Donepezil, rivastigmine or galantamine (AChE inhibitors)
2nd: Memantine (NDMA blockers)

54
Q

What is the pathophysiology of Alzheimer’s dementia?

A

Degeneration (with atrophy and amyloid plagues) which reduces the amount of Acetylcholine

55
Q

What is the pathophysiology of vascular dementia?

A

Cumulative effect of many small strokes, sudden onset and stepwise pathology

56
Q

What is the pathophysiology of lewy body dementia?

A

Deposition of abnormal proteins within the brainstem and neocortex. Associated with alpha synuclein

57
Q

What is the pathophysiology of frontotemporal dementia?

A

Specific atrophy of the frontal and temporal lobes.

58
Q

What is the diagnostic criteria for depression?

A
  • Affect ability to function in normal activity and represent a decline from previous level of function
  • Can’t be explained by delirium or other major psychiatric disorder
  • Have been established with a formal cognitive assessment
  • Involve impairment of at least two of: Short term memory/ judgement/ visuospatial ability/ language/ personality
59
Q

What must a newly diagnosed dementia patient be advised about driving?

A

Must inform DVLA (although some may be able to continue driving)

60
Q

What medication is used in alcohol withdrawal?

A

1st Line benzodiazepines (Chlordiazepoxide).

2nd Line: Carbamazepine

61
Q

Name 4 symptoms of alcohol withdrawal?

A

Symptoms start 6-12 hours after Tremor, sweating, tachycardia, anxiety

62
Q

Name a characteristic side effect of mirtazepine?

A

Increased appetite

63
Q

Name 5 atypical anti-psychotics

A 
Clozapine
Olanzapine
Risperidone
Quetiapine
Aripiprazole
Amisulpride
64
Q

Name 5 side effects of atypical anti-psychotics?

A 
Dry mouth
Constipation 
Dizziness
Weight gain (increased appetite)
Blurred vision
65
Q

What are the 4 first rank symptoms of schizophrenia?

A

Delusions
Auditory Hallucinations
Thought disorder (insertion, removal, broadcasting)
Lack of insight

66
Q

Name 3 negative (chronic) symptoms of schizophrenia?

A 
Underactivity
Low motivation
Social withdrawal
Emotional flattening 
Self-neglect
67
Q

What is the peak incidence of delirium tremens, what are some of the syx? (3)

A

Peak 48-72 hours post withdrawal

Tremor, confusion, delusions, hallucinations, fever, tachycardia

68
Q

What is the first line management for patients with delirium tremens?

A

Lorazepam

69
Q

What is somatisation disorder?

A

Multiple physical symptoms present for at least 2 years

Px won’t accept reassurance or negative results

70
Q

What is hypochondrial disorder?

A

Persistent belief in underlying SERIOUS disease

Can’t accept reassurance

71
Q

What is conversion disorder?

A

Loss of motor or sensory function, not consciously feigned

Patient not seeking material gains

72
Q

What is dissociative disorder?

A

Separate off certain memories

- Amnesia, stupor etc

73
Q

What is Munchausen’s syndrome?

A

Also known as factitious disorder
“The intentional production of physical or psychological symptoms”

‘Faking’

74
Q

What is malingering?

A

Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

75
Q

What is the diagnostic criteria of schizophrenia?

A

Two or more positive symptoms

Lasting more than one month

76
Q

Name 4 different atypical antipsychotics, what groups can they be split into?

A

Sedative: Olanzapine and quetiapine (cause weight gain)

Agitative: Aripiprazole and risperidone (no weight gain)

77
Q

What are the first three lines of tx for schizophrenia?

A

1) Atypical antipsychotic (quetiapine/ olanzapine/ risperidone/ aripiprazole)
2) Try alternative antipsychotic
3) Clozapine

78
Q

What is the most common SE of clozapine, what is the most dangerous?

A

Common: Postural hypotension

Danagerous: Agranulocytosis (weekly bloods for 18 weeks)

79
Q

Name three possible treatments for personality disorders?

A
  • CBT (Socratic)
  • IPT (assuming difficulties from interpersonal problems like role definition and grief)
  • Group psychotherapy (interpersonal problems correcting maladaptive ideas)
80
Q

What is a schizoid type personality disorder?

A

Emotionally cold, doesn’t like contact

Rich fantasy word

81
Q

What is a schizotypal personality disorder?

A

Eccentric behaviour, odd ideas, lack of emotion, see or hear strange things

82
Q

What is a borderline or EUPD personality disorder?

A

Impulsive, hard to control emotions, often self harm
Feel empty
Make relationships quickly but use them easy
Paranoia and depression

83
Q

What is a histrionic type personality disorder?

A 
Over-dramatize events
Self-centred
Strong emotions which change quickly
Worry about appearance
Crave new things
84
Q

What is a narcissitic personality disorder?

A 
Strong sense of self-importance
Dream of unlimited success and power
Crave attention, but show few warm feelings
Take advantage of others
Ask for favours, not returned
85
Q

What characterises an avoident personality disorder?

A
  • Very anxious and tense
  • Worry a lot
  • Feel insecure and inferior
  • Have to be liked and accepted
  • Extremely sensitive to criticism
86
Q

What characterises on OCD (anankastic) personality disorder?

A

Worry and doubt
Perfectionist, always checking
Routines
Preoccupied with detail

87
Q

What is are the three diagnostic criteria for anorexia?

A
  1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
  2. Intense fear of gaining weight or becoming fat, even though underweight.
  3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
88
Q

What are the diagnostic criteria for Bulimia nervosa?

A
  • Recurrent episodes of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances)
    a sense of lack of control over eating during the episode
  • Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
  • Binge eating and compensatory behaviours both occur, on average, at least once a week for three months.
89
Q

What guidance is given regarding DNACPR decision?

A

Made by senior clinician

However should seek advice from the family regarding previous wishes etc

90
Q

What is an advance decision?

A

Advance decisions can be drawn up by anybody with capacity to specify treatments they would not want if they lost capacity. They may be made verbally unless they specify refusing life-sustaining treatment (e.g. Ventilation) in which case they need to be written, signed and witnessed to be valid. Advance decisions cannot demand treatment

91
Q

What is an LPA?

A

Appoints an attorney to act on their behalf (financial and health)

  • Only has authority on life-sustaining treatment if LPA specifies it
  • Must be registered with the office of the public guardian
92
Q

How do you manage a paracetamol overdose?

A
  • Activated charcoal if ingested <1hr ago

- N-acetylcysteine

93
Q

How do you manage an aspirin overdose?

A

Haemodialysis

94
Q

How do you manage an opiate overdose?

A

Naloxone

95
Q

How do you manage a benzodiazepine overdose?

A

Flumazenil

96
Q

How do you manage a TCA overdose?

A

IV bicarbonate may reduce risk of seizures and arrhythmia’s

97
Q

Name 5 risk factors for completed suicide once an attempt is known?

A

1) Planned
2) Effort to avoid discovery
3) Left a note
4) Final acts such as sorting out finances
5) Violent method

98
Q

What acronym can be used to explore the causes of falls?

A

Drugs (polypharm, sedatives, antihypertensives)
Age related (vision, cognitive, gait, OA)
Medical (arrhythmias, PD, stroke, cataracts)
Environmental (walking aids, footwear, home hazards)

99
Q

What questions should be asked in a falls history?

A 
Before the fall:
- (Where, when, what before, why)
During the fall:
- Lose consciousness? Injury? 
After the fall:
- How did they get help? Could they get up? Injury?
100
Q

Name 4 investigations which should be done after a fall?

A

Bloods (FBC, U+E, LFT to look for cause and dehydration)
ECG for arrhythmias
Tinetti Assessment Tool (to calculate future falls risk)
FRAX Assessment Tool (for fracture risk)

101
Q

What makes up the AMTS10?

A 
1- Age?
2- DOB?
3- 42 West Street (repeat at end)
4- Time to nearest hour?
5- Year?
6- Where are we now?
7- Identify two people? 
8- Year 1st world war (1914-18)
9- Name of current queen?
10- Count backwards from 20-1
102
Q

When do alcohol withdrawal consequences of a) symptoms b) seizures and c) delirum tremens occur?

A

Alcohol withdrawal

  • symptoms: 6-12 hours
  • seizures: 36 hours
  • delirium tremens: 72 hours
103
Q

Which antipyschotic has the most tolerated side effected profile?

A

Aripiprazole

MBChB - Full Clinical Topics (23 decks)

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